Written by: Dr. Caitlin A. Bender, OTR/L with additional credit to Caylin Dean and Kelly Struthers (OTR/L)
Dopamine’s Role
Fine motor skills refers to all the precise tasks we do with our hands: from grasping and releasing objects, to pinching, twisting, and opposing the thumb. These skills develop throughout our childhood, and typically take 7-8 years to fully master. Firstly we have to understand the context of the situation, “my shoe has come untied.”, then we have to interact with the task and rely on detailed sensory input to assess the size, shape, texture and weight of the shoelace. This information is transmitted to our brainstem, specifically the cerebellum, which coordinates fine motor movement. Our brain efficiently processes this information to then produce appropriate grip, power, and complex movement in order to complete the task. Underlying all our motor behavior is a perfect interplay of complex sensory systems, neurons communicating within the brain, and muscle fibers contracting. Dopamine, the key neurotransmitter being affected by Parkinson’s Disease, works in delicate balance with other neurotransmitters to help coordinate the millions of nerve and muscle cells in the body to produce controlled movement. Previously it was thought Parkinson’s Disease pathophysiology predominantly affected the basal ganglia, however recent studies suggest that these changes may extend into other portions of the brain, including the fine tuned cerebellum (Li, 2023). This suggests that fine motor control could be directly impacted as a result of Parkinson’s Disease, and that fine motor impairment may be evident in early Parkinson’s Disease, but go unnoticed and undertreated (Iakovakis, 2020).
Daily Impact
Fine motor difficulties may be a direct result of Parkinson’s Disease pathophysiology, but it can also be a product of the progressive motor and non-motor symptoms. Fine motor tasks often require strength, coordination, precision, and speed, however with tremors, slowed movements, and rigidity fine motor tasks can become increasingly more challenging to complete. Fine motor tasks also rely heavily on visual processing skills, which can be affected directly by Parkinson’s Disease, aging, and our posture in relation to the task. As posture is pulled down typically so are our eyes, which means we are losing out on valuable contextual information for what task we are trying to perform. Cognitive skills such as maintaining attention, understanding the sequence of events, memory, and problem solving are also key in successfully performing fine motor tasks. Throughout a typical day we may expect to get dressed, write our names, hand change to the store clerk, use our phones, drive from place to place, and all have an expected order of operations and countless fine motor skills. Deficits in these areas may lead to reduced chances to engage in these tasks and a loss of independence, which can result in a reduced quality of life (Huang, 2024).
Medication Management
Levodopa, a commonly prescribed dopamine replacement for Parkinson’s Disease, helps manage tremors, rigidity, and even non-motor symptoms, which ultimately improves gross motor performance; however for fine motor skills medication management may not be as straightforward. Research in this area seems to be limited, but one study featuring the effects of Levodopa on handwriting noted improvement with simple writing tasks involving repetition of letters, however the same benefit was not seen in more complex tasks, such as copying sentences (Zham, 2019). Another fine motor task study on the effects of Levodopa found that medication timing did not have an effect on improving handwriting tasks (Tilly, 2016). While Levodopa may not directly improve fine motor skills, there is evidence dopamine replacement improves motor learning of an upper extremity task in people with Parkinson Disease. One study found that those who practiced fine motor tasks during their “on” period learned motor tasks better than when in “off” states (Serene, 2020), which means medication timing and practicing functional tasks is key in maintaining independence.
OT Tips and Tricks
Managing tremors
Tremors can worsen with stress, so practice breathing techniques that can help to reduce stress and reduce occurrence of tremors interfering with daily activities.
Weighted cuffs have been reported to reduce intensity of tremors, however this needs to be determined on a case by case basis, as there is evidence it can also fatigue the muscles quicker.
There is evidence to suggest that reciprocal movements, specifically arm cycling, can reduce the intensity and occurrence of tremors.
Self-feeding
Larger gripped handles for silverware are easier to manage, although weighted utensil versus lightweight utensil may differ from person to person. Spoons with a swivel head can also be helpful for people with tremors.
Use a plate guard or plates with a higher edge to assist in scooping pieces of food during meal time.
Try adaptive cups to help assist with drinking if you have limited neck extension or tremors.
Grooming
Similarly to silverware, larger handles for hair or makeup brushes are easier to manage.
Try switching over to electric toothbrushes and razors for easier grooming.
A universal cuff could be a useful tool if you have weaker grip to help manage different items while getting ready.
Prop your elbows up on a steady surface during grooming activities to stabilize your movement
Clothing
Elastic waistbands and shoelaces can be easier to manage than buttons, clips, and trying to keep shoes from coming untied.
Buttonhooks can help manage shirt and pant buttons.
Handwriting
Sit upright at a table with the forearm supported on the table and make sure there is adequate lighting.
Use lined paper: wide ruled is best because it gives a visual cue to make the letters or numbers as big as possible.
Write important letters or sign checks during times when medication is most effective.
Practice! Utilize strategies such as tracing letters, copying shapes, tablet
programs, and coloring books.
Use mental imagery: visualize what the words will look like in your head before you start writing.
If you have trouble gripping the pen, find one that is wider or “build it up” by wrapping tape around the base.
A weighted pen or wrist weights may help with tremors.
A gel pen may write more smoothly than a ballpoint pen.
Use a slant board or a 3 ring binder under paper to put the wrist into proper extension.
Use an auditory cue, such as a metronome or rhythmic music to help with initiation and pacing.
Practice writing the alphabet BIG in the air. Use a light dumbbell or can of soup for a strength challenge.
Use a whiteboard or piece of paper to write letters, numbers, or shapes that take up the entirety of the paper.
Fine motor exercises
The best way to preserve hand function is to practice! Functional tasks like getting ready for the day, cooking, or working are the best ways to work the brain and body, so try to keep engaging in the activity even if it becomes more challenging, or looks different than expected.
Here are some good warm-up exercises to do before completing a fine motor task:
“Flick” the hands open and closed.
Touch each finger to the thumb, making sure to open the hand all the way between each touch.
“Sock puppet” - open the hands wide, then bring the fingers and thumb together like you would when making a sock puppet talk.
Start with elbows at the side and palms facing the ceiling, then flip the palms to the floor and continue alternating.
“Rev the motorcycle” - with the hands in fists, flick the wrists up and down. Hold the writing utensil between the fingers and “walk” the fingers up and down.
Squeeze a stress ball or mold play-doh to strengthen the small muscles of the hands.
Bridges for Parkinson’s fine motor drills, PWRMoves and the LSVT BIG program can improve perceived occupational performance and satisfaction and produce gains in hand strength and dexterity for people with Parkinson’s Disease.
References
1. Doucet, B. M., Blanchard, M., & Bienvenu, F. (2021). Occupational performance and hand function in people with Parkinson’s disease after participation in Lee Silverman voice treatment (LSVT) big®.The American Journal of Occupational Therapy, 75(6). https://doi.org/10.5014/ajot.2021.042101
2. Huang, Y. (2024). Deterioration of fine motor skills and functional disability in patients with moderate-to-advanced Parkinson disease: A longitudinal follow-up study. Archives of Gerontology and Geriatrics. https://doi.org/10.1016/j.archger.2024.105366.
3. 1.Iakovakis, D., Chaudhuri, K.R., Klingelhoefer, L. et al. Screening of Parkinsonian subtle fine-motor impairment from touchscreen typing via deep learning. Sci Rep 10, 12623 (2020). https://doi.org/10.1038/s41598-020-69369-1.
4. Li, T., Le, W. & Jankovic, J. Linking the cerebellum to Parkinson disease: an update. Nat Rev Neurol 19, 645–654 (2023). https://doi.org/10.1038/s41582-023-00874-3.
5.Serene S. Paul, Leland E. Dibble, Genevieve N. Olivier, Christopher Walter, Kevin Duff, Sydney Y. Schaefer. (2020). Dopamine replacement improves motor learning of an upper extremity task in people with Parkinson disease. Behavioural Brain Research.
6. Tilly, Collette Maria, "The Effects of Levodopa on the Performance of Fine Motor Tasks in Individuals with Parkinson's Disease" (2016). Honors Theses. 1454.
7. Zham P, Kumar D, Viswanthan R, Wong K, Nagao KJ, Arjunan SP, Raghav S, Kempster P. Effect of levodopa on handwriting tasks of different complexity in Parkinson's disease: a kinematic study. J Neurol. 2019 Jun;266(6):1376-1382. doi: 10.1007/s00415-019-09268-2.
8. Credit to Kelly Stuthers, Caylin Dean, and Tori Vik for their contributions in compiling and formatting a considerable amount of resources regarding fine motor function.
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