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HAND FUNCTION IN THE CHILD: FOUNDATIONS FOR REMEDIATION Copyright © 2006,1995 by Mosby Inc.

ISBN-13: 978-0323-03186-8 ISBN-I0: 0-323-03186-2

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CONTRIBUTORS Dorit Haenosh Aaron, MA, OTR, CHT, FAOTA Coordinator Hand Therapy Fellowship Department of Occupational
CONTRIBUTORS
Dorit Haenosh Aaron, MA, OTR, CHT, FAOTA
Coordinator
Hand Therapy Fellowship
Department of Occupational Therapy
Texas Women’s University
Houston, Texas
Mary Benbow, MS, OTR
Private Consultant and Lecturer
La Jolla, California
Charlotte E. Exner, PhD, OTR/L, FAOTA
Professor
Department of Occupational Therapy and
Occupational Science
Dean
College of Health Professions
Towson University
Towson, Maryland
Jane Case-Smith, EdD, OTR/L, FAOTA
Professor
Division of Occupational Therapy
The Ohio State University
School of Allied Medical Professions
Columbus, Ohio
Kimberly Brace Granhaug, OTR, CHT
Clinical Manager
Sports Medicine and Rehabilitation
Christus St. Catherine
Katy, Texas
Anne Henderson, PhD, OTR
Professor Emeritus
Department of Occupational Therapy
Boston University/Sargent College of Allied
Health Professions
Boston, Massachusetts

Sharon A. Cermak, EdD, OTR/L, FAOTA Professor of Occupational Therapy Department of Rehabilitation Sciences Boston University, Sargent College; Director of Occupational Therapy Training Leadership and Education in Neurodevelopment Disabilities Children’s Hospital and University of Massachusetts Medical Center Boston, Massachusetts

Ann-Christin Eliasson, PhD, OT Associate Professor Neuropsychiatric Research Unit Institution of Woman and Child Health Karolinska Institute Stockholm, Sweden

Elke H. Kraus, PhD, BSc.Occ.Ther., Dip.Ad.Ed Professor of Occupational Therapy Alice-Saloman University of Applied Sciences Berlin, Germany

Carol Anne Myers, MS, OTR/L Occupational Therapist Early Childhood Education Program Newton Public Schools Newton, Massachusetts

Charlane Pehoski, ScD, OTR/L, FAOTA Consultant Eunice Kennedy Shriver Center University of Massachusetts Medical School Waltham, Massachusetts

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vi

Contributors

Ashwini K. Rao, EdD, OTR Assistant Professor of Clinical Physical Therapy Program in Physical Therapy Department of Rehabilitation Medicine Columbia University New York, New York

Birgit Rösblad, PhD, PT Associate Professor Community Medicine and Rehabilitation, Physiotherapy University of Umeå Umeå, Sweden

Colleen M. Schneck, ScD, OTR/L, FAOTA Professor and Post Professional Program Graduate Coordinator Department of Occupational Therapy Eastern Kentucky University Richmond, Kentucky

James W. Strickland, MD Clinical Professor Indiana University School of Medicine Indianapolis, Indiana

Scott D. Tomchek, MS, OTR/L Chief of Occupational Therapy Child Evaluation Center University of Louisville School of Medicine Department of Pediatrics Louisville, Kentucky

Laura K. Vogtle, PhD, OTR/L, ATP Associate Professor Department of Occupational Therapy University of Alabama at Birmingham Birmingham, Alabama

Margaret Wallen, MA, OT Senior Occupational Therapist – Research Department of Occupational Therapy The Children’s Hospital at Westmead Westmead, New South Wales, Australia

Jenny Ziviani, BAppScOT, BA, MEd, PhD Associate Professor School of Health and Rehabilitation Science The University of Queensland Queensland, Australia

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PREFACE TO THE SECOND EDITION The everyday occupations that most of us engage in involve
PREFACE TO THE SECOND EDITION
The everyday occupations that most of us engage in
involve extensive use of our hands. As we perform these
occupations we give little thought to the enormous
variety of actions our hands can do. A hand can be a
platform, a vise, or a hook. It can push and poke, pull
and twist, scratch or rub. It can hold a football, an
apple, or a raisin. It is the enabler of multiple tool uses.
A major task of childhood is the development of this
wide variety of hand actions. When a child’s hands are
not functioning well or if there is a delay in develop-
ment, the occupations of childhood are affected, such
as
playing with objects, dressing, and using tools such
as
spoons, scissors, or pencils. Remediation of the hand
is
therefore a major focus of intervention.

Hand Function in the Child originally grew out of the recognition that there was a significant gap in the professional literature addressing the problems of hand dysfunction in children, despite the importance of the hand to the child’s development. It has been 10 years since the first edition was published and it still remains the only complete text covering this topic. This second edition again reviews detailed information on the neurological, structural, and developmental founda- tions of hand function in children. We maintain the focus on the hand as a tool for action and an organ of accomplishment and highlight the complexity of skilled hand use and the long developmental period needed for its perfection. As many of the chapters review information from rapidly changing fields of study, an important purpose of the revised edition was to update these chapters. Another purpose was to add chapters in several areas of content that we felt to be important. The content is presented in three parts. The first part, “Foundation of Hand Skills,” provides informa- tion on the anatomical, neurological, physiological, and psychological aspects of hand function. This section begins with an updated chapter on control within the central nervous system that describes the mechanisms that allow skilled use of the hand as it relates to hand- object interaction. This is followed by a chapter on the embryology, anatomy, kinesiology, and biomechanics

of the hand. The third chapter explores sensory control and the way in which the control of grasp and lifting of objects varies with differing sizes, shapes, and textures. The next chapter examines the development and eval- uation of the ability of infants and children to recognize objects and object properties felt by the hand. The fifth chapter updates the research on the role of vision in the control of movements in the environment, and covers the development of visual control in childhood. The final chapter in Part I is new in this edition and high- lights the cognitive processes required for the acquisi- tion and performance of hand skills. Part II, Development of Hand Skills, explores the changes in hand skills that occur with age. The first chapter on the early development of grasp, release, and bimanual activities has been revised to present the con- tent in the context of infant play from birth to 2 years. The second chapter examines object manipulation from birth throughout childhood. Chapter 9, on handedness and its development, is new and includes an extensive review of research on hand preference as well as on the evaluation of hand preference. Chapter 10, on the development of self-care activities in relation to the development of hand skills, contains additional infor- mation on current measures and on cultural influences. The final chapter in Part II has a new, extensive review of recent research on handwriting. Therapeutic intervention is presented in Part III. The chapters focus on the overall remediation of hand skills, on the remediation of special problems, and on specific areas of intervention. Chapters 12 and 15 have been updated and revised. The remaining six chapters in this section are new. Chapter 13 presents ideas on how the engage the preschool child in hand activity and to incorporate treatment activities into the classroom. The next chapter reviews problems related to hand- writing difficulties and presents formal and informal assessments. Chapters 16, 17, and 18 focus on specific areas of dysfunction and intervention. We chose a review of research on the effectiveness of improving hand function for the final chapter.

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viii Preface to the Second Edition

Our primary vision continues to be to present in a single text current information on the neurological foundations of hand skills, the development of hand skills, and intervention for children with problems related to hand skills. We hope that a comprehensive review of the hand will provide an important resource and clinical guide for students, practicing pediatric therapists, and others who work with children.

ACKNOWLEDGMENTS

The editors wish first to acknowledge with gratitude the time and expertise donated by the contributors to this volume. These authors are highly regarded in their respective fields, and we thank them for their insights and the wealth of practical and theoretical under- standing they bring through their chapters. We hope that the diversity of ideas presented here will enrich the reader’s understanding and appreciation of the im- mense complexity and the multiple dimensions of the human hand and particularly of its importance to daily living from birth through adolescence. This book is the culmination of the efforts of many people who contributed ideas over an extended period of time. The formal beginnings of the book occurred during a series of workshops for occupational and physical therapists funded by the Maternal and Child

Health Bureau, U.S. Department of Health and Human Services, Department of Public Health. The workshops were sponsored by the Occupational Therapy and Physical Therapy Departments at the University of Illinois at Chicago between 1988 and 1991. Several of the contributors to the first edition participated in yearly task groups on the hand of the child, motivated by the need to share information in a field where so little had previously been written. It was from these meetings that the idea of a comprehensive book on hand skills in children arose. The reception of the first edition by many professional colleagues and their comments helped shape this second edition. We would also like to acknowledge the help and assistance of Kathy Falk, our editor at Elsevier, whose support enhanced all the phases of the production of this book by answering our questions and providing a workable and timely schedule. Thanks also to Sarah Wunderly, our production manager, and other Elsevier staff for assisting in the final phase of our work. Finally we want to recognize the families and children we and our authors have known through our professional practice and research for they have contributed much to our current knowledge of hand function in the child.

Anne Henderson

Charlane Pehoski

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PREFACE TO THE FIRST EDITION …[M]an though the use of his hands, as they are
PREFACE TO THE FIRST EDITION
…[M]an though the use of his hands, as they are energized by mind and will, can
influence the state of his own health.
(Reilly, 1962, p.2)
opment and dysfunction in childhood, it seemed timely
to review that which is currently known.
This book is intended for the professional and
student interested in the current research and treat-
ment of problems in children’s hand skills. The text is
organized around themes from neurobehavior and
development, drawing together information that is
pertinent to the understanding of dysfunction in the
hand in children and as a guidance to intervention.
Hand function is reviewed from the perspectives of
neurophysiology, neuropsychology, cognitive psychology,
developmental psychology, and therapeutic intervention.
The text is organized into three sections, each of
which presents several dimensions of hand function.
Section I includes chapters on the biologic and
psychologic foundations of hand function. The first
chapter describes the cortical control of skilled hand

The hand is our primary means of interaction with the physical environment, both though the dexterous grasp and manipulation of objects and as the enabler of multiple tool functions. The enormous variety of actions accomplished by our hands ranges from the practical to the creative. The hand is incredibly versatile. It can be a platform, a hook, or a vise. It can hold a football, a hammer, or a needle. It can explore objects, express emotion, or communicate language. The hand is the subject of this book, most spe- cifically the hand as a tool for action, as an organ of accomplishment. The motor functions of the hand are some of the most complex and advanced of all human motor skills. Hand use is voluntary, under the control of the conscious mind, and is regulated by feedback from sensory organs. The complexity of skilled hand use is shown by the long developmental period needed for its perfection. The ability to manipulate objects with the efficiency and precision of an adult continues to im- prove throughout late childhood and early adolescence. The plan for this book grew out of the recognition that, although the treatment of hand dysfunction has been a critical area of occupational therapy practice since the beginning of the profession, for many years the professional literature in pediatrics placed a greater emphasis on the neurophysiology and development of gross motor abilities than on manipulative skills. A renewed attention to manipulative abilities, beginning about 15 years ago, was spearheaded by the writings of therapists such as Rhonda Erhart, Reggie Boehm, and Charlotte Exner, and professional literature on the devel- opmental treatment of hand skills has since increased. During a similar period there has been increasing research attention in the fields of neurophysiology and psychology to the motor skills of the hand. Although there are many unresolved issues about hand devel-

use and identifies the properties of that control that are different from the control of gross motor skills. The second chapter presents the anatomic structure and function of the hand facilitating the varied functions. Two chapters on the sensory guidance of the hand function follow, one on touch and proprioception and the other on vision. The other two chapters in Section

I review knowledge from several branches of psy-

chology, including the perceptual functions of the hand and the role of cognition in hand activity. Section II focuses on development in both general and specific areas of hand skill. Two chapters in this section focus on the development of basic skills. The first reviews research on the development of grasp, release, and bimanual skills in infancy and the second the development of object manipulation. Other chapters cover specific and complex skill areas of graphic skill and self-care and the development of hand dominance.

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x Preface to the First Edition

Section III provides knowledge from selected pediatric clinical practice areas. Two of the five chapters describe dysfunction and treatment of special popula- tions with cerebral palsy and Down syndrome. Another chapter presents the principles and practice of the remediation of hand skill problems, while a fourth focuses on the specific area of teaching handwriting. The remaining chapter identifies the many toys that are the natural media for the treatment of hand dys- function in children. Despite the acceleration of research in the last

information on hand skills will stimulate interest in the development of research programs that will increase the body of knowledge about normal and deviant hand skill development and the efficacy of intervention. This text was written primarily for pediatric occu- pational therapists and could serve as a graduate level text or as a reference book in entry level education. However, we anticipate that it will be of value for anyone working with toddlers and children, including preschool and elementary teachers, special educators, early intervention providers, and other therapists.

decade, the study of the development of hand use and the treatment of hand dysfunction in children is still in

Anne Henderson

its infancy. It is our hope that assembling this

Charlane Pehoski

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Chapter 1 CORTICAL CONTROL OF HAND-OBJECT INTERACTION Charlane Pehoski CHAPTER OUTLINE MOVING THE FINGERS
Chapter 1
CORTICAL CONTROL OF
HAND-OBJECT INTERACTION
Charlane Pehoski
CHAPTER OUTLINE
MOVING THE FINGERS INDEPENDENTLY: DIRECT
CORTICOSPINAL CONNECTIONS TO ALPHA
MOTOR NEURONS OF THE HAND AND PRIMARY
MOTOR CORTEX
Direct Corticospinal Connections to Alpha Motor
Neurons of Hand Muscles
Primary Motor Cortex
Use-Dependent Organization of the Primary Motor
Cortex
SENSORY GUIDANCE OF HAND MOVEMENTS:
PRIMARY SOMATOSENSORY CORTEX
Cortical Organization of the Somatosensory System

Use-Dependent Organization Within the Primary Somatosensory Cortex

Role of Somatosensory Input in Grasp

Role of Somatosensory Cortex in Motor Learning

THE TRANSFORMATION OF VISUALLY OBSERVED CHARACTERISTICS ABOUT OBJECTS INTO APPROPRIATE HAND CONFIGURATIONS:

POSTERIOR PARIETAL LOBE AND VENTRAL PREMOTOR CORTEX

Role of the Inferior Parietal Lobe in Preshaping of the Hand

Role of the Ventral Premotor Cortex in Preshaping of the Hand

Use-Dependent Organization of the Inferior Parietal and Ventral Premotor Cortex

The Inferior Parietal Cortex and Tool Use

SUMMARY AND THERAPEUTIC IMPLICATIONS

When I first met Katie she was 6 years old and was having a great deal of difficulty managing the fine motor tasks typical of most kindergarten children. She was clumsy and had difficulty with such tasks as buttoning and using tools. Her score on the Peabody Developmental Fine Motor Scales was 2.33 standard deviations below the mean for her age and her age equivalent score was 3 years 6 months. This is not an unusual profile for children referred because of poor fine motor skills. What was unique about Katie was that the source of her difficulty was known. A benign tumor had been removed from her right posterior parietal lobe when she was 3 years old. Many of the difficulties she experi- enced in hand–object interaction could be attributed to the location of her lesion. For example, she was under- responsive to tactile input and often used excess force when holding objects. When asked to feel forms placed in her hand without looking, she just grasped them and did not explore them with her fingers. She had a great deal of difficulty in tasks that required “in-hand manip- ulation,” such as moving a small object from the palm of the hand to the fingers. Objects often were dropped. This chapter discusses the posterior parietal lobe and its importance for hand–object interaction. However, this is not the only important area; other cortical regions are also explored. The capacity to use the hand with skill in hand– object interactions represents an evolutionary ability characteristic of the behavior of higher primates. Three fundamental prerequisites are necessary for this func- tion: (a) the capacity for independent control over the fingers, (b) a sophisticated somatosensory system to guide finger movements, and (c) the ability to trans- form sensory information concerning object properties into appropriate hand configurations (Binkofski et al., 1999). Each of these prerequisites is served by separate

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4 Part I • Foundation of Hand Skills

but interconnected areas of the cerebral cortex. This includes the primary motor cortex, primary somato- sensory cortex, parietal cortex (particularly the area around the intraparietal sulcus), and premotor cortex (particularly the ventral portion). That is not to say that other motor structures, such as the supplementary motor areas, cingulated motor areas, cerebellum, and basal ganglion do not also serve important functions (e.g., Ehrsson, Kuhtz-Buschbeck, & Forssberg, 2002; Lemon, 1999; Schlaug, Knorr & Seitz, 1994), but rather that the cortical regions mentioned previously seem critically related to skilled action of the hand, partic- ularly as it interacts with objects. This chapter reviews each of the mentioned prerequisite skills and the cor- tical areas important for their functions. The purpose of this chapter is to better understand the problems of children like Katie and provide evidence for the need to encourage skilled hand use in these children.

MOVING THE FINGERS INDEPENDENTLY: DIRECT CORTICOSPINAL CONNECTIONS TO ALPHA MOTOR NEURONS OF THE HAND AND PRIMARY MOTOR CORTEX

DIRECT CORTICOSPINAL CONNECTIONS TO ALPHA MOTOR NEURONS OF HAND MUSCLES

As indicated, one prerequisite for skilled hand use is the control over individual finger movements. This is true even for a seemingly simple task such as picking up an object using a precision grip. 1 Try picking up a small object between your index finger and thumb. Pick it up slowly enough so you can observe the action of the fingers. Note the isolation of movement between the index finger and thumb and the movement of the remaining fingers as they get out of the way of the action. If, during this task, your hand muscles had been attached to an electromyograph (EMG) you would have seen that the muscles necessary for this task showed marked variation with respect to the precise timing of their onset and time course of activity during the task, resulting in the specificity of finger move-

1 This chapter uses the term “precision grip” when referring to the act of picking up a small object between the index finger and thumb because this is the term used in the neurophysiologic research that is reviewed.

ments. This is in contrast to a power grip, in which all the muscles are coactivated (Bennett & Lemon, 1996; Muir, 1985). Even simple finger movements such as this require hand muscles to work in a specific temporal order and with varying amounts of force (Darian- Smith, Burman, & Darian-Smith, 1999). This ability to “fractionate,” or move the fingers individually, is thought to result from the special contri- bution of direct corticospinal connections primarily from neurons in the motor cortex to the alpha motor neuron of hand muscles in the ventral horn in the spinal cord (see Lemon, 1993, for a review). The ven- tral horn of the spinal cord is divided into two main sections, an interneuron zone and the motor neuronal pool or “final common pathway” to the muscle. The motor neurons in the ventral horn are not randomly distributed but are clustered into cell columns, a medial cell column that contains the motor neurons for the trunk, shoulder girdle, and hips, and a lateral cell col- umn that contains motor neurons for the distal extrem- ities (Kuypers, 1981). Almost all descending motor fibers first terminate in the interneuronal zone, so that there is at least one interneuron between the descend- ing motor fiber and motor neuron. An important exception is the direct corticospinal fibers to alpha motor neurons of the distal extremity (Figure 1-1). This direct path is fast and thought to be important in moving the hand with speed and skill. These special connections also are thought to be preferentially related to the intrinsic hand muscles (Maier et al., 2002). The intrinsic hand muscles provide the ability to handle small objects with precision (Long et al., 1970). Direct corticospinal fibers seem to be a feature unique to

Corticospinal tract Direct corticospinal input Indirect corticospinal input Interneuron zone Muscle of distal
Corticospinal tract
Direct corticospinal input
Indirect corticospinal input
Interneuron zone
Muscle of distal
extremity

Termination of the corticospinal tract in the

spinal cord. The diagram shows a single fiber that synapses in the interneuronal zone and then makes connections with a muscle through the interneuron. Also shown is a fiber within the corticospinal tract that makes a direct connection to a motor neuron of a distal limb muscle.

Figure 1-1

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primates and are particularly well developed in the most dexterous primate species (Nakajima et al., 2000). Lemon (1993) suggests that the direct corticospinal projections allow motor commands to bypass spinal mechanisms and break up synergies by direct access to the motoneurons and the final common pathway. This allows the flexibility of individual finger movements with wrist actions appropriate to a given task.

PRIMARY MOTOR CORTEX

Although a large number of structures are involved in the neural control of the hand, the importance of the primary motor cortex for the execution of independent finger movements is well established (Ehrsson et al., 2002; Huntley & Jones, 1991) (Figure 1-2). Neurons that are the source of the direct corticospinal connec- tions are more numerous in the hand area of the primary motor cortex than connections from other cor- tical areas, such as the supplementary motor cortex (Lemon et al., 2002; Maier et al., 2002). This area of cortex is particularly well represented in nonhuman primates by the ability to form a precision grip. Damage to the motor cortex results in deficits in fine manual coordination. Monkeys with lesions to this area lose the ability to produce a precision grip and small objects are picked up by the use of a more mass grasp in which all the fingers work together (Fogassi et al., 2001; Rouiller et al., 1998; Schieber & Poliakov, 1998). Difficulty with independent finger movements can also be seen in humans with lesions restricted to the primary motor cortex or the corticospinal tract. Lang and Schieber (2003) found that the fingers of the affected hand in patients with damage to these areas moved less independently than the fingers of the uninvolved extremity or normal controls. This was par- ticularly true for abduction and adduction of the fin-

Primary motor cortex

Central sulcus

adduction of the fin- Primary motor cortex Central sulcus Figure 1-2 Diagram of the primary motor

Figure 1-2

Diagram of the primary motor cortex.

Cortical Control of Hand-Object Interaction • 5

gers. When EMG recordings were made of hand muscles during abduction and adduction movements of the fingers, activation of the first dorsal interosseous of the normal hand was seen only when the person moved the index finger. That is, the muscle’s response was isolated and only related to the movement of this one finger. In the disabled hand, this muscle was active with thumb, index, and ring finger movements. The authors concluded that cerebral areas and descending pathways that are spared in humans may activate finger muscles, but cannot fully compensate for the highly selective control provided by the primary motor cortex. The primary motor cortex has a particular relation- ship to the hand. The cortical representation of muscles involving the fingers occupies a larger area than those concerned with shoulder movement (Paillard, 1993). Hand muscles may also be more dependent on cortical mechanisms. Turton and Lemon (1999) used trans- cranial magnetic stimulation (TMS) to look at the effects of stimulation of the primary motor cortex on EMG output of the deltoid, biceps, and first dorsal interosseous muscles when the participants contracted each muscle. (TMS is a noninvasive way to stimulate neurons in the motor cortex using a small coil placed over the appropriate area of the head.) They found that the EMG response to this additional facilitation was significantly greater in the hand muscles than the biceps, which was greater than in the deltoid. That is, the “extra” input provided by the TMS through the primary motor cortex was greatest in the hand muscles. They suggest that this reflects a major difference in the dependence on cortical mechanisms in hand muscles as opposed to more proximal muscles. Therefore the hand seems to have a privileged relationship with the primary motor cortex.

USE-DEPENDENT ORGANIZATION OF THE PRIMARY MOTOR CORTEX

One of the significant research findings in the last few years is that the functional organization of the primary motor cortex is dynamic and changes as a result of use. “Use-dependent” changes have been seen in the motor cortex of a wide variety of animals (e.g., Kleim et al., 1996; Remple et al., 2001), including humans (e.g., Classen et al., 1998; Pascual-Leone, Grafman, & Hallett, 1994). What appears to happen is that the representation of the “used” muscles expands or the movements that are used together are represented together (Nudo et al., 1996). There is not one repre- sentation of the human hand in the motor cortex; rather, multiple overlapping representations are func- tionally connected through a horizontal network between motor neurons (Butefisch, 2004; Huntley & Jones, 1991; Sanes & Donoghue, 2000). Dynamically

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6 Part I • Foundation of Hand Skills

changing patterns can be achieved by changing the strength of these horizontal networks through use (Butefisch, 2004). This is a requirement for motor learning. The brain must have the ability to adapt to new and changing circumstances, including both the learning of new skills and recovery from injury (Jackson & Lemon, 2001). An example of a “use-dependent” change was demon- strated by Karni et al. (1998). In this study, typical adults practiced a finger sequence task daily for 5 weeks (opposing the fingers of the nondominant hand to the thumb in a specific order). The participants also were given a second finger sequence that was not practiced and served as a control for the study. Functional mag- netic resonance imaging (fMRI) of the cerebral cortex was done at the start of the experiment and then weekly until the end of the experiment. The authors found that in the initial images done before the experiment began there were no differences between the cortical representation of the experimental and control sequences. At 3 weeks, when the experimental sequence had been well learned, the area of motor cortex repre- senting the experimental sequence had become larger. Changes also have been seen using intracortical microstimulation in monkeys, in which the neuronal representative of movements in the distal forelimb area of the primary motor cortex can be specifically mapped. In one study the extent of the representation of the hand was mapped and then the monkeys were trained to pick up small food pellets from a food well (Nudo et al., 1996). After training, intracortical microstimula- tion of the primary motor cortex was done again and the researchers found that the representation of the movements used in the food retrieval task had expanded. They also looked at the representation of unpracticed wrist and forearm movements, and found that the representation of these movements had con- tracted. To demonstrate that these changes are reversible and that the primary motor cortex changes are based on use, the monkeys were then trained to perform supination and pronation movements in a key turning task. Intracortical microstimulation demon- strated an expansion of the forelimb area and contrac- tion of the digital representational zones. They also found that movement combinations used in the acqui- sition of these skilled motor tasks had come to be represented in the same cortical territory. Consequently, use of a particular motor pattern causes structural reorganization in the primary motor cortex. Actions that are practiced come to represent a larger area of cortex and the muscle groups involved also come to be represented together in what appear to be functional groupings (Nudo et al., 1996); however, not all “use” or practice may be as effective in driving these changes. As discussed later, passive movements and

strength training appear to be less effective in driving reorganization of the primary motor cortex. Alternately, skill training or learning may be a par- ticularly powerful force for reorganization. With respect to passive movements, Lotze et al. (2003) used fMRI to look at the effects of 30 minutes of passive versus active wrist movement in typical adults. They found that the accuracy of wrist move- ments improved more with active movements and that cortical reorganization as measured by fMRI also was greater with active compared with passive movement. In a clever experiment that looked at the effect of strength training, Remple et al. (2001) trained one group of rats to break increasingly larger bundles of pasta with their forelimb and a second group to break single strands of pasta. A control group that had no training in either task also was included in the study. After 30 days of training, the researchers found an increase in the proportion of motor cortex occupied by distal forelimb movements in both experimental groups but not the control group. They concluded that the development of skilled forelimb movements, but not increased forelimb strength, is associated with reorganization of forelimb areas in the primary motor cortex. The need for the animal to be engaged in a skilled task or actually learn a task for significant changes in the primary motor cortex to be observed also has been reported. In two complementary studies, Nudo et al. (1996) and, Plautz, Miliken, and Nudo (2000), the researchers trained monkeys to retrieve food pellets from food wells. In one group, the well was large and therefore the task was fairly easy, so no skill or learning was involved (Plautz et al., 2000) (Figure 1-3). Another group of monkeys was required to use much smaller food wells that required learning to retrieve the food pellet (Nudo et al., 1996). Both groups used the same fingers and were given the same number of pellets to retrieve but only in the group of monkeys in which the task required learning a new skill was there evidence of modification of cortical maps. The authors concluded that,

“Repetitive motor activity alone does not produce functional reorganization of cortical maps. Instead we propose that motor skill acquisition or motor learning is a prerequisite factor in driving representational plasticity in the primary motor cortex” (Plautz et al., 2000; p. 27).

Even adult patients who had reached a plateau in their recovery after suffering a stroke showed an increase in function (Taub & Morris, 2001) and expan- sion of the cortical hand representation (Liepert et al., 2000) after constraint induced movement therapy (noninvolved extremity restrained to force use of the involved extremity).

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11.5mm 9.5mm 13.5mm 19.5mm 26mm
11.5mm
9.5mm
13.5mm
19.5mm
26mm

Figure 1-3

large pellet retrieval task. Note the relative simplicity of the task because of the size of the well compared with the size of the animal’s hand. (Redrawn from Plautz E, Miliken G, Nudo R [2000]. Effects of repetitive motor training on movement representation in adult squirrel monkeys: Role of use versus learning, Neurobiology of Learning and Memory, 74:27–55.)

Depiction of a squirrel monkey performing a

Use can change the organization of the primary motor cortex, but disuse also can have an effect on centers important to motor skills. Using kittens, Martin et al. (2004) demonstrated that restricting the use of one paw for the first 7 weeks after birth created perma- nent changes both in the skill of that paw and the morphology of the direct corticospinal connections in the spinal cord. In another example, a group of researchers followed adults who had undergone sur- gical treatment of the flexor tendons of the hand (deJong et al., 2003). For 6 weeks after surgery, the patients were required to wear a dynamic immobi- lization splint that allowed passive but not active finger flexion. After the splint was removed, the patients complained of a temporary clumsiness of the hand that could not be explained by stiffness of the fingers or adhesions. In one patient, EMG studies were done after splint removal and flexion of the fingers showed increased cocontraction of the extensor muscles and no full relaxation of this muscle was seen between sets of movement. In four patients, positron emission tomography (PET) was used to look at task-related increases in cerebral blood flow as they flexed their fingers. These scans were done immediately after the splint was removed and again 6 to 10 weeks after removal. They found that scans immediately after splint removal demonstrated activation in the posterior parietal lobe and cingulate sulcus. This was not seen in the nonsurgical hand. The authors suggested that the increase in parietal involvement (an area of tactile and visual convergence discussed later in this chapter) may

Cortical Control of Hand-Object Interaction • 7

be related to an increased demand on body scheme representation that is needed for instructing the appropriate parts of the hand to move. The cingulate may represent the recruitment of secondary motor function for the execution of simple hand movements. After the splint had been removed for several weeks, a second scan showed movements related to the puta- men, a subcortical structure. The authors indicated that the shift from cortical to subcortical involvement may indicate that movements have been relearned. In summary, hand skill is possible because of the ability to move the finger individually and with speed. This ability is provided by the primary motor cortex and direct corticospinal fibers to hand muscles. The integrity of this cortical motor system is being tested in part when a child is asked to tap his or her index finger and thumb together as rapidly as possible or quickly oppose the individual fingers to the thumb. The speed with which these movements can be per- formed increases with age (e.g., Denckla, 1974). Evans, Harrison, and Stephens (1990) suggest that there is a relationship between a child’s ability to perform rapid finger movements and maturation of a cutaneo- muscular reflex dependent on the corticospinal tract, as well as the main sensory pathway. The results of maturation in this system are demonstrated when an infant of 9 to 10 months begins to use a precision grip to pick up small objects (Siddiqui, 1995). It is apparent that the hand needs to be used, particularly in skilled tasks. This need for use also is seen for other cerebral areas involved in control of the hand, particularly the primary somatosensory cortex, which is discussed next.

SENSORY GUIDANCE OF HAND MOVEMENTS: PRIMARY SOMATOSENSORY CORTEX

The hand is both a motor and sensing organ and there is a tight interplay between these two functions. The delicate movements of the hand and fingers are needed to “gather” sensory information, and those delicate movements need sensory feedback to guide action, particularly actions with objects. When objects are handled they do not fall from the fingers, nor does one use excessive force when picking things up. The information needed for these activities is provided by sensory feedback. The importance of this sensory infor- mation is obvious when one removes a glove to gather change from a pocket or when performing any delicate activity with the hand. Figure 1-4 shows the attempts of a woman with complete loss of sensation in her right hand trying to crumple a piece of paper (Jeannerod,

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8 Part I • Foundation of Hand Skills

RH LH
RH
LH

Figure 1-4

somatosensory cortex and superior parietal lobe attempting to crumble a sheet of paper with her left hand (LH) and involved right hand (RH). (Redrawn from Jeannerod M, Michel M, Prablanc C [1984]. The control of hand movements in a case of hemianaesthesia following a parietal lesion. Brain, 107:899–920.)

Schematic of a woman with a lesion in the

Michel, & Prablanc, 1984). Note the difficulty she has in coordinating the fingers of her right hand. She was reported to be able to reach for objects, eat normally, and write (although with difficulty), all tasks she could control using vision. Activities outside visual control, such as combing hair or buttoning, were problematic, as were activities that require the fingers to work together as in the paper-crumbling task. No detectable motor deficit, such as the ability to perform rapid tapping of the index finger, was noted (i.e., motor functions were intact). A computed tomography (CT) scan found that this woman had a very large lesion involving the somatosensory cortex and superior parietal lobe (Jeannerod, Michel, & Prablanc, 1984). (Note that this woman’s lesion extended beyond the primary sensory cortex and probably contributed to the severity of her disability). Figure 1-5 shows similar disorganization of finger movements in a monkey with a lesion in area 2 of the somatosensory cortex (Hikosaka et al., 1985). Brochier, Boudreau, and Smith (1999) also found a loss of finger coordination and poor positioning of the fingers when grasping objects in monkeys with inactivation of the somatosensory cortex. This section discusses the important roles sensory information plays in skilled hand movements, including the role it plays in motor learning.

CORTICAL ORGANIZATION OF THE SOMATOSENSORY SYSTEM

The primary receiving area for somatosensory informa- tion from the limbs is the area of cortex just behind the central gyrus. This area generally is called the primary somatosensory cortex (Figure 1-6). It is the major ter- mination of the dorsal columns, which carries discrete somatosensory information from the periphery. This major tract has evolved in parallel with the corticospinal tract, and like this system it reaches it highest level of development in humans (Paillard, 1993). Information carried in the dorsal columns can register even small movements of joints and provide knowledge of the exact location of stimulus on the skin. It was designed to provide specific information about what is happen- ing in the periphery. In both monkeys (Sakata & Iwamura, 1978) and humans (Moore et al., 2000) the primary somatosen- sory cortex is composed of four areas, generally called Brodmann’s areas 3a, 3b, 1, and 2 (see Figure 1-6). An understanding of the function of the primary somato- sensory area is helpful to appreciate the complexity of information processing within this area, particularly for the hand. Afferent fibers from the dorsal columns project mainly to area 3b for cutaneous input and area 3a for

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Cortical Control of Hand-Object Interaction • 9

AM Page 9 Cortical Control of Hand-Object Interaction • 9 IPSI CONTRA Figure 1-5 to right)

IPSI

CONTRA

Figure 1-5

to right) shows the animal’s attempts at picking up a piece of apple from a funnel. IPSI indicates the “normal” hand ipsilateral to the inactivated region. CONTRA indicates the disorganized movements of the affected hand contralateral to the inactivated region. (Redrawn from Hikosaka O, Tanaka M, Sakamoto M, Iwamura Y [1985]. Deficits in manipulative behaviors induced by local injection of muscimol in the first somatosensory cortex of the conscious monkey. Brain Research,

325:375–380.)

Disruption of finger coordination after inactivation of area 2 in a monkey. The sequence of movements (left

deep, proprioceptive information (information arising from an activity such as active flexion and extension of the fingers) (Iwamura, 1998; Moore et al., 2000). Area 3b sends information to area 1 and area 1 sends information to area 2. Both areas then send informa- tion to the parietal lobe (Inoue et al., 2004). Therefore there is a serial or hierarchical processing of informa- tion across this area (Ageranioti-Belanger & Chapman, 1992; Inoue et al., 2004; Iwamura, 1998; Iwamura et al., 1985). One of the transformations in sensory information that is seen as information is processed in more posterior cortical regions is the response of a single neuron to stimulation over wider areas of skin. For example, there is an increase in the number of multidigit receptive fields (the area from which stimu- lation causes a single cortical neuron to fire) when pro- gressing from area 3b, where 46% of neurons respond to multiple sites; to area 1, where the percentage is 63%; to area 2, where 85% of neurons respond to stimulation from multiple sites (Ageranioti-Belanger & Chapman, 1992). That is, the discrete information that first arises from the periphery appears to be combined into progressively more functionally relevant networks. In a study of neurons in area 2 of monkeys, Iwamura et al. (1985) suggested that this convergence represents skin surfaces that come in contact as the result of com-

mon behaviors of the animal. Like the primary motor cortex, which tends to cluster muscles that have repeat- edly worked together in interconnected networks, the same appears to be true of sensory information processed in the primary somatosensory cortex. Also like the motor cortex, the organization of the sensory cortex is dependent on use. Therefore these two areas allow for a great deal of flexibility in how information is organized to best serve a variety of functional activities.

USE-DEPENDENT ORGANIZATION WITHIN THE PRIMARY SOMATOSENSORY CORTEX

The primary sensory cortex is dynamic and changing. This has led one researcher to suggest that at any given time the details of the somatosensory cortex organ- ization reflect the behavioral experience of the animal (Recanzone et al., 1992). That is, the sensory represen- tation of the extremities contracts or expands depend- ing on the use or lack of use of a body part. In an interesting study, Scheibel et al. (1990) did a post- mortem examination of the dendritic complexity in several areas of the cerebral cortex in 10 individuals. The authors found a great deal of variability in the hand area of the somatosensory cortex of these individuals

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10 Part I • Foundation of Hand Skills

Central Sulcus 3a 3b 1 2 Primary somatosensory cortex A Central Central sulcus sulcus 2
Central Sulcus
3a
3b
1
2
Primary
somatosensory
cortex
A
Central Central
sulcus sulcus
2
1
B
3b
3a

Figure 1-6

of somatosensory cortex showing Brodmann’s areas 3a,

3b, 1, and 2.

A. Somatosensory cortex. B. Cross section

and felt that at least in some (e.g., former typist, appli- ance repairman) these differences might be related to the individual’s premorbid occupation. In a more recent study, Hashimoto et al. (2004) used noninvasive tech- niques to study the somatosensory cortex in string players. They found an enlarged cortical representation of the hand area in these individuals compared with controls who did not play a string instrument. Like the motor cortex, research seems to indicate that skilled learning or attention to a task may be par- ticularly effective in mediating these cortical changes. Using a behavioral task similar to the one used for studying the changes in the motor cortex of monkeys, animals were trained to pick up food pellets placed in wells of varying diameters (Xerri et al., 1999). This included large-diameter wells in which the pellets were easy to retrieve, and smaller-diameter wells in which retrieval was more difficult. The researchers found that sensory neurons responsive to the specific finger sur- faces that had been engaged in the small retrieval task showed major representative changes within area 3b of the somatosensory cortex that were not seen with other finger surfaces. That is, changes reflected digital surfaces that were necessary for object retrieval under

difficult task conditions or in which the animal had to learn a skilled task. In another study, Recanzone et al. (1992) trained two groups of monkeys to place their hands on a mold of the hand. The purpose of the mold was to keep the hand in the same position so a vibratory stimulus could be given to a small site on one of the fingers. One group of animals was trained to lift the hand when they perceived changes in the vibratory input. In other words, these monkeys were to attend to and then make an adaptive response to this tactile stimulus. Another group of monkeys also received the vibratory stimulus but were trained to lift the hand to changes in an auditory stimulus. These animals therefore received the vibratory stimulus in a passive manner and were not required to act on the input. When the area in the primary sensory cortex of these animals that represents

the stimulated portion of skin was mapped, both exper-

imental animals showed an increase in the represen- tation of this skin area. However, the increase in the

animal who had been the passive recipient of the vibra- tory stimulus was modest. The authors suggest that attention influences cortical reorganization and that stimulation alone is far less effective in driving cortical reorganization than an active response to the stimulus. In other words, being engaged in the activity and making an adaptive response based on sensory input were the most efficient means of driving the cortical changes seen in this study. It also should be mentioned that in humans, Godde, Ehrhardt, and Braun (2003) showed a 20% decrease in two-point thresholds on the tip of the index finger and a change in the cortical map of this finger after 3 hours of intermittent, purely passive tactile stimulation to the fingertip. Apparently passive input also can promote organizational changes in the primary somatosensory cortex along with some modest improvement in tactile discrimination.

ROLE OF SOMATOSENSORY INPUT IN GRASP

Tactile information from the fingers is necessary to adjust the grip to the weight and friction of an object. This is particularly true when picking up a small object in the fingertips. Sensitive tactile receptors in the fingertips are able to sense the “slip” of an object even before this slip comes to conscious attention. Appro- priate adjustments in the grip then can be automatically made (Johansson & Westling 1984, 1987; Westling & Johansson, 1984). If the friction between the finger and objects is different for different fingers, these dif- ferences are monitored separately (Edin, Wrestling, & Johansson, 1992). That is, if one side of an object is covered with silk and contacted by the index finger and

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the other side of the object is covered with sandpaper and contacted by the thumb, each finger adjusts to the frictional conditions on its grip surface. Anesthesia of the fingers results in an increase in the dropping of objects (particularly small and slippery objects) and the application of significantly greater grip forces (Augurelle et al., 2003; Monzee, Lamarre & Smith, 2003; Westling & Johansson, 1984). The “just right grip,” which includes just enough margin of safety so the object will not be dropped, is lost. Anesthesia of the fingers also appears to prevent the exact alignment of the fingers on the object surface. Monzee, Lamarre, and Smith (2003) found that although these misalign- ments were too small to be visually apparent, they still caused enough of a tangential force so that the meas- ured grip forces were close to the slip point. Therefore sensation from the fingers not only allows the appli- cation of appropriate grip forces and adjustments to small slips, this information also appears to help place- ment of the fingers to the most appropriate position for a secure grip. Because accurate sensory information is necessary for calibrating the “just right” grip force, children with reduced sensation in the hand, such as Katie, might have difficulty modulating grip and therefore manipu- lating small objects. This reduction in sensation has been found in children with cerebral palsy (see Eliasson, this volume), as well as children with developmental coordination disorders and attention deficit disorder (Pereira et al., 2001). Differences in establishing the “just right” grip also might be suspected in children with Down syndrome who have been shown to have impaired peripheral somatosensory function in the upper extremity (Brandt, 1996; Brandt & Rosen, 1995). Even in young children, the ability to adjust the grip force to the “just right” level is problematic. Young children, particularly those 4 years or younger, tend to use significantly larger grip forces when compared with adults (Forssberg et al., 1991). This may be one reason why an in-hand manipulation task such as moving a small peg from the palm to the fingers or turning a peg over in the fingers is difficult for children 4 years of age and younger (Pehoski, Henderson, & Tickel-Degnen, 1997a,b). This was a difficult task for Katie; she often dropped the manipulated object.

ROLE OF SOMATOSENSORY CORTEX IN MOTOR LEARNING

Area 2 in the primary sensory cortex is connected to the primary motor cortex through corticocortical con- nections (Asanuma & Pavlides, 1997). Sensory infor- mation from the hand may be important to learn a new motor skill but not to retain a skill already learned. For

Cortical Control of Hand-Object Interaction • 11

example, Pavlides, Miyashita, and Asanuma (1993) had monkeys learn a new motor task, but with each of the two hands subject to different conditions. In the first condition, the somatosensory cortex to one hand was lesioned. When the monkey had recovered from sur- gery, both hands were trained to retrieve food pellets falling at various velocities from a dispenser. The authors found that the hand contralateral to the lesion had difficulty learning the task and even when learned, never achieved the skill of the “normal” hand. In the second condition or experiment, the primary sensory cortex to the “normal” hand was lesioned. Despite this damage, the ability to perform the task with this hand remained. The authors concluded, “The corticocortical projections from the somatosensory to the motor cor- tex play an important role in learning new motor skills, but not in the execution of existing motor skills” (Pavlides, Miyashita, & Asanuma, 1993, p. 733). Practicing a task produces a vigorous circulation of impulses among the peripheral sensory inputs, somato- sensory cortex, and primary motor cortex (Asanuma & Pavlides, 1997; Nadler, Harrison, & Stephens, 2000; Stefan et al., 2000). This specific input from the pri- mary somatosensory cortex to the motor cortex is said to serve as a “teacher” (Asanuma & Pavlides, 1997). The “teacher” informs the motor cortex of the results of a movement so that eventually the exact combi- nation and sequence of muscles needed for the task can be selected. Everyone has experienced clumsiness when learning a new skill. The movements are not smooth and unnec- essary movements (and therefore muscles) are used when performing the task. As the task is practiced, these unnecessary movements are eliminated and an efficient, reproducible series of actions is seen. Try this activity. Pick up a pencil with your preferred hand with the fingers close to the eraser end rather than the writing end. Now move your fingers up the pencil shaft until they are in the proper position for writing. Try the same activity with your nonpreferred hand. Did you note a marked difference in the skill of this task on the two sides? Was the nonpreferred side awkward and clumsy? A possible interpretation of the study by Asanuma and Pavlides (1997) is that practice is one of the differences between the two hands in this task. The nonpreferred hand has not had an opportunity for sensory feedback to “teach” the motor cortex how to do the task most efficiently. It is not hard for people to understand how impor- tant sensory feedback is to hand function. Everyone has experienced the frustration of picking up a small object from the table with a Band-Aid covering the distal pad of one finger. Just think of how clumsy skilled motor acts of the hand would be if this reduction in sensation

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12 Part I • Foundation of Hand Skills

were experienced throughout the entire hand. One would have difficulty moving the fingers with skill and adjusting the hand to the “just right” grip so objects are not dropped. 2 There might even be some difficulty learning a new motor task with the hands. Nonetheless actual engagement with objects is more complicated than just picking them up so they do not drop or manipulating them within the hand. This is particularly true for tool use. Preparation for grasp occurs even before the object is touched and is based on the observed characteristics of the object and the use that will be made of the object. Consideration of the pos- terior parietal lobe and connection with the premotor cortex is covered next.

THE TRANSFORMATION OF VISUALLY OBSERVED CHARACTERISTICS ABOUT OBJECTS INTO APPROPRIATE HAND CONFIGURATIONS:

POSTERIOR PARIETAL LOBE AND VENTRAL PREMOTOR CORTEX

Think for a moment what it would be like if one had an excellent mechanism for the control of finger movements and somatosensory feedback to guide the movements but did not have a mechanism for selecting the grasp appropriate for a particular object. There would be a lot of trial and error. Movements would be slow. A glass would be approached in the same way as a fork. The hand would land on an object and then “feel” for the appropriate grasp. One function that would help would be vision. Up until now vision has not been considered. The primary motor cortex has limited access to direct visual information (Jeannerod et al., 1995). Vision allows for the preparation of grasp before contact; therefore the hand could be preshaped to match objects of different shapes, sizes, and orien- tation. Any final adjustments could be made by somatosensory feedback on contact. This preshaping of the hand is one of the functions provided by a posterior parietal cortex–prefrontal lobe cortex circuit.

2 It should be noted that besides the neural mechanisms responsible for the “just right” grip, there are other ways to increase the friction at the finger–object interface, the oils or moisture of the fingers themselves. Washing and drying the hands (Johansson & Westling, 1984) or the introduction of chemicals that reduce sweating of the hands (Smith, Codoret, & St-Amour, 1997) cause an increase in the grip force.

ROLE OF INFERIOR PARIETAL LOBE IN PRESHAPING OF THE HAND

Almost all interactions with objects start with a reach. Reach is composed of two main parts, the transport of the hand and the preparation of the hand for grasp (see Rosblad, this volume). Each of these requires different visual information about the object. Reach requires the analysis of distance and direction. Preparation of the hand for grasp requires the analysis of the object’s shape, size, and orientation (Jeannerod et al., 1995). Try this: Place two objects of different sizes on the table, such as a paper clip and the box the paper clip comes in, then reach for each one. Note the difference in the hand opening for the larger as opposed to the smaller object. As the hand is brought toward the object, the fingers open to ready the hand for grasp, and this opening is calibrated to the size of the object to be grasped, although it is always a bit larger than the object itself (Jeannerod, 1981). Here is another activity. With one hand, hold a pencil out in front of you and reach for it with the other hand while the pencil is held in a vertical position and then with the pencil in a horizontal position. Did you rotate your forearm during the reach to accommodate the difference in orientation of the pencil (e.g., “thumb up” for the vertical position and “thumb down” for the horizontal position)? Not only is the hand opening “programmed” as a part of the reach, but forearm rota- tion and wrist position also are part of the pattern of the reach. All of this preparation ensures that a secure grasp is achieved once contact with the object is made (Jeannerod et al., 1995). The ability to scale the hand opening and orient the hand appropriately to an object is not seen in young infants. Changes to the orientation of the wrist or forearm to an object is seen at about 7 to 9 months of age (Lockman, Ashmead, & Bushnell, 1984; Morrongiello & Rocca, 1989; von Hofsten & Fazel- Zandy, 1984; McCarthy et al., 2001) and adjusting the opening of the hand to changes in an object’s size at about 9 months of age (von Hofsten, 1979, 1991; von Hofsten & Ronnquist, 1988). The transformation of the visual image of an object into an appropriate hand opening and orientation is processed in the posterior parietal lobe. In a study of reach and grasp in monkeys, the timing of the firing of neurons in the posterior parietal lobe was compared with those of the primary somatosensory cortex (Debowy et al., 2001). The researchers found that the neurons in the posterior parietal lobe were more active during the approach stage as the hand was preshaped and before the hand touched the object. Most of the somatosensory neurons fired on contact with the

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object. Contact appeared to be the transition point from visually guided behavior to tactile guidance of the action. The posterior parietal lobe is composed of two parts, the superior and inferior parietal lobes (Figure 1-7). It is an important center for the integration of sensory information, particularly somatosensory and visual information. With respect to somatosensory input, this area completes the hierarchical processing of this infor- mation that started in the primary somatosensory cor- tex. The superior parietal lobe receives information from area 1 and more strongly from area 2 in the primary somatosensory cortex (Hyvarinen, 1982). The inferior parietal lobe’s sensory representation is more complex than the superior parietal lobe because it not only receives information from areas 1 and 2 and the superior parietal lobe, it also receives a great deal of information from the visual cortex; therefore this is an area where visual and somatosensory information converge (Hyvarinen, 1982; Mountcastle et al., 1975). Within the inferior parietal lobe is an area that has recently attracted much attention, the anterior intra- parietal sulcus (see Figure 1-7). In this area are neurons related to grasping that fire preferentially to the shape, size, and orientation of objects (Sakata et al., 1995, 1999; Taira et al., 1990). Patients with lesions in this area have no difficulty in reaching but hand shaping is significantly disturbed and often there is no preshaping of the hand at all (Binkofski et al., 1998). Monkeys with reversible inactivation of this area also have diffi- culty grasping. Grasping in these animals often is achieved only after several corrections that rely on tactile feed- back (Gallese et al., 1994). Binkofski et al. (1999) found neurons in the intraparietal sulcus active (along

Central sulcus

Primary

somatosensory

cortex Superior parietal lobe Intraparietal sulcus Inferior parietal lobe
cortex
Superior
parietal
lobe
Intraparietal
sulcus
Inferior parietal lobe

Figure 1-7

the superior parietal lobe and inferior parietal lobe.

Diagram of the intraparietal sulcus dividing

Cortical Control of Hand-Object Interaction • 13

with the ventral premotor area, superior parietal lobe, and secondary sensory cortex) when imaging studies were done of typical adults manipulating complex objects in their hands.

ROLE OF THE VENTRAL PREMOTOR CORTEX IN PRESHAPING OF THE HAND

Registering information about an object’s size, shape, and orientation is important, but the parietal lobe is primarily a sensory area and this information must be transferred from sensory to motor areas for use in actual movement execution. The anterior interparietal sulcus has corticocortical connections with the ventral premotor area (Luppino et al., 1999) (Figure 1-8). The “description” of the object is used here to select the most appropriate grip. Neurons in the ventral premotor cortex area of monkeys, such as those in the anterior parietal sulcus, are selective in the type of objects that cause them to fire (Rizzolatti et al., 1988). In monkeys, many neurons in this area can be classified by their action (e.g., grasping, holding, tearing, or manipulating); grasping neurons are most represented. Many also are selective to the type of prehension used, such as a precision grip, finger prehension, or whole hand pre- hension. (These grips are the three most common grips seen in monkeys [Fadiga & Craighero, 2003].) Some neurons in this area are specific for different finger configurations within a grip type. They are also selec- tive to what part of the grip movement they fire. Some discharge during the whole action with the object, others during finger closure, and others after contact with the object; therefore these neurons form a “vocabulary”

Primary motor cortex Ventral premotor cortex

Primary motor cortex Ventral premotor cortex Central sulcus Figure 1-8 relationship to primary motor

Central sulcus

Figure 1-8

relationship to primary motor cortex.

Diagram of ventral premotor area and

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14 Part I • Foundation of Hand Skills

of possible actions the hand can take on an object (see Rizzolatti & Fadiga, 1998, for a review). This vocab- ulary is related more to the goal of an action than to individual movements (e.g., a specific neuron might fire to “grasping” with the mouth and also with either hand) (Rizzolatti et al., 1988; Rizzolatti & Fadiga,

1998).

The ventral premotor cortex is connected to the primary motor cortex and from there to the direct corticospinal fibers to hand muscles (Luppino et al., 1999). What differentiates the primary motor cortex from the ventral premotor cortex is that the latter stores motor schemata that are goal directed, whereas the primary motor area stores movements regardless of the action or context in which they are used (Rizzolatti & Fadiga, 1998). That is, the visual infor- mation processed in the anterior intraparietal sulcus about the three-dimensional characteristics of an object is sent to the ventral premotor cortex for the selection of grip and then to the motor cortex for sequencing of the actual muscles to be used. Neurons in the inferior premotor area are known to facilitate neural action in the primary motor cortex. Stimulation of a neuron in the hand area of the primary motor cortex of monkeys causes changes in the EMG reading from hand muscles, but stimulation of an inferior premotor neuron or inferior parietal neuron alone does not. If stimulation is first given to the premotor cortex and then to the primary motor cortex, the EMG hand muscle response is greater than when the motor cortex is stimulated alone. The authors indicate that this input might be part of the wider control system that helps shape the pattern of activity of different hand muscles for grasp of specific objects (Shimazu et al., 2004). If a small injection of an agent that temporarily inactivates neurons is placed in the ventral premotor cortex of monkeys, the results are similar to those seen with inactivation of the anterior interparietal sulcus. That is, the animal is able to use tactile feedback to succeed in an appropriate grasp when preshaping of the hand is absent, but only after contact with the object, This is particularly true for small objects (Fogassi et al., 2001). It is interesting that large lesions at this site also produced problems with hand shaping of the ipsilateral hand. Further, when monkeys with large lesions were presented with raisins placed in a board with two rows of six horizontally placed holes, the monkeys tended to pick up the raisins in the right holes with the right hand and those on the left with the left hand. They also tended to remove the raisin first from the holes ipsilateral to the injection site. When food was pre- sented bilaterally, they always preferred the ipsilateral presentation.

USE-DEPENDENT ORGANIZATION OF THE INFERIOR PARIETAL AND VENTRAL PREMOTOR CORTEX

Although use-dependent changes have not been directly studied in either the anterior intraparietal sulcus or the ventral premotor area, it seems apparent that these areas are influenced by use. As an example, one of the most common types of grasping neurons found in the ventral premotor cortex in monkeys are those that respond to a precision grip, a grip formation that is not seen in young infant monkeys, but is seen with increasing regularity as monkeys get older (Lemon, 1993). Rizzolatti and Luppino (2001) suggest that the matching between the visually observed characteristics of an object and appropriate motor programs occurs early in life and is accomplished through processes that associate the intrinsic visual properties of the object with the grips that are effective in interacting with them.

THE INFERIOR PARIETAL CORTEX AND TOOL USE

Hand positioning to pick up an object requires a posture adapted to the features of the object (e.g., size, shape), but picking up an object to actually use it also requires that the grip anticipate what action will be performed. Think about the difference in hand position used when holding a pencil to punch a hole in a piece of cardboard as opposed to picking up a pencil to write. The posterior parietal lobe is implicated in this function. Sirigu et al. (1995) describe a patient with a bilateral lesion in the posterior parietal lobe who had normal sensory and motor functions, yet had a great deal of difficulty grasping tools. Figure 1-9 illustrates some of the patient’s problems grasping common objects, such as a nail clipper, spoon, and scissors. At home she had difficulty using objects in such tasks as brushing her teeth, locking her door, and cutting meat. What was of particular interest in this patient was that if the examiner corrected the patient’s grasp and the object was placed in her hand appropriately, she could per- form with normal movement kinematics. Further, if the patient was asked to just grasp an object and not use it, appropriate preshaping of the hand and wrist to the object’s physical characteristics was seen. It was the capacity to match the grasp to the object’s use that seemed to be missing in this patient. Apparently the posterior parietal cortex is important for this function. Another feature of skilled tool use is that when the hand uses a tool, the tool becomes an extension of the hand. When one writes, one is not aware of the pen as a tool separate from the hand. Rather, it is an integral

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Cortical Control of Hand-Object Interaction • 15

A B C D 1 2 3 4
A
B
C
D
1
2
3
4

Figure 1-9

attempts to use a: (A) lighter, (B) nail clipper, (C) soup spoon, and (D) scissors (successive attempts). (Redrawn from Sirigu A, Cohen L, Duhamel J, Pillon B, Dubois B, Agid Y [1995]. A selective impairment of hand posture for object utilization in

apraxia. Cortex, 31:41–55.)

Spontaneous hand use of a woman with a bilateral disturbance of the posterior parietal lobe as she

part of the automatic movements that create the letters. It appears that the sense of the tool as an extension of the hand has a neurologic correlate that includes the tool into the body scheme of the hand. Working with monkeys, Iriki, Tanaka, and Iwamura (1996) pointed out that the visual receptive fields of neurons within the anterior intraparietal sulcus changed when the monkey used a rake to obtain food pellets (Figure 1-10). Soon after the monkey began to use the rake, the visual field was seen to change to not only cover the area around the hand but also to include the total length of the rake. This did not happen when the animal only held the tool or just moved a stick back and forth. That is, when the rake was used as a tool, the rake and the body schema of the hand came to be represented together. When imaging studies were done of humans picking up a small object with tongs or with just the fingers, the intraparietal sulcus was again implicated in the tool use task (Inoue et al., 2001). It appears that the anterior intraparietal sulcus is an important area concerned with the preparation and grasp of objects and may be particularly important for tool use. This area has strong connections with the

ventral premotor area, which also appears to be impor- tant for hand use. There is one other function of the parietal lobe related to object interaction that should be mentioned, the guidance of movements when explor- ing an object manually. The term “tactile apraxia” has been used to define a problem in this area (Pause et al., 1989). In patients with tactile apraxia, exploratory movements are described as slow and clumsy and may consist of only squeezing the object (Binkofski et al., 2001; Pause & Freund, 1989; Valenza et al., 2001). This problem has been seen in a variety of parietal lesions (Binkofski et al., 2001; Pause & Freund, 1989; Valenza et al., 2001), including the primary somato- sensory cortex (Motomura et al., 1990; Tomberg & Desmedt, 1999). The problem does not appear to be related to the severity of any somatosensory distur- bances that might be present. That is, a patient with a significant sensory loss may be better able to manipu- late an object for identification than a patient with better-preserved sensation (Pause et al., 1989; Valenza et al., 2001). Problems moving her finger around objects in a manual form identification task was one area with which Katie had difficulty. She tended to just

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16 Part I • Foundation of Hand Skills

A B table Food dispenser
A
B
table
Food dispenser

Figure 1-10

Simple stick manipulation task in which the food pellet was delivered at a reachable distance as a reward for swinging the stick. (Redrawn from Obayashi S, Suhara T, Kawabe K, Okauchi, Maeda J, Akine Y, Onoe H, Iriki A (2001): Functional brain mapping of monkey tool use, Neuroimage 14: 853-861.)

A. Monkey using a rake to obtain a food pellet that was dispensed out of its reach from a container. B.

hold the object. As one group of researchers said, “The parietal lobe is not only involved in the elaboration and further processing of somatosensory information, but also in the conception and generation of those motor programs required to collect this information.” (Pause et al., 1989, p. 1622).

SUMMARY AND THERAPEUTIC IMPLICATIONS

This section reviews the covered information. The primary motor cortex is critical to the ability to move the fingers individually and speedily. Without this input, hand movements are characterized by varying degrees of muscle cocontraction so movements are stiff, awkward, and slow. This ability to “fractionate” movements of the hand is transmitted by the cortico- spinal tract, particularly through direct corticospinal connections to the motoneurons of hand muscles. Through intracortical connections of the various hand muscles in the primary motor cortex, movements used together come to be represented together. When a movement is performed, this action generates sensory feedback. Discrete information related to the move- ments is carried back to the primary sensory cortex by the dorsal columns. This information can then be fed back to the motor cortex via corticocortical connec- tions so any necessary corrections of the movements can be made. Through practice, the correct combina- tion and timing of muscles can be perfected through this mechanism. Once learned, feedback is much less important. This is not to say that everyday, learned movements are not dependent on sensory information. The ability to pick up an object and hold it with just

enough force so that it is not dropped is dependent on sensory input from the fingers. The exact placement of the fingers on an object after grasp is also dependent on sensory feedback. Humans have an important cortical loop for the control of skilled hand function and the interaction with objects, the primary motor cortex and primary sensory cortex connection (Figure 1-11). However, the described actions are relatively simple and human object use is not simple. The second cortical circuit between the posterior parietal lobe (particularly the anterior intraparietal sulcus) and the ventral premotor area is important in the selection of the appropriate grip patterns. As indicated, the inferior portion of the posterior parietal lobe receives both somatosensory information from the primary sensory cortex and visual information from the visual cortex, resulting in com- plex bimodal neurons (neurons that respond to both somatosensory and visual information). Vision infor- mation about an object provides information about the object’s size, shape, and orientation. This allows the hand to be preshaped to the object’s characteristics before contact. This visual information is transferred to the premotor area through corticocortical connections in which the appropriate grip pattern is chosen. The premotor area then sends this information to the pri- mary motor cortex for the selection and timing of the necessary muscles. This in turn results in sensory infor- mation fed to the primary sensory cortex and back to the motor cortex, completing the circuit (see Figure 1-11). The anterior intraparietal sulcus of the posterior parietal lob also is important for incorporating the tool into the body schema of the hand, therefore making the tool an extension of the hand. It also should be noted that there are hand skills that have not been discussed in this chapter; many of these are covered in

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Cortical Control of Hand-Object Interaction • 17

4 1 4 3 2 3 1 2 Dorsal column Corticospinal tract A B
4
1
4 3
2
3
1 2
Dorsal column
Corticospinal
tract
A
B

A. Diagram of a somatosensory and a primary motor cortex circuit. (1) A message from the primary motor

cortex is sent to the muscles via the corticospinal tract; (2) sensory feedback is sent through the dorsal column as a result of the movement (3) of sensory input to the primary somatosensory cortex; (4) sensory information is sent from the primary sensory cortex to the primary motor cortex for any necessary correction of the movement. B. Diagram of somatosensory, inferior parietal lobe, ventral premotor cortex, and motor cortex circuit. (1) Sensory information is sent to the inferior parietal lobe; (2) visual information also is transferred to the inferior parietal lobe; (3) information from the inferior parietal lobe is sent to the ventral premotor cortex; (4) the ventral premotor area transfers information to the primary motor cortex and from there to the corticospinal tract.

Figure 1-11

other chapters of this book (e.g., handedness, reaching, eye–hand coordination, and perceptual functions of the hand). This chapter has concentrated on the performance of the hand in hand–object interaction, and has not discussed the shoulder or postural support as back- ground for these skilled movements. These are also important aspects of hand function. For example, Smith-Zuzovsky and Exner (2004) found that 6- and 7-year-old children who were positioned in furniture that was fitted to their size did significantly better on a test of in-hand manipulation than children using typical classroom furniture. In most natural movements the more proximal muscles provide the stability that allows skilled actions of the hand. Thus the corticospinal connections to proximal and distal muscles must coop- erate (Turton & Lemon, 1999), but the roles of reach and postural functions are different and therefore so are the basic neural mechanisms that control them. The primary role of posture and the shoulder in skilled hand function is one of stability. If the shoulder lacks stability for hand function or the postural muscles cannot adequately support the trunk, then this needs to be addressed through mechanisms to increase stability and strength. Hand muscles also may need strengthening, but remember that the primary roles of the hand are to act, move, and perform with skill. If a child presents with shoulder instability, poor trunk support, and poor hand use, these should be worked on simultaneously. The hand should not wait until some minimal level of postural support is achieved. The choice of proper positioning and creative selection of activities can make it possible for the child to use his or her hands even when postural support is poor.

As discussed, the cortical reorganization responsible for skilled learning, particularly as it relates to hand– object interaction, is use dependent. It is through use that functional patterns of movement or the muscles necessary for the action come to be represented togeth- er. The same is true of patterns of somatosensory input. Surfaces that are used together come to be represented together. This happens through practice. Also as indi- cated, this structural reorganization is best accom- plished through tasks that require skill or the learning of an activity. It also requires attention to the task. Passive movements and strength training are much less effective in driving this cortical reorganization. Children with poor hand skills, like Katie, often avoid or are so poor at fine motor tasks that they may actually get less practice than their peers. Skill requires attention to the activity and is facilitated when there is an interest in the outcome. Children with poor hand skills may need help to select and adapt to activities to meet their level of performance and interest. The art of therapy is being able to provide activities that challenge the child within the scope of his or her abilities and elicit the child’s enthusiastic cooperation.

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Chapter 2 ANATOMY AND KINESIOLOGY OF THE HAND James W. Strickland CHAPTER OUTLINE EMBRYONIC DEVELOPMENT
Chapter 2
ANATOMY AND KINESIOLOGY
OF THE HAND
James W. Strickland
CHAPTER OUTLINE
EMBRYONIC DEVELOPMENT
EMBRYONIC DEVELOPMENT
ANATOMY OF THE FULLY DEVELOPED HAND
Osseous Structures
Joints
Muscles and Tendons
Nerve Supply
Skin and Subcutaneous Fascia
Functional Patterns

One cannot expect to adequately understand the devel- opment and function of the hand and arm without a solid working knowledge of the intricate anatomic and kinesiologic relationships of the upper extremity, including the embryonic growth stages through which the extremity progresses. Only through comprehension of the normal formation and anatomy of the human hand can one adequately develop an appreciation for the disturbance in function that accompanies injury, disease, or dysfunction. It is appropriate, therefore that an early chapter in a book devoted to development of fine motor coordination be concerned with the embryology, anatomy, kinesiology, and biomechanics of the hand. Because it is impossible in this chapter to review in great detail the enormous amount of literature that has been written about these fields of knowledge, readers are directed to the Suggested Readings.

Inspection of a normal newborn’s hands never ceases to evoke awe and wonderment. The tiny nails punctuating the ends of intricately formed fingers and opposable thumbs, each delicately marked with familiar patterns of joint wrinkles, immediately identify the newcomer as human. All of the ingredients that eventually provide an unbelievably extensive continuum of function from exquisitely fine dexterity to great power are present in the tiny waving arms and hands. However, the normal embryonic process through which the upper extrem- ities develop is both predictable and consistent (Arey, 1980; Bora, 1986; Bunnell, 1944; Moore, 1982). Upper limb buds are discernible at 4 weeks of gesta- tion. The scapula, humerus, radius, and ulna are appar- ent at 5 weeks as cartilage, and by 6 weeks upper arm, forearm, and hand divisions are present. Also at 6 weeks the webbed swellings of the three central digits appear and are soon followed by the two border digits. The metacarpals are present as cartilage, as are the prox- imal phalanges of the index through small fingers. Initially, each extremity is aligned longitudinally with the body trunk, but at 7 weeks the arms rotate outward and forward at the shoulder level to assume a hand-to- face position with the flexor surface of the forearm and hand turned inward toward the body and the extensor surface turned outward. Elbows and wrists are slightly flexed. Innervation of the limbs has already occurred at this point, and vessels extend to the distal extremity. Muscles, muscle groups, joint hollows, and digital cleav- ages, including thumb differentiation, are also present at 7 to 8 weeks. Webbing between the digits dimin- ishes, and the fingers and thumb are independent of each other by 8 weeks. Carpal bones are cartilaginous, and the os centrale fuses to the scaphoid at 8 weeks.

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22 Part I • Foundation of Hand Skills

For the remainder of gestation after 8 weeks, limb changes primarily involve growth of already present structures.

ANATOMY OF THE FULLY DEVELOPED HAND

The anatomy of the hand must be approached in a systematic fashion with individual consideration of the osseous structures, joints, musculotendinous units, and nerve supply. However, it is obvious that the systems do not function independently, but that the integrated presence of all these structures is necessary for normal hand function. In presenting this material, this chapter strays into the important mechanical and kinesiologic considerations that result from the unique anatomic arrangement of the hand.

OSSEOUS STRUCTURES

The unique arrangement and mobility of the bones of the hand (Figure 2-1) provide a structural basis for its enormous functional adaptability. The osseous skeleton consists of eight carpal bones divided into two rows:

The proximal row articulates with the distal radius and ulna (with the exception of the pisiform, which lies palmar to and articulates with the triquetrum); the distal four carpal bones in turn articulate with the five

metacarpals. Two phalanges complete the first ray, or thumb unit, and three phalanges each comprise the index, long, ring, and small fingers. These 27 bones, together with the intricate arrangement of supportive ligaments and contractile musculotendinous units, are arranged to provide both mobility and stability to the various joints of the hand. Although the exact anatomic configuration of the bones of the hand need not be memorized in detail, it is important that one should develop knowledge of the position and names of the carpal bones, metacarpals, and phalanges and an under- standing of their kinesiologic patterns to proceed with the management of many hand problems. The bones of the hand are arranged in three arches (Figure 2-2), two transversely oriented and one that is longitudinal. The proximal transverse arch, the keystone of which is the capitate, lies at the level of the distal part of the carpus and is reasonably fixed, whereas the distal transverse arch passing through the metacarpal heads is more mobile. The two transverse arches are connected by the rigid portion of the longitudinal arch consisting of the second and third metacarpals, the index and long fingers distally, and the central carpus proximally. The longitudinal arch is completed by the individual digital rays, and the mobility of the first, fourth, and fifth rays around the second and third allows the palm to flatten or cup itself to accommodate objects of various sizes and shapes. To a large extent the intrinsic muscles of the hand are responsible for changes in the configuration of the

A

Distal phalanx Middle phalanx Proximal phalanx Metacarpal Trapezoid Hamate Capitate Hamate Pisiform Trapezium
Distal phalanx
Middle phalanx
Proximal phalanx
Metacarpal
Trapezoid
Hamate
Capitate
Hamate
Pisiform
Trapezium
Triquetrum
Triquetrum
Scaphoid
Lunate

B

Figure 2-1

Hand and upper extremity splinting. St Louis, Mosby.)

Bones of the right hand. A. Palmar surface. B. Dorsal surface. (From Fess EE, Gettle K, Philips CA, et al. [2005].

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Anatomy and Kinesiology of the Hand • 23

Proximal Distal transverse transverse arch arch arch A
Proximal
Distal
transverse
transverse arch
arch
arch
A

Longitudinal

B

Distal transverse arch Proximal transverse arch
Distal transverse arch
Proximal transverse arch

Figure 2-2

transverse arch, through the metacarpal heads. The longitudinal arch is made up of the four digital rays and the carpus proximally. B. Proximal and distal transverse arches. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

A. Skeletal arches of the hand. The proximal transverse arch passes through the distal carpus; the distal

osseous arches. Collapse in the arch system can con- tribute to severe disability and deformity. Flatt (1979, 1983, 1995) has pointed out that grasp is dependent on the integrity of the mobile longitudinal arches and when destruction at the carpometacarpal joint, metacarpophalangeal joint, or proximal interphalangeal joint interrupts the integrity of these arches, crippling deformity may result.

JOINTS

The multiple complex articulations among the distal radius and ulna, the eight carpal bones, and the metacarpal bases comprise the wrist joint, whose prox- imal position makes it the functional key to the motion at the more distal hand joints of the hand. Functionally the carpus transmits forces through the hand to the forearm. The proximal carpal row consisting of the scaphoid (navicular), lunate, and triquetrum articulates distally with the trapezium, trapezoid, capitate, and hamate; there is a complex motion pattern that relies both on ligamentous and contact surface constraints. The major ligaments of the wrist (Figure 2-3) are the palmar and intracapsular ligaments. There are three strong radial palmar ligaments: the radioscaphocapitate or “sling” ligament, which supports the waist of the scaphoid; the radiolunate ligament, which supports the lunate; and the radioscapholunate ligament, which con- nects the scapholunate articulation with the palmar portion of the distal radius. This ligament functions as a checkrein for scaphoid flexion and extension. The ulnolunate ligament arises intra-articularly from the triangular articular meniscus of the wrist joint and inserts on the lunate and, to a lesser extent, the triquetrum. The radial and ulnar collateral ligaments are capsular ligaments, and V-shaped ligaments from the capitate to

the triquetrum and scaphoid have been termed the deltoid ligaments. Dorsally, the radiocarpal ligament connects the radius to the triquetrum and acts as a dorsal sling for the lunate, maintaining the lunate in apposition to the distal radius. Further dorsal carpal support is provided by the dorsal intracarpal ligament. These strong ligaments combine to provide carpal stability while permitting the normal range of wrist motion. The distal ulna is covered with an articular cartilage (Figure 2-3, C) over its most dorsal, palmar, and radial aspects, where it articulates with the sigmoid or ulnar notch of the radius. The triangular fibrocartilage com- plex describes the ligamentous and cartilaginous struc- ture that suspends the distal radius and ulnar carpus from the distal ulna. Blumfield and Champoux (1984) have indicated that the optimal functional wrist motion to accomplish most activities of daily living is from 10° of flexion to 35° of extension. Taleisnik (1976a,b, 1985a,b, 1992) has emphasized the importance of considering the wrist in terms of longitudinal columns (Figure 2-4). The central, or flex- ion extension, column consists of the lunate and the entire distal carpal row; the lateral, or mobile, column comprises the scaphoid alone; and the medial, or rotation, column is made up of the triquetrum. Wrist motion is produced by the muscles that attach to the metacarpals, and the ligamentous control system pro- vides stability only at the extremes of motion. The distal carpal row of the carpal bones is firmly attached to the hand and moves with it. Therefore during dorsi- flexion the distal carpal row dorsiflexes, during palmar flexion it palmar flexes, and during radial and ulnar deviation it deviates radially or ulnarly. As the wrist ranges from radial to ulnar deviation, the proximal carpal row rotates in a dorsal direction, and a simultaneous

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24 Part I • Foundation of Hand Skills

Deltoid ligaments Space of Poirier Lunotriquetral ligament Radioscaphocapitate ligament Vestigial ulnar collateral
Deltoid ligaments
Space of Poirier
Lunotriquetral ligament
Radioscaphocapitate
ligament
Vestigial ulnar
collateral ligament
Scapholunate
ligament
Ulnocarpal
Radial collateral
meniscus homologue
ligament
Radiolunate
Ulnolunate ligament
ligament
(ulnolunate-triquetral)
(radiolunotriquetral)
Radioscapholunate
ligament
(ligament of Testut
and Kuenz)
A
Dorsal intercarpal ligament Dorsal radiocarpal ligament (radiotriquetral)
Dorsal
intercarpal
ligament
Dorsal radiocarpal
ligament
(radiotriquetral)

B

C Td H Tm P 1 Tq S L 7 2 4 3 5 6
C
Td
H
Tm
P
1 Tq
S
L
7
2 4
3 5
6

C

Figure 2-3

the flexed wrist, including the triangular fibrocartilage. 1, Ulnar collateral ligament; 2, retinacular sheath; 3, tendon of extensor carpi ulnaris; 4, ulnolunate ligament; 5, triangular fibrocartilage; 6, ulnocarpal meniscus homologue; 7, palmar radioscaphoid lunate ligament. P, Pisiform; H, hamate; C, capitate; Td, trapezoid; Tm, trapezium; Tq, triquetrum; L, lunate; S, scaphoid. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Ligamentous anatomy of the wrist. A. Palmar wrist ligaments. B. Dorsal wrist ligaments. C. Dorsal view of

translocation of the proximal carpus occurs in a radial direction at the radiocarpal and midcarpal articulations. This combined motion of the carpal rows has been called the rotational shift of the carpus. It was once taught that palmar flexion takes place to a greater extent at the radiocarpal joint and secondarily in the midcarpal joint, but because dorsiflexion occurs prima- rily at the midcarpal joint and only secondarily at the radiocarpal articulation, this now appears to be a sig- nificant oversimplification. The complex carpal kine- matics are beyond the scope of this chapter, and the reader is referred to the works of Weber (1988),

Taleisnik (1985a,b), Lichtman and Alexander (1988), and Cooney, Linscheid, and Dobyns (1998) to gain a thorough understanding of this difficult subject. The articulation between the base of the first metacarpal and the trapezium (Figure 2-5) is a highly mobile joint with a configuration thought to be similar to that of a saddle. The base of the first metacarpal is concave in the anteroposterior plane and convex in the lateral plane, with a reciprocal concavity in the lateral plane and an anteroposterior convexity on the opposing surface of the trapezium. This arrangement allows the positioning of the thumb in a wide arc of

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Central column Medial Lateral column column
Central
column
Medial
Lateral
column
column

Figure 2-4

mobile or lateral column. The central, or flexion extension, column comprises the lunate and the entire distal carpal row. The medial, or rotational, column comprises the triquetrum alone. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Columnar carpus. The scaphoid is the

St Louis, Mosby.) Columnar carpus. The scaphoid is the Figure 2-5 thumb. A wide range of

Figure 2-5

thumb. A wide range of motion (arrows) is permitted by the configuration of this joint. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Saddle-shaped carpometacarpal joint of the

motion (Figure 2-6), including flexion, palmar and radial abduction, adduction, and opposition. The ligamen- tous arrangement about this joint, while permitting the wide circumduction, continues to provide stability at the extremes of motion, allowing the thumb to be brought into a variety of positions for pinch and grasp, but maintaining its stability during these functions. The articulations formed by the ulnar half of the hamate and the fourth and fifth metacarpal bases allow a modest amount of motion (15° at the fourth carpo- metacarpal joint and 25° to 30° of flexion and exten- sion at the fifth carpometacarpal joint). A resulting “palmar descent” of these metacarpals occurs during strong grasp. The metacarpophalangeal joints of the fingers are diarthrodial joints with motion permitted in three

Anatomy and Kinesiology of the Hand • 25

First metacarpal
First metacarpal

A

and Kinesiology of the Hand • 25 First metacarpal A B Figure 2-6 occur at the

B

Figure 2-6

occur at the carpometacarpal joint of the thumb. B. The thumb moves (arrow) from a position of adduction against the second metacarpal to a position of palmar or radial abduction away from the hand and fingers and can then be rotated into positions of opposition and flexion. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

A. Multiple planes of motion (arrows) that

planes and combinations thereof (Figure 2-7). The cartilaginous surfaces of the metacarpal head and the bases of the proximal phalanges are enclosed in a com- plex apparatus consisting of the joint capsule, collateral ligaments, and the anterior fibrocartilage or palmar plate (Figure 2-8). The capsule extends from the borders of the base of the proximal phalanx proximally to the head of the metacarpals beyond the cartilaginous joint surface. The collateral ligaments, which reinforce the capsule on each side of the metacarpophalangeal joints, run from the dorsolateral side of the metacarpal head to the palmar lateral side of the proximal phalanges. These ligaments form two bundles, the more central of which is called the cord portion of the collateral ligament and inserts into the side of the proximal phalanx; the more palmar portion joins the palmar plate and is termed the accessory collateral ligament. These collateral ligaments are somewhat loose with the metacarpophalangeal joint in extension, allowing for considerable “play” in the side-to-side motion of the digits (Figure 2-9). With the metacarpophalangeal joints in full flexion, however, the cam configuration of the metacarpal head tightens the collateral ligaments and limits lateral mobility of the digits. This alteration in tension becomes an important factor in immobilization of the metacarpophalangeal joints for any length of time, because the secondary

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26 Part I • Foundation of Hand Skills

Hinge (anteroposterior motion) Diarthrodial (multiplane motion)
Hinge
(anteroposterior
motion)
Diarthrodial
(multiplane
motion)

Figure 2-7

configuration of the metacarpophalangeal joint permits motion in multiple planes, whereas the biconcave-convex hinge configuration of the interphalangeal joints restricts motion to the anteroposterior plane. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Joints of the phalanges. The diarthrodial

Cord portion of collateral ligaments Cord portion of collateral ligaments Accessory collateral Accessory collateral
Cord portion of
collateral ligaments
Cord portion of
collateral ligaments
Accessory collateral
Accessory collateral
ligament
Palmar
ligaments
Palmar
fibrocartilaginous
fibrocartilaginous
plates
plates

Figure 2-8

The collateral ligaments of the metacarpophalangeal and interdigital joints are composed of a strong cord portion with bony origin and insertion. The more palmarly placed accessory collateral ligaments originate from the proximal bone and insert into the palmar fibrocartilaginous plate. The palmar plates have strong distal attachments to resist extension forces. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Ligamentous structures of the digital joints.

shortening of the lax collateral ligaments that may occur when these joints are immobilized in extension results in severe limitation of metacarpophalangeal joint flexion by these structures. The palmar fibrocartilaginous plate on the palmar side of the metacarpophalangeal joint is firmly attached

Collateral ligament (loose in extension) Palmar plate Membranous portion of palmar plate (folds in flexion)
Collateral ligament
(loose in extension)
Palmar plate
Membranous portion
of palmar plate
(folds in flexion)
Collateral ligament
(tight in flexion)

Figure 2-9

collateral ligaments are loose in extension but become tightened in flexion. The proximal membranous portion of the palmar plate moves proximally to accommodate for flexion. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby. Modified from Wynn Parry CB, et al. [1973]. Rehabilitation of the hand. London, Butterworth.)

At the metacarpophalangeal joint level, the

to the base of the proximal phalanx and loosely attached to the anterior surface of the neck of the metacarpal by means of the joint capsule at the neck of the metacarpal. This arrangement allows the palmar plate to slide proximally during metacarpophalangeal joint flexion. The flexor tendons pass along a groove anterior to the plate. The palmar plates are connected by the transverse intermetacarpal ligaments, which connect each plate to its neighbor. The metacarpophalangeal joint of the thumb differs from the others in that the head of the first metacarpal is flatter and its cartilaginous surface does not extend as far laterally or posteriorly. Two small sesamoid bones are also adjacent to this joint, and the ligamentous structure differs somewhat. A few degrees of abduction and rotation are permitted by the ligament arrange-

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ment of the metacarpophalangeal joint at the thumb, which is of considerable functional importance in deli- cate precision functions. There is considerable variation in the range of motion present at the thumb metacar- pophalangeal joints. The amount of motion varies from as little as 30° to as much as 90°. The digital interphalangeal joints are hinge joints (see Figure 2-7) and, like the metacarpophalangeal joints, have capsular and ligamentous enclosure. The articular surface of the proximal phalangeal head is convex in the anteroposterior plane with a depression in the middle between the two condyles, which artic- ulates with the phalanx distal to it. The bases of the middle and distal phalanges appear as a concave surface with an elevated ridge dividing two concave depres- sions. A cord portion of the collateral ligament and an accessory collateral ligament are present, and the collateral ligaments run on each side of the joint from the dorsolateral aspect of the proximal phalanx in a palmar and lateral direction to insert into the distally placed phalanx and its fibrocartilage plate (Figure 2-10).

A strong fibrocartilaginous (palmar) plate is also

present, and the collateral ligaments of the proximal and distal interphalangeal joints are tightest with the joints in near full extension. The stability of the proximal interphalangeal joint is

ensured by a three-sided supporting cradle produced

by the junction of the palmar plate with the base of the

middle phalanx and the accessory collateral ligament structures (see Figure 2-10). The confluence of liga- ments is strongly anchored by proximal and lateral extensions called the checkrein ligaments. This system

Cord Collateral ligament Accessory Palmar plate Checkrein ligaments Checkrein Cord Collateral ligament ligaments
Cord
Collateral ligament
Accessory
Palmar plate
Checkrein ligaments
Checkrein
Cord
Collateral ligament
ligaments
Accessory
Palmar plate

Figure 2-10

Strong, three-sided ligamentous support

system of the proximal interphalangeal joint with cord and accessory collateral ligaments and the fibrocartilaginous plate, which is anchored proximally by the checkrein ligamentous attachment. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby. Modified from Eaton RG [1971]. Joint injuries of the hand. Springfield, IL, Charles C Thomas.)

Anatomy and Kinesiology of the Hand • 27

has been described as a three-dimensional hinge that results in remarkable palmar and lateral restraint. A wide range of pathologic conditions may result from the interruption of the supportive ligament sys- tem of the intercarpal or digital joints. At the wrist level, interruption of key radiocarpal or intercarpal liga- ments may result in occult patterns of wrist instability that are often difficult to diagnose and treat. In the digits, disruption of the collateral ligaments or the fibrocartilaginous palmar plates produces joint laxity or deformity, which is more obvious.

MUSCLES AND TENDONS

The muscles acting on the hand can be grouped as extrinsic, when their muscle bellies are in the forearm, or intrinsic, when the muscles originate distal to the wrist joint. It is essential to thoroughly understand both systems. Although their contributions to hand function are distinctly different, the integrated function of both systems is important to the satisfactory performance of the hand in a wide variety of tasks. A schematic representation of the origin and insertion of the extrinsic flexor and extensor muscle tendon units of the hand is provided in Figures 2-11 and 2-15. The important nerve supply to each muscle group is reviewed in these figures and again when discussing the nerve supply to the upper extremity.

Extrinsic Muscles

The extrinsic flexor muscles (see Figure 2-11) of the forearm form a prominent mass on the medial side of the upper part of the forearm: The most superficial group comprises the pronator teres, the flexor carpi radialis, the flexor carpi ulnaris, and the palmaris longus; the intermediate group the flexor digitorum super- ficialis; and the deep extrinsics the flexor digitorum profundus and the flexor pollicis longus. The pronator, palmaris, wrist flexors, and superficialis tendons arise from the area about the medial epicondyle, the ulnar collateral ligament of the elbow, and the medial aspect of the coronoid process. The flexor pollicis longus originates from the entire middle third of the palmar surface of the radius and the adjacent interosseous membrane, and the flexor digitorum profundus origi- nates deep to the other muscles of the forearm from the proximal two-thirds of the ulna on the palmar and medial side. The deepest layer of the palmar forearm is completed distally by the pronator quadratus muscle. The flexor carpi radialis tendon inserts on the base of the second metacarpal, whereas the flexor carpi ulnaris inserts into both the pisiform and fifth metacarpal base. The superficialis tendons lie superficial to the profun- dus tendons as far as the digital bases, where they bifurcate and wrap around the profundi and rejoin over

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28 Part I • Foundation of Hand Skills

Composite Flexor digitorum superficialis Nerve: median Action: flexion of proximal interphalangeal and
Composite
Flexor digitorum superficialis
Nerve: median
Action: flexion of proximal
interphalangeal and
metacarpophalangeal
joints
Superficial
Palmaris longus
Nerve: median
Action: tension of
palmar fascia
Flexor carpi ulnaris
Nerve: ulnar
Action: flexion of wrist;
ulnar deviation of
hand
Flexor carpi radialis
Nerve: median
Action: flexion of wrist;
radial deviation
of hand
Flexor carpi ulnaris
Palmaris longus
Flexor carpi radialis
Pronator
quadratus
Nerve: median
Action: forearm
pronation
Supinator
Pronator
Supinator
teres
Nerve: radial
Action: forearm
supination
Pronator teres
Nerve: median
Action: forearm
Brachioradialis
Supination
Pronation
pronation

Pronator quadratus

Brachioradialis Nerve: radial Action: pronation or supination, depending on position of forearm

Figure 2-11

(From Fess EE, Gettle K, Philips CA, et al. (2005). Hand and upper extremity splinting. St Louis, Mosby. Modified from Marble HC [1960]. The hand, a manual and atlas for the general surgeon. Philadelphia, WB Saunders.)

Extrinsic flexor muscles of the arm and hand. (Dark areas represent origins and insertions of muscles.)

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Anatomy and Kinesiology of the Hand • 29

Flexor digitorum profundus Nerve: median—index and long ulnar—ring and small Action: flexion of distal
Flexor digitorum profundus
Nerve: median—index and long
ulnar—ring and small
Action: flexion of distal
interphalangeal, proximal
interphalangeal, and
metacarpophalangeal
joints
Composite
Deep
Flexor pollicis longus
Nerve: median
Action: flexes
interphalangeal and
metacarpophalangeal
joints of thumb

Figure 2-11—cont’d.

the distal half of the proximal phalanx as Camper’s chiasma (Figure 2-12). The superficialis tendon again splits for a dual insertion on the proximal half of the middle phalanges. The profundi continue through the superficialis decussation to insert on the base of

FDS FDP FDP Camper's chiasma FDS
FDS
FDP
FDP
Camper's chiasma
FDS

Figure 2-12

flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP), and the proximal portion of the flexor tendon sheath. The superficialis tendon divides and passes around the profundus tendon to reunite at Camper’s chiasma. The tendon once again divides before insertion on the base of the middle phalanx. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Anatomy of the relationship among the

the distal phalanx. The flexor pollicis longus inserts on the base of the distal phalanx of the thumb. At the wrist the nine long flexor tendons enter the carpal tunnel beneath the protective roof of the deep transverse carpal ligament in company with the median nerve. In this canal the common profundus tendon to the long, ring, and small fingers divides into the indi- vidual tendons that fan out distally and proceed toward the distal phalanges of these digits (Figure 2-13). At about the level of the distal palmar crease the paired profundus and superficialis tendons to the index, long, ring, and small fingers and the flexor pollicis longus to the thumb enter the individual flexor sheaths that house them throughout the remainder of their digital course. These sheaths with their predictable annular pulley arrangement (Figure 2-14) serve not only as a protective housing for the flexor tendons, but also provide a smooth gliding surface by virtue of their synovial lining and an efficient mechanism to hold the tendons close to the digital bone and joints. There is an increasing recognition that disruption of this valuable

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30 Part I • Foundation of Hand Skills

Flexor digitorum profundus Digital flexor sheath Flexor digitorum superficialis Sheath of flexor pollicis longus
Flexor digitorum
profundus
Digital flexor
sheath
Flexor digitorum
superficialis
Sheath of
flexor pollicis
longus
Hypothenar
Median nerve
muscles
Thenar muscles
Ulnar artery
Ulnar nerve
Transverse carpal
ligament
Radial artery

Figure 2-13

Fibroosseous digital sheaths with their pulley arrangement are shown, as is a division of the superficialis tendon about the profundus in the proximal portion of the sheath. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Flexor tendons in the palm and digits.

pulley system can produce substantial mechanical alterations in digital function, resulting in imbalance and deformity. Extension of the wrist and fingers is produced by the extrinsic extensor muscle tendon system, which consists of the two radial wrist extensors, the extensor carpi ulnaris, the extensor digitorum communis, extensor indicis proprius, and the extensor digiti quinti proprius (extensor digiti minimi) (Figure 2-15). These muscles originate in common from the lateral epicondyle and the lateral epicondylar ridge and from a small area posterior to the radial notch of the ulna. The brachio- radialis originates from the epicondylar line proximal to the lateral epicondyle and, because it inserts on the distal radius, it does not truly contribute to wrist or digit motion. The extensor carpi radialis longus and brevis insert proximally on the bases of the second and third metacarpals, respectively, and the extensor carpi ulnaris inserts on the base of the fifth metacarpal. The long digital extensors terminate by insertions on the bases of the middle phalanges after receiving and giving fibers to the intrinsic tendons to form the lateral bands that are destined to insert on the bases of the distal phalanx. Digital extension, therefore results from a com- bination of the contribution of both the extrinsic and intrinsic extensor systems. The extensor pollicis longus

A-1 A-2 C-1 A-3 C-2 A-4 A-5 C-3
A-1
A-2
C-1
A-3
C-2 A-4
A-5
C-3

Figure 2-14

The sturdy annular pulleys (A) are important biomechanically in guaranteeing the efficient digital motion by keeping the tendons closely applied to the phalanges. The thin pliable cruciate pulleys (C) permit the flexor sheath to be flexible while maintaining its integrity. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby. Modified from Doyle JR, Blythe W [1975]. American Academy of Orthopaedic Surgeons: Symposium on tendon surgery in the hand. St Louis, Mosby.)

Components of the digital flexor sheath.

and brevis tendons, together with the abductor pollicis longus, originate from the dorsal forearm and, by virtue of their respective insertions into the distal phalanx, proximal phalanx, and first metacarpal of the thumb, provide extension at all three levels. The exten- sor pollicis longus approaches the thumb obliquely around a small bony tubercle on the dorsal radius (Lister’s tubercle) and therefore functions not only as an extensor but as a strong secondary adductor of the thumb. The extensor indicis proprius also originates more distally than the extensor communis tendons from an area near the origin of the thumb extensor and long abductor. It lies on the ulnar aspect of the com- munis tendon to the index finger and inserts with it in the dorsal approaches of that digit. The extensor digiti quinti proprius arises near the lateral epicondyle to occupy a superficial position on the dorsum of the forearm with its paired tendons lying on the fifth metacarpal ulnar to the communis tendon to the fifth finger. It inserts into the extensor apparatus of that digit. At the wrist, the extensor tendons are divided into six dorsal compartments (Figure 2-16). The first com- partment consists of the tendons of the abductor pollicis longus and extensor pollicis brevis and the second compartment houses the two radial wrist exten- sors, the extensor carpi radialis longus and brevis. The third compartment is composed of the tendon of the extensor pollicis longus and the fourth compartment allows passage of the four communis extensor tendons and the extensor indicis proprius tendon. The extensor

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Anatomy and Kinesiology of the Hand • 31

Extensor carpi radialis longus and brevis Nerve: radial Action: extension of wrist and radial deviation
Extensor carpi radialis
longus and brevis
Nerve: radial
Action: extension of
wrist and radial
deviation of hand
Extensor carpi
ulnaris
Nerve: radial
Action: extension of
wrist and ulnar
deviation of hand
Extensor indicis
proprius
Nerve: radial
Action: extension of
index finger
Composite

Extensor pollicis longus Nerve: radial Action: extension of interphalangeal joint and metacarpophalangeal joint of thumb

Extensor digitorum communis and extensor digiti quinti proprius Nerve: radial Action: extension of fingers

Figure 2-15

and upper extremity splinting. St Louis, Mosby. Modified from Marble HC [1960]. The hand, a manual and atlas for the general

surgeon. Philadelphia, WB Saunders.)

Extrinsic extensor muscles of the forearm and hand. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand

Continued

digiti quinti proprius travels through the fifth dorsal compartment and the sixth houses the extensor carpi ulnaris.

Intrinsic Muscles

The important intrinsic musculature of the hand can be divided into muscles comprising the thenar eminence, those comprising the hypothenar eminence, and the remaining muscles between the two groups (Figure

2-17). The muscles of the thenar eminence consist of the abductor pollicis brevis, the flexor pollicis brevis, and the opponens pollicis, which originate in common from the transverse carpal ligament and the scaphoid and trapezium bones. The abductor brevis inserts into the radial side of the proximal phalanx and the radial wing tendon of the thumb, as does the flexor pollicis brevis, whereas the opponens inserts into the whole radial side of the first metacarpal.

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32 Part I • Foundation of Hand Skills

Abductor pollicis longus Nerve: radial Action: abduction of thumb
Abductor pollicis
longus
Nerve: radial
Action: abduction of thumb

Extensor pollicis brevis Nerve: radial Action: extension of metacarpophalangeal joint of thumb

Figure 2-15—cont’d.

First dorsal interosseous Extensor digitorum Extensor communis indicis proprius Extensor Extensor digiti quinti
First dorsal
interosseous
Extensor digitorum
Extensor
communis
indicis proprius
Extensor
Extensor digiti quinti
proprius
pollicis brevis
Abductor digiti quinti
Extensor
Extensor carpi ulnaris
pollicis longus
Extensor carpi
radialis
longus and brevis
1
5
6
2
3
4
Abductor
3
pollicis
2
4
5
longus
6
1

Figure 2-16

Arrangement of the extensor tendons in the compartments of the wrist.

The flexor pollicis brevis has a superficial portion that is innervated by the median nerve and a deep portion that arises from the ulnar side of the first metacarpal and is often innervated by the ulnar nerve. The hypothenar eminence in a similar manner is made up of the abductor digiti quinti, the flexor digiti quinti brevis, and the opponens digiti quinti, which originate primarily from the pisiform bone and the pisohamate ligament and insert into the joint capsule of the fifth metacarpophalangeal joint, the ulnar side of the base of

the proximal phalanx of the fifth finger, and the ulnar border of the aponeurosis of this digit. The strong thenar musculature is responsible for the ability to posi- tion the thumb in opposition so that it may meet the adjacent digits for pinch and grasp functions, whereas the hypothenar group allows a similar but less pro- nounced rotation of the fifth metacarpal. Of the seven interosseous muscles, four are consid- ered in the dorsal group (Figure 2-18, B) and three as palmar interossei (Figure 2-18, C). The four dorsal

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Anatomy and Kinesiology of the Hand • 33

Abductor pollicis brevis Nerve: median Action: abduction of thumb Opponens pollicis Nerve: median Action: rotation
Abductor pollicis brevis
Nerve: median
Action: abduction of thumb
Opponens pollicis
Nerve: median
Action: rotation of first
metacarpal toward palm
Flexor pollicis brevis
Nerve: median—superficial
ulnar—deep
Action: flexion and rotation of thumb
Adductor pollicis
Nerve: ulnar
Action: adduction
of thumb
Abductor digiti quinti
Nerve: ulnar
Action: abduction of small finger
(flexion of proximal phalanx, extension of
proximal and distal interphalangeal joints)
Flexor digiti quinti brevis
Nerve: ulnar
Action: flexion of proximal phalanx
of small finger and forward
rotation of fifth metacarpal

Figure 2-17

splinting. St Louis, Mosby. Modified from Marble HC [1960]. The hand, a manual and atlas for the general surgeon. Philadelphia,

WB Saunders.)

Intrinsic muscles of the hand. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity

Continued

interossei originate from the adjacent sides of the metacarpal bones and, because of their bipennate nature with two individual muscle bellies, have separate inser- tions into the tubercle and the lateral aspect of the proximal phalanges and into the extensor expansion. The more palmarly placed three palmar interossei

(Figure 2-18, C) have similar insertions and origins and are responsible for adducting the digits together, as opposed to the spreading or abducting function of the dorsal interossei. In addition, four lumbrical tendons (Figure 2-19, A) arising from the radial side of the palmar portion of the flexor digitorum profundus

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34 Part I • Foundation of Hand Skills

Lumbricals Nerve: median—index and long ulnar—ring and small Action: supplements metacarpophalangeal flexion and
Lumbricals
Nerve: median—index and long
ulnar—ring and small
Action: supplements metacarpophalangeal
flexion and extension of proximal and
distal interphalangeal joints
Composite
All interossei
Nerve: ulnar
Action: flexion of
metacarpophalangeal
joints and extension of
proximal and distal
interphalangeal joints
Dorsal
interossei
Dorsal interossei
Nerve: ulnar
Action: spread of
index and ring fingers
away from long finger
Palmar
interossei

Palmar interossei Nerve: ulnar Action: adduction of index, ring, and fifth fingers toward long finger

Figure 2-17—cont’d.

tendons pass through their individual canals on the radial side of the digits to provide an additional contri- bution to the complex extensor assemblage of the digits. The arrangement of the extensor mechanism, including the transverse sagittal band fibers at the metacarpophalangeal joint and the components of the extensor hood mechanism that gain fibers from both the extrinsic and intrinsic tendons, can be seen in Figure 2-19, B, C. An oversimplification of the function of the intrinsic musculature in the digits would be that they provide strong flexion at the metacarpophalangeal joints and extension at the proximal and distal interphalangeal joints. The lumbrical tendons, by virtue of their origin from the flexor profundi and insertion into the digital extensor mechanism, function as a governor between the two systems, resulting in a loosening of the antago- nistic profundus tendon during interphalangeal joint

extension. The interossei are further responsible for spreading and closing of the fingers and, together with the extrinsic flexor and extensor tendons, are invaluable to digital balance. A composite, well-integrated pattern of digital flexion and extension is reliant on the smooth performance of both systems; and a loss of intrinsic function results in severe deformity. Perhaps the most important intrinsic muscle, the adductor pollicis (Figure 2-18, A), originates from the third metacarpal and inserts on the ulnar side of the base of the proximal phalanx of the thumb and into the ulnar wing expansion of the extensor mechanism. This muscle, by virtue of its strong adducting influence on the thumb and its stabilizing effect on the first metacarpophalangeal joint, functions together with the first dorsal interosseous to provide strong pinch. The adductor pollicis, deep head of the flexor pollicis brevis, ulnar two lumbricals, and all interossei, as well as the

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B

A

Anatomy and Kinesiology of the Hand • 35

Adductor pollicis Abductor Opponens pollicis brevis digiti quinti Flexor pollicis Flexor digiti brevis quinti
Adductor
pollicis
Abductor
Opponens
pollicis brevis
digiti quinti
Flexor pollicis
Flexor digiti
brevis
quinti
Transverse carpal
ligament
Abductor digiti
Opponens
quinti
pollicis
Flexor carpi
ulnaris
Pronator
Ulnar nerve
quadratus
3 4 2 1 Abductor Dorsal interossei (1 to 4) Palmar interossei (1 to 3)
3
4
2
1
Abductor
Dorsal
interossei
(1 to 4)
Palmar
interossei
(1 to 3)
digiti
1
2
3
minimi

Figure 2-18

Position and function of the intrinsic muscles of the hand.

C

hypothenar muscle group, are innervated by the ulnar nerve. Loss of ulnar nerve function has a profound influence on hand function.

Muscle Balance and Biomechanical Considerations

When there is normal resting tone in the extrinsic and intrinsic muscle groups of the forearm and hand, the wrist and digital joints are maintained in a balanced position. With the forearm midway between pronation and supination, the wrist dorsiflexed, and the digits in moderate flexion, the hand is in the optimum position from which to function. It may be seen that muscles are usually arranged about joints in pairs so that each musculotendinous unit has at least one antagonistic muscle to balance the

involved joint. To a large extent the wrist is the key joint and has a strong influence on the long extrinsic muscle performance at the digital level. Maximal digital flexion strength is facilitated by dorsiflexion of the wrist, which lessens the effective amplitude of the antag- onistic extensor tendons while maximizing the con- tractural force of the digital flexors. Conversely, a posture of wrist flexion markedly weakens grasping power. At the digital level, metacarpophalangeal joint flex- ion is a combination of extrinsic flexor power supple- mented by the contribution of the intrinsic muscles, whereas proximal interphalangeal joint extension results from a combination of extrinsic extensor and intrinsic muscle power. At the distal interphalangeal joint the intrinsic muscles provide a majority of the

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36 Part I • Foundation of Hand Skills

Ulnar Radial Triangular ligament Lateral band Slip of long extensor to lateral band Dorsal extensor
Ulnar
Radial
Triangular ligament
Lateral band
Slip of
long extensor
to lateral band
Dorsal extensor expansion
Sagittal bands
Lumbrical muscle
Long extensor tendon
Interosseous muscle

A

Sagittal bands Long extensor tendon Dorsal extensor expansion Interosseous muscle Flexor profundus tendon Lumbrical
Sagittal bands
Long extensor tendon
Dorsal extensor expansion
Interosseous
muscle
Flexor profundus tendon
Lumbrical muscle
B
Flexor digitorum superficialis

Central slip of common extensor Lateral band

Long extensor tendon Sagittal bands Interosseous Lumbrical muscle Bony insertion of interosseous tendon on proximal
Long extensor tendon
Sagittal bands
Interosseous
Lumbrical muscle
Bony insertion of
interosseous tendon on
proximal phalanx
Distal movement of
extensor expansion
during flexion
muscle
Lateral band
C

Figure 2-19

metacarpophalangeal joint flexion is shown.

A. Extensor mechanism of the digits. B, C. Distal movement of the extensor expansion with

A03186-Ch02.qxd 17/8/05 3:24 PM Page 37

extensor power necessary to balance the antagonistic flexor digitorum profundus tendon. The distance that a tendon moves when its muscle contracts is defined as the amplitude of the tendon and has been measured in numerous studies. In actuality the effective amplitude of any muscle is limited by the motion permitted by the joint or joints on which its tendon acts. It has been suggested that the amplitude of wrist movers (flexor carpi ulnaris, flexor carpi radialis, extensor carpi radialis longus, extensor carpi radialis brevis, and extensor carpi ulnaris) is approximately 30 millimeters with the amplitude of finger extensors averaging 50 millimeters; the thumb flexor, 50 mm; and the finger flexors 70 millimeters (Figure 2-20). Although these amplitudes have been thought to be important considerations when deciding on appro- priate tendon transfers, Brand (1974, 1999) has shown that the potential excursion of a given tendon such as the extensor carpi radialis longus may be considerably

0 mm 3 mm 16 mm 26 mm (S) 23 mm (P) 16 mm (S)
0
mm
3
mm
16 mm
26 mm (S)
23 mm (P)
16
mm (S)
17
mm (P)
44 mm
5 mm (P)
46
mm (S)
38
mm (P)
88
mm (S)
55 mm
85
mm (P)

Figure 2-20

tendons at various levels. The numbers on the dorsum of the extended finger represent the excursion in millimeters necessary at each level to bring all distal joints from full flexion into full extension. The numbers shown by arrows on the palmar aspect of the flexed digit represent the excursion in millimeters for the superficialis (S) and the profundus (P) necessary at each level to bring the finger from full extension to full flexion. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby. Modified from Verdan C [1979]. Tendon surgery of the hand. London, Churchill Livingstone.)

Excursion of the flexor and extensor

Anatomy and Kinesiology of the Hand • 37

greater than the excursion that was necessary to produce full motion of the joints on which it acted in its original position. Efforts have been made to determine the power of individual forearm and hand muscles and a formula based on the physiologic cross section is generally accepted as the best method for determining this value. The number of fibers in cross section determines the absolute muscle power of a given muscle, whereas the force of muscle action times the distance or amplitude of a given muscle determines the work capacity of the muscle. Therefore a large extrinsic muscle with rela- tively long fibers such as the flexor digitorum profun- dus is found to be capable of much more work than is a muscle with shorter fibers such as a wrist extensor. Table 2-1 is an indicator of the work capacities of the various forearm muscles. It can be seen that the flexor digitorum profundus and superficialis have a signifi- cantly greater work capacity than do the remaining extrinsic muscles. The abductor pollicis longus, pal- maris longus, extensor pollicis longus, extensor carpi radialis brevis, and flexor carpi radialis have less than one fourth the capacity of these muscles. Several mechanical considerations are important in understanding the effect of a muscle on a given joint. The moment arm of a particular muscle is the perpen- dicular distance between the muscle or its tendon and the axis of the joint. The greater the displacement of an unrestrained tendon from the joint on which it acts, the greater is the angulatory effect created by the increased length of the moment arm. Therefore a tendon posi-

tioned close to a given joint either by position of the

joint or by a restraining pulley has a much shorter moment arm than a tendon that is allowed to displace away from the joint (Figure 2-21). In simplifying the biomechanics of musculotendi- nous function, Brand (1974, 1999) has emphasized that the “moment” of a given muscle is the power of the muscle to turn a joint on its axis. It is determined by multiplying the strength (tension) of the muscle by the length of the moment arm. Again, it can be seen that the distance of tendon displacement away from the joint is the critical factor and that it does not matter where the tendon insertion lies. The importance of the various anatomic restraints of the extrinsic musculo- tendinous units at the wrist and in the digits is mag- nified by these mechanical factors.

NERVE SUPPLY

In considering the nerve supply to the forearm, hand, and wrist, understand that these nerves are a direct continuation of the brachial plexus and that at least a working knowledge of the multiple ramifications of the

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38 Part I • Foundation of Hand Skills

Table 2-1

Work capacity of muscles

Muscle

Mkg

Flexor carpi radialis

0.8

Extensor carpi radialis longus

1.1

Extensor carpi radialis brevis

0.9

Extensor carpi ulnaris

1.1

Abductor pollicis longus

0.1

Flexor pollicis longus

1.2

Flexor digitorum profundus

4.5

Flexor digitorum superficialis

4.8

Brachioradialis

1.9

Flexor carpi ulnaris

2.0

Pronator teres

1.2

Palmaris longus

0.1

Extensor pollicis longus

0.1

Extensor digitorum communis

1.7

From Von Lanz T, Wachsmuth W (1970). Praktische anatomie. In JH Boyes, editor: Bunnell’s surgery of the hand, 5th ed. Philadelphia, Lippincott.

plexus is necessary if one is to fully appreciate the more distal motor and sensory contributions of the nerves of the upper extremity. Injuries at either the spinal cord or plexus level or to the major peripheral nerves in the upper extremity result in a substantial functional impairment for which splinting may be necessary. The median, ulnar, and radial nerves, as well as the terminal course of the musculocutaneous, are respon- sible for the sensory and motor transmission to the forearm, wrist, and hand. The superficial sensory distri- bution is shared by the median, radial, and ulnar nerves in a fairly constant pattern (Figure 2-22). This chapter is concerned with the most frequent distribution of

Normal C-1 A-3 C-2 A-4 C-3 A-5 A-2 IAPD A PTE A-1 IAPD PTE 90
Normal
C-1 A-3
C-2 A-4 C-3 A-5
A-2
IAPD
A
PTE
A-1
IAPD
PTE
90
B
Abnormal
% 2 A-4
1
% 2 A-2
1
IAPD
C
PTE
IAPD
PTE
90
D
MA
MA
MA
MA

Figure 2-21

system. A. The arrangement of the annular and cruciate pulleys of the flexor tendon sheath. A, B, Normal moment arm (MA), the intra-annular pulley distance (IAPD) between the A-2 and A-4 pulleys, and the profundus tendon excursion (PTE), which occurs within the intact digital fibroosseous canal as the proximal

interphalangeal joint is flexed to 90°. Annular pulleys:

A-1, A-2, A-3, A-4, and A-5; cruciate pulleys: C-I, C-2, C-3. C, D, Biomechanical alteration resulting from excision of the distal half of the A-2 pulley together with the C-1, A-3, C-2, and proximal portion of the A-4 pulley. The moment arm is increased, and a greater profundus tendon excursion is necessary to produce 90° of flexion because of the bowstringing that results from the loss of pulley support. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby. Modified from Strickland JW [1983]. Management of acute flexor tendon injuries. Orthopaedic Clinics of North America, vol 14. Philadelphia, WB Saunders.)

Biomechanics of the finger flexor pulley

these nerves, although it is acknowledged that variations are common. The palmar side of the hand from the thumb to a line passed longitudinally from the tip of the ring finger to the wrist receives sensory innervation from the median nerve. The remainder of the palm, as well as the ulnar half of the ring finger and the entire small finger, receives sensory innervation from the ulnar nerve. On the dorsal side, the ulnar nerve distribution again includes the ulnar half of the dorsal hand and the ring and small fingers, whereas the radial side is supplied by the superficial branch of the radial nerve. Some inner-

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Anatomy and Kinesiology of the Hand • 39

Median Median Median Ulnar Radial Radial Ulnar nerve Superficial branch of radial nerve Median A
Median
Median
Median
Ulnar
Radial
Radial
Ulnar
nerve
Superficial branch
of radial nerve
Median
A
nerve
B

Figure 2-22

K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Cutaneous distribution of the nerves of the hand. A. Palmar surface. B. Dorsal surface. (From Fess EE, Gettle

vation to an area distal to the proximal interphalangeal joints is supplied by the palmar digital nerves origi- nating from the median nerve. The area around the dorsum of the thumb over the metacarpophalangeal joint is frequently supplied by the end branches of the lateral antebrachial cutaneous nerve. The extrinsic and intrinsic musculature of the fore- arm and hand is supplied by the median, ulnar, and radial nerves (Figure 2-23). The long wrist and digital flexors, with the exception of the flexor carpi ulnaris and the profundi to the ring and small fingers, are all supplied by the median nerve. The pronators of the forearm and the muscles of the thenar eminence, with the exception of the deep head of the flexor pollicis brevis and the adductor pollicis, which are innervated by the ulnar nerve, are also supplied by the median nerve. All muscles of the hypothenar eminence, all interossei, the third and fourth lumbrical muscles, the deep head of the flexor pollicis brevis, the adductor pollicis brevis, as well as the flexor carpi ulnaris and the ulnar-most two profundi, are supplied by the ulnar nerve. The radial nerve supplies all long extensors of the hand and wrist, as well as the long abductor and short extensor of the thumb, the supinator, and the brachioradialis of the forearm. When considering sensibility, one should remember that the hand is an extremely important organ for the detection and transmission to the brain of information relating to the size, weight, texture, and temperature of objects with which it comes in contact. The types of cutaneous sensation have been defined as touch, pain, hot, and cold. Although most of the nervous tissue

in the skin is found in the dermal network, smaller branches course through the subcutaneous tissue fol- lowing blood vessels. Several types of sensory receptors have been described, and in most areas of the hand there is an interweaving of nerve fibers that allows each area to receive nerve input from several sources. In addition, deep sensibility from nerve endings in mus- cles and tendons is important in the recognition of joint position. The high interruption of the median nerve above the elbow results in a paralysis of the flexor carpi radialis, the flexor digitorum superficialis, the flexor pollicis longus, the profundi to the index and long fingers, and the lumbricals to the index and long fin- gers. In addition, pronation is weakened as a result of the loss of innervation of both the pronator teres and quadratus muscles and, most importantly, the patient loses the ability to oppose the thumb because of paralysis of the median nerve-innervated thenar muscle group. A more distal interruption of the median nerve at the wrist level produces loss of opposition and both lesions result in a critical impairment of sensation in the important distribution of that nerve to the palmar aspect of the thumb, index, long, and radial half of the ring finger. High ulnar nerve interruption produces paralysis of the flexor carpi ulnaris, the flexor profundi and lumbricals to the ring and small fingers and, most importantly, the interossei, adductor pollicis brevis, and deep head of the flexor pollicis brevis. The resulting loss of the antagonistic flexion at the metacarpopha- langeal joints of the ring and small fingers permits

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40 Part I • Foundation of Hand Skills

Proper palmar digital nerves Common digital nerves Palmar nerves to thumb Motor (thenar) branch of
Proper
palmar digital
nerves
Common
digital
nerves
Palmar nerves
to thumb
Motor (thenar)
branch of
median nerve
Median nerve
A
Proper palmar
digital nerves
Proper palmar
digital nerve
to fifth finger
Common digital
nerve to ring and
small fingers
Motor (deep)
branch of ulnar
nerve
Ulnar nerve
B

Figure 2-23

(B) nerves in the palm. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis,

Mosby.)

Distribution of the median (A) and ulnar

hyperextension at this level by the unopposed long extensor tendons, often resulting in a claw deformity. The loss of the strong adducting and stabilizing influence of the adductor pollicis combined with the paralysis of the first dorsal interosseous muscle results in profound weakness of pinch and produces a collapse deformity of the thumb, necessitating interphalangeal joint hyperflexion for pinch (Froment’s sign). More distal lesions of the ulnar nerve usually result in a greater degree of claw deformity because of the sparing of the profundi function of the ring and small fingers. Sensory loss after ulnar nerve interruption involves the palmar ring (ulnar half) and small fingers.

Radial nerve lesions at or proximal to the elbow result in a complete wrist drop and inability to extend the fingers at the metacarpophalangeal joints. It should be remembered that paralysis of this nerve does not result in inability to extend the interphalangeal joints of either the thumb or digits because of the contribution to that function by the intrinsic muscles. The sensory deficit over the dorsoradial aspect of the wrist and hand resulting from radial nerve interruption is of much less significance than are lesions to nerves innervating the palmar side. Various combinations of paralyses involving more than one nerve of the upper extremity are frequently encountered; those of the median and ulnar nerve are the most common. High lesions of these two nerves produce paralyses of both the extrinsic and intrinsic muscle groups with total sensory loss over the palmar aspect of the hand. More distal combined median and ulnar lesions have their effect primarily on the intrinsic muscles, resulting in the most disabling deformities with metacarpophalangeal hyperextension, interpha- langeal flexion, and thumb collapse. An inefficient pattern of digital flexion consisting of a slow distal-to- proximal rolling grasp results from the loss of the integrated intrinsic participation.

SKIN AND SUBCUTANEOUS FASCIA

The palmar skin with its numerous small fibrous con- nections to the underlying palmar aponeurosis is a highly specialized, thickened structure with little mobility. Numerous small blood vessels pass through the underlying subcutaneous tissues into the dermis. In contrast, the dorsal skin and subcutaneous tissue are much looser with few anchoring fibers and a high degree of mobility. Most of the lymphatic drainage from the palmar aspect of the fingers, web areas, and hypothenar and thenar eminences flows in lymph channels on the dorsum of the hand. Clinical swelling, which frequently accompanies injury or infection, is usually a result of impaired lymph drainage. The central, triangularly shaped palmar aponeurosis (Figure 2-24) provides a semirigid barrier between the palmar skin and the important underlying neuro- vascular and tendon structures. It fuses medially and laterally with the deep fascia covering the hypothenar and thenar muscles, and fasciculi extending from this thick fascial barrier extend to the proximal phalanges to fuse with the tendon sheaths on the palmar, medial, and lateral aspects. In the distal palm, septa from this palmar fascia extend to the deep transverse metacarpal ligaments forming the sides of the annular fibrous canals, allowing for the passage of the ensheathed flexor tendons and the lumbrical muscles and the neuro- vascular bundles.

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Palmar aponeurosis (reflected) Flexor digitorum superficialis Sheath of flexor pollicis longus Median nerve Ulnar
Palmar aponeurosis
(reflected)
Flexor digitorum
superficialis
Sheath of flexor
pollicis longus
Median nerve
Ulnar
artery
Thenar muscles
Ulnar
nerve
Transverse
carpal ligament

Figure 2-24

reveals septa and underlying palmar anatomy.

Palmar aponeurosis reflected distally

Dorsally the deep fascia and extensor tendons fuse to form the roof for the dorsal subaponeurotic space, which, although not as thick as its palmar counterpart, may prove restrictive to underlying fluid accumulations or intrinsic muscle swelling.

FUNCTIONAL PATTERNS

The prehensile function of the hand depends on the integrity of the kinetic chain of bones and joints extend- ing from the wrist to the distal phalanges. Interruptions of the transverse and longitudinal arch systems formed by these structures always result in instability, defor- mity, or functional loss at a more proximal or distal level. Similarly, the balanced synergism–antagonism relationship between the long extrinsic muscles and the intrinsic muscles is a requisite for the composite func- tions necessary for both power and precision functions of the hand. It is essential to recognize that the hand cannot function well without normal sensory input from all areas. Many attempts have been made to classify the differ- ent patterns of hand function, and various types of grasp and pinch have been described. Perhaps the more simplified analysis of power grasp and precision handling as proposed by Napier (1955, 1956) and refined by Flatt (1979, 1983, 1995) is the easiest to consider.

Anatomy and Kinesiology of the Hand • 41

As generally stated, power grip is a combination of strong thumb flexion and adduction with the powerful flexion of the ring and small fingers on the ulnar side of the hand. The radial half of the hand employing the delicate tripod of pinch among the thumb, index, and long fingers is responsible for more delicate precision function. An analysis of hand functions requires that one consider the thumb and the remainder of the hand as two separate parts. Rotation of the thumb into an opposing position is a requirement of almost any hand function, whether it is strong grasp or delicate pinch. The wide range of motion permitted at the carpo- metacarpal joint is extremely important in allowing the thumb to be correctly positioned. Stability at this joint is a requirement of almost all prehensile activities and is ensured by a unique ligamentous arrangement, which allows mobility in the midposition and provides stability at the extremes. As can be seen in Figure 2-25, the thumb moves through a wide arc from the side of

2-25, the thumb moves through a wide arc from the side of Figure 2-25 with changes

Figure 2-25

with changes in object size. Adaptation takes place primarily at the carpometacarpal joint of the thumb and the metacarpophalangeal joints of the digits. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Progressive alterations in precision grasp

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42 Part I • Foundation of Hand Skills

the index finger tip to the tip of the small finger, and the adaptation that occurs between the thumb and digits as progressively smaller objects are held occurs primarily at the metacarpophalangeal joints of the digits and the carpometacarpal joint of the thumb. For power grip the wrist is in an extended position that allows the extrinsic digital flexors to press the object firmly against the palm while the thumb is closed tightly around the object. The thumb, ring, and small fingers are the most important participants in this strong grasp function, and the importance of the ulnar border digits cannot be minimized (Figure 2-26). In precision grasp, wrist position is less important, and the thumb is opposed to the semiflexed fingers with the intrinsic tendons providing most of the finger movement. When the intrinsic muscles are paralyzed, the balance of each finger is markedly disturbed. The metacarpophalangeal joint loses its primary flexors, and the interphalangeal joints lose the intrinsic contribu- tion to extension. A dyskinetic finger flexion results in which the metacarpophalangeal joints lag behind the interphalangeal joints in flexion. When the hand is closed on an object, only the fingertips make contact rather than the uniform contact of the fingers, palm, and thumb that occurs with normal grip (Figure 2-27). Certain activities may require combinations of power and precision grips, as seen in Figure 2-28. Pinching between the thumb and either the index or long finger is a further refinement of precision grip and may be classified as tip grip, palmar grip, or lateral grip (Figure 2-29), depending on the portions of the pha- langes brought to bear on the object being handled. In these functions the strong contracture of the adductor pollicis brings the thumb into contact against the tip or sides of the index or index and long fingers with digital

sides of the index or index and long fingers with digital Figure 2-26 the thumb, ring,

Figure 2-26

the thumb, ring, and small fingers around the hammer handle with delicate precision tip grip employed to hold the nail. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Strong power grip imparted primarily by

A
A
B
B

Figure 2-27

Uniform areas of palm and digital contact are shaded. B. Intrinsic minus (claw hand grasping the same cylinder). The area of contact is limited to the fingertips and the metacarpal heads. (From Brand PW [1999]. Clinical mechanics of the hand, 2nd ed. St Louis, Mosby.)

A. Normal hand grasping a cylinder.

resistance imparted by the first and second dorsal interossei. The size of the object being handled dictates whether large thumb and digital surfaces, as in palmar grip, or smaller surfaces, as in lateral or tip grasp, are used. Flatt (1972) has pointed out that the dual importance of rotation and flexion of the thumb is often ignored in the preparation of splints, which permit only tip grip because the thumb cannot oppose the pulp of the fingers to produce palmar grip. The patterns of action of the normal hand depend on the mobility of the skeletal arches, and alterations of the configuration of these arches are produced by the balanced function of the extrinsic and intrinsic muscles. Whereas the extrinsic contribution resulting from the large powerful forearm muscle groups is more important to hand strength, the fine precision action imparted by the intrinsic musculature gives the hand an enormous variety of capabilities. Although one need

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A03186-Ch02.qxd 17/8/05 3:24 PM Page 43 Figure 2-28 bottle with precision handling of the bottle top

Figure 2-28

bottle with precision handling of the bottle top by the opposite hand. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby.)

Power grip used to hold the squeeze

A B C
A
B
C

Figure 2-29

B. Palmar grip. C. Lateral grip. (From Fess EE, Gettle K, Philips CA, et al. [2005]. Hand and upper extremity splinting. St Louis, Mosby. Modified from Flatt AE [1974]. The care of the rheumatoid hand, 3rd ed. St Louis, Mosby.)

Types of precision grip. A. Tip grip.

not specifically memorize the various patterns of pinch, grasp, and combined hand functions, it is essential to understand the underlying contribution of the various muscle-tendon groups, both extrinsic and intrinsic, to these activities.

ACKNOWLEDGMENTS

I am extremely grateful to Gary W. Schnitz for many of the excellent illustrations used in this chapter. This chapter has been edited by Elaine Ewing Fess, MS, OTR, FAOTA, CHT for inclusion in this book. The

Anatomy and Kinesiology of the Hand • 43

original unabridged work may be found in Fess EE, Gettle KS, Philips CA, Janson JR (2005). Hand and upper extremity splinting: Principles and methods, 3rd ed. St Louis, Mosby.

REFERENCES

Arey L (1980). Developmental anatomy, 7th ed. Philadelphia, WB Saunders. Basmajian JU (1980). Electromyography—dynamic gross anatomy: A review. American Journal of Anatomy,

159:245–260.

Bell-Krotoski J (1990). Light touch-deep pressure testing using Semmes-Weinstein monofilaments. In J Hunter, L Schneider, E Mackin, A Callahan, editors. Rehabilitation of the hand, 3rd ed. St Louis, Mosby. Blumfield RH, Champoux JA (1984). A biomechanical study of normal functional wrist motion. Clinical Orthopedics, 187:23–25. Bora FW (1986). The pediatric upper extremity. Philadelphia, WB Saunders. Brand PW (1974). Biomechanics of tendon transfer. Orthopedic Clinics of North America 5:202–230. Brand PW, Hollister A (1999). Clinical mechanics of the hand, 3rd ed. St Louis, Mosby. Bunnell S (1944). Surgery of the hand. Philadelphia, JB Lippincott. Cooney W, Linscheid R, Dobyns J (1998). The wrist diagnosis and operative treatment. St Louis, Mosby. Flatt AE (1972). Restoration of rheumatoid finger joint function. III. Journal of Bone & Joint Surgery,

54A:1317–1322.

Flatt AE (1979). The care of minor hand injuries. St Louis, Mosby. Flatt AE (1983). Care of the arthritic hand. St Louis, Mosby. Flatt AE (1995). The care of the arthritic hand, 5th ed. St Louis: Quality Medical Publishing. Lichtman D, Alexander A (1988). The wrist and its disorders. Philadelphia, WB Saunders. Long C, Conrad MS, Hall EA, Furler MS (1970). Intrinsic- extrinsic muscle control of the hand in power grip and precision handling. Journal of Bone & Joint Surgery,

52A:853–867.

Moberg E (1958). Objective methods of determining the functional value of sensibility of the hand. Journal of Bone & Joint Surgery, 40B:454–476. Moore KL (1982). The developing human: Clinically oriented embryology, 3rd ed. Philadelphia, WB Saunders. Napier J (1955). The form and function of the carpometacarpal joint of the thumb. Journal of Anatomy,

89:362.

Napier JR (1956). The prehensile movements of the human hand. Journal of Bone & Joint Surgery, 38B:902–913. Taleisnik J (1976a). Wrist anatomy, function, and injury. American Academy of Orthopedic Surgeons’ Instructional Course Lectures, vol. 27. St Louis, Mosby. Taleisnik J (1976b). The ligaments of the wrist. Journal of Hand Surgery [America] 1:110–118. Taleisnik J (1985a). The wrist. New York, Churchill Livingstone. Taleisnik J (1985b). Carpal kinematics. In The wrist. New York, Churchill Livingstone.

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44 Part I • Foundation of Hand Skills

Taleisnik J (1992). Soft tissue injuries of the wrist. In JW Strickland, AR Rettig, editors: Hand injuries in athletes. Philadelphia, WB Saunders. Weber ER (1982). Concepts governing the rotational shift

of the intercalated segment of the carpus. Orthopedic

Clinics of North America, 15:193–207.

Weber ER (1988). Physiologic bases for wrist function. In

D Lichtman, A Alexander, editors: The wrist and its

disorders. Philadelphia, WB Saunders.

SUGGESTED READINGS

Chase RA (1973). Atlas of hand surgery. Philadelphia, WB Saunders. Chase RA (1984). Atlas of hand surgery, vol. 2. Philadelphia, WB Saunders. Clemente CD (editor) (1990). Gray’s anatomy of the human body, 14th ed. Philadelphia, Lea & Febiger. Hollingshead HW (editor) (1982). Anatomy for surgeons, vol 4. The back and limbs. New York, Harper & Row.

Kaplan EB (1965). Functional and surgical anatomy of the hand, 2nd ed. Philadelphia, JB Lippincott. Landsmere J (1976). Atlas of anatomy of the hand. Edinburgh, Churchill Livingstone. Mackin E, Callahan A, Skirven TM, Schneider L, Osterman AL (editors) (2002). Hunter, Mackin, & Callahan’s rehabilitation of the hand and upper extremity, 5th ed. St Louis, Mosby. Matsen FA, Fu FH, Hawkins RJ (1993). The shoulder: A balance of mobility and stability, Rosemont, IL, American Academy of Orthopedic Surgeons. Morrey BF (2000). The elbow and its disorders, 3rd ed. Philadelphia, WB Saunders. Rasch P, Burke R (1990). Kinesiology and applied anatomy, 9th ed. Philadelphia, Lea & Febiger. Rockwood CA, Matsen FA, Wirth MA, Lippitt SB (editors) (2004). The shoulder, 3rd ed. Philadelphia, WB Saunders. Zancolli E (1968). Structural and dynamic basis of hand surgery. Philadelphia, JB Lippincott.

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Chapter 3 NORMAL AND IMPAIRED DEVELOPMENT OF FORCE CONTROL IN PRECISION GRIP Ann-Christin Eliasson CHAPTER
Chapter 3
NORMAL AND IMPAIRED DEVELOPMENT
OF FORCE CONTROL IN PRECISION GRIP
Ann-Christin Eliasson
CHAPTER OUTLINE
DEVELOPMENT OF MOVEMENT CONTROL
THEORIES
LEARNED MOVEMENTS
AFFERENT INFORMATION
Proprioception
Touch
BASIC COORDINATION OF FORCES DURING
GRASPING
Development of Manipulatory Forces
DEVELOPMENT OF ANTICIPATORY CONTROL
Weight
Size

Friction

ORGANIZATION OF SENSORIMOTOR CONTROL

IMPAIRED FORCE CONTROL AND CLINICAL IMPLICATIONS

Force Coordination

Anticipation of the Properties of Objects

Sensory Information Used for Force Control

SUMMARY

The hand is an effective tool that is used in many different tasks of daily life. The successful performance of manual skills in daily life depends on a complex process incorporating several different aspects of a person’s capability (Figure 3-1). The usefulness of the hand is highly dependent on cognition because one has to understand the value of using one’s hands for a

meaningful purpose. Then the task to be performed has to be encoded and translated into purposeful actions, and these must be performed in the appropriate order. In the last decade, considerable attention has been given to the development of prehensile force control during the manipulation of objects in both healthy children and children with cerebral palsy (CP), as well as attention deficit hyperactivity disorder (ADHD) and other kinds of dysfunctions related to the central ner- vous system (CNS). It is known that integration of somatosensory information is crucial for the fine tuning of motor commands, force regulation, and the build up of memory strategies for grasping and manipulating objects. Coordination of movements and somatosen- sory control develop rapidly during the first years of life. The refinement continues for many years, and adult-like sensorimotor control is not attained until the early teenage years. If somatosensory control is dys- functional, a person is observed to be clumsy to a greater or lesser degree. Furthermore, people’s percep- tions have an effect on their performance of manual skills because their sensory impressions should be trans- lated into meaningful information even for the very simplest of tasks. The perceptual system provides infor- mation about the position of the hand in space, as well as the position of the target, both of which are impor- tant for goal-directed movement. Finally, the musculo- skeletal components are crucial for motor output. Although any movement a person brings about is high- ly dependent on how the CNS plans and organizes the movement, the contractile components of the muscles, bones, and joints are the effectors of the planned move- ment. Another cognitive aspect is motivation, which is closely related to attention and concentration, and all of which have an influence on the successful perform- ance of manual skills. A reduced focus on a task almost certainly limits the ability to learn. Thus self-efficacy

45

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46 Part I • Foundation of Hand Skills

Motivation

Cognition

Task-comprehension

Sensorimotor system

Attention

Task-focus

Task-comprehension Sensorimotor system Attention Task-focus Hand use Perception Self-efficacy Muscles and skeletal

Hand use

Perception

Self-efficacy

Muscles and

skeletal system

Figure 3-1

(2004). Improving the use of the hands in daily activities: aspects of the treatment of children with cerebral palsy. Physical and Occupational Therapy in Pediatrics, 25:37–60.)

Descriptive illustration of components influencing children’s ability to use their hands. (From Eliasson AC

and body image have an impact on one’s ability to perform tasks. Although the performance of manual skills is complex, this chapter discusses how the sensory information received about an object is increasingly well integrated with motor processing during develop- ment, leading to smooth, coordinated movements of the hand. This chapter also describes how impairment, mainly arising from CP, but also from dysfunctions such as those seen in children with ADHD and devel- opmental coordination disorder (DCD) affects sensori- motor control of the hand. Dysfunction or impairment of the CNS almost always affects hand function. There is a continuum of decreasing hand function from being somewhat clumsy to having severe impairment. It seems that the diag- nosis is less important; it is the grade of impairment or dysfunction that is crucial. Children with CP have different degrees of impaired hand function. Some children only have difficulty performing differentiated finger movements or in-hand manipulation, whereas others have severe impairments that make it impossible even to grasp an object. Most children with ADHD have fairly good hand function, but when DCD is present also, the clumsiness is more apparent. Regard- less of the degree of severity, decreased hand function has an impact on children’s daily self-care or school activities, and it affects their engagement in play or leisure. The ability to analyze a child’s capacity to use his or her hands and compare the child’s capabilities with the complexity of the task is a prerequisite for intervention planning. This chapter explains the under- lying causes of the impairment or clumsiness apparent in children with impairment or dysfunction in their CNS. By understanding the mechanisms normally responsible for controlling movements, intervention that takes into consideration the mechanism control- ling manual skills can be planned. Some examples of this are given later in this chapter.

DEVELOPMENT OF MOVEMENT CONTROL THEORIES

At the beginning of this century, sensory stimuli were thought to be responsible for the generation of move- ments. This concept was based on studies by Mott and Sherrington (1895) on deafferented monkeys. By transecting the dorsal roots, researchers cut sensory fibers and left the motor fibers intact. The complete sensory loss resulted in permanent abolishment of almost all voluntary movements, especially in the distal segments. A model was proposed in which the move- ments were generated by chain reflexes; the sensory information from the first muscle contraction elicited the subsequent spinal reflex. This reflex origin of movement was disputed by Brown (1911), who studied locomotion in spinal cats. He suggested instead a central origin in which neuronal networks could generate basic locomotor activity in the absence of sensory information (half center model). The task of the afferents was restricted to modifying and compensating for ongoing movements. However, it took quite a long time before this idea was con- firmed. Nowadays there are several elegant studies that indicate that innate neural networks control rhythmic motor behavior in a variety of species such as locusts, lampreys, and cats (Forssberg, Grillner, & Halbertsma, 1980; Forssberg et al., 1980; Grillner, Wallen, & Brodin, 1991; Wilson, 1964). Neural networks, called central pattern generators (CPGs), consist of a group of inter- neurons that interact in an organized manner to pro- duce a motor act. Detailed knowledge of how one CPG operates has been demonstrated in the lamprey, a prim- itive vertebrate fish. The lamprey is especially suited for such studies because the spinal cord survives in vitro for several days, and neurons involved in the locomotor network for swimming are visible under the micro-

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Normal and Impaired Development of Force Control in Precision Grip • 47

scope, which facilitates microelectrode recording. The swimming can be initiated by stimulation of specific areas in the brainstem, sensory stimuli if some skin areas are left innervated, and bath-applied excitatory amino acids. Information about the networks also has been used for computer simulation (Grillner et al., 1991). The central origin of motor behavior has been fur- ther demonstrated in other rhythmic movements, such as mastication, swallowing, and respiration (Feldman & Grillner, 1983; Lund & Olsson, 1983; Miller, 1972). Swallowing occurs after the denervation of muscles activated early in the sequence, indicating that the brain sets the motor program for the whole motor act in advance. However, this does not diminish the impor- tance of afferent signals for modulation and learning of movements. Movements are activated by efferent signals from several higher levels of the CNS, which are modulated by afferent signals from the sensory system and by visual, auditory, and somatosensory information. There are many reasons to believe that the human nervous system is organized in the same way. Sponta- neous movements in the human fetus appear from the eighth gestational week, just after the first functional synapses between neurons are developed. The move- ments seem to be generated by neural networks, and the afferents may not be needed for initiating the movements but are used mainly to adjust and com- pensate for disturbances (de Vries, Visser, & Pechtl, 1982; Okado, 1980, 1981). Innate motor programs, such as breathing, sucking, and swallowing, function at birth. The complex pattern of infant stepping also is innate, but this program is immature in the newborn and cannot be used for independent walking until the child has learned to control and adjust the patterns to external conditions. The system develops both through practice and by the process of maturation, in which connections with higher central and afferent sensory input continue to be established. This is the concept from which new therapeutic approaches are developed.

LEARNED MOVEMENTS

Voluntary movements in humans are complex. It is difficult to demonstrate a simple fixed pattern from a CPG, although skilled movements appear to depend on a set of motor programs. According to Brooks (1986),

“Motor programs are a set of muscle commands that are structured before the motor acts begin and that can be sent to the muscles with the correct timing so that the entire sequence can be carried out in the absence of peripheral feedback” (p. 7),

or, in other words, can follow an initial plan. In well- learned, fast movements the trajectory exactly follows this initial plan. The initiation and termination are

planned together, and the movements are almost impossible to stop until completed. This is true, for example, when throwing a ball and in more complex actions, such as typing. Even continuous movements of moderate speed, such as handling well-known objects, are programmed but allow some amount of sensory feedback. Both kinds of movements are called antic- ipatory or feed-forward controlled movements, with the characteristic bell-shaped, single-peaked velocity profile (see later discussions). Slow movements generally are not programmed, allowing time for correction of the ongoing movement by afferent signals, and demonstrated by a discon- tinuous velocity profile (Brooks, 1986). The motor programs are learned by practice when the afferent infor- mation adjusts the ongoing movement and updates the motor program for the final movement. The impor- tance of sensory information is demonstrated by bird- song learning in the European chaffinch. Normally, the young birds are exposed to singing by their mothers but do not start singing themselves until 10 months of age. If the birds are not exposed to the adult song, they produce only rudimentary sequences. If the birds are exposed to adult song during the first 4 months of life and then isolated from songs during the month after, they start to sing properly. This indicates that auditory experience is necessary for the motor program to be fully developed. If the birds are deafened after 4 months but before they start to sing, they sing in a very awk- ward way. Deafening after they start to sing, however, does not affect the song. This indicates that birds also must compare the initial motor program for singing with the actual song, that is, afferent information also is necessary to be able to learn to use the program of singing. The afferent information corrects the song and updates the program, which could be used without afferent feedback when the song was established (Konishi, 1965; Nottebohm, 1970).

AFFERENT INFORMATION

The importance of afferent information is seen in patients with large sensory fiber neuropathies, in which the large afferent fibers generating proprioceptive and tactile information degenerate. Unless these patients see their limbs, they do not know their position and cannot detect limb motion. When reaching toward a target without seeing the moving hand, they make large errors; if they look at the hand before reaching, the hand comes closer to the target. This indicates that these patients can compensate for the lack of somato- sensory information visually and also use vision to program the reaching in advance. Because the patients cannot stop the movement precisely at the desired

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48 Part I • Foundation of Hand Skills

target, information from various receptors in the skin is essential for precise movements (Ghez et al., 1990). Impaired sensation is also common in children with hemiplegic CP and has to be taken into account when planning treatment.

PROPRIOCEPTION

The proprioceptive system gives information about the stationary position of the limbs (limb position sense) and movements of the limb (kinesthesia). The latter information is mediated from tendon organs and mus- cle spindles and also from receptors in the skin, sensitive to skin stretch. The tendon organ signals information about the strength of muscle contraction, increased signaling indicating increased tension. Signals from the muscle spindle regulate the length of the muscle fibers. The receptors are rather complicated and, despite inten- sive research, their function is not fully understood. It has been agreed, however, that the muscle spindle is responsible for small changes in muscle contraction, which may be important for force regulation during the grasping act. There are muscle spindles in almost all skeletal muscles, and they mediate information mainly through 1a afferents to the spinal cord. The muscle spindle also has efferent innervation to intrafusal mus- cle fibers, in which the primary and secondary endings set the sensitivity to the afferent signals. The different contractions of intrafusal muscle fibers are probably crucial for the information sent to the CNS. Alpha and gamma motor neurons are co-activated by central mechanisms to maintain the sensitivity of the muscle spindles throughout the range of almost all move- ments. There have been different models for the co- activation of alpha and gamma motor neurons, but it appears that descending commands activate both, as demonstrated by Vallbo (1970) in studies of micro- neurography. The afferent signals are used to update and correct the motor programs, and the information can be used in a conscious way to give knowledge about the limb movement and position in space.

TOUCH

The tactile system is used to discriminate between different surfaces and shapes and also provides sensory input to the CNS, which regulates the force of the muscles during grasping and holding of objects. Touch transmits nerve impulses from mechanoreceptors to the CNS via axons with different diameters. Large fibers with a fast conduction rate mediate tactile sensation from the skin, whereas thin fibers with a slow con- duction rate mediate sensation of pain and tempera- ture. The receptors mediating tactile sensation can be classified on the basis of their receptive fields and

morphology: Two receptor types, Meissner and Pacini corpuscles, are fast adapting; Meissner corpuscles have small, sharply delineated sensory fields; and Pacini corpuscles have large and diffuse sensory fields. Two other types of receptors that are slow-adapting units are Merkel corpuscles, with small and sharply delineated sensory fields, and Ruffini corpuscles, with large and diffuse fields. Mechanoreceptors with small receptive

fields are suitable for fine spatial discrimination because they have a high sensitivity over the entire field, whereas mechanoreceptors with large receptive fields have a central area of high sensitivity and decreased sensitivity

in the border of the receptive field. Because there are

about 17,000 tactile units in the hand and approxi- mately 70% of them have small receptive fields, it can

be postulated that the tactile system of the hand is highly developed to detect small movements and dis- criminate among different surfaces (Johansson & Vallbo, 1983). People explore the surface of an object by manip- ulation of the fingers. The difference between explor- ing known and unknown surfaces is the speed of the finger movements (Roland, Ericsson, & Widen, 1989).

A relevant movement for exploring the different sur-

faces of an object is by touch through digital manip- ulation, whereas a more adequate way to explore the shape is by rotation of the wrist and bimanual hand activity. The fingertips are very sensitive to tactile infor- mation, and tactile discrimination occurs early during development. One-year-old children can recognize

dissimilar objects, and they are able to use the two different exploratory maneuvers for objects differing in texture or shape (Ruff, 1984). Newborn monkeys can distinguish different textures by choosing the texture that gives milk (Carlson, 1984). These examples indi- cate that, despite an immature nervous system, there is early interaction between somatosensory signals and motor output.

BASIC COORDINATION OF FORCES DURING GRASPING

During the last decade Johansson and Westling (1984, 1987, 1988, 1990) have studied grasping movement

to understand how somatosensory information is inte-

grated with motor control. In adults, movements of the hand and fingers are precise and the forces of the

fingers well controlled. This is not an innate behavior;

in fact, these functions develop during early childhood

and may be dysfunctional if there is impairment in the CNS (Eliasson & Gordon, 2000; Eliasson, Gordon, &

Forssberg, 1991, 1992, 1995; Forssberg et al., 1991, 1992, 1995, 1999; Gordon et al., 1992).

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Normal and Impaired Development of Force Control in Precision Grip • 49

Most grasping acts involve lifting and holding objects, grasping with the fingers, and lifting with the arm. The object seen in Figures 3-2 and 3-3 measures grip force from each grip surface (thumb and index finger), a combined vertical load force by strain-gauge transducers, and vertical movement by a photoresistor (Eliasson et al., 1991). With this instrument it has been possible to define different phases of the lift and under-

stand how they are linked to produce smooth move- ments. When grasping the instrument, there is a short delay before the vertical load force starts to increase. This preload phase is important for establishment of the grasp. During the loading phase the grip and load forces increase in parallel until the instrument starts to move. The rates of grip and load forces have mainly bell-shaped profiles (see later discussion) adjusted to

bell-shaped profiles (see later discussion) adjusted to Figure 3-2 Child lifting the experimental object. Figure 3-3

Figure 3-2

Child lifting the experimental object.

to Figure 3-2 Child lifting the experimental object. Figure 3-3 without any visual changes. Experimental

Figure 3-3

without any visual changes.

Experimental instrument in which the grip surfaces are exchangeable and the weight can be covaried

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50 Part I • Foundation of Hand Skills

the weight, size, and frictional character of the surface of the object. After the loading phase there is a transi- tion phase, in which the lift reaches the final position and the forces are well adjusted to the current prop- erties of the object. In the final static phase the object is held in the air (Figure 3-4). Tactile information triggers different motor com- mands and links the different phases together. The different types of receptors respond differently during the lift, which has been demonstrated by microneu- rography from single tactile units innervating the glabrous skin of the fingers. Fast-adapting receptors send bursts of impulses when first touching an object,

at the beginning of the loading phase and at lift-off but are silent during the static phase. Slow-adapting recep- tors send impulses continuously during the static phase (Johansson & Vallbo, 1983). This ability makes it pos- sible to handle small fragile objects without crushing them. To investigate how separate components affect the grasping act, the object has a slot in which blocks of different weights may be inserted while the visual appearance remains constant; the contact pads can be covered with silk or sandpaper, each having different frictional character, and the size can be adjusted by boxes of different size attached to the instrument (see Figure 3-3).

1 Year

6 Years

Adult

4 N 2 N 40 mm 40 N/S Cerebral Palsy
4 N
2 N
40
mm
40
N/S
Cerebral Palsy

0.2s

Grip Force, N

Load Force, N

Position, mm

Grip Force

Rate, N/S

Grip Force

Load Force

Grip Force

Rate, N/S

3 N

3 N

40 N/S

Figure 3-4

palsy with various degree of severity. Grip force, load force, position, and grip force rate are shown as functions of time. When lifting the object, the grip force starts to increase; then the grip force and load force increase until the object starts to move. When the forces overcome gravity, the signal measuring position increases, followed by a static phase when the object is held in the air. (Modified from Forssberg H, Eliasson AC, Kinoshita H, Johansson RS, Westling G [1991]. Development of human precision grip. I. Basic coordination of force. Experimental Brain Research, 85:451–457; Forssberg H, Eliasson AC, Redon-Zouiteni C, Mercuri C, Dubowitz L [1999]. Impaired grip-lift synergy in children with unilateral brain lesions. Brain,

Superimposed traces of representative lifts performed at different ages and in three children with cerebral

122:1157–1168.)

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Normal and Impaired Development of Force Control in Precision Grip • 51

DEVELOPMENT OF MANIPULATORY FORCES

During the loading phase, just before the movement starts, the grip and load forces are generated in parallel for coordinated movements. This parallel increment of both grip and load force increases with heavier objects, resulting in prolonged latency until lift-off. If the contact surface changes, the grip force increases more for slippery materials compared with rough materials, whereas the load force remains the same. Still the forces increase in parallel but with different slope. This par- allel force generation forms a lifting synergy to simplify movements (Bernstein, 1967). It develops from the second year when the pincer grasp is fully developed. Smaller children cannot generate grip and load forces in parallel; they initiate forces sequentially. This is clearly seen in Figure 3-5; most of the grip force increases before the onset of load force. The force rate profile is irregular and has several peaks in young children, whereas older children and adults perform mainly a bell-shaped force rate profile, adjusted to the

weight of the object at lift-off, indicating anticipatory controlled movements (Brooks, 1986; Forssberg et al.,

1991).

Small children also have more variation than adults because they cannot repeatedly produce similar move- ments. However, 1-year-old children can use tactile and proprioceptive information to adjust the forces by sensory feedback during the static phase. All phases are prolonged, and the different phases are not triggered elegantly as in adults (Forssberg et al., 1995). There is an increased difference between thumb and finger contact, probably because of an immature ability to adjust the finger toward the object’s size (von Hofsten & Ronnquist, 1988). This uncoordinated movement in small children is likely attributable to immature motor output and sensory processing. There is rapid devel- opment until age 2. The refined coordination then progressively develops until leveling out at ages 4 to 6 and continues gradually until the teenage years, when the lifts are completely adult-like (see Figure 3-4) (Forssberg et al., 1991).

Grip Force 2 N Load Force 2 N 8 Months 2 Years Adult 4 N
Grip Force
2 N
Load Force
2 N
8 Months
2 Years
Adult
4 N
DIPLEGIA
HEMIPLEGIA

Figure 3-5

of different ages and children with cerebral palsy. Trials are superimposed for each subject. (Modified from Forssberg H, Eliasson AC, Kinoshita, H, Johansson RS, Westling G [1991]. Development of human precision grip. I. Basic coordination of force. Experimental Brain Research, 85:451–457; Eliasson AC, Gordon AM, Forssberg H [1991]. Basic coordination of manipulative forces in children with cerebral palsy. Developmental Medicine and Child Neurology, 33:661–670.)

Grip force during the preload and the loading phase (before lift-off) is plotted against load force in children

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52 Part I • Foundation of Hand Skills

DEVELOPMENT OF ANTICIPATORY CONTROL

Anticipatory control of manipulation apparently requires the nervous system to efficiently use sensory information to integrate and store information for internal representation or memory representation of an object. This internal representation is necessary to produce rapid and well-coordinated transitions between the various movement phases because of a long delay between motor command and sensory feed- back. This is true for reaching, grasping, and lifting movements, as well as for movement involving the whole body. In the lifting task the motor output is based on internal representation of the object’s prop- erties learned by prior experience of the weight, friction, size, and haptic cues of the object (Gordon et al., 1991a,b; Johansson & Westling, 1990).

WEIGHT

When the weight of the object is varied but the visual appearance remains constant, adults typically scale the grip and load force rates based on earlier experience of the object’s weight. This is indicated by higher grip and load force rates for heavier objects. The forces are decreased at lift-off to harmonize with the weight of the object. The anticipatory mechanism can be further demonstrated when lifting an unexpectedly light object. For example, if one lifts an unopened but empty can of soda, the lift will probably be too high because a heavier can is expected. However, this occurs only once for the same can. Somatosensory information adjusts the forces to the object’s actual weight during the static phase and updates the internal representation of the object for a smooth movement the next time the object is lifted. Children cannot handle this type of situation as efficiently as adults. However, despite uncoordinated force generation and large variation of grip and load force rates, 2-year-old children start to scale the forces toward different weights. It takes several years until the anticipatory control of weight is fully developed. Children between the ages of 6 and 8 are nearly adult- like although the variation is still larger than in adults (Figure 3-6). This indicates that anticipatory scaling of forces occurs in conjunction with maturation of coordinated movement (Forssberg et al., 1992).

SIZE

Anticipatory control also is predicted from visual infor- mation about an object’s size (Gordon et al., 1991a,b). When the object is kept proportional to the volume,

A

B

200 800 100 80 60 40 20 0 4 3 2 1 0 Age (yrs)
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800
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60
40
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1-2 2-4 4-6 6-8 8-11
11-15 Adult
Peak Grip Force Rate (N/s)Acceleration
(N/s 2 )

Figure 3-6

(400 g for 1- to 2-year-old children) in the constant lifting series for peak grip force rate (A) and peak acceleration (B). The means and standard error of means of the individual means for each subject indicate the major changes during development. (Modified from Forssberg H, Kinoshita H, Eliasson AC, Johansson RS, Westling G [1992]. Development of human precision grip. II. Anticipatory control of isometric forces targeted for object’s weight. Experimental Brain Research, 90:393–398).

Influence of the 200- and 800-g weight

there are appropriately scaled forces toward the expected weight relative to the volume. When only the size of the object is co-varied and the weight is kept constant, the employed grip force rate is higher for the larger than the smaller object. However, adults and older children perceive the small objects as heavier. This indicates a dichotomy between the perceptual and motor systems because of the size-to-weight illusion (Charpentier, 1891). People predict a big object to be heavier than a small one, yet this is not always true. This understanding of the discrepancy between size and weight and a proper scaling of the motor output starts to develop at 3 years. Children younger than 3 are not able to control the motor output according to size but do use a higher grip force rate for heavier

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Normal and Impaired Development of Force Control in Precision Grip • 53

objects. This suggests that the associative transforma- tion between the object’s size and weight involves additional demands of cortical processes, requiring fur- ther cognitive development. In children 3 to 7 years of age the difference between large and small objects is greater than in adults. Older children seem capable of reducing the effect if it is not purposeful for manip- ulation, whereas younger children still strongly rely on visual information (Gordon et al., 1992).

FRICTION

Tactile influence on the force coordination is available on touching an object, contrary to weight influence, which is not available until lift-off. Tactile information from fingertips triggers prestructured motor com- mands based on sensorimotor memories and adjusts the force coordination based on the friction of the contact surface. The employed grip forces are different when one holds a slippery bottle than when holding a tool covered with rubber, even if they have the same weight. When contact pads on the test object are altered by exchangeable contact surfaces of silk and sandpaper, the relationship between grip force and load force is changed before lift-off. In adults there is an initial adjustment to the new frictional condition during the first 0.1 second and secondary adjustments during the loading and static phases (Johansson & Westling, 1987). These adjustments are important in establishing an adequate safety margin, which prevents one from dropping the object. The ratio between grip and load force actually used, minus the slip ratio necessary to prevent the object slipping out of the hand, makes up the safety margin. One-year-old children have a larger safety margin than adults. Gradually, the safety margin decreases in conjunction with increased coordination and less variability during the first 5 years (Figure 3-7). Some children of 18 months can scale the grip force based on tactile information in the beginning of the lift. They have a higher grip force for slippery materials than for rough ones during consecutive lifts with the same friction. Several years are necessary before children can handle objects with different frictional surfaces in the same elegant way as adults. Children younger than 6 years of age, sometimes up to 10 or 12 years, need several lifts and a predictable order to adjust the grip force to the current friction and form an internal representation before setting the parameters of the programmed motor output. The difference between adaptation to weight and adaptation to friction is that frictional conditions appear directly upon touching the object, whereas weight information is likely more crucial for anticipatory control because the weight is not available until lift-off. Grip forces of high amplitude

Safety Margin 300 sp si 250 200 150 100 50 0 Age (yrs) 1-2 2-3
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300
sp
si
250
200
150
100
50
0
Age (yrs)
1-2 2-3 3-4 4-5 5-6 6-10
11-15 Adult
Percent

Figure 3-7

individual means of the safety margin for lifts with sandpaper and silk plotted for different age groups. The safety margin is expressed in percent of the slip ratio. Significant differences are indicated by an asterisk (p < 0.05). (Modified from Eliasson AC, Gordon AM, Forssberg H [1995]. Tactile control of isometric finger forces during grasping in children with cerebral palsy. Developmental Medicine and Child Neurology, 37:72–84.)

The mean and standard deviation of

are a useful compensatory strategy to avoid dropping objects (Forssberg et al., 1995).

ORGANIZATION OF SENSORIMOTOR CONTROL

These studies have enhanced our knowledge of the mechanisms underlying sensorimotor integration and anticipatory control in a grasping task. The model implies that for this manipulatory act visual, tactile, and proprioceptive information are integrated with memo- ries of similar objects from previous manipulative expe- rience. The appropriate muscles are then activated in the proper sequence based on the internal memory representation of the object, resulting in a well timed and coordinated grasping and lifting act. The act includes selection of motor programs that control ori- entation of the hand and the subsequent limb trajec- tories. These programs may be stored in sensorimotor (procedural or implicit) memory and used in an uncon- scious way, different from declarative (explicit) memory that is used in conscious recall of facts, events, and percepts (Squire, 1986) (see Chapter 6). The existence of sensorimotor memory has been demonstrated by disorders in higher brain function. It seems that net- works involving cortical function, especially posterior parietal cortex, are important for anticipation. Jeannerod

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54 Part I • Foundation of Hand Skills

(1986) has described deficit in shaping the fingers toward the size of the object in patients with damage to the parietal area. The maturation of control mechanisms for the grasping movement continues throughout childhood. All measured parameters rapidly develop during the first years. Force coordination is poorly developed in 1- year-old children; for example, they usually crush an ice cream cone, whereas children of 2 years manage quite well. There is a continuum of improvement of the parallel generation of grip and load forces as well as scaling of the forces toward the object’s different weight and friction. In 4-year-old children the motor output becomes less varied and more coordinated, in conjunction with a decreased safety margin. Children have more coordinated and adjusted movements and are able, for example, to carry a kitten and handle fragile objects. At that age there is even force scaling to the size of the object. However, the appropriate antici- patory scaling with acceleration of the lift to harmonize with the weight of the object is not developed until 6 to 8 years of age. Even so, there are still large variations in the ability to properly scale the forces according to frictional demands. It is not until ages 10 to 12 that scaling approaches adult levels. Efficient control of finger movements continues to develop until adoles- cence, when children can learn to play musical instru- ments and develop good handwriting with accurate speed. Obviously, there is parallel processing of cogni- tive functions and sensorimotor control during normal development. The maturation processes probably occur at many levels. Both the motor cortex and corticospinal tract with monosynaptic connections are important for pre- cision grip and are highly related to force generation. In monkeys the monosynaptic projections to the spinal cord are not fully developed until the end of the first year (Lawrence & Hopkins, 1976). Myelination of the axons and increased conduction rate of cortical motor neuronal activity develop over several years and prob- ably influence the temporal parameters of the lift (Muller, Hornberg, & Lenard, 1991). Because many areas of the brain are apparently involved in the grasp- ing act, its full development obviously depends on establishment of appropriate synaptic connections between the cortex and all other areas associated with the act. These maturation processes are shown by reor- ganization of reflex responses with more efficient and faster triggering, which continues until adolescence (Evans, Harrison, & Stephens, 1990; Forssberg et al., 1991; Issler & Stephens, 1983). There are cortical net- works mediating monosynaptic corticospinal projec- tions to the motor neurons controlling distal muscles (Fetz & Cheney, 1980; Muir & Lemon, 1983), which

are active in fine manipulation and force regulation (Smith, 1981; Wannier, Toltl, & Hepp-Reymond, 1986). There may exist subcortical motor centers and even networks in the spinal cord important for storing certain motor acts; for example, the C3-C4 proprio-

spinal system in cats can be used to mediate and update cortical commands for visually guided reaching (Alstermark et al., 1987). This provides several solu- tions for a particular movement through a wide range of central and peripheral inputs. During development there may be reorganization of networks in the spinal cord caused by increased descending control on pre- motor neurons. The descending control may break up the innate grasp reflex synergy allowing independent finger movement and may form a grip/lift synergy (Forssberg et al., 1991). Learning motor activities proceeds by trial and error;

it is not really understood how the information from

subsequent lifts is stored in memory to result in effi- cient programming. It is known that the anterior lobe of the cerebellum is involved in force regulation before

a lift because the amplitude of the force is correlated

with activity in neurons in this region, which has cuta- neous and muscle afferent inputs from the hand (Espinoza & Smith, 1990). There are radical changes in synaptic activity, reflected in regional cerebral blood flow, during learning of motor sequence for finger movements. In the initial part of learning there is activation of the cortical areas, cerebellum, and struc- tures providing information to those areas, namely the anterior language area and somatosensory association areas. As learning progresses, the activation in the lan- guage areas of the cortex disappears, leaving a reduced region in the somatosensory area, whereas different motor structures and the cerebellum show consistent increase in activity. This may mean that motor pro- grams for motor sequence learning of finger move- ments are established and can be produced in a feed-forward strategy with less sensory information. It appears that memories are not stored in a single cell or in one particular cortical structure (Seitz et al., 1990).

IMPAIRED FORCE CONTROL AND CLINICAL IMPLICATIONS

Clumsiness or impaired hand function may have dif- ferent origins. The most common diagnoses of devel- opmental disorders in children are ADHD, DCD, and CP. Although of different origin, they are all associated with more or less impaired force control during grasping (Eliasson et al., 1991; Forssberg et al., 1999; Pereira, Eliasson, & Forssberg, 2000). The dysfunction

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could be seen as a continuum, with clumsy children at one end and severely impaired children with CP at the other. Children with CP have disturbed hand function because the primary or secondary lesions involve the sensorimotor cortex and the corticospinal tract, both of which have great implication for the performance of precision grips and for independent finger movement (Lawrence & Kuypers, 1968; Muir & Lemon, 1983) (see also Pehoski, Chapter 1). These children are known to be slow and weak with disturbed mobility of their finger movements (Brown et al., 1987; Ingram, 1966). In addition, they have different degrees of spasticity and tactile discrimination, especially those children with hemiplegic CP (Brown et al., 1987; Uvebrant, 1988). Little is known about the neural mechanisms that cause the impaired motor behavior in children with ADHD. The main problems are hyper- activity and poor attention, as indicated by the name, but about half of the children who have been diag- nosed with ADHD also have motor problems (Barkley, 1990; Kadesjö & Gillberg, 1998). In particular, their fine motor skills are diminished (Szatmari, Offord, & Boyle, 1989; Whitmont & Clark, 1996), affecting, for example, their handwriting and performance on other highly skilled tasks (Doyle, Wallen, & Whitmont, 1995; Raggio, 1999). DCD is characterized by minor motor problems that occur as an isolated phenomenon in some children (American Psychiatric Association, 1994), which is to say that the minor motor problems appear without the symptoms attributable to ADHD but also can be found in conjunction with ADHD. These DCD children in the past were called “clumsy children” or children with motor coordination prob- lems. The cause of the dysfunction is unknown but the group generally can be distinguished from typically developed children from the results of a test like the Movement ABC (Henderson & Sugden, 1992). As indicated, dysfunctioning prehensile force control is common to all children with ADHD, DCD, and CP.

FORCE COORDINATION

When making a lift, the temporal pattern is rarely impaired in children with ADHD regardless of whether or not the ADHD is accompanied by DCD (Pereira et al., 2000); for children with CP, it is almost always disturbed to some degree. In these children the differ- ence in the time at which the first finger or thumb makes contact with the object and the time at which the second finger makes contact is larger than in typi- cally developing children, indicating disturbed coordi- nation of finger movement and shaping of the fingers toward the size of the object, although there is a great deal of variation within the group, from almost as good

as the average of the control group to severely impaired (Eliasson et al., 1991; Forssberg et al., 1999). The parallel grip and load force typical of normal develop- ment rarely is seen. Instead, the forces increase sequen- tially with the grip force increasing before the load force (see Figure 3-5). Consequently, they do not produce the force rates in mainly bell-shaped profiles, but in stepwise, irregular, and extremely variable pro- files (see Figure 3-4). However, this slow, sequential initiation of movements is an adequate strategy pro- viding security in a manipulative task in which the coordination of force generation is not fully functional. For both groups of children (ADHD and CP), the grip force is larger and more unstable when performing a lift than it is for controls, in addition to which there is more variability between one lift and another (see Figure 3-4) (Eliasson et al., 1991). This large variability seems to be a characteristic of immaturity, as well as of dysfunction and impairment. It means that the children cannot repeat a task in the same way, or transfer the experience of performing one task to the performance of a similar one, making their performance unpre- dictable or clumsy. The relation between the develop- ment of force control and the severity of hand function has been demonstrated previously (Forssberg et al.,

1999).

However, the slow performance commonly observed in children with CP may be a good adaptation to their impairment. An example of the usefulness of such slow and sequential movement is evident when one con- siders the impaired release of the grasp. When effi- ciently putting down and releasing an object, including toys, the object has to be lowered and placed on a surface, not too quickly and not too slowly. This neces- sitates a low velocity of the movement close to the surface on which the object is to be placed (Figure 3-8). Then the force of the grasp ceases and the indi- vidual fingers are removed quickly and almost simul- taneously. In a hemiplegic hand, a reversed pattern is found: The placement is performed fairly quickly, and the velocity of the movement is high upon making contact with the table, making the movement abrupt. Then it is hard for the child to decrease the force, resulting in a prolonged movement phase during which the fingers are released one at a time in an uncoor- dinated manner (see Figure 3-8) (Eliasson & Gordon,

2000).

How can this knowledge be used in clinical practice? The case of a 4-year-old girl with hemiplegia playing with small plastic animals is one example. Every time she tried to lift and then place the horse, it fell. It was obvious that she was releasing the object too abruptly. By giving a simple instruction, “Straighten your fingers slowly,” she had the clue she needed to immediately

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56 Part I • Foundation of Hand Skills

Control CP T0 T1 T2T3 T0 T1 T2 T3 Grip force (ind) Grip force (th)
Control
CP
T0
T1
T2T3
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Grip force (th)
6 N
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2 mm/s 2
1 sec

Figure 3-8

position, velocity, and acceleration as a function of time for representative trials during object replacement and release for one child in the control group and one child with hemiplegia. The grip and load force rates are shown using a ±20 point numerical differentiation. Vertical lines indicate the initiation of vertical displacement (T0), object contact with the table (T1), release of one digit (T2) and then the opposing digit (T3). The measured force parameters are shown by arrows indicating peak velocity (F1), peak load force rate corresponding to table contact (F2), minimum grip force rate (F3), grip force at replacement (F4), grip force at table contact (F5), and grip force at load force zero (F6) (dashed line in the right traces). (Modified from Eliasson AC, Gordon AM [2000]. Impaired force coordination during object release in children with hemiplegic cerebral palsy. Developmental Medicine in Child Neurology, 42:228–234.)

Grip force from the index finger (ind) and thumb (th), grip force rate, load force, load force rate, vertical

succeed. By analyzing her performance in the light of the knowledge that the hand of the child with hemi- plegic CP has impaired force coordination, the thera- pist was able to give the girl precise information. The therapist recognized that although she appeared to be slow when replacing the horse, she was not slow enough in the crucial part of the action—when she had to loosen her grasp. That part had to be performed even more slowly, and she was able to succeed by increasing her awareness of that part of the movement sequence. Normally this behavior is performed in an uncon- scious way (i.e., by implicit processes) (Gentile, 1998). However, after a lesion has occurred in the CNS, it may be necessary to use an explicit process, at least in the early stage of learning. Knowledge about normal and abnormal behavior and the ability to analyze the task made it possible to give precise instructions. The idea was to help the child to learn how her impaired nervous system works and give her a strategy that could enable her to perform this task successfully; then she might be able to use the same strategy when releasing other objects in different situations (Eliasson, 2005).

ANTICIPATION OF THE PROPERTIES OF OBJECTS

During normal development small children are able to scale the force that needs to be applied when gripping an object even before the action starts, taking into account the weight and friction, as well as the size of the object. This happens even before the typical parallel force coordination with the mainly bell-shaped force rate profile is developed. Hardly any of the children with CP who were aged 6 to 8 years, or the children with ADHD plus DCD who were 9 to 15 years, scaled the force amplitude appropriately for different weights, whereas children with only ADHD anticipated the weight fairly well (Eliasson et al., 1992; Pereira et al., 2000). This indicates that a different type of dysfunc- tion (diagnosis), at least on a group level, influences the ability to scale the motor output. Although children with ADHD plus DCD can apply an appropriate force the first time they lifted a familiar object such as a glass, or an unopened packet of milk, they cannot do this efficiently with an unfamiliar object, when they have only seen but not touched or lifted it (Pereira

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Normal and Impaired Development of Force Control in Precision Grip • 57

et al., 2000). Appropriate force involves anticipatory scaling. That means that when heavier and larger objects such as an unopened packet of milk are to be lifted, the child increases the load force at a greater rate during the initial lifts than when lifting smaller light objects like the glass. Children with ADHD plus DCD are able to build up a memory representation of the object, although this is not as efficient as for typically developed children and adults. This deficient control was also demonstrated in a group of children with hemiplegic CP who were unable to scale the force output to match the weight of a previously lifted object until they had lifted the object at least 15 times. This has to be compared with the one or two times neces- sary in age-matched peers (Gordon & Duff, 1999). However, most participants with CP demonstrated anticipatory scaling when lifting familiar objects, which means that they are capable of learning by practice, despite having a dysfunctional nervous system. The question, then, is how this practice should be planned and performed. An investigation was carried out in another experiment in which children lifted novel objects that varied in weight in either a blocked series, with one weight being lifted several times, or a random series in which different weights were ran- domly assigned to be lifted (Duff & Gordon, 2003). Blocked practice resulted in greater differentiation of the force rates between objects during acquisition than random practice. However, both types of practice resulted in similar performance retention 24 hours later. These findings suggest that children with hemi- plegic CP are able to build up internal representations that are used for anticipatory force scaling of novel objects, and that practice is valuable, although it appears that the type of practice schedule employed is not important. The importance of practice can be demonstrated by adolescents with hemiplegic CP who were practicing Frisbee golf using their hemiplegic hand. Being able to throw a Frisbee as well as possible toward a target requires the ability to plan the direction of the move- ment, use a certain amount of force, and release the grasp with exact timing. Playing Frisbee with a hemi- plegic hand may seem crazy, but it was an activity practiced at a 2-week, 5-day-a-week day camp in which the adolescents were treated by Constraint Induced Movement Therapy (Eliasson et al., 2003). The goal of the Frisbee game was to traverse a 350-foot-long course, at the end of which was a basket. The object of the game was to use the fewest number of throws to get the Frisbee in the basket. Nine adolescents prac- ticed 30 minutes for 7 days during the day camp. All adolescents improved at this game, and the number of throws needed to get the Frisbee into its basket

decreased from the first to the last day of camp, from 20 (range 14 to 35) to 14 (range 12–18) (Eliasson et al., 2003). It appears that it is possible to improve at Frisbee golf, as well as to learn to scale the force output during grasping applied to objects by practice, at least for these groups of children with CP.

SENSORY INFORMATION USED FOR FORCE CONTROL

Sensory information is essential for prehensile force control because it provides the nervous system with information about different aspects of the physical properties of objects in the immediate environment and, as described, it is used for anticipatory scaling and to adjust ongoing movements. Sensory impairments have been described for children with hemiplegic CP but have not been observed in children with diplegic CP or ADHD (Uvebrant, 1988). In children with hemiplegic CP, a decrease in two-point discrimination and stereognosia occurs in 50% to 70% of children. Processing of proprioceptive information also is impaired. This can be seen during vibration of a muscle, in which the muscle spindles are stimulated, giving rise to an illusion of arm movement; this illusion occurs in normal children, but only in 50% of children with CP (Tardieu et al., 1984). However, there is an unclear relationship between the perceived sensation of this kind and the ability to adjust the force output to match the physical properties of an object. All children with CP who participated in earlier studies perceived the difference between weight and frictional contact surfaces of the object to be lifted although some of them had decreased two-point discrimination and stereognosis. That is, almost all of them have decreased ability to transform sensory information into appro- priate “settings” for a motor command. There was no simple correlation between two-point discrimination and ability to adjust the force output based on frictional condition of the object (Eliasson et al., 1995). This may indicate that two point discrimination needs to be processed at a higher level in the central nervous system than adjustment of forces for grasping. The children with CP should be able to rely on sensory feedback for grasping because, as mentioned, their anticipatory control is impaired. Relying on sen- sory feedback means that the forces increase in a steplike manner, permitting sensory feedback, until lift- off. This results in a prolonged loading phase for heavier objects, but fairly well-adjusted forces taking into account both the weight of the object and the friction of the contact surfaces during the static phase when the object is held still in the air (Eliasson et al., 1992, 1995). Yet there is large variation in the grip

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58 Part I • Foundation of Hand Skills

force applied during the isometric force coordination, making the performance unpredictable and, of course, inconvenient for daily life. This is a common feature

in the early development of all children, including chil-

dren with different diagnoses (Eliasson et al., 1991; Brogren, Forssberg, & Hadders-Algra, 2001; Pereira et

al., 2000). A way of solving this problem is to increase the safety margin to prevent objects from being dropped. This compensatory behavior was obvious in all the children with CP who were investigated. It is evidently

a successful compensatory strategy for those with

impaired sensory processing, lack of anticipatory con- trol, and slow adaptation (Eliasson et al., 1995). How- ever, it does make it difficult to handle fragile objects

because there is a danger that the object will be crushed, and it also makes it difficult for children with CP to handle heavy objects because, in this case, a high level

of

force is needed and weakness is a common problem

in

children with CP.

The question that needs to be addressed is: How can children with sensory dysfunction learn to handle

objects as efficiently as possible? Sensory information

is crucial for the performance of precise movements.

Tactile information is the most important information for discrete finger movements, whereas proprioception

is more important for reaching in different directions

and handling objects of different weights. Tasks in which tactile information is crucial are, for example, buttoning up a shirt, picking raspberries, and opening a door with a key. For many bimanual tasks, having intact sensibility in only one hand does not terribly influence the task performance because people usually hold the object (an action requiring less sensory infor- mation) with their impaired hand and manipulate (requires efficient tactile regulation) with their domi- nant hand (Krumlinde-Sundholm & Eliasson, 2002). However, an important compensation for tactile disturbance is to use visual information. Vision strongly influences manipulatory actions and should not be overlooked when attempts are made to gain a deeper understanding of how the somatosensory systems influence manipulatory actions. The ability to use visual information as a form of compensation was seen when the results of hand surgery were evaluated. Children with CP and impaired sensibility tended to benefit more or at least as much from upper limb surgery as measured by a timed dexterity task than children with intact sensibility (Figure 3-9) (Eliasson, Ekholm, & Carlstedt, 1998). This probably has something to do with the ability to “see the grasp” being performed after surgery because before the surgery was per- formed, the hand was pronated, the wrist was flexed,

and the thumb was in-palm, making it impossible to see the grasping act as it was conducted. After surgery, in contrast, the hand was more extended and supinated

Dexterity before and after surgery

140 120 100 80 60 40 20 0 Normal Impaired Sec
140
120
100
80
60
40
20
0
Normal
Impaired
Sec

Sensibility

Figure 3-9

cubes and placing them on the opposite side of a vertical border on the table. Individual results of 11 subjects with normal two-point discrimination (2PD) and 14 with impaired 2PD before and after surgery. 2PD: 3 to 4 mm was tested for in a randomized order, their fingers were touched with a distinct but light touch with one or two points, 10 times on each finger. Before examination, the task was demonstrated for them to see and feel the differences between one and two points on both hands. Normal 2PD required at least eight correct answers on two of three digits. The time decreased 14.5 s (md) compared with 9 s (md) for children with normal sensation. (Modified from Eliasson A.C, Ekholm C, Carlstedt T [1998]. Hand function in children with cerebral palsy after upper-limb tendon transfer and muscle. Developmental Medicine in Child Neurology, 40:612–621.)

Dexterity, in seconds when moving 10

and the thumb was able to meet the fingers, making it possible to use vision to compensate for impaired sensi- bility. This may indicate that impaired sensation could be an indication for surgery, at least from one per- spective. This is opposite to what commonly is recom- mended but has to be considered. One other important way to compensate for lack of control that should not be overlooked is to concentrate and pay deliberate attention to the performance of the task. The compen- satory strategies are crucial, but they often make the children slower.

SUMMARY

Motor control—meaning how the CNS controls move- ment—is complex, but by understanding the principles of how movements are organized, it is possible to use the knowledge that has been gained to plan interven- tion. By using this perspective we can help children to learn more about themselves and help them find more efficient ways to use their possibilities rather than focusing on the impaired or odd movement. An impor- tant perspective to put across is that there is nothing

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wrong or right about a movement, rather, when there is a task that needs to be performed, it can often be done in a number of different ways. As therapists, we can help them to learn themselves by adopting strate- gies and ensuring that repetition consolidates improve- ments. Thus, if knowledge of motor control is used alongside the principles of motor learning, a new and useful concept of treatment results. In addition, it should be remembered that we do not know the rela- tionship between the maturation of the CNS and the performance of different tasks; however, we do know that practice is necessary. Given this, it seems logical that a less efficient nervous system needs more practice than an appropriately functioning one. It is also known that improvement in any task strongly depends on motivation. Improvement induced by motivation is shown nicely in a task measuring pronation and supination of the hand: The children are induced to increase their range of movement by hitting a drum rather than by just performing the movement (van der Weel, van der Meer, & Lee, 1991). For the children concerned, it is the game itself that is the goal:

They are not interested in the specific movement of arms and hands, and the therapist should remember this. For success in skills, the therapist should encour- age children to find tasks they are motivated to repeat and learn, working on their possibilities rather than on their limitations. We have to bear it in mind that the task performance we see may look odd from a per- spective of “normal” movements, but it may be a solu- tion to a problem based on their way to handle their impaired nervous system

REFERENCES

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