HANDWRITING IN HEALTHY PEOPLE AGED 65 YEARS AND OVER NADEGE VAN DREMPT BHSc (OT Hons) SID: 307238717 Supervisor: Dr Annie McCluskey Associate Supervisor: Dr Natasha Lannin Thesis submitted in fulfillment of the requirements for the degree of Master of Applied Science Faculty of Health Sciences The University of Sydney, Australia March, 2010 ii Student Certification I, Nadege van Drempt, hereby declare that this submission is my own work and that it contains no material previously published or written by another person except where acknowledged in the text. Nor does it contain material which has been accepted for the award of another degree. In addition, ethical approval from the University of Sydney Human Research Ethics Committee was granted for the study presented in this thesis. Subjects were required to read a Participant Information Statement and informed consent was gained prior to data collection. Name: Nadege van Drempt Signed ……………………………………………………… Date …………………….. Student Certification iii Table of Contents Title Page…………………………………………………………………………………… i Student Certification……………………………………………………………………… ii Table of Contents…………………………………………………………………………iii List of Tables……………………………………………………………………………..vii List of Figures…………………………………………………………………………....viii List of Appendices………………………………………………………………………...ix Abstract…………………………………………………………………………………….x Presentations…………………………………………………………………………….... xi Acknowledgements……………………………………………………………………….xii Chapter One...……………………………………………………………………………... 1 1.1 Background to Adult Handwriting…………………………………………………. 1 1.2 Aim of the Study…………………………………………………………………….4 1.3 Significance of the Study…………………………………………………………… 4 1.4 Scope of the Study………………………………………………………………….. 4 1.5 Key Terms………………………………………………………………………….. 5 1.6 Synopsis and Overview of the Thesis……………………………………………….6 Chapter Two: Literature Review………………………………………………………… 7 2.1 Introduction……………………………………………………………………….....7 2.2 Search Strategies……………………………………………………………………. 8 2.3 Handwriting Parameters……………………………………………………………..9 Legibility…………………………………………………………………………… 9 Pressure……………………………………………………………………………. 13 Handwriting Style…………………………………………………………………. 15 Table of Contents iv Error Correction…………………………………………………………………… 16 2.4 Motor Control……………………………………………………………………... 18 Pen Grip…………………………………………………………………………… 18 In-Hand Manipulation…………………………………………………………….. 22 Speed……………………………………………………………………………….23 Handwriting Fluency……………………………………………………………… 28 Handwriting Movements………………………………………………………….. 28 Posture…………………………………………………………………………….. 32 2.5 Sensorimotor, Perceptual and Cognitive Processes Involved in Handwriting……. 35 Kinesthesia…………………………………………………………………………35 Visual Perception………………………………………………………………….. 36 Visual-Motor Integration………………………………………………………….. 37 Motor Planning……………………………………………………………………. 38 2.6 Handwriting Activities and Personal Factors……………………………………... 41 Modes of Handwriting…………………………………………………………….. 41 Reasons for Handwriting………………………………………………………….. 42 Length and Frequency of Handwriting Occasions…………………………………43 Characteristics of the Writing Implement………………………………………… 43 Use of Technology…………………………………………………………………45 Age…………………………………………………………………………………47 Hand Preference……………………………………………………………………49 Socio-Economic Status……………………………………………………………. 51 Gender……………………………………………………………………………...53 2.7 Handwriting Assessments………………………………………………………… 55 2.8 Handwriting Retraining…………………………………………………………… 59 Table of Contents v 2.9 Methods for Collecting Handwriting Data………………………………………... 66 Digital Pen………………………………………………………………………… 66 Direct Observation………………………………………………………………… 67 Self-Monitoring…………………………………………………………………… 68 Surveys and Interviews……………………………………………………………. 70 Rationale for Selected Methods…………………………………………………… 70 2.10 Statement of the Problem…………………………………………………………..71 2.11 Study Aims…………………………………………………………………………74 2.12 Synopsis…………………………………………………………………………… 74 Chapter Three: Methods…………………………………………………………………75 3.1 Introduction………………………………………………………………………...75 3.2 Sampling and Recruitment…………………………………………………………75 3.3 Instrument Development and Pilot Testing……………………………………….. 76 3.4 Data Collection Procedures……………………………………………………….. 78 3.5 Measurement Procedures………………………………………………………….. 80 3.6 Data Analysis……………………………………………………………………… 88 3.7 Synopsis…………………………………………………………………………… 89 Chapter Four: Results…………………………………………………………………… 90 4.1 Introduction………………………………………………………………………...90 4.2 Participant Demographics………………………………………………………….90 4.3 Use and Non-Use of the Pen………………………………………………………. 92 4.4 Parameters of Adult Handwriting…………………………………………………. 93 4.5 Motor Control……………………………………………………………..…….....99 4.6 Handwriting Activities and Personal Factors……………………………..…….....99 4.7 Questionnaire Results……………………………………………………………. 103 Table of Contents vi 4.8 Synopsis………………………………………………………………………….. 104 Chapter Five: Discussion………………………………………………………………. 106 5.1 Introduction……………………………………………………………………….106 5.2 The Sample………………………………………………………………………. 106 5.3 Variability of Adult Handwriting…………………………………………………108 5.4 Measuring Legibility……………………………………………………………...109 5.5 Mixed Script and Error Corrections did not Negatively Affect Legibility………. 111 5.6 Handwriting Was Infrequent and Sample Lengths Were Short…………………..112 5.7 Handwriting and Other Demands…………………………………………………113 5.8 Reasons for Handwriting………………………………………………………… 114 5.9 Self-Generated Text was More Common Than Copied Text……………………. 115 5.10 Other Findings…………………………………………………………………… 116 5.11 Study Limitations…………………………………………………………………117 5.12 Implications for Practice…………………………………………………………. 119 5.13 Implications for Education………………………………………………………..120 5.14 Implications for Future Research…………………………………………………122 5.15 Conclusion……………………………………………………………………….. 124 References………………………………………………………………………………..126 Appendices……………………………………………………………………………… 140 Table of Contents vii List of Tables Table 2.1 A Four Point Legibility Scale With Handwriting Samples……………….. 11 Table 2.2 Mean Handwriting Speed (Letters Written per Minute) in Previous Studies, Modified From Feder and Majnemer (2007)………….…………. 26 Table 2.3 Normative Data on Handwriting Speed in Adults Using a Sub-Test From the Jebsen-Taylor Hand Function Test……………………...…………….. 27 Table 2.4 Upper Limb Movements Used in Picking up and Using a Pen or Pencil…. 30 Table 2.5 Examples of Modes of Handwriting………………………………………. 42 Table 2.6 Summary of Clinical Trials Evaluating the Effectiveness of Interventions to Improve Children‟s Handwriting……………………………………….. 62 Table 3.1 The Modified Four Point Legibility Scale Adapted From Rodriguez-Vera and Colleagues……………....…………………………………………….. 84 Table 4.1 Demographic Characteristics of Participants (N =30)…………………….. 91 Table 4.2 Components of Handwriting Legibility…………...………………….…… 95 Table 4.3 Legibility of MMSE (N = 30) and Envelope (N = 30) Samples as Rated Using the Four Point Legibility Scale……………………………………...96 Table 4.4 Regression Analysis of Legibility of the MMSE samples (N = 30)………. 97 Table 4.5 Mean Error Corrections (SD) in the Writing Samples of Older Adults (N = 30) With and Without Puzzles…………………………………..…..99 Table 4.6 Handwriting Activities Completed Over Three Consecutive Days by Participants Aged 65 Years and Over (N = 30)………………..….……....101 Table 4.7 Roles Fulfilled by Participants Aged 65 Years and Over While Handwriting (N = 30)……………..………………………………..……..102 List of Tables viii List of Figures Figure 2.1 Common Pen Grips………………………………………………………... 19 Figure 2.2 (A) Habitual and (B) modified grip as described by Baur et al. (2006)…... 31 Figure 2.3 Pegasus NoteTaker Digital Pen and Memory Unit………………………... 67 Figure 3.1 Pegasus NoteTaker Memory Unit Clipped Onto Paper (A) and (B) Displaying Recorded Text………………………………………………….79 Figure 3.2 Measurement of Between-Word Spacing, Slant and Baseline Angle……...81 Figure 3.3 Measurement of Letter Width and Height………………………………… 82 Figure 3.4 Example of „Cursive Script Only‟………………………………………… 84 Figure 3.5 Example of „Printing Only‟…..…………………………………………….85 Figure 3.6 Example of „Mixed Style‟…….……………………………………………85 Figure 4.1 Copybook Handwriting (Melbourne Education Department, 1910)……… 93 Figures 4.2a and 4.2b Excerpts From Participants‟ Handwriting Samples……………... 93 Figure 4.3 Communication Modes and Technology Used by Participants (N = 30) in the Previous Three Days………………………………………………. 104 List of Figures ix List of Appendices Appendix A HAB Data Collection Form………………………………………………140 Appendix B Handwriting Log…………………………………………………….….... 151 Appendix C Participation Information Statement…………………………..…………. 153 Appendix D Consent Form…………………………………………………………….. 156 Appendix E Handwriting Questionnaire…………………………………………....…. 157 Appendix F Envelope Address Copying Task.………………………………………... 161 Appendix G The Role Checklist…….………………………………………………….162 List of Appendices x Abstract Background: Handwriting is an important activity which is commonly affected after a stroke. Handwriting research has predominantly involved children. In adults, the focus of handwriting research has been identifying forgery, doctors‟ handwriting legibility and the kinematics of writing strokes. There are no known studies which provide information on unimpaired adult handwriting in real situations to guide stroke rehabilitation therapists. Aim: This study aims to describe the handwriting practices of 30 unimpaired adults aged 65 years and over to inform adult handwriting rehabilitation. Methods: This study used a cross-sectional observational design. Three data collection methods were used: self-report questionnaire, handwriting