Technology-Assisted Rehabilitation of Writing Skills in Parkinson's Disease: Visual Cueing versus Intelligent Feedback

Rehabilitative interventions for impaired handwriting in people with Parkinson's disease: a scoping review

BACKGROUND

People with Parkinson's disease (PD) often complain about handwriting difficulties. Currently, there is no consensus on the rehabilitative treatment and outcome measures for handwriting rehabilitation in PD.

OBJECTIVES

This study aims to investigate evidence on handwriting rehabilitation in people with PD, examining characteristics of interventions and outcomes.

METHODS

A scoping review was conducted according to Arksey and O'Malley's framework and PRISMA-ScR List. We searched electronic databases of PubMed, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, and Embase since inception to January 2023. We included interventional studies assessing the effects of structured rehabilitation programs for impaired handwriting in people with PD. Two reviewers independently selected studies, extracted data, and assessed the risk of bias using the Cochrane Collaboration's tool for assessing Risk of Bias version 2 or the Risk Of Bias In Non-randomized Studies. We performed a narrative analysis on training characteristics and assessed outcomes.

RESULTS

We included eight studies. The risk of bias was generally high. Either handwriting-specific or handwriting-non-specific trainings were proposed, and most studies provided a home-based training. Handwriting-specific training improved writing amplitude while handwriting-non-specific trainings, such as resistance and stretching/relaxation programs, resulted in increased writing speed.

CONCLUSIONS

The current knowledge is based on few and heterogeneous studies with high risk of bias. Handwriting-specific training might show potential benefits on handwriting in people with PD. Further high-quality randomized controlled trials are needed to reveal the effect of handwriting training in people with PD on standardized outcome measures. Handwriting-specific training could be combined to resistance training and stretching, which seemed to influence writing performance.

Novel insights into the effects of levodopa on the up- and downstrokes of writing sequences

Motor control of automatized and overlearned sequences, such as writing, is affected in Parkinson's disease (PD), impacting patients' daily life. Medication effects on motor performance are not only task-specific, but also variable within tasks. The nature of this variance is still unclear. This study aimed to investigate whether medication affects writing sequences differently when producing up- or downstrokes. Writing was assessed in healthy controls (HC) (N = 31) and PD (N = 32), when ON and OFF medication in a randomized order (interspersed by two months). Subjects wrote a sequential pattern with an increasing size on a digital tablet. Writing outcomes were movement vigor (amplitude and velocity), error and end-point variability, and sequence continuation, calculated separately for up- and downstrokes. Results showed that PD patients OFF-medication reduced movement vigor (amplitude) for up- and downstrokes compared to HC. Clear deficits were found for up- but not for downstroke error in PD patients in OFF, suggesting a directional bias. Dopaminergic medication improved motor vigor by increasing writing amplitude and upstroke continuation, but this occurred at the cost of the downstroke trajectory. Other writing outcomes did not improve with medication intake. In conclusion, we interpret these findings as that the impact of dopamine is complex, highly task-specific, supporting the most highly energy demanding components of a writing sequence. As medication did not regulate downstroke writing, we recommend supplementary training to address task demands that were less modulated by dopamine (registration: https://osf.io/gk5q8/ , 17 July 2018).

Treating Speech Movement Hypokinesia in Parkinson's Disease: Does Movement Size Matter?

Purpose

This study evaluates the effects of a novel speech therapy program that uses a verbal cue and gamified augmented visual feedback regarding tongue movements to address articulatory hypokinesia during speech in individuals with Parkinson's disease (PD).

Method

Five participants with PD participated in an ABA single-subject design study. The treatment aimed to increase tongue movement size using a combination of a verbal cue and augmented visual feedback and was conducted in 10 45-min sessions over 5 weeks. The presence of visual feedback was manipulated during treatment. Articulatory working space of the tongue was the primary outcome measure and was examined during treatment and in cued and uncued sentences pre- and posttreatment. Changes in speech intelligibility in response to a verbal cue pre- and posttreatment were also examined.

Results

During treatment, 4/5 participants showed a beneficial effect of visual feedback on tongue articulatory working space. At the end of the treatment, they used larger tongue movements when cued, relative to their pretreatment performance. None of the participants, however, generalized the effect to the uncued sentences. Speech intelligibility of cued sentences was judged as superior posttreatment only in a single participant.

Conclusions

This study demonstrated that using an augmented visual feedback approach is beneficial, beyond a verbal cue alone, in addressing articulatory hypokinesia in individuals with PD. An optimal degree of articulatory expansion might, however, be required to elicit a speech intelligibility benefit.