Continuing Education Activity

Fine motor disability is an individual's inability or impairment to perform tasks that require a degree of manual dexterity. Fine motor ability is usually synonymous with 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.

Objectives:

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

Introduction

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.[3][4] 

Additionally, injuries to musculoskeletal components may also affect fine motor abilities. Fine motor ability is usually synonymous with the literature concerning the ability of an individual to make precise, voluntary, and coordinated movements with their hands. However, foot dexterity is also described in terms of athletic ability and the precise lower limb coordination required to perform subtle movements in sports.[5] Strikingly, individuals with a congenital absence of hands with professions requiring fine motor ability, such as painters, have cortical 'toe maps' instead 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 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 in performing tasks required in day-to-day life. A defining feature of anthropoids is the ability to perform skillful maneuvers with their hands. It has been postulated 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 than 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. Fine motor ability is 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 predict social and cognitive ability in pre-kindergarten children independently. 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 grip force scaling, speed of movement, and motor coordination.[12]

Etiology

The intact fine motor function involves complex coordination between numerous central and peripheral nervous system structures; the underlying etiology of subsequent impairment is vast. Below is a brief synopsis of the etiology of fine motor disability concerning neuroanatomical areas and more generalized causes escaping precise anatomical causation. The following neuroanatomical areas play crucial roles in fine motor control; 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 movement coordination, especially in initiating complex pre-planned fine motor movements. A cerebellar hemisphere lesion is more likely to lead to limb ataxia and, therefore, fine motor disability than lesions of the vermis that lead to truncal ataxia.[14]

The basal ganglia are essential for coordinated movement and a gatekeeper for voluntary movement. Examples of diseases that specifically affect the basal ganglia are Parkinson and Huntington disease. The intentional tremor associated with these conditions and 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 carry upper motor neuron signs, with spasticity, increased reflexes, and varying gross and fine motor dysfunction levels 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 carry integrated motor information from the spinal cord to the target muscle groups. Depending on which nerve is affected determines 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 visual feedback. There are numerous examples of professional musicians who were born blind yet have a remarkable fine motor ability in playing the piano.[18]

Sensory system: The hand is 1 of the most highly concentrated areas of sensory nerves and receptors in the human body. Direct sensory feedback with regard 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 a 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 depends 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. Initiating 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 have been postulated to be secondary to cognitive development delay.[23][24]

Epidemiology

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

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]

Pathophysiology

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 is similarly broad.

History and Physical

Fine motor disability is differentiated from gross motor disability and is reflected in how clinicians separately test fine motor ability compared with gross motor ability. Gross motor ability is tested classically in a myotomal or nerve distribution fashion. 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 innervated sufficiently by the C5 myotome.[28] Conversely, Fine motor control is assessed by a clinician asking the patient to perform tasks that require subtle coordinated movement, testing the intact integrated function of various neuromuscular structures, as previously mentioned. Examples frequently used in a clinical setting may include unbuttoning a shirt, picking up a coin, or drawing a shape such as a spiral.[29][30][31] Handwriting- Legibility and speed of writing have been used in children and adults to determine 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 gold standard test for assessing manual dexterity in multiple sclerosis.[33]

Evaluation

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 by 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 are the most common tests required to determine common underlying causative factors; this list is not exhaustive:

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

Treatment / Management

The treatment of fine motor disability depends 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 such as anterior/posterior decompression for cervical myelopathy, for example.[39] Noninvasive brain stimulation involving noninvasive magnetic pulses in stroke patients has been shown as a potential novel treatment to improve manual dexterity.[40] Deep brain stimulation is appropriate 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 Disease).[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

The 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 and has varied etiologies.

Complications

Complications depend on the onset's age, symptoms' severity, 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 2 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 healthcare professionals to the parents of young children.[46] Similarly, fine motor disability has considerable consequences on 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 is key to optimizing overall health in this population group.[45]

Pearls and Other Issues

Key facts to keep in mind about fine motor disability are as follows:

• Fine motor disability is a symptom of a disease rather than a disease in and of itself. 
• Fine motor disability is usually considered 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 it.

Enhancing Healthcare Team Outcomes

Fine motor disability has numerous causes and can affect any individual at any age. Interprofessional teamwork is key to assessing, investigating, and treating the numerous causes of fine motor disability. Depending 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 disease, recommend the coordinated clinical approach of interprofessional teams as a way of improving patient safety and outcomes.[47][48]

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References

1.

Bos AF, Van Braeckel KN, Hitzert MM, Tanis JC, Roze E. Development of fine motor skills in preterm infants. Dev Med Child Neurol. 2013 Nov;55 Suppl 4:1-4. [PubMed: 24237270]

2.

Fraser SA, Li KZ, Penhune VB. Dual-task performance reveals increased involvement of executive control in fine motor sequencing in healthy aging. J Gerontol B Psychol Sci Soc Sci. 2010 Sep;65(5):526-35. [PubMed: 20478900]

3.

Ludwig PE, Reddy V, Varacallo MA. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Oct 10, 2022. Neuroanatomy, Central Nervous System (CNS) [PubMed: 28723039]

4.

Morris R, Whishaw IQ. Arm and hand movement: current knowledge and future perspective. Front Neurol. 2015;6:19. [PMC free article: PMC4319398] [PubMed: 25705202]

5.

Lyle MA, Valero-Cuevas FJ, Gregor RJ, Powers CM. Lower extremity dexterity is associated with agility in adolescent soccer athletes. Scand J Med Sci Sports. 2015 Feb;25(1):81-8. [PMC free article: PMC4053489] [PubMed: 24325628]

6.

Dempsey-Jones H, Wesselink DB, Friedman J, Makin TR. Organized Toe Maps in Extreme Foot Users. Cell Rep. 2019 Sep 10;28(11):2748-2756.e4. [PMC free article: PMC6899508] [PubMed: 31509738]

7.

Dosman CF, Andrews D, Goulden KJ. Evidence-based milestone ages as a framework for developmental surveillance. Paediatr Child Health. 2012 Dec;17(10):561-8. [PMC free article: PMC3549694] [PubMed: 24294064]

8.

Liu MJ, Xiong CH, Hu D. Assessing the manipulative potentials of monkeys, apes and humans from hand proportions: implications for hand evolution. Proc Biol Sci. 2016 Nov 30;283(1843) [PMC free article: PMC5136595] [PubMed: 27903877]

9.

Young RW. Evolution of the human hand: the role of throwing and clubbing. J Anat. 2003 Jan;202(1):165-74. [PMC free article: PMC1571064] [PubMed: 12587931]

10.

Catani M. A little man of some importance. Brain. 2017 Nov 01;140(11):3055-3061. [PMC free article: PMC5841206] [PubMed: 29088352]

11.

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. Hum Mov Sci. 2003 Nov;22(4-5):495-513. [PubMed: 14624830]

12.

Allgöwer K, Hermsdörfer J. Fine motor skills predict performance in the Jebsen Taylor Hand Function Test after stroke. Clin Neurophysiol. 2017 Oct;128(10):1858-1871. [PubMed: 28826016]

13.

Khaku AS, Tadi P. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 7, 2023. Cerebrovascular Disease. [PubMed: 28613677]

14.

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. 2012 Jun;11(2):457-87. [PMC free article: PMC4347949] [PubMed: 22161499]

15.

Groenewegen HJ. The basal ganglia and motor control. Neural Plast. 2003;10(1-2):107-20. [PMC free article: PMC2565420] [PubMed: 14640312]

16.

Javed K, Reddy V, Lui F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 24, 2023. Neuroanatomy, Lateral Corticospinal Tract. [PubMed: 30521239]

17.

Menorca RM, Fussell TS, Elfar JC. Nerve physiology: mechanisms of injury and recovery. Hand Clin. 2013 Aug;29(3):317-30. [PMC free article: PMC4408553] [PubMed: 23895713]

18.

Trés ES, Brucki SMD. Visuospatial processing: A review from basic to current concepts. Dement Neuropsychol. 2014 Apr-Jun;8(2):175-181. [PMC free article: PMC5619126] [PubMed: 29213900]

19.

Marzvanyan A, Alhawaj AF. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 14, 2023. Physiology, Sensory Receptors. [PubMed: 30969683]

20.

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. Reumatol Clin. 2012 Dec-2013 Jan;8 Suppl 2:25-32. [PubMed: 23219083]

21.

Bullock J, Rizvi SAA, Saleh AM, Ahmed SS, Do DP, Ansari RA, Ahmed J. Rheumatoid Arthritis: A Brief Overview of the Treatment. Med Princ Pract. 2018;27(6):501-507. [PMC free article: PMC6422329] [PubMed: 30173215]

22.

Matei R, Ginsborg J. Music performance anxiety in classical musicians - what we know about what works. BJPsych Int. 2017 May;14(2):33-35. [PMC free article: PMC5618811] [PubMed: 29093935]

23.

Mokobane M, Pillay BJ, Meyer A. Fine motor deficits and attention deficit hyperactivity disorder in primary school children. S Afr J Psychiatr. 2019;25:1232. [PMC free article: PMC6424539] [PubMed: 30899581]

24.

Lloyd M, MacDonald M, Lord C. Motor skills of toddlers with autism spectrum disorders. Autism. 2013 Mar;17(2):133-46. [PMC free article: PMC3188325] [PubMed: 21610184]

25.

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;144(4) [PMC free article: PMC7076808] [PubMed: 31558576]

26.

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. Arch Phys Med Rehabil. 2014 May;95(5):986-995.e1. [PMC free article: PMC4180670] [PubMed: 24462839]

27.

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 Morb Mortal Wkly Rep. 2015 Jul 31;64(29):777-83. [PMC free article: PMC4584831] [PubMed: 26225475]

28.

Shahrokhi M, Asuncion RMD. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jan 16, 2023. Neurologic Exam. [PubMed: 32491521]

29.

Yip SL, Yen CH, Chan WL, Leung HB, Mak KH. Pick-up test: an indication for opponensplasty in patients with severe carpal tunnel syndrome. J Orthop Surg (Hong Kong). 2009 Aug;17(2):183-6. [PubMed: 19721148]

30.

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. Ann Rehabil Med. 2018 Feb;42(1):18-25. [PMC free article: PMC5852222] [PubMed: 29560320]

31.

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;11(10):e0162799. [PMC free article: PMC5061372] [PubMed: 27732597]

32.

Seo SM. The effect of fine motor skills on handwriting legibility in preschool age children. J Phys Ther Sci. 2018 Feb;30(2):324-327. [PMC free article: PMC5851374] [PubMed: 29545705]

33.

Feys P, Lamers I, Francis G, Benedict R, Phillips G, LaRocca N, Hudson LD, Rudick R., Multiple Sclerosis Outcome Assessments Consortium. The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis. Mult Scler. 2017 Apr;23(5):711-720. [PMC free article: PMC5405844] [PubMed: 28206826]

34.

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 Neurol. 2014 Sep;71(9):1143-9. [PMC free article: PMC4266395] [PubMed: 25048157]

35.

Rocchi L, Niccolini F, Politis M. Recent imaging advances in neurology. J Neurol. 2015 Sep;262(9):2182-94. [PubMed: 25808503]

36.

Tavee J. Nerve conduction studies: Basic concepts. Handb Clin Neurol. 2019;160:217-224. [PubMed: 31277849]

37.

Hrishi AP, Sethuraman M. Cerebrospinal Fluid (CSF) Analysis and Interpretation in Neurocritical Care for Acute Neurological Conditions. Indian J Crit Care Med. 2019 Jun;23(Suppl 2):S115-S119. [PMC free article: PMC6707491] [PubMed: 31485118]

38.

Franceschini N, Frick A, Kopp JB. Genetic Testing in Clinical Settings. Am J Kidney Dis. 2018 Oct;72(4):569-581. [PMC free article: PMC6153053] [PubMed: 29655499]

39.

Bakhsheshian J, Mehta VA, Liu JC. Current Diagnosis and Management of Cervical Spondylotic Myelopathy. Global Spine J. 2017 Sep;7(6):572-586. [PMC free article: PMC5582708] [PubMed: 28894688]

40.

Kubis N. Non-Invasive Brain Stimulation to Enhance Post-Stroke Recovery. Front Neural Circuits. 2016;10:56. [PMC free article: PMC4961863] [PubMed: 27512367]

41.

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. Nat Rev Neurol. 2019 Mar;15(3):148-160. [PMC free article: PMC6397644] [PubMed: 30683913]

42.

Villeneuve M, Penhune V, Lamontagne A. A piano training program to improve manual dexterity and upper extremity function in chronic stroke survivors. Front Hum Neurosci. 2014;8:662. [PMC free article: PMC4141215] [PubMed: 25202258]

43.

Rizek P, Kumar N, Jog MS. An update on the diagnosis and treatment of Parkinson disease. CMAJ. 2016 Nov 01;188(16):1157-1165. [PMC free article: PMC5088077] [PubMed: 27221269]

44.

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. J Phys Ther Sci. 2015 Oct;27(10):3151-4. [PMC free article: PMC4668154] [PubMed: 26644663]

45.

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. J Aging Health. 2017 Oct;29(7):1144-1159. [PMC free article: PMC5179315] [PubMed: 27339106]

46.

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 Dev. 2012 Jul-Aug;83(4):1229-44. [PMC free article: PMC3399936] [PubMed: 22537276]

47.

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. J Parkinsons Dis. 2020;10(3):1087-1098. [PMC free article: PMC7415700] [PubMed: 32444563]

48.

Clarke DJ, Forster A. Improving post-stroke recovery: the role of the multidisciplinary health care team. J Multidiscip Healthc. 2015;8:433-42. [PMC free article: PMC4590569] [PubMed: 26445548]

Disclosure: Pierce Burr declares no relevant financial relationships with ineligible companies.

Disclosure: Parichita Choudhury declares no relevant financial relationships with ineligible companies.