Article Text

Download PDFPDF

How to use pen and paper tasks to aid tremor diagnosis in the clinic
  1. Jane Alty1,
  2. Jeremy Cosgrove1,
  3. Deborah Thorpe2,3,
  4. Peter Kempster4,5
  1. 1Department of Neurology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  2. 2Department of Electronics, University of York, York, UK
  3. 3Centre for Medieval Studies, University of York, York, UK
  4. 4Department of Neurosciences, Monash Medical Centre, Clayton, Australia
  5. 5Department of Medicine, Monash University, Clayton, Australia
  1. Correspondence to Dr Jane Alty, Department of Neurology, Leeds General Infirmary Leeds, UK; jane.alty{at}


When a patient presents with tremor, it can be useful to perform a few simple pen and paper tests. In this article, we explain how to maximise the value of handwriting and of drawing Archimedes spirals and straight lines as clinical assessments. These tasks take a matter of seconds to complete but provide a wealth of information that supplements the standard physical examination. They aid the diagnosis of a tremor disorder and can contribute to its longitudinal monitoring. Watching the patient’s upper limb while they write and draw may reveal abnormalities such as bradykinesia, dystonic posturing and distractibility. The finished script and drawings can then be evaluated for frequency, amplitude, direction and symmetry of oscillatory pen movements and for overall scale of penmanship. Essential, dystonic, functional and parkinsonian tremor each has a characteristic pattern of abnormality on these pen and paper tests.

  • tremor
  • parkinson-s disease
  • dystonia
  • handwriting
  • archimedes spiral

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

View Full Text

Statistics from


  • Contributors All authors have equally contributed to the manuscript.

  • Funding Dr Thorpe was part-funded by the Wellcome Trust [ref: 105624] through the Centre for Chronic Diseases and Disorders (C2D2) at the University of York.

  • Competing interests JA is employed by Leeds Teaching Hospitals NHS Trust. She has previously been awarded grants by Parkinson’s UK, Ipsen, UCB Foundation, Merz, Medtronic and Bial. She has received honoraria from Allergan and Medical Update Ltd. She has stock ownership in Clear Sky Diagnostics. She receives royalties from Taylor & Francis Group for medical textbooks she has coauthored.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Provenance and peer review Commissioned; externally peer reviewed. This paper was reviewed by Peter Bain, London, UK, and Simon Lewis, Sydney, Australia.

  • Data sharing statement None.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles

  • Editors’ commentary
    Phil E M Smith Geraint N Fuller