Regaining Gross and Fine Motor Function in Post-Stroke Recovery
Regaining gross and fine motor function is one of the most challenging aspects of stroke recovery for ischemic stroke survivors. These skills play a vital role in activities of daily living and the loss of them can be devastating for any stroke survivor. As an occupational therapist, I’ve observed stroke survivors who are frustrated that their fine motor skills did not come back as quickly as their gross motor skills. The good news is that there are proactive steps you can take to regain and maintain the gross and fine motor function of your hands and arms post-stroke, regardless of whether your affected side is your dominant side.
Here are some important things to know about the differences between gross and fine motor function, how they might impact your stroke rehabilitation and new technology to boost your therapy success.
By Amanda Saylor, OTR/L, CNS, CBIS–Occupational Therapist certified as a Neuro Specialist and Brain Injury Specialist
Gross Vs. Fine Motor Function Post-Stroke
First and foremost, it is important to understand the differences between gross and fine motor function related to hand and arm impairment and the key role they play in your stroke rehabilitation. While both come with unique challenges, research shows that repetition during stroke therapy is essential to regaining the function needed to live a more independent life.
Gross motor function refers to skills that involve much larger muscle movements, like throwing a ball or extending the arm while reaching for a shelf. Fine motor skills involve smaller muscles and impact activities like buttoning shirts, handwriting or manipulating objects.
Depending on the circumstances surrounding your stroke, you may experience unique challenges in regaining either gross or fine motor function.
Regaining Skills—What Comes First?
While some stroke survivors might have different goals in their rehabilitation journey, many tend to prioritize regaining fine motor skills faster, as they are generally more meaningful in day-to-day life. However, gross motor movements may return sooner. You may be able to lift your arm to put your shirt on much sooner than you are able to tie your shoes.
Fine motor functions that stroke survivors most often prioritize in recovery are tying shoes, cutting food, styling their hair, holding a phone and typing – one of the highest-level fine motor tasks you can reach as a survivor. However, fine motor function may take longer to regain than gross motor skills because of the precision and repetition it requires. The key to recovering upper limb function is high-repetition, task-specific training to build new connections with the brain. I’ll have my stroke clients practice flipping simulated food with spatulas, opening packages, stacking coins, using a screwdriver, or write their name hundreds of times per occupational therapy session.
Spasticity is very common among stroke survivors and can negatively impact task performance when you are unable to move out of the synergistic patterns during reaching or grasping tasks. Spasticity is directly correlated to the stroke-damaged nerve pathways to the brain that control muscle movement resulting in exaggerated reflexes and, when severe enough, result in tight muscles, which your therapist may refer to as “high tone.”
Because spasticity can restrict much of the function lost to hand and arm impairment, work with your occupational therapy and physical therapy teams to identify treatments that can improve these skills and, ultimately, your quality of life. By consistently engaging in the appropriate evidence-based therapies, the once-damaged connections to the brain will strengthen, helping to refine and sustain motor function over time.
There are challenges in the journey to regain both gross and fine motor skills. This is made even more complex by the unique journey that stroke survivors experience throughout the rehabilitation process.
When it comes to fine motor function, the primary challenges are closely linked. Many stroke survivors with impaired fine motor skills can experience significant difficulty grasping and releasing objects with their hands. For grasping objects, the challenges primarily stem from the composite movements of fingers – they tend to all work together as movement first returns post-stroke. It can be challenging to isolate these movements post-stroke in motor function rehabilitation. Flexor tone, resulting in tightness of the muscles on the inside of the forearm, also poses challenges with extending or opening the hand, making release even more difficult.
Refining Supination and Pronation
Stroke survivors with hand and arm impairment must also hone the orientation of their impacted upper limbs as they regain motor function, something known as supination and pronation of the forearm.
Supination refers to the palm and forearm facing up and impacts activities turning a doorknob or holding one’s hand out to receive change at the store. Pronation, or the downward orientation of the palm and forearm, is traditionally involved in activities like pouring a drink into a cup. Many tasks require quick and frequent movements In and out of supination and pronation, so both movements are Important for function.
The two orientations converge in activities like grasping a water bottle or shaking hands, where the hand and arm are facing neither up nor down. Shifting from supination to pronation is a significant milestone in regaining fine and gross motor function in stroke therapy, as it allows stroke survivors greater independence and range of movement.
Compensation and Trunk Movements
As stroke survivors improve their hand and arm function, they may compensate or “cheat” with trunk movements to support the nonuse of the impacted limb. For example, a stroke survivor struggling with hand and arm impairment that affects reach may use the trunk and joint muscles as a workaround to get closer to the object and/or the desired location for the item. Your body and your brain (as well as your therapist!) are telling you to reach for the cup, and if you haven’t regained the fine and gross motor function necessary to complete that task, an easy way to “cheat” is to lean forward.
Trunk movements engage the hips and abdomen, which can cause pain and limit full-body mechanics if you’re doing too many compensations. A remedy is to try straightening your elbow and then reaching. If you’re using too many compensations or trunk movements, this may also be a cue for the therapist to make the task more achievable, like lowering the item and the shelf.
Learned nonuse is another form of compensation I frequently observe among stroke survivors whose affected side was their non-dominant hand and arm. I cannot stress enough how equally important it is to recover as much fine and gross motor function in your affected hand and arm, even if it’s not your dominant side. While it is often easier to regain function in the dominant side, since that’s the side you’re used to completing tasks with, being able to use both hands and arms will allow you to be more independent in your activities of daily living and can lower your risk of injuring your un-affected upper extremity from overuse.
Think about your goals that require both hands for safety and effectiveness – driving, washing and blow drying your hair, cutting food, tying shoes, using your phone, etc. Let your goals motivate you!
Exercises to Encourage Motor Function Progression
Whether at the clinic or at home, always stretch before working on your therapy tasks. Stretching your arms, hands and entire upper body can help prepare your muscles for change.
As you work to regain both fine and gross motor skills in stroke therapy, there are some key activity milestones that can be tracked to show progress and readiness to increase challenge in movement.
When it comes to fine motor function, it is important to right the just-right challenge based on your functional abilities, which your therapist can help determine. For example, if your fingers are not opening completely, your therapist may challenge you in grasping and releasing thin items such as playing cards and then progress to thicker objects such as a cup or a ball. If in-hand manipulation, a higher-level skill, is what is needed in your next step of recovery your therapist may have you rotate golf balls in your palm or crumple paper into a ball.
Stroke therapy is not only about strength and force – but you also must have control and precision in all these movements to regain upper limb function and enhance your quality of life.
How Does Vivistim Help Enhance Fine and Gross Motor Skills?
The Vivistim Paired VNS System is an FDA-approved, drug-free intervention that can help improve hand and arm function after an ischemic stroke by strengthening the connections in the brain to make more significant changes than occupational or physical therapy alone.
An ischemic stroke damages connections in the brain that control hand and arm movement. Vivistim Therapy pairs vagus nerve stimulation with occupational therapy or physical therapy, as well as daily activities, to help strengthen brain connections for improved fine & gross motor skills needed for daily tasks. Vivistim is such a breakthrough device that has been proven safe and effective for stroke recovery, and it is the only system of its kind.
I’ve seen firsthand how high-repetition occupational therapy tasks paired with vagus nerve stimulation produce amazing outcomes for stroke survivors so that they can feel like themselves again. If you’re an ischemic stroke survivor, six months or more post-stroke with some gross motor and minimal fine motor ability in your hand and arm, I encourage you to visit vivistim.com to learn more about Vivistim Therapy.
About Amanda Saylor, OTR/L, CNS, CBIS
Amanda Saylor, OTR/L, CNS, CBIS, is an Occupational Therapist certified as a Neuro Specialist and Brain Injury Specialist. She led the team integrating the FDA-approved Vivistim® Paired VNS™ System at AdventHealth Orlando and is now using Vivistim Therapy for several of her chronic stroke patients. She currently serves as the lead Occupational Therapist across AdventHealth’s 11 outpatient neurology clinics in Central Florida.
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