Parkinson's and micrographia; 5 questions and answers

Micrographia, or small handwriting, is a common and annoying symptom of Parkinson’s disease. We frequently get asked about this issue and about what can be done to improve it. We sat down with Saba Shahid who has given this topic a great deal of thought and has begun to develop some notion as to how to approach the issue.

Who is Saba Shahid, M.S?

She is the Chief Smiling Officer of Creative Neurology. She is also the author and creator of the Let’s Combat Micrographia® Books and Workshop series. 

Saba was instrumental in developing Let’s Combat Micrographia® in 2014 after seeing a need to educate the public, professionals, and most importantly provide a resource to those living with Parkinson’s disease. Creative Neurology®, formerly known as The Art Cart, is the only organization in the world that provides research-based programming to those living with micrographia. The Let’s Combat Micrographia® resources and workshop series her group has developed is listed by the National Library of Medicine.

1.    What is micrographia?

Micrographia is small, slanted, illegible handwriting. It is frequently a symptom of Parkinson’s disease. Micrographia is a prodromal symptom, meaning it can occur early and maybe even before someone’s diagnosis. However, many people learn about their change in handwriting laterin their disease progression. Micrographia comes in varying forms. Below is an example of what small, slanted illegible handwriting looks like and how it can be improved overtime with practice.

People’s handwriting may also get progressively smaller the longer they attempt to write.

2.    Can micrographia be reversed?

There are ways to improve the small, slanted, illegible handwriting and make it larger and more legible. Improving handwriting requires discipline and focus— much like the same type of discipline needed when starting a new exercise routine.

Let’s imagine getting back into an exercise routine. The first time you go to the gym and get on that treadmill— you feel the burn instantly. As each week goes by, your cardiovascular endurance builds, you feel stronger and are able to push yourself more. The week you decide to stop exercising to take a few weeks off, you will notice a decline in your endurance. Improving micrographia is similar to this experience. The more you practice, the more you write, the easier it will be. However, if you stop writing you will notice your handwriting may start to get smaller again.

I can share my experience in trying to address micrographia though notably this is not the only approach. In our Let’s Combat Micrographia® Workshops, our primary goal is to motivate people with Parkinson’s disease to start being open and engaging in the writing process again. We can sometimes see a change in our patient’s handwriting in as little as 3-6 weeks. This occurs through patience, steady progress, and lots of deliberate practice. Handwriting that was once small, slanted, and illegible can in many cases be larger and readable again. A recent Let’s Combat Micrographia® participant stated, “My dad said my writing on the envelope and his birthday card were noticeably better and more like “normal” writing! I was so pleased.”

3.    What can I do to start improving my

handwriting?

We don’t have all the answers, but we do recommend to our participants to write during their “ON” dopaminergic periods— most commonly this is 30-45 minutes after taking Parkinson’s medication. You have an advantage during your “ON” periods as your motor and non-motor symptoms are less apparent. which may possibly enable you to write with less frustration.

We believe that the first step to improving your handwriting is accepting that your handwriting has changed and being receptive to the process of re-training yourself to write again with the goal of improving your handwriting. Our approach has been to use the Let’s Combat Micrographia® Second Edition Workbook. Again, this is not the only approach to micrographia but in our approach we start with introducing concepts to help you to re-train your mind and body to start working together— then it takes you through physical hand exercises to regain strength. After that step comes the writing exercises for you to start feeling confident in the writing process again. Start simple, be patient with yourself, and do not expect yourself to be writing long sentences right away.

The ability to be able to write again will require hand strength. Start off by doing a few stretches with your hands every day to allow you to get the blood flowing. Something as simple as opening and closing your fingers or creating a fist and squeezing your hands 10 times for 20-30 seconds may help. Overtime, your hands will regain strength and you will feel more comfortable holding your writing instrument— and the added hand strength may help you in other areas of your life too. Here is quote from a recent Let’s Combat Micrographia® graduate- “The Let’s Combat Micrographia® workshop series not only improve my handwriting, but due to the strength I gained in my hands I am now able to start playing piano again!” .

4.    What are some tools to help with

micrographia?

Writing aids, such as a pen or pencil grip, are helpful as they help provide additional surface area. Increased surface area provides stability and added space to hold a skinny pen or pencil with more comfort and confidence. Heavy weighted pens have been shown in some studies to be beneficial for people who have hand tremor— the weight of the pen provides stability. There are also weighted gloves that can be worn to decrease the shakiness and provide additional control. The benefits of using these tools may vary from person to person— we have found that each individual is different and may respond to different approaches.

5.    We live in a technologically advanced world,

what are the benefits of handwriting?

·      Stimulates the Brain:  Handwriting is a rich mind-body experience that helps stimulate the brain. When writing you are working on creating letters, joining those letters to other letters, then creating words, and ultimately forming sentences. This requires brain power.

·      Develops Fine Motor Skills:  Handwriting exercises a complex cognitive process involving neuro-sensory experiences and fine motor skills. The ability to hold a tiny pen or pencil requires strength and coordination. Continuing to write as well as to perform hand stretches may help develop fine motor skills.

·      Increases Focus:  Writing increases focus because we are forced to slow down, think about forming letters into words, and then into sentences. Our brain is working extra hard to string all the pieces together.

·      Helps Improve Memory:  Handwriting may in some cases improve a person’s memory for new information as the act of writing requires more focus and allows you to visualize what is in front of you. In our Let’s Combat Micrographia® Workshops, we often take a walk down memory lane and write about our favorite past experiences.

·      Encourages Creativity:  Writing can lead to “journaling” which can then lead to doodling and more practice. Anytime you use a writing instrument you’re allowing your creative brain to come to life! Looking for an easy writing activity to get involved in? Look no further as you can enter into our Let’s Combat Micrographia® Writing Competition where you be encouraged to select a list of words and create a short story.

There are also more papers and research on micrographia in Parkinson’s disease and we recommend the following articles:

Aparna Shukla at the University of Florida wrote extensively on the topic and subtypes of micrographia and Parkinson’s disease.

Mathew Thomas also published a nice recent review article on micrographia and Parkinson’s disease.

To read more books and articles by Michael S. Okun MD check Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #Livingwith Parkinson’s #EndingPD #Parkinsonsecrets #LessonsFromTheBedside

He also serves as the Medical Advisor for the Parkinson’s Foundation.

To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance.