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\begin{document}


\def\RunningAuthor{Monisha R and Ganapathy Sankar U}
\firstPage{6347}
\articleType{Original Article}
\receivedDate{15 Jan 2020}
\acceptedDate{15 Feb 2020}
\revisedDate{02 Feb 2020}
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\title{\textbf{Evaluation of Hand Strength, Handwriting, and Functional Skills in Children with Developmental Coordination Disorder (DCD)}}
\author{Ganapathy~Sankar~U, 
            Monisha~R\textsuperscript{*}~\\[5pt]{SRM College of Occupational therapy, SRM Institute of Science and technology, SRM Nagar, Kattankulathur-603203, Kanchipuram, Chennai, Tamil Nadu, India}}

\begin{abstract}
Dysgraphia and difficulty in activities of daily living skill are well documented in the research database as impairments affecting children with developmental coordination disorder. Pinch and grip strength has a predominant role in various activities of daily living skills, and a child can fulfil the playing skill only with good pinch and grip strength. To estimate hand strength evolution difference in children with developmental coordination disorder and to analyze the correlations in grip and pinch strength, handwriting and its components, and activities of daily living skills in children with and without developmental coordination disorder. Twenty children were selected and assigned into two groups, typically developing children and children with DCD. Each child was evaluated with pinch and grip strength, handwriting speed and legibility, pencil grip, and levels of performance in functional skills. When considering the strength development pattern, there exists a similar trend in children with and without DCD. Grip strength is having a perfect correlation with pencil control in both children with and without DCD. Handwriting is poor in the children with DCD but not in children without DCD. This study provides evidence that grip and pinch strength are important components when considering therapeutic intervention for enhancing handwriting skill in children with DCD.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Hand Grip,\newline hand strength,\newline DCD,\newline ADL,\newline Functional activity
\end{keywords}
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\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Monisha~R~\\ Phone:\ 9940228679~\\  Email:\ monisha\_ravikumar@srmuniv.ac.in
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\section{Introduction}
Dysgraphia and difficulty in activities of daily living skill are well evidenced in the research database as motor difficulties in children with developmental coordination disorder. During baseline evaluation of the child with DCD, it is mandatory to assess the pinch strength and grip strength. Assessment forms should include pinch and grip strength evaluation as there is a perfect correlation between hand strength and performance in occupation and other academic activities \unskip~\citep{893492:20408386}. 

Researchers documented that children with developmental coordination disorder have poor fine motor functioning and have weaker grip strength than typically developing children. This current research elaborates the findings and debates of the relationship between grip and pinch strength as well as functional performance in children with developmental coordination disorder and in typically developing children. Through this study, researchers can establish rehabilitation strategies for children with developmental coordination disorder \unskip~\citep{893492:20408387}.

Pinch and grip strength has a predominant role in various activities of daily living skills, and a child can fulfil the playing skill only with good pinch and grip strength. Low strength can hinder performance in green land play with peer group as well as in the classroom. The fine motor skill plays a dominant role in children's academic performance in school. Handwriting is an essential prerequisite skill to attain to enhance academic performance and to get the passing grade in schools. Children with developmental coordination disorder have poor handwriting, which makes them achieve less in academics \unskip~\citep{893492:20408388}. 

Handwriting is an essential skill to get mastered to achieve successful education. The handwriting was necessarily coupled together for the development of efficient penmanship. Handwriting training and learning are involved rather than are naturally attained as a skill itself, and there is an enormous number of variations in the activities, which is considered to enhance the handwriting legibility \unskip~\citep{893492:20408389}. 

Many occupational therapists documented that useful sensory feedback is sufficient to enhance handwriting legibility. However, an assessment of fine motor development combined with precise and elaborate handwriting instruction should be included in delivering handwriting intervention for a child with DCD, and every therapist should practice activity that develops pinch strength \unskip~\citep{893492:20408390}.

 Previous researchers have identified and documented that dysgraphia evaluation process should include pinch strength assessment. However it has been used in common routine, there is no reliable data established for pinch strength among children with and without DCD, and no researcher had analyzed pinch strength and handwriting for children with developmental coordination disorder in Tamilnadu context \unskip~\citep{893492:20408391}.

The research focused on evaluating a variety of handwriting rehabilitation techniques. However, Among primary school children in Tamilnadu, no research has focused on the relation between pinch and grip strength and handwriting performance \unskip~\citep{893492:20408392}. Handwriting is an essential task for children to cherish in academics \unskip~\citep{893492:20408393}.

\textbf{Methodology}

\textbf{Participants}

Typically developing children (n=10) and children with DCD (n=10) were participated in the study and the criteria is fixed for the participants, who have to be in age group range of 5{\textendash}10 years, and they should able to understand and follow the instructions delivered by the therapist. If they were able unable to understand and follow directions were excluded.

For the recruitment of participants in this current study, a pediatric clinic in Kancheepuram is selected. Flyers were posted to the clinic and given to parents in person. Clinics recommended parents to participate in the study, and they elaborated the importance of the study. Typically developing children's were identified by forwarding emails to the employees in hospitals in and around Kancheepuram. Majority of the employees, who received the mails, motivated their children to participate in the study. After approval from the SRM College of occupational therapy, SRM institute of science and technology, full written consent and assent form were obtained for all children participating in the study. Participants were divided into two groups by random allocation method: typically developing children and children with developmental coordination disorder.

Grip and pinch strength was assessed using a hand dynamometer and pinch meter. Instruments were tested and calibrated to enhance proper measurement. Motor coordination subtest from Beery's VMI was opted to assess pencil grasp and control. VMI is a standard test to evaluate the motor coordination involved in pencil control in children aged 2{\textendash}18 yr. The VMI has been used in many countries as it delivers high psychometric properties. The child's handwriting legibility is assessed using ETCH. A questionnaire has been used to assess the functional activities of their daily living skills \unskip~\citep{893492:20408394}. 

Participants were assessed for grip and pinch strength at both right and left hand using the ASHT protocol. Each child attempted three trials, and the mean value will be documented for further analysis. The VMI was used to evaluate pencil control. Handwriting legibility was assessed using ETCH, Upper Case, Lower Case, and Numbers subtests were analyzed. All tests, as mentioned above, were documented and measured using two assessors to maintain accuracy.

\textbf{Data Analysis}

Grip strength and pinch strength were analyzed three times, and the average value is documented and evaluated. The coefficient of variation (CV) was analyzed to identify the variance in measurement for each child. VMI raw scores once obtained is converted into T scores for further analysis. ETCH score is calculated as legibility percentage, and the functional skills assessment was documented to demonstrate independence.


\begin{table*}[!htbp]
\caption{\boldmath {Mean Grip And Pinch Strength In Pounds, By Age} }
\label{tw-99643de472af}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.0802\linewidth-2\tabcolsep}p{\dimexpr.0998\linewidth-2\tabcolsep}p{\dimexpr.09\linewidth-2\tabcolsep}p{\dimexpr.09\linewidth-2\tabcolsep}p{\dimexpr.09\linewidth-2\tabcolsep}p{\dimexpr.09\linewidth-2\tabcolsep}p{\dimexpr.09\linewidth-2\tabcolsep}p{\dimexpr.09\linewidth-2\tabcolsep}p{\dimexpr.09\linewidth-2\tabcolsep}p{\dimexpr.09\linewidth-2\tabcolsep}p{\dimexpr.10\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}{\multirow{2}{*}{Age }} & \multicolumn{2}{p{\dimexpr(.1898\linewidth-2\tabcolsep)}}{Sample Size} & \multicolumn{2}{p{\dimexpr(.18\linewidth-2\tabcolsep)}}{Grip Strength} & \multicolumn{2}{p{\dimexpr(.18\linewidth-2\tabcolsep)}}{Tip Pinch Strength} & \multicolumn{2}{p{\dimexpr(.18\linewidth-2\tabcolsep)}}{Lateral Pinch Strength} & \multicolumn{2}{p{\dimexpr(.19\linewidth-2\tabcolsep)}}{Palmar Pinch Strength}\\
\rowcolor{kwdboxcolor} & TD & DCD & TD & DCD & TD & DCD & TD & DCD & TD & DCD\\
\tblmidrule 
5-6 &
  1 &
  3 &
  14.5 &
  10.2 &
  1.5 &
  1.2 &
  1.2 &
  1.0 &
  1.6 &
  1.2\\
6-7 &
  2 &
  2 &
  16.5 &
  12.5 &
  1.8 &
  1.3 &
  3.2 &
  1.8 &
  2.5 &
  1.9\\
7-8 &
  3 &
  3 &
  20.2 &
  18.5 &
  2.5 &
  1.8 &
  5.3 &
  3.5 &
  3.8 &
  1.9\\
8-9 &
  2 &
  1 &
  22.7 &
  20.2 &
  3.9 &
  2.0 &
  6.3 &
  3.9 &
  5.2 &
  2.6\\
9-10 &
  2 &
  1 &
  30.6 &
  25.6 &
  5.0 &
  3.0 &
  8.2 &
  5.7 &
  8.5 &
  5.9\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

    
\section{Results and Discussion}
The mean age of children with and without DCD was 7 yr 9 months, and 80\% of the children were right dominant. The current study adds to evidence that the typically developing children and children with Developmental coordination disorder showed increasing grip and pinched strength with increasing age. Results of the current study proved their no significant association Exist among gender, hand dominance, and strength. However, grip strength is having a perfect correlation with pencil control as measured in the VMI subtest.

Children with and without DCD have similar hand grip and strength had similar developmental, but the child with DCD established lower scores in strength than their typically developing children. When analyzing the results in detail, it has been established that Grip strength is having a perfect correlation with pencil control for both children with and without DCD. 

Handwriting legibility is also having a perfect correlation with grip strength in typically developing children. A significant limitation of this study lies with the need for a larger sample size. However, with this small sample size, it isn't easy to examine the relationship between groups and variables. It is also difficult for the researcher to examine the reliable recording of grip strength and pinch strength measurement in children with DCD \unskip~\citep{893492:20408395}. 

Characteristics which are inherent in the diagnosis of DCD, such as motor coordination difficulty, poor VMI, Gross motor and fine motor difficulty interfered with the children's ability to produce consistent results \unskip~\citep{893492:20408396}. No research to date has examined the relationship between pinch and grip strength with handwriting in children with developmental coordination disorder. Limited research has outlined the correlation of pinch as well as grip strength with functional performance \unskip~\citep{893492:20408393,893492:20408397}. American Society of Hand Therapists devised positioning methods for assessment of pinch and grip strength measurement \unskip~\citep{893492:20408399}. 

When the previous researchers documented evidence on the handgrip, and handwriting strategies were examined, it has been concluded that The influence of hand dominance and gender on hand strength development is not clear and still it is under debate \unskip~\citep{893492:20408400}. 

The research was utterly lag on the evaluation of pinch and grip strength norms in children with developmental coordination disorder\ensuremath{^{. }} The current study aims to establish a correlation between hand strength and pencil control assessed and documented with VMI Motor Coordination subtest. 

For children in both group (with and without DCD) grip strength correlated with T scores on the VMI subtest, thus it elaborates that stronger the grip strength, the better the pencil control \unskip~\citep{893492:20408401}. 

However, it is proved that pinch strength is not correlated with pencil control. The current study employed the usage of a manual-read dynamometer. To maintain consistency, the total scores were converted into the whole number. 

To elaborate on the functional activities and its correlation with grip and pinch strength, we performed a discriminate analysis (see Table~\ref{tw-99643de472af}). Grip and pinch strength were strongly related, and it influences functional activities in both groups.
    
\section{Conclusions}
It has been concluded that strengthening the intrinsic muscles of the hand are necessary aspects to intervene when considering therapeutic intervention for enhancing handwriting skill in children with DCD. With effective therapeutic application over grip strength and pinch strength for children with DCD, they can enjoy independence over functional activities of daily living skills. 

\textbf{Conflict of Interest }

The authors declare that they have no conflict of interest for this study.

\textbf{Funding Support }

The authors declare that they have no funding support for this study.
    

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