Assessing Handwriting in Patients with Parkinson‘s Disease

Authors: L. Masárová 1;  P. Drotár 3;  J. Mekyska 3;  Z. Smékal 3;  I. Rektorová 1,2
Authors‘ workplace: I. neurologická klinika LF MU a FN u sv. Anny v Brně 1;  Výzkumná skupina Aplikované neurovědy, CEITEC – Středoevropský technologický institut MU, Brno 2;  Ústav telekomunikací, FEKT, VUT v Brně 3
Published in: Cesk Slov Neurol N 2014; 77/110(4): 456-462
Category: Original Paper

Podpořeno grantem IGA MZČR NT/ 13499: Řeč, její poruchy a kognitivní funkce u Parkinsonovy nemoci. Peter Drotár je finančně podporován projektem CZ.1.07/2.3.00/30.0005 Vysokého učení technického v Brně.


The aim of this study was to assess micrographia in patients with Parkinson’s disease (PD) as compared to healthy controls (HC) using a digitizing tablet.

We included 40 PD (mean 68.6 ± 11.36 years, duration of illness 8.02 ± 4.79 years) and 40 age- and sex-matched HC (mean 62.55 ± 11. 22 years). All subjects were right-handed, without the presence of depression or dementia. Each subject underwent seven exercises for writing and drawing of Archimedes spiral and ellipses using a digitizing tablet. The speed parameters of micrographia and drawing during the movement of a pen in the air and on the tablet were evaluated. The Mann-Whitney U test, Spearman correlation and Benjamini-Hochbergs method were used for statistical data analysis.

A statistically significant reduction in parameters of velocity, acceleration, and jerk was found when comparing both groups during writing. Changes were more pronounced with increased length of the written segment. The differences between the two groups were more pronounced when the in-air movements were assessed, i.e. during movement preparation. The values decreased up to 20% compared to HC.

PD-specific changes assessed with a digitizing tablet were demonstrated not only during writing but also during preparation for writing. The results of the study may have a direct clinical impact: further research into its use as a clinical marker of early PD is likely to follow.

Key words:
micrographia – Parkinson‘s disease – writing


1. Pangelinan, MM, Kagerer FA, Momen B, Hatfield BD,Clark JE. Electrocortical dynamics reflect age‑related differences in movement kinematics among children and adults. Cereb Cortex 2011; 21(4): 737– 747. doi:10.1093/ cercor/ bhq162.

2. Eichhorn TE, Gasser T, Mai N, Marquardt C, Arnold G,Schwarz J et al. Computational analysis of open loop handwriting movements in Parkinson‘s disease: a rapid method to detect dopamimetic effects. Mov Disord 1996; 11(3): 289– 297.

3. Mergl R, Tigges P, Schröter A, Möller HJ, Hegerl U.Digitized analysis of handwriting and drawing movements in healthy subjects: methods, results and perspectives. J Neurosci Methods 1999; 90(2): 157– 169.

4. Siebner HR, Ceballos‑ Baumann A, Standhardt H, Auer C, Conrad B, Alesch F. Changes in handwriting resulting from bilateral high‑frequency stimulation of the subthalamic nucleus in Parkinson‘s disease. Mov Disord 1999; 14: 964– 971.

5. Wagle Shukla A, Ounpraseuth S, Okun MS, Gray V,Schwankhaus J, Metzer WS. Micrographia and related deficits in Parkinson‘s disease: a cross‑ sectional study. BMJ Open 2012; 2(3): e000628. doi: 10.1136/ bmjopen‑ 2011‑ 000628.

6. Iwasaki Y, Ikeda K, Shindoh T, Suga Y, Ishikawa I, Hara M et al. Micrographia in Huntington‘s disease. J Neurol Sci 1999; 162(1): 106– 107.

7. Nakamura M, Hamamoto M, Uchida S, Nagayama H,Amemiya S, Okubo S et al. A case of micrographia after subcortical infarction: possible involvement of frontal lobe function. Eur J Neurol 2003; 10(5): 593– 596.

8. Ho SL. Micrographia in Chinese characters. J Neurol Neurosurg Psychiatry 1995; 59(5): 471.

9. Yoshida T, Yamadori A, Mori E. A case of micrographia with the right hand due to left putaminal infarction. Rinsho Shinkeigaku 1989; 29(9): 1149– 1151.

10. Gangadhar G, Joseph D, Chakravarthy VS.Understanding Parkinsonian handwriting through a computational model of basal ganglia. Neural Comput 2008; 20(10): 2491– 2525. doi: 10.1162/ neco. 2008.03‑ 07‑ 498.

11. Rektorová I, Rektor I. Parkinsonský syndrom. In: Rektor I, Rektorová I et al (eds). Centrální poruchy hybnosti v praxi. Praha: Triton 2003: 21– 70.

12. Tucha O, Mecklinger L, Thome J, Reiter A, Alders GL, Sartor H et al. Kinematic analysis of dopaminergic effects on skilled handwriting movements in Parkinson‘s disease. J Neural Transm 2006; 113(5): 609– 623. doi: 10.1007/ s00702‑ 005‑ 0346‑ 9.

13. Hoshiyama M, Kaneoke Y, Koike Y, Takahashi A, Watanabe S. Hypokinesia of associated movement in Parkinson‘s disease: a symptom in early stages of the disease. J Neurol 1994; 241(9): 517– 521.

14. Kawakami O, Hoshiyama M, Hirayama M, Koike Y, Sobue G. Impaired associated movement in Parkinson‘s disease. Nihon Rinsho 1997; 55(1): 179– 184.

15. Marsden CD. Which motor disorder in Parkinson‘s disease indicates the true motor function of the basal ganglia? Ciba Found Symp 1984; 107: 225– 241.

16. Van Gemmert AW, Teulings HL, Stelmach GE. Parkinsonian patients reduce their stroke size with increased processing demands. Brain Cogn 2001; 47(3): 504– 512. doi: 10.1006/ brcg.2001.1328.

17. Unlu A, Brause R, Krakow K. Handwriting Analysis for Dia­gnosis and Prognosis of Parkinson’s Disease. In: Proceedings of the 7th international conference on Biological and Medical Data Analysis. Berlin: Springer‑ Verlag 2006: 441– 450.

18. Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical dia­gnosis of idiopathic Parkinson’s dis­ease: a clinicopathological study of 100 cases. J Neurol Neurosurg Psychiatry 1992; 55(3): 181– 184.

19. Fahn S, Elston RL, members of the UPDRS Development Committee. Unified Parkinson’s disease rating scale. In: Fahn S, Marsden CD, Goldstein M, Calne DB (eds). Recent developments in Parkinson’s disease. Vol 2. New York: Macmillan 1987: 153– 163.

20. Tomlinson CL, Stowe R, Patel S, Rick C, Gray R,Clarke CE. Systematic review of levodopa dose equivalency reporting in Parkinson‘s disease. Mov Disord 2010; 25(15): 2649– 2653. doi: 10.1002/ mds.23429.

21. Louis ED, Yu Q, Floyd AG, Moskowitz C, Pullman SL.Axis is a feature of handwritten spirals in essential tremor. Mov Disord 2006; 21(8): 1294– 1295. doi: 10.1002/ mds.20915.

22. Pullman SL. Spiral analysis: a new technique for measuring tremor with a digitizing tablet. Mov Disord 1998; 13 (Suppl 3): 85– 89.

23. Saunders‑ Pullman R, Derby C, Stanley K, Floyd A, Bressman S, Lipton RB et al. Validity of spiral analysis in early Parkinson‘s disease. Mov Disord 2008; 23(4): 531– 537. doi:10.1002/ mds.21874.

24. Wang H, Yu Q, Kurtis MM, Floyd AG, Smith WA, Pullman SL. Spiral analysis‑ improved clinical utility with center detection. J Neurosci Methods 2008; 171(2): 264– 270. doi: 10.1016/ j.jneumeth.2008.03.009.

25. Westin J, Ghiamati S, Memedi M, Nyholm D, Johansson A, Dougherty M et al. A new computer meth­­od for assessing drawing impairment in Parkinson‘s disease. J Neurosci Methods 2010; 190(1): 143– 148. doi: 10.1016/ j.jneumeth.2010.04.027.

26. Lepelley MC, Thullier F, Bolmont B, Lestienne FG.Age‑related differences in sensorimotor representation of space in drawing by hand. Clin Neurophysiol 2010; 121(11): 1890– 1897. doi: 10.1016/ j.clinph.2010.04.024.

27. Bidet‑ Ildei C, Pollak P, Kandel S, Fraix V, Orliaguet JP.Handwriting in patients with Parkinson disease: effect of L‑ dopa and stimulation of the sub‑thalamic nucleus on motor anticipation. Hum Mov Sci 2011; 30(4): 783– 791. doi: 10.1016/ j.humov.2010.08.008.

28. Gallucci RM, Phillips JG, Bradshaw JL, Vaddadi KS, Pantelis C. Kinematic analysis of handwriting movements in schizophrenic patients. Biol Psychiatry 1997; 41(7): 830– 833. doi: 10.1016/ s0006‑ 3223(96)00544‑ 6.

29. Van Gemmert AW, Teulings HL, Contreras‑ Vidal JL,Stelmach GE. Parkinson‘s disease and the control of size and speed in handwriting. Neuropsychologia 1999; 37(6): 685– 694.

30. Teulings HL, Contreras‑ Vidal JL, Stelmach GE, Adler CH. Parkinsonism reduces coordination of fingers, wrist and arm in fine motor control. Exp Neurol 1997; 146(1): 159– 170. doi: 10.1006/ exnr.1997.6507.

31. Teulings HL, Contreras‑ Vidal JL, Stelmach GE, Adler CH. Adaptation of handwriting size under distorted visual feedback in patients with Parkinson‘s disease and elderly and young controls. J Neurol Neurosurg Psychiatry 2002; 72(3): 315– 324.

32. Ondo WG, Satija P. Withdrawal of visual feedback improves micrographia in Parkinson‘s disease. Mov Disord 2007; 22(14): 2130– 2131. doi:10.1002/ mds.21733.

33. Dounskaia N, Van Gemmert AW, Leis BC, Stelmach GE. Biased wrist and finger coordination in Parkinsonian patients during performance of graphical tasks. Neuropsychologia 2009; 47(12): 2504– 2514. doi: 10.1016/ j.neuropsychologia.2009.04.020.

34. Ling H, Massey LA, Lees AJ, Brown P, Day BL. Hypokinesia without decrement distinguishes progressive supranuclear palsy from Parkinson‘s disease. Brain 2012; 135(4): 1141– 1153. doi: 10.1093/ brain/aws038.

Paediatric neurology Neurosurgery Neurology

Article was published in

Czech and Slovak Neurology and Neurosurgery

Issue 4

2014 Issue 4

Most read in this issue
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account