OT 180: Evaluation Techniques inOT 180: Evaluation Techniques inOccupational Therapy for Physical

Dysfunctions

July 16, 2009

Enrico C. Aguila, OTRP

skills in moving and interacting with task, objects andenvironment

Posture

• Stabilizes• Aligns

Mobility

• Walks• Reaches

Coordination

• Coordinates• Manipulates

Strength andEffort

• Moves• Transports

Energy

• Endures• Paces

• Positions • Bends • Flows • Lifts• Calibrates• Grips

Gross Motor SkillsGross Motor Skills

Involve the large muscles ofthe body that enable suchfunctions as walking,kicking, sitting upright,lifting, and throwing a ball.

Depend on both muscle toneand strength.

Fine Motor SkillsFine Motor Skills

Involve the small muscles of thebody that enable such functionsas writing, grasping smallobjects, and fastening clothing.

Involve strength, fine motorcontrol, and dexterity.and strength. control, and dexterity.

GMS

Mobility

Explorationof

environment

Play

Participationin sports

activities and

Negotiationof obstacles

in theenvironment

Play

Performanceof ADL and

IADL

Socialinteraction

activities andphysical

education

• Consciousness , temperament and personality functions, energy and drivefunctions, perceptual functions, mental functions of sequencing complexmovement (motor planning)

• visual acuity, visual field, balance, kinesthesia, joint position sense,• visual acuity, visual field, balance, kinesthesia, joint position sense,sensitivity to touch, ability to discriminate, sensitivity to pressure, pain

• range of motion, postural alignment, mobility of bone functions, strength,muscle tone, endurance, motor reflex functions , righting reactions,supporting reactions, tremors

Nonstandardized procedures

– Interview

– Observation

Standardized

– Peabody Developmental Motor Scales - Second Edition (PDMS-2)

– Bruininks-Osteretsky Test of Motor Proficiency, Second Edition[BOTMP-2]

– Test of Gross Motor Development - Second Edition [TGMD-2]

– Gross motor function measure (GMFM-66 & GMFM-88)

– GMFCS - Expanded and Revised (2007)

Ability to perform age-appropriate GMS

– Walking, running, jumping, climbing, hopping, skipping,playing on playground equipment, playing with a ball

Play and functional tasks

– Dressing, reaching for and carrying objects, negotiatingobstacles or uneven groundobstacles or uneven ground

Ask for ability to ride a bike, swim, engage in PE class, etc. andparticipation and interest in sports activities

Note for indicators of balance, endurance, strength, ROM, agility,coordination and bilateral integration

M. Rhonda Folio and Rebecca R. Fewell (2000 Edition)

Ages: Birth through 5 years

Testing Time: 45-60 minutes

Test Type: Norm-Referenced

Scores include

– Gross Motor Quotient which is a composite of the Reflexes,Stationary, Locomotion and Object Manipulation subtests,

– Fine Motor Quotient, a composite of the Grasping and Visual-Motor Integration subtests, and

– Total Quotient, a combination of the gross and motor subtests.

Robert H. Bruininks and Brett D. Bruininks

Ages: 4 through 21 years

Testing Time: Complete Battery - 45-60 minutes; Short Form -15-20 minutes

Scores/Interpretation: Age-based standard scores, percentileranks, and stanines; age equivalents for the Complete Batteryranks, and stanines; age equivalents for the Complete Batteryonly

8 subtests

5 composite scores

1. Fine Motor Precision - 7 items (e.g., cutting out a circle, connecting dots)

2. Fine Motor Integration - 8 items (e.g., copying a star, copying a square)

3. Manual Dexterity - 5 items (e.g., transferring pennies, sorting cards,stringing blocks)

4. Bilateral Coordination - 7 items (e.g., tapping foot and finger, jumpingjacks)

5. Balance - 9 items (e.g., walking forward on a line, standing on one leg on a5. Balance - 9 items (e.g., walking forward on a line, standing on one leg on abalance beam)

6. Running Speed and Agility - 5 items (e.g., shuttle run, one-legged side hop)

7. Upper-Limb Coordination - 7 items (e.g., throwing a ball at a target,catching a tossed ball)

8. Strength - 5 items (e.g., standing long jump, sit-ups)

BOT-2 provides a separate measure of gross and fine motor skills,making it possible to obtain meaningful comparisons ofperformance in two areas

– Fine Manual Control

– Manual Coordination

– Body Coordination– Body Coordination

– Strength and Agility

– Total Motor Composite

Dale A. Ulrich

Ages: 3 through 10

Norm-referenced

12 skills (six for each subtest):

– Locomotor: run, gallop, hop, leap, horizontal jump, slide;– Locomotor: run, gallop, hop, leap, horizontal jump, slide;

– Object Control: striking a stationary ball, stationary dribble,kick, catch, overhand throw, underhand roll.

Dianne J. Russel, Peter L.Rosenbaum, Lisa M. Avery, MaryLane

Clinical measure designed toevaluate change in GMS (CP,DS)DS)

2 versions:

– GMFM-88

– GMFM-66

GMFCS - Expanded and Revised(2007)

5 level classification system thatdescribes the gross motor function ofchildren and youth with cerebralpalsy on the basis of their self-palsy on the basis of their self-initiated movement with particularemphasis on sitting, walking, andwheeled mobility.

Righting reactions

Equilibrium reactions

Protective reactions

Balance skills

Head controlHead control

Trunk control

Pelvic control

Anticipatory postural control – catching, reaching, throwing

Supine

Prone

Prone on elbows

Quadruped

KneelingKneeling

Standing

Crawling

Creeping

Walking

Running

Jumping Jumping

Going up and down the stairs

Effective use of hands to engage in a variety occupations dependson a complex interaction of hands skills, postural mechanisms,cognition, and visual perception. (Exner, 2005)

Fine Motor Coordination

requires small, discrete, specialized muscles tofunction together, usually the hand muscles, such asthe opposing thumb-to-fingers position that isrequired to hold a pen

Reach Reach

extension and movement of the arm for grasping orplacing objects

Grasp

attainment of an object with the hand

Carry

transportation of a hand-held object from one place toanother; also referred to as “moves” and “lifts”(AOTA, 2002)

Voluntary release

intentional letting go of a hand-held object at aspecific time and place

In-hand manipulation

adjustment of an object in the hand after grasp

Bilateral hand use

use of two hands together to accomplish an activity

Tool

a device for working on something; serves as an extension of thelimbs and enhance the efficiency with which skills are performed

Midrange controlMidrange control

Midline crossing

Isolated finger control

Dexterity

Visual Skills

plays a major role in the development of hand skillsin children especially in learning new motor skills

4 months: infants begin to move their hands undervisual control as they reach fro an object and makedifferentiated finger movements

6 months: visuomotor development required foraccurate reach is achieved

6 months: visuomotor development required foraccurate reach is achieved

9 months: infant guides his or her hand movementsusing visual somatosensory integration

important in isolated movements of the fingers and thumbmovements

6 months: able to match haptic perception (knowledge of objectsgathered by means of active touch) of some 3D objects with visualperception

2.5 years old: child can identify common objects by touch alone

5 years old: good haptic recognition of unfamiliar objects

6 years old: identification of common objects and perception ofspatial orientation are well developed

important factors to consider: sensory registration,tactile hypersentivity, poor tactile discrimination anddyspraxia

6 months: infant uses visual and tactile stimuli to guide finemotor development and begins to develop awareness of objectplacement in space

Between 6-12 months: object learning is encouraged

9-10 months: infants adapt their arm positions to horizontalversus vertical object presentations and shape their handsappropriately for convex and concave objects

2 years old: relate objects with one another with more accuracyand purpose

Functions of Joints and Bones

– hand integrity is important for hand function

– consider the following: missing one or more digits,LOM, muscle weakness and joint inflammationLOM, muscle weakness and joint inflammation

Muscle Functions

– includes muscle power (strength), muscle tone and muscleendurance

– strength is needed to initiate all types of grasp patterns andmaintain these patterns during lifting and carryingmaintain these patterns during lifting and carrying

– tone is needed for stability of the parts of the arms and handsduring activities and the types of movements possible

Reach

Grasp Patterns

In-Hand Manipulations

Carry

Voluntary Release

Bilateral Hand Use

Tool Use

Reaching with an extended arm starts at 12-22 weeks of age; the objects are rarelygrasped and then only by accident

Midline orientation develops with the handsinitially close to the body; unilateral reachingoccurs when there is increasing dissociation ofoccurs when there is increasing dissociation ofthe two body sides; hands opens inpreparation for grasping the object (usually,the hand is more open than necessary for thesize of the object)

Mature reach is seen with sustained trunk extensionand a slight rotation of the trunk toward the object ofinterest

Over the next few years, reaching skills become refinedwith increasing accuracy of arm placement and thewith increasing accuracy of arm placement and thegrading of finger extension as appropriate to the size ofthe object

Optimal hand opening for the object size at theinitiation of reach is achieved at age 12.

According to Napier

According to Weiss and Flat

According to Erdhardt Prehension Developmental AssessmentAccording to Erdhardt Prehension Developmental Assessment(EDPA)

Non-prehensile - pushing or lifting an object with thefingers or the entire hand

Prehensile - it is the grasp of an object

– Precision grasp – opposition of the thumb andfingertipsfingertips

– Power grasp – use of the entire hand; the thumbis held flexed or abducted to other fingers

Grasp with no thumb opposition

– Hook Grasp – used to carry objects; transverse metacarpalarch is flat, fingers are adducted with flexion at the IP jointsand flexion and extension occurs at the MCP joints; thumbcan be flexed over the fingers (if additional power is needed)

Ex: Holding a handle

– Power Grasp – used to control tools or other objects; it is theflexion of the ulnar fingers and less flexion with the radialfingers and thumb extension and adductionfingers and thumb extension and adduction

Ex: brushing hair

– Lateral Grasp – used to exert power on or with a small object;there is partial thumb adduction, MCP flexion and slight IPflexion; pad of thumb is placed against the radial side of theindex finger at or near the distal DIP joint

Ex: using a key

Grasp with thumb opposition

– Tip pinch – opposition of the thumb tip and the tip of theindex finger, forming a circle; all joints of the index fingerand thumb are partly flexed; control of this grasp suggeststhe child’s ability to dissociate the two sides of the hand andto use tips of the index finger and thumb

Ex: Picking up small beadsEx: Picking up small beads

– Palmar pinch

• Standard

pad to pad or two-point pinch or pincer grasp

three-point pinch or three-jaw chuck pattern

– Spherical – there is wrist extension, finger abduction and somedegree of flexion at the MCP and IP joints; requires the stability ofthe longitudinal arch to grasp large objects; hypothenar eminenceassists the cupping of the hand for control of the object ; control ofthis grasp suggests the child’s ability to balance control of theintrinsic and extrinsic hand muscles

Ex. Throwing a ball

– Cylindrical – transverse arch is flattened to allow the fingers tohold against the object; fingers are slightly abducted and IP andMCP joint flexion is graded according to the size of the object; foradditional force, palmar surface of the hand contacts the objectmore

Ex. Opening a jar

Disk – finger abduction is graded according to the size ofthe object; hyperextension of the MCP joints and flexionof the IP joints are evident; wrist is more flexed whenobjects are larger and only the pads of the fingers contactthe object; thumb extension also increases with objectsizesize

Ex. Holding a CD

A. Grasp of PelletAge Skill

Natal No grasp or visual attention

3 months No attempt to grasp, but gives visual attention

6 months Raking and contacting object

7 months Inferior-scissors grasp. Rake into palm. adduction and flexion ofthumb and flex or partially extended fingersthumb and flex or partially extended fingers

8 months Scissors grasp. Between thumb and side of curled index finger

9 months Inferior pincer grasp. Between ventral thumb and index; beginningof thumb opposition

10 months Pincer grasp. Between distal pads of thumb and index; thumbopposed

12 months Fine pincer. Between fingertips or fingernails; thumb joint flexed

B. Grasp of CubeAge Skill

Neonate Visual attention; palmar reflex grasp

3 months Visual attention; may swipe object; grasp upon contact of little fingerside, wrist flex

4 months Primitive squeeze grasp/crude palmar grasp. Object squeezedagainst other hand or body

5 months Palmar grasp. Fingers on top of object press it into center palm;thumb adducted

6 months Radial-palmar grasp. Fingers on far side of object press it againstopposed thumb and thumb side of palm

7 months Radial palmar grasp with wrist straight; transfer cube from one handto another hand

8 months Radial-digital grasp. Opposition of thumb and fingertips; spacevisible between

9 months Radial-digital; wrist straight

–Ulnar grasp, palmar grasp, radial grasp

–Palmar contact, finger surface contact, fingerpad contact

–Use of long finger flexors, use of intrinsic–Use of long finger flexors, use of intrinsicmuscles with extrinsic muscles (long flexors andextensors)

requires control of the arches of thepalm

includes translation, shift androtationrotation

Wrist stability

Opposed grasp with thumb opposition and objectcontact with the finger surface (not in the palm

Isolated thumb and radial finger movement

Control of the transverse metacarpal arch Control of the transverse metacarpal arch

Dissociation of the radial and ulnar sides of the hand

Successive increases and decreases in fingertip forces

Finger to palm translation - an object is heldby the pad of one or more fingers and thepad of the thumb and moved into the palmproximal to the metacarpal-phalangealjoints

Ex. Picking up a coin

Palm to finger translation - an object ismoved from some area of the palm out tothe distal finger surface

Ex. Putting a coin inside a coinbank

Shifting - movement occurring at the finger andthumb pads with alternation of thumb and (usuallyradial) finger movement

Ex. Inserting thread through a bead

Simple rotation - occurs when an object is turned orrolled between the pads of the fingers and the padrolled between the pads of the fingers and the padof the thumb via an alternation between thumbmovement and finger movement

Ex. Unscrewing a bottle cap

Complex rotation –fingers and thumb alternate inproducing the movement and the fingers moveindependently of one another

Ex. Turning a pencil to use an eraser

In-hand with stabilization - several objects held inhand; manipulating an object in one hand andstabilizing othersstabilizing others

involves a smooth combination of body movementsaccompanied by stabilization of an object in thehand

child must be able to hold the forearm stable whilein any degree of rotation and movement and mustbe able to modify the forearm and wrist positions tobe able to modify the forearm and wrist positions toachieve optimal position

Initially involuntary dropping, then object pulled out of one handby the other hand; by 9 months, release by full armextension; refinement up to age 4 with graded release

Components:

– Replacement

– Release– Release

Age Skill Age Skill

0-1months

No release;grasp reflex

strong

7- 10months

Press down onsurface to release

1-4months

Involuntary 8 months Above surface withwrist flexion

4 months Mutual fingeringin midline

9-10months

Into container withwrist straight

4-8(7)months

Transfer fromhand to hand

10-14 months Clumsy into smallcontainer

hs

5-6months

2-stage transfer 12-15months

Precise, controlledwith wrist straight

6-7months

1-stage transfer 18 months Raisin dumping intosmall container

7-9months

Volitional release

– Asymmetric movements prevail until 3months

– Symmetric movements emerge until 10months

• Types:

– Symmetrical

– Asymmetrical

– Reciprocal

Age Skill

12-18months

Use of both hands for differentfunctions

18-24months

Manipulation skills emergemonths

2.5 yearsold

Use of two different hands forvery 2 different functions

is a purposeful, goal-directed form of complex objectmanipulation that involves the manipulation of thetool to change the position, condition or action ofanother object

tools enhance the proficiency with which skills are tools enhance the proficiency with which skills arepreformed and are needed for feeding, writing,grooming, cutting and a variety of other tasks basicto activities of daily living.

Mature Grasp Immature Grasp

Isolates middle finger andthumb for insertion intoscissor loops

Stabilizes lower loop withthe index finger

No fingers in loopsTwo hand approachIndex and middle fingers

in loopsScissor loops to close othe index finger

Rests the scissor loops nearthe bent middle joints ofthe fingers

Ulnar fingers flexedUsually achieved at age 6

Scissor loops to close oknuckles

Age Skill

1-1.5 year/s old Shows interest in scissors

2 years old Snips with scissorsSnipping is closing the scissors on the paper with no

movement of the paper and with no ability to repetitivelyopen and close the scissors.

2.5 years old Cuts across a 6-inch piece of paper

3-3.5 years old Cuts across a 6-inch line3-3.5 years old Cuts across a 6-inch line

3.5 -4 years old Cuts a 5-inch circle with ½ inch limits; cuts 5-inch trianglewith ½ inch limits

4.5 – 5 yearsold

Cuts square

5 years old Cuts zigzag lines and curves

6 years old Cuts out items such as house, tree, flower, sun

Age Grasp

1-1.5yearsold

Palmar supinate grasp- held with fisted hand- wrist slightly flexed- wrist slightly supinated away from mid-position- arm moves as a unit

2-3 Digital pronate2-3yearsold

Digital pronate- held with fingers- wrist straight- wrist pronated- wrist slightly flexed- wrist ulnarly deviated- forearm moves as a unit

3.5 – 4 yearsold

Static tripod- held with crude approximation of thumb, index and middle

fingers- continual adjustments by other hand- ring and little fingers only slightly flexed- grasped proximally- no fine localized movement of digit component; hand

moves as a unit

4.5 -6 years old Dynamic tripod- held with precise opposition of distal phalanges of thumb,

index and middle fingers- ring and little fingers flexed to form stable arch- wrist slightly extended- grasped distally- MCP joints stabilized during fine, localized movements of

PIP

Other grasps:- Lateral tripod- Dynamic Quadrupod- Lateral Quadrupod

Developmental Stage

Age Skill

1 year Imitative scribbleMouth crayonsBangs crayon on paper

1 ¼ years old Incipient imitative scribble

1.5 years old Spontaneous scribble

2 years old Imitates vertical strokeImitates circular stroke

2.5 years old Imitates horizontal strokeImitates 2 or more strokes for cross

3 years old Copies circleImitates crossImitates cross

3.5 years old Traces diamond with rounded angles

4 years old Copies cross

4.5 years old Copies squareTraces cross

5 years Copies triangle

6 years old Copies diamondPrint ABC; uses pencil eraser

7 years old Copies vertical diamond

Age Skill

2-4years old

Hand preference

5-6years old

Hand dominance established

7 and up Handedness

Conduct a screening

Conduct a formal hand skills evaluation

– Measurement of active and passive ROM

– Evaluation of strength

– Evaluation of tactile and proprioceptive functioning

– Assessment of postural alignment and postural stability

– Administration of standardized general developmental test

– Administration of a developmental motor test

– Administration of standardized test of fine motor skills for olderchildren and adolescents

– Administration of visual-motor integration test

– Assessment of hand skills in prevocational or work task– Assessment of hand skills in prevocational or work task

Prerequisite skills:

Small muscle development

Eye-hand coordination

Ability to hold utensils or writing toolsAbility to hold utensils or writing tools

Capacity to form basic strokes smoothly

Letter perception such as ability to recognize forms,notice of likeness and differences

Orientation to printed language

Domains of handwriting

writing the alphabet in both uppercase and lowercase lettersalong with numbers

copying is the capacity to reproduce numerals, letters, andwords from a similar model, either manuscript to manuscriptor cursive to cursive

near-point copying is producing letters or words from anearby modelnearby model

far-point copying is copying from a distant vertical model tothe writing surface

transition from manuscript to cursive

dictation

composition is the generation of a sentence or paragraph bythe child

letter formation

- it is the leading in and leading out of letters, includes rounding of lettersand closure of letters

- it is starting from the correct starting point

alignmentalignment

- also called baseline orientation

- placement of text on and within the writing guidelines

spacing

– dispersion of letters within words and words within sentences

– includes text organization on the entire sheet of paper

size

– this refers to the letter relative to the writing guidelines and to the other letters– this refers to the letter relative to the writing guidelines and to the other letters

slant

– angle of the text must be consistent or uniformed

Writing speed

– number of letters written per minute

Ergonomic factors

– includes writing posture, upper extremity stability and mobility and pencil grip

– writing posture: does the child rest his or her head on the forearm or desktop whenwriting? Is the child falling and spilling out of his or her chair? Does the child standbehind the desk or kneel on the chair? Are the desktop and chair at suitable height?

– stability and mobility of the upper extremities refer to the stabilization of the shouldergirdle, elbow, wrist to allow the dexterous hand to manipulate the writing instrument.

– Grasp: Poor writers tend to demonstrate a greater variety of atypical grasp patterns.

Examining written work samples

Discussing the child’s performance with the parent,teacher and other team members

Reviewing the child’s educational and clinical records

Directly observing the child when he or she is writing inthe natural settingthe natural setting

Evaluating the child’s actual performance ofhandwriting

Assessing any suspected performance skills interferingwith handwriting

PDMS-2

BOTMP-2

EDPA