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Improving the Use of Hands in Daily Activities

Article in Physical & Occupational Therapy in Pediatrics · August 2005

DOI: 10.1300/J006v25n03_04

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Improving the use of Hands

in Daily Activities:
Aspects of the Treatment of Children
with Cerebral Palsy
Ann-Christin Eliasson

ABSTRACT. Effective treatment for children with cerebral palsy re-

quires a careful analysis of the behavior taking into consideration the
complex issue of using the hands. In addition, it is important that the
treatment is grounded in well-defined theories and methods. With the as-
sistance of the International Classification of Functioning, the ICF, ex-
amples are provided of the effect of treatment on the level of Body
Function. On the Activity Level, examples are given of treatment that
applies recent knowledge of motor control and principles of motor learn-
ing. This paper is not intended to be a review of the literature, but rather,
a set of examples from basic science, clinical practice and studies of in-
tervention that highlight the possibilities of improving the usefulness of
the hands in daily life.

KEYWORDS. Occupational therapy, motor learning, motor control,

children, cerebral palsy, upper extremity and therapeutics

Ann-Christin Eliasson OT, PhD, is Associate Professor at the Department of

Woman and Child Health, Karolinska Institute. The work address is Astrid Lindgren
Hospital, Neuropediatirc Research Unit, Q207, S-171 76 Stockholm, Sweden (E-mail:
[email protected]).
The paper was presented at the International Conference on Cerebral Palsy, Quebec
City Canada May 2003.
Physical & Occupational Therapy in Pediatrics, Vol. 25(1/2) 2005
http://www.haworthpress.com/web/POTP
© 2005 by The Haworth Press, Inc. All rights reserved.
Digital Object Identifier: 10.1300/J006v25n03_04 37
38 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

Is improving the ability to use one’s hands in daily activities an

achievable goal for intervention in children with cerebral palsy? This
question is not easily answered. Searching for evidence in the literature,
one finds a considerable number of articles describing aspects of hand
function (Eliasson et al., 1991; 1992; 1995; Gordon & Eliasson, 2000;
Conolly, 1998; Brown & Walsh, 2000) and suggestions for treatment
(see Trombley, 1995), but only a few articles actually evaluating treat-
ment (see Boyd, 2001 for review). When asking therapists in clinical
practice about the possibilities of this goal, there is no common re-
sponse to the question. There are probably several reasons for this lack
of consistency, but certainly one of them is that the topic has rarely been
highlighted for consideration. The main focus of treatment for children
with cerebral palsy has been gross motor function, sitting position and
“handling” to improve the children’s ability in ADL (Bobath & Bobath,
1984). The focus probably depends on the theory and methods com-
monly used during the recent decades, where gross motor abilities have
been identified as the prerequisite for fine motor skills (Bobath &
Bobath, 1984, Gordon 1987).
The possibilities of improving the usefulness of the children’s hands
will be discussed in relation to Body Function as well as Activity & Par-
ticipation, using the International Classification of Functioning (ICF)
WHO, 2001. Different types of treatment can be classified according to
the ICF. To categorize treatment based on ICF is a helpful tool for de-
veloping the type of intervention as well as the expectations for out-
comes. However, in order to plan and perform the treatment, models for
intervention are needed. There are several models available, for exam-
ple the Canadian Model of Occupational Performance (CMOP) and the
Model Of Human Occupation (MOHO) (Law et al., 1996, Kielhofner,
2000). In my opinion, any model could be used to formulate the goal for
treatment as long as it adopts a client-centered perspective. The focus in
this article will be on the content and effect of treatment. When discuss-
ing treatment linked to Body Function, the examples will center on up-
per extremity surgery and Botulinum Toxin type A. When discussing
treatment linked to Activity & Participation, the focus will be on Activ-
ity; Participation in a life situation as the overall goal. The treatment
linked to Activity is based on knowledge from recent research of the ba-
sic mechanisms of hand function and principles of motor learning. This
is not intended to be a review of the literature; instead, examples from
both experimental research, clinical practice and studies of intervention
will be highlighted with the overall goal to demonstrate the possibility
to use motor learning as a concept for treatment.
 Ann-Christin Eliasson 39

DEVELOPMENT OF HAND SKILLS

One crucial factor when evaluating treatment is to take into consider-

ation the natural history of development. It is important to be able to dis-
tinguish between development as an effect of age and development as
an effect of treatment. Unfortunately, the knowledge about the natural
history of development of hand function in children with cerebral palsy
is limited, as is the effect of treatment. In my experience, clinicians
commonly encounter progress of hand skills during the pre-school pe-
riod, but they also find that the progress diminishes or even decreases
during adolescence. In a literature search, only two studies describing
development were found. The first study reported development of the
grip pattern and the spontaneous use of the hemiplegic hand in a group
of 31 children with hemiplegic cerebral palsy (Fredrizzo et al., 2003).
These children demonstrated only a weak tendency to adopt more ad-
vanced grip patterns and the spontaneous use of the hand was stable
over time. All scorings were done from video recordings and the chil-
dren were examined over a ten year period, starting from before four
years of age. The other study included 51 children with cerebral palsy
between 16 and 60 months involved in a study of treatment during the
nineties (Law et al., 1997). By recalculating the available data, growth
curves were constructed based on four sets of data collections for each
child made during a 10 month period (Hanna et al., 2003). By this
method, it was possible to demonstrate that the development depended
on the severity of hand dysfunction. Children with mild impairment had
a fairly good development, while the children with severe impairment
had at early age a negative trend in the development measured with the
Peabody Developmental test, a norm referenced test describing the
overall fine motor development. While the calculation was based on
QUEST (Quality of Upper Extremity Skills Test) an impairment based
measure of quality of movement there was only minor improvement up
to 2-4 year dependent on severity of hand function. On the other hand,
in an unpublished study (Eliasson and Gordon), ten children with
diplegia or hemiplegia were investigated with the Jebson Hand function
test (Jebson & Taylor, 1969; Taylor et al., 1973) twice, with a 13 year
gap in between. When the first data were collected, the children were
6-8 years old. Comparing the results, all participants were found to be
faster when picking up the different objects in the test at the age of
19-21 years. The time decreased from an average of 181 seconds to 110
seconds. The examples tell us that there is no simple relationship be-
40 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

tween impairment and the development of skills, i.e. between the ICF
level: Body function and Activity. Yet, the present examples can be un-
derstood this way: The grip patterns (Fredizzo et al., 2003) and the qual-
ity of movement (QUEST: Hanna et al., 2003) reflect the impairment
and are not easily changed, but children can learned effective strategies,
resulting in increased skills confirmed by the result of the Jebson Hand
Function Test and the Peabody Development Test (Eliasson & Gordon
unpublished, Hanna et al., 2003). This can be interpreted such as chil-
dren have learned to handle their deviant grip and movement pattern
during their development. This interpretation gives positive evidence
for the possibility to improve hand skills through training of activities
relevant for he children.

The Complexity of Hand Skills

Successful manual skills for use in daily life are dependent on a com-
plex process and incorporate different aspects of a person’s capability
(Mackenzie & Iberall 1994, Exner & Hendersson 1995). Commonly en-
countered words like hand function, in-hand manipulation or fine motor
ability are used, however these words are mainly associated with the
ability to move the fingers and that is just part of the problem to be
solved.
The usefulness of the hand is highly dependent on cognition (Exner &
Hendersson, 1995). One has to understand the value of using one’s
hands for a meaningful purpose (Fig. 1). Then the task has to be en-
coded and translated into purposeful actions, and these must be per-
formed in the appropriate order. Developmental limitations may result
in a lack of ability to comprehend the constraints of a task. Motivation
also influences hand skills because one has to be motivated if one is to
learn a task. If not, one may never master the task with a high level of
skill. The individual’s own motivation has probably been an aspect that
has been underestimated when planning treatment. Motivation is closely
related to attention and concentration and, when attempting to learn a
task, a reduced focus on the task will almost certainly limit the ability to
learn (Smith & Wrisberg 2000). Overall, self-efficacy and body image,
influenced by personal as well as environmental factors, have an impact
on task performance.
The physical part, composition of the hand’s manipulation, is also
complex (Eliasson 1995, Exner & Hendersson 1995, Mackenzie &
Iberall 1994). A person’s perception will influence their action as their
 Ann-Christin Eliasson 41

sensory impressions have to be transformed into meaningful informa-

tion. The perceptual system provides information, in this case, about the
position of the hand in space as well as the position of the target, both
of which are important for goal directed movements (Rösblad 1995).
Perception is closely linked to sensorimotor components, but integra-
tion of somatosensory information is required for the fine tuning of
motor commands, for force regulation and to build up memory strate-
gies for grasping and the manipulation of objects (Eliasson 1995). Fi-
nally, the musculo-skeletal components are crucial for the motor output.
Although movement is highly dependent on how the central nervous
system plans and organizes the movement, the contractile components
of the muscles, bone and joints are the effectors of the planned move-
ment.
Although hand movements are the component most easily measured
by therapist, the complexity of hand skills is easily neglected if only
hand movements are assessed (Fig. 1). Movement has to be investigated
in relation to the possibility to handle objects. Object related actions of
hand needs to be identified i.e. the ability to reach, grasp and manipulate
(Kimmerle et al., 2003). These actions are needed in different combina-
tion when carrying out daily activities. The efficiency of these actions
depends on the parameters of the task, like the object’s location and
properties such as its weight, size and texture. The complexity of the
movement patterns required and the demands made upon the control of
the timing accuracy and forces are parameters that determine the quality
of the performance as has been extensively investigated in experimental
research (Eliasson 1995).
The ability to analyze a child’s capacity to use his or her hands and to
compare their possibility to the complexity of the task is a prerequisite
for treatment planning. An important component to analyze is hand
roles, that is, how the two hands play together (Kimmerle et al., 2003).
In this analysis the therapist identifies whether one hand is used or
whether the child is capable of performing different types of collabora-
tive action with both hands. Collaborative hand use is essential in daily
activities such as dressing, eating and play. Children with cerebral palsy
often display decreased hand function, and often the differences in their
hand use is not solely related to handedness. The common problem is
not isolated to children with hemiplegic cerebral palsy but is also pres-
ent in children with spastic diplegia.
42 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

ICF LEVEL BODY FUNCTION:

TREATMENT DIRECTED
AT IMPROVING BODY FUNCTION

Upper extremity surgery and Botulinum Toxin type A (BTX-A) are

examples of treatment intended to rectify the impairment or minimize
the symptoms on the level of Body Function (ICF, WHO 2001). The
treated component in both cases is most likely the musculo-skeletal sys-
tem. However, this kind of treatment does not guarantee improved hand
skills in children with cerebral palsy, although this outcome is com-
monly expected by clinicians (Fig. 1).
The literature about upper extremity surgery in cerebral palsy is sub-
stantial although, there are few controlled studies (Boyd et al., 2001).
Nevertheless, all of studies indicate similar results: that there is a shift in
the position of the hand from flexion of the wrist, pronation of arm and
thumb within the hand to improved extension, supination and thumb ab-
duction, aimed at improving grasping (Eliasson et al., 1998, Manske
1990, Van Heest et al., 1999, Dahlin et al., 1998). Sometimes, however,
therapists question the benefit derived from the results with comments
like: the changes are very small and the children do not use their hands
more than they did before the surgery. Then the questions arises: How
large must a change be to become meaningful to the child? Upper ex-
tremity surgery is related to the muscle and skeletal component and has
to be discussed from that perspective. It does not change perceptual
abilities, sensorimotor components or cognition, all of which are impor-
tant factors for the usefulness of hands (Fig. 1). Let me give you an ex-

FIGURE 1. Descriptive Illustration of Components Influencing the Children’s

Ability to Use Their Hands.

Motivation
Cognition Sensorimotor system
task-comprehension
Attention Perception
Task-focus
Hand use
Self-efficacy Muscles &
skeletal system
 Ann-Christin Eliasson 43

ample describing small but important changes. It comes from a small

study of 10 children/adolescents with hemiplegic cerebral palsy with
the advantage of a five-year follow-up, at which time they were 12-24
years (Sköld et al., 1999). After surgery involving tendon transfer and
muscle release, the children showed improved extension of the wrist
and supination of the arm, and these changes were persistent at the
five-year follow-up. The quality of different types of grasp was im-
proved as a result of the changed position of the hand. Functional mea-
surements also improved, the grip strength increased and had increased
further when measured five years later (Fig 2A). Interestingly, there
were no difference in any measures on the dominant hand. Dexterity at
picking up cubes and moving them from one place to another improved
in the hemipegic hand and the participants become more dexterous as
shown at the five-year follow-up (Fig 2B). If we want to know about the
value of these small changes, we have to ask the participants about their
experiences. In an unpublished study, two main themes concerning the
importance of the small changes were revealed by conducting inter-
views with the same children five years later as adolescents (Sköld et
al.unpublished). The interviews concerned changes in grasping abilities
and appearance. The grip had changed in different ways. Some partici-
pants said “I can grasp smaller things”, another said “I can grasp bigger
things” or “My grip is more reliable”. The participants discussed the re-
sults in terms of what they could do now but had not been able to do be-
fore the surgery. The other theme was appearance, which was important
for many of the adolescents. One boy said, “The appearance is the most
important it [my hand] looks a lot better and that is very important.” The
results indicate that the treatment aimed at improving Body Function
had an effect both on Body Function and on Activity, and in this case
also on Participation (ICF, WHO 2001). Improved appearance influ-
ences self-esteem, which may in turn lead to increased engagement in
other life situations.
In recent years, BTX-A injections have been used for the upper ex-
tremities. This treatment is less dramatic than upper extremity surgery.
The primary aim is also slightly different, as it focuses on decreasing
spasticity, leading to increased mobility and the performing of move-
ments with less effort. The effectiveness has only been investigated in
two randomized controlled studies (Corry et al., 1997; Felhing et al,
2000, Hoare & Imms, 2004). The fairly consistent results are that
spasticity decreases and mobility seems to improve (Hoare & Imms,
2004). Functional test such as the Quality of Upper Extremities Skills
Test (QUEST) (DeMatteo et al., 1992) and Pediatric Evaluation Dis-
44 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

FIGURE 2. Ten participants with hemiplegic CP who underwent upper extrem-

ity surgery. At the time of the 5 year follow-up, the participants were between
12 and 24 years of age. The evaluation was done before surgery, after 6
months and again after about 5 years. A: Data concerning grip strength. The
strength was measured with the Martin vigorimeter. B: data for dexterity, i.e.,
ten wooden cubes were grasped and moved to the opposite side of a vertical
line on the table. The assessment was made by measuring the amount of time
it took to perform the task.

Grip Strength
35

30

25

20
kPa

15

10

0
Median
⫺5 25%-75%
before 6 mo 5 yr

Dexterity
50

45

40

35
seconds

30

25

20

15
Median
10 25%-75%
before 6 mo 5 yr
 Ann-Christin Eliasson 45

ability Inventory (PEDI) (Haley et al,. 1992) demonstrate some changes

after BTX-A when it occur in combination with occupational therapy
(Felhing et al., 2000). Preliminary results of the study by Boyd and
co-workers (2004) also demonstrate some improvement of hand function,
measured by Melbourne Unilateral Upper Limb Assessment (Johnsson
et al., 1994) when occupational therapy is combined with BTX-A rather
than when the treatment is occupational therapy in isolation. The effects
of BTX-A decrease with time, however one study so far indicate that
functional goal seems to be persistent (Wallen et al., 2004).
There are similarities in the results between, upper extremity surgery
and BTX-A, namely decreased spasticity and increased mobility, im-
proved appearance and changes to the posture of the hand. Both types of
treatment need to be combined with training for increased hand use. The
grip pattern, however, seems to be more easily changed by surgery
(Eliasson et al., 1998, Boyd et al., 2004). On the other hand, by using
BTX-A and thereby reducing the spasticity, the underlying motor capa-
bility becomes apparent. This knowledge is important when discussing
the expected result of surgery or some other treatment. If the child can
only make small unintentional movements, improvement is difficult to
achieve by either treatment. It is important to investigate the specific
outcomes from each type of treatment and, with this knowledge, recom-
mend one treatment or the other, or a combination of treatments. It is
also important to specify the goal of the treatment to make sure that the
expectations are reasonable given the child’s capacity. Autti-Rämö and
co-authors (2000) have defined different levels of expectations for
BTX-A, including improvement of the quality of movement or specific
functions, mimicing planned surgery of the upper extremity, improving
the posture of and care for children with no functional abilities and con-
trolling spasticity after acquired brain injury. The same specification of
goals could obviously also be used for upper extremity surgery.

ICF LEVEL ACTIVITY:

TREATMENT INTENDED TO IMPROVE ACTIVITY

Treatment aimed at improving activities requiring manual ability has

always been used in pediatrics, however the methods by which this can
be achieved have rarely been specified. The method most commonly
used is Neurodevelopmental Therapy (NDT). By this method, hand
function is not specifically treated; instead, the objective is to enhance
the brain’s capacity to master hand skills by improving the quality of
46 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

movements through the facilitation of normal movements. After such

movements have been developed, it is assumed that the movements are
used in activities without any specific attention being paid to the train-
ing of the task. Another assumption is that the development progresses
from the proximal to distal parts of the body and therefore requires that,
at first, treatment intended to improve postural control has to be pro-
vided (Bobath & Bobath, 1984, Gordon 1987). However, it has been
difficult to find evidence for these assumptions (Butler & Darrah, 2001)
and, to my knowledge, no NDT studies focus on the ability to improve
hand skills or discuss the complexity of hand skills.
Current treatments can be based on recent knowledge of motor control,
and principles of motor learning, taking into account the complexity of
hand skills (Eliasson, 1995, Larin, 1998, Mathiowetz & Haugen, 1994).
This concept is task-oriented, and, in brief, the message is “You learn
what you practice”. This concept needs to be further developed, clarified
and proved for children with cerebral palsy. There are some examples
where the concept is applied to various extents. Goal directed treatment is
one such example, where the focus is on goal setting (King et al., 1999).
Cognitive Orientation for Daily Occupational Performance is another
concept with the focus on the explicit learning processes for children with
Developmental Coordination Disorders (Missiuna et al., 2001). Another
example is Constraint Induced Movement Therapy developed for adults
after stroke, which specifically focuses on improving hand skills by re-
straining the non-affected hand (Taub et al., 1994). In this article, I will
focus explicitly on how to use motor control and principles of motor
learning to plan and accomplish treatment. Several authors have con-
tributed to the knowledge, including Schmidt and Wrisberg (1991,
2000), Mathiowetz, Haugen and Larin, who have worked with the im-
plementation for clinical practice (1994, 1995, 1998, 2000), and my
co-authors and others who have investigated the basic mechanism for
hand function (Eliasson et al., 1991; 1992;1995; Eliasson & Gordon,
2000; Kuhtz-Buschbeck et al., 2000). I would like to discuss their ideas
further by giving examples of how theoretical work can be applied in
clinical practice.
Motor learning is designed to facilitate permanent processes of
change for producing a motor task (Smith and Wriesberg 2001) Three
foci for treatment based on motor learning will be discussed: (1)
Learning tasks by implementing strategies required for success, (2)
Learning tasks through practice and repetition, (3) Learning to use the
hand through practice. There is an overlap between these aspects, but
by separating them, children’s various main problems can be empha-
 Ann-Christin Eliasson 47

sized and, thereby, examples can be given about how to provide treat-
ments in a more precise way.

Learning Tasks by Implementing Strategies Required for Success

Any task is made up of a sequence of actions. To successfully per-

form a task, the sequences need to be executed in a certain order, form-
ing a successful strategy for the task. Secondly, each sequence needs to
have a certain quality of skilled performance to be achieved in the task
as a whole. The order of the sequences and the quality of the movements
in each sequence always influence the outcome (Gentile 1987). A child
may have problem with both together, or one or the other individually.
Experimentation and repeated practice adopting different strategies are
needed to find the optimal solutions to the motor problems and to de-
velop skilled performance (Schmidt & Wrisberg, 2000). I will give you
two examples from clinical practice of how to work with learning tasks
by solving the problem of strategies.

Putting paper in a file requires that the actions are performed

in a certain order

Marcus is 20 years old and has diplegic cerebral palsy. He is able to

walk but has serious difficulties managing activities of daily life. He can
make a simple breakfast but need assistance in many daily activities. It
is known that he has learning difficulties and serious problems with vi-
sual perception. The occupational therapist asked Marcus if there were
any daily activities that he felt it was important to accomplish by him-
self. Marcus replied that he was not able to put a paper into a file, a task,
he felt to be important for organizing accounts and contracts, etc. The
therapist video-recorded his attempt and analyzed the performance. It
was obvious that Marcus had no idea how to organize the task. He tried
to accomplish it in several ways by moving both the paper and the file.
He could not see the relationship between the hole in the paper and the
‘pin’ in the file. Marcus needed help to understand the structure of the
task and the following sequences were defined and practiced: (1) Place
the file in front of you. Don’t move it. (2) Place the paper so it covers the
right side of the folder with the hole beside the ‘pins’. (3) Use the hole
furthest in. (4) Feel with your fingers where the pins are. Three weeks of
treatment was planned, comprised of 10 sessions of 15 minutes. The
treatment session started with a discussion of the strategies and Marcus
had to memorize the order of the sequences. The second part of treat-
48 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

ment session was to repeat the task. For the evaluation, the Goal
Attainment Scale (GAS) (King et al 1999) was used as follows:

⫺2 Can not put a piece of paper in a file

⫺1 Put a sheet of paper in an empty folder, with verbal guidance
0 Independently put a sheet of paper in an empty file
+1 Put a sheet of paper in the right place in a file with an index, with
verbal guidance
+2 Independently put in a piece of paper in the right place in a folder
with an index

During the first session Marcus needed both physical and verbal
guidance. The following three treatment sessions started with verbal
repetition of the strategies, and thereafter, the task was practiced. After
the forth session and about 35 attempts, Marcus achieved 0 on the GAS:
he could put the paper in the folder without any help. He continued to
practice to achieve a higher score on the GAS and to learn the task in a
more flexible manner. After six sessions he achieved +2 on the GAS.
Marcus learned the task more rapidly than had been expected; the essen-
tial part for him had been to understand the strategy required to accom-
plish the task. As soon as he understood the structure, it was not difficult
memorizing the strategy.
This is an example where the occupational therapist used a client cen-
tered approach to formulate a specific goal, then knowledge of task
analysis and principles of motor learning to plan and execute the treat-
ment. Knowing about Marcus’ visual problem, the therapist understood
that the task needed to be highlighted from a different perspective using
a cognitive strategy. The task was broken down into parts, but practiced
as a whole. Feedback was given using both Knowledge of the Result
(KR) and Knowledge of Performance (KP). The most important part
was probably the occupational therapist’s talent in structuring the task
and giving information using demonstration, and physical and verbal
guidance, in a sensitive way (Smith & Wrisberg, 2000). The hand func-
tion per se had not changed, but the usefulness of the hands in this
specific situation had improved.

To release unstable toys requires certain quality of movements

The next example is related to the quality of movement and is based

on a study of basic components of hand function, in this case, impaired
coordination during the release of an object (Eliasson et al., 2000).
 Ann-Christin Eliasson 49

When putting down and releasing an object or any toy efficiently, the
object has to be moved downwards and placed on a surface, not too
quickly and not too slowly, using low velocity of the movement close to
the surface of the table. Then, the force of the grasp is quickly released
and the finger is removed from the object almost simultaneously. In a
hemiplegic hand, a reversed pattern is found; the placement is per-
formed fairly quickly, but the velocity of the movement is high upon
contact with the table making the movement abrupt. Then it is hard for
the children to decrease the force, resulting in a prolonged movement
phase and the fingers are released one at a time in an un-coordinated
manner. How can this knowledge be used? I meet Emma, who is four
years old. She was playing with small plastic animals. Every time she
tried to move the horse-it fell. It was obvious that Emma was releasing
the object too abruptly, not taking into account her impaired coordina-
tion when releasing her grasp. By giving a simple instruction-straighten
your fingers slowly-she immediately succeeded. By analyzing her per-
formance, based on the knowledge of impaired release of objects, I was
able to give Emma precise information. She appeared to be slow when
replacing the horse, but she was not slow enough in the crucial part of
the action, when she had to open up her fingers. That part had to be per-
formed even more slowly and by increasing her awareness of that
movement sequence, she was able to succeed. Normally this behavior is
performed in an unconscious way, i.e., by implicit processes (Gentile
1987). After a lesion in the central nervous system, it seems to be more
efficient to use an explicit process, at least in the early stage of learning.
Knowledge about typical and atypical behavior and the ability to ana-
lyze the task made it possible to give a precise instruction. The idea was
to teach Emma how her impaired nervous system worked. If she was
made aware of a strategy that enabled her to be successful in this task,
then she might be able to use the same strategy when releasing other ob-
jects in different situations.

Learning Tasks Through Practice

Practice or repetition is an important part of the learning process.

Practice is defined as “repeated attempts to produce motor behavior that
are beyond the present capability” (Smith, 1991 page 49). The result of
practice is learning, although a task has not been learned until there is a
relatively consistent performance and retention of the task is possible.
Three stages of learning have been defined. They are named somewhat
differently in the literature. The following stages are described in Smith &
Wrisberg (2000): (1) The Verbal-Cognitive Stage. In this stage children
50 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

need information about the general idea. This could be physical or ver-
bal information, to help them to learn the strategy. It is common for typi-
cally developing children to guide themselves by talking to themselves,
making it easier to maintain attention and follow through the strategy.
This is the stage in which Marcus and Emma, in the examples above,
needed help. The second step is the (2) Motor Stage. In this stage, chil-
dren can perform the activity and the performance becomes increas-
ingly more consistent. Performance is slow and the quality is low in the
early stage, but the children start to work on the fine details of the task.
They need to give the task their full attention but instruction and feed-
back become less important. Children with motor dysfunction seem to
commonly stay in this stage for a long time and the learning process is
slow. Children with cerebral palsy require more practice than typically
developing children demonstrated in learning simple tasks in laboratory
settings (Gordon & Duff, 1999; Valvano & Newell, 1998). The last step
is the (3) Autonomous Stage, which is attained when the child can pro-
duce the action almost automatically with little or no attention.
I have found these three stages of the learning process very useful in
clinical practice. Using them helps the therapist to avoid giving too
much help and emphasizes discussing the procedure of the task, This
step may be the most important way to encourage the children to con-
tinue to practice until the task has been learned thoroughly. It is only
through repetition that there is progression from one stage of learning to
another (Smith & Wrisberg 2000). Automatic task performance with a
low energy cost requires a larger number of repetitions. Through repetition,
the memory representation of the procedure is established (Gordon &
Duff, 1999). The memory traces are then recalled and used when per-
forming the task on another occasion. Children with cerebral palsy usu-
ally exhibit slow and uncoordinated motor performance (Eliasson et al
1991, Eliasson & Gordon 2000). This characteristics probably leads to a
reduced number of spontaneous repetitions and, consequently, a less
skillful performance than necessary. This highlights the clinical di-
lemma. How can we create a situation that encourages an adequate
amount of practice! There are few examples demonstrating the learning
abilities when performing functional tasks in children with cerebral
palsy, but here are some suggestions.

Learning frisbee golf

This example comes from a study of adolescents practicing Frisbee

golf using the hemiplegic hand (Eliasson et al., 2003). Playing Frisbee
with the hemiplegic hand may seem ridiculous, but it was relevant for a
 Ann-Christin Eliasson 51

2-week day camp where the adolescents were treated by Constraint In-
duced Movement Therapy (for further explanation se further on, on
Constraint Induced Movement therapy, see page 15). When playing
Frisbee, the goal was to transverse a 350 foot long course, ending up
with the Frisbee in a basket, using the fewest number of throws. The ad-
olescents practiced seven times for about 30 minutes each during the
two week period. All adolescents improved at the game, and the number
of throws needed to get the Frisbee into its basket decreased from the
first to the last day of camp (Fig. 3). The reduced number of throws oc-
curred in conjunction with an increased ability to time the release of the
Frisbee and to generate a directly appropriate force. Three important as-
pects of the result can be emphasized; (1) you learn what you practice,
(2) progress in the game was the important aspect of the game for the
adolescents-they focused on the activity itself not increased quality of
the movements, (3) the improved movement quality in releasing the
grasp and generating force may or may not be transferred to other activi-
ties. This issue was not clarified by the design, but the transfer of abili-
ties between tasks is a tentative suggestion. Also, it is unclear can be
whether this improvement was due to solely the practice of frisbee golf
to intensive general practice of the hand during the day-camp. These
questions need further investigation.

FIGURE 3. Number of Frisbee golf throws obtained before and after interven-
tion (n = 9).

Frisbee golf
38

34

30

26

22

18

14

10
before - after intervention
52 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

Practicing manipulative skills

Manipulation skills involve independent finger movements and in-hand

manipulation requiring extensive motor control, and this is known to be
lacking in children with hemiplegic cerebral palsy (Brown & Walsh,
2000). With this in mind, we engaged the same group as above, consist-
ing of nine adolescents with fairly mild hemiplegic cerebral palsy, to
practice an in-hand manipulation task (Eliasson et al., 2003). The task
was pen shift, i.e., moving a pen linearly from the point to the top of the
pen back and forth (Exner, 1992). This task is similar to the task of ad-
justing a knife within the hand to cut food. The adolescents practiced
this task for about 5-10 minutes each day over a period of two weeks.
The practice led to improved performance. Since no standardized as-
sessment criterion existed for the task, a rating scale of motor compo-
nents ranging from 0 to 8 was developed. The performance was evaluated
by a non-involved therapist. The ability increased and was sustained at
follow-up (Fig. 4). Some differences between the end of practice and
the follow up indicated that the task had not been sufficiently learned,
i.e., that the adolescents were still performing the action in the Motor
Stage. Interestingly, the result demonstrates the possibility to improve
in-hand manipulation through practice, which is not commonly re-
ported for children with CP.

FIGURE 4. In-hand manipulation of the pen shift task before and after interven-
tion and at the 5 month follow-up assessment (n = 9).

Shift
9
8
7
6
5
4
3
2
1
0
⫺1
Before After Follow-up
 Ann-Christin Eliasson 53

Learning to use the Hand Through Practice

Most children with hemiplegic cerebral palsy do not to use the

hemiplegic hand if it is not necessary. Minimizing the use of the hand
might lead to decreased performance (Taub et al., 1994). The way in
which different tasks are performed is generally dependent on habits
(Kielhofner 2002). Therefore, therapists have always encouraged chil-
dren to use their hemiplegic hand in as many situations as possible and
more frequently than they would otherwise do, without referring to any
specific method. This is usually called bimanual training. It has been as-
sumed that, by using the hand in the presence of varying constraints and
changes in the environment, the performance will become more effi-
cient and effective. By practicing activities in general, it is assumed that
important aspects of hand function, like speed, precision and manipula-
tion were exercised (McLaughlin Gray, 1998). The aim is to practice
general aspects of hand function rather than the activity itself. From this
perspective, Constraint Induced Movement Therapy is an interesting
concept.

Constraint Induced Movement Therapy

Constraint Induced Movement Therapy (CIMT) is, to some extent,

based on the above assumption, although the concept is more clearly de-
fined. It is hypothesized that “learned non-use” will affect the use of the
hemiplegic hand. (Taub, 1977; Taub et al., 1994). According to Taub
(1994), one reason why individuals do not always use their affected
hand is the repeated experience of failure they have when using the
hand. To overcome learned non-use, it has been suggested that the
well-functioning extremity needs to be restrained. The principle of
CIMT first developed during the 1950’s when Taub investigated the
role of sensory information in movement control and learning. Somatic
sensation was surgically abolished from a single upper extremity by
dorsal rhizotomy on monkeys, which led the monkeys to stop using the
affected arm immediately after deafferentation (Taub et al., 1994).
However, by immobilizing the intact arm for a period of time, the mon-
keys started reusing the deafferentated arm, indicating that the loss of
limb usage was the result of behavior suppression. It was considered
that this forced use technique might also uncover latent motor potential
in stroke patients. After a pilot case study (Ostendorf & Wolf, 1981), a
number of studies of CIMT have been performed. The recommended
period of treatment is two weeks, during which time a sling or a glove is
54 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

used to restrain the dominant hand 90% of the waking hours. Specific
training is undertaken for six hours each day. A few case studies have
examined the concept in children diagnosed with hemiplegic cerebral
palsy. All have indicated a positive outcome for the treatment (Crocker
et al., 1997; Charles et al., 2001; Kaman, et al., 2003). One small ran-
domized controlled study demonstrated that the children improved on
the Peabody Developmental Motor Scales after one month. The chil-
dren were restraint by casting without intensive treatment versus stan-
dard therapy. Although the follow up rate was low (68%) there is some
evidence that some improvements persisted at 6 months (Willis et al.,
2001). Finally, there is one study of nine adolescents demonstrating
improvements of different aspects of hand function after a 2 week day
camp and at 5 month follow up (Eliasson et al, 2003).
In order to use this concept in pediatrics and for small children it was
important to make this method more child-friendly and to base the treat-
ment on recent knowledge of motor control research of hand function
and principles of motor learning. We have developed an adapted model
and used it in a pilot project and in a study of small children between 18
months and 4 years (Eliasson et al., 2004). Since the intensity and dura-
tion of the practice are both important aspects when planning treatment,
the total time in our adapted model was comparable to Taub’s concept,
but the intensity was adjusted (Taub et al., 1994). The children wore a
restraining glove on the dominant hand for two hours each day for two
months. The treatment was not shaped in the same way described by
Taub and collaborators (Taub et al., 1994). We were not training spe-
cific movement patterns and we were not concerned about deviant
movements but were interested in the outcome i.e. the quality of the per-
formed activity. When applying principles of motor learning, the most
important concept is motivation and this was taken into serious consid-
eration during treatment. It had to be acceptable to the children to wear
the glove and fun to practice with the hemiplegic hand. If we could not
find activities that were sufficiently enjoyable, the child would not ac-
cept wearing the glove and we had to break off the treatment. This also
emphasizes the importance of choosing the right toys and activities. It
should be possible to carry out the activities with the hemiplegic hand,
but they should be neither too easy nor too hard, taking into consider-
ation the complexity of hand skills. A selection of activities was chosen
on the basis of each child’s particular interests, these activities were
up-graded during the treatment to mirror each child’s level of ability
and motivation. To facilitate performance, also the treatment should
take place in an environment that is relevant to and natural for the child,
 Ann-Christin Eliasson 55

i.e., at home or in pre-school. The parents or a pre-school teacher was

responsible for facilitating these activities under supervision. Super-
vision from the therapist was an important agent when expecting the
family and preschool teacher to be responsible for undertaking the train-
ing. By meeting the child and trainer once a week, it was possible to ad-
just the level of difficulties of the activities. It was also important to
support and encourage the child and the trainer to ensure that they main-
tained the program. Twenty-one children between 18 months and 4
years have gone through this program. An additional four children were
included but refused to continue. We stopped the program after one
week if it was still difficult to ensure the child wore the constraining
glove. In order to understand the effort for the families of the treatment,
we asked the parents and pre-school teacher about the possibility of re-
peating the program. With the exception of one pre-school teacher no
one would mind repeating it. The results for the five children in the pi-
lot project were easily detected from a video recording. An occupa-
tional therapist not involved in the study made a judgment by examining
the children’s performance when playing with toys requiring manipula-
tion with two hands before and after treatment. Improved use of the
hemiplegic hand was also apparent in the larger study, with sustained
ability evident four months later (Eliasson et al., 2004). The problem
was evaluating the usefulness of the hand in a meaningful manner.
Therefore, a new assessment, the Assisting Hand Assessment (AHA)
was developed. The AHA is a Rasch analysis based measure using a
semi-structured play situation to measure the usefulness of the assisting
hand (Krumlinde Sundholm & Eliasson, 2003). It is an assessment mea-
suring the children’s level of activity using the framework of ICF.

CONCLUSION

It seems possible that children with cerebral palsy can improve their
ability to use their hands in daily activities requiring manual perfor-
mance by treatment on the Level of Body Function as well as on the
Level of Activity of the ICF. More scientific studies are necessary be-
fore each treatment can be considered to be evidence based practice.
The treatments discussed are examples of the effect of upper extremity
surgery and BTX-A and activity based examples that apply theories of
motor control and principles of motor learning. By highlighting the
complexity of the ability to use one’s hands, it becomes apparent that
the evaluation of treatment needs to be directed at the treated compo-
56 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

nent of the hand to discover whether changes have occurred. It is un-

clear whether and to what extent there is a transfer of improvement
between different levels of ICF, as well as between different tasks and
situations. This means, for example, that if the treatment is intended to
reduce spasticity (ICF: Body Function), then the spasticity component
should be a focus of the evaluation. If there are expectations of further
effect such as increased skills or cosmetics, those aspects can also be ex-
amined in order to support continuous treatment. This highlights the im-
portance of making a careful analysis both of the child’s problems and
the intended outcome of the treatment before starting to provide treat-
ment. When planning treatment for increased Level of Activity (ICF),
based on motor control and the principles of motor learning, in depth
task analysis is important since one can concentrate on different aspects
of the learning process, such as learning to perform a task by developing
strategies, learning a task by practicing skills and learning to use the
hemiplegic hand through task practicing. Furthermore, a combination
of treatment of the Level of Body Function and Activity might be a
successful strategy because these appear to be complementary. Even
though these treatments may only lead to small changes, we must not
neglect their importance.

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