Fine Motor Disability

Continuing Education Activity

Fine motor disability is an inability or impairment of an individual to perform tasks that require a degree of manual dexterity. Fine motor ability is usually synonymous within the literature concerning the ability of an individual to make precise, voluntary, and coordinated movements with their hands. This activity summarizes the evaluation and treatment of fine motor disability and highlights the role of the interprofessional team in evaluating and treating patients with this condition.


  • Identify the etiology of fine motor disability.
  • Review the appropriate evaluation of fine motor disability.
  • Outline the management options available for fine motor disability.
  • Summarize interprofessional team strategies for improving care coordination and communication to enhance the care of fine motor disability and improve outcomes.


Fine motor disability is an inability or impairment of an individual to perform tasks that require a degree of manual dexterity.[1][2] Fine motor disability is a symptom of an underlying disease process rather than a disease in its own right. To perform even simple fine motor movements requires communication between the premotor and motor cortex, cerebellum, basal ganglia, corticospinal tracts, and peripheral nerves, not to mention visuospatial, sensory, and executive function processing as well.[3][4] 

Additionally, injuries to musculoskeletal components may also affect fine motor abilities. Fine motor ability is usually synonymous within the literature concerning the ability of an individual to make precise, voluntary, and coordinated movements with their hands. However, foot dexterity is also described concerning athletic ability and the precise lower limb coordination required to perform subtle movements required in sport.[5] Strikingly, individuals with a congenital absence of hands with professions requiring fine motor ability such as painters have cortical 'toe maps' in place of hand representation.[6]

Despite these examples, the manual dexterity of the hand plays a much larger role in evaluating a fine motor disability. For example, all fine motor development milestones in children relate to the ability of a child to use their hands in more and more refined and purposeful movements.[7] For example, at 2 months of age, a child may be expected to hold a rattle, and at 12 months, the ability to hold something with a ‘pincer grip’ between 2 fingers on the same hand.[7] This focus on hand dexterity reflects the importance of an individual’s hands to perform tasks required in day to day life. A defining feature of anthropoids is the ability to perform skillful maneuvers with the hands and has been postulated both in common parlance and the scientific community that pincer ability associated with the opposable thumb garners humans the unique capacity for complex, subtle motor tasks.[8]

The selection pressure of our evolutionary ancestors regarding hand morphology, joint flexibility, and survival advantage in utilizing and fashioning tools created a strong symbiosis between the hands and brain's combined ability to survive and thrive in the environment.[9] This interdependence is reflected in gross neuroanatomy. Dr. Penfield vividly represented the overrepresented hand in the motor and sensory cortex in his 3D homunculus, where the hands represent a vastly greater proportion of the cortex compared with the actual anatomical size of the hands.[10]

Fine motor disability can affect anyone at any age but is especially important during a child’s development with fine motor ability closely monitored by clinicians as significant delays in recognized milestones can indicate a range of underlying neurological disorders.[7] Fine motor skills have been found to independently predict social and cognitive ability in pre-kindergarten children. This further reflects the linked development of problem-solving to the physical manipulation of the environment and the importance of fine motor skills in social play.[11] Three major components of fine motor control are thought to be grip force scaling, speed of movement, and motor coordination.[12]


The intact fine motor function involves complex coordination between numerous central and peripheral nervous system structures; the underlying etiology of subsequent impairment is therefore vast. Below is a brief synopsis of the etiology of fine motor disability with regards to neuroanatomical areas and more generalized causes escaping precise anatomical causation. The following neuroanatomical areas play crucial roles in fine motor control, and therefore any lesion can cause fine motor disability. Causes of lesions/damage include a space-occupying lesion, infection, stroke, toxins, autoimmune inflammation, metabolic, trauma, and congenital absence or abnormality.

Pre-motor and motor cortex- These are higher cortical centers that initiate movement. Specific damage to these areas can lead to complete paralysis of the specific muscle groups and, therefore, the inability to perform fine or gross motor tasks.[13]

Cerebellum- Vital for coordination of movement, especially in the initiation of complex pre-planned fine motor movements. A cerebellar hemisphere lesion is more likely to lead to limb ataxia and, therefore, fine motor disability compared with lesions of the vermis that lead to truncal ataxia.[14]

Basal ganglia- Essential for coordinated movement and acts as a gatekeeper for voluntary movement. Examples of diseases that specifically affect the basal ganglia are Parkinson's and Huntington's disease. The intention tremor associated with these conditions, as well as rigidity, impedes flowing fine movements required for fine motor tasks.[15]

Descending corticospinal tracts- These carry integrated motor information via the brainstem to synapse with lower motor neurons at the relevant spinal nerve level. Lesions will therefore carry upper motor neuron signs, with spasticity, increased reflexes, and varying levels of gross and fine motor dysfunction dependent on lesion severity. An example of dysfunction may arise in the form of cervical myelopathy secondary to pressure from cervical disc prolapse.[16]

Peripheral nerves- These carry integrated motor information from the spinal cord to the target muscle groups. Depending on which nerve is affected will determine the severity of the disability. An example of dysfunction includes carpal tunnel syndrome with worsening fine motor control in the affected hand due to median nerve compression under the flexor retinaculum.[17]

Visuospatial- Visual feedback is an important part of developing fine motor control but can be developed without any visual feedback. There are numerous examples of professional musicians that were born blind yet have a remarkable fine motor ability in playing the piano, for example.[18]

Sensory system- The hand is one of the most highly concentrated areas of sensory nerves and receptors in the human body. Direct sensory feedback with regards to proprioception, tactile sensation, vibration, and avoidance of noxious stimuli is a key component of coordinated goal-directed fine motor behavior concerning one's environment. Any interruption in this sensory feedback can cause debilitating loss of fine motor control. One example of this is diabetic peripheral neuropathy.[19]

Musculoskeletal- The hand contains over 30 muscles, 20 major joints, and hundreds of ligaments. Fine motor control is dependent on precise joint movement; therefore, any disease process that causes joint inflammation/damage/sarcopenia can cause fine motor disability.[20] One example of this is rheumatoid arthritis.[21]

Psychosocial- Any process that interferes with the relay of coordinated motor sequences can limit fine motor control even in well-trained experts. 'Choking' describes the situation of an athlete or musician performing well below their usual level of motor control due to performance-related anxiety. The initiation of the fight or flight response is thought to disrupt the subconscious access to pre-programmed complex coordinated pathways with a more conscious hyper-aware state resulting in poor or clumsy performance.[22]

Neuropsychiatric- Autism spectrum disorder and attentional deficit disorder have both been strongly correlated to developmental delays in fine motor control and has been postulated to be secondary to cognitive development delay.[23][24]


Owing to the enormous variety and causes of fine motor disability, precise epidemiology remains challenging, and fine motor disability is infrequently independently researched, especially with regards to population-based epidemiology. Below are the prevalences of etiologies of fine motor disability; an important caveat being data may include individuals without a significant fine motor disability but a condition strongly associated with fine motor disability.

Estimated developmental disability in children in the US- 17.8%. Further broken down: Attention deficit hyperactivity disorder 9.5%, autism spectrum disorder 2.5%, intellectual disability 1.2% and other causes 4.1%[25]

In adults: 

  • Stroke- 2.8% of the US population, 50% of which had a hemiparesis[26]
  • Rheumatoid arthritis- 2% of North America, 30% require assistance for personal care[26]
  • Traumatic brain injury- 1.1% of the US population, 43% of patients have a lasting disability[26]
  • Self-care- 3.6% of the US population, have a disability[27]


As fine motor disability should be thought of as a symptom of an underlying disease process rather than a disease in and of itself, there is no single unifying pathophysiology. As described, the etiology is vast, and the underlying pathophysiology similarly broad.

History and Physical

Fine motor disability is differentiated from gross motor disability and is reflected in the way in which clinicians separately test fine motor ability compared with gross motor ability. Gross motor ability is tested classically in a myotomal or nerve distribution fashion whereby the patient is asked to perform a simple motor task that indicates to the clinician intact innervation.[28] For example, a clinician may ask a patient to hold their arm out to the side and resist the clinician pushing it down towards the ground. This would indicate that the deltoid muscle is working and therefore is being innervated sufficiently by the C5 myotome.[28]

Fine motor control, conversely, is assessed by a clinician asking the patient to perform tasks that require subtle coordinated movement, therefore, testing the intact integrated function of various neuromuscular structures as previously mentioned. Examples frequently used in a clinic setting may include unbuttoning a shirt, picking up a coin, or the drawing of a shape such as a spiral.[29][30][31]

Handwriting- Legibility and speed of writing have been used in children and adults as a way of determining fine motor ability in patients.[32]

Nine-hole peg test- This tests the ability of an individual to remove and replace 9 small pegs into 9 small holes. This is the current gold standard test for assessing manual dexterity in multiple sclerosis.[33]


Owing to the varying etiology of fine motor disability, laboratory and radiographic should be determined on a case-by-case basis based on the history and physical examination elucidated from the patient. Furthermore, in some incidents, a fine motor disability can be diagnosed on a purely clinical basis without the need for any further invasive imaging and/or blood tests. However, modalities of investigation are mandatory for numerous etiologies. Below lists the most common tests required to determine common underlying causative factors; this list is not exhaustive:

  • Blood tests: Complete blood count (CBC), comprehensive metabolic panel (CMP), liver function test (LFT), C-reactive protein (CRP), B12 level, folate level, bone profile, rheumatoid factor (RF), anti-neutrophil cytoplasmic autoantibody (ANCA), fasting glucose, and hemoglobin A1c[34]
  • Imaging: Computed tomography (CT) brain/spine, X-ray cervical spine, magnetic resonance imaging (MRI) brain/spine[35]
  • Nerve conduction studies[36]
  • Cerebrospinal fluid (CSF) sampling: Microbiology, biochemistry, and specialized tests as indicated[37]
  • Genetic testing[38]

Treatment / Management

Treatment of fine motor disability is dependent on the underlying etiology. Below is a non-exhaustive list of interventions for different causes of fine motor disability to highlight the variation in management. 

Surgical intervention- Anterior/posterior decompression for cervical myelopathy for example[39]

Noninvasive brain stimulation- Using noninvasive magnetic pulses in stroke patients has been shown as a potential novel treatment to improve manual dexterity[40]

Deep brain stimulation- For patients with Parkinson disease and other acquired movement disorders[41]

Musical training- Has been shown to increase manual dexterity in stroke survivors[42]

Pharmacological intervention- For example, targeting movement disorder pathways (carbidopa/levodopa in Parkinson's)[43]

Physiotherapy and occupational therapy in stroke and other neuropsychological etiologies of fine motor disability[44]

Differential Diagnosis

As fine motor disability is a symptom rather than a disease in its own right as described in the history and physical section, there are multiple ways of determining if this symptom is present. The subsequent underlying differential diagnosis is vast, as previously described.


Prognosis is entirely dependent on the underlying cause, and therefore there is no single identifiable prognosis. Fine motor disability can affect anyone of any age for a number of varied etiologies.


Complications are dependent on the age of onset, the severity of symptoms, and underlying etiology. Fine motor disability can cause severe impediments to activities of daily living with subsequent effects on mood and cognition.[45]

Deterrence and Patient Education

There is a strong correlation between fine motor disability in children and development disorders. Furthermore, a correlation exists between fine motor ability and better cognition and emotional development, with the two thought to be interlinked with delays in cognitive and emotional ability affecting fine motor ability and vice versa.[46]

The promotion and encouragement of fine motor tasks in children should be encouraged by health care professionals to the parents of young children.[46] Similarly, fine motor disability has considerable consequences in the quality of life in the geriatric population as fine motor ability is linked to the ability to perform activities of daily living. Optimization of surgical, pharmacological, physiotherapy, and occupational therapy interventions are key to optimizing overall health in this population group.[45]

Pearls and Other Issues

  • Fine motor disability is a symptom of a disease rather than a disease in and of itself. 
  • Fine motor disability is usually thought of as an impairment of fine movements of the hands but can include the feet. 
  • Fine motor disability requires integrated complex coordination between numerous neuroanatomical structures; damage to any key structure can cause a fine motor disability.

Enhancing Healthcare Team Outcomes

Fine motor disability has numerous causes and can affect any individual at any age. Interprofessional teamwork is, therefore, key to assessing, investigating, and treating the numerous causes of fine motor disability. Dependent on the presenting history and age of the patient, potential team members include neurologists, radiologists, radiographers, nurses, primary care clinicians, pharmacists, neurosurgeons, psychologists, pediatricians, occupational therapists, and physiotherapists. Experts in the major causes of fine motor disability such as stroke and Parkinson's disease, recommend the coordinated clinical approach of interprofessional teams as a way of improving patient safety and outcomes.[47][48]

Article Details

Article Author

Pierce Burr

Article Editor:

Parichita Choudhury


1/29/2021 6:05:22 AM

PubMed Link:

Fine Motor Disability



Bos AF,Van Braeckel KN,Hitzert MM,Tanis JC,Roze E, Development of fine motor skills in preterm infants. Developmental medicine and child neurology. 2013 Nov;     [PubMed PMID: 24237270]


Fraser SA,Li KZ,Penhune VB, Dual-task performance reveals increased involvement of executive control in fine motor sequencing in healthy aging. The journals of gerontology. Series B, Psychological sciences and social sciences. 2010 Sep;     [PubMed PMID: 20478900]


Ludwig PE,Reddy V,Varacallo M, Neuroanatomy, Central Nervous System (CNS) 2020 Jan;     [PubMed PMID: 28723039]


Morris R,Whishaw IQ, Arm and hand movement: current knowledge and future perspective. Frontiers in neurology. 2015;     [PubMed PMID: 25705202]


Lyle MA,Valero-Cuevas FJ,Gregor RJ,Powers CM, Lower extremity dexterity is associated with agility in adolescent soccer athletes. Scandinavian journal of medicine     [PubMed PMID: 24325628]


Dempsey-Jones H,Wesselink DB,Friedman J,Makin TR, Organized Toe Maps in Extreme Foot Users. Cell reports. 2019 Sep 10;     [PubMed PMID: 31509738]


Dosman CF,Andrews D,Goulden KJ, Evidence-based milestone ages as a framework for developmental surveillance. Paediatrics     [PubMed PMID: 24294064]


Liu MJ,Xiong CH,Hu D, Assessing the manipulative potentials of monkeys, apes and humans from hand proportions: implications for hand evolution. Proceedings. Biological sciences. 2016 Nov 30;     [PubMed PMID: 27903877]


Young RW, Evolution of the human hand: the role of throwing and clubbing. Journal of anatomy. 2003 Jan;     [PubMed PMID: 12587931]


Catani M, A little man of some importance. Brain : a journal of neurology. 2017 Nov 1;     [PubMed PMID: 29088352]


Smits-Engelsman BC,Wilson PH,Westenberg Y,Duysens J, Fine motor deficiencies in children with developmental coordination disorder and learning disabilities: an underlying open-loop control deficit. Human movement science. 2003 Nov;     [PubMed PMID: 14624830]


Allgöwer K,Hermsdörfer J, Fine motor skills predict performance in the Jebsen Taylor Hand Function Test after stroke. Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology. 2017 Oct;     [PubMed PMID: 28826016]


Khaku AS,Tadi P, Cerebrovascular Disease (Stroke) 2020 Jan;     [PubMed PMID: 28613677]


Manto M,Bower JM,Conforto AB,Delgado-García JM,da Guarda SN,Gerwig M,Habas C,Hagura N,Ivry RB,Mariën P,Molinari M,Naito E,Nowak DA,Oulad Ben Taib N,Pelisson D,Tesche CD,Tilikete C,Timmann D, Consensus paper: roles of the cerebellum in motor control--the diversity of ideas on cerebellar involvement in movement. Cerebellum (London, England). 2012 Jun;     [PubMed PMID: 22161499]


Groenewegen HJ, The basal ganglia and motor control. Neural plasticity. 2003;     [PubMed PMID: 14640312]


Javed K,Reddy V,Lui F, Neuroanatomy, Lateral Corticospinal Tract 2020 Jan;     [PubMed PMID: 30521239]


Menorca RM,Fussell TS,Elfar JC, Nerve physiology: mechanisms of injury and recovery. Hand clinics. 2013 Aug;     [PubMed PMID: 23895713]


Trés ES,Brucki SMD, Visuospatial processing: A review from basic to current concepts. Dementia     [PubMed PMID: 29213900]


Marzvanyan A,Alhawaj AF, Physiology, Sensory Receptors 2020 Jan;     [PubMed PMID: 30969683]


Vargas A,Chiapas-Gasca K,Hernández-Díaz C,Canoso JJ,Saavedra MÁ,Navarro-Zarza JE,Villaseñor-Ovies P,Kalish RA, Clinical anatomy of the hand. Reumatologia clinica. 2012 Dec-2013 Jan;     [PubMed PMID: 23219083]


Bullock J,Rizvi SAA,Saleh AM,Ahmed SS,Do DP,Ansari RA,Ahmed J, Rheumatoid Arthritis: A Brief Overview of the Treatment. Medical principles and practice : international journal of the Kuwait University, Health Science Centre. 2018;     [PubMed PMID: 30173215]


Matei R,Ginsborg J, Music performance anxiety in classical musicians - what we know about what works. BJPsych international. 2017 May;     [PubMed PMID: 29093935]


Mokobane M,Pillay BJ,Meyer A, Fine motor deficits and attention deficit hyperactivity disorder in primary school children. The South African journal of psychiatry : SAJP : the journal of the Society of Psychiatrists of South Africa. 2019;     [PubMed PMID: 30899581]


Lloyd M,MacDonald M,Lord C, Motor skills of toddlers with autism spectrum disorders. Autism : the international journal of research and practice. 2013 Mar;     [PubMed PMID: 21610184]


Zablotsky B,Black LI,Maenner MJ,Schieve LA,Danielson ML,Bitsko RH,Blumberg SJ,Kogan MD,Boyle CA, Prevalence and Trends of Developmental Disabilities among Children in the United States: 2009-2017. Pediatrics. 2019 Oct;     [PubMed PMID: 31558576]


Ma VY,Chan L,Carruthers KJ, Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Archives of physical medicine and rehabilitation. 2014 May;     [PubMed PMID: 24462839]


Courtney-Long EA,Carroll DD,Zhang QC,Stevens AC,Griffin-Blake S,Armour BS,Campbell VA, Prevalence of Disability and Disability Type Among Adults--United States, 2013. MMWR. Morbidity and mortality weekly report. 2015 Jul 31;     [PubMed PMID: 26225475]


Shahrokhi M,Asuncion RMD, Neurologic Exam 2020 Jan;     [PubMed PMID: 32491521]


Yip SL,Yen CH,Chan WL,Leung HB,Mak KH, Pick-up test: an indication for opponensplasty in patients with severe carpal tunnel syndrome. Journal of orthopaedic surgery (Hong Kong). 2009 Aug;     [PubMed PMID: 19721148]


Cheong YS,Kim AR,Park E,Yang WJ,Huh JW,Oh HM,Min YS,Kim CH,Jung TD,Lee YS, Validity of the Buttoning Test in Hand Disability Evaluation of Patients With Stroke. Annals of rehabilitation medicine. 2018 Feb;     [PubMed PMID: 29560320]


San Luciano M,Wang C,Ortega RA,Yu Q,Boschung S,Soto-Valencia J,Bressman SB,Lipton RB,Pullman S,Saunders-Pullman R, Digitized Spiral Drawing: A Possible Biomarker for Early Parkinson's Disease. PloS one. 2016;     [PubMed PMID: 27732597]


Seo SM, The effect of fine motor skills on handwriting legibility in preschool age children. Journal of physical therapy science. 2018 Feb;     [PubMed PMID: 29545705]


Feys P,Lamers I,Francis G,Benedict R,Phillips G,LaRocca N,Hudson LD,Rudick R, The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis. Multiple sclerosis (Houndmills, Basingstoke, England). 2017 Apr;     [PubMed PMID: 28206826]


Callaghan BC,Kerber KA,Lisabeth LL,Morgenstern LB,Longoria R,Rodgers A,Longwell P,Feldman EL, Role of neurologists and diagnostic tests on the management of distal symmetric polyneuropathy. JAMA neurology. 2014 Sep;     [PubMed PMID: 25048157]


Rocchi L,Niccolini F,Politis M, Recent imaging advances in neurology. Journal of neurology. 2015 Sep;     [PubMed PMID: 25808503]


Tavee J, Nerve conduction studies: Basic concepts. Handbook of clinical neurology. 2019;     [PubMed PMID: 31277849]


Hrishi AP,Sethuraman M, Cerebrospinal Fluid (CSF) Analysis and Interpretation in Neurocritical Care for Acute Neurological Conditions. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine. 2019 Jun;     [PubMed PMID: 31485118]


Franceschini N,Frick A,Kopp JB, Genetic Testing in Clinical Settings. American journal of kidney diseases : the official journal of the National Kidney Foundation. 2018 Oct;     [PubMed PMID: 29655499]


Bakhsheshian J,Mehta VA,Liu JC, Current Diagnosis and Management of Cervical Spondylotic Myelopathy. Global spine journal. 2017 Sep;     [PubMed PMID: 28894688]


Kubis N, Non-Invasive Brain Stimulation to Enhance Post-Stroke Recovery. Frontiers in neural circuits. 2016;     [PubMed PMID: 27512367]


Lozano AM,Lipsman N,Bergman H,Brown P,Chabardes S,Chang JW,Matthews K,McIntyre CC,Schlaepfer TE,Schulder M,Temel Y,Volkmann J,Krauss JK, Deep brain stimulation: current challenges and future directions. Nature reviews. Neurology. 2019 Mar;     [PubMed PMID: 30683913]


Villeneuve M,Penhune V,Lamontagne A, A piano training program to improve manual dexterity and upper extremity function in chronic stroke survivors. Frontiers in human neuroscience. 2014;     [PubMed PMID: 25202258]


Rizek P,Kumar N,Jog MS, An update on the diagnosis and treatment of Parkinson disease. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2016 Nov 1;     [PubMed PMID: 27221269]


Lee J,Lee B,Park Y,Kim Y, Effects of combined fine motor skill and cognitive therapy to cognition, degree of dementia, depression, and activities of daily living in the elderly with Alzheimer's disease. Journal of physical therapy science. 2015 Oct;     [PubMed PMID: 26644663]


Fauth EB,Schaefer SY,Zarit SH,Ernsth-Bravell M,Johansson B, Associations Between Fine Motor Performance in Activities of Daily Living and Cognitive Ability in a Nondemented Sample of Older Adults: Implications for Geriatric Physical Rehabilitation. Journal of aging and health. 2017 Oct;     [PubMed PMID: 27339106]


Cameron CE,Brock LL,Murrah WM,Bell LH,Worzalla SL,Grissmer D,Morrison FJ, Fine motor skills and executive function both contribute to kindergarten achievement. Child development. 2012 Jul-Aug;     [PubMed PMID: 22537276]


Radder DLM,Nonnekes J,van Nimwegen M,Eggers C,Abbruzzese G,Alves G,Browner N,Chaudhuri KR,Ebersbach G,Ferreira JJ,Fleisher JE,Fletcher P,Frazzitta G,Giladi N,Guttman M,Iansek R,Khandhar S,Klucken J,Lafontaine AL,Marras C,Nutt J,Okun MS,Parashos SA,Munneke M,Bloem BR, Recommendations for the Organization of Multidisciplinary Clinical Care Teams in Parkinson's Disease. Journal of Parkinson's disease. 2020;     [PubMed PMID: 32444563]


Clarke DJ,Forster A, Improving post-stroke recovery: the role of the multidisciplinary health care team. Journal of multidisciplinary healthcare. 2015;     [PubMed PMID: 26445548]