aado / hkssh conjoint scientific meeting 2014 (activity of the … · aado / hkssh conjoint...
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AADO / HKSSH Conjoint Scientific Meeting 2014 (Activity of the 2014 HKSSH Annual Congress)
Occupational Therapy in Pediatric Orthopedic Upper Limb condition
Leung Yuen Shan Cecilia (Occupational Therapist I, Queen Elizabeth Hospital)
9 March 2014
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Content
1. Common types of Pediatric Orthopedic UL condition
2. Fine motor, pen grip & writing Development
3. Aim of Occupational Therapy
4. Occupational Therapy Assessment
5. Occupational Therapy Treatment
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Common types of Pediatric Orthopedic Cases
1. Traumatic injury
2. Congenital hand anomalies
3. Fine motor developmental problem
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(1) Traumatic Injury
– Sports & Domestic Injury
– Burn, Scald, Fracture, Soft Tissue Injury etc
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(2) Common Congenital Hand Anomalies
• Polydactyly
– Type I to Type VII
• Syndactyly
• Constriction Band Syndrome
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• Hypoplastic Thumb
• Radial/ Ulnar Club Hand
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(3) Fine motor developmental problem
• subtle fine motor problem when the child grows up
• c/o poor eye hand coordination
• clumsiness / poor fine motor control and finger dexterity
• slow handwriting speed / hand writing difficulties
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Fine motor Development
0-1 mth
1-2 mth
2-3 mth
• hands fisted, thumb in
• grasp reflex (0-3m)
• immediately drops rattle placed in hand
• ATNR position frequent
and causes involuntary hand regard and visual fixation
• hands loosely open, thumb out
• moves hands and feet at sight of stimulating toys
• closes and tightens hand around rattle touched to palm
• briefly retains rattle placed in hand
• hand mostly open and in
midline
• unilateral approach to
side only, not midline
• sustained voluntary grasp upon contact, ulnar side, no thumb involvement
• carries toy accidentally to mouth
• scratching own face, body and clothing
• involuntary release
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9
4-6 mths 7 – 9 mths.
Posture • ATNR decrease (4) • Fingers extended or slightly flexed (4) • Thumb hang downwards (4) Vision & Regard • Regard hand after contact has been established (4) • Track slow moving object within visual field (6) • No squint (6) Approach • Reach for toys • Unilateral circular approach, controlled elbow extension,
forearm between pronation and supination, overreaching (6)
Grasp • Primitive voluntary squeeze (no thumb/palm
involvement) (5) • Palmar grasp (6) Release • Clumsy 2 stages transfer (5) • Smooth 2 stages transfer (6) • Voluntary release object held in 1 hand with the
presentation of another object (6) Manipulation • Bring hands together in midline (4) • Take toys to mouth (4) • Hold one cube in each hand (6)
Posture • radial fingers dominate, wrist ulnar deviate, thumb oppose Approach • unilateral approach (7) • exhibit good directional control (8) • direct approach forefinger approx. straight line towards objects (9) Grasp • radial palmar grasp (7-8) • inferior scissor grasp (thumb add) (7) • scissor grasp (thumb not oppose) (8) • inferior pincer grasp (9) Release • hand transfer (7) • can release toy against firm resistance but cannot yet drop (9) Manipulation • rake raisins • strike one object with another (7) • shake and bang objects with 1 hand (8) • turn object over to examine • ambidextrous
10-12 mths. 13 – 15 mths.
Posture • Thumb oppose in almost all grasp Approach • Approach with appropriate pronation/supination (12) • Crossing midline with either hand (12)
Grasp • Neat pincer tip to tip (12) Release • Voluntary release into container in crude manner (10)
• Give to adult (12)
• Precise release into small container with wrist
extended (12)
• Difficulty in releasing small objects (12) Manipulation • Extend I/F to poke
• Bang 2 objects together
• Push toy car (10)
• Take object in/out of container (10)
• Drop and throw toy deliberately (12)
Release • Precise release small objects into small bottle (15) Manipulation • Stack rings on peg • Pat and manipulate a picture book • Remove lid from box • Manipulation possible without looking at hand and object consistently (15) Club • Tower of two (15) Writing • Hold crayon in own fashion • Incipient imitative strokes (15)
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16-18 mths. 19-24 mths.
Manipulation
• Turn 2 to 3 pages of a book • Hand preference begin Cube • Build a tower of 3-4 Writing
• Hold pencil in midshaft with palmar grasp
(16)
• Spontaneous scribbling
Manipulation
• Turn single page
• Unscrew bottle lid
• Hand preference emerge (24) Cube
• Tower of 5-6 (21)
• Tower of 6-7 (24) Writing • Hold a pencil well down shaft (24)
• Enjoy vigorous straight scribble and imitate
circular scribble (21)
• Imitate vertical strokes (24)
Paper Folding • Fold paper (general attempt) Bead Threading • Thread 2.5cm beads Imitation of Finger • Thumb up
• Thumb / index opposition
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2-2.5 yrs. 2.5 – 3 yrs.
Manipulation • Screw and unscrew toy
• Hold knob of puzzle & turn to insert Cube • Tower of 8-9 cubes Writing • Hold pencil with preferred hand with digital-
pronate grasp
• Imitate horizontal strokes
• Imitate oblique strokes Bead Threading • Thread 1cm small beads 3-4 no. Use of Scissor • Hold with thumb and fingers in correct holes
• Snip with scissor Imitation of Finger • Diamond shape, fingers touching
Cube • Tower of 9 Writing • Hold pencil with static tripod grip
• Copy O, X, V, T, H
• Write between 2.5cm path Use of Scissor • Cut paper into half along a straight line crudely Imitation of Finger • Make a fist and wriggle thumb on imitation
3 – 4 yrs. 4-5 yrs. 5 – 6 yrs.
Manipulation
• Place small pegs in
holes on board Cube • Tower of 10 or more Writing • Static tripod grip with
good control
• Copy ladder, square
• Use template
• Join 2 dots 5cm apart Bead Threading • Sew card with up and
down concept Imitation of Finger • Oppose each fingers
with thumb
• Pivot fingers with thumb
Manipulation • Clip cloth peg
• Spread paste on one side
of paper and turn over to stick it
Writing • Dynamic tripod grip
• Copy triangle, diamond
• Trace over simple design
• Colour well within lines
• Write few characters
Paper Folding • Fold paper in halves with
edges met Bead Threading • Can thread tiny beads to
make necklace Use of Scissor • Cut along curved or
straight lines
Manipulation
• Tear along lines
• Tie a plain knot
• Erase words in 2cm sq.
• Hand dominance established (6.5) Writing • Complete complicated point-line
picture
• Colour picture neatly
• Write small words within 2cm sq. Paper Folding • Fold paper sq. 2 times diagonally
on limitation Use of Scissor • Cut out circle, triangle, square
and simple design
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Pen grip Development
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Writing Development
Aim of Occupational Therapy
1. Provide support to family
• understand the child’s diagnosis & its impact on
daily function & hand skills.
2. Measure & strengthen hand strength or functional
ability.
3. Teach new skills
• improve hand skill, promote independence in
self-care, schoolwork and play
• reach a developmental milestone 16
4. Provide adaptive equipment
• improve hand function
5. Pre-operation splintage trial
• assess the appropriateness & indication of hand surgery
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Occupational Therapy Assessment 1. Range of Motion (ROM)
2. Pinch & grip strength
3. Fine Motor Skills
4. Functional skills in ADL(e.g., dressing, grooming, feeding)
5. School Work (e.g., Handwriting, typing)
6. Leisure (e.g., Sports, musical instruments)
7. Oedema & scar
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Fine Motor Ax
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Fine Motor Ax:
Bayley Scales of Infant and Toddler Development (3rd edition)
Peabody Developmental Motor Scales (2nd edition)
Age range: ( 0 – 3.5 yrs. ) ( 0 - 5 yrs. )
Feature: comprehensive assessment Norm-referenced Assess: • Cognitive • Language • Motor
In depth assessment Norm-referenced Assess: • Reflexes • Stationary • Locomotion • Object Manipulation • Grasping • Visual-Motor Integration
Fine Motor Ax
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Fine Motor Ax:
Hong Kong Preschool Fine Motor Developmental Assessment (HK-PFMDA)
Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT – 2)
Age range: ( 0 – 6yrs. ) ( 4 – 21 yrs. 11 mths. )
Feature: H.K. local norm Assess fine motor developmental function
Comprehensive assessment Norm-referenced
Assess items includes : Fine motor items - • Fine Motor Precision • Fine Motor Integration • Manual Dexterity • Bilateral Coordination
Gross motor items - • Balance • Running Speed and
Agility • Upper-Limb
Coordination • Strength
Fine Motor Ax.: Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT – 2) Video show: Transferring pennies Placing pegs into a pegboard Sorting cards Stringing blocks Dropping & catching ball Handwriting 21
Handwriting Ax
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Handwriting Ax:
A Chinese handwriting Assessment Tool (CHAT)
Copying Speed Test for Hong Kong Secondary Students (CST-HK)
Grade level : Primary 1 – 6 Form 1 – 6
Features: HK local norm Assess : speed & accuracy of handwriting
HK local norm Assess : speed and accuracy of Chinese & English handwriting
Occupational Therapy Treatment
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1. Splintage
2. Pressure therapy
3. Fine motor training
4. Handwriting training
5. Aids prescription
6. School accommodation
7. Family education & counseling
(1) Splintage
• correct joint angulations, stretch stiff joints & contractures
• position post-surgery hand in the best position for function
• minimize pain and maximize hand function
• Pre-operative splinting trial to assess the indication of hand surgery
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Splintage • Flexor Tendon Injury
• Fracture Forearm Fracture Humerus
with Radial Nerve Palsy
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Splintage
• Brachial plexus injury
• Hypoplastic Thumb
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(2) Pressure Therapy
• Providing post-surgical care, including pressure garment, splintage, de-sensitization & mobilization
• Constrict Band Syndrome Syndactyly
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(3) Fine motor training
• improve specific hand skills
• encourage to use affected hand or
both hands in daily activities
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(4) Handwriting training
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(5) Aids Prescription
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(6) School accommodation
• Extended examination time limit
• Enlarge grids or double line spacing answer sheet • Multiple choice
• Use Computer instead of handwriting in
answering the exam papers
• Request an assistant to turn the question papers & write the answer on answer sheet
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(7) Family Education and Counseling • Providing support and suggestions to the child’s
parents, to enable her/him to incorporate the child without drawing focus to the hand anomaly
• Providing information and resources on support groups / organizations that pair children with similar anomalies to provide a social/emotional outlet
• Providing referrals to social workers or other providers for counseling and to genetic counseling for future family planning
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Summary
1. 3 types of Pediatric Orthopedic UL conditions : • Traumatic injury, Congenital hand anomalies, Fine
motor developmental problem
2. Aims of O.T. to the child with orthopedic UL problem are : • Provide support to family, Measure & strengthen
hand strength or functional ability, Teach new skills, Provide adaptive equipment, Pre-operation splintage trial
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3. Occupational Therapy Assessment :
• ROM, Pinch & grip strength, Fine Motor & hand writing Ax., Oedema & scar
4. Occupational Therapy Treatment :
• Splinting, Pressure therapy, Fine motor training , Handwriting training, Aids prescription, School accommodation, Family education & counseling
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THANK YOU
END
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