Hand Function Assessment and Training

Original Editor - Pam Versfeld
Top Contributors - Robin Tacchetti and Jess Bell

Introduction

Hand function in infants can be assessed using a play-based approach. A play-based assessment provides insight into an infant’s present abilities, response to the social and physical environment, and motivation to move and interact with toys and other interesting objects.

Standardised Assessments

The following standardised assessments of hand function are used for infants with unilateral cerebral palsy (CP):

1. Mini-Assisting Hand Assessment (Mini-AHA):
   • measures how well children aged 8-18 months with signs of unilateral or hemiplegic cerebral palsy use their more affected hand, when using both hands together to play
   • the Mini-AHA is useful for rehabilitation professionals as it:
     • describes how a child with unilateral cerebral palsy uses their affected (assisting) hand
     • helps them carefully plan therapy aimed at each child’s level of ability
     • measures whether therapy or an intervention has been effective
2. Hand Assessment for Infants (HAI):
   • developed for infants at risk of cerebral palsy aged 3-12 months
   • measures the degree and quality of goal-directed actions performed with each hand separately and both hands together
   • the outcome of the test renders a separate score for each hand, illustrating possible asymmetric hand use
   • provides a criterion-referenced measure of general upper limb ability
   • comparing the infant's result to norm-referenced values can assist in identifying infants who would benefit from intervention

The GAME Protocol for Early Intervention

The GAME intervention (Goals - Activity - Motor Enrichment) is based on the principles of active motor learning, family-centred care, parent coaching and environmental enrichment. Interventions are customised to the parent's goals and enrichment style and the child’s motor ability.

Read more on the GAME intervention here.

A Dynamic Systems and Task-oriented Approach to Intervention

Building on the GAME approach to intervention, a dynamic systems and task-oriented approach to intervention is informed by the following ideas:

1. Family-centred care - involving parents in selecting goals and providing opportunities for practising movement skills are essential to success
2. Therapy always starts with the infant's present abilities - i.e. what they can do at this present moment and how this creates an opportunity for learning to do more
3. An emphasis on training intensity, repetition and many daily opportunities for practising a task in a variety of contexts
4. Self-initiated action and exploring ways of doing things support and enhance motor learning
5. Intrinsic motivation, curiosity, and the drive to explore and interact with people and objects support learning new movement skills  
6. Promoting enjoyable and meaningful social interaction and communication is central to intervention and supports the learning of motor tasks

Guidelines for a Dynamic Systems Task-oriented Assessment of Hand Function

1. Listen to the parents' views of their child's abilities and also their expectations for the therapy session
2. Explain the purpose of the assessment:
   • identify the infant's abilities, especially their strengths
   • explore ways to enhance the variability and complexity of the infant's actions in ways that will promote progress along the developmental pathway and towards identified goals
   • assessment is an opportunity for caregivers to:
     • gain insight into their infant's abilities and the factors that enhance and constrain progress towards more advanced hand function
     • identify ways to enhance perceptual-motor learning
3. Observe the infant in a starting position that is appropriate for their age and abilities. Positions for infants not yet sitting can include supine, reclined and sitting on a caregiver's lap.

Assessment in Supine

For very young infants (newborn to about 12 weeks) and those who are not yet able to keep the head stable when supported in sitting, observation starts with the infant in supine. Supine is a good position to observe:

• how an infant uses their hands to explore their face and bodies, clothing and the surrounding supporting surfaces
• an infant’s level of spontaneous movement and if they have started to swipe at or reach for toys presented within easy reach

Assessment in a Reclined Position

We can assess the hand function of infants who can maintain a steady head and trunk when moving their hands (usually from around 3-4 months) when they are lying supine in a seat that is inclined or supported on a feeding cushion. In this position, we can observe:

• an infant's ability to reach for and grasp a toy presented within easy reach and in the midline

Raising an infant's head and trunk makes it easier for them to lift their arms forward to grasp a toy and keep their hand and toy within their visual field.

Assessment While Sitting on a Caregiver's Lap

Lap sitting is a good position to observe an infant’s hand function as it allows the caregiver to provide as much support as is needed to keep the infant's head and trunk steady. In this position, the infant feels safe and secure and is more likely to move their hands to engage with interesting objects presented within reach. We can look at the following:

• does the infant reach for toys presented within easy (arm’s) reach?
• once the infant gets hold of a toy, what do they do?
• does the infant hold a toy in one hand and use the other hand to manipulate it?

Training Hand Function in Infants

Typically developing infants and toddlers tend to actively explore their environment and spend a great deal of time figuring out  different ways to interact with the objects and toys they encounter.

Relevant Research

Herzberg et al. recorded and analysed the spontaneous activity of crawling and walking infants and toddlers.

• During two 2-hour visits, they observed infants interacting with many different toys and household objects - these interactions took up around 60% of the infants' time during the visits
• Interactions were brief, lasting an average of 9 seconds

This research suggests that exuberant object play with many "brief, time-distributed, variable interactions with objects" may encourage infants to:

• learn about the properties and functions of objects
• enhance motor skill acquisition
• encourage cognitive, social and language development

Tokeshi et al. conducted an observational study on the relationships between full-day arm movement characteristics and developmental status in infants with typical development as they learn to reach. Arm movements were measured over a full day using wearable sensor technology. Tokeshi et al. found that:

1. infant arm movement characteristics were related to motor, cognitive and language scores on the Bayley Scales of Infant and Toddler Development, which suggests that there is "a relationship between daily movement characteristics and developmental status"
2. the infants who moved more experienced greater increases in their language and cognitive scores across visits
3. greater changes in movement characteristics across visits were related to higher motor scores

Experience is important

Experience with many different objects is important for learning hand tasks and, as Tokeshi et al. note, there is an association between infant arm movements and scores on the Bayley Scales of Infant and Toddler Development. Therapists and caregivers must, therefore, ensure that an infant/child has many opportunities to play with varied and interesting objects and toys. This should include dedicated time spent working on specific tasks supported by a play partner. This is particularly important for:

• infants with motor delay
• infants who were born preterm
• infants who are at risk for cerebral palsy

Importance of a stable sitting posture

A stable sitting posture is important for learning to reach for and manipulate objects. Marcinowski et al. concluded that the ability of infants to sit erect with their hands free, albeit with some support, enhances their ability to explore objects visually and manually. Therefore, it is important to provide external support for toddlers whose sitting stability is not yet good to allow them to maintain an erect sitting posture when moving their hands to reach for and manipulate objects.

Sitting erect also allows the child to look around and build a map of the environment, notice where people and objects are situated and when and how they move. This information is important for planning actions.

Constraint-induced Movement Therapy

Although research shows that older children with hemiplegic cerebral palsy benefit from constraint-induced movement therapy (CIMT), the efficacy of CIMT among the infant population is unknown.

• In 2022, Dionisio and Terrill conducted a scoping review to examine CIMT protocols to learn more about the dosage, constraint, administration, training and education for parents, and objective outcome measures used in current research
  • They concluded that current literature supports the use of CIMT for infants with cerebral palsy
  • However, they note that there is considerable variability in the studies in terms of protocol design and outcome measures
  • They, therefore, concluded that higher level research is needed to "support the efficacy of CIMT" for infants with cerebral palsy
• Walker et al. also conducted a scoping review of CIMT in 2022 that aimed "to identify current evidence for CIMT protocols for children 3 months to 5 years 11 months as well as clinical applications for practice and gaps in research"
  • The ten studies selected for review showed that CIMT is a "feasible and effective treatment" for infants and toddlers
  • CIMT should include caregiver coaching, treating the child in their usual environment and providing the right activities.
  • Walker et al. also concluded that further research is needed to ascertain what effect different dosages have in early CIMT, and the long-term effects of CIMT on development throughout childhood

Resources

• Hand Function 0-7 Months
• Hand Function 7-24 Month Period
• Skills for Action: The SPEEDI Play Based Intervention