The first sign many carers notice is not tremor. It is that when writing a letter, a cheque or a signature, the handwriting gets smaller and smaller, and by the last few words it is too small to read. This is called micrographia. It is a very characteristic sign of Parkinson's disease, and it is most often put down to "long sight with age" or plain "tremor". From the occupational therapy (OT) point of view of keeping daily self-care function, this article concentrates on fine hand writing tasks. It explains why writing shrinks, the most practical visual cues, training methods that can be done at home, reasonable expectations, and how to work around handwriting to keep a signature and deal with important documents when training is not enough. Whole-body large-amplitude training (LSVT BIG) for walking, turning and balance belongs to physiotherapy, and is only mentioned briefly here.
What is micrographia?
Micrographia means handwriting that is unusually small when the pen is put down, and often gets smaller as it goes along. Comparing the start and the end of a line, the later writing shrinks clearly. The condition has long been recorded in medicine. A foundational study (McLennan et al., 1972) described it in detail, pointing out that it can appear separatelyfrom tremor and stiffness, and that about 5% of patients had micrographia as their very first early sign. The same study also first put forward the idea that "parallel lines help to keep the size of the writing", which is still in use today.
What causes micrographia
To treat the right thing, the underlying mechanism has to be clear. The root of micrographia is the slowness of movement (bradykinesia) and reduced movement size (hypometria)caused by Parkinson's disease. The internal system in the brain that "calibrates how big a movement is" is disturbed, so the size of each stroke narrows step by step as the pen goes down. Once this is understood, the problem is no longer mistaken for the situations below.
| Not an eyesight problem | The patient can usually see what has been written clearly. It is the hands that cannot be controlled to write at a normal size. Reading glasses therefore do not solve the problem. |
| Not just tremor | Tremor makes the writing shaky, while micrographia makes the letters small. The two have different causes and can appear separately (McLennan et al., 1972). |
| Not a matter of will or laziness | The letters get smaller because the system in the brain that controls the size of movement has failed, and not because the patient is careless or not trying. Even if the patient tries hard, it is hard to write bigger by willpower alone. |
| A reduction in movement size | Slowness of movement together with reduced movement size (hypometria) makes each stroke smaller and smaller. The right way to improve it is therefore to give an "external cue" and combine it with the patient "deliberately writing bigger". |
Key idea: Micrographia happens because the brain cannot control the size of the movement accurately, and it does not mean the hands cannot write. The most effective approach is therefore to give a clear signal or target in the surroundings, to help the brain recalibrate the size of the movement. The visual cues described below use exactly this principle.
Using a parallel line to enlarge the writing
Among the many interventions, visual cues are the easiest to use and work the fastest. The method is very simple: add a parallel horizontal line to a sheet of plain paper and have the patient write along the line. A pilot study (Bryant et al., 2010, 11 male patients) found that with this parallel line, the patient's writing length rose significantly from about 17.8 cm to 23.4 cm (P=0.008). As explained above, the principle is to use an external reference line to help the brain get past the barrier of slowness of movement and bring the size of the writing movement back towards normal straight away.
An earlier mechanism study (Oliveira et al., 1997) also showed that both visual cues (dots marked on the paper to show how large the letters should be) and auditory or spoken cues(another person reminding "write bigger") immediately brought the size of writing back to a more normal state, and that the effect lasted for a short time after the cue was taken away. This shows well the role of "external cues", but the same study also revealed a trade-off that has to be faced, which is discussed below.
Key points of research on a horizontal-line visual cue
- Method: use ordinary lined paper, or draw one parallel horizontal line on plain paper, and have the patient write along the line.
- Result: the length of the written line increased from about 17.8 cm to about 23.4 cm (P=0.008, Bryant et al., 2010).
- Principle: the reference line on the paper helps the brain get past slowness of movement and adjust the size of each stroke straight away (Oliveira et al., 1997).
- Limit: this is a small, short-term pilot study. To keep the effect over the long term, practice has to continue (see the section on transfer below).
Grid lines compared with a single horizontal line
Since one horizontal line already helps, would adding vertical lines to make a grid work even better? Many people do buy grid notebooks on purpose to practise writing, but the research evidence does not support this instinct. Bryant et al. (2010) also tested the "grid (horizontal plus vertical lines)" in their study, and the result showed that adding vertical lines to make a grid brought no extra benefit compared with a single parallel horizontal line.
There is no need to buy a grid notebook.What really helps is the "horizontal line" that the patient writes along. Adding vertical lines to make a grid gives no extra help in lengthening the written line (Bryant et al., 2010). An ordinary lined notebook is already effective and economical.
Writing training that can be done at home
A visual cue is like an "instant walking stick", and regular training is the "long-term work". Besides drawing a horizontal line on the paper, the training points below are commonly used by occupational therapists and suit starting at home. These are general training principles only, and the actual amount and progress of training are still best set by an occupational therapist for each individual.
- Use lined paper as a visual cue—A single parallel horizontal line already gives an effective visual cue and clearly enlarges the writing, with no need to buy a grid notebook on purpose (Bryant et al., 2010).
- Build an awareness of "writing big"—When writing, deliberately write each character bigger than usual, to counter the tendency to get smaller. Combining an external cue with a deliberate intention to write big makes the effect steadier.
- A thick or weighted pen, and a slower pace—A thicker pen barrel or a pen grip means the hand does not need to grip the pen so hard, and a slower writing speed helps the patient to keep a steady size of movement.
- Writing amplitude feedback training—Technology that gives instant feedback (for example showing straight away whether the writing is big enough) helps the patient adjust the size of each stroke. This is another cue-based training method (Nackaerts et al., 2017).
- Build in real tasks—The practice material can move from short sentences and shopping lists gradually to items really used in daily life, such as a signature, so that the benefit of writing large carries over into daily life.
Does the benefit "transfer" to words that were not practised? RCT evidence on intensive amplitude training
The question carers ask most often is whether, after practice, the benefit stays limited to the few words that were practised again and again, with other words still written as before. This is what rehabilitation calls the problem of "transfer". A placebo-controlled randomised controlled trial (Nackaerts et al., 2016, 38 patients) gave a direct answer.
This RCT confirmed that, provided the training is intensive enough and kept up, intensive amplitude writing training can make the movement of enlarging the writing automatic, transfer the benefit to words that had not been practised, and keep it for a while. A later brain imaging study (Nackaerts et al., 2018) went further and found that this kind of intensive writing training changes neural connectivity in the brain (strengthening the coupling from the left-hemisphere visuomotor pathway to the supplementary motor area), and that the training benefit could be seen both with and without an immediate cue, and was still there after the cue was removed. This confirms at the level of neural mechanism that the benefit of amplitude feedback training can transfer.
Limits of the evidence: The studies above give positive results, but the evidence is only of moderate strength. The sample size was small, and the training required was quite intensive (30 minutes a day, 5 days a week, for 6 weeks). If only a few words are practised now and then, the transfer will naturally be limited. Training therefore has to be kept up, and one should not expect that "a few sessions will bring all the writing back to normal size".
The relationship between letter size, speed and fluency
This point is often overlooked, but it is very important for adjusting expectations. The study by Oliveira et al. (1997) found that patients manage to enlarge their writing mainly by lengthening the time of the writing movement, and not by writing faster. In other words, letter size, speed and fluency are hard to keep together. To write larger and clearer, the writing speed will usually slow down.
Writing big and slowly does not mean doing badly. Taking more time over the movement is one of the normal ways in which writing can be brought back to a bigger size. The aim of practice is the function of "writing that can be read, being able to sign and being able to fill in forms", and is not to chase writing that is fast, big and neat all at once.
Tools and methods to replace handwriting
The practical principle of occupational therapy is that rehabilitation training and "working around handwriting" can go together, and it is not a choice of one or the other. When writing by hand is too hard, or its efficiency can no longer keep up with what daily life needs, working around handwriting does not mean giving up on treatment. It is a sensible way to keep daily self-care function.
- The writing is so small that neither the person nor others can read it
- Writing a short passage takes a long time and is very tiring
- Repeated signing (acknowledging receipt, forms) is a heavy burden
- After practising for a while, the transfer is still limited
- A large-lined notebook or thick-lined paper, with the horizontal-line visual cue
- Voice input (speech turned into text), to cut down handwriting
- Typing on a computer or tablet, for long text and formal documents
- A stamp for an everyday repeated signature
Handling signatures on bank, legal and form documents (workarounds)
Working around handwriting in ordinary daily matters is quite straightforward, but when signatures, bank, insurance and legal documents are involved, extra care is needed. Because such documents involve identity verification and legal effect, the patient must not change the way of signing alone. The general directions below do not constitute legal advice.
- For informal signatures (such as an ordinary acknowledgement of receipt), a stamp can be considered in place of a handwritten signature, to lighten the writing burden.
- For bank, insurance and legal documents, ask the organisation concerned or a lawyer which arrangements are acceptable, for example a witnessed signature or setting up a power of attorney.
- If a handwritten signature is needed on an important document, try to arrange it in the "on" period when the medication works best, and avoid forcing a signature in the "off" period when the medication has worn off.
- Until the organisation concerned has confirmed, never change the way of signing a formal document alone, to avoid affecting its legal effect.
Disclaimer: The content on this page about signatures, banks and legal documents is general information and not legal advice. What is acceptable for an individual document, and its legal effect, should follow the professional advice of the bank, insurance company or lawyer concerned.
How this divides the work with whole-body large-movement training (LSVT BIG)
Micrographia and shrinking steps in walking share a mechanism (both are a reduction in movement size), but each rehabilitation area has its own part. The occupational therapy discussed on this page deals with fine hand tasks, covering self-care functions such as writing, signing, buttoning and using cutlery. LSVT BIG, the amplitude-focused exercise for large whole-body movements (including walking, turning, balance and posture), belongs to physiotherapy and is not described in detail here. If the patient's daily trouble is not limited to writing and walking and balance are also affected, whole-body large-movement training should be considered at the same time. See large-amplitude movement training for Parkinson's disease (physiotherapy).
Writing and self-care training from NovaHealth home occupational therapy
Waiting times for occupational therapy in the public medical system are long, and the ideal training for micrographia is built directly into the patient's real life, using the desk where the patient usually signs, the pens and notebooks used every day, and the forms that actually have to be filled in. NovaHealth home occupational therapy can start functional writing training right in the home environment, and adjust the patient's daily self-care arrangements on the spot (including discussing workarounds for signing, filling in forms and dealing with bank documents), so that the benefit of training really lands in daily life and is not just a one-off exercise inside a clinic.
Community resources and support in Hong Kong
Hong Kong generally uses a single Chinese name for Parkinson's disease (柏金遜症). Besides rehabilitation treatment, the local organisations below also offer patient education and community support, and readers may contact them as needed: the Hong Kong Parkinson's Disease Association (HKPDA), the Hong Kong Society for Rehabilitation (Jockey Club "柏動愛" Parkinson's care programme), the patient education materials of the Hong Kong Movement Disorders Society (HKMDS), and the Elderly Health Service of the Department of Health. Many people in Hong Kong mistake "writing that gets smaller and smaller" for normal ageing or plain tremor. Noticing it early and getting assessed is the key to keeping daily self-care function.