Adaptation of handwriting size under distorted visual feedback in patients with Parkinson's disease and elderly and young controls

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Abstract
Objective: The ability to use visual feedback to control handwriting size was compared in patients with Parkinson's disease (PD), elderly people, and young adults to better understand factors playing a part in parkinsonian micrographia. Methods: The participants wrote sequences of eight cursive l loops with visual target sizes of 0.5 and 2 cm on a flat panel display digitiser which both recorded and displayed the pen movements. In the pre-exposure and postexposure conditions, the display digitiser showed the actual pen trace in real time and real size. In the distortion exposure conditions, the gain of the vertical dimension of the visual feedback was either reduced to 70% or enlarged to 140%. Results: The young controls showed a gradual visuomotor adaptation that compensated for the visual feedback distortions during the exposure conditions. They also showed significant after effects during the postexposure conditions. The elderly controls marginally corrected for the size distortions and showed small after effects. The patients with PD, however, showed no trial by trial adaptations or after effects but instead, a progressive amplification of the distortion effect in each individual trial. Conclusion: The young controls used visual feedback to update their visuomotor map. The elderly controls seemed to make little use of visual feedback. The patients with Parkinson's disease rely on the visual feedback of previous or of ongoing strokes to programme subsequent strokes. This recursive feedback may play a part in the progressive reductions in handwriting size found in parkinsonian micrographia.