Intensive training programme improves handwriting in a community cohort of people with Parkinson’s disease

Micrographia is a common motor symptom in PwP and can have profound negative impacts on quality of life. This study assessed the impact of a 6-week remote training programme on handwriting of PwP. It was the first of its kind in Ireland and was conducted through a community-based online physiotherapy clinic. In our study, two independent raters marked the handwriting assessments, and we subsequently assessed the reproducibility between these two raters, who had been blinded to each other’s scoring. Our analysis showed high inter-rater reliability between these raters for total SOS-PD score, size, and speed, as well as the legibility scores. For the internal items, there were variable findings, with fluency, transitions, regularity, word spacing, and straightness of lines showing moderate to low agreement, in line with previous reported assessments [14], suggesting that some of the SOS-PD items may be redundant in these types of studies in PwP.

The participants were not pre-selected and represented a broad range of disease duration. Overall, results from the data analysis suggest that, following completion of the 6-week programme, participants’ handwriting improved. There was a significant decrease in the total SOS-PD score, which is reflective of an increase in handwriting quality and legibility. Further analysis of the handwriting scores showed that size, fluency, regularity of letter size, and straightness had all improved after training. These findings are important, as fluency and regularity of letter size have previously been found to be the most affected aspects of handwriting in PwP [14, 15, 19]. One previous study reported that size and progressive letter height in a sentence were the main handwriting problems exhibited by PwP [14]. We found no significant changes in the speed of handwriting, in transition between letters, or in space between words, between pre- and post-programme assessments. This is consistent with a previous study that used the SOS-PD tool in PwP and also reported no significant changes in these items [14]. Furthermore, increasing handwriting speed was not a goal of the training programme. The focus was on increasing the size of each letter and working on fluency. It is interesting that, in our study, there were improvements in several SOS-PD items, thus resulting in an overall enhancement in the legibility of the text, without slower letter production. This data is supported by our additional independent assessments of handwriting legibility, where a significant decrease in illegible words was documented, along with a corresponding increase in total percentage legibility. These items were a novel assessment to supplement the SOS-PD and have not been carried out in PwP to date.

All patients continued to take their regular medications throughout the study, as medication timings are imperative to symptom management in PD. Regarding our study protocol, we did not observe a significant change in the timing of medication intake between the pre- and post-programme assessments. Freezing and tremor in participants' non-writing hands were not observed to change over the course of the programme. However, participants were noted to have significantly less tremor in their writing hand at the post-programme assessment. Although it is noteworthy that this was an observed tremor, we cautiously conclude that tremor does not have a significant impact on handwriting as reflected in participant’s scores. Tremor can be a bothersome symptom for PwP. Based on the findings of this study, PwP can be reassured that although they have a tremor, it should not impact upon their handwriting, as the scores do not show any effect of tremor. It has been suggested that micrographia is a component of bradykinesia, as the two symptoms are correlated [14], and indeed tremor may not affect speed or size of handwriting. Interestingly, it was observed that in the Post-Programme assessments, the handwriting style of three of the participants changed from being cursive to non-cursive, upon completion of the programme. This may be reflective of increased control of fine motor movement, or that the participant was more attentive or cognisant of their handwriting style after completion of the training programme.

Participants were from a community setting and represented various stages of PD. The physiotherapists did not exclude people based on stage of disease or on disease duration. This is important as it means that even people who were considered to have severe PD were offered the opportunity to complete a training programme that targets handwriting issues, symptoms that are known to be important to them. There was a significant drop-out rate in the programme, which reflects the intensity of the programme being considered to be too high by some participants. This does not necessarily mean that those participants who dropped out did not benefit from the programme. They received a detailed workbook and information on the training programme, and so it is possible that they continued the programme at their own pace.

The observed improvements in handwriting in our study have potential to improve the quality of life for PwP. This training programme could relatively easily be implemented in the care of individuals with early-stage PD, potentially delaying or preventing the observed micrographia seen in many PwP, thereby preserving fine motor control and improving independence and quality of life. PwP frequently report frustration relating to micrographia, as it can impede their independence [11, 15]. Future studies could select individuals with earlier stages of PD to complete this handwriting programme, perhaps with modifications. Writing aids such as rulers, weighted pens, or different pen types, such as fountain pens, could be used in conjunction with the programme. It is relevant to consider whether the conditions of remote assessments used in our study may have affected the performance of participants. Here, participants performed the assessments in their own homes, in a relaxed and familiar setting. There may have been different outcomes if the assessments had been carried out in a more stressful clinical environment. It is important to note, however, that the influence of a ‘practice effect’ may have contributed to the observed differences in our study, by altering participants’ respective performances during the repeated assessments [20].

Our study lacked a control group, but previous studies using this training method had established the training protocol and found measurable differences in size and speed of handwriting when comparing PwP to a control group [14]. The SOS assessment has also been reported to confer improvements of up to 17% in size of handwriting in PwP [18]. In our study, we found 20% improvement in overall SOS scores, 8% change in the size, and 7.5% improvement in handwriting legibility. To note, 16 of the participants did not complete our study, due to the intensity of the training programme. These participants reported hand and muscle cramps, as well as fatigue. Future participants could be advised to include relaxation movements or timed breaks, to alleviate fatigue. The training programme was highly intensive, comprising of 1 h per day for 5 days, over 6 weeks. In future studies, participants could be stratified based on their disease stage, with a more intensive programme used for people with early-stage PD and a less intensive one for individuals with advanced PD, to tailor the handwriting programme to suit the needs of the individual. In another study, good retention of participants was achieved in a less intensive programme over a longer period of time [20]. The online nature of this training has potential to increase the accessibility of resource, for example, to those living in rural communities without access to physiotherapy clinics. Further flexibility could also be implemented in the programme; for example, individuals with PD who are working may choose to take the course online or to use recorded training videos.

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