Hand Function Assessment and Training

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

Ideas for training hand function in infants not yet sitting

One way to assess hand function in infants from birth-early sitting is by use of the play based approach. A play based assessment provides insight into the infant’s present abilities, response to the social and physical environment, motivation to move and interact with toys and other interesting objects.

Observation of an infant’s behavior in the presence of interesting objects provides the information needed to create opportunities for the infant to explore  different ways to use their hands to gather information and explore different, more varied and complex ways of interacting with toys and other interesting objects.

The following are quick reviews of standardized assessments of hand function in infants with unilateral cerebral palsy:

1. The Mini-Assisting Hand Assessment (Mini-AHA):
   • measures how well young children with signs of unilateral or hemiplegic cerebral palsy use their more affected hand, when using both hands together to play
   • The main reasons therapists use Mini-AHA
     • Describe how a child with unilateral cerebral palsy is using their affected (assisting) hand
     • Carefully plan therapy aimed at each child’s level of ability
     • Measure whether therapy or intervention has been effective
2. Hand Assessment for Infants (HAI):
   • developed for infants at risk of cerebral palsy (CP) in the age range 3-12 months
   • measures the degree and quality of goal directed actions performed with each hand separately as well as with both hands together
   • outcome of the test renders a separate score for each hand, illustrating possible asymmetric hand use.
   • also provides a criterion referenced measure of general upper limb ability
   • comparing the infants result to norm referenced values can assist in identifying infants who would benefit from intervention.

Constraint induced movement theray

Although research shows that older children with hemiplegic CP benefit from constraint-induced movement therapy (CIMT), the efficacy of CIMT among the infant population is unknown. In this scoping review,  the researchers  examined CIMT protocols for an overview of dosage, constraint, administration, parent training and education, and objective outcome measures. They concluded that existing literature supports CIMT protocols for infants with CP. However, much variability exists in protocol design and appropriate outcome measures among studies. The authors conclude that higher level research is needed to support the efficacy of CIMT among infants with CP.

A recent coping review of CIMT

The aim of this scoping review was to 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 10 studies selected for review showed that CIMT for infants and toddlers is a feasible and effective treatment consisting of caregiver coaching, treatment in the child's typical environment, and just right activities. Future research is needed to determine the effects of different dosages in early CIMT, and the long term developmental effects throughout childhood.

**A recommended dynamic systems and task oriented approach to intervention is informed by the International Clinical Practice Guideline for Early Intervention for Children Aged 0 to 2 Years with or at risk for CP

The  GAME protocol for early intervention.

The GAME intervention is based on the principles of active motor learning, family cantered care, parent coaching and environmental enrichment. Intervention is customized to parent goals and enrichment style and the child’s motor ability.

Morgan C et al GAME (Goals - Activity - Motor Enrichment): protocol of a single blind randomised controlled trial of motor training, parent education and environmental enrichment for infants at high risk of cerebral palsy.

Supporting Play, Exploration, and Early Development Intervention (SPEEDI)

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 centered care and the involvement of parents in selecting goals and providing opportunities for practice of movement skills is essential to success.
2. Therapy always starts with the infant's present abilities - 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 practicing a task in a variety of contexts.

1. Self-initiated action, along with exploration of possibilities for doing things, supports and enhances motor learning.

1. Intrinsic motivation, curiosity, and the drive to explore and interact with people and objects supports learning new movement skills.  
2. Promoting enjoyable and meaningful social interaction and communication is central to intervention and supports learning of motor task.

Guidelines for a dynamic systems task oriented assessment of hand function

The first step is to listen to the parent's views of their infants' abilities and also their expectations for the therapy session.

Next, explain the purpose of assessment:

• identify the infant's abilities, especially 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 carers to gain insight into their infant's abilities and the factors that enhance and constrain progress towards more advanced hand function and identify ways to enhance perceptual-motor learning.

The next step is to observe the infant in a start position that is appropriate for their age and abilities.

Assessment in supine

For very young infants (newborn to about 12 weeks) and those that 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 the infant uses their hands to explore their face and bodies, clothing and the surrounding supporting surfaces. It is also a good position for observing an infant’s level of spontaneous movement as well as whether they have started to swipe at or reach for toys presented within easy reach.

Assessment in a reclined position

From about 3-4 months when infants are able to maintain a steady head and trunk when moving the hands, lying supine in a seat that is inclined or supported on a feeding cushion, are good positions for observing an infants ability to reach for and grasp a toy presented within easy reach  and in the midline. Raising the head and trunk makes it easier to lift the arms forwards to grasp a toy and keep the hand and toy within the infant’s visual field.

Observation sitting on a carer’s lap

Lap sitting is also a good position to observe an infant’s hand function. Lap sitting allows the carer to provide as much support as is needed to keep the head and trunk steady. In this position the infant feels safe and secure and is more likely to move the hands to engage with interesting objects presented within reach. 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?

A study by Tokeshi et al., 2018 performed 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. The main findings were:

1. infant arm movement characteristics as measured by full-day wearable sensor data were related to Bayley motor, cognitive and language scores, indicating a relationship between daily movement characteristics and developmental status
2. infants who moved more had larger increases in language and cognitive scores across visits
3. larger changes in movement characteristics across visits were related to higher motor scores

Training hand function in sitting infants

The importance of experience and a stable sitting posture

Typically developing toddlers actively explore their environment

Typically developing infants and toddlers tend to very actively explore their environment and will spend a great deal of time figuring out  different ways to interact with objects and toys they encounter.  Researchers from the  from the Department of Psychology, New York University conducted frame-by-frame video analyses of spontaneous activity in two 2-h home visits with crawling and walking infants and toddlers. Infants interacted with a wide variety of toys and household objects in brief bouts that summed to ~60% of their time.  Interactions were brief – with and average of 9 seconds for an interaction. This research suggests that infant exuberant object play with immense amounts of brief, time-distributed, variable interactions with objects-may be conducive to learning object properties and functions, motor skill acquisition, and growth in cognitive, social, and language domains.

Experience is important

We know that experience with many different objects is important for learning hand tasks.

Joanne Shida-Tokeshi and colleagues from the  Infant Neuromotor Control Laboratory at the  University of Southern California have shown that the amount of arm movement as measured by wearable sensors across a full day  is associated with scores on the Bailey scale. This means that perhaps the most important role of the therapist and carers is to make sure that the child has  many opportunities to play with varied and different 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, those who were born preterm  and those who are at risk for CP are often less active and not as motivated to explore and figure things out.

Importance of a stable sitting posture

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

Resources

• Hand Function 0-7 Months
• Hand Function 7-24 Month Period