Immediate effects of a novel hand rehabilitation board on fine motor skills in children with cerebral palsy: A pilot study

Abstract

BACKGROUND:

In children with cerebral palsy (CP), fine motor skills limit forearm supination and active extension of the elbow, wrist, or fingers. Therapeutic interventions focusing on improving the ranges at these joints while facilitating active movements are the key to augmenting fine motor skills.

OBJECTIVE:

This pilot study examines if children with CP (with UE involvement) exposed to the Novel Hand Rehabilitation (NHR) Board will demonstrate 1) changes in spasticity and passive ROM of forearm and wrist/finger muscles, and 2) improvement in fine motor abilities.

METHODS:

The forearm and wrist/fingers of children with spastic CP (N = 15; M = 7, F = 8) aged 49–72 months (65.33±6.355 months) were positioned on the NHR board till their tolerance limit or a minimum duration of 30 minutes. The outcome measures, i.e., spasticity (Modified Ashworth Scale), passive range of motion (PROM) of wrist and fingers, and fine motor skills (PDMS-2 - Fine motor scale), were recorded.

RESULTS:

The spasticity of forearm pronators (0.001) and wrist flexors (0.008) reduced significantly, but not in wrist extensors. Post-intervention improvements in wrist extension (p = 0.005) and ulnar deviation ROM (p = 0.007) were significant. In thumb, changes were non-significant for the CMC flexion, but extension (0.003) and abduction (0.001) as well as MCP extension (0.004) were significant. The post-intervention MCP extension ROM for the 2^nd (0.001), 3^rd (0.007), and 4^th fingers (0.014) were also substantial, but not for PIP and DIP joints. The post-intervention percentage change in the Grasping and Visual-motor integration subtests of PDMS-2 was 11.03% (p = 0.002) and 5.09% (p = 0.001) respectively.

CONCLUSION:

The immediate effects on fine motor skills in children with CP after the NHR board application were positive and encouraging. Hence, the NHR board can be recommended as an intervention to improve the fine motor abilities of children with CP.

Keywords

Cerebral palsy hand rehabilitation fine motor skills peabody developmental scale (PDMS-2)novel hand rehabilitation (NHR) board

1 Introduction

The spasticity in children with cerebral palsy (CP) affects fine motor control and upper limb (UL) dexterity, leading to slowness/discontinuous movement, variable hand trajectories, inappropriate coordination of grasping forces, and deficits in anticipatory motor planning (Mutsaarts et al., 2006; Steenbergen et al., 2008). The changes due to muscle tone abnormalities depend on position, posture, motion, reduced muscle strength, loss of selective motor control, contractures, and deformities (Duruöz, 2019). It gives rise to anterior tilting, medial rotation, and protraction of scapula; shoulder internal rotation; elbow and wrist flexion; forearm pronation; with flexion and adduction of fingers and thumb (Makki et al., 2014; Simon-Martinez et al., 2017), leading to immature grasp i.e., wrist flexion, metacarpophalangeal (MCP) hyperextension, proximal interphalangeal (PIP) flexion and sharp distal interphalangeal (DIP) flexion. Hence, children with CP adapt to using all fingers together as a unit instead of the palm (Noronha et al., 1989). These variations abridge a child’s ability to use hand and wrist both in supination and pronation, which is essential for prehension and bilateral hand use, thus affecting reaching and grasping activities (Yasukawa, 1990).

Although oral and intrathecal baclofen, botulinum toxin, and orthopedic approaches have frequently been practiced. The physiotherapeutic strategies, i.e., Proprioceptive neuromuscular facilitation (PNF) techniques, Bobath’s neurodevelopment treatment (NDT) positioning using the critical points of control, constraint-induced movement therapy (CIMT), hand-arm bimanual intensive training, neuromuscular electrical stimulation, biofeedback therapy, inhibitory orthosis, Johnstone pressure splints, are standard measures used to facilitate upper extremity motor skills in children with CP (Sakzewski et al., 2009; Scheker et al., 1999).

The anti-spastic positioning of extremities (within the limits of an individual’s tolerance) aids in desensitizing the stretch receptors of the spastic muscles through prolonged stretching (Akbayrak et al., 2005). Daily application of therapeutic elongation in non-neural structures for a sufficient duration (30 minutes) is recommended to promote muscle growth by reversing the muscle shortening because it reduces spasticity by decreasing reflex sensitivity (Wilton, 2003). This is done through orthosis/splints to restrain the joints in a desired position to enhance the functions of agonists by inhibiting the antagonists (Akbayrak et al., 2005).

Orthosis (dynamic or fixed) and positional devices like volar resting splints are commonly used to correct or prevent upper extremity impairments and facilitate functional usage of the hand (Autti-Rämö et al., 2006). These orthoses include a) wrist splints with reflex-inhibiting components and b) neoprene splints to position the thumb in abduction and forearm in supination (thumb-abduction supinator splint [TASS]) based on Bobath’s key point of control to improve bilateral hand activities and prehension skills by reducing the spasticity (Autti-Rämö et al., 2006; Reid, 1992; Wilton, 2003). However, therapists have observed moderate benefits from hand splinting; therefore, differing outcomes were reported from the splining devices in spastic hands of children with CP (Neuhaus et al., 1981).

The neurophysiological approach for treating children with CP is universally acceptable; hence, hand splinting has been questioned. Rood stated that the application of splints contradicts their purpose by activating sensory stimuli of touch, pressure, and stretch, resulting in undesirable muscle contraction. Rood and other authors recommended applying constant pressure over the wrist and finger flexors to achieve an inhibitory effect on the long flexors (Mathiowetz et al., 1983).

Although various splints and positional devices have been studied to improve hand functions in children with CP, each has certain limitations. The Novel Hand Rehabilitation (NHR) Board was indigenously made at the Neuro-Sensory developmental unit of Kasturba Medical College Hospital to facilitate the development of fine motor functional skills in children with CP. The NHR Board is unique for children with CP because it addresses the concerns raised by Rood’s. Our clinical experience while working with children with CP suggests that the NHR board progressively increases forearm supination and wrist and finger extension ROM while allowing active flexion/passive extension of fingers at MCP, PIP, and DIP joints. These movements enhance the self-initiated fine motor skills of the hands in children with CP. Therefore, this study examines the immediate effects of the NHR board on the hand functions through the PDMS-2 fine motor subset in children with CP (Wang et al., 2006).

2 Methodology

2.1 Ethics statement

This study had a quasi-experimental pilot study design and a convenient sampling method was used. The study was approved by the scientific and institutional ethics committees of Kasturba Medical College, Mangalore (IEC/KMC/20/2012-2013), and meets the ethical principles guidelines of the Declaration of Helsinki. The purpose of the study was explained to the parents/guardians of selected children with CP, and written informed consent was obtained.

2.2 Participants

Fifty-eight children with spastic CP were screened based on the inclusion criteria [≥ three years of age; unilateral or bilateral upper extremity movement impairment of both genders; Manual Ability Classification System (MACS) Level IV; Modified Mini-Mental Status Examination score ≥24 (age 3 to 5 years), and ≥28 (age ≥ six years)] (Jeevanantham et al., 2015). The exclusion criteria were children with CP treated previously with NHR board or h/o Botox injections in the last six months or on muscle relaxants like baclofen, and diazepam, h/o any surgery for upper limbs, and having active seizure disorders (Akbayrak et al., 2005).

The sample size was calculated using the formula: $n = \frac{Z {\overset{'}{α}}^{2} σ^{2}}{d^{2}}$

Where, $Z \overset{´}{α} = 1.96$ (95% CI), σ= 20.6, d = 10% of 101.9 (90% power) Through this process, 15 children with spastic CP were selected.

2.3 Novel Hand Rehabilitation Board

It is a 40/40 cm polypropylene board (0.8 mm thick) with 45° angled multiple holes (0.5 mm² diameter) at the center covering a 5 cm² surface area. In contrast, the remaining surface area is covered with round vertical holes angled at 90° (0.5 mm² diameters). Each hole is spaced at a distance of 1.5 cm. The 8 cm long metal stick (0.45 mm² diameter) padded with Ethaflex (10 nos) is designed to be fitted snuggly in the polypropylene board holes (both 45° angled and vertical 90°). The finger loops, along with elastic bands, are used to facilitate active finger motions (Flexion and extension), while the forearm is positioned in supination by 45° angled multiple holes and wrist/fingers in extension (functional position) by vertical 90° holes.

2.4 Peabody Developmental Motor Scale 2^nd Edition (PDMS-2)

The PDMS-2 is a reliable and valid tool for the evaluation of gross and fine motor skills in children (Wang et al., 2006). The PDMS-2 fine motor scale has two subtests, i.e., Grasping (26 items) and Visual-Motor Integration (72 items). Scoring is done on a 3-point scoring system: 0 (zero) if the child’s performance of a task is unsuccessful; 1 (one) if the child’s performance resembles the item but does not fully meet the criteria; and 2 (two) if child’s performance is successful, as described by the scoring criteria (Stokes et al., 1990).

2.5 Procedure

Children with CP were comfortably positioned on the floor in a long sitting position over a firm cushion (to support the pelvis) with the trunk in an upright orientation and hips in neutral rotation. Both knees were in extension (supported by a small soft bolster under the popliteal fossa), and feet were on the floor (heels supported with a small soft bolster). A therapy bench of proportional height is used at a mid-thigh level to keep the NHR board while the trunk is aligned in an upright, erect posture. The affected UL is positioned on the NHR board by first stabilizing the proximal radio-ulna joint with round vertical holes angled at 90°. Then, the forearm was placed in supination by 45° angled holes up to the distal radio-ulna joint. After that, the wrist and fingers were aligned in a functional extension position using vertical holes angled at 90°, the thumb was aligned in abduction/neutral extension with loops (supported by an elastic band), and finger loops (for all four fingers) were used with elastic bands to facilitate active finger motions (flexion and extension). This position was continued until the child’s tolerance limit or for a minimum period of 30 minutes. Post-intervention, the hand was removed from the NHR Board after 10 minutes of rest (Fig. 1).

Fig. 1

A subject’s involved hand positioned on the NHR Board.

2.6 Recording of outcome measures

The outcome measures a). spasticity by Modified Ashworth Scale (MAS), b). passive range of motion (PROM) by goniometer and, c). fine motor skills by PDMS-2_ Fine motor scale were recorded before and after the application of the NHR Board (Harb & Kishner, 2022; Jain & Passi, 2005; Wang et al., 2006). All children with CP received pre-planned therapy per NDT guidelines; however, no treatment was given on the day the NHR board was used.

CONSORT diagram: Study Procedure.

2.7 Statistical analysis

Statistical analysis was done using the Statistical Package for Social Science (SPSS) version 17.0. Descriptive statistics were used to calculate the subject’s demographic characteristics. All variables (MAS, PROM measurement, and PDMS-2_ Fine motor scale) were analyzed using the Wilcoxon signed-rank test (Non-parametric T-test) to determine the differences between pre- and post-intervention. Correlation analysis for each variable was done using Spearman’s rank correlation. The level of significance p < 0.05 was considered statistically significant with a 95% confidence interval.

3 Results

Fifty-eight children with CP were screened for eligibility to participate in the study, and 15 children (boys = 7, girls = 8) with spastic CP aged 49–72 months (mean age 65.33±6.355 months) were enrolled. The demographic details of children with spastic CP who participated in this study are summarized in Table 1.

Table 1
Descriptive details of the subjects included

Demographic Subjects

characteristics

Age (Mean±SD) Months 65.33±6.355

Gender Boys = 7

Girls = 8

Hand dominance Right = 7

Left = 8

Demographic	Subjects
Age (Mean±SD) Months	65.33±6.355
Gender	Boys = 7
	Girls = 8
Hand dominance	Right = 7
	Left = 8

3.1 Changes in spasticity of wrist and forearm muscles

The spasticity of wrist and forearm muscles through the MAS was analyzed to examine the scientific basis of functional changes in PDMS 2 Fine motor subtests. This significantly reduced the spasticity of forearm pronators (0.001) and wrist flexors (0.008). However, for the wrist extensors, post-intervention changes were not substantial (Table 2).

Table 2
Changes in Wrist and Forearm Muscle Spasticity (MAS), Wrist ROM, and PDMS 2 Fine motor subtests following NHR Board application

Variables Pre-intervention Post-intervention Change (%) T P

Wrist and Forearm Pronators 1.77±0.26 1.37±0.23 – 3.464 0.001*

Forearm Muscle Wrist Flexors 1.50±0.38 1.27±0.26 2.646 0.008*

Spasticity (MAS) Wrist Extensors 0.60±0.51 0.60±0.51 0 1

Wrist ROM Flexion 101.67±13.18 102±13.34 1 0.317

Extension 75.93±18.15 79.47±17.21 2.84 0.005*

Ulnar Deviation 32.93±14.79 36.27±14.02 2.69 0.007*

Radial Deviation 28.67±11.75 28.40±9.92 1.19 0.236

PDMS-2 Subtests Grasping 19.33±12.10 21.47±12.66 11.03 3.09 0.002*

VMI 47.13±33.60 49.53±34.21 5.09 3.43 0.001*

	Variables	Pre-intervention	Post-intervention	Change (%)	T	P
Wrist and	Forearm Pronators	1.77±0.26	1.37±0.23	–	3.464	0.001*
Forearm Muscle	Wrist Flexors	1.50±0.38	1.27±0.26		2.646	0.008*
Spasticity (MAS)	Wrist Extensors	0.60±0.51	0.60±0.51		0	1
Wrist ROM	Flexion	101.67±13.18	102±13.34		1	0.317
	Extension	75.93±18.15	79.47±17.21		2.84	0.005*
	Ulnar Deviation	32.93±14.79	36.27±14.02		2.69	0.007*
	Radial Deviation	28.67±11.75	28.40±9.92		1.19	0.236
PDMS-2 Subtests	Grasping	19.33±12.10	21.47±12.66	11.03	3.09	0.002*
	VMI	47.13±33.60	49.53±34.21	5.09	3.43	0.001*

3.2 Changes in wrist ROM

Many children with CP had the attitude of wrist flexion and ulnar or radial deviation. This was because of the spastic nature of the volar muscles. The results indicated significant improvement in ROM of wrist extension (p = 0.005) and ulnar deviation (p = 0.007) post-intervention (Table 2). Thus, prolonged and sustained position influences the ROM at the wrist joint.

3.3 Changes in finger joint ROM

NHR board retained the MCP joints in extension (while PIP and DIP joints were in neutral position) both for the thumb and the other four fingers. The results indicated non-significant changes in flexion ROM but significant changes only for the extension ROM at CMC (p = 0.003) and MCP (p = 0.004) and abduction at the CMC joint (p = 0.001) of the Thumb. In fingers, changes were noted for extensions of the MCP joint only post-intervention in the 2^nd, 3^rd, and 4^th fingers (p = 0.001, 0.007, and 0.014).

3.4 Changes in PDMS-2 fine motor subtests: Pre-post intervention

The percentage change post-intervention for the PDMS-2 Grasping subtest was 11.03%, while for the Visual-motor integration subtest, it was 5.09%. These changes were significant (p = G: 0.002; VMI: 0.001) (Table 2).

3.5 Correlation between PDMS-2 fine motor subtests

To examine the effect of the NHR Board on PDMS-2 Fine motor subtests, Spearman’s correlation coefficient analysis was done for the MAS and wrist and finger ROM. These correlations were significant for wrist extensor spasticity for Grasping (r = –0.616; p = 0.015) and VMI (r = –0.553; p = 0.033) subtests of PDMS-2. There was no correlation between wrist and finger ROM except for a few variables (Table 4).

Table 3
Changes in Finger joint ROM following NHR Board application

Movements

Flexion Extension Abduction

Thumb Fingers Thumb Fingers Thumb

CMC MP/MCP IP/PIP CMC MP/MCP IP/PIP CMC

Pre-Int. 34.67±28.02 75±21.95 63.67±22.79 22±14.08 39.33±33.37 56.53±37.77 35.80±16.15

Post Int. 35.33±29.02 75.67±22.27 64.33±22.82 26.27±14.67 42.20±32.59 56.87±38.1 40.87±15.11

T; P 1.34; 0.18 1; 0.317 1; 0.317 2.99; 0.003* 2.89; 0.004* 1; 0.317 3.37; 0.001*

	Movements
	Flexion	Extension	Abduction
	Thumb	Fingers	Thumb	Fingers	Thumb
	CMC	MP/MCP	IP/PIP	CMC	MP/MCP	IP/PIP	CMC
Pre-Int.	34.67±28.02	75±21.95	63.67±22.79	22±14.08	39.33±33.37	56.53±37.77	35.80±16.15
Post Int.	35.33±29.02	75.67±22.27	64.33±22.82	26.27±14.67	42.20±32.59	56.87±38.1	40.87±15.11
T; P	1.34; 0.18	1; 0.317	1; 0.317	2.99; 0.003*	2.89; 0.004*	1; 0.317	3.37; 0.001*

Table 4

Correlation (post-intervention) between PDMS 2 Fine motor subtests (Grasping and Visual Motor Integration), Modified Ashworth scale and Wrist Joint ROM

Variables	Muscle Groups /ROM	PDMS-2 Subtests
		Grasping (r; p)	Visual-Motor Integration (r; p)
Wrist and Forearm	Forearm Pronators	0.245; 0.379	0.332; 0.226
Muscle Spasticity (MAS)	Wrist Flexors	–0.357; 0.192	–0.341; 0.213
	Wrist Extensors	–0.616; 0.015*	–0.553; 0.033*
Wrist Joint ROM	Wrist Flexion	0.135; 0.631	0.393; 0.148
	Wrist Extension	–0.049; 0.862	–0.287; 0.3
	Ulnar Deviation	0.508; 0.053	0.456; 0.088
	Radial Deviation	0.015; 0.959	0.006; 0.982

4 Discussion

More than 50% of children with CP have significant wrist and hand involvement, and 69% of them have reduced hand control because of spasticity (e.g., scapular retraction and depression, shoulder internal rotation, forearm pronation, elbow, and wrist flexion along with flexion and adduction of thumb and fingers). Additionally, poor postural control and influence of reflex activity affect the coordination between arm and hand, thereby affecting the fluidity of movement sequences during fine motor functional tasks, i.e., reaching, grasping/releasing/manipulating objects and manually writing or cutting (Duruöz, 2019; Hanna et al., 2003).

The results of this study showed significant changes post-intervention in children with CP for both subtests [11.03% (Grasping) and 5.09% (VMI)] of the PDMS-2 fine motor scale immediately after using the NHR board. These changes align with those seen in the spasticity of forearm pronators and wrist flexors muscles (Table 2).

The reduction in spasticity of these muscles increased the freedom of flexion movement at the finger joints because the position of the forearm in neutral pronation and extension at the wrist by the NHR board resisted the finger flexors (while being contracted actively), causing increased afferent firing and increased recruitment of alpha motor neurons (Mathiowetz et al., 1983) (Table 2). The stretch also stimulated these muscles’ muscle spindle and Golgi tendon organs. This led to the initial activation of gamma fibers which are connected to the contractile part of the intrafusal muscle fiber, instigating contraction in the contractile part and stretching of the non-contractile part (causing stimulation of stretch receptors through the alpha motor neurons, producing contraction of extrafusal muscle fibre that stimulates Golgi tendon organ). Thus, inhibition of alpha motor neurons inhibited the extrafusal muscle fibre, hence, the relaxation of spastic muscles. The passive stretch to the contracted muscles through the NHR Board also facilitated adhesion breakdown, increasing its elasticity (Jackman et al., 2014).

During everyday activities, antagonists and synergists muscles are stretched in response to the active contraction of agonists muscles at the same joint. The NHR Board induces controlled irradiation or overflow instead of the stretch alone (when active flexion movement at fingers is practiced, while flexor muscles are positioned in elongated stated) in those muscles, hence more significant changes in the fine motor subtests of PDMS-2 (Mathiowetz et al., 1983).

Simultaneously, significant changes were also noted in the ROM for wrist extension, ulnar deviation (Table 2), CMC joint of thumb for extension and abduction, and MCP joint extension for all fingers (except the 5^th finger) (Table 3). These improvements in ROM facilitated acute changes in the muscle length (in response to stretch) by two mechanisms, as reported by Nicola Theis et al., 2013; a) the effect on motor neuronal discharges was dampened by the Golgi tendon organs, thereby inducing relaxation in the muscle-tendon unit, that reset its resting length; b) the Pacinian corpuscles acting as the pressure sensors to regulate pain tolerance (Theis et al., 2013). These mechanisms brought only acute changes in the maximal muscle-tendon length, providing necessary stimulus for the muscle’s adaptive process and improving functional motor skills.

We observed increased active use of thumb movement in relation to 1^st, 2^nd, and 3^rd fingers after positioning the forearm, wrist, and finger joints on the NHR board (Table 3). Additionally, reduced wrist flexor spasticity and improved CMC and MCP joint extension ROM enriched the motor activities qualitatively, thereby increasing the functional use of wrist and fingers on PDMS-2 fine motor subsets.

The correlation between the PDMS-2 subtests and wrist and finger ROM/flexors muscle spasticity was insignificant. Therefore, this study does not confirm the role of either of the factors that may have influenced the performance of children with CP on fine motor subtests of PDMS 2 (Table 4).

4.1 Limitations

Even though the study findings showed significant improvement in fine motor skills, the NHR board has some limitations. Only a few children could not tolerate continuous 30 minutes of intervention on the NHR board. Hence, the intervention was shortened, or hand repositioning became necessary after a few minutes. Another limitation was the inclusion of a heterogeneous group of children with CP. Therefore, findings can vary for specific subtypes of CP. Although the immediate effects were sound, the follow-up changes were not studied.

Thus, future research needs to focus on specific subtypes of CP using the NHR board compared to the functional hand splints or focused, therapeutic strategies, determining inter-rater reliability, and deciding the optimum therapy dosage to sustain the long-term effectiveness.

5 Conclusion

The immediate effects of NHR Board intervention among children with CP were impressive on both fine motor subtests (Grasping and VMI) of PDMS-2, hence the improved fine motor skills. Furthermore, children with CP also showed considerable reduction in spasticity of forearm pronators and wrist flexors and improvements in wrist and finger extension ROM, indicating that the NHR board is potent enough to be recommended as an effective therapeutic strategy to enhance fine motor skills in children with CP.

Footnotes

Acknowledgments

The authors humbly acknowledge Mr. Prataph Sethi (prosthetist and orthotist), Innovative Rehabilitation Centre, Mangalore, for designing the Noble Hand Rehabilitation Board. We want to thank all participants and their families for cooperating in this study.

Conflicts of interest

The authors declare that no competing interests exist.

Funding

The funding organizations did not participate in, comment on, or influence the analysis or write-up of the manuscript.

Author’s contributions

All authors contributed to the article and approved the submitted version.

Ethics statement

The study was approved by the scientific and institutional ethics committees of Kasturba Medical College, Mangalore (IEC/KMC/20/2012-2013), and meets the ethical principles guidelines of the Declaration of Helsinki.

References

Akbayrak,

, Armutlu,

, Gunel,

M. K.

, Nurlu,

(2005). Assessment of the short-term effect of antispastic positioning on spasticity. Pediatrics International, 47(4), 440–445. https://doi.org/10.1111/j.1442-200x.2005.02086.x

Autti-Rämö,

, Suoranta,

, Anttila,

, Malmivaara,

, Mäkelä,

(2006). Effectiveness of Upper and Lower Limb Casting and Orthoses in Children with Cerebral Palsy. American Journal of Physical Medicine & Rehabilitation, 85(1), 89.

Duruöz,

M. T.

(Ed.). (2019). Hand Function: A Practical Guide to Assessment. Springer International Publishing.

Hanna,

S. E.

, Law,

M. C.

, Rosenbaum,

P. L.

, King,

G. A.

, Walter,

S. D.

, Pollock,

, Russell,

D. J.

(2003). Development of hand function among children with cerebral palsy: Growth curve analysis for ages 16 to 70 months. Developmental Medicine & Child Neurology, 45(7), 448–455. https://doi.org/10.1111/j.1469-8749.2003.tb00939.x

Harb,

, Kishner,

(2022). Modified Ashworth Scale. In StatPearls. StatPearls Publishing.

Jackman,

, Novak,

, Lannin,

(2014). Effectiveness of hand splints in children with cerebral palsy: A systematic review with meta-analysis. Developmental Medicine & Child Neurology, 56(2), 138–147. https://doi.org/10.1111/dmcn.12205

Jain,

, Passi,

G. R.

(2005). Assessment of a Modified Mini-Mental Scale for Cognitive Functions in Children. Indian Pediatrics, 42, 6.

Jeevanantham,

, Dyszuk,

, Bartlett,

(2015). The Manual Ability Classification System: A Scoping Review. Pediatric Physical Therapy, 27(3), 236–241. https://doi.org/10.1097/PEP.0000000000000151

Makki,

, Duodu,

, Nixon,

(2014). Prevalence and pattern of upper limb involvement in cerebral palsy.. Journal of Children’s Orthopaedics, 8(3), 215–219. https://doi.org/10.1007/s11832-014-0593-0

10.

Mathiowetz,

, Bolding,

D. J.

, Trombly,

C. A.

(1983). Immediate effects of positioning devices on the normal and spastic hand measured by electromyography. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association, 37(4), 247–254. https://doi.org/10.5014/ajot.37.4.247

11.

Mutsaarts,

, Steenbergen,

, Bekkering,

(2006). Anticipatory planning deficits and task context effects in hemiparetic cerebral palsy. Experimental Brain Research, 172(2), 151–162. https://doi.org/10.1007/s00221-005-0327-0

12.

Neuhaus,

B. E.

, Ascher,

E. R.

, Coullon,

B. A.

, Donohue,

M. V.

, Einbond,

, Glover,

J. M.

, Goldberg,

S. R.

, Takai,

V. L.

(1981). A Survey of Rationales For and Against Hand Splinting in Hemiplegia. The American Journal of Occupational Therapy, 35(2), 83–90. https://doi.org/10.5014/ajot.35.2.83

13.

Noronha,

, Bundy,

, Groll,

(1989). The Effect of Positioning on the Hand Function of Boys With Cerebral Palsy. The American Journal of Occupational Therapy, 43(8), 507–512. https://doi.org/10.5014/ajot.43.8.507.

14.

Reid,

D. T.

(1992). A Survey of Canadian Occupational Therapists’ Use of Hand Splints for Children with Neuromuscular Dysfunction. Canadian Journal of Occupational Therapy, 59(1), 16–27. https://doi.org/10.1177/000841749205900104

15.

Sakzewski,

, Ziviani,

, Boyd,

(2009). Systematic Review and Meta-analysis of Therapeutic Management of Upper-Limb Dysfunction in Children With Congenital Hemiplegia. e-e. Pediatrics, 123(6), e1111–e1122. https://doi.org/10.1542/peds.2008-3335

16.

Scheker,

L. R.

, Chesher,

S. P.

, Ramirez,

(1999). Neuromuscular Electrical Stimulation and Dynamic Bracing as a Treatment for Upper-Extremity Spasticity in Children with Cerebral Palsy. Journal of Hand Surgery, 24(2), 226–232. https://doi.org/10.1054/JHSB.1998.0002

17.

Simon-Martinez,

, Jaspers,

, Mailleux,

, Desloovere,

, Vanrenterghem,

, Ortibus,

, Molenaers,

, Feys,

, Klingels,

(2017). Negative Influence of Motor Impairments on Upper Limb Movement Patterns in Children with Unilateral Cerebral Palsy. A Statistical Parametric Mapping Study. Frontiers in Human Neuroscience, 11, 482. https://doi.org/10.3389/fnhum.2017.00482.

18.

Steenbergen,

, Charles,

, Gordon,

A. M.

(2008). Fingertip force control during bimanual object lifting in hemiplegic cerebral palsy. Experimental Brain Research, 186(2), 191–201. https://doi.org/10.1007/s00221-007-1223-6

19.

Stokes,

N. A.

, Deitz,

J. L.

, Crowe,

T. K.

(1990). The Peabody Developmental Fine Motor Scale: An Interrater Reliability Study. The American Journal of Occupational Therapy, 44(4), 334–340. https://doi.org/10.5014/ajot.44.4.334

20.

Theis,

, Korff,

, Kairon,

, Mohagheghi,

A. A.

(2013). Does acute passive stretching increase muscle length in children with cerebral palsy? Clinical Biomechanics (Bristol, Avon), 28(9-10), 1061–1067. https://doi.org/10.1016/j.clinbiomech.2013.10.001

21.

Wang,

H.-H.

, Liao,

H.-F.

, Hsieh,

C.-L.

(2006). Reliability, Sensitivity to Change, and Responsiveness of the Peabody Developmental Motor Scales-Second Edition for Children With Cerebral Palsy. Physical Therapy, 86(10), 1351–1359. https://doi.org/10.2522/ptj.20050259

22.

Wilton,

(2003). Casting, splinting, and physical and occupational therapy of hand deformity and dysfunction in cerebral palsy. Hand Clinics, 19(4), 573–584. https://doi.org/10.1016/S0749-0712(03)00044-1

23.

Yasukawa,

(1990). Upper Extremity Casting: Adjunct Treatment for a Child With Cerebral Palsy Hemiplegia. The American Journal of Occupational Therapy, 44(9), 840–846. https://doi.org/10.5014/ajot.44.9.840

Demographic	Subjects
characteristics
Age (Mean±SD) Months	65.33±6.355
Gender	Boys = 7
	Girls = 8
Hand dominance	Right = 7
	Left = 8