How to Use Pen and Paper Tasks to Aid Tremor Diagnosis in the Clinic

HOW TO DO IT Pract Neurol: first published as 10.1136/practneurol-2017-001719 on 26 August 2017. Downloaded from How to use pen and paper tasks to aid tremor diagnosis in the clinic Jane Alty,1 Jeremy Cosgrove,1 Deborah Thorpe,2,3 Peter Kempster4,5 1Department of Neurology, Leeds ABSTRACT automatically. Handwriting tasks, familiar General Infirmary, Leeds Teaching When a patient presents with tremor, it can be and straightforward as they are, prove to Hospitals NHS Trust, Leeds, UK useful to perform a few simple pen and paper 2Department of Electronics, be very useful diagnostic tools in tremor University of York, York, UK tests. In this article, we explain how to maximise disorders. Tremor has its core characteris- 3Centre for Medieval Studies, the value of handwriting and of drawing tics of frequency, amplitude, direction University of York, York, UK Archimedes spirals and straight lines as clinical 4 and task specificity and may be conjoined Department of Neurosciences, assessments. These tasks take a matter of Monash Medical Centre, Clayton, with features such as bradykinesia, seconds to complete but provide a wealth of Australia dystonia, ataxia and distractibility. The 5Department of Medicine, information that supplements the standard clinician’s challenge is to integrate all of Monash University, Clayton, physical examination. They aid the diagnosis of a this simultaneously occurring visual infor- Australia tremor disorder and can contribute to its mation during examination in order to longitudinal monitoring. Watching the patient’s Correspondence to classify a tremor. Simple pen and paper upper limb while they write and draw may reveal Dr Jane Alty, Department of tests take a matter of seconds to Neurology, Leeds General abnormalities such as bradykinesia, dystonic complete. Having observed a patient Infirmary Leeds, UK; jane.alty@ posturing and distractibility. The finished script during the process of writing and hyms.ac.uk and drawings can then be evaluated for frequency, amplitude, direction and symmetry of drawing, the form and content of the Accepted 12 July 2017 samples can be evaluated afterwards. Published Online First oscillatory pen movements and for overall scale 26 August 2017 of penmanship. Essential, dystonic, functional These records of complex dynamic motor and parkinsonian tremor each has a characteristic activity supplement the neurological pattern of abnormality on these pen and paper examination and can track the progres- tests. sion of a tremor disorder or its response to therapy. This paper explains how to maximise http://pn.bmj.com/ INTRODUCTION the usefulness of writing and drawing In his Essay on the Shaking Palsy, James tasks in a busy clinic or by the bedside. Parkinson referred to deterioration of Digitising tablets and other electronic handwriting.1 By the end of the 19th tools can evaluate the pen movements in century, writing analysis had been devel- more detail but are beyond the scope of oped as a clinical tool in neurology. this article. on September 23, 2021 by guest. Protected copyright. David Marsden cited the example of handwriting to support his hypothesis that the basal ganglia are responsible for HANDWRITING the implementation of learnt motor Cuneiform, the earliest known writing plans. Holding a felt-tipped pen in system, began before 3000 BC as picto- different ways, he showed how the char- grams impressed into clay with a pointed acter of his penmanship was conserved tool. Alphabetic writing arose in the Near irrespective of the size of the script or the East, developed by the Phoenicians and muscles used to execute it. He argued then adopted around the Mediterranean that the deeply engrained, highly repro- to form the basis of modern phonemic ducible motor planning of writing was scripts. Until the invention of printing particularly vulnerable to breakdown in presses in the 15th century, handwriting Parkinson’s disease and other extrapyra- was the only way of committing verbal midal disorders.2 information from memory to record. The To cite: Alty J, Cosgrove J, Nearly all literate adults can write natural histories of various tremors have et al Pract Neurol Thorpe D, . fluidly, having ‘over learnt’ handwriting been documented in medieval scripts 2017;17:456–463. in childhood and come to perform it (figure 1).3 4 456 Alty J, et al. Pract Neurol 2017;17:456–463. doi:10.1136/practneurol-2017-001719 HOW TO DO IT Pract Neurol: first published as 10.1136/practneurol-2017-001719 on 26 August 2017. Downloaded from Figure 1 Medieval scripts. The handwriting of a 13th-century scribe known as ‘The Tremulous Hand of Worcester’ shows features consistent with essential tremor.3 There is a fine amplitude tremor of regular frequency, no micrographia, and the letters with long vertical sections such as ‘h’ and ‘þ’ (black boxes) demonstrate an 8–2 o’clock unidirectional tremor axis. (Detail of MS. Junius 121, fol. vi recto. The Bodleian Libraries, University of Oxford). Charcot examined the scripts of patients suffering VERTICAL AND HORIZONTAL LINE DRAWINGS from paralysis agitans with a magnifying glass, and he This task complements the other two as nearly all adults carefully studied their writing posture. He noted how can hold the pen well enough with each hand for valid tremulousness was chiefly expressed in the upstrokes side-to-side comparisons. The longer, straighter pen of letters.5 Close associations between forensic writing strokes enable an estimate of tremor frequency to be analysis and neuroscience date from this period. made and are quite sensitive to tremor variability, as is Arthur Conan Doyle’s tales of Sherlock Holmes, often present in a functional tremor. which contain curious literary parallels with Charcot’s case histories, prefigure scientific methods in police HOW TO DO IT detection that include questioned document analysis. There is no right or wrong way, but we begin by ’ Holmes assertion to Dr Watson in The Adventure of asking the patient to write Mary had a little lamb ’ the Reigate Squire that a man s handwriting could with the dominant hand. Performing this once is often normally place him in the true decade of his lifespan enough, but there are circumstances in which repeti- 6 is an exaggeration, however. tion will pay dividends. Dystonic posturing of the ARCHIMEDES SPIRAL http://pn.bmj.com/ This spiral is named after the Greek polymath Archi- medes (287–212 BC), having appeared in his 225 BC essay On Spirals. The shape had actually been described a few years earlier by his friend Conon of Samos (280–220 BC), a Greek astronomer who on September 23, 2021 by guest. Protected copyright. named the star constellation Coma Berenices. The spiral’s formula r = a+b gives a constant separation distance between each turn. The Archimedes spiral has been a decorative motif since prehistory, appearing on pottery and other artefacts from the Neolithic and Bronze Ages (figure 2). Spiral shapes seen in nature (mollusc shells, plants, cyclonic weather systems, galaxies) are different, usually having logarithmic forms. The Archimedes spiral drawing captures the frequency, amplitude and direction of a tremor Figure 2 Decorative Archimedes spirals. Top: detail of spirals without the necessity of allowing for stylistic differ- on a late Bronze Age clay jug from Akrotiri, Santorini ences of handwriting. Because it demands one (Wikimedia Commons, user: Zde). Bottom left: triple spirals on the entrance stone of the prehistoric monument at Newgrange, continuous pen movement without the brief breaks Ireland (Wikimedia Commons, user: Jal74). Bottom right: the between writing words, the spiral emphasises the winding spiral of the Phaistos Disc, a clay artefact dating from abnormal movements of dystonia, hypokinesia and the second millennium BC (Wikimedia Commons, user: C tremor. messier). Alty J, et al. Pract Neurol 2017;17:456–463. doi:10.1136/practneurol-2017-001719 457 HOW TO DO IT Pract Neurol: first published as 10.1136/practneurol-2017-001719 on 26 August 2017. Downloaded from wrist and fingers may become more obvious with longer periods of writing (figure 3). Decrementing micrographia in Parkinson’s disease occasionally needs an extended writing task to manifest. Thereafter, we draw an Archimedes spiral and ask the patient to copy it, first with the dominant hand and then the non- dominant. Some clinicians prefer to demonstrate the task by tracing a spiral in the air, leaving the patient to determine the size of the drawing. Lastly, we instruct the patient to draw horizontal and vertical lines with each hand; the lines should be at least 10 cm long. Repetition of the drawing tasks may also Figure 3 Longer handwriting samples may be required. This be useful—in suspected functional tremor to look for patient had mild writer’s cramp that was only apparent with variability or in cases of subtle or episodic tremor to quick repetition of the writing task. The first two lines of writing increase the chance of recording it. If nothing is were executed reasonably normally but there was progressive flexor posturing of the wrist and an obvious deterioration in the visible, it may help to ask the patient to lift their hand quality of the letter formations by the third and fourth lines. off the paper while performing each task. This tends to amplify a tremor and any associated posturing. Each tremor condition has a distinctive pattern with will only be visible in one. Variability between the writing and drawing. Often these aberrations are seen tasks may itself be diagnostically useful.

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