Introduction

Fine motor skills (FMS) refer to the ability to use small muscles, working alongside the brain and nervous system, to control movements of the hands, fingers, wrists and tongue. These abilities are essential for completing everyday tasks such as writing, buttoning clothes, and using utensils- requiring precision, coordination, and dexterity. Early childhood is one of the most intensive periods for the development of FMS, contributing heavily to a child’s language development, academic achievements and cognitive abilities. 

Improper development or impairment of such skills has been associated with a spectrum of motor disorders. This is not a condition on its own, but rather a symptom of an underlying disease.¹ This highlights the importance of engaging in developmentally appropriate activities during these early years, as well as during the recovery process following neurological disorders. These activities come under the term occupational therapy (OT), a technique used to develop, improve, or restore fine motor skills in people of all ages. OT has been proven to significantly increase autonomy in performing daily activities and independence.² 

Importance of Fine Motor Skills (FMS)

FMS are essential for completing everyday tasks and having a sense of independence, but they have also been strongly associated with social behaviours through participation in group settings. Children experiencing fine motor difficulties may avoid social interactions, resulting in low self-esteem.³ As well as this, studies have found the development of FMS to be a strong contributor to school readiness.⁴ This is due to the impact it has on vocabulary, auditory and visual skills, demonstrated by studies showing that strong FMS performed better in mathematics and reading.⁵ Hand-eye coordination also requires FMS with hands being directed by the eyes to perform a task. Without visual input, hand movements cannot be effectively carried out.⁶ 

This highlights the great importance of developing a good foundation of FMS as they are used to perform a number of daily activities.

Developmental Milestones

It should be noted, children progress through developmental stages at their own pace, and therefore the developmental milestones for the acquisition of FMS should be regarded as a benchmark not an absolute. The typical progression of fine motor skills is as follows:

• 4 - 5 months: Babies develop a palmar grasp, using their whole hand to grasp objects (e.g., a crayon or a rattle)
• 12 months: Infants develop a pincer grip/ grasp, holding an object between 2 fingers on the same hand (generally the forefinger and thumb). They can also manipulate objects at this age by pushing buttons, turning book pages, and making crude scribbles. This is the period where dominance of either the left or right hand is established
• 15 - 18 months: Toddlers begin to stack cubes, placing 10 cubes in a cup. They are able to self-feed using a spoon to scoop and can throw a ball
• 2 - 3 years: Toddler develops more of a steady hand for playing and writing with the ability to imitate strokes using a crayon, specifically horizontal and vertical strokes to write numbers and letters, as well as being able to draw a circle and a human figure. The ability to use utensils develops further by using a fork. They can also dress themselves clumsily⁷
• 4 years: The child can achieve the tasks of buttoning and zipping clothing 
• 5 years: Learn the ability to tie shoelaces

Although the basics of fine motor skills predominantly develop during the early years of life, they are constantly evolving for greater precision and accuracy. This includes cooking, sewing and driving. 

Common Conditions Affecting Fine Motor Skills

Developmental Delays

Developmental delays occur when a child does not reach the predicted developmental milestones compared to peers in the same population. ⁸ According to the World Health Organisation, approximately 10% of the population in each country experiences a form of developmental disability.⁹ Examples of developmental delays are:

• Down Syndrome 
• Autism Spectrum Disorder (ASD)
• Attention Deficit Hyperactivity Disorder (ADHD)

Neurological Disorders

Neurological disorders are those that affect the brain and spinal cord, resulting in a range of symptoms, specifically relating to muscle movement. This involves tremors and muscle stiffness, making it difficult to complete tasks requiring precision due to having reduced dexterity and hand-eye coordination. This hinders individuals with neurological disorders from performing rapid finger and hand movements.¹⁰ Examples of neurological disorders are:

• Parkinson’s Disease 
•  Stroke survivor patients showed deficits in fine motor dexterity, finger strength and force control¹¹ 
• Approximately 50% of children with  Cerebral Palsy have an arm-hand dysfunction making it difficult to perform precise movements¹² 

Musculoskeletal Conditions 

Musculoskeletal conditions refer to pain or injuries in joints, ligaments, muscles, bones, and tendons. This involves muscle weakness, lack of strength and coordination which could ultimately lead to ataxia (the loss of bodily movements). Examples of musculoskeletal conditions are:

• Multiple Sclerosis where patients have shown significantly decreased dexterity compared to control groups¹³
• Arthritis
• Carpal Tunnel Syndrome 

Age-related Decline 

Ageing has been linked to the deterioration of FMS through the gradual decrease in brain volume, specifically the cerebellum which is essential for coordination and balance. A study found larger cerebral volumes resulted in greater performance in a FMSl test, like the spiral-drawing performance test.¹⁴ 

Occupational Therapy (OT)

OT involves the assessment, intervention, and maintenance to ultimately help individuals ‘to perform daily occupations, facilitate successful adaptations to disruptions in lifestyle, prevent losses of function and improve psychological status’.¹⁵ 

OT is carried out by occupational therapists which tends to be practised in hospitals, but it can also be performed in schools and retirement homes.¹⁶

Assessments in Occupational Therapy

Assessments for FMS are generally inexpensive and easy to perform, taking less than 15 minutes with results being reliable, repeatable, and valid. These assessments tend to involve grasping and manipulating objects under timed conditions using the individual's dominant hand. 

Nine-Hole Peg Test 

This test involves a board with nine holes, nine pegs, and a stopwatch to assess the individual's dexterity. The assessment requires the individual to put each of the pegs in the board as fast as they can and then take them out, whilst being timed.¹⁷ 

Moberg Pick-up Test 

A timed functionality test requires the individual to pick up twelve small objects (e.g., a coin, paperclip, or a key) and place them into the container one by one as fast as possible. The time taken to perform the task is noted down.¹⁸ 

Minnesota Rate of Manipulation Test

Individuals place disks into the holes of a board as quickly as they can with their dominant hand, followed by a turning test of the disks before placing them into the holes using both hands.¹⁹ 

Box and Block Test

Typically involves 150 wooden blocks placed in a series of different orientations on one side of a partition. The individual is then required to transport as many blocks as they can over the partition in one minute.²⁰ 

Coin Rotation Test 

Using a coin, individuals are instructed to rotate it either toward or away from themselves as fast as they can using their thumb, index, and middle finger. Every 180° rotation of the coin is measured. The test will stop once 20 rotations are complete and the time taken is recorded.²¹

Intervention Techniques In Occupational Therapy For Fine Motor Skills

Handwriting  

Improving handwriting legibility is achieved by learning how to hold a pencil correctly through individualised exercises to form neat letters.²² This requires practice and repetition, usually by following workbooks targeted for learning handwriting skills. 

Activities

Activities can involve using tongs to retrieve beads from a bucket full of beans, using scissors to make shapes, screwing and unscrewing a bottle cap, and hole punching.²³

Hand-eye Coordination

Throwing and catching a ball, playing darts, video games, sports particularly tennis, all can help improve hand-eye coordination. 

Challenges in Occupational Therapy for Fine Motor Skills

OT requires active participation from the individual, however many patients experiencing fine motor impairments tend to also have a diagnosis of depression and therefore, a lack of motivation. This makes it difficult to engage in therapy and maintain the goals set for them in the long term. 

In addition, there have been growing concerns that occupational therapists are choosing methods of intervention based on their convenience as opposed to what would be most appropriate for the case. Every individual and case is unique, so a greater emphasis must be placed on providing tailored interventions.²⁴ 

Summary

FMS allows the movement of hands and fingers, essential for completing everyday tasks. These skills are generally acquired during childhood, but developmental delays, neurological disorders, and ageing, can disrupt fine motor skills. This can result in daily tasks such as buttoning clothes, using utensils, and dressing oneself, challenging. However, through the use of OT, such skills can be improved and even be regained to ultimately improve individuals quality of life.