An Exploratory Randomised Trial of a Self-Managed Home-Based Exaggerated Spatial Cueing Intervention for Handwriting in Parkinson’s Disease

Handwriting impairment is a cardinal symptom of Parkinson’s. However, treatment options are limited. Here we evaluate the utility and estimate effects of a novel low-resource handwriting intervention (Clinicaltrials. gov NCT03369587). Forty-eight people with Parkinsons with self-reported handwriting problems were recruited to an exploratory, assessor-blind two-arm parallel randomized trial to either diverging (n = 24, n = 19 analysed) or parallel (n = 24, n = 20 analysed) groups. Both received a six-week, five times a week, handwriting program: writing a daily diary on lined paper (diverging: 10 mm increasing to 13 mm apart, parallel: 10 mm apart). Outcomes were measures of impairment (cursive ‘el’, single and dual-task), handwriting function (sentence and free writing) and self-reported difficulties. Median diary entries (31, IRQ: 17.5–39) were greater than requested (30) with no differences between groups, p = 0.302. No adverse events were reported. Regardless of group, improvements were found in writing ‘el’ speed (single task: d = −0.90, 95% CI: −1.41: −0.38, p = 0.001; dual task: d = −0.72, 95% CI: −1.24: −0.21, p = 0.09) and amplitude (single task: d = 1.07, 95% CI: 0.49: 1.66, p < 0.001; dual task: d = 0.86, 95% CI: 0.35: 1.37, p = 0.002). Sentence amplitude (d = 0.80, 95% CI: 0.30: 1.29, p = 0.003) and perceived difficulties also improved (OR = −3.6, 95% CI: −12.6: −1.0, p = 0.047). Between-group effects were small (d = 0.11 to 0.48). Large improvements to handwriting, which required less attention, were found after self-directed well-adhered-to practice. Potential additional benefits of exaggerated cueing were small.