Handwriting Impairments in People With Parkinson’s Disease and Freezing of Gait

Heremans, Elke; Nackaerts, Evelien; Broeder, Sanne; Vervoort, Griet; Swinnen, Stephan P.; Nieuwboer, Alice

doi:10.1177/1545968316642743

Cited by 31 publications

(23 citation statements)

References 57 publications

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“…Analysis of the quality items revealed that fluency in writing and regularity of letter height were more affected in PD. The latter is in line with earlier findings, based on tablet technology, showing increased variability of writing size and decreasing letter height during writing in patients with PD while both in the on- and off-phase of the medication cycle [ 29 – 31 ]. Even though writing fluency in the current study was determined by means of sudden changes in movement directions, difficulties with writing fluency were shown previously in PD by means of an increased normalized jerk during writing-like movements [ 4 , 32 , 33 ].…”

Section: Discussionsupporting

confidence: 92%

“…Finally, recent work from our group has shown that differences between patients with and without freezing of gait can be detected with the SOS-test [ 29 ] and that the SOS-test is sensitive enough to detect improvements in writing size after intensive amplitude training [ 40 ]. These results suggest that the SOS-test can be used to monitor writing difficulties with time and detect intervention effects in PD.…”

Section: Discussionmentioning

confidence: 99%

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Validity and reliability of a new tool to evaluate handwriting difficulties in Parkinson’s disease

et al. 2017

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BackgroundHandwriting in Parkinson’s disease (PD) features specific abnormalities which are difficult to assess in clinical practice since no specific tool for evaluation of spontaneous movement is currently available.ObjectiveThis study aims to validate the ‘Systematic Screening of Handwriting Difficulties’ (SOS-test) in patients with PD.MethodsHandwriting performance of 87 patients and 26 healthy age-matched controls was examined using the SOS-test. Sixty-seven patients were tested a second time within a period of one month. Participants were asked to copy as much as possible of a text within 5 minutes with the instruction to write as neatly and quickly as in daily life. Writing speed (letters in 5 minutes), size (mm) and quality of handwriting were compared. Correlation analysis was performed between SOS outcomes and other fine motor skill measurements and disease characteristics. Intrarater, interrater and test-retest reliability were assessed using the intraclass correlation coefficient (ICC) and Spearman correlation coefficient.ResultsPatients with PD had a smaller (p = 0.043) and slower (p<0.001) handwriting and showed worse writing quality (p = 0.031) compared to controls. The outcomes of the SOS-test significantly correlated with fine motor skill performance and disease duration and severity. Furthermore, the test showed excellent intrarater, interrater and test-retest reliability (ICC > 0.769 for both groups).ConclusionThe SOS-test is a short and effective tool to detect handwriting problems in PD with excellent reliability. It can therefore be recommended as a clinical instrument for standardized screening of handwriting deficits in PD.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Validity and reliability of a new tool to evaluate handwriting difficulties in Parkinson’s disease

et al. 2017

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“…More recently, our group revealed that in part of the patients with PD freezing episodes take place during handwritinglike movements [7] and that freezers experience decreased writing amplitude, i.e. aggravated micrographia, and increased variability outside these freezing episodes [8]. Similar to gait, non-gait freezing is responsive to cueing [9].…”

Section: Introductionmentioning

confidence: 91%

Altered effective connectivity contributes to micrographia in patients with Parkinson’s disease and freezing of gait

et al. 2017

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Recently, it was shown that patients with Parkinson's disease (PD) and freezing of gait (FOG) can also experience freezing episodes during handwriting and present writing problems outside these episodes. So far, the neural networks underlying increased handwriting problems in subjects with FOG are unclear. This study used dynamic causal modeling of fMRI data to investigate neural network dynamics underlying freezing-related handwriting problems and how these networks changed in response to visual cues. Twenty-seven non-freezers and ten freezers performed a pre-writing task with and without visual cues in the scanner with their right hand. The results showed that freezers and non-freezers were able to recruit networks involved in cued and uncued writing in a similar fashion. Whole group analysis also revealed a trend towards altered visuomotor integration in patients with FOG. Next, we controlled for differences in disease severity between both patient groups using a sensitivity analysis. For this, a subgroup of ten non-freezers matched for disease severity was selected by an independent researcher. This analysis further exposed significantly weaker coupling in mostly left hemispheric visuo-parietal, parietal - supplementary motor area, parietal - premotor, and premotor-M1 pathways in freezers compared to non-freezers, irrespective of cues. Correlation analyses revealed that these impairments in connectivity were related to writing amplitude and quality. Taken together, these findings show that freezers have reduced involvement of the supplementary motor area in the motor network, which explains the impaired writing amplitude regulation in this group. In addition, weaker supportive premotor connectivity may have contributed to micrographia in freezers, a pattern that was independent of cueing.

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“…To this effect, many research groups have used a variety of methods and approaches to understand the pathophysiological mechanisms behind FoG. Among the most notable approaches are behavioral and clinical measures ranging from gait and posture (7)(8)(9)(10)(11)(12)(13) to upper limb biomechanics (14), jaw displacement (15), saccade latency, velocity, and gain (16), audio-spinal reflex (17), handwriting measures (18), foot pedal measures (19), speech (20), electromyography (EMG) (21,22), and even rapid eye movement frequency (23). However, to explore the physiological changes specifically related to FoG in neurological pathways and their effect on motor control, it is necessary to detect efficacious neural biomarkers that may differentiate PD from healthy controls and PD subtypes from one another.…”

Section: Introductionmentioning

confidence: 99%

Neural Correlates of Freezing of Gait in Parkinson's Disease: An Electrophysiology Mini-Review

et al. 2020

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Freezing of gait (FoG) is a disabling symptom characterized as a brief inability to step or by short steps, which occurs when initiating gait or while turning, affecting over half the population with advanced Parkinson's disease (PD). Several non-competing hypotheses have been proposed to explain the pathophysiology and mechanism behind FoG. Yet, due to the complexity of FoG and the lack of a complete understanding of its mechanism, no clear consensus has been reached on the best treatment options. Moreover, most studies that aim to explore neural biomarkers of FoG have been limited to semi-static or imagined paradigms. One of the biggest unmet needs in the field is the identification of reliable biomarkers that can be construed from real walking scenarios to guide better treatments and validate medical and therapeutic interventions. Advances in neural electrophysiology exploration, including EEG and DBS, will allow for pathophysiology research on more real-to-life scenarios for better FoG biomarker identification and validation. The major aim of this review is to highlight the most up-to-date studies that explain the mechanisms underlying FoG through electrophysiology explorations. The latest methodological approaches used in the neurophysiological study of FoG are summarized, and potential future research directions are discussed.

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Handwriting Impairments in People With Parkinson’s Disease and Freezing of Gait

Abstract: Writing is more severely affected in PD patients with FOG than in those without FOG. These results indicate that deficient movement sequencing and adaptation is a generic problem in patients with FOG.

Cited by 31 publications

References 57 publications

Validity and reliability of a new tool to evaluate handwriting difficulties in Parkinson’s disease

Validity and reliability of a new tool to evaluate handwriting difficulties in Parkinson’s disease

Altered effective connectivity contributes to micrographia in patients with Parkinson’s disease and freezing of gait

Neural Correlates of Freezing of Gait in Parkinson's Disease: An Electrophysiology Mini-Review

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