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Home > Muscle Coordination, Muscle Tone, and Strength > HEMIPLEGIA and encouraging bilateral skills

HEMIPLEGIA and encouraging bilateral skills


A child with hemiparesis sometimes has excess muscle tone in the hand. They may have problems isolating finger movement, turning their hand over (palm up), holding their wrist at a proper angle, and grasping and releasing objects.

Supination Ideas (Turning the hand over, palm up)


  • Ringing water out of a towel by twisting it

  • Sensory water/oil/glitter bottles turning up and down

  • Say "palms up" to give them a snack, or finger foods often 

  • Turning pages of a book.

  • "Guess which hand" games, where something is hidden in one hand, the partner guesses which by tapping the guessed hand, and the hider turns both palms up and opens her hands. If correct the guesser gets a point. If not, the hider gets the point, and so on.

  • A simple "Slinky" is a great toy to encourage supination.

  • Build with cones (for example, discarded spools from textile factories). You can build towers or set them up for "bowling", etc. If you place or the child grasps the cone closest to the thumb, the child has to actively supinate at least to neutral to effectively place the cone.

  • For older kids, grasping a magnet (adapt type and size to the child's needs) and guiding a magnetic "car" along a path (the path is drawn on oaktag or similar thin but sturdy paper). The path is held with the non-affected hand and the child holds the magnet in the affected hand, under the path to guide the car.

  • Benik splints with the supinator straps, especially for children with some active supination.

  • Sand or water play can encourage a lot of wrist rotation and supination (palms up) movements.  Scooping up sand or water and pouring into another container, or sand/water wheel toy (Discovery Toys has a good one). Making sand castles, scooping and pouring motions!

  • Using a snack activity such as scooping and eating pudding.

  • Placing stickers, stamps, etc. on the inner arm - turn to look at it and take off.

  • Playing with money and reaching for change

  • "Give me five" with palms up 

  • Fill plastic Easter eggs with varying items to make hand held maracas!  Supination to pronation, flexion to extension of either the wrist or the elbow, crossing the midline...

  • Hiding little stickers on the bottoms of large pegs in a pegboard


Sensory Activities


  • Playing in rice, sand, different textures

  • Weight bearing provides sensory input and can help stretch tight muscles

  • Be sure to include lots of bilateral activities actively using both hands together. Not a lot of two year olds tolerate direct handling to an affected side, so you need to be creative and fun.

  • You may also want to consider a neoprene splint if they continually rests their hand in a fisted position.

  • A tray full of - chocolate pudding, whipped cream, jello - makes a great place to "paint" with two hands - also nice to lick the stuff off both hands.

  • You can also do texture hand painting on a mirror, side of tub, dry erase marker board or painting easel 

  • The classic containers of rice, beans, sand in  tupperware container and bury treasures in it.

  • Larger tactile containers or kiddie pools you can have them lean or weight bear on the affected hand into the large container while they search for treasures or search with the affected hand. (Also, works for toes and feet).

  • Paint fingernails wild colors to stimulate interest in their affected hand.

  • Colorful handsplints and rings and bracelets on affected side.

  • Let them paint on their arm with washable markers or paints. This will help especially if they are seeking stimulation.


  • Occupational therapy activities for children with hemiplegia:  

  • Bilateral upper extremity weight bearing activities and unilateral reach to both side (works on lengthening the involved side)

  • trunk rotation (both ways)

  • bilateral activities where both hands move together and where one hand stabilizes and the other manipulates

  • bilateral and unilateral reaching in different planes in a variety of positions

  • holding large light objects when walking such as a ball or cone in hand 

  • In terms of grasp try to stabilize the arm as much as possible when grasping eg. rest forearm on the table initially.

  • Need to work on wrist extension also for a good grasp.

  • Keep in mind that you may only get to a functional assist on that side.

  • A soft thumb abduction splint will probably help with grasp

  • Wheelbarrow walking is great for weight bearing.

  • Bilateral coordination tasks: pushing a swing with both hands, scooter in prone propelling with both hands, and waving bubble wands in the air with the affected hand is a good way to make it fun!

  • To encourage reaching with the involved hand, position the child so that the involved side is close enough to reach to touch a lamp which would turn on and off by touch.

  • Cozy coupe cars are great for children with left hemiplegia. Encourage the child to open the door by pushing with left arm. It also helps develop lower extremities to power the car.

  • Use squishy balls to squeeze or toys that required gripping in 2 hands. 

  • Finger foods, ask the child pick up every other potato chip or snack food with the involved hand with assistance.

  • Try to incorporate these activities into everyday play and routines.


In the kitchen

  • Have the child hold onto the mixing bowl with the affected hand and stir with the other hand

  • Help unload the dishwasher with the affected hand pulling out all of the silverware

  • Putting up boxes of cereal, etc. when unloading the groceries.

  • Pouring just about anything - hold cup with affected hand (find one that's the right size)


For the wrist


  • Fingerpainting on easel.

  • Wrist rotation fidget toys, rubix cube, etc. 

  • Sensory bottles

  • Shaving cream on the wall of the bathtub.

  • Colorforms on a mirror - puts on and pulls off with affected hand.

  • Leaning into the wall with the affected hand while they paint a picture.

  • Batting a lightweight ball or balloon (like volleyball).

  • Play dough activities, pretend cooking (flipping pancakes), and the shaker bottles with corn syrup and glitter, plastic confetti, etc. (can make your own with water bottle, or small plastic bottle).

  • Toys with the keys you turn, toy oven knobs, etc.

  • Carrying tray- pretend foods, playing 'waiter'- hold the tray under the bottom side with one hand

  • Playhouses with keys and shape sorters with keys are fabulous 


Weight bearing


  • Wheelbarrowing

  • Side sitting and weight bearing while they play board games or do puzzles.

  • Pretending you are animals and crawling through the jungle.

  • Take the cushions off the sofa and chairs - jumble them up and hide toys underneath - have child crawl up and over cushions and weight bear on hand while reaching for toys.


Bilateral activities


  • Catching balls.

  • Carrying containers of toys when you clean up.

  • Opening packages of CANDY (much motivation) and baggies of food.

  • Lots of two handed baby toys - those popping beads, duplos/legos.

  • Dressing Barbies.

  • Emptying the trash cans.

  • Clearing the dinner table (buy non-breakable dishes).

  • Zoom football that's on a string.

  • Trapeze bar swing in the backyard.

  • Stringing beads.

  • Sewing - get a embroidery hoop and place fabric in this - hold onto hoop with affected hand and sew with other hand.

  • Holding paper down with affected hand and drawing.

  • Holding paper with affected hand and cutting.

  • Pushing a laundry basket with two hands on the floor (fill with heavy phone books, cover with a baby blanket and then put baby doll inside) - do it on knees and get in some leg work also.




  • Indoor jump-o-lene that's inexpensive and great for helping with balance.

  • Walking on curbs with arms extended.

  • Wrestling for fun.

  • Lots of swinging at the park.


    Safety netted trampolines 

Music and hand play


  • Percussion instrument like the marimba might be a good one,

  • The glockenspiel

  • A tambourine is also a great instrument to use for supination/pronation because it is so visual. Get one of those cute animal ones for children that has a handle in the middle. The weight is more easily distributed.

  • They might be able to develop the fine muscle movements needed for writing by doing exercises on the keyboard/piano geared for strengthening. 

  • In terms of the right brain/left brain ability, music is one of the only activities that a person can do that requires the whole brain.


Pincer Grasp


  • Picking small items and matching in an egg carton

  • Water Bottle Fun. Using clear plastic pop bottles. Using tweezers and chop sticks, have the child place items in the empty bottle. Items can be anything that will tolerate being in water such as plastic flowers, glitter, metal confetti, etc. Then fill the bottle with water which is colored or plain. If you are concerned about the child opening it, you can tape or glue the lid on. This engages the hands and is visually appealing.  Oil and food coloring add a nice effect. 

  • For kids working on pinch/fine motor, place stickers on the non-affected hand/arm. This way the child has to use the affected hand to remove the sticker. Most children love stickers and love to make pictures with them. 

  • Tissue paper scrunching is a really low tech exercise. Have the child crumple up bits of soft paper and then throw them round the room. Then they have to chase them by walking or crawling and pick them up with their toes. This helps with hands and feet!

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