Role of exercise prescription to improve handwriting speed in healthy children

Disha R Monsara; Rajiv D Limbasiya

doi:10.4103/ijptr.ijptr_82_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 4 | Issue : 1 | Page : 58-63

Role of exercise prescription to improve handwriting speed in healthy children

Disha R Monsara, Rajiv D Limbasiya
Department of Physiotherapy, Sarvajanik College of Physiotherapy, Surat, Gujarat, India

Date of Submission	08-Dec-2021
Date of Decision	09-May-2022
Date of Acceptance	07-Jun-2022
Date of Web Publication	30-Jul-2022

Correspondence Address:
Dr. Disha R Monsara
Vidhyadeeep Institute of Physiotherapy, Surat, Gujarat
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_82_21

Abstract

Context: Currently, multiple kinds of research are done on undergraduate students for improving handwriting speed. This study will help to provide planned exercises for effective handwriting speed and to have a better outcome in the field of academics.
Aim: The purpose of this study was to determine the combined effects of an upper limb resistance and coordination Exercise program on handwriting speed in healthy school-aged children.
Setting and Design: A randomized control trial was conducted in the schools of Surat city.
Materials and Methods: Healthy school-going children aged 10–12 years with slow handwriting speed (n = 62), i.e., average word per minute (WPM) of 10 or less than that of a 10-year-old, 12 or less than that of an 11-year-old, and 14 or less than that of a 12-year-old, were randomly allocated to experimental and control groups. In the experimental group, both resisted and coordination exercises were given. In the control group, handwriting practice was given for 4 days a week for 4 weeks. Outcome measures were assessed as WPMs and Handwriting Proficiency Screening Questionnaire (HPSQ) at baseline, after 2 weeks and after 4 weeks.
Statistical Analysis Used: The mean difference within and between groups was determined using a repeated-measure analysis of variance.
Results: There was a significant difference within the group for both the outcome measures and both the groups (P < 0.05). For between-group analysis, the experimental group showed a significant difference in WPMs (P = 0.001) and handwriting proficiency screening score (P = 0.250) compared to the control group after 4 weeks of intervention.
Conclusion: Upper limb resisted, and coordination exercise improves handwriting speed in school-going children.

Keywords: Coordination exercises, Handwriting speed, Resisted exercises, Upper limb

How to cite this article:
Monsara DR, Limbasiya RD. Role of exercise prescription to improve handwriting speed in healthy children. Indian J Phys Ther Res 2022;4:58-63

How to cite this URL:
Monsara DR, Limbasiya RD. Role of exercise prescription to improve handwriting speed in healthy children. Indian J Phys Ther Res [serial online] 2022 [cited 2023 Jun 6];4:58-63. Available from: https://www.ijptr.org/text.asp?2022/4/1/58/353023

Introduction

Handwriting is a complicated activity requiring precise synchronization of the musculoskeletal and neurological systems. Fine, precise, and coordinated motions in the upper extremities occur during writing, and it is one of the most distinctive elements of human cultural evolution.^[1],[2],[3] Speed is vital in academic performance since it is closely tied to the ability to precise information about many disciplines. Because it is closely tied to the capacity to articulate knowledge about various subjects, speed plays a vital role in academic performance.^[4]

Handwriting is a crucial doorway to academic achievement because it promotes classroom engagement and offers a vital source of self-esteem in children, creating a competitive advantage among students, and handwriting is one of the modes of communication in the test.^{[5],[6],[7],[8],[9]} While toddlers start to combine visual and proprioceptive information by copying shapes and letters.^[10] When they are toddlers, they learn to correlate motions with the mental image of the letters and to write from dictation while also being able to regulate the movements proactively.^[11]

Slow handwriting lengthens the time necessary to accomplish projects, but it also alters the character of writing itself. Students never learn to flow through thoughts and words when the velocity of writing is reduced significantly or when the writing is continually stopped by a manual chore.^[12],[13] In an examination setting, handwriting speed is critical. Because there is a fundamental trade-off connection between handwriting speed and readability, having to write fast adds the extra dimension of creating readable text.^[14],[15]

The grip is the ability of the hand to grasp objects between the fingers and thumb. It is well believed that grip and pinch strength assessments give an objective indication of upper extremity functional integrity. Gripping, manipulation, and expressiveness are the primary tasks of the hand.^[16] Most of the previous studies were done on undergraduate students' handwriting speed. The main aim of the present study was to know whether there was an improvement in school-going children after the exercise or not.

Subjects and Methods

Study design and ethical consideration

The current research was a randomized control trial with convenient sampling. Participants were selected from four schools in two different zone of Surat city. The institutional ethics committee approved the research, which was carried out at the school. The study's goal was described, and written informed permission was acquired from teachers who signed as guardians, as well as oral consent was taken from parents.

Participants and randomization

Following screening of 200 individuals, a total of 69 children met the inclusion criteria, in which participants were divided into two groups, the experimental group having 35 participants and the control group having 34 participants. Allocation to the groups was done using the lottery method. The participants randomly picked up the chit, with each number corresponding to the group. During the study, seven participants were dropped out, so 62 participants completed the study with 31 in each group. These were counted based on the pilot research, and the sample size was determined to be 62, with an effect size of 0.25, a power of 0.8, and an α value of 0.05. Even though this sample size was quite small due to time constraints and after screening the overall population, only a few people met the criteria of slow writing speed. The groups were assigned using a simple randomized procedure. Allocation to the groups was done using the lottery method. The participants randomly picked up the chit, with each number corresponding to the group. The researcher assumed a 5% drop-off ratio and would strive to reach a 95% response rate, resulting in a sample size of n = 62, which was ideal for the planned study population.

The experimental group and control group were evaluated at the beginning, after 2 weeks, and after 4 weeks with words per minute (WPMs) and Handwriting Proficiency Screening Questionnaire (HPSQ). Targeted participants were included in the study if they were between the ages of 10 and 12, enrolled in English medium schools, and had an average WPM of 10 or less than that for a 10-year-old, 12 or less than that for an 11-year-old, and 14 or less than that for a 12-year-old.^[17] If a participant experienced an upper extremity fracture or amputation, upper limb musculoskeletal sickness, or upper extremity neurological condition, they were excluded [Figure 1].

Figure 1: Consort flow diagram

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Measurement of treatment outcome

Writing speed by words per minute

It is a measure of words written in a minute. In that, participants have to write the same paragraph on A4 size paper for 1 min and WPMs were counted. In general, the average writing speed of the students is around 25 WPMs. From these 5, 6, and 7 school-year students, the average WPM is 10, 12, and 14.^[17] Outcome measures were taken at the baseline, after 2 weeks, and after 4 weeks. Here, the speed of handwriting was measured by either the length of time it takes to compose a certain text or the quantity of text reproduced in a given period.^[17] For writing speed assessment, one paragraph was given for writing, i.e., Once there was an elephant. People called him motu. He had a friend. He was a rat. His name was Chhotu. Both Chhotu and Motu loved swimming. Writing of this paragraph on A4 size paper for 1 min and the WPMs were counted. Every participant's writing paper and size were the same.

Handwriting proficiency screening questionnaire

Handwriting proficiency was assessed using an HPSQ. It is a 5-point Likert scale scoring. The scale consists of 0–4 scores, on which the words are printed as 0 refers to “never” and 4 refers to “always;” that higher score indicates poorer performance. Scales subdomains include legibility, performance time, and physical and emotional well-being. Teachers did the scoring for this scale.^[18]

Procedure for intervention

Experimental group (n = 31)

This group got a total of 12 exercises, including resisted activities of the shoulder extensors, flexors, internal rotators, abductors, external rotators, protractors, retractors, elevators, and wrist extensors, flexors, radial deviators, and ulnar deviators using a red TheraBand. Red TheraBand had medium resistance as compared to yellow and green TheraBand, which were better ideal for this age group of children. An additional hand and forearm got a total of four activities, including finger spread, volcano, finger pinching, and squeezing with yellow Thera putty and coordination with the Purdue pegboard. Muscles were chosen based on electromyographic studies of upper limb muscles^[19],[20] as well as earlier research that showed these same muscles.^{[12],[20],[21],[22]} These exercises were performed 4 days a week for 4 weeks, each set consisting of ten repetitions, and likewise, two sets were performed for each exercise [Figure 2] and [Figure 3].

Figure 2: Resisted exercise of upper limb

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Figure 3: Coordination exercise with use of Purdue peg board

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Control group (n = 31)

Participants in this group wrote the same content every day in their notebooks. That paper was not provided by the researcher to avoid bias with experimental group participants. The control group participants were writing continuously for 45 min and 4 days a week. They write the same chapter every day and that was supervised by the researcher. The children were asked to perform the same task 4 days a week for 4 weeks [Figure 4].

Figure 4: Handwriting practice (control) group

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Statistical analysis

Statistical analysis was done using SPSS version 21 International Business Machines (IBM) Corporation is an American multinational technology corporation headquartered in Armonk, New York, USA with operations in over 171 countries. Normality distribution was assessed using the Shapiro–Wilk test. Descriptive statistics including frequency distribution, mean, and standard deviation were done to compare the means between two groups. Inferential statistics were done by using repeated-measure analysis of variance (ANOVA). Because the outcome measures were measured at multiple time intervals and generated interval data, repeated-measure multivariate ANOVA was used as the primary statistical analysis for within-group and between-group comparisons. P < 0.05 was considered statically significant.

Results

The present study was conducted on children with slow handwriting to find improvement in handwriting speed by different intervention procedures. There were 10, 10, and 11 students from the experimental and 10, 11, and 10 students from the control group belonging to standards 5, 6, and 7, respectively. There were 24 boys and 7 girls in the experimental group with 25 boys and 6 girls in the control group. A total of 57 were right-dominant while 5 were left-dominant children. In Experimental group,9 (29%) in sports and 4 (12.9%) in musical instrument playing activities participants were there. In the control group, 7 (22.6%) participated in sports and 5 (16.1%) in musical instrument playing activities.

The mean value of WPM and HPSQ both improved statistically significantly, as shown in [Table 1]. WPM showed a greater improvement (P=0.03) compared to HPSQ (P=0.04). In the experimental group, there was a greater difference compared to the control group. For within- and between-group analyses, repeated-measure ANOVA with the Greenhouse-Geisser correlation was used which showed overall significant statistical differences. The within-group comparison P-value for both outcome measures was significant (P=0.001). In WPM, the P-value for the between-group comparison was significant (P=0.001), but it was not significant (P=0.25) for HPSQ.

Table 1: Within- and between-group comparison for both the outcome measures^a

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Discussion

The results of the between-group comparison revealed that the experimental group improved more than the control group in terms of WPM, indicating that there is an improvement in handwriting speed because of the combined effect of resisted and coordination exercises compared to handwriting practice.

Hence, on the basis of this, clinically, it proves that, with the training of a combination of resisted and coordination exercises, children can write their examinations and homework without pain and with good handwriting compared to those without exercise group participants. Muscle strength is essential for a child to accomplish their gross and fine motor abilities, which are the basis of excellent legible handwriting. A lack of muscular power has also resulted in an epidemic of bad pen/pencil grips.

Previous research indicates that upper limb strengthening training has an effect on handwriting speed in undergraduate students. The exercise group outperformed the handwriting practice group, according to the results. It occurs because when the larger muscles of the shoulder girdle operate effectively together, they provide stability for the smaller muscles of the hand and arm to do their job properly.^[23] Another research found that strengthening exercises for the brachioradialis, wrist extensors, biceps, coordination exercises for the hand and forearm, and endurance exercises for the hand and forearm muscles statistically enhanced pinch grip strength, handwriting speed, and upper limb coordination.^[12]

In one previous study, researchers performed research on handwriting speed. The exercise intervention was carried out for three components, i.e., strength, coordination, and endurance exercise, which was a structured exercise program. They concluded that a forearm, hand, and wrist exercise program can improve handwriting speed. The mechanism was that shoulder integrity is an important component in handwriting. If the shoulder is strong, wrist stability is a key element for having fine finger control and thus improved handwriting. With a strong shoulder, maintaining precise finger control and improving handwriting depend on wrist stability.^[24]

In the present study, age group and the sample size were limited. Children studying in English medium only included. Children playing any musical instruments or any sports were also included in the statistics, which might affect the outcome of the study. Further study can be done by taking the more standards of children and also finding the difference between boys and girls. The study also can be done to find out the right- and left-dominant handwriting speed difference. Handwriting speed can be checked by different pencil grips also.

Conclusion

The results of the present study concluded the beneficial effect of a combined training protocol of resisted and coordination exercises on handwriting speed in school-going children. However, the handwriting proficiency did not show significant improvement. Based on the study results, children with slow handwriting speed can be prescribed exercises at a small age so that it will give better academic performance and success.

Acknowledgment

We would like to express our heartfelt gratitude to Dr. A. Thangamani Ramalingam for his support in statistical analysis. We are grateful to all school principals for permitting us to conduct the study and providing research-related infrastructure. We are thankful to all the individuals for participating in the study, without whom the study would not have been possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Koppenhaver KM. Factors That Cause Changes in Handwriting. Forensic Document Examination: Principles and Practice. Totowa, NJ: Humana Press; 2007. p. 27-36.
2.	Rosenblum S, Aloni T, Josman N. Relationships between handwriting performance and organizational abilities among children with and without dysgraphia: a preliminary study. Res Dev Disabil 2010;31:502-9.
3.	Schieber MH, Santello M. Hand function: peripheral and central constraints on performance. J Appl Physiol (1985) 2004;96:2293-300.
4.	Ziviani J, Watson-Will A. Writing speed and legibility of 7–14-year-old school students using modern cursive script. Aust Occup Ther J 1998;45:59-64.
5.	Engel-Yeger B, Nagauker-Yanuv L, Rosenblum S. Handwriting performance, self-reports, and perceived self-efficacy among children with dysgraphia. Am J Occup Ther 2009;63:182-92.
6.	Erhardt RP, Meade V. Improving handwriting without teaching handwriting: The consultative clinical reasoning process. Aust Occup Ther J 2005;52:199-210.
7.	Alaniz ML, Galit E, Necesito CI, Rosario ER. Hand strength, handwriting, and functional skills in children with autism. Am J Occup Ther 2015;69:p1-9.
8.	Feder KP, Majnemer A. Handwriting development, competency, and intervention. Dev Med Child Neurol 2007;49:312-7.
9.	Connelly V, Dockrell JE, Walter K, Critten S. Predicting the quality of composition and written language bursts from oral language, spelling, and handwriting skills in children with and without specific language impairment. Written Commun 2012;29:278-302.
10.	Daly CJ, Kelley GT, Krauss A. Relationship between visual-motor integration and handwriting skills of children in kindergarten: A modified replication study. Am J Occup Ther 2003;57:459-62.
11.	Meulenbroek RG, Van Galen GP. Foreperiod duration and the analysis of motor stages in a line-drawing task. Acta Psychol (Amst) 1988;69:19-34.
12.	Nilukshika KVK, Nanayakkarawasam PP, Wickramasinghe VP. The effects of upper limb exercises on handwriting speed. Indian J Physiother Occup Ther 2012;6:6.
13.	Konur O. Teaching disabled students in higher education. Teach High Educ 2006;11:351-63.
14.	Weintraub N, Graham S. Writing legibly and quickly: A study of children's ability to adjust their handwriting to meet common classroom demands. Learn Disabil Res Pract 1998;13:146-52.
15.	Franzsen D, Stewart A. Identifying the factors that contribute to handwriting problems experienced by students at a higher education institution in South Africa. S Afr J Occup Ther 2014;44:3-8.
16.	Incel NA, Ceceli E, Durukan PB, Erdem HR, Yorgancioglu ZR. Grip strength: Effect of hand dominance. Singapore Med J 2002;43:234-7.
17.	Hedderly R. Assessing pupils with specific learning difficulties for examination special arrangements at GCSE, 'A' level and degree level. Educ Psychol Pract 1996;12:36-44.
18.	Rosenblum S. Development, reliability, and validity of the Handwriting Proficiency Screening Questionnaire (HPSQ). Am J Occup Ther 2008;62:298-307.
19.	Naider-Steinhart S, Katz-Leurer M. Analysis of proximal and distal muscle activity during handwriting tasks. Am J Occup Ther 2007;61:392-8.
20.	Linderman M, Lebedev MA, Erlichman JS. Recognition of handwriting from electromyography. PLoS One 2009;4:e6791.
21.	Kisner C, Colby LA. Therapeutic Exercise. 6^th ed. JPB/FAD: F A DAVIS Company; 2012.
22.	Servies SC. 4 Week Theraputty Programme. Available from: https://www.nhsggc.org.uk/kids/healthcare-professionals/paediatric-occupational-therapy/theraputty-hand-strength-exercise. [Last accessed on 2018 Nov 12].
23.	Kamalanathan P, Banu HS. Effects of upper limb strengthening exercises on handwriting speed in undergraduate students. International Journal of Pharmaceutical and Clinical Research 2017;9:475-9.
24.	Kumar YP, Shweta SH, Anagha MJ. Effect of forearm, hand and wrist exercises on writing speed in health science students of Nagpur. Semantic scholar 2013;19:6.