Human Movement Science 43 (2015) 18

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Human Movement Science

journal homepage: www.elsevier.com/locate/humov

Biomechanical analyses of prolonged handwriting in subjects

with and without perceived discomfort
Shao-Hsia Chang a, Chien-Liang Chen b, Nan-Ying Yu b,
a
b

Department of Occupational Therapy, I-Shou University, Kaohsiung 82445, Taiwan

Department of Physical Therapy, I-Shou University, Kaohsiung 82445, Taiwan

a r t i c l e

i n f o

Article history:
Received 12 December 2014
Revised 4 June 2015
Accepted 7 June 2015

Keywords:
Handwriting
Pain
Biomechanics
Kinesiology

a b s t r a c t
Since wrist-joint position affects nger muscle length and grip strength, we studied its
biomechanical relevance in prolonged handwriting. We recruited participants from young
adults, aged 1824, and separated them into control (n = 22) and in-pain (n = 18) groups,
based whether or not they experience pain while handwriting. The participants then performed a writing task for 30 min on a computerized system which measured their
wrist-joint angle and documented their handwriting kinematics. The in-pain group perceived more soreness and had a less-extended wrist joint, longer on-paper time, and
slower stroke velocity compared to control group. There was no signicant difference in
handwriting speed and quality between the two groups. The wrist extension angle significantly correlated with perceived soreness. Ergonomic and biomechanical analyses provide
important information about the handwriting process. Knowledge of pen tip movement
kinematics and wrist-joint position can help occupational therapists plan treatment for
individuals with handwriting induced pain.
2015 Elsevier B.V. All rights reserved.

1. Introduction
Handwriting is a fundamental skill needed for everyday activities that can be performed with many different hand positions and pen-holding styles. It is an essential, ne motor skill directly related to most school activities. The ability to produce uent and legible script is important for expressing, communicating, and recording ideas, as well as for educational
development, achievement in school, and self-esteem (Phelps, Stemple, & Speck, 1985).
With the gradual substitution of handwriting for its digital forms, such as computer keyboards and tablets in daily life
situations, the instruction and monitoring of handwriting development can be overlooked at younger ages (de Almeida,
da Cruz, Magna, & Ferrigno, 2013). However, handwriting is still an important means for taking notes, writing reports,
and taking examinations in school. Difculty in handwriting could result in problems in situations that demand intense
handwriting use in class, such as the inability to properly perform written exams due to signicant discomfort.
Over the past decades, studies have been carried out to investigate the role handwriting plays in composition writing in
children (e.g., Jones & Christensen, 1999; Medwell, Strand, & Wray, 2007; Wagner et al., 2011; Yan et al., 2012) and university students (e.g., Connelly, Campbell, MacLean, & Barnes, 2006). For example, Yan et al. (2012) demonstrated that speed
and uency measures were strongly predictive of overall writing quality. For both children and adults, faster handwriting

Corresponding author at: Department of Physical Therapy, I-Shou University, No. 8, Yida Rd., Yanchao District, Kaohsiung City 82445, Taiwan.
E-mail address: ying@mail.isu.edu.tw (N.-Y. Yu).
http://dx.doi.org/10.1016/j.humov.2015.06.008
0167-9457/ 2015 Elsevier B.V. All rights reserved.

S.-H. Chang et al. / Human Movement Science 43 (2015) 18

speed is related to higher-quality essay writing; for adults, handwriting speed is also related to higher-quality lecture notes
(Peverly, 2006). Especially in a written examination, handwriting uency requires the writer to maintain sufcient speed
with a certain level of legibility. The ability to demonstrate knowledge by producing a sufcient amount of information
in a set time period becomes a concern in secondary and tertiary education. Interventions for handwriting difculty are often
required to support students requests for extra writing time during examinations.
Since there is an increase in the demands for speed and production of written information during the progression in academic life, monitoring the handwriting process through classroom notes and especially through evaluations could enhance
the performance of students in written assignments, ensuring greater comfort and productivity and reducing the risk of
cumulative trauma and injuries. Parush, Levanon-Erez, and Weintraub (1998) assessed quality, speed and ergonomic factors
prior to writing and after writing for 10 consecutive minutes. They demonstrated that children with both poor and good
handwriting were inuenced by fatigue. Especially, the children with poor handwriting had inferior pencil, paper and body
positioning, stabilization of paper and consistency of pressure, compared to children with good handwriting.
The proximal stability, believed to be a prerequisite for manipulative hand use, is widely accepted among clinical therapists (Kurtz, 1994; Naider-Steinhart & Katz-Leurer, 2007). The forearm muscles play an active role in stabilizing the hand
posture while keeping a xed wrist angle (Van Galen, Mller, Meulenbroek, & Van Gemmert, 2002). In an EMG analysis of
two handwriting grasp patterns in young adults, de Almeida et al. (2013) monitored the surface EMG activity of muscles of
the upper arm and forearm during a handwriting task. They found that people who used the static tripod grasp showed statistically signicant changes in the EMG activity of the trapezius and biceps brachii muscles during handwriting when compared to the dynamic tripod groups subjects. Their ndings suggested an increased activity of the proximal muscles among
subjects using transitional grasps, such as the static tripod grasp, indicating potential higher energy expenditure and muscular harm with the maintenance of this motor pattern in handwriting tasks, especially during progression in academic life.
The handwriting apparatus can actually be described in terms of three degrees of freedom; one corresponding to the
wrist-joint movement, and the other two to the nger-joint movements (Teulings, Thomassen, & Maarse, 1989). As stated
by Valls-Sol and Hallett (1995), the coordinated function of the wrist exor and wrist extensor muscles is important for
performing ne and accurate hand movements. The lateral progression of western handwriting is an important coordination
task where wrist extension has a separate degree of freedom for motor control. Their results indicated the importance of
wrist control in handwriting. Therefore, this study focused on the wrist position, which is important to the proximal stability
in handwriting.
Since wrist-joint position affects the length of the nger muscles and then the grip force, its inuence on the handwriting
process, product quality and efciency was studied in this research. To examine the effect of the wrist angle on the perceived
discomfort in long lasting handwriting tasks, we conducted a pilot study (Yu, Chang, & Chang, 2011) of participants from a
university Chinese literature class. According their self perceived soreness, subjects were classied into effortless and
hard groups. Wrist joint angles were found to be signicantly different between the two groups. In this study, we recruited
control and in-pain groups and performed a repeated-measures experiment to test whether the angle of wrist extension had
a signicant inuence on the kinematic characteristics, handwriting quality and the perceived soreness of the writing hand.
2. Methods
2.1. Participants recruitment
Forty participants were recruited from the university where this study was conducted. Table 1 shows the demographic
data of the recruited participants. Participants who reported having a painful experience while performing the task were
placed in the in-pain group. Those who completed the task without experiencing pain were placed in the control group.
None of the participants had any neuromuscular disorders, nor had they undergone any treatments or surgeries for musculoskeletal disorders in their upper limbs. There was no signicant difference between the two groups in terms of age (independent t test) or their dominant hand (Fishers exact test) and gender proportions (Chi-square test). Ethical approval for the
study was obtained from Institutional review board (IRB) of E-Da Hospital, Kaohsiung, Taiwan.
2.2. Handwriting task
The participants in this study performed a prolonged handwriting task in which they continuously wrote Chinese characters for a xed time (30 min). The writing material given to them was sufcient enough so that every participant would be
able to write continuously for the whole time without running out of characters. For the purpose of simulating the heavy
Table 1
Demographic data of participants.
Group

Age, mean (SD)

Gender, male (female)

Dominant hand, right (left)

Control (n = 22)
In-pain (n = 18)
Comparison between the two groups

20.45 (.77)
20.61 (1.19)
t38 = .515
p = .609

12 (10)
6 (12)
v2def=1 = 1.045
p = .307

19 (3)
16 (2)
p = .617

S.-H. Chang et al. / Human Movement Science 43 (2015) 18

requirements of a Chinese literacy class, the content was selected from a college-level, Chinese literacy textbook. In order to
ensure that the participant did not run out of content before the time was up, the total number of characters given was double the average amount that could typically be completed in 30 min. Therefore, the participants all had the same length by
time for the task, but not a dened number of characters to be written; the objective was to keep them writing throughout
the set time period rather than requiring them to complete a dened number of written characters.
During the task, the participants were requested to perform traditional Chinese handwriting. They copied from a stimulus
model in a sequence of columns. The rst column started at the upper right-hand corner of the page. Individual characters
were written from top to bottom, with new columns continuing from right to left. As depicted in Fig. 1, they moved their
entire hand along a downward progression of discrete characters (ex. from P1 to P2) until they reached the bottom of a column. In some cases, as shown in the graph on the right, they only exed the wrist further to write characters around P2.
When initiating a new column, the entire hand returned to the top left of the previous column. In contrast to western scripts,
the wrist usually maintains a certain position for stabilization while writing the strokes of a character. Fig. 1 shows the direction of Chinese script progression, and the related movements of muscles in the wrist and ngers.
2.3. The experiment setup and protocol
In the experiment, the participants were seated on a standard school chair and in front of a standard school desk, which
was appropriate for his or her height. The tasks were written on normal, ruled writing paper, which was afxed to the digitizing tablet (487  318  12 mm, Wacom, Intuos 5, Japan). A sheet of A4 sized paper was centered on the top of the digitizing tablet. A regular wireless electronic inking pen with a force sensitive tip was used to simultaneously write on the
sheet of paper and collect the movement data on the digitizing tablet. The axial pen force, and the X (horizontal) and Y (vertical) positions of the pen tip were sampled at a frequency of 200 Hz with a spatial resolution of 0.005 mm. The participants
were requested to write as fast and as accurately as possible. Each participant received the same instruction about what he or
she would be required to do.
A ber-optic electrogoniometer (S700 ShapeSensor, Measurand Inc., Fredericton, NB, Canada), which allows one degree of
freedom measurements, was utilized to measure the movement of the wrist joint. The lightweight and exible sensor could
be comfortably worn without hindering the actual movement of the joint. The electrogoniometer was tted so it could reach
across the joint so that the two end blocks could be mounted where the least movement occurs between the skin and the
underlying skeletal structure. The two end blocks were mounted on the dorsum over the 3rd metacarpal and distal radius
(Fig. 2). The angle of rotation between the two end blocks was measured and recorded. The unit of measurement was degree

Fig. 1. An anatomical drawing of a hand holding a pencil. The arrows show the different contraction forces of wrist exors (lower) and extensors (upper).
This affects the length and efciency of nger exors (shown in black) when making strokes within a character.

Fig. 2. The measuring system: a digitizing tablet with an ink pen and electrogoniometer for measuring the wrist angle.

S.-H. Chang et al. / Human Movement Science 43 (2015) 18

(). When the longitudinal axes of the two end blocks are in the same line on the sagittal plane, it is dened as 0 of wrist
extension, which is the neutral position. As the dorsum of the 3rd metacarpal moves toward the dorsum of the forearm, the
angle of the wrist extension increases. When they are perpendicular to each other, it is dened as 90 of wrist extension. The
electrogoniometer data were acquired in a sampling rate of 100 Hz. In order to avoid electrical interference, the data were
smoothed with a 4th order Butterworth low-pass lter with a cut-off frequency of 10 Hz.
2.4. Procedure and measuring parameters
In the experiment, there were six measures, including self-perceived soreness, writing speed, handwriting quality,
wrist-extension angle, and temporal and kinematic parameters of pen-tip movements. For evaluating the effect of time
on the participants, the test was divided into three ten-minute sections, but without resting periods between them. The following shows how to measure these data in every section.
1. Self perceived soreness (SPS): A visual analog scale with a length of ten centimeters was used to measure the
self-perceived soreness at the end of every section. The participants marked a point on the line to indicate the degree
of soreness he/she perceived. In the second and third measurements, the participants were blind to the point they previously marked.
2. Writing speed: Since the task time was xed, the writing speed was measured by counting the completed number of
words in every section.
3. Wrist-extension angle: Before the task, the participants were rst requested to actively extend their wrist as extremely as
possible, in order to measure their maximum range of active extension. This measurement was used as a covariant in the
statistical analysis of repeated-measures ANCOVA. During the handwriting task, the degree of wrist extension was measured and recorded at the 3rd, 6th, and 9th minute of every 10-min section. Every measurement was 1-min long and the
data was averaged. The average of the three measurements in the 10-min section represents the degree of wrist extension
in that section.
4. The handwriting quality: Two Chinese literacy teachers blind to the participants and the test procedure measured the
handwriting quality. For measuring the overall quality, a 7-point scale was administered to provide a score in every section (Ziviani & Watson-Will, 1998). The testretest reliability has been tested by two measurements (a separation of two
weeks) of 40 samples by an examiner. The interrater reliability had been tested by two Chinese literacy teachers scoring
60 samples separately. High Spearman rank correlation coefcients of testretest (r = .96) and interrater (r = .78) reliability showed as a strong testing method of the handwriting quality.
5. Ratio of in-air to on-paper time (RAPT): This temporal parameter is derived from the total in-air time (pen tip is above the
paper) spent on the task divided by the total on-paper time (pen tip contacts the paper). This measures the temporal proportion of pen lift in the whole writing task.
6. Mean stroke velocity (MSV): This kinematic parameter is derived from the total trajectory length divided by the total
on-paper time. This measures the average stroke speed of the pen-tip movements.
2.5. Statistical analyses
Statistical testing was performed with SPSS for Windows/PC (SPSS Inc., version 18.0, Chicago, Illinois). The testing variables, except for the degree of wrist extension, were entered into a general linear model repeated-measures procedure with
three 10-min test sections as the repeated measure and 2 levels of groups (control and in-pain) as the between-subject variable. With the baseline as a covariance, a repeated-measures ANCOVA test was used to determine the difference in the
wrist-extension angle across sections and groups. Signicant ANOVA or ANCOVA results were followed up using post hoc
comparisons with Bonferroni correction. For observing the interaction of the variations in the wrist-joint angle and the perceived soreness, Pearson correlation was used to test their correlations with the baseline of the wrist-joint angle as a covariance of the degree of wrist extension. The relationship between writing speed and handwriting quality was also tested using
the Pearson correlation analysis. In all of the analyses, a signicance criterion of a = .05 (two-tailed) was used.
3. Results
As shown in Table 2, the repeated-measures ANOVA showed signicant group and time effects on the variation in the
wrist-extension angle, the perceived pain (SPS), pen up/down ratio (RAPT) and stroke velocity (MSV). There was a signicant
time effect, but no group effect, on the variation of handwriting quality. A signicant interaction effect was found in the variation of SPS and in the handwriting quality across the groups and sections. As shown in Fig. 3, the handwriting quality of the
in-pain group decreased abruptly between sections two and three. Except for the time effect, there was no signicant group
or interaction effect on the writing speed.
In the analysis of self-perceived soreness in handwriting, the in-pain group showed signicantly higher SPS than did the
control group. As the time progressed, the SPS increased signicantly. The signicant interaction effect indicated that the

S.-H. Chang et al. / Human Movement Science 43 (2015) 18

Table 2
Measuring parameters across sections and groups.

Control

In-pain

Group effect
Time effect
Interaction
effect

Section

SPS

Handwriting
quality

Wrist-extension
angle

Writing speed

RAPT

MSV

1
2
3
1
2
3

3.19 (2.01)
3.37 (1.65)
2.88 (1.39)
4.71 (1.66)
5.63 (1.79)
6.49 (1.32)
F1,38 = 34.048,
p < .001
F2,76 = 3.939,
p = .024
F2,76 = 7.551,
p = .001

4.45 (.90)
4.32 (.96)
4.20 (.96)
4.61 (.87)
4.53 (.77)
4.08 (.93)
F1,38 = .071,
p = .791
F2,76 = 22.730,
p < .001
F2,76 = 4.008,
p = .022

39.80 (13.87)
40.09 (15.03)
38.91 (15.39)
39.89 (14.59)
37.82 (13.26)
38.22 (12.01)
F1,37 = 11.360,
p = .002
F2,74 = 3.820,
p = .026
F2,74 = 1.660,
p = .197

41.82 (7.88)
44.05 (7.92)
42.06 (8.80)
43.44 (6.74)
44.17 (6.96)
42.31 (8.51)
F1,38 = .082,
p = .777
F2,76 = 3.259,
p = .044
F2,76 = .557,
p = .575

1.71 (.59)
1.66 (.57)
1.61 (.60)
1.33 (.38)
1.31 (.41)
1.26 (.42)
F1,38 = 5.029,
p = .031
F2,76 = 5.810,
p = .004
F2,76 = .158,
p = .854

10.58 (2.80)
9.49 (2.18)
8.98 (2.28)
8.65 (2.01)
8.03 (1.60)
8.01 (2.46)
F1,38 = 5.239,
p = .028
F2,76 = 7.728,
p = .001
F2,76 = 1.273,
p = .286

increase in the in-pain group was larger than the increase in the control group. In the control group, the increase of SPS was
only from section 1 to section 2. In the last section, different from the in-pain group, the SPS decreased instead.
In the analysis of wrist-joint angle in handwriting, the ANCOVA showed a signicant interaction between the maximum
wrist-extension angle and the time-effect (F2,74 = 5.971, p = .008). The repeated measures ANCOVA was conducted by the
correction of maximum wrist-extension angle. As shown on Table 2, the signicant group-effect showed those in the
in-pain group did not extend their wrists as much as those in the control group. The signicant time-effect showed that
the wrist-extension angle varied as time progressed. However, the interaction across the groups and sections did not reach
statistical signicance.
The repeated-measures ANOVA also showed a signicant group and time effect on the variation of RAPT and MSV. The
in-pain group showed signicantly smaller RAPT and slower MSV than did those in the control group. With the progression
of time, both groups showed gradually reduced RAPT and MSV. A signicant difference of RAPT was found between the rst
and third sections (p = .019) but not between adjacent sections. The MSV slowed down with the progression of time. There
were signicant differences of MSV between section 1 and 2 (p < .001) and section 2 and 3 (p = .005).
To investigate the effect of the wrist-joint angle on the perceived soreness, the correlation of these two parameters was
analyzed. In a partial correlation analysis of wrist-joint angle and the perceived soreness with the correction of the baseline,
there were fairly signicant correlations between the SPS and the wrist extension angle in section 2 and 3 (r = .369, p = .021
and r = .352, p = .028, respectively) but not in section 1 (r = .208, p = .223). It indicated that the progression of perceived
soreness was coincident with their less-extended wrist.
In the correlation analysis between the handwriting speed and perceived discomfort, the result showed no signicant
relationship in any of the task sections (from section 1 to 3, r1 = .183, p1 = .258; r2 = .167, p2 = .303; r3 = .029, p3 = .857, respectively). The result indicated that the writing speed with a fairly consistent value was independent of the variation of
self-perceived soreness.
In observing the association between writing speed and quality, the result of the Spearman rank correlation showed no
signicant relations in any of the task sections (from section 1 to 3, r1 = .201, p1 = .212; r2 = .219, p2 = .175; r3 = .037, p3 = .823,
respectively). It also indicated that the slowly decreased handwriting quality was independent of the consistent writing
speed.
4. Discussion
The current study represents one step in addressing the challenges of perceived discomfort and handwriting quality in
tasks usually needed for taking notes in class, or for pen and paper examinations. The results show the relevance of ergonomic and kinematic factors on speed and quality of handwriting.
The results of this study show that the in-pain group perceived more soreness at every testing point in the prolonged
handwriting task. Not only did they perceive discomfort at the end of the long-lasting task, but they also perceived discomfort after only 10 min of handwriting. Discomfort in the in-pain group increased with time throughout the task. However, the
control group did not show any increased discomfort.
The participants in the present study were asked about strategies for maintaining speed and quality, but not about strategies for coping with pain. As expected, most participants maintained their speed. The results showed that the writing speed
was not different across groups and sections. It was not associated with perceived pain or handwriting quality. However, in
prolonged handwriting, especially in the in-pain group of this study, character quality declined when maintaining comparable writing speeds. On the other hand, with better adaptation, the control group could maintain both handwriting speed
and quality throughout the task. These results suggest that the control group had good ergonomics and employed better
strategies that helped them continue writing.
Normal wrist movements are in a direction opposite the nger motions, so an alternate elongation of the nger exors
over the wrist is obtained by wrist extension. Such elongation adds to the efciency of these muscles in exing the ngers,

S.-H. Chang et al. / Human Movement Science 43 (2015) 18

Fig. 3. Handwriting quality rating (means and standard errors) in the two groups across the three time sections.

promoting optimal efciency for grasping (Houglum & Bertoti, 2012). Even though gripping a pen does not necessarily
require great strength, it is not an easy task to sustain for a prolonged period of time. When handwriting proceeds vertically,
such as in the task described in this study, if the forearm does not move downward to the same extent as the pen tip, for the
proceeding characters, the wrist would be less extended. From the kinesiological basis, handwriting with less wrist extension
may adversely affect optimal efciency. This lessened efciency may explain the nding in the present study where the
in-pain group showed a less-extended wrist and perceived more discomfort in the prolonged handwriting task.
Fluent and legible handwriting requires accurate nger movements, which are dependent upon the cooperative activity
of the wrist and nger muscles. When the ngers grasp an object, the wrist exor and extensor muscles coactivate to stabilize the wrist and allow accurate nger and hand functions (Werremeyer & Cole, 1997). Handwriting is a typical example in
which gripping and manipulating a pen require a stabilized wrist in an extended position. ODriscoll et al. (1992) reported
that maximum grip strength occurred at a 35 wrist extension, with reductions of grip strength up to 73% at less favorable
wrist positions. When the wrist is maintained in this position, all of the wrist muscles have some tension, and the nger exors are stretched to some extent, to improve their grasping power. The lengthened tendons of the nger exors also assist in
stabilizing the wrist (Werremeyer & Cole, 1997). The present study reveals that consistent wrist extension in the control
group did not result in increased soreness. The less-extended wrist in the in-pain group was associated with increased discomfort. These results demonstrate the importance of wrist extension in handwriting tasks, and suggest the importance of
consistent wrist extension, for better ergonomics with efcient nger muscles.
In the analysis of temporal parameters, the RAPT of the in-pain group was found to be smaller than that of the control
group. This indicated they spent more time with the pen on paper rather than lifting the pen above the paper. In the study
of Rosenblum, Parush, and Weiss (2003), the handwriting of most of the nonprocient handwriters was characterized by a
longer pause time and a wandering path within two successive stroke segments. They found the in air time of nonprocient handwriters was especially longer, compared to the procient handwriters. This nding is different from the result of
this study showing the relatively less in-air time in the in-pain group. The difference might come from the populations and
handwriting problems they addressed being quite different from ours. In their study, children with handwriting difculty
were characterized by their poor motor control with longer in-air time and trajectory length. It might be a problem in planning or in the locating of the discrete stroke origins of a character. It may not be applicable to the present study addressing
more issues relating to ergonomics factors.
This study shows that there is no signicant correlation between perceived discomfort and writing speed in prolonged
handwriting. Similar research was reported by Summers and Catarro (2003) while studying handwriting speed, output,
and their related factors. They found that students who reported a lower level of pain wrote signicantly less words than
those who reported more pain for both short and long durations of writing. They interpreted the results as: the faster
one writes, the more pain one experiences. They explained that discomfort may come from an effort faster handwriting.
Utilizing computerized analysis, this study went further into the handwriting process and found that the in-pain group
showed a slower stroke velocity and spent more time moving the pen tip on the paper. The demand of muscle activity is
different between pen movement in-air or on-paper. Consistently larger proportion of time on paper in the in-pain group
may explain their progressive soreness in the prolonged task. However, the in-pain group neither produced more characters,
nor maintained satisfactory quality throughout the entire task. This result indicates an over-exertion on the writing muscles
in the in-pain group. The over-exertion might come from the poor ergonomics or pen tip kinematics that they are accustomed to using in their daily handwriting activities. To address these problems, the use of softer writing implements
(brushes) (Kao et al., 2014) and softer pen grips (Udo, Otani, Udo, & Yoshinaga, 2000) can be suggested as methods for reducing excessive exertion on the wrist-hand system.

S.-H. Chang et al. / Human Movement Science 43 (2015) 18

In view of planning effective intervention to improve the inefciency of handwriting, the proper employment of both
phasic and tonic stiffness is required for the dynamic stability of pen-tip movement (van Galen, Portier, Smits-Engelsman,
& Schomaker, 1993). In handwriting, phasic stiffness can be employed by a faster stroke movement. Tonic stiffness can be
attained by the application of co-contraction in agonist and antagonist muscles or by varying friction forces with the working
surface (Smits-Engelsman, Niemeijer, & van Galen, 2001). However, increasing the axial pen force requires more muscle
force, which increases muscle soreness or muscle fatigue and may have harmful effects on the muscles of the upper limbs.
The clinical implication for therapeutic intervention would be the encouragement of speeding up the stroke movement for
better stability and an improved efciency consequentially. Utilizing a real-time feedback of the stroke velocity to speed up
the stroke movement, Chang and Yu (2014) showed a promising result in improving the problem of long pauses of the pen
tip on the paper in children. Not only did the faster stroke velocity not sacrice the quality, but signicant improvements
were also found in measurements of legibility. However, it may be different in handwriting when pain and fatigue, rather
than learning to write, are important considerations. The cause of pain might be fatigue and overuse of the ne muscle
groups. Writing faster would not help if fatigue was the problem, as found in this study where the result showed a significantly slower stroke speed in the in-pain group. The slower stroke speed might reect fatigue in the task. A faster stroke
velocity does not always mean writing faster. It means a relatively shorter time spent on performing a stroke of same length.
For a nal goal of faster writing and reduced exertion of hand muscles, biofeedback systems are suggested to monitor and
shape the kinematic data (Chang & Yu, 2014) or EMG information to use the muscles necessary for handwriting in an efcient manner (Naider-Steinhart & Katz-Leurer, 2007).
4.1. Clinical implications
Clinical therapists are often required to evaluate the underlying components that support a students handwriting, such
as muscle strength, endurance, coordination, and motor control. Our results have the following implications for physical and
occupational therapy practice:
 Wrist position, pen tip kinematics, and temporal parameters showed relevance with regards to handwriting performance
and perceived discomfort.
 Maintaining a consistent wrist extension angle is imperative in prolonged handwriting for the efciency of muscle contraction and the stability of the wrist joint.
 Slower stroke velocity and longer time spent on the paper associated with more soreness. Therefore, a stroke speed fast
enough to maintain the phasic stiffness and a shorter duration of stroke movement are needed to improve efciency for
better handwriting performance.
4.2. Limitations
The muscle EMG activity was not assessed in this study. The authors believed that the muscles activated in the handwriting task are mostly intrinsic muscles, which are difcult to identify, and their activities are difcult to record. The electrodes
adhered inside the palm could alter the grasp pattern and may modify the handwriting movement. Instead, this study
assessed pain and fatigue in a handwriting task to monitor the amount of exertion and the potential muscular harm.
However, the future improvement in the technology of EMG may help the investigation of the effect of these muscles in
the handwriting task. Myoelectrical measures can be incorporated to verify the role of extensors or exors inuencing
the performance efciency and muscular conditions. In future studies, the role of the elbow and shoulder could be added
to determine the effect of the upper limbs posture on the handwriting performance. Further research is suggested on the
difference between Western and Chinese handwriting to explore the possibly different implications.
5. Conclusion
In summary, the results of this study indicate that ergonomic and kinematic analysis provide important information
about the handwriting process. The strenuous work of handwriting was found to be consistent with lower performance efciency and can be characterized by inferior ergonomics. The results of the present study suggest that the soreness in the prolonged handwriting of the in-pain group may come from this lower efciency of pen tip movement and muscle activation.
Handwriting with a less extended wrist may increase the exibility of nger movements, but may reduce the efciency for
building up a contraction force. The clinical implication would be maintaining of the wrist-extension angle for the efciency
of muscle contraction with less exertion on the writing hand. This strategy with a decreased level of axial pen force would
also ease the stiffness and result in faster writing.
Acknowledgment
The authors would like to thank the Minister of Science and Technology of the Republic of China for supporting this work
nancially under contract Nos. NSC-95-2221-E-214-008 and NSC-97-2221-E-214-054-MY2.

S.-H. Chang et al. / Human Movement Science 43 (2015) 18

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