Emily: I hope you are able to take something home and have something ready for you to use in your practice. It is a little bit frustrating for me to go to continuing education classes where you do not get many ideas for you to try and implement in your practice. Today, my focus is discussing fine motor, visual motor, and visual perceptual foundations to help students be successful in the classroom.
Fine Motor Review
As an occupational therapist, fine motor skills are part of our treatment protocol. Fine motor intervention involves the hands and fingers, and those skills require the small muscles of the hands to work together and to complete precise and refined movements for all sorts of different activities that we use throughout the day. Fine motor tasks also incorporate more than just the small muscles of the hands. There are many different foundational elements that we need to review and will do so in a few moments.
Fine Motor Skill Affects Students' Academic Success
An interesting study found that early fine motor skills in kindergarten were a predictor for reading and math achievement in early elementary school. It is interesting to think that what we are doing with our hands can really affect our students' ability to learn math and reading concepts that they will be using throughout their elementary career.
Fine Motor Skill Impairments Affect Students’ Ability to Access Curriculum
How do these fine motor skills impact our students' ability to access the curriculum? As an OT who works in the school system, I get many referrals for students who are having difficulty with fine motor skills. This referral might be to address their ability to manage classroom materials, hold a pencil or scissors, manage their lunchboxes, manage classroom materials like a stapler or paperclips, manage their pencil box, or complete self-care skills. These types of struggles get us referrals in the school-based system. Self-care skills are not something we address on a regular basis, but impaired fine motor skills can impact their ability to use the toilet, change clothes for PE, washing and drying their hands, or even eating that might be seen at a preschool level.
Impaired fine motor control can also affect their social-emotional health. They may start refusing activities, have difficulty with self-esteem, and demonstrate low confidence. Kids often do not want to participate in these activities because they are challenging.
Fine Motor Skill Foundations
There are many foundational skills for fine motor control.
- Proximal Stability & distal mobility
- Motor control
- Postural control & core strength
- Range of motion
- Sensory processing
They need to have proximal stability so that they can then have distal mobility. They also need to have postural control and core strength so that they can sit in a chair or on the floor to participate in those fine motor activities. We need to consider the student's range of motion especially for some of those kids who have physical disabilities. We also need to think about the sensory processing component of fine motor activities. There is definitely a tactile component as you know. If they do not have the appropriate processing and interpretation of the sense of touch, it makes using their hands that much more difficult. Visually, they need to be able to locate tools and the appropriate proprioception in order to grade force. They need to then use all of these skills to coordinate movements smoothly using both motor planning and input from their vestibular system. The motor planning or the ability to execute these types of activities are vitally important. Students that have difficulties in all three of those phases of praxis.
Here are some of the other fine motor skill foundations.
- Hand development
- Arches of the hand
- Separation of the hand
- Finger opposition
- Finger isolation
- Strength & endurance
- UB strength, pincer strength, intrinsic muscle strength, grip strength
- Wrist Extension
- Bilateral motor coordination & bilateral integration
We need to consider their hand development, the arches of the hand, the separation of their hands, finger opposition, and finger isolation. All of those things really impact their ability to use precise and refined movement. Along with that proximal stability and core strength, they need to have some hand strength and endurance as well. Many students have low hand strength, low endurance, and the ones that are tired after writing only a few words or letters with their pencil. They can also use too much force and tire themselves out. We also need to consider upper body strength, pincer strength, intrinsic hand strength, and grip strength. These can all impact how they manage their fine motor skills with precision and refinement. They also need some wrist extension for writing and using a pencil in a coordinated manner. Bilateral motor coordination and bilateral integration are important so that one hand can stabilize, while the other hand is active.
Fine Motor Skills Using the Hand and Wrist
- In hand manipulation
- Simple and complex rotation
- Simple and complex translation
- Grasp patterns & prehension
- Dexterity & precise refinement of movement
For in hand manipulation skills, there are simple and complex rotations, translations, and the shifting. You can see these pretty easily with kids who do not hold a pencil properly. We also have to consider their grasp and prehension patterns as well as dexterity and the precise refinement of movement. I would like to look at all of those areas of fine motor skill and talk about some treatment ideas. Hopefully, you will have some new ideas to take back to school.
Upper Extremity Treatment Ideas
Proximal Stability Treatment Ideas
- Weight-bearing – animal walks, WB walks
- Hand hockey – assume a plank position facing each other and make a goal by throwing a beanbag between your opponent's hands/UB.
- Writing or drawing supine on the floor to the underside of a table
- Zoomball – standing or vertically
- Oversized wall mazes or race tracks
We can do activities that incorporate weight bearing to help give their shoulders and upper body muscles a workout. Playing a game of hand hockey is also great. Students face each other and assume a plank position. Their arms are completely extended, and they try and toss a beanbag between their opponent's arms. They then use one hand to stop the beanbag as it is coming their way. There encourages good weight shifting, weight bearing, and eye-hand coordination. They have to aim and throw the beanbag while grading force. You can always encourage them to do some writing or drawing while lying supine on the floor or on the underside of a table. Kids think that this is a funny thing to do because you are not supposed to do that normally. Zoomball can be completed in a standing or vertical position. I like do it in the vertical position. This works on the motor planning of using their upper extremities to propel the ball through or across the ropes. I like to put it at the top of a doorframe or something and have the student lay on the ground. It is a really great way of working on that upper body coordination because they cannot pull their arms backward because the floor is there. I also like taking a large piece of paper and make a big roadmap. I have them push matchbox cars and trace their way through the mazes without going outside of the lines.
Figure 1 is an activity with a therapy ball between you and the child. They are not allowed to use their tummy.
Figure 1. Pushing a therapy ball.
This is an activity that I like to use for proximal stability where you have therapy ball in between you, and you are pushing against each other. You are trying to see which one of you is going to lose your balance and tip over. The kids really get into this, and it is an excellent sensory activity for providing proprioceptive input or calming and regulating kids. While at the same time, they are using their muscles for proximal stability.
Motor Control Treatment Activities
Here are some motor control treatment activities.
- Placing marbles on top of golf tees
- Placing marbles on top of bath mats suction cups
- Stacking blocks – try using more than one sized block
- Blockhead game
- Suspend Jr.
You can place marbles on the top of golf tees or bath mats (Figure 2). You can also use tongs to put those marbles on top of the golf tees. It is great for motor control. Another great proprioceptive activity is to hammer in golf tees into a foam board.
Figure 2. Marbles on suction cups.
Stacking blocks is another great activity. There is a game called Blockhead that has blocks of all different shapes. You try to balance all of those blocks without knocking them over. Figure 3 shows the game Suspend Jr.
Figure 3. Suspend Jr.
This is a great fine motor game as it also has a spinner. With a spinner, you can work on finger isolation and motor planning. This can be a tricky thing for some of our kids to learn.
Sensory Processing Treatment Ideas
Let's look at some quick sensory ideas.
- Tactile ideas:
- Rice bin w/magnetic letters, stereognosis, drawing letters on the back of hand or back, finger painting, making messy recipes
- Proprioceptive ideas:
- Stacking block towers using tongs, masking tape, playdough, putty locating items and replacing them, sharpening pencils with a manual sharpener, using a stapler, using a hole puncher
- Vestibular ideas:
- Crossing midline to pick up objects or place stickers, moving objects from floor to above head, swinging while completing an FM task, marble maze in a cardboard box, rolling over a barrel or ball to retrieve items in prone or supine
- Visual – we’ll get to this later
I could talk to you guys about sensory treatment ideas as that is my specialty. It is what I love doing, and it is what I do most of my time in the clinic.
For tactile activities, we can hide magnetic letters in a bin of rice or beans. This activity can work on letter identification for some of your younger clients, and you can use those same letters for a game of stereognosis. You can draw letters on the back of their hand or on their back. The kids love to do it to you as well. Finger painting and messy recipes are great tactile activities.
As far as proprioceptive activities go, you can stack blocks using tongs as I mentioned earlier. They can work on grading the force with using tongs and placing the blocks down. Using masking tape gives a lot of proprioceptive feedback and strengthening to the fingertips especially if they are using two hands to rip it. Play-Doh and putty are standard OT ideas for proprioceptive activities. I find that letting the kids pull and push things in the putty helps with strengthening. They think it is very exciting to hide something for the next person. Do not forget to use manual pencil sharpeners. They take a lot of grading of force. You have to have just the right amount. If you do not, nothing happens, and if you have too much, the pencil does not want to turn very nicely. A stapler and a hole punch are also great tools for strengthening and proprioception.
Vestibular activities can include the simple placement of your activities. Examples are crossing midline to pick up objects or place something into a bucket with tongs or with a grabber. Doing fine motor activities on a dizzy disk where they have to move their body and cross over to the other side is another great way of incorporating that vestibular component. Moving objects from the floor to above your head. This is a great way of getting that head in inversion. I will caution you that sometimes kids have a hard time processing this amount of vestibular input. You have to be really careful about regulating input as it may become dysregulating. In the same way, a downward dog yoga position gets the kid's head in inversion. I do not know how many of you have access to swinging equipment in your therapy rooms. Doing activities on a swing that is moving ever so gently provides another layer or vestibular input. You can make marble mazes in a cardboard box for working on the bilateral skills as well. Costco has flat-type boxes, and you can have the kids either draw the maze inside on the box or you can use tape and straws to make physical boundaries of a maze and then the kids have to put a marble in the box and move the marble through the maze using both hands on both sides of the box. Another fun activity is having a kid roll over a barrel or a therapy ball to retrieve items, and you can do this either in prone or supine. Supine is a little more intense as far as the vestibular input goes. You can start by having the child face you with the ball or the bolster behind them, and then you roll them over to the other side of that barrel in order to retrieve something. You can also do a puzzle, a bean bag toss, or pick up the Lego pieces.
We are going to get to the visual component shortly.
Arches of the Hand Treatment Ideas
Some activities for using the arches of your hands are below.
- Slide tiny rubber bands from the MC joint to the fingertip sliding the rubber band up and down on the finger, try transferring the rubber bands from finger to finger without dropping them
- Lay a piece of newspaper flat on the table, with one hand without lifting it from the table, gather the newspaper into the palm
I use teeny rubber bands as you see in Figure 4. They are the ones that you can put on your hair ties. I usually get them at like a Dollar Tree or something like that. You put it over your finger here and you move that down your finger.
Figure 4. Example of moving rubber hands on fingers.
As you can see, it really gets those arches going and then you can either have them go down to a certain knuckle or you can go all the way down to the base of their finger but then you can have them move that rubber band back up. The tricky part is having them move it over to the next finger and trying to get that rubber band over their finger and then back down to the next knuckle. You might have to get it started for them.
Another great idea for working on those arches is putting a big piece of paper or a sheet of newspaper on the table. They can scrunch up that paper without letting their hand and forearm off the table. They have to use all their fingers to gather that newspaper into a ball in their palm on the table.
- Airplane clips: use clothespins with popsicle sticks glued perpendicular to the end of one end of the clothespin and use only fingertips and the tip of the thumb to squeeze open the clothespins
Figure 5. Airplane clips.