Signal-to-noise velocity peaks difference: a new method for evaluating the handwriting movement fluency in children with dysgraphia

Fast micrographia and frontal lobe dysfunction post-traumatic brain injury: insights into pacing impairment and rehabilitation strategy

Micrographia, characterised by small handwriting, is often linked to Parkinson's disease, but also resulted to injured brain lesions. The left-handed women in her 20s developed 'fast micrographia' after a traumatic brain injury from a traffic accident, showing bilateral subdural haematomas and frontal lobe contusions, but she had no paralysis and extrapyramidal symptoms. Neuropsychological tests showed reduced processing speed and memory deficits, aligning with frontal lobe damage. A 3-month handwriting training programme improved performance with cues, but issues persisted without them. This case highlights the complexity of fast micrographia and the need for targeted rehabilitation strategies and further research.

Dysgraphia Differs Between Children With Developmental Coordination Disorder and/or Reading Disorder

Handwriting deficits, or dysgraphia, are present in several neurodevelopmental disorders. To investigate whether dysgraphia differs according to the associated disorder, we performed a detailed analysis of handwriting in a group of French children with developmental coordination disorders (DCD), reading disorder (RD), or comorbid RD and DCD. Handwriting deficits were investigated at the product (quality of the trace) and the process (movement that generates the trace) levels. Nineteen children with singular RD (among which eight with dysgraphia), 13 children with singular DCD (among which seven with dysgraphia), 16 children with comorbid RD+DCD (among which 11 with dysgraphia), and 20 typically developing children, age 7 to 12, performed the BHK (Brave Handwriting Kinder) test, a standardized assessment of handwriting, on a graphic tablet. Developmental coordination disorders primarily affected handwriting quality, while RD affected slowness and, to a lesser extent, quality. Children with RD, solely or comorbid with DCD, wasted time by lifting and stopping the pen when writing. The comorbidity added to but did not worsen, handwriting difficulties. These results reflect distinct motor impairments and/or strategies in children with DCD or RD. We identified subtypes of dysgraphia and advocated for a fine-grained analysis of the writing process and the assessment of motor and reading skills when studying dysgraphia.

Tablet-based Rey-Osterrieth Complex Figure copy task: a novel application to assess spatial, procedural, and kinematic aspects of drawing in children

The paper-and-pencil Rey-Osterrieth Complex Figure (ROCF) copy task has been extensively used to assess visuo-constructional skills in children and adults. The scoring systems utilized in clinical practice provide an integrated evaluation of the drawing process, without differentiating between its visuo-constructional, organizational, and motor components. Here, a tablet-based ROCF copy task capable of providing a quantitative assessment of the drawing process, differentiating between visuo-constructional, organizational, and motor skills, is trialed in 94 healthy children, between 7 and 11 years of age. Through previously validated algorithms, 12 indices of performance in the ROCF copy task were obtained for each child. Principal component analysis of the 12 indices identified spatial, procedural, and kinematic components as distinct dimensions of the drawing process. A composite score for each dimension was determined, and correlation analysis between composite scores and conventional paper-and-pencil measures of visuo-constructional, procedural, and motor skills performed. The results obtained confirmed that the constructional, organizational, and motor dimensions underlie complex figure drawing in children; and that each dimension can be measured by a unique composite score. In addition, the composite scores here obtained from children were compared with previsions results from adults, offering a novel insight into how the interplay between the three dimensions of drawing evolves with age.

Motor Adaptation Deficits in Children with Developmental Coordination Disorder and/or Reading Disorder

Procedural learning has been mainly tested through motor sequence learning tasks in children with neurodevelopmental disorders, especially with isolated Developmental Coordination Disorder (DCD) and Reading Disorder (RD). Studies on motor adaptation are scarcer and more controversial. This study aimed to compare the performance of children with isolated and associated DCD and RD in a graphomotor adaptation task. In total, 23 children with RD, 16 children with DCD, 19 children with DCD-RD, and 21 typically developing (TD) children wrote trigrams both in the conventional (from left to right) and opposite (from right to left) writing directions. The results show that movement speed and accuracy were more impacted by the adaptation condition (opposite writing direction) in children with neurodevelopmental disorders than TD children. Our results also reveal that children with RD have less difficulty adapting their movement than children with DCD. Children with DCD-RD had the most difficulty, and analysis of their performance suggests a cumulative effect of the two neurodevelopmental disorders in motor adaptation.

Benefits of a Light-Painting Technique for Learning to Write New Characters: A Proof of Concept With Adults

Learning to write relies on the effective integration of sensory feedback and a transition from motor control based on written tracings to motor control based on expert writing movements. This study aimed to test whether the photographic technique of light painting (LP) would facilitate this transition. To achieve this, we conducted two experiments using different LP setups. LP involves moving a light source in a dark environment while taking a long-exposure photograph. LP entails both a real-time reduction of product-related visual information and a post-trial addition of process-related visual information. In the first experiment, we conducted a pre-test, training, and post-test in which 16 adults wrote four new characters with the non-dominant hand. During the training sessions, participants stood and wrote in a vertical frame (1 × 1.2 m) two characters in the control condition (with a marker on the vertical support) and two characters in the LP condition (with a flashlight in the air). In the test phases, participants were seated at a table and copied the four characters into a square (4 cm * 4 cm) on a fixed sheet of graphics paper. As in-air writing strongly differs from classical handwriting situations, we performed a second LP experiment. The aim was to implement LP training in a condition closer to writing. Sixteen new participants followed the same protocol but sat at a table and wrote in a horizontal square (20 cm * 20 cm). In both experiments, participants who trained with the LP method wrote faster and with less pressure than those trained in the control condition. We also observed an improvement in spatial accuracy in Experiment 2, whatever the training condition. LP seemed to have led participants to focus on the writing process, probably because it modified the nature and timing of the visual information used for writing. LP may be a promising technique for remediating writing difficulties.

Is There a Deficit in Product and Process of Handwriting in Children with Attention Deficit Hyperactivity Disorder? A Systematic Review and Recommendations for Future Research

Handwriting abnormalities in children with attention deficit hyperactivity disorder (ADHD) have sometimes been reported both (i) at the product level (i.e., quality/legibility of the written trace and speed of writing) and (ii) at the process level (i.e., dynamic and kinematic features, such as on-paper and in-air durations, pen pressure and velocity peaks, etc.). Conversely, other works have failed to reveal any differences between ADHD and typically developing children. The question of the presence and nature of handwriting deficits in ADHD remains open and merits an in-depth examination. The aim of this systematic review was, therefore, to identify studies that have investigated the product and/or process of handwriting in children with ADHD compared to typically developing individuals. This review was conducted and reported in accordance with the PRISMA statement. A literature search was carried out using three electronic databases. The methodological quality of the studies was systematically assessed using the Critical Appraisal Skills Program (CASP) criteria. Twenty-one articles were identified. Of these, 17 described handwriting quality/legibility, 12 focused on speed and 14 analyzed the handwriting process. All the studies (100%) with satisfactory methodology procedures reported an impaired product and process in children with ADHD, while 25% evidenced a difference in the speed of production. Most importantly, the studies differed widely in their methodological approaches. Substantial gaps remain, particularly with regard to ascertaining comorbidities, ADHD subtypes and the medical status of the included children. The lack of overall homogeneity in the samples calls for higher quality studies. We conclude with recommendations for further studies.

Teaching and Rehabilitation of Handwriting for Children in the Digital Age: Issues and Challenges

Handwriting is a determining factor for academic success and autonomy for all children. Making knowledge accessible to all is a challenge in the context of inclusive education. Given the neurodevelopmental diversity within a classroom of children, ensuring that the handwriting of all pupils progresses is very demanding for education professionals. The development of tools that can take into account the variability of the profiles and learning abilities of children with handwriting difficulties offers a new potential for the development of specific and adapted remediation strategies. This narrative review aims to present and discuss the challenges of handwriting learning and the opportunities offered by new technologies involving AI for school and health professionals to successfully improve the handwriting skills of all children.

Does modifying visual feedback facilitate learning to write new pseudoletters?

Learning to write relies on the efficient integration of visual and proprioceptive feedback, with a transition from a control, based on the visual inspection of the written trace at the beginning of the learning process to a more predictive control, based mainly on handwriting movement, in proficient writers. The aim of this study was to test the effect of a partial deletion of the written trace, as well as the effect of supplementary visual information, on handwriting kinematics in a learning task. Twenty-four adults learned to write six new pseudoletters using their non-dominant hand on a touch screen digital tablet. Three pseudoletters were trained with modified visual feedback conditions and the other three, in the control condition, i.e. without any visual modification. Results revealed that, in the short-term, the pseudoletters learned with modified visual feedback were traced faster and more fluently than those learned in the control condition, without spatial accuracy reduction. This method seems to be efficient in adults, which is a prerequisite before testing a method with children.

Identification and characterization of learning weakness from drawing analysis at the pre-literacy stage

Handwriting learning delays should be addressed early to prevent their exacerbation and long-lasting consequences on whole children's lives. Ideally, proper training should start even before learning how to write. This work presents a novel method to disclose potential handwriting problems, from a pre-literacy stage, based on drawings instead of words production analysis. Two hundred forty-one kindergartners drew on a tablet, and we computed features known to be distinctive of poor handwriting from symbols drawings. We verified that abnormal features patterns reflected abnormal drawings, and found correspondence in experts' evaluation of the potential risk of developing a learning delay in the graphical sphere. A machine learning model was able to discriminate with 0.75 sensitivity and 0.76 specificity children at risk. Finally, we explained why children were considered at risk by the algorithms to inform teachers on the specific weaknesses that need training. Thanks to this system, early intervention to train specific learning delays will be finally possible.

The Effects of Number and Separation of Support Lines on the Size, Velocity, and Smoothness of Handwriting

We examined the effects of number of and separation between support lines on handwriting characteristics of primary school students with satisfactory and unsatisfactory handwriting. Students (mean age 7.9 years) copied a text on paper with a baseline and with two or four support lines with a separation of 3 or 4 mm between the central lines. Handwriting size, velocity, and smoothness were determined for the four conditions relative to baseline. Children with unsatisfactory handwriting wrote larger and had more lifts during baseline condition. Writing between support lines, especially with small separation, immediately reduced the size of handwriting, but also adversely affected velocity and smoothness. Future research is needed to assess long-term effects.

Analysis of Graphomotor Tests with Machine Learning Algorithms for an Early and Universal Pre-Diagnosis of Dysgraphia

Five to ten percent of school-aged children display dysgraphia, a neuro-motor disorder that causes difficulties in handwriting, which becomes a handicap in the daily life of these children. Yet, the diagnosis of dysgraphia remains tedious, subjective and dependent to the language besides stepping in late in the schooling. We propose a pre-diagnosis tool for dysgraphia using drawings called graphomotor tests. These tests are recorded using graphical tablets. We evaluate several machine-learning models and compare them to build this tool. A database comprising 305 children from the region of Grenoble, including 43 children with dysgraphia, has been established and diagnosed by specialists using the BHK test, which is the gold standard for the diagnosis of dysgraphia in France. We performed tests of classification by extracting, correcting and selecting features from the raw data collected with the tablets and achieved a maximum accuracy of 73% with cross-validation for three models. These promising results highlight the relevance of graphomotor tests to diagnose dysgraphia earlier and more broadly.

Learning Handwriting: Factors Affecting Pen-Movement Fluency in Beginning Writers

Skilled handwriting of single letters is associated not only with a neat final product but also with fluent pen-movement, characterized by a smooth pen-tip velocity profile. Our study explored fluency when writing single letters in children who were just beginning to learn to handwrite, and the extent to which this was predicted by the children’s pen-control ability and by their letter knowledge. 176 Norwegian children formed letters by copying and from dictation (i.e., in response to hearing letter sounds). Performance on these tasks was assessed in terms of the counts of velocity inversions as the children produced sub-letter features that would be produced by competent handwriters as a single, smooth (ballistic) action. We found that there was considerable variation in these measures across writers, even when producing well-formed letters. Children also copied unfamiliar symbols, completed various pen-control tasks (drawing lines, circles, garlands, and figure eights), and tasks that assessed knowledge of letter sounds and shapes. After controlling for pen-control ability, pen-movement fluency was affected by letter knowledge (specifically children’s performance on a task that required selecting graphemes on the basis of their sound). This was the case when children retrieved letter forms from dictated letter sounds, but also when directly copying letters and, unexpectedly, when copying unfamiliar symbols. These findings suggest that familiarity with a letter affects movement fluency during letter production but may also point towards a more general ability to process new letter-like symbols in children with good letter knowledge.

Phenotyping features in the genesis of pre-scriptural gestures in children to assess handwriting developmental levels

Acquiring writing skills is a long developmental process that is conditioned by both the mastery of the gesture and the spatio-temporal arrangement of characters across the page. While the researches in the literature mainly focused on spatio-temporal and kinematics parameters of tracing letters or words using digitizing tablets, no recent research has previously studied the developmental prerequisites of the organization of handwriting useful for clinical assessment and remediation. Aims of the present study was to investigate and validate the phenotyping of the developmental genesis of pre-scriptural graphomotor gestures among school-aged children in achieving correct handwriting. The subject was examined in depth in an ecological setting similar to school, with the objective of assessing handwriting developmental levels. The pre-scriptural graphomotor task studied was to copy a line of cycloid loops on a paper sheet put on the table. This task was chosen because it reflects the execution of the hand movements from one end of the line to the other and in an anti-clockwise direction, as in handwriting. A new methodological approach was applied incorporating both the maturative evolution of postural-gestural features (video-recorded for analysis in 2D reconstruction) and spatio-temporal/kinematic measures collected with a digital pen connected to an analysis software tool to assess the developmental level and provide an understanding of the phenotypical features of the graphomotor gesture. And we also evidence the concurrent validity of the data in displacements, and the better are the spatio-temporal and kinematic measures. Consequently there are phenotypical features, both postural-gestural and spatio-temporal/kinematic in the developmental genesis of the graphomotor gesture with an easy pre-scriptural task. Typically developing school children from 1st to 5th grade, was collected from elementary schools. Five main patterns of displacement gestures were found for the production of the line of loops with a significant developmental progress from 1st to 5th grade. In addition, significant results in comparisons with spatio-temporal and kinematic age-related normative data were highlighted, associated with the quality of the coordination gesture. Lastly external validity in relation to normative values with the standardized handwriting scale BHK (French adaptation of the Concise Evaluation Scale for Children’s handwriting) showed certain significant correlations with spatio-temporal and kinematic measures and the evolution of the displacement gestures (five patterns) used to draw the loops. The better the motor control of the handwriting gesture, the less variety there is in inter-segmental and joint-scriptural task, enabling handwriting developmental levels to be assessed in screening for handwriting disorders, possibly co-occurring with other learning disabilities, and also useful in clinical decision-making processes for handwriting remediation, or simply to assist handwriting gesture acquisition in elementary school.

"It Is Not the Robot Who Learns, It Is Me." Treating Severe Dysgraphia Using Child-Robot Interaction

Writing disorders are frequent and impairing. However, social robots may help to improve children's motivation and to propose enjoyable and tailored activities. Here, we have used the Co-writer scenario in which a child is asked to teach a robot how to write via demonstration on a tablet, combined with a series of games we developed to train specifically pressure, tilt, speed, and letter liaison controls. This setup was proposed to a 10-year-old boy with a complex neurodevelopmental disorder combining phonological disorder, attention deficit/hyperactivity disorder, dyslexia, and developmental coordination disorder with severe dysgraphia. Writing impairments were severe and limited his participation in classroom activities despite 2 years of specific support in school and professional speech and motor remediation. We implemented the setup during his occupational therapy for 20 consecutive weekly sessions. We found that his motivation was restored; avoidance behaviors disappeared both during sessions and at school; handwriting quality and posture improved dramatically. In conclusion, treating dysgraphia using child-robot interaction is feasible and improves writing. Larger clinical studies are required to confirm that children with dysgraphia could benefit from this setup.

Dysgraphia detection through machine learning

Dysgraphia, a disorder affecting the written expression of symbols and words, negatively impacts the academic results of pupils as well as their overall well-being. The use of automated procedures can make dysgraphia testing available to larger populations, thereby facilitating early intervention for those who need it. In this paper, we employed a machine learning approach to identify handwriting deteriorated by dysgraphia. To achieve this goal, we collected a new handwriting dataset consisting of several handwriting tasks and extracted a broad range of features to capture different aspects of handwriting. These were fed to a machine learning algorithm to predict whether handwriting is affected by dysgraphia. We compared several machine learning algorithms and discovered that the best results were achieved by the adaptive boosting (AdaBoost) algorithm. The results show that machine learning can be used to detect dysgraphia with almost 80% accuracy, even when dealing with a heterogeneous set of subjects differing in age, sex and handedness.

A Tablet-Based App to Discriminate Children at Potential Risk of Handwriting Alterations in a Preliteracy Stage

Failing to master handwriting, as in the case of Dysgraphia, has negative consequences on children's lives. In early stage of development, Dysgraphia diagnosis is delayed and not easily achievable. Thus, the aim of this work is to propose a valid tool to anticipate Dysgraphia screening at a preliteracy age. We developed a tablet application to analyze characteristics altered in dysgraphic handwriting, such as rhythmical laws (isochrony and homothety), or a collection of kinematic and dynamic parameters (smoothness, pressure, frequency contents). To be suitable for the pre-literacy stage, possible alterations are investigated in symbol drawings. The app is tested on 104 preschoolers, both with normal (n=76) and delayed graphical abilities (n=28), reporting excellent acceptance. Some isochrony alterations were reported only for children with delayed graphical abilities. Moreover, kinematic and dynamic parameters are effective in discriminating between risk and norisk conditions. Indeed, the logistic classification adopted resulted in a 0.819 area under the precision-recall curve. These findings pave the way toward an early screening of future handwriting alteration, starting from a pre-literacy age.

Musical sonification improves motor control in Parkinson's disease: a proof of concept with handwriting

A growing number of studies postulate the use of music to improve motor control in patients with Parkinson's disease (PD). The effects of music are greatly variable from one individual to the other and do not always reach the expected benefits. This study aimed to optimize the use of music in the management of movement disorders inherent to PD in a handwriting task. We developed and tested musical sonification (MS), a method that transforms in real-time kinematic variables into music. Twelve patients with PD, on medication, and 12 healthy controls were recruited in a pretest/training/posttest design experiment. Three training sessions were compared, for which participants were asked to produce graphomotor exercises: one session with music (unrelated to handwriting), one with MS (controlled by handwriting), and one in silence. Results showed that the performance in training was better under MS than under silence or background music, for both groups. After training, the benefits of MS were still present for both groups, with a higher effect for PD patients than for control group. Our results provide a proof of concept to consider MS as a relevant auditory guidance strategy for movement rehabilitation in patients with PD.

Developmental coordination disorder and dysgraphia: signs and symptoms, diagnosis, and rehabilitation

Developmental coordination disorder (DCD) is a common and well-recognized neurodevelopmental disorder affecting approximately 5 in every 100 individuals worldwide. It has long been included in standard national and international classifications of disorders (especially the Diagnostic and Statistical Manual of Mental Disorders). Children and adults with DCD may come to medical or paramedical attention because of poor motor skills, poor motor coordination, and/or impaired procedural learning affecting activities of daily living. Studies show DCD persistence of 30-70% in adulthood for individuals who were diagnosed with DCD as children, with direct consequences in the academic realm and even beyond. In particular, individuals with DCD are at increased risk of impaired handwriting skills. Medium-term and long-term prognosis depends on the timing of the diagnosis, (possible) comorbid disorders (and their diagnosis), the variability of signs and symptoms (number and intensity), and the nature and frequency of the interventions individuals receive. We therefore chose to investigate the signs and symptoms, diagnosis, and rehabilitation of both DCD and developmental dysgraphia, which continues to receive far too little attention in its own right from researchers and clinicians.

Handwriting movements for assessment of motor symptoms in schizophrenia spectrum disorders and bipolar disorder

The main aim of the present study was to explore the value of several measures of handwriting in the study of motor abnormalities in patients with bipolar or psychotic disorders. 54 adult participants with a schizophrenia spectrum disorder or bipolar disorder and 44 matched healthy controls, participated in the study. Participants were asked to copy a handwriting pattern consisting of four loops, with an inking pen on a digitizing tablet. We collected a number of classical, non-linear and geometrical measures of handwriting. The handwriting of patients was characterized by a significant decrease in velocity and acceleration and an increase in the length, disfluency and pressure with respect to controls. Concerning non-linear measures, we found significant differences between patients and controls in the Sample Entropy of velocity and pressure, Lempel-Ziv of velocity and pressure, and Higuchi Fractal Dimension of pressure. Finally, Lacunarity, a measure of geometrical heterogeneity, was significantly greater in handwriting patterns from patients than from controls. We did not find differences in any handwriting measure on function of the specific diagnosis or the antipsychotic dose. Results indicate that participants with a schizophrenia spectrum disorder or bipolar disorder exhibit significant motor impairments and that these impairments can be readily quantified using measures of handwriting movements. Besides, they suggest that motor abnormalities are a core feature of several mental disorders and they seem to be unrelated to the pharmacological treatment.

On the Auditory-Proprioception Substitution Hypothesis: Movement Sonification in Two Deafferented Subjects Learning to Write New Characters

The aim of this study was to evaluate the compensatory effects of real-time auditory feedback on two proprioceptively deafferented subjects. The real-time auditory feedback was based on a movement sonification approach, consisting of translating some movement variables into synthetic sounds to make them audible. The two deafferented subjects and 16 age-matched control participants were asked to learn four new characters. The characters were learned under two different conditions, one without sonification and one with sonification, respecting a within-subject protocol. The results revealed that characters learned with sonification were reproduced more quickly and more fluently than characters learned without and that the effects of sonification were larger in deafferented than in control subjects. Secondly, whereas control subjects were able to learn the characters without sounds the deafferented subjects were able to learn them only when they were trained with sonification. Thirdly, although the improvement was still present in controls, the performance of deafferented subjects came back to the pre-test level 2 h after the training with sounds. Finally, the two deafferented subjects performed differently from each other, highlighting the importance of studying at least two subjects to better understand the loss of proprioception and its impact on motor control and learning. To conclude, movement sonification may compensate for a lack of proprioception, supporting the auditory-proprioception substitution hypothesis. However, sonification would act as a “sensory prosthesis” helping deafferented subjects to better feel their movements, without permanently modifying their motor performance once the prosthesis is removed. Potential clinical applications for motor rehabilitation are numerous: people with a limb prosthesis, with a stroke, or with some peripheral nerve injury may potentially be interested.

"Let Me Hear Your Handwriting!" Evaluating the Movement Fluency from Its Sonification

The quality of handwriting is evaluated from the visual inspection of its legibility and not from the movement that generates the trace. Although handwriting is achieved in silence, adding sounds to handwriting movement might help towards its perception, provided that these sounds are meaningful. This study evaluated the ability to judge handwriting quality from the auditory perception of the underlying sonified movement, without seeing the written trace. In a first experiment, samples of a word written by children with dysgraphia, proficient children writers, and proficient adult writers were collected with a graphic tablet. Then, the pen velocity, the fluency, and the axial pen pressure were sonified in order to create forty-five audio files. In a second experiment, these files were presented to 48 adult listeners who had to mark the underlying unseen handwriting. In order to evaluate the relevance of the sonification strategy, two experimental conditions were compared. In a first 'implicit' condition, the listeners made their judgment without any knowledge of the mapping between the sounds and the handwriting variables. In a second 'explicit' condition, they knew what the sonified variables corresponded to and the evaluation criteria. Results showed that, under the implicit condition, two thirds of the listeners marked the three groups of writers differently. In the explicit condition, all listeners marked the dysgraphic handwriting lower than that of the two other groups. In a third experiment, the scores given from the auditory evaluation were compared to the scores given by 16 other adults from the visual evaluation of the trace. Results revealed that auditory evaluation was more relevant than the visual evaluation for evaluating a dysgraphic handwriting. Handwriting sonification might therefore be a relevant tool allowing a therapist to complete the visual assessment of the written trace by an auditory control of the handwriting movement quality.

The effect of real-time auditory feedback on learning new characters

The present study investigated the effect of handwriting sonification on graphomotor learning. Thirty-two adults, distributed in two groups, learned four new characters with their non-dominant hand. The experimental design included a pre-test, a training session, and two post-tests, one just after the training sessions and another 24h later. Two characters were learned with and two without real-time auditory feedback (FB). The first group first learned the two non-sonified characters and then the two sonified characters whereas the reverse order was adopted for the second group. Results revealed that auditory FB improved the speed and fluency of handwriting movements but reduced, in the short-term only, the spatial accuracy of the trace. Transforming kinematic variables into sounds allows the writer to perceive his/her movement in addition to the written trace and this might facilitate handwriting learning. However, there were no differential effects of auditory FB, neither long-term nor short-term for the subjects who first learned the characters with auditory FB. We hypothesize that the positive effect on the handwriting kinematics was transferred to characters learned without FB. This transfer effect of the auditory FB is discussed in light of the Theory of Event Coding.

Analysis of in-air movement in handwriting: A novel marker for Parkinson's disease

BACKGROUND AND OBJECTIVE

Parkinson's disease (PD) is the second most common neurodegenerative disease affecting significant portion of elderly population. One of the most frequent hallmarks and usually also the first manifestation of PD is deterioration of handwriting characterized by micrographia and changes in kinematics of handwriting. There is no objective quantitative method of clinical diagnosis of PD. It is thought that PD can only be definitively diagnosed at postmortem, which further highlights the complexities of diagnosis.

METHODS

We exploit the fact that movement during handwriting of a text consists not only from the on-surface movements of the hand, but also from the in-air trajectories performed when the hand moves in the air from one stroke to the next. We used a digitizing tablet to assess both in-air and on-surface kinematic variables during handwriting of a sentence in 37 PD patients on medication and 38 age- and gender-matched healthy controls.

RESULTS

By applying feature selection algorithms and support vector machine learning methods to separate PD patients from healthy controls, we demonstrated that assessing the in-air/on-surface hand movements led to accurate classifications in 84% and 78% of subjects, respectively. Combining both modalities improved the accuracy by another 1% over the evaluation of in-air features alone and provided medically relevant diagnosis with 85.61% prediction accuracy.

CONCLUSIONS

Assessment of in-air movements during handwriting has a major impact on disease classification accuracy. This study confirms that handwriting can be used as a marker for PD and can be with advance used in decision support systems for differential diagnosis of PD.

From micrographia to Parkinson's disease dysgraphia

Micrographia, an abnormal reduction in writing size, is a specific behavioral deficit associated with Parkinson's disease (PD). In recent years, the availability of graphic tablets has made it possible to study micrographia in unprecedented detail. Consequently, a growing number of studies show that PD patients also exhibit impaired handwriting kinematics. Is micrographia still the most characteristic feature of PD-related handwriting deficits? To answer this question, we identified studies that investigated handwriting in PD, either with conventional pencil-and-paper measures or with graphic tablets, and we reported their findings on key spatiotemporal and kinematic variables. We found that kinematic variables (velocity, fluency) differentiate better between control participants and PD patients, and between off- and on-treatment PD patients, than the traditional measure of static writing size. Although reduced writing size is an important feature of PD handwriting, the deficit is not restricted to micrographia stricto sensu. Therefore, we propose the term PD dysgraphia, which encompasses all deficits characteristic of Parkinsonian handwriting. We conclude that the computerized analysis of handwriting movements is a simple and useful tool that can contribute to both diagnosis and follow-up of PD.