What are some of most common/difficult clinical problems you have encountered in your pediatric practice?
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Question 2. (12/13/2007): Some of the kids with handwriting problems have trouble grading their pencil pressure. They either press too hard, tearing the paper or making lines that are impossible to erase, or they press so lightly their writing is hard to see.
Answer 2. (12/31/2007): There is a simple activity I call Carbon Paper. It gives the child sensory feedback and helps him adjust his pressure. It begins with placing a piece of paper on his leg, and asking him to draw on it as hard as possible. Then he draws another line, as soft as possible. Then he is asked to press between hard and soft. This gives him some parameters and direction of what he is trying to accomplish. Next, alternate carbon paper with 4 layers of paper on a clipboard. He is to draw so heavily that the line is visible on the bottom sheet. Next, draw so softly that the line is not visible through any layers. Continue, aiming for visibility through 1, 2, and then 3 layers.

Question 1. (8/10/2007): What I see over and over is the extreme wrist flexion in kids with cerebral palsy. It really limits their hand function. I've tried different ways of getting more extension such as passive ROM, weight-bearing, splinting, and drawing on vertical surfaces (for the mild cases), but don't have as much success as I would like. Does anyone have more ideas?
Answer 1. (8/17/2007): My favorite way of getting more active and sustained wrist extension is by sensory input, that is, proprioceptive and kinesthetic. Usually the child with excessive wrist flexion is also tight throughout the shoulder and arm, so I begin by inhibiting/facilitating more normal tone through NDT techniques such as passive manual vibration, shaking, etc. followed by elongating the muscle groups surrounding shoulder, elbow, wrist, and finger joints. Then I find ways to help the child use available surfaces to guide shoulder and elbow movement while actively sliding the forearm, extended wrist, and hand forward toward a goal target (e.g. to knock it over), maintaining total contact on the surface. That sensory feedback seems to be retained for feedforward as we repeat the movement, and generalize it by varying the direction, speed, pressure, and, of course, the goal-oriented activity. I may have to assist at first by applying pressure at certain points on the arm where necessary, then changing those points of control and/or reducing my pressure until the child moves independently, and even returning if he loses contact with the surface at some point. The child who cannot maintain an open hand during this activity is encouraged to keep the hand fisted at first, but with the thumb outside the palm. Those children also have limited supination, so the activity is first begun with the forearm pronated. This reaching movement is not combined with grasping the goal object until the child can maintain the wrist extension.