Handwriting difficulties are a common source of referrals to school therapists. By age 10 to 12 years, children have completed formal instruction in writing, full kinesthetic sensitivity is present, and the development of prehensile skills of the hand is mature.1,2 However, some children continue to exhibit difficulty with handwriting. These children are routinely referred for occupational or physical therapy consultation.3,4 If a motor deficit cannot be documented following standardized testing and clinical observations, recommendations are made for a review of handwriting practice.5,6 Therapy services are not generally prescribed. The question is whether or not these children have a deficit in kinesthetic sensitivity, and if so, therapy that addresses the deficit may be indicated. We hypothesized that children who have completed formal instruction in penmanship but continue to exhibit nonproficient handwriting skills may have a deficit in kinesthetic sensitivity of the upper extremity. The focus of this research was somatosensory issues; other factors that may influence handwriting legibility such as visual perception, visual motor performance, motor planning, in-hand manipulation, and ergonomic and socioeconomic factors were not addressed.3,7,8
Kinesthetic sensitivity is defined here as the ability to discriminate the positions of body parts and the amplitude and direction of one's movements.7 Kinesthetic sensitivity is believed to be related to the tension of the muscles receptors more than to the superficial skin receptors. The input from these receptors is predominantly distributed to spinal cord interneurons and the cerebellum.9 A deficit in kinesthesia could result in difficulty learning to control the movements involved in handwriting.1,7,10,11
Kinesthetic sensitivity and somatosensory deficits have been identified in children with poor hand writing.7,11–13 The relationship between kinesthetic sensitivity and handwriting proficiency, as well as the effect of kinesthetic training on handwriting quality, has been addressed in the literature with varying conclusions. Kinesthetic sensitivity encompasses the ability to grade pressure of the digits on writing tools, pressure of pencil on paper, movement fluency and pressure consistency of written letters, and position sense of the hand.3,11,14–16 Bairstow and Laszlo17 found significant positive correlations between writing/drawing skills and kinesthetic sensitivity in children aged 6 to 7 years, as measured by a passive kinesthetic sensitivity test. Copley and Ziviani15 found a positive relationship between handwriting quality and kinesthetic sensitivity in children in first grade using a manual pointing task. Parush et al14 reported that children with poor handwriting had inferior consistency of pressure during writing. Although studies have shown that pencil grasp is not a significant predictor of handwriting quality, Schneck11 found that type of pencil grasp was linked to kinesthetic finger awareness.4 Children aged 6 to 7 years, with poor handwriting and decreased kinesthetic finger awareness, had atypical pencil grasps.11
In studies testing the benefits of kinesthetic training for children with nonproficient handwriting, a kinesthetic deficit was not always a criterion for inclusion. Harris and Livesey18 found that children in first grade with nonproficient handwriting improved handwriting quality following kinesthetic sensitivity practice. Smits-Engelman et al3 found that children in fourth to fifth grades, identified as having developmental coordination disorder and nonproficient handwriting, improved their handwriting quality following physical therapy providing fine motor and kinesthetic training. Sudsawad et al13 reported no difference in handwriting performance between children in first grade receiving kinesthetic training and children in a handwriting practice group. Denton et al5 state that therapeutic handwriting practice, not sensorimotor treatment that included kinesthetic sensitivity activities, increased handwriting legibility in 6- to 11-year-old children. The literature presents different tests to measure kinesthetic sensitivity and inconsistencies regarding the relationship between kinesthetic sensitivity and handwriting quality. These differences are likely due to a variety of factors including the age of the children, variations in the task, and test measurements.
Controversy also exits over which assessment tools best identify handwriting quality. Recent handwriting research has incorporated a computerized digitizing graphic tablet to measure and analyze handwriting.1,10,19 Reisman20 stated that handwriting judgments made by an occupational therapist were consistent with those of a classroom teacher. Use of a formal or standardized evaluation for handwriting is important because it allows for objective and quantitative measures.21,22 Both qualitative and quantitative measures were used to measure handwriting legibility in this study.
Are there correlations between other somatosensory measures and handwriting legibility in children? Assessments for discriminate tactile awareness, graphesthesia, diadochokinesia, and stereognosis have been used to assess neurological function, finger function, and motor development.7,12,23,24 Discriminate tactile awareness is hypothesized to involve the superficial sensory receptors in the fingers and the primary somatosensory cortex.9 Tactile awareness influences fine motor function during handwriting. The perception of graphesthesia encompasses the ability to identify a shape that is drawn on the fingertip or hand. Tests of graphesthesia examine the pressure receptors in the fingertips and address force regulation during finger tasks. Graphesthesia is hypothesized to involve the dorsal column, medial leminiscus system, and parietal lobe.9
Diadochokinesia, although not a test of somatosensory function, requires functional kinesthesis to rapidly alternate movement with smooth coordination. Diadochokinesia is believed to test cerebellar and basal ganglia function in the control of movement and gross motor timing.9 Berninger and Ruthberg12 found that diadochokinesia, discriminate tactile awareness, and finger succession measures correlated consistently with handwriting legibi-lity and fluency measures in children aged 6 to 9 years.12
Stereognosis is the ability to identify a familiar object placed in the hand, with vision occluded. This requires integration of visual and somatosensory inputs with the memory of objects. Stereognosis is primarily believed to be a function of the lower posterior parietal lobe and requires highly integrative functions of the brain.9 Tactile discrimination and stereognosis are strongly related to hand dexterity in children with cerebral palsy.23
Kinesthetic sensitivity, diadochokinesia, and other tests of the somatosensory system have not previously been used together in a systematical evaluation of hand sensitivity and handwriting quality. The purpose of this preliminary study was to identify differences in kinesthetic sensitivity and other measures of hand sensitivity between children with nonproficient handwriting and children with proficient handwriting.
This pilot study was approved by an institutional review board. Children developing typically enrolled in grades 4 to 6 and between the ages of 10 and 12 years, identified by their teachers as having either nonproficient or proficient handwriting, were included in this study. Informed consent and assent were obtained from parents and subjects prior to participation. Separate teacher and parent questionnaires were developed to screen the subjects for inclusion/exclusion criteria and to obtain additional information. Twenty-six children were identified for inclusion by their teachers.
The teacher and parent questionnaires included yes/no questions and a 5-point Likert scale. The teacher Likert scale rated the child's handwriting legibility and was expressed in terms of the following 5 categories: 1, very low; 2, low; 3, average; 4, high; and 5, very high. Subjects expected to be a member of group 1 needed a score of 1 or 2 on the Likert scale. Subjects expected to be a member of group 2, the control group, needed a rating of 3, 4, or 5 (Table 1). In addition to screening for inclusion/exclusion criteria, the questionnaires rated daily exposure to music, ball skills, drawing, and skill using eating utensils.
Exclusion criteria included identified intellectual or physical deficits, musculoskeletal disorders, neurological deficits, documented sensory processing or sensory integration dysfunction, uncorrected visual or auditory impairment, lack of appropriate attention span, and the use of medication for a medically diagnosed condition. Children with known neurological dysfunction, including diagnosis of attention-deficit/hyperactivity disorder and learning disabilities, were excluded. Attempts were made to exclude children with motor delays, visual perceptual, and visual motor deficits. This allowed for isolation of the assessment of sensitivity of the distal sensory system and the sensory receptors in the arm and hands, as opposed to sensory-motor processing that involves more central nervous system functions.
Eight boys with nonproficient handwriting volunteered and met criteria for inclusion in group 1. Eight boys with proficient handwriting were recruited for inclusion in group 2 (Table 1).
This study used a small convenience sample. Interrater reliability was not established with other raters and group membership was known to the examiner. Children were tested individually by one of the authors, an experienced physical therapist working within the school setting. Tests chosen were specific to the sensory component tested and based on the current understanding of neuroanatomy and physiology. Tests used in the study have been standardized as part of other assessment tools or in published research articles and were easy to reproduce in the clinical setting. An occupational therapist certified in the use of the Sensory Integration and Praxis Test provided consultation in procedural aspects and scoring of subtests Kinesthesia and Manual Form Perception (MFP).25 Permission was obtained from the publisher.
Raw scores from testing were averaged and a median score and interquartile range were used to portray data that were qualitative or ordinal. The interquartile range is a way to describe the variability in the data. The interquartile range is the range in which 50% of the scores fall, with 25% of the scores above and 25% scores below the range. Mean and standard deviation were calculated for each set of scores. A nonparametric test, the Mann-Whitney U test, was used for group comparisons because of small sample size and use of ordinal data. Scores from the handwriting test and sensitivity tests were compared to see whether there were significant differences (P < .05) in hand sensitivity and handwriting quality bet ween group 1 (children with nonproficient hand writing) and group 2 (children with proficient handwriting).
Active range of motion of the upper extremity was observed and the preferred hand was determined. A subtest of the Test of Handwriting Skills, titled “BUS,” was given to objectify handwriting quality.26 The Test of Handwriting Skills has specific scoring criteria for manuscript letter formation. The subtest “BUS” asks the child to write the lowercase alphabet from memory on unlined paper. Letter formation is evaluated and scored on a 0 to 3 scale.26
Kinesthetic Sensitivity Tests
Five tests were used to assess kinesthetic sensitivity: (1) Pressure Score during writing; (2) Pressure Consistency during writing; (3) Hand Position Sense with Visual Cues; (4) Hand Position Sense with Kinesthetic Cues; and (5) a subtest of the Sensory Integration and Praxis Test titled Kinesthesia.14,16,25 A Pressure Score is found by rating the maximum pressure applied to the paper during writing. To arrive at this score, 4 additional sheets of paper are placed under the sheet upon which the child writes, with carbon paper between each. The number of the last sheet of paper that is still readable is the Pressure Score. Pressure Consistency evaluates the consistency of darkness of letters on the sheet of paper lying underneath the one on which the child wrote.14 A simple dichotomous scale of YES and NO was used.
Hand Position Sense incorporates both qualitative and quantitative measures of kinesthetic sensitivity.16 This test examines the child's kinesthetic ability to copy hand gestures presented first with visual cues and then with kinesthetic cues. The hands are positioned behind a screen. For Hand Position Sense with Visual Cues, the examiner demonstrates a hand gesture, and the child copies it with the preferred hand. Eight different hand gestures are presented and accuracy is graded on a scale of 0 to 3. The sum of all trials that receive a score of 3 is the kinesthetic sensitivity score. The response time (1/100 second) for trials is averaged. In Hand Position Sense with Kinesthetic Cues, the child's nonpreferred hand is positioned in each hand gesture and the child is asked to reproduce the gesture with the preferred hand. Three separate measurements are recorded: accuracy of hand position; speed of response; and ability to hold the cued position with nonpreferred hand.16
The fifth test of kinesthetic sensitivity is the test Kinesthesia.25 This subtest of the Sensory Integration and Praxis Test reports interrater reliability (r = 0.99). During the test, vision is occluded, while the examiner moves the participant's index finger from point A to point B, and back to Point A, along a piece of paper. The examiner then asks the child to move the index finger to point B independently.25 The distance between Point B and the actual finger position is measured to the nearest 10th of a centimeter.
Discriminate Tactile Awareness
Berninger's27 Process Assessment of the Learner: Test Battery for Reading and Writing includes a test of tactile discrimination called Finger Localization. The child is asked to identify the finger that was touched by the examiner with hands positioned behind a screen. In addition, we asked the child to point to the specific area on the finger that was touched. Separate scores are gathered for correct identification of the finger and the specific location on the finger touched.27
A test of diadochokinesia used the Finger Repetition test, also part of the Process Assessment of the Learner: Test Battery for Reading and Writing.27 The participant is asked to perform 20 touches between the thumb and index finger with the hands out of view. Time, to the whole second, was recorded for preferred and nonpreferred hands.
The MFP test Parts I and II was used to test stereognosis.25 Reported interrater reliability of MFP is r = 0.99. In part I of MFP, thin plastic blocks are placed in the child's hand with vision occluded. The child identifies the block by pointing to the correct form on a card depicting 4 to 10 blocks. Both hands are used, one at a time, over 10 trials. The response time was recorded in seconds. During part II of MFP, a bilateral task, the child touches a form that is secured to a base with one hand, while using the other to identify a similar form selected out of a row of 5 forms.25
The Fingertip Writing test, a subtest of the Process Assessment of the Learner: Test Battery for Reading and Writing, was used to assess graphesthesia.27 The child closes the eyes, while the examiner writes a letter or number (¼ inch tall) on the tip of the finger, with a wooden probe. The second through the fifth digits on both hands are used. Trials with a score of 0 are repeated once.
Scores from the handwriting test and sensitivity tests were compared to see whether there were significant differences in hand sensitivity and handwriting quality between children with nonproficient handwriting and children with proficient handwriting.
A statistically significant difference was found between the 2 groups of children on the objective handwriting test BUS (Mann-Whitney U test, P = .018), with the control group having higher scores, indicating better handwriting (Table 2). This confirmed teachers' ability to accurately assess handwriting quality using a 5-point Likert scale. No significant difference was found between the 2 groups on performance, or speed, on any of the 5 tests for kinesthetic sensitivity (Table 3). The data collected do not support our hypothesis that children with nonproficient handwriting will demonstrate decreased kinesthetic sensitivity.
Additional subject characteristics were gathered from parent questionnaires. Parents reported that a greater number of children with nonproficient handwriting resisted writing tasks and demonstrated less enjoyment throwing/catching balls. Parents' ratings of skill with eating utensils, enjoyment of drawing and painting, and daily exposure to music were similar between groups. The data from these questionnaires were not included in the study.
In kinesthetic sensitivity tests during handwriting, only 1 child in the nonproficient handwriting group demonstrated pressure consistency versus 3 of 8 in proficient handwriting group (Table 3). The Pressure Score, total pressure applied during writing, was similar between groups. In other kinesthetic tests, the group with nonproficient handwriting had equal or slightly better scores than controls (Table 3).
Diadochokinesia speeds were slightly slower for the nonproficient handwriting group when the preferred hand was observed. Speeds were equal in the nonpreferred hand in both groups (Table 4).
Stereognosis accuracy was similar between groups (Table 5). The nonproficient handwriting group had a faster speed of response on MFP Part I. The graphesthesia test of fingertip writing demonstrates slightly increased accuracy in the group with nonproficient handwriting (Table 6).
The greatest differences between the groups were found in discriminate tactile awareness. Four of the 8 children in the nonproficient handwriting group were unable to identify all fingers correctly (Table 7). However, the ability to correctly identify the specific area of the finger touched was similar between the groups. In summary, differences in kinesthetic sensitivity and other measures of hand sensitivity were not significant.
In an effort to focus on somatosensory issues, other factors that may influence handwriting proficiency were not addressed in this preliminary study. Kinesthetic sensitivity and other tests for the somatosensory system have not previously been used together in a systematic evaluation of hand sensitivity and handwriting quality. The literature points to the fact that kinesthetic sensitivity may affect handwriting quality. We felt confident that decreased kinesthetic sensitivity would be demonstrated in our sample of children with nonproficient handwriting. A significant difference in the quality of handwriting in the 2 groups was demonstrated (Mann-Whitney U test, P = .018). These scores correspond to the teachers' assessment and underscore teachers' ability to differentiate handwriting in a clinical range using a qualitative scale.
Children with diagnosed neurological deficits were excluded; a single therapist completed all testing, using specific testing and scoring criteria; children were matched for gender, handedness, and age range; teachers' assessment of handwriting was confirmed by an objective measure: data were carefully analyzed. Yet, there were no significant differences between the 2 groups of children in kinesthetic sensitivity, nor did we find significant differences in the other areas tested: diadochokinesia, stereognosis, tactile discrimination, and graphesthesia.
This lack of significance between groups may be due to insufficient statistical power to detect that difference, especially with ordinal data. The small sample size may also limit the interpretation of the descriptive measures reported in this study. The group assignments of subjects were known to the examiner, and the study did not evaluate reliability with other raters allowing potential for bias. Lastly, exclusion criteria were based on teacher and parent questionnaires that would exclude children with significant deficits in the area of visual motor/perception, motor delay, or in-hand manipulation skills. However, these criteria do not rule out the possibility that nonproficiency with handwriting production was a result of other factors.
In the area of kinesthetic sensitivity, it was found that children with nonproficient handwriting had decreased pressure consistency and accuracy with hand position sense. On other tests of kinesthetic sensitivity, children with nonproficient handwriting had accuracy and speed scores equal or slightly better than controls.
Children with neurological diagnoses may be more likely to have decreased kinesthetic sensitivity. However, is the kinesthetic deficit a major component of the handwriting difficulty? And if so, would treatment that addresses kinesthetic sensitivity allow for acquisition of improved control and gradation of finger movement during letter formation? According to the data in our sample population, kinesthetic sensitivity may not be a dominant factor in the fluency of the mechanical writing task in children with nonproficient handwriting as their only complaint.
Although not significant, there appears to be a greater similarity in scores between right and left hands of children in the nonproficient handwriting group, with greater sensitivity of the preferred hand in the control group. The majority of tests incorporated measures of both right and left hands, or tests that required the child to use both hands simultaneously. Most of the tests, in which raw scores were based on testing of the preferred hand only (pressure consistency, handwriting test, diadochokinesia), show a decreased ability (not significant) in performance of children in the nonproficient handwriting group. The idea that one group of children may have less sensitivity and specialization of the preferred hand could affect the interpretation of the data collected from tests with equal trials using both hands.
It is possible that in some children the maturation of the kinesthetic sensitivity of the hands and digits may occur later than their peers.2,10 If sufficient maturation of the somatosensory system does not occur by kindergarten and first-grade (during formal handwriting instruction) children may develop inefficient letter formation affecting readability that may perpetuate into the later grades. Patterns of letter formation are difficult to reverse once the child has begun writing, even in the absence of physical or neurological delay. It may be that these children are not motivated in the area of handwriting. The difficulty in changing habitual motor patterns of letter formation and the influence of behavior warrants further investigation.
The test of discriminate tactile awareness addresses the fine motor components of handwriting by assessing the sensitivity of the pressure receptors in the hand. Children with nonproficient handwriting did quite poorly on this test. Four of the children in the group with nonproficient handwriting were unable to identify fingers correctly. The 4 children who made errors during the tactile test also exhibited poor pressure consistency during handwriting. Only 1 child in the control group had difficulty identifying all fingers. A quick, simple test of finger localization could provide much information to the therapist in the clinical setting.
Based on these results, future questions arise regarding the role of the somatosensory system in writing acquisition and remediation. In particular, the sensitivity of the pressure receptors in the skin, and the degree of sensitivity between the hands, in children with nonproficient handwriting, may merit further investigation.
This sample of children aged 10 to 12 years with nonproficient handwriting as their only complaint did not demonstrate statistically significant deficits in kinesthetic sensitivity, discriminate tactile awareness, diadochokinesia, stereognosis, or graphesthesia. The data suggest that kinesthetic sensitivity of the hands and digits may not play a dominant role in handwriting quality in children within this age group. Some differences in pressure consistency, sensitivity of the preferred hand, and tactile awareness were noted in the children with nonproficient handwriting.
Failure to detect significant differences may be accounted for by inadequate statistical power associated to the small number of subjects in the groups. Based on this preliminary research, physical therapy and occupational therapy that address kinesthetic sensitivity may not be appropriate for children aged 10 to 12 years, who do not have other factors that may impede handwriting quality. Future research into the distal sensory system and the sensory receptors in the arm and hands in children with nonproficient handwriting is warranted.
We thank Bob Nee, PT, Jill Sacherman, MOTR/L, Nicole Koleshis, OTR/L, Carolyn Kelley, OTR/L, MOT, Kathy Cokelet, MEd, OTR/L, Christine Coble, MA, OT/L, Allen Senear, PhD, and Thomas O'Leary, MD, for advice and assistance. We thank the Seattle Public School therapists, teachers, and schools that assisted in recruitment efforts; Sarah and David Brink; and the children and families who participated in this study.
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Keywords:Copyright © 2011 Academy of Pediatric Physical Therapy of the American Physical Therapy Association
child; hand; handwriting; kinesthesis; sensation