J Neurol (2013) 260:23572361

DOI 10.1007/s00415-013-6996-x

ORIGINAL COMMUNICATION

Handwriting as an objective tool for Parkinsons disease diagnosis

Sara Rosenblum Margalit Samuel
Sharon Zlotnik Ilana Erikh Ilana Schlesinger

Received: 5 May 2013 / Revised: 3 June 2013 / Accepted: 4 June 2013 / Published online: 16 June 2013
Springer-Verlag Berlin Heidelberg 2013

Abstract To date, clinical assessment remains the gold

standard in the diagnosis of Parkinsons disease (PD). We
sought to identify simple characteristics of handwriting
which could accurately differentiate PD patients from
healthy controls. Twenty PD patients and 20 matched
controls wrote their name and copied an address on a paper
affixed to a digitizer. Mean pressure and mean velocity was
measured for the entire task and the spatial and temporal
characteristics were measured for each stroke. Results of
the MANOVAs for the temporal, spatial, and pressure
measures (stroke length, width, and height; mean pressure;
mean time per stroke; mean velocity), for both the name
writing and address copying tasks, showed significant
group effects (F(6,32) = 6.72, p \ 0.001; F(6,31) =
14.77, p \ 0.001, respectively). A discriminant analysis
was performed for the two tasks. One discriminant function
was found for the group classification of all participants
(Wilks Lambda = 0.305, p \ 0.001). Based on this
function, 97.5 % of participants were correctly classified
(100 % of the controls and 95 % of PD patients). A Kappa

The statistical analysis was performed by Sara Rosenblum from the

Department of Occupational Therapy, Faculty of Social Welfare and
Health Sciences University of Haifa, Israel.
S. Rosenblum (&)
Department of Occupational Therapy, Faculty of Social Welfare
and Health Sciences, University of Haifa, 31905 Haifa, Israel
e-mail: rosens@research.haifa.ac.il
M. Samuel  S. Zlotnik
Department of Occupational Therapy, Rambam Health Care
Campus, Haifa, Israel
I. Erikh  I. Schlesinger
Department of Neurology, Technion Faculty of Medicine,
Rambam Health Care Campus, Haifa, Israel

value of 0.947 (p \ 0.001) was calculated, demonstrating

that the group classification did not occur by chance. In this
pilot study we identified two simple short and routine
writing tasks which differentiate PD patients from healthy
controls. These writing tasks have future potential as costeffective, fast and reliable biomarkers for PD.
Keywords Parkinsons disease  Biomarker  Non-motor 
Handwriting  Diagnosis  Digitizer

Introduction
To date, clinical assessment remains the gold standard in
the diagnosis of Parkinsons disease (PD). In recent years,
an effort has been made to identify an objective biomarker
by organized initiatives such as the Parkinson Progression
Marker Initiative (PPMI) [1] and the Longitudinal and
Biomarker Study-Parkinsons disease [2] using varied
approaches including examination of blood, saliva, exhaled
breath [3], cerebrospinal fluid and neuroimaging. Finding a
biomarker is important not only for the diagnosis and follow-up of disease progression but also for testing of
potential neuroprotective interventions with the hope of
screening and preventing this disease [4, 5]. In striving for
a tool that will objectively diagnose PD, the US Food and
Drug Administration (FDA) recently approved the dopamine transporter (DAT) ligand [(123)I] ioflupane, with
single-photon emission computed tomography (SPECT,
DaTscan) for evaluating parkinsonian syndromes and for
distinguishing Parkinsons disease from essential tremor.
However, this testing modality exposes patients to radioactive material and does not distinguish Parkinsons disease from multiple system atrophy or corticobasal
degeneration [6].

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J Neurol (2013) 260:23572361

Handwriting is one of the most common daily activities

performed by adults in a variety of leisure and professional
settings. Handwriting is a complex human activity, which
requires fine dexterity abilities and involves an intricate
blend of cognitive, sensory and perceptual-motor components [7]. Therefore it is not surprising that abnormal
handwriting, is a well recognized manifestation of PD, with
micrographia being characteristic [8]. It may appear years
before the clinical diagnosis is made and thus may be one
of the first signs of impending disease, enabling neuroprotective interventions when identified. Previous research
has shown that handwriting measures have the potential for
identifying various stages of PD, effects of varied interventions [9] and the effect of medication [10]. Studies
focusing on understanding the mechanism underlying micrographia found significant differences between the
handwriting of PD patients and healthy subjects [1114].
In this pilot study we sought to identify simple characteristics of handwriting kinematics which could accurately
differentiate PD patients from healthy controls so that they
may potentially be used as a diagnostic and screening tool
for incipient disease.

The study was approved by the institutional review

board. All subjects signed a written informed consent.
Methods

Subjects and methods

Writing tasks were performed on A4-size lined paper

affixed to the surface of an Intuos II WACOM (404 X 306
X 10 mm) X and Y digitizing tablet, using a wireless
electronic pen with a pressure-sensitive tip (Model GP110). Displacement, pressure, and pen-tip angle were
sampled at 100 Hz via a 1,300 MHz Pentium (R) M laptop
computer. A computerized handwriting evaluation (ComPET, a revised version of the Penmanship Objective
Evaluation tool) [18], was used to administer the stimuli
and to collect and analyze the data. The tool includes two
main functions: (1) data collection, which is languageindependent and easy to use for any handwriting tasks, and
(2) data analysis, which is programmed via MATLAB
software toolkits. The computerized system enables the
collection of spatial, temporal, and pressure data for the
entire task, as well as for each stroke, while the subject is
writing.
Participants were requested to write their name and to
copy an address (same address for all). Patients performed
the study in the on state.

Subjects

Outcome Measures

Forty subjects, 20 PD and 20 controls (aged 3881), with at

least 12 years of education (mean 13.37 SD 2.93) were
included in the study. PD patients, diagnosed according to
the UK Brain Bank criteria [15], Hoehn and Yahr [16]
stages II-III, mini-mental state exam (MMSE) scores of
[17] 30, were randomly selected from those attending the
Movement Disorder Clinic at Rambam Health Care Campus in Haifa, Israel. The control group comprised of
healthy subjects matched for gender, age (mean age of
controls, 61.66 10.00; PD 61.18 9.11), years of education, and hand dominance. For further details see
Table 1.

Handwriting performance of written outputs were varied in

their length among participants (as in writing ones full
name). Thus, we compared the measures of strokes and not
those of the entire task. A stroke was defined as a continuous
line written by the subject. A stroke can be one of two types:
on-paper stroke, which is a stroke, written on the paper, or
in-air stroke, which is a stroke that the pen creates when it
does not touch the paper, i.e. between on-paper strokes.
The primary outcome measures included temporal, spatial,
and pressure measures of handwriting kinematics. Temporal
measures included the mean time taken to write each stroke,
the mean on-paper stroke time, the mean in-air stroke
time, and the mean velocity for the entire task in seconds.
The spatial measures included the mean strokes path
length, width, and height in centimeters. The pressure
measure was the mean pressure applied to the writing surface in non-scaled units from 0 to 1,024 for the entire task.
All analyses were done by one of the authors (S.R.) who was
blinded to subject diagnosis (healthy vs. PD).

Table 1 Demographic and clinical characteristics of the study

participants
Characteristic

Controls (n = 20)

PD (n = 20)

p value

Age, mean, years

61.66 10.00

61.18 9.11

NS

Female sex, no. (%)

Years of education

11 (55)
13.78 1.65

11 (55)
12.80 1.70

NS
NS

MMSE

30 0

29.88 0.33

NS

Hoehn and Yahr

2 0.79

UPDRS

25.05 14.04

Disease duration

8.05 3.90

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Statistical analysis
MANOVA analyses were used to test for group differences
(controls vs. PD) across the computerized spatial, temporal
and pressure measures for each of the two writing tasks

J Neurol (2013) 260:23572361

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(e.g., writing ones full name and address copying). In

order to examine the source of any significance, the data
from each task were subjected to univariate ANOVAs.
T-tests were used for analyzing the group differences in
two components of the mean stroke duration: stroke
duration on paper and in air. Finally, discriminant analysis
was conducted in order to determine which of the computerized measures best predicted group membership (i.e.,
control vs. PD) for each of the tasks
Wilks Lambda 0:601F6;74 8:20; p\0:0001 g2 0:399:

Results
Results of the MANOVAs for both the name writing
(F(6,32) = 6.72, Wilks Lambda = 0.442 p \ 0.001
g2 = 0.558) and address copying tasks (F(6,31) = 14.77,
Wilks Lambda = 0.259 p \ 0.001 g2 = 0.741), showed
significant group effects. The univariate ANOVAs indicated significant differences between the groups for several
measures of the name writing task and for all measures of
the address copying task. The means and standard deviations are presented in Table 2.
In order to further analyze the mean stroke duration,
t-tests were conducted for the mean stroke duration on
paper and in air for the address copying task. Mean
stroke duration on paper (controls 0.19 0.02 s vs. PD
0.27 0.10 s p = 0.001) and in air (controls
0.21 0.06 s vs. PD 0.38 0.15 s p \ 0.001) were significantly different between controls and PD patients.
For both tasks, compared with controls, PD participants
wrote significantly smaller letters, applying significantly
less pressure on the writing surface, and requiring significantly more performance time. The gap in the stroke
duration in air was more dramatic than the gap in the
Table 2 Kinematic measures
for writing tasks

Measures

stroke on paper. For both groups, the stroke size

decreases as the task requirements increased, as shown in
Table 2.
In order to assess the relative importance of the different variables in differentiating between PD and control
participants, a discriminant analysis was performed for the
two tasks. One discriminant function was found for the
group classification of all participants (Wilks Lambda
(= 0.305, p \ 0.001). As shown in Table 3, the variables
which made the greatest contribution to group membership were the mean width, duration and height in both
tasks. Based on this function, 97.5 % of participants were
correctly classified (100 % of the controls and 95 % of
PD patients). A Kappa value of 0.947 (p \ 0.001) was
calculated, demonstrating that the group classification did
not occur by chance. Thus, taken together these two
handwriting tasks had 95 % sensitivity and 100 %
specificity.

Discussion
Using two simple short and routine writing tasks, PD
patients could be distinguished from healthy controls with
very high accuracy. None of the controls were categorized
as suffering from PD while one of the PD patients was
incorrectly categorized as being healthy. Thus, taken
together these two handwriting tasks had 95 % sensitivity
and 100 % specificity. Handwriting was chosen as a possible biomarker for PD based on previous reports of micrographia appearing many years before the diagnosis of
PD [19]. It is a noninvasive method that is easily performed. Hence, the sensitivity and specificity for the distinction of PD patients from healthy controls could allow a
quick and simple initial diagnosis in a non-specialist

Writing ones full name

Copying an address

Healthy mean
(SD)

Healthy mean
(SD)

PD mean (SD)

PD mean (SD)

Spatial measures
Stroke length (cm)

0.96 (0.40)

0.60 (0.34)*

0.75 (0.14)

0.53 (0.16)**0

Stroke width (cm)

0.32 (0.11)

0.18 (0.07)**

0.23 (0.04)

0.17 (0.04)**0

Stroke height (cm)

0.47 (0.16)

0.36 (0.25)

0.35 (0.07)

0.27 (0.07)**0

Stroke duration (sec)

0.16 (0.04)

0.21 (0.09)

0.20 (0.04)

0.32 (0.12)**

Velocity (cm/sec)

5.18 (1.26)

3.10 (1.30)**

4.86 (0.96)

2.67 (0.91)**

783.55 (149.04)

591.77 (160.98)**

788.61 (146.59)

603.29 (164.08)**

Temporal measures

Pressure measures
Pressure
(Non-scaled units
01,024)

* p \ 0.05, ** p \ 0.01

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Table 3 Discriminant analysis structure matrix predictors loading

values
Measure
Writing ones full name

Stroke width on paper

Loading
0.496

Copying an address

Stroke duration in air

Copying an address

Stroke width on paper

-0.477
0.422

Copying an address

Stroke height in air

0.392

Copying an address

Stroke duration on paper

-0.389

Writing ones full name

Stroke duration in air

-0.219

Writing ones full name

Copying an address

Stoke height in air

Stroke duration on paper

0.183
-0.143

setting. Hence, the writing task could be applied by general

practitioners to ensure the speedy referral of new PD
patients to the specialists, who would confirm the diagnosis
and choose an adequate therapeutic approach.
Our study was designed to examine the possibility of
handwriting as a biomarker for PD, but in doing so also
shed light on the ability of PD patients to perform this task.
We found that it is importance to analyze handwriting not
only on paper but also in air, as significant differences
were observed between these two conditions, more so for
the address copying task. In fact, in-air time is a manifestation of planning the next movement, as required in
the sequential process of handwriting [14] and thus reflects
cognitive ability, as shown in our previous studies [20, 21],
and supplies important information about the writer [22].
Hence, the current study results indicate a motor planning
deficit among PD patients, even in a very short functional
common task such as copying an address. Our findings
further support previous observations that in comparison
with controls, patients with PD exhibit more variable peak
accelerations and stroke sizes and smaller than normal
handwriting, a phenomenon known as micrographia [8, 11
14, 23].
Less pressure was applied on the writing surface by the
PD group for both the name and address writing tasks. This
may be an indication of a deficit in force modulation as seen
in the speech of PD patients, expressed as hypophonia [24].
In this pilot study we identified two simple, short and
routine writing tasks which differentiate PD patients from
healthy controls. If our findings are corroborated in larger
studies, these writing tasks have future potential as costeffective, fast and reliable biomarkers for PD, and handwriting, an everyday non-threatening activity, could be
assessed as a possible marker of preclinical PD in at-risk
populations.
Conflicts of interest

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The authors declare no disclosures.

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