Using Haptic Handwriting Aids with Constraint-Induced Movement Therapy to Improve Function in

Adults with Neurological Impairments

Abigail Mendenhall

Natalie Mortensen

Jen Trinh

Eric Wray

Kyle Johnson

University of Utah Department of Occupational Therapy

Introduction and Aims

Stroke occurs in 16.9 million people in the world every year and is one of the primary
causes of acquired adult disability. This disability very often includes motor impairments of the
upper limb (Kwakkel, Veerbeek, & Wegen, 2015). These impairments can affect many important
daily activities such as eating, performing hygiene routines, dressing, driving, writing, and many
other things that are necessary for independent living and quality of life.
Constraint Induced Movement Therapy (CIMT) is an intervention that was designed to
assist rehabilitation of those that have suffered from a stroke. According to Kwakkel et al. (2015)
the CIMT treatment process includes several important parameters. First, there needs to be
constraint of the non-impaired limb. It also requires great amounts of task specific practice and
use with the affected arm for as much as 6 hours a day for 2 weeks. Additionally, it requires the
use of techniques that help to ensure that the results of the treatment can transfer to more natural
settings outside of treatment (Kwakkel et al., 2015). Additionally, it has been shown that CIMT
has been successfully used to improve function and control of the upper limbs across various
patient populations (DeLuca, Trucks, & Wallace, 2017; Wolf et al., 2006).
Another intervention that has been shown to improve fine motor skills and functional use
of hands is Haptic handwriting. Haptic handwriting is an intelligent control software that allows
people with poor fine motor skills to be guided through the process of letter formation. The
Haptic Handwriting Aid (HHA) allows the user to choose between a character, word, or group of
words to enter into the devices control system. (Mullins, Mawson, & Nahavandi, 2005)
Though there is clear evidence of the effectiveness of both HHA and CIMT separately,
there is a lack of evidence supporting both therapies combined. Additionally, there is relatively
little evidence of handwriting interventions being used with adults. Therefore, we are proposing
a combined potential of both HHA and CIMT for increased effectiveness in current treatment of
stroke survivors.
Aim 1: Establish and test a protocol consisting of CIMT with computer assisted
handwriting intervention to improve handwriting, motor skills, strength, and fatigue in the
affected limb of post-stroke patients.

Hypothesis 1: We hypothesize that a treatment protocol consisting of CIMT combined with

computer assisted handwriting intervention will produce more significant improvements in
handwriting, motor skills, strength, and fatigue in the affected limb of post-stroke patients than a
treatment protocol consisting of CIMT only.

Background and Review of Literature

CIMT
Constraint-induced movement therapy (CIMT) was created as a treatment method to help
restore upper limb functions of post-stroke survivors and is one of the most commonly used
treatments for this population. Numerous studies have examined treatment practices of CIMT to
be effective at improving motor and upper extremity functions, and habitual use of the affected
arm in activities of daily living (Abd El-Kafy, Alghamdi, & Elshemy, 2014; DeLuca et al., 2017;
Peurala, Kantanen & Sjögren, 2012; Kwakkel et al., 2015; Wolf et al., 2006). In addition,
Peurala et al. (2012) found that various treatment practice durations of 15-56 hours and
frequencies of anywhere between 2-10 weeks of CIMT produced greater results for hand
mobility function of the affected limb in post-stroke survivors on activity and participation.
Current evidence in literature shows that CIMT produced greater results of hand function
and overall quality of life in post-stroke survivors (Kwakkel et. al., 2015). Of the large pool of
RCTs that are current in literature, studies have suggested that procedures of CIMT incorporates
repetitive exercises and guidelines for modifying changes in behavior, which are the most
pertinent aspects to improved functional hand-use for adults post stroke (Peurala et al., 2012;
Kwakkel et al., 2015). Similarly, these RCT studies also suggest that CIMT has greater
influences on motor function mobility when implemented in the earlier stages of post stroke for a
duration of 60-72 hours over a two-week period. Whereas in the later phases, CIMT was
reported to only affect arm-hand activities by the use of compensation strategies to improve
upper limb performance within daily activities when compared to a controlled group. In terms of
self-care improvements, only 30-hours of CIMT was needed for three weeks of post stroke to see
drastic changes in ADL functions (Kwakkel et al., 2015; Peurala et al., 2012)
Handwriting Programs and Aids
Literature in handwriting therapies have generally focused on writing skill development
through two main methodologies; sensorimotor and cognitive focused interventions (Hoy, Egan,
& Feder, 2011). Both methods showed improvement in varying degrees in fine motor skills,
visual motor integration and writing speed, legibility, and accuracy (Chang & Yu, 2014; Denton,
Cope, & Moser, 2006; Howe, Roston, Sheu, & Hinjosa, 2012; Hoy, et al, 2011; Zwicker &
Hadwin, 2009). Additionally, Hoy et al. (2011) found that repetition and intense practice in
handwriting was a key component with many of the methods of intervention for handwriting.
One limitation among current research is the few research studies including adult participant
samples (Drempt, Mccluskey, & Lannin, 2011).
There has been more recent research that has investigated therapeutic writing treatments
among adults with strokes and other neurological impairments (Mullins et al., 2005; Palsbo,
Marr, Streng, Bay, & Norblad, 2011). Specifically, computer assisted devices and haptic
handwriting aids may be used therapeutically to provide feedback and help stroke patients
improve handwriting. Haptic handwriting aids provide stimulation and sensory feedback to the
user in visual and tactile sensations while guiding the hand through the strokes of writing
(Mullins et al., 2005; Palsbo, et al., 2011).
Preliminary research has shown that the repetitive, instant sensory feedback and the hand
and pencil guidance through the strokes of letter formation has led to improvement in skills
needed for handwriting (Mullins et al., 2005; Palsbo, et al., 2011). Interestingly there are
parallels in practice and repetition of strokes in both the handwriting programs of children and
the haptic handwriting devices used in the adult research cases.
Purpose of Study
As has been discussed haptic handwriting improves fine motor skills and CIMT improves
fine motor skills by using the affected upper extremity and constraining the functional
limb. Through the combining of these two techniques there may be greater improvement in the
affected upper extremity of adults who have suffered a stroke. Based on existing research, we
hypothesize that using haptic handwriting as a therapeutic modality in conjunction with CIMT
will result in improved fine motor skills, strength, and endurance in the affected upper limbs of
post-stroke adults.
Using the principles of CIMT combined with a Haptic Handwriting Aide, a stroke
survivor can easily and affordably implement a home program to supplement regular therapy.
Haptic technology has been decreasing over the years and is more practical to use within therapy
(Mullins et al., 2005). The combined therapies may show quicker and longer lasting results in
fine motor skills than other more time-consuming therapies.
The results of this study will help to provide evidence for the use of CIMT and Haptic
handwriting in occupational therapy intervention and treatment of individuals impacted by a
stroke. These outcomes of improved motor skills, strength, and decreased fatigue are important
to the functional use of limbs in post stroke individuals in their activities of daily living and can
provide a stronger tool for intervention for occupational therapists.
Method
Participants
Participants will be recruited with the help of local doctor’s offices in the Wasatch area.
Doctors will be given information about the study and asked to recommend qualifying patients to
our research team for further consideration for the study. Participants must be 18 years and older
who have experienced a stroke and suffer from hemiplegia with some function in the affected
side. Mild cognitive dysfunction as deemed by medical practitioner is also required. Participants
need to have some control of wrist and finger extensors, which is a standard requirement to be
considered for CIMT treatment. To minimize concerns for balance and posture instability, those
selected for CIMT are required to stand independently for 2 minutes either with or without an
external support. Other inclusion criteria include minimal pain and spastic characteristics, no
previous episodes of having stroke and must be medically cleared to participate in a rigorous
CIMT protocol. Participants will receive full disclosure of the study’s procedures, requirements,
and how their information will be used. All participants will need to sign a consent form that
includes this information and will be kept on file for the course of the study.
Research Design
In order to attribute potential improvements in strength, fine motor, and lessen fatigue in
our participants to our treatment protocol, we plan to conduct a randomized controlled trial
 involving a control group that does not receive our specific treatment protocol and an
experimental group that does receive our specific treatment protocol. Baseline measures will be
taken before and after the protocol administration.
Measures
There will be two measures used for this study: The Wolf Motor Function Test (WMFT)
and the Neurology Quality of Life (Neuro-QoL) item Bank v.1.0 Upper Extremity Function
assessment. The test was specifically designed to evaluate improvement through CIMT treatment
for stroke and traumatic brain injury patients (Morris, Uswatte, Crago, Cook, & Taub, 2001)
through the measurement of fine motor skills, strength, and overall functional use of upper limb.
Additionally, the WMFT uses timed and functional tasks to quantify motor ability in the upper
extremity with 15- task performance items and 2 strength-based items. It has been used
extensively for CIMT intervention therapy and has been shown to have high interrater
reliabilities, internal consistency, and test-retest reliability (Morris et al., 2001).
The Neuro-QoL item Bank v.1.0 Upper Extremity Function was developed to assess
neuromotor dysfunction in patients and provides a measure for fine motor skills that includes
fatigue in upper extremity and functional ability of activities of daily living. It has high internal
consistency (Cronbach’s alpha = .85-.98) and acceptable level of test-retest reliability (Gershon
et al. 2011). Additionally, the correlations with disease specific and other generic measures were
as expected in the direction and strength which also validated the short forms and scales (Cella et
al., 2012; Gershon et al., 2011).
Procedure
IRB approval will be sought and obtained before the commencement of this study. The
treatment group will receive CIMT combined with computer assisted handwriting intervention
for 60 hours over two weeks as this has been found to be most effective for improving motor
function mobility. The control group will receive standard therapy with the same frequency and
duration as the experimental group. We will obtain baseline data for each of these outcomes for
every participant before administration of our protocol and the same outcomes after the treatment
protocol sessions have been completed.
Data Analysis Plan
To determine whether there have been changes in the outcomes of fine motor skills,
strength, and improved levels of fatigue of the affected limb, we will be running an independent
and paired samples t-test. A paired samples t-test will test the two groups pre and post
intervention. The independent test will measure the effects of the treatment between the groups.
Running too many tests can increase the chance of a type 1 error. Therefore, we will run a
Bonferroni correction to minimize testing error. P-value for the proposal will be set at p<.05, this
signifies that there will be less than a 5% chance that we got our results by chance and that we
are 95% confident that our results were not by chance and that our null hypothesis of CIMT with
computer assisted handwriting intervention did in fact improve handwriting, motor skills,
strength, and fatigue of affected limb of post-stroke patients.
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