CH 8. Hand Skills 연세대학교작업치료학과김정란
} Introduction } Components of hand skills } Factors that contribute to the development of hand function } Development of hand skills } Reach and carry, grasp, in-hand manipulation skills,, voluntary release, bilateral hand use, ball throwing skills, tool use } Evaluation of hand skills in children 2
} 손기술은아동이환경과상호작용하는데절대적으로필요함 } 일상생활 (ADL), play, school functions의수행에가장많이사용됨 } 세상을연결해주는 도구 } 환경과의상호작용에중요한요소 } Case-Smith, J., & Exner, C. E.(2015).Hand function evaluation and intervention. In J. Case-Smith &, J. C. O`Brien (Eds.), Occupational therapy for children and adolescents (7 th ed., pp. 230-231). St. Louis: Mosby. } 아동의손기술장애는어떠한영향을줄까? 3
Components of hand skills } Fine motor coordination/ Fine motor skills/ Dexterity Reach Grasp Carry Voluntary release In-hand manipulation Bimanual skills 4 movement of the arm and hand for the purpose of contacting an object with the hand 손에물체를닿게하려는목적으로팔과손을움직이는것 attainment of an object with the hand 물체를손에가지는것 transportation of a hand-held object from one place the another 손에있는물체를한장소에서다른장소로옮기는것 intentional letting go of a hand-held object at a specific time and place 적절한시간에손에있는물체를의도적으로놓는것 adjustment of an object within the hand after grasp 물체를잡은다음에손안에서물체를다루는것 coordinated use of two hands together to accomplish an activity( 순서적으로나동시적으로 ) 활동을수행하기위해두손의협응된사용
Factors that contribute to the development of hand function } Contributions of context factors to hand skills 1) Social factors : socioeconomic status, gender, role expectation } 도구의사용과물체의복잡한조작에필요한기술 } 사용할수있는도구의차이발생함 : 예 > 연필, 가위 2) Cultural factors : tool-specific skills, expectation, play material } 사용하는도구의차이, 성취하길기대하는나이의차이, 놀이차이 } 예 > 다양한식사도구 } 예 > Play : 소근육운동, 대근육운동 5
Factors that contribute to the development of hand function } Contributions of somatosensory functions } 손가락과엄지의 isolated movement 에중요한부분임 } Haptic perception: active touch 를통해체성감각정보 를해석하는것 } Grasp force : tactile and proprioceptive 입력과통합 필요함 } Sensory integration: tactile hypersensitivity/poor discrimination, dyspraxiaà 손기술활동회피및기회 상실 6
Factors that contribute to the development of hand function } Contributions of visual perception and cognition } Vison: 새로운기술학습, 손의정확한움직임활동에 중요함 } 시지각발달에따라물체에대한이해가향상되면손의 action 을수정함 물체의특성, 움직임의스피드, 물체를효과적으로조절하기위해적절 한힘에대한지각이필요 } Attention and planning skills(cognition) 의발달에따 라동시에두개의물체를조작하는향상됨 7
Factors that contribute to the development of hand function } Contributions of musculoskeletal integrity } Function of joint and bones } Hand integrity: 완전한형태, thumb à grasp pattern 에영향줌 } Range of motion 의제한 : joint contracture, muscle weakness, arthritis } Muscle function } Strength: 잡기패턴형성과유지, 물체무게에따른증가 } Muscle tone: hyperà ROM 감소, hypoà 과도한 ROM/ 감소된 안정성 8
1. Reach and carry 2. Grasp patterns 3. In-hand manipulation skills 4. Voluntary release 5. Bimanual skills 6. Ball-Throwing skills 7. Tool use 9
1. Reach and Carry: } The goal of reach: to transport the hand to target, with precision in both time and space } 움직임속도, 공간안에서의조절 } 신생아의팔동작 : 비대칭적à 점차시각적주시증가 } 몇달안으로일반적인팔동작이확대 :12-22주 } More active swiping( 휘두르기 ), 물건치기, arm abducted à 가끔물건잡기나놓기가우연히되기도함 10
1. Reach and Carry: } 3-4 months } hand 의 midline orientation 발달 } 초기에는 hand 는손에가까이위치함 } 4-5 months } visual regard 와 proximal arm 의 stability 증가 à 점차손의위치가몸에서멀어짐 } symmetrical bilateral reaching unilateral reaching ( 양측의분리된움직임패턴증가) } 6 months: supine ( 크게원을그리며사물에팔을뻗어잡음 ), prone( 한쪽으로체중 을이동하고한손을사용해서원하는사물을잡음 ) } 8-9 months: 앉은자세에서몸의중앙을가로질러뻗기가가능함 } 10-11 months : 전완을회외하여물체를잡고, 앉은자세에서상지분리시켜뻗음 } scapular control 과 trunk stability 가성숙되면서유아는 reaching 시 shoulder flexion, slight ly external rotation, full elbow extension, forearm supination, slight wrist extension 보 임
1. Reach and Carry: children (6 th ed.). St. Louis: Mosby. 12 } Mature reach } Trunk 안정성확보, 관심있는물체를향해 trunk rotation 가능 } Reaching 하는동안, shoulder flexion, slight ER, Full elbow extension, forearm supination, slight wrist stability } 물체의사이즈나방향에맞춰서팔의 placement 정확성향상되고, 손가락펴기조절 } Figure 8-1 From Case-Smith, J., & Exner, C. E.(2010).Hand function evaluation and intervention. In J. Case-Smith &, J. C. O`Brien (Eds.), Occupational therapy for
1. Reach and Carry: } Carrying } 손안에잡은물체를한장소에서다른장소로옮기기 } 옮기는동안물체를유지하기하기위해서는조화로운신 체움직임이필요함 } Co-contraction 의유지 : forearm, wrist, and hand } Modify: forearm and wrist } Use shoulder rotation : with shoulder flexion and abduction 13
2. Grasp patterns } 활동과물체의특성에따라결정됨 } 물건의크기가 grasp 형태결정함 } 일반적으로작은물건은 precision grasp 사용 } 큰물건은 power grasp } 대표적인잡기패턴 1 Precision grasp } opposition of the thumb to fingertips 2 Power grasp } use of the entire hand } thumb은 flexed 또는 abducted 14
2. Grasp patterns Table 8-1. Mature grasping patterns used in functional activities Power grasp Hook grasp used to control tools or other object 서류가방같은물체를옮길때사용 - ulnar side 의 finger 는 flexion, radial side 의 finger 는 less flexion - 손의 ulnar side 로물건을고정, radial side 로 control, use IP flex. MCP ext or flex. Spherical grasp Small ball을유지할때사용 wrist extension, finger abduction. MCP & IP flexion Cylindrical grasp 컵이나캔주변을잡고유지할때 IP & MCP 물체의크기에따라 flexion Disk grasp 디스크를유지할때사용 물체의사이즈에따라 finger abd. MCP hyperextension. IP flexion. Lateral pinch 전원을켤때 ( 키로시동켤때 ) - thumb add. IP/ MCP flex. - Thumb pad- radial side(dip) of the index finger Pincer grasp Three-jaw chuck or tripod grasp 작은물체잡고유지할때사용 필기도구나식사도구유지하고사용할때 thumb-index finger pad, two-point pinch Thumb-index-middle finger pad, Three-point pinch Tip pinch Tiny objects 잡고유지할때 Thumb-index finger tip, 15 Forming a circle
2. Grasp patterns 16 출처 : 대한아동학교작업치료학회.(2013). 아동작업치료. 서울 : 계축문화사.
2. Grasp patterns 17 출처 : 대한아동학교작업치료학회.(2013). 아동작업치료. 서울 : 계축문화사.
2. Grasp patterns } Sequential development of grasp patterns } Grasping pattern 에서사용되는 hand/fingers 부분 } Ulnarà Palmarà Radial } 물체가위치하는손의면 } palmar contact à finger surface contact à finger pad contact } 사용되는근육활성 } extrinsic muscle activation à intrinsic muscles activation with extrinsic muscle 18
2. Grasp patterns } 초기 6 개월 : 전형적순서보임 } 다양한자극에대한반응으로손을 open and close } 점차 traction and grasp reflex 감소 à voluntary palmar grasp 시작됨 } 6m : 요측손바닥잡기 } 이후 6 개월기간 : 손기술발달의 key period } 6-9월에다양한물체를잡는능력이유의하게향상됨 } 엄지사용증가 } 8-9m : 엄지와두요측손가락이용한잡기 19
2. Grasp patterns From Case-Smith, J., & Exner, C. E.(2010).Hand function evaluation and intervention. In J. Case-Smith &, J. C. O`Brien (Eds.), Occupational therapy for children (6 th ed.). St. Louis: Mosby. 20
2. Grasp patterns } 0-5개월 : no voluntary use, 감각에대한반응 } Traction response and grasp reflex 감소 } 6-12개월 : key period : Active thumb을이용한잡기패턴 } 미숙한갈퀴형잡기 ( 작은물체 ) : 7m } Finger surface- thumb의작은물체잡기 : 9m } Thumb-finger pad control: 9-12m } 12-15개월 : Intrinsic muscle의조절증진à 납작한물체잡기 } 18개월-3세 : Disk, cylindrical, spherical grasp } 3세 : lateral pinch } 4-5세 : dynamic tripod position } 5세경 : grasp pattern의전반적인발달 21
3. In hand manipulation skills 1 Finger to palm translation : 12~15m 지갑에서동전꺼내기 2 Palm to finger tanslation : 2y~2y 6m 자판기에돈넣기 3 Shift 손가락패드부분을이용하여사물의위치를적절하게변경함 책장넘기기, 연필을잡은후끝쪽으로손가락이동하기등 4 Simple rotation : 2y~2y 6m Finger pad로물체를 90도미만으로 turn or rolls 페그보드꽂기위해수평위치에서수직위치로돌리기, 퍼즐조각돌리기 ( 퍼즐맞추기직전 90도미만 ) 5 Complex rotation : 3y 6m~5y 6m 작은물체를 180-360도 rotate( 한번에또는반복해서 ) 동전이나페그를거꾸로뒤집기, 연필지우개사용, 22
4. Voluntary release } 유아는 voluntary 하게물건을놓지못함 } tactile 과 proprioceptive stimuli 에대한 nondiscriminative response 가감소하고시각조절과인지발달이증가하면서 release 에대한자발적조절가능해짐 } 생후 9 개월 : 자발적으로 release 시작 } humeral control elbow stability 발달 } 생후 12 개월 : shoulder, elbow, wrist stability 를가지고 release } MCP joint 는 unstable( 과도한손가락신전보임 ) } 작은통 (small container) 에물건넣는능력발달 } 블록쌓기 23
4. Voluntary release From Case-Smith, J., & Exner, C. E.(2010).Hand function evaluation and intervention. In J. Case-Smith &, J. C. O`Brien (Eds.), Occupational therapy for children (6 th ed.). St. Louis: Mosby. 24
5. Bimanual skills } 생후 3 개월이전에는비대칭적움직임이특징적 } 생후 3-10 개월사이에는대칭적 pattern 이우세 } bilateral reach, grasp, 손이나물건입으로가져가기 } 생후 9-10 개월 : 양손에하나씩물체잡고두드리기 (bang) } 생후 10 개월 : bimanual action } 한손은물체 grasping, 다른한손은물체의부분들을탐색함 (Figure 8-7) 25
5. Bimanual skills } 생후 17-18 개월 : role-differentiated strategies } 한손은고정이나물체잡기, 다른손은조작또는 activate } 신체의 two-sides 의분리가능함 à 다른기능에두손을동시에사용함 } 생후 18-24 개월 : simultaneous manipulation( 동시적조작 ) 섬세한발달을위한 skills 발달 : reach, grasp, release 등 } 생후 2-3 세 : simultaneous manipulation } bilateral hand use 의 mature stage } 예. 가위질등학령기에이루어지는활동들 26
6. Ball-throwing } voluntary release, U/Ex sequence and time movement 요구됨 } 2 세 : 앞으로던지기 } 2 세 6 개월 ~3 세 : 타겟맞추기 } 3 세 6 개월 : 일직선상에서거의벗어나지않게 5-7feet 앞으로던지기 } 5 세 : 5 feet 거리타겟맞추기 } 6~7 세 : 12 feet 거리타겟맞추기 27
7. Tool use skills } purposeful, goal directed form of complex object manipulation to change the position, condition, or action of another object à 연습을통해높은수준의기술을습득하게됨 } 가위사용 (PDMS) : Table 8-2 } 2 세 : 잡기가능 } 2세 6개월 : 종이자르기 à 가위손잡이에손가락을넣고벌렸다오므렸다함 } 3 세 ~3 세 6 개월 : 선따라자르기 à forearm pronation 에서 midposition 가능 } 3세 6개월 ~4세 : 동그라미자르기 } 4세 6개월 ~5세 : 사각형자르기 } 6세 ~7세 : 복잡한모양자르기 } Utensil of eating } 18 개월 : Spoon } 2 세 6 개월 : Fork } 6 세 : Knife 28
Evaluation of hand sills
} Evaluation of hand skills in children 1) Screening } Information gathering Functional problems with a daily life skills Age, motor skills, cognitive and perceptual skills, sensory processing, social situation and skills, emotional development } Comprehensive hand function evaluation<table 8-3 > } Case-Smith, J., & Exner, C. E.(2015).Hand function evaluation and intervention. In J. Case-Smith &, J. C. O`Brien (Eds.), Occupational therapy for children and adolescents (7 th ed., pp. 233). St. Louis: Mosby. 30
2) Assessment } DDST II(Denver Developmental Screening Test II) } 평가연령 : 생후 1 개월 ~6 세 } Personal social, fine motor adaptive, language, gross motor } E-Lap(The Early Learning Accomplishment Assessment) } 평가연령 : 생후 1 개월 ~36 개월 } Gross motor, fine motor(73), cognitive, language, self-help, social-emotional/ 총 416 항목 } Jebson Taylor hand function test } Writing, carding, small objects, simulate feeding, checkers, light/heavy object } Bruininks-Oseretsky test of motor preficiency } 평가연령 : 4세 6개월 ~14세 6개월 } gross motor, fine motor } EDPA 대한아동학교작업치료학회.(2013). 아동작업치료. 서울 : 계축문화사. 31
Reference } Case-Smith, J., & O`Brien, J. C. (2015). Occupational therapy for children and adolescents(7th ed.). St. Louis: Mosby. } 대한아동학교작업치료학회.(2013). 아동작업치료. 서울 : 계축문화사. 32