Wednesday, August 5, 2015

Activating the hands in Cerebral Palsy

This post is a follow up to the previous post on sensory brain exercises for CP.  Although these sensory exercises are useful, they are somewhat limited when you are presented with a hand that is consistently (and/or rigidly) closed or fisted.  In addition, the closed fist is almost always accompanied and characterized by some distortion and asymmetry...both of which may make simple sensory exercises difficult and frustrating.  With this in mind, I wanted to shed some additional light on the issue of hands and (hopefully) provide some options and avenues for those parents and families that want to actively potentiate some improvement in the hands and, perhaps more importantly, provide some clarity on some realities about the developmental process...which always proves to be helpful and immediately useful.

"Don't put that in your mouth"

Words that every parent has said (or yelled) at one time or another, correct?  Although it is an intuitive understanding that babies / children will put things in their mouth, it is oftentimes difficult for parents (and people in general) to truly understand and formulate the reason why this is done...and universally across the board.  ALL humans do / did this!

 This type of behaviour is simply the manifestation of the natural developmental process of exploration and discovery.  In the first few months, a baby's visual field is still quite immature therefore in order to genuinely get "a sense" of themselves and their surroundings, they need to expose things to those senses that have reached a higher order.  In other words, they formally "feel" things with their mouths.  This includes hands, feet, and pretty much any object that is within reach. 

As a natural and healthy part of the developmental process, children will go through this phase during the first few months (and first year) and then when their visual competence and acuity begins to develop more, they will begin to actually grasp and hold things within their field of view.  Although they are still likely to put things into their mouths for "enhanced feedback", they will consistently stare at and track objects that enter their field of view. 

Missing Links and Activation in CP

When we put this into the context of CP (and neurodevelopmental disorders), the reality in many cases is that the opportunity to enter this exploration phase of "hands / feet / objects in the mouth" has never been experienced...whether due to direct neurological impairment, significant physical limitations, or both the hands (and even the feet) have never been fundamentally "woken up" or activated. 

Point of interest:  A new born baby will consistently manifest a closed fist (with the thumbs outside), but as he/she develops and begins the fundamental process of self-exploration, the hands and fingers are exposed to high levels of sensory input...essentially activating them, while at the same time the brain itself is formally "registering" the hands / feet and creating a working body map of them as well.    In CP, more specifically in those GMFCS Level 4 and 5 classifications, the hands seem to maintain some level of "closure" and (as the hands and fingers get longer and wider) distortion.  This is not to say that distortion and/or asymmetry in the hands is 100% due to this missing phase...however, the fact that fundamental activation VIA these mechanisms was limited or even absent is most certainly a part of the reason...and therefore, by definition, part of the solution. 

"Little things...BIG difference"

With respect to tangible and practical "things to do", this would vary greatly on an individual level...however there are certainly some standardized and "generic" ideas that are usually quite helpful and, paradoxically, nothing new.  Alot of what is done within the scope of Occupational Therapy fits quite well within this narrative, however as parents it is always strategically wise to potentiate and activate your own level of understanding, knowledge, and skill...for the simple reason that whatever is done in the home and by YOU is done with the most care, attention, and concentration possible.

It is not likely a realistic idea to attempt to literally put a hand into the mouth, but it is relevant to know and understand that the head and face are areas of high sensory competence...meaning that hands that are passively touching, brushing along, and/or placed onto the head and face (especially near the mouth) generate a very powerful sensory "activation".  Beyond some of the sensory brain exercises mentioned in my earlier post, massaging and rubbing the hands with creams, essential oils (Lavender), or balms will also impose useful and productive stimulus. 

If your child has relativilty good visual acuity, you can combine these with some active (relatively unstructured) play with tools / toys of varied textures (feathers, balls, etc...) that can be brought into their field of vision and (with help) encourage interaction. 

"Awareness before Activation"

One of the fundamental messages proposed in the previous post is the simple understanding that a "mechano-sensory awareness" must be developed in order for any productive activation can begin.  Extrapolating this idea, FUNCTION (which is the overall objective) is formally the manifestation of organized and coordinated activation...therefore starting at the root and addressing the fundamentals of awareness will provide significant help in achieving that objective. 



  1. Hola Gavin!. Es posible que puedas subir estos posts en español?? Muchas gracias y saludos!

    1. Hola! Me encantaría poner más publicaciones en español, pero no tienen las "habilidades lingüísticas" necesarias para traducirlo correctamente. Desafortunadamente mis habilidades escritas en español son bastante limitadas. Esperemos que voy a ser capaz de tener algunos posts traducidos pronto. Es difícil identificar qué posts deben ser traducidos, ya que aunque la mayor parte de la obra FT se hace en América del Sur, sólo aproximadamente el 3% de los lectores del blog provienen de Argentina o Chile.

    2. Gracias por tu respuesta; para empezar podrían ser este mismo, éste (Developmental Exercises for Improved Arm Function: The Fascia Therapy Techniques) y éste (Sensory Body Mapping: Brain Exercises for Cerebral Palsy)... Saludos ;)