A teenage girl has found it difficult to keep up with schoolwork for a while, and whose teachers have commented on the need to tidy up her work. She has had pain in her hand, wrist and forearm whilst writing for long pieces of work and in tests. She found it difficult to finish her exam papers due to slow writing and pain in her arm. However, she has just about managed to get by year on year. Until the end of year 10 and the first term of year 11, when the school start doing mock GCSEs.
She finds across the board that she’s struggling to finish her papers and in fact fails a number of her mock exams because the teachers can’t read her writing; as in order to speed up, the writing has become illegible. The girl is now feeling very anxious about her exams, feeling very low in self esteem, and negative about her future. Unless she can get the grades needed, she won’t be able to attend the college course she wants to do.
Her parents seek an occupational therapy assessment to see if there is anything that can be done to help her to:
1. Speed up her writing, whilst keeping it legible.
2. Reduce pain in hand and arm during writing.
3. Improve self-confidence.
4. Reduce anxiety levels.
5. Achieve sufficient grades to pursue her chosen college course.
The girl was assessed using the DASH speed of handwriting test. This allowed the therapist to objectively measure the degree of difficulty with speed, but also allowed clear observational assessment of the specific physical difficulties, potential visual-spatial difficulties, and any other executive functioning issues which may all be contributing to this girl’s handwriting difficulties.
A detailed discussion took place about how the girl developed and progressed with her handwriting from the outset at primary school. Also, to establish if there were any other difficulties noted with learning, eg reading, concentration, or participation in other fine motor tasks.
The therapist finds that the girl has always struggled to write quickly and neatly but has up to this point just about managed and not wanted to ask for help. It was noted by school support staff in year 7 that she needed some extra help but found that she was reluctant to engage and look different to her peers as she saw it. Parents had tried to help by buying her alternative pens, but she had been reluctant to use them to avoid being different.
Fast forward to the spring term of year 11, the girl has failed nearly all her mock GCSEs, she is feeling like a failure, and has no hope for the future. However, she is motivated to work on her handwriting in an intensive way, in order to improve her speed and legibility enough to pass her exams.
1. Locked pen grasp, where the thumb overlaps the fingertips at the base of the pen, obscuring the tip of the pen. This resulted in hand, wrist and hand pain from muscle tension and fatigue, from not being able to move the pen with her fingers.
2. Letter formation is incorrect with many of the letter groups/families affecting the flow of the writing, affecting the speed of the writing and affecting spelling. She used a mixture of different routes of letter formation, which showed difficulties with motor planning. She had to constantly think about how she would achieve the writing.
3. There was little to no space between her words and between the lines. Often, she was writing over the letters above and below and all letters filled the entire line space. This really affected the legibility of her writing, to the point where even she couldn’t read back what she had written. There was also no difference between sizing of any letters.
4. When laying out maths questions and working out, she was unable to space the work in a way that was legible and allowed the working out to be seen.
5. Pressure on the paper when writing was extreme, which impacted on the tension of writing and therefore the level of pain and fatigue in the hand and arm.
What we did – Intervention
Committed to twice weekly therapy sessions for the next 3 weeks, and then once a week for up to 6 weeks.
Girl & parents committed to practice at home in between sessions to capitalize on any changes made and allow generalization of skills.
Used GCSE revision booklets as part of the therapy to ensure the work done was relevant and effective and gave real time strategies to improve the chances of passing her exams.
Liaison with high school to request extra time/rest breaks during GCSEs, as well as access to a laptop computer to produce some written work.
Looked at relaxing the grip on her pen, to help the arm relax and therefore reduce pain. Changed the pen grasp to one between her first and second fingers and guided her to hold it a little further up the barrel. This instantly allowed the pen to be stable without any extra effort required. However, it did feel “weird” and the pen/pencil has to be narrow barreled. She was persuaded to use this grip consistently both in therapy and at home when performing her training programme between sessions. She admitted that it did help with reducing the pain in her hand and arm, and it allowed her to move the pen with her fingers rather than her arm, so she changed her habits.
Introduced an angled, nonslip surface in the form of a filled, firm lever arch file with a nonslip mat on the top surface. This is such a mainstream study item, and no-one would think it was different to have on the desk. The purpose of this is to elevate the writing page, to improve visibility, reduce the pressure and reduce the tension. This was also a successful intervention.
Went back to basics with regards to letter formation, broke down to letter families, ensuring that the correct patterns were generalized into her everyday writing.
Used the “Speed up” programme, a standard devised schedule of activity, involving upper limb strengthening, controlled movement of the upper limb, hand & fingers, and other visual-motor planning activities, to help with developing the speed and flow of writing. Use of the warmup activities from the programme at home, prior to performing writing activities. There are several letter family patterns used in the programme too which reinforced the rhythm and the shape and route used to form the letters.
Introduced therapeutic putty as a stress reliever but also for hand and finger strengthening, to manipulate daily when relaxing, or prior to writing activity to warm up hand muscles.
Worked on spacing of work, by introducing strategies, including:
1. Adding extra red lines halfway between lines on writing paper, to allow practice of varying letter sizing.
2. Not writing on every line, leaving a line gap between while she was learning to reduce the size of her writing.
3. Using a space guide between words, to ensure not overcrowded on the line.
4. With maths work, dividing the plain page into squares @ 4cmx4cm, to use each square for each question, preventing overlap from one question to another.
The teenager completely engaged with the therapy intervention. She was motivated to improve her written work in order to go to college. However, she was very negative about herself throughout.
Whilst she used the modified grip initially, she gradually moved back to a more controlled tripod grasp, using a Yoropen. This prevented her from holding the pen too far down the barrel and she could always see the pen tip.
The restrictions of the added lines helped her to control the size of her letters and writing in general. The improved letter formation allowed her to join letters more fluently which helped to speed up the writing and helped with spelling.
The girl was happy that she could now read her own writing and although she did not like to stand out, fellow students and teachers all commented on how much better her writing and work in general was. This did have a positive effect on her wellbeing. In class she was reluctant to use the Yoropen but was happy to use it in exams. She was allocated extra time for exams but didn’t in the event require it.
This teenage girl passed all her written GCSEs and was able to commence the college course she applied for, which at the start of the year had looked unlikely.
This is an example of how a structured programme of Occupational Therapy intervention can have a big impact on physical performance and overall wellbeing, and long-term future progression.