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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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Fine Motor training

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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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