Toddlers and children with movement conditions such as joint hypermobilty, low muscle tone, developmental coordination disorder, dyspraxia, Down's syndrome and autism often have difficulties performing everyday fine motor tasks that require good hand and wrist muscle strength and coordination. 

Functional strength training (also called task oriented training) is the best way to strengthen hands because it takes into account the relationship between muscle strength, type of muscle contraction and coordination needed for an action. This is important because different tasks use different combinations and requirements. 

Different hand tasks have different coordination and strength requirements 

Different hand tasks use a different combination of movements of the fingers and wrist, so that the coordination and strength requirements differ from task to task. 

Because the coordination, grasp and manipulation patterns and the strength requirements are specific to the particular hand task, the most effective way to improve hand function is to base exercises on everyday hand tasks. This approach is referred to as functional strength training or task oriented training. 

Muscles become stronger when they are made to work harder than usual. This is known as the overload principle. In functional strength training the overload principle is applied by adapting the task to increase the resistance the muscles need to overcome, as well as amount of work done by increasing the number of repetitions or rate of work. 

Adapting exercises to avoid stressing joints

Generalized joint hypermobility is a  common reasons for weakness of the wrist and hand muscles. The small joints in the thumb and fingers of hypermobile individuals are easily overextended. One of the benefits of functional strength training for the hand is that individuals learn to adapt the grips used for different tasks so that the thumb and finger joints are not overstretched. 

Important note Exercises for children who have very hypermobile hands (Ehlers Danlos - Hypermobility Type) and who experience pain in the thumb and finger joints should be overseen by a physical therapist who can advise on joint protection measures. 

Many activities that require a grasping an object between the thumb and the fingers. In hypermobile hands this leads to overextension of the finger and thumb joints. Pencil grip can be adapted to avoid overextension. 

Principles of strength training 

The 10 repetitions to fatigue rule
Muscles get stronger when they are made to work against a load that is at least 60-80 % of their  maximum capacity. If a group of muscles can do an activity against a load just 10-12 times before they are tired, then you know that the load is good for increasing strength. This is the 10 repetitions to fatigue rule. 

You know that the muscles are tiring when the movement becomes slower and is not being performed smoothly. Another indication of tiredness is a tendency to start using momentum to overcome the load. 

Tasks that use a hook grip  

A hook grip is used to grasp objects with a small diameter. The fingers are bent at all the joints.

A hook grip is used for holding a bucket and hanging from an overhead bar. .   

Power grip 

A power grip is used to grasp and hold a cylindrical object between the fingers and the the thumb. Notice the gap between the thumb and the forefinger, as well as the position of the thumb joints.  

Many power grip activities also involve movements of the wrist or elbow to move the lift, tip or tilt the object. When picking up an object using a power grip, the grasp force needs to be carefully adjusted to ensure that the object is firmly held and does not slip out of the hand as the object is moved. 

Examples of a power grip

Carrying a beanbag on a tube 

Picking up a bottle with a handle

Climbing on a climbing frame 

Climbing activities require a strong power grip to support the weight of the body. 

Palmer grasp

A palmar grasp is used to hold objects or tools with a long handle The handle of the tool is held diagonally across the palm of the hand. The thumb is used to stabilize the grasp. In some tasks the thumb is used along the length of the object, such as when holding a hammer. 

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Pouring from a saucepan with a long handle

The handle of the pot rests across the palm of the hands. To pour from the pot that forearm is twisted. 

Young children use a palmar grasp when using a spoon to for eating or picking up rice or sand with a spoon. A palmar grasp is also used when digging with a trowel. 

A spherical grip is used with round objects

A spherical grip is used when the fingers need to be shaped to grasp a round object.  This grip is used to grasp a ball shaped or flat round object, such as the lid of a tub. 

When unscrewing the lid of a jar, one hand is used to stabilize the jar - this action requires a power grip. The fingers of the other hand grasp the lid of the jar  firmly, and then use a movement of the forearm to loosen the lid.

A lumbrical grip 

A lumbrical grip is used to hold an object without wrapping the fingers around it. .The fingers need to be straight, rather than curved. 

The forearm muscle contract to bend the knuckle (metacarpophalangeal) joints and the small hand muscles hold the fingers straight. This grip is difficult to maintain if the small hand muscles are weak. . 

A pincer (precision) grip  

Small objects are picked up between the tip of the thumb and forefinger.  From 8-10 months of age infants use this grip to pick up small objects. 

The thumb is held at right angles to the palm and is straight. The small joints of the fingers are bent.  

This position of the fingers is difficult for individuals with hypermobile finger joints. The small joints of thumb and forefinger tend to hyperextend, especially when some degree of force is needed. It is best to use an adapted grip when force needs to be applies to a small object. The object is picked up between the tip of the thumb and the side of the forefinger - this is often called a key grip. See below. 

Stretching a rubber band 

Instructions

1. You will need one or more sturdy rubber bands for this activity. 
2. Grasp the rubber band on each side between the tip of the forefinger and the thumb.
3. Move the hands apart to stretch the rubber band as far ae it will go.  
4. Maintain this stretched position for 15-20 secs.
5. If you are able to hold the fully stretched band easily for 20 seconds, try holding and stretching two bands.

Making BluTack (Prestick/Tack It) balls 

1. Break a  piece of Blu Tack into pea sized pieces. You need enough putty to make 20 pieces. 
2. Roll the pieces into small balls between your forefinger and thumb. 
3. Use the balls to mount pieces of colored paper to a piece of card to make a mosaic. 

A key grip 

Many activities involve gripping a small flat surface between the thumb and side of the forefinger. The other fingers are flexed to provide additional support. This combination of movements allows considerable force to be applied to the object. 

A key grip is used to turn a key, when tearing paper, lifting up a box by grasping on the sides. pulling on Velcro fastenings, pulling up trousers and socks. 

Picking up a box 

Instructions 

1. Use a cardboard or plastic box with straight sides, about the size of a shoe box,  for this activity
2. You will also need several books that can lie flat to act as weights. 
3. Put the box on chair with 2 books inside. 
4. Grasp the box using a key grip and lift it up to about chest height and hold it there for 20 secs. 
5. Put the  box back down on the chair. 
6. If the box can be lifted and held easily, add another book to make it more difficult to hold the box up for 20 secs. 
7. Keep adding books until holding the book up for 15 secs is very hard work. 

Swinging a sock sand bag

1. Half fill a sock with sand, beans or rice. 
2. Tie a knot at the top of the sock 
3. use a key grip to grasp the sock by the knot and lift the hand forwards to chest height with the elbow bent. 
4. Swing the sock backwards or forwards, or round and round 20 times. 
5. If it is easy to hold and swing the sock beanbag 20 times. add some snad to the bag to make it heavier. 

A chuck grip

Tools, such as a spoon or knife are often grasped using the thumb, fore- and ring finger. 

The fingers need to firmly grasp and stabilize the tool while at the same time move to manipulate it. This is a complex action which young children only start to effectively master at 4-5 years. 

A chuck grip is used to hold and manipulate a spoon, unscrew small lids. 

 A tripod grip 

A tripod grip is used for holding a pen when drawing and writing

A good pencil allows the child to hold the pencil in the hand  in such a way that  small movements of the fingers and wrist can be used to move the pencil point in all directions on the paper. 

The three finger tripod grip the most common configuration: the pencil is stabilised between the thumb and the side of the index and middle fingers. 

• The ring and middle fingers rest lightly in the palm of the hand.
• The wrist is held straight (in extension). 

 A good grip allows the child to make small bending and straightening movements of the fingers.

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In this short video you see how I use a combination of small finger movements, combined with small wrist movements to draw short lines in different directions.  TIP: Click on the gear to for slow motion playback. 

The position of the thumb varies

Some children adopt a typical tripod grip with the thumb held away from the index finger with a gap between the thumb and index finger. 

The thumb may also be held close to the index finger (thumb adduction). This position is commonly seen in children with hypermobile fingers.  (More about thumb position)

More about hand function

Hypermobile hands 

How to assess your child's pencil grip and finger movements 

How drawing in kindergarten improves motor control and endurance 

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