OT 180: Evaluation Techniques in

Occupational Therapy for Physical

Dysfunctions
July 16, 2009

Enrico C. Aguila, OTRP

 skills in moving and interacting with task, objects and
environment

Strength and
Posture Mobility Coordination Energy
Effort
• Stabilizes • Walks • Coordinates • Moves • Endures
• Aligns • Reaches • Manipulates • Transports • Paces
• Positions • Bends • Flows • Lifts
• Calibrates
• Grips
Gross Motor Skills
 Involve the large muscles of
the body that enable such
functions as walking,
kicking, sitting upright,
lifting, and throwing a ball.
 Depend on both muscle tone
and strength.
Fine Motor Skills
 Involve the small muscles of the
body that enable such functions
as writing, grasping small
objects, and fastening clothing.
 Involve strength, fine motor
control, and dexterity.
 Mobility

Negotiation
Exploration
of obstacles
of
in the
environment
environment

Participation GMS
in sports
activities and Play
physical
education

Performance
Social
of ADL and
interaction
IADL
• Consciousness , temperament and personality functions, energy and drive
functions, perceptual functions, mental functions of sequencing complex
movement (motor planning)

• 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, negotiating
obstacles or uneven ground
 Ask for ability to ride a bike, swim, engage in PE class, etc. and
participation 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, percentile
ranks, and stanines; age equivalents for the Complete Battery
only
 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, jumping
jacks)
5. Balance - 9 items (e.g., walking forward on a line, standing on one leg on a
balance 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 of
performance in two areas
– Fine Manual Control
– Manual 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;
– Object Control: striking a stationary ball, stationary dribble,
kick, catch, overhand throw, underhand roll.
 Dianne J. Russel, Peter L.
Rosenbaum, Lisa M. Avery, Mary
Lane
 Clinical measure designed to
evaluate change in GMS (CP,
DS)
 2 versions:
– GMFM-88
– GMFM-66
 GMFCS - Expanded and Revised
(2007)
 5 level classification system that
describes the gross motor function of
children and youth with cerebral
palsy on the basis of their self-
initiated movement with particular
emphasis on sitting, walking, and
wheeled mobility.
 Righting reactions
 Equilibrium reactions
 Protective reactions
 Balance skills
 Head control
 Trunk control
 Pelvic control
 Anticipatory postural control – catching, reaching, throwing
 Supine
 Prone
 Prone on elbows
 Quadruped
 Kneeling
 Standing
 Crawling
 Creeping
 Walking
 Running
 Jumping
 Going up and down the stairs
 Effective use of hands to engage in a variety occupations depends
on a complex interaction of hands skills, postural mechanisms,
cognition, and visual perception. (Exner, 2005)
 Fine Motor Coordination
requires small, discrete, specialized muscles to
function together, usually the hand muscles, such as
the opposing thumb-to-fingers position that is
required to hold a pen
 Reach
extension and movement of the arm for grasping or
placing objects
 Grasp
attainment of an object with the hand
 Carry
transportation of a hand-held object from one place to
another; also referred to as “moves” and “lifts”
(AOTA, 2002)
 Voluntary release
intentional letting go of a hand-held object at a
specific 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 the
limbs and enhance the efficiency with which skills are performed
 Midrange control
 Midline crossing
 Isolated finger control
 Dexterity
Visual Skills
 plays a major role in the development of hand skills
in children especially in learning new motor skills
 4 months: infants begin to move their hands under
visual control as they reach fro an object and make
differentiated finger movements
 6 months: visuomotor development required for
accurate reach is achieved
 9 months: infant guides his or her hand movements
using visual somatosensory integration
 important in isolated movements of the fingers and thumb
movements
 6 months: able to match haptic perception (knowledge of objects
gathered by means of active touch) of some 3D objects with visual
perception
 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 of
spatial orientation are well developed
 important factors to consider: sensory registration,
tactile hypersentivity, poor tactile discrimination and
dyspraxia
 6 months: infant uses visual and tactile stimuli to guide fine
motor development and begins to develop awareness of object
placement in space
 Between 6-12 months: object learning is encouraged
 9-10 months: infants adapt their arm positions to horizontal
versus vertical object presentations and shape their hands
appropriately for convex and concave objects
 2 years old: relate objects with one another with more accuracy
and 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 inflammation
Muscle Functions
– includes muscle power (strength), muscle tone and muscle
endurance
– strength is needed to initiate all types of grasp patterns and
maintain these patterns during lifting and carrying
– tone is needed for stability of the parts of the arms and hands
during 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 rarely
grasped and then only by accident
 Midline orientation develops with the hands
initially close to the body; unilateral reaching
occurs when there is increasing dissociation of
the two body sides; hands opens in
preparation for grasping the object (usually,
the hand is more open than necessary for the
size of the object)
Mature reach is seen with sustained trunk extension
and a slight rotation of the trunk toward the object of
interest
Over the next few years, reaching skills become refined
with increasing accuracy of arm placement and the
grading of finger extension as appropriate to the size of
the object
Optimal hand opening for the object size at the
initiation of reach is achieved at age 12.
According to Napier

According to Weiss and Flat

According to Erdhardt Prehension Developmental Assessment

(EDPA)
 Non-prehensile - pushing or lifting an object with the
fingers or the entire hand
 Prehensile - it is the grasp of an object
– Precision grasp – opposition of the thumb and
fingertips
– Power grasp – use of the entire hand; the thumb
is held flexed or abducted to other fingers
Grasp with no thumb opposition
– Hook Grasp – used to carry objects; transverse metacarpal
arch is flat, fingers are adducted with flexion at the IP joints
and flexion and extension occurs at the MCP joints; thumb
can 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 the
flexion of the ulnar fingers and less flexion with the radial
fingers 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 IP
flexion; pad of thumb is placed against the radial side of the
index 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 the
index finger, forming a circle; all joints of the index finger
and thumb are partly flexed; control of this grasp suggests
the child’s ability to dissociate the two sides of the hand and
to use tips of the index finger and thumb
Ex: 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 some
degree of flexion at the MCP and IP joints; requires the stability of
the longitudinal arch to grasp large objects; hypothenar eminence
assists the cupping of the hand for control of the object ; control of
this grasp suggests the child’s ability to balance control of the
intrinsic and extrinsic hand muscles
Ex. Throwing a ball

– Cylindrical – transverse arch is flattened to allow the fingers to

hold against the object; fingers are slightly abducted and IP and
MCP joint flexion is graded according to the size of the object; for
additional force, palmar surface of the hand contacts the object
more
Ex. Opening a jar
 Disk – finger abduction is graded according to the size of
the object; hyperextension of the MCP joints and flexion
of the IP joints are evident; wrist is more flexed when
objects are larger and only the pads of the fingers contact
the object; thumb extension also increases with object
size
Ex. Holding a CD
A. Grasp of Pellet
Age 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 of

thumb 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; beginning
of thumb opposition
10 months Pincer grasp. Between distal pads of thumb and index; thumb
opposed
12 months Fine pincer. Between fingertips or fingernails; thumb joint flexed
B. Grasp of Cube
Age Skill
Neonate Visual attention; palmar reflex grasp

3 months Visual attention; may swipe object; grasp upon contact of little finger
side, wrist flex
4 months Primitive squeeze grasp/crude palmar grasp. Object squeezed
against 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 against
opposed thumb and thumb side of palm

7 months Radial palmar grasp with wrist straight; transfer cube from one hand
to another hand
8 months Radial-digital grasp. Opposition of thumb and fingertips; space
visible between
9 months Radial-digital; wrist straight
– Ulnar grasp, palmar grasp, radial grasp
– Palmar contact, finger surface contact, finger
pad contact
– Use of long finger flexors, use of intrinsic
muscles with extrinsic muscles (long flexors and
extensors)
 requires control of the arches of the
palm
 includes translation, shift and
rotation
 Wrist stability
 Opposed grasp with thumb opposition and object
contact with the finger surface (not in the palm
 Isolated thumb and radial finger movement
 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 held
by the pad of one or more fingers and the
pad of the thumb and moved into the palm
proximal to the metacarpal-phalangeal
joints
Ex. Picking up a coin

Palm to finger translation - an object is

moved from some area of the palm out to
the distal finger surface
Ex. Putting a coin inside a coinbank
Shifting - movement occurring at the finger and
thumb pads with alternation of thumb and (usually
radial) finger movement
Ex. Inserting thread through a bead

Simple rotation - occurs when an object is turned or

rolled between the pads of the fingers and the pad
of the thumb via an alternation between thumb
movement and finger movement
Ex. Unscrewing a bottle cap
Complex rotation –fingers and thumb alternate in
producing the movement and the fingers move
independently of one another
Ex. Turning a pencil to use an eraser

In-hand with stabilization - several objects held in

hand; manipulating an object in one hand and
stabilizing others
 involves a smooth combination of body movements
accompanied by stabilization of an object in the
hand
 child must be able to hold the forearm stable while
in any degree of rotation and movement and must
be able to modify the forearm and wrist positions to
achieve optimal position
Initially involuntary dropping, then object pulled out of one hand
by the other hand; by 9 months, release by full arm
extension; refinement up to age 4 with graded release
Components:
– Replacement
– Release
 Age Skill Age Skill

0-1 No release; 7- 10 Press down on

months grasp reflex months surface to release
strong
1-4 Involuntary 8 months Above surface with
months wrist flexion
4 months Mutual fingering 9-10 Into container with
in midline months wrist straight
4-8 Transfer from 10-14 months Clumsy into small
(7)mont hand to hand container
hs
5-6 2-stage transfer 12-15 Precise, controlled
months months with wrist straight
6-7 1-stage transfer 18 months Raisin dumping into
months small container
7-9 Volitional release
months
– Asymmetric movements prevail until 3
months
– Symmetric movements emerge until 10
months
• Types:
– Symmetrical
– Asymmetrical
– Reciprocal
Age Skill
12-18 Use of both hands for different
months functions
18-24 Manipulation skills emerge
months
2.5 years Use of two different hands for
old very 2 different functions
 is a purposeful, goal-directed form of complex object
manipulation that involves the manipulation of the
tool to change the position, condition or action of
another object
 tools enhance the proficiency with which skills are
preformed and are needed for feeding, writing,
grooming, cutting and a variety of other tasks basic
to activities of daily living.
Mature Grasp Immature Grasp

Isolates middle finger and No fingers in loops

thumb for insertion into Two hand approach
scissor loops Index and middle fingers
Stabilizes lower loop with in loops
the index finger Scissor loops to close o
Rests the scissor loops near knuckles
the bent middle joints of
the fingers
Ulnar fingers flexed
Usually achieved at age 6
Age Skill

1-1.5 year/s old Shows interest in scissors

2 years old Snips with scissors

Snipping is closing the scissors on the paper with no
movement of the paper and with no ability to repetitively
open 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 line

3.5 -4 years old Cuts a 5-inch circle with ½ inch limits; cuts 5-inch triangle
with ½ inch limits
4.5 – 5 years Cuts square
old
5 years old Cuts zigzag lines and curves
6 years old Cuts out items such as house, tree, flower, sun
Age Grasp

1-1.5 Palmar supinate grasp

year - held with fisted hand
s - wrist slightly flexed
old - wrist slightly supinated away from mid-position
- arm moves as a unit
2-3 Digital pronate
year - held with fingers
s - wrist straight
old - wrist pronated
- wrist slightly flexed
- wrist ulnarly deviated
- forearm moves as a unit
3.5 – 4 years Static tripod
old - 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 scribble
Mouth crayons
Bangs crayon on paper
1 ¼ years old Incipient imitative scribble
1.5 years old Spontaneous scribble
2 years old Imitates vertical stroke
Imitates circular stroke
2.5 years old Imitates horizontal stroke
Imitates 2 or more strokes for cross
3 years old Copies circle
Imitates cross
3.5 years old Traces diamond with rounded angles
4 years old Copies cross
4.5 years old Copies square
Traces cross
5 years Copies triangle
6 years old Copies diamond
Print ABC; uses pencil eraser
7 years old Copies vertical diamond
Age Skill

2-4 Hand preference

years old

5-6 Hand dominance established

years old
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 older
children and adolescents
– Administration of visual-motor integration test
– Assessment of hand skills in prevocational or work task
Prerequisite skills:
Small muscle development
Eye-hand coordination
Ability 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 letters
along with numbers
 copying is the capacity to reproduce numerals, letters, and
words from a similar model, either manuscript to manuscript
or cursive to cursive
 near-point copying is producing letters or words from a
nearby model
 far-point copying is copying from a distant vertical model to
the writing surface
 transition from manuscript to cursive
 dictation
 composition is the generation of a sentence or paragraph by
the child
letter formation
- it is the leading in and leading out of letters, includes rounding of letters
and closure of letters
- it is starting from the correct starting point
alignment
- 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
 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 when
writing? Is the child falling and spilling out of his or her chair? Does the child stand
behind 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 shoulder
girdle, 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 in
the natural setting
Evaluating the child’s actual performance of
handwriting
Assessing any suspected performance skills interfering
with handwriting
 PDMS-2
 BOTMP-2
 EDPA