Functional Hand Use
Childhood disabilities have historically been approached with a focus on ‘fixing’ impairments, often driven by societal expectations. For example, in conditions like Cerebral Palsy, the goal has been to equalise functionality. However, a new perspective is emerging, challenging the traditional definition of health and emphasising adaptability and self-management as key aspects. This paradigm shift is transforming how we understand and provide therapy to children with disabilities.
By Amy Davidson, Occupational Therapist.
Challenging the Sterotype
Childhood disabilities are conditions that do or are likely to impact the direction of a child’s development. Many of these conditions have neurological components, although impairments can often include factors such as musculoskeletal, genetics, cognition, social-emotional, behavioural, or communication disorders (Rosenbaum & Gorter, 2011). In understanding childhood disability, we explore a traditional view of treating childhood disability, which was strongly influenced by the ‘biomedical approach’ of managing and treating health problems. In this sense, the focus was on examining, deciphering possibilities, diagnosing, and implementing the appropriate treatment, all while documenting progress post-treatment. This model of care is of course supported in acute care or in certain situations where outcomes are to be assessed or treated with time sensitivity.
However, in consideration to childhood disabilities, take Cerebral Palsy for example, this biomedical framework places great emphasis on the concept of “fixing.” Meaning, by making a diagnosis this will lead to the appropriate interventions and biomedical impairments will be revised or improved. Therefore, for a child with unilateral or hemiplegia Cerebral Palsy, where one side of the body is affected more than the other, by engaging in therapy, the goal (either by societal or familial expectations) is viewed as fixing the more affected side to bring about the same success of function as the dominant side.
In recent and positive revelations, the way in which we view and think about disability is changing. International health experts have recently challenged the current World Health Organisation (WHO) definition of health and proposed a new – more fluid and empowering definition “health is the ability to adapt and to self-manage” (Huber et al., 2011).
If it’s Not Fixing, then what is it?
In fact, on a neurological level, humans are not hard-wired to find the more challenging ways of doing things. Unless motivated by external sources, we will always look to perform our occupations in effective, efficient, and successful manners (Hoare & Greaves, 2017). And thinking back to our consideration of a child with Cerebral Palsy, this means that the evidence-based research is in support of finding alternative ways of achieving functional hand use that is: effective, efficient, and successful.
There is an emphasis on how the hands are used in activities. Understanding that while the hands may play very differing roles, we can learn to appreciate that such role differences are okay! (Krumlinde‐Sundholm et al., 2007).
Keeping in mind – What hand would you use to complete the following tasks?
- Brush your teeth
- Throw a ball
- Open a door
- Give someone a high-5
Functional Hand Use Can look like:
Using a dominant hand to…
- Handle & manipulate objects to engage in daily occupations
Using a non-dominant or affected side to…
- Stabilise or position objects against the body
- Help or assisting the dominant hand to complete tasks
- Hold objects while the dominant hand engages in the task
With functional hand use, we always come back to the three ingredients. Is the child effective, efficient, and successful in what they want to achieve given the environmental and task demands? Were their attempts completed with minimal effort? And if so, it is likely that the task only requires a dominant hand in achieving. In a situation where two hands are not required or relevant, a child with unilateral CP will never use their affected side or non-dominant side unless prompted to. Meaning, it is unlikely that this particular task or activity will be a natural progression to improving their bimanual skills.
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At Centre of Movement, our occupational therapists, use a theoretical framework for understanding the client, their environment, and the occupations that they want to, need to, or are expected to do. They foster a strengths based-approach to evaluate the client, while emphasising their strengths and capabilities which helps to empower and foster self-efficacy. Interventions are then able to be tailored, meaningful, and supported by enhancing motivation for participation.
“Children with disabilities may not do things nicely and ‘normally’ but they are still making developmental progress. I think there’s more than one path to success. And I would strongly encourage all of us to enable and support children to do things in whatever ways they can. Because the more they do, the more they practice. The more they practice, the better they get at it. If they never do it beautifully, that’s to me, not a big problem.”
Professor Peter Rosenbaum.