Background: Persons with Parkinsons disease (PD) typically have small handwriting, especially when writing faster and/or larger. However, visual cues can help persons with PD increase their handwriting size. This study tested if lined paper would improve handwriting in persons with PD, even when writing faster and or larger. Secondarily, we wanted determine if persons with PD perceived handwriting as stressful, and if perceived stress was associated with writing performance.

Methods: The study included 22 subjects with Parkinsons disease and 11 age-gender-matched controls. Participants completed eight trials (2 times 2 times 2) of printing a P and C, at a comfortable speed and also as fast as possible in two different sizes (1, 2 cm). The participants wrote with a ballpoint pen on lined paper. Bipolar electromyography (EMG) sensors recorded muscle activity from the index finger extensor (extensor digitorum communis (EDC)) and flexor (first dorsal interosseous (FDI)). Participants completed all of the trials for a particular pace (conditions were randomized) before completing all the trials of the other pace (order was counterbalanced).

Results: Handwriting height was smaller for persons with PD when required to write fast. There was also a trend for patients with PD to write slower and have smaller peak pen accelerations, but these were not statistically significant. Persons with PD found handwriting to be more stressful than healthy older adults did; and perceived stress negatively correlated with letter height and EMG activity.

Conclusions: Our study found that visual cues did not normalize handwriting height in persons with PD when writing large and or fast. Persons with PD find handwriting to be stressful, and stress may negatively influence their handwriting.