Research in Developmental Disabilities 34 (2013) 1152–1159

Contents lists available at SciVerse ScienceDirect

Research in Developmental Disabilities

The effect of lower body stabilization and different writing tools on

writing biomechanics in children with cerebral palsy
Hsin-Yi Kathy Cheng a,1, Yueh-Ju Lien a, Yu-Chun Yu a,b, Yan-Ying Ju c,*, Yu-Cheng Pei d,
Chih-Hsiu Cheng e, David Bin-Chia Wu f
a
Graduate Institute of Early Intervention, Medical College, Chang Gung University, 259 Wen-Hua 1st Rd., Kwei-Shan, Tao-Yuan 333, Taiwan
b
National Taoyuan Special School, Taiwan
c
Department of Adapted Physical Education, National Taiwan Sport University, Tao-Yuan, Taiwan
d
Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
e
Department of Physical Therapy and Graduate Institute of Rehabilitation Science, Medical College, Chang Gung University, Taiwan
f
Jeffrey Cheah School of Medicine and Health Sciences, Monash University Sunway Campus, Malaysia

A R T I C L E I N F O A B S T R A C T

Article history: A high percentage of children with cerebral palsy (CP) have difficulty keeping up with the
Received 27 October 2012 handwriting demands at school. Previous studies have addressed the effects of proper
Received in revised form 22 December 2012 sitting and writing tool on writing performance, but less on body biomechanics. The aim of
Accepted 28 December 2012 this study was to investigate the influence of lower body stabilization and pencil design on
Available online 30 January 2013 body biomechanics in children with CP. Fourteen children (12.31  4.13 years old) with CP
were recruited for this study. A crossover repeated measures design was employed, with two
Keywords: independent variables: lower body stabilization (with/without) and pencil (regular/assigned
Cerebral palsy
grip height/biaxial). The writing task was to trace the Archimedean spiral mazes.
Biomechanics
Electromyography (EMG) of the upper extremity, the wrist flexion/extension movements,
Handwriting
Posture
and the whole body photography were recorded to quantify the changes in posture and upper
Biaxial pencil extremity biomechanics. Two-way repeated measures ANOVA was used for statistical
analysis. No significant main effects were revealed in the EMG and wrist kinematics. The lower
body stabilization significantly decreased the trunk lateral and forward deviations, and the
visual focus-vertical angle. The biaxial pencil and the assigned grip height design significantly
decreased the head, shoulder, trunk, and pelvic deviations compared with the regular design.
The results indicated that the lower body positioning was effective in improving the trunk
posture. A pencil with an assigned grip height or with a biaxial design could improve head,
shoulder, trunk and pelvic alignment, but did not influence the muscle exertion of the upper
extremity. This study could provide guidelines for parents, teachers and clinicians regarding
the selection of writing tools and the knowledge of proper positioning for the children with
handwriting difficulties. Further analyses can focus on the design, modification and clinical
application of assitive sitting and writing devices for the use in children with handwriting
difficulties.
ß 2013 Elsevier Ltd. All rights reserved.

* Corresponding author at: Department of Adapted Physical Education, National Taiwan Sport University, 250 Wen-Hua 1st Rd., Kwei-Shan, Tao-Yuan,
Taiwan. Tel.: +886 3 3283201x8624; fax: +886 3 3277475.
E-mail addresses: kcheng@mail.cgu.edu.tw (H.-Y. Cheng), melody6584@yahoo.com.tw (Y.-J. Lien), ot.spring.yu@gmail.com (Y.-C. Yu),
yanju@mail.ntsu.edu.tw, kathyju@hotmail.com (Y.-Y. Ju), yspeii@gmail.com (Y.-C. Pei), chcheng@mail.cgu.edu.tw (C.-H. Cheng), david.wu@monash.edu
(D.-C. Wu).
1
Tel.: +886 3 211 8800x3667; fax: +886 3 211 8700.

0891-4222/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ridd.2012.12.019
 H.-Y. Cheng et al. / Research in Developmental Disabilities 34 (2013) 1152–1159 1153

1. Introduction

Writing and related fine motor activities account for 30–60% of the academic day for school-aged children (McHale &
Cermak, 1992). Although many school-aged children with spastic cerebral palsy (CP) have the capability to write, a high
percentage of them have difficulty keeping up with the handwriting demands at school (Rigby & Schwellnus, 1999). For
children with hemiplegia, handwriting difficulties were reported in functional writing, organization, neatness and speed
(DuBois, Klemm, Murchland, & Ozols, 2004). Other than their sensory and cognitive impairments, children with CP exhibit a
group of movement and posture disorders that might affect their handwriting (Odding, Roebroeck, & Stam, 2006). They
usually experience spasticity of their extremities, lack of righting and equilibrium reactions and easy fatigue, which caused
them to sit in a reclined position on their sacra (Odding et al., 2006; Reid, 1996). This sacrum-sitting position does not
promote writing with upper extremities.
Due to this poor sitting posture, problems such as shoulder and neck soreness (Murphy, Buckle, & Stubbs, 2004), back pain
(Trevelyan & Legg, 2006), kyphosis (Murphy et al., 2004) and myopia (Saw, 2003) would develop in children with CP, and
therefore inevitably impact on their learning and academic success. In order for the upper extremities to function effectively,
proper positioning is important. A certain number of research demonstrates that control of the following factors can
maximize upper extremity function: the symmetrical fixation of the child by a belt anchored under the seat; the use of an
abduction orthosis; the placement of the line of gravity of the upper body anterior to the axis of rotation at the ischial
tuberosities; and forearms supported against a table (Myhr & von Wendt, 1990; Nwaobi, 1987; Stavness, 2006).
Proper sitting can only facilitate writing function in children with CP to some degree, however. Most children with CP also
demonstrate poor grip function (Kavak & Bumin, 2009), imparied tactile and proprioceptive sensation (Odding et al., 2006),
insufficient muscular endurance (Odding et al., 2006) and inadequate upper extremity motor control (Reid, Elliott, Alderson,
Lloyd, & Elliott, 2010). They may have to grip with excessive efforts to compensate their sensory and motor deficits, which
might in turn elicit synergy pattern of the arm or the asymmetrical tonic neck reflex causing trunk inclination. If these
conditions persist, consequently, an imbalance between the bilateral trunk musculature would occur, along with muscle
pain or neck and trunk symptoms. A writing tool that minimizes children’s neuromuscular demands during handwriting
activities should be able to attenuate the above problems (Goonetilleke, Hoffmann, & Luximon, 2009; Yu, 2011).
A good writing performance cannot be achieved without proper-aligned sitting posture (Noda & Tanaka-Matsumi, 2009).
Most studies investigating the effects of proper sitting and writing tool focused on writing performance, but little of them
discussed the effects on posture and body biomechanics, including joint angles and muscle activities of upper extremities
and trunk. The aim of this study was to investigate the influence of lower body stabilization and pencil design on body
biomechanics in children with CP. We hypothesized that children with lower body stabilization and with the use of proper
writing tool will improve their axial alignment and spend less effort during handwriting.

2. Materials and methods

2.1. Participants

Fourteen children with CP between age seven and seventeen were recruited for this study. The inclusion criteria were: the
ability to write with regular pencil; right hand dominancy; Manual Ability Classification System (MACS) levels 1–3, upper
extremity rating scale (Koman et al., 2008) at none or mild; and the ability to follow commands. Exclusion criteria were: Any
orthopedic anomalies, upper extremity surgery within the past six months; nerve block or botulinum toxin injection within
the past three months; significant visual, auditory and cognitive deficits that would interfere with handwriting performance;
past experience with biaxial pencil usage; and epilepsy. The Institutional Review Board for Human Studies of Chang Gung
Memorial Hospital approved this protocol. Written informed consents were obtained from all participants and their legal
guardians.

2.2. Design and procedures

A crossover repeated measures design was employed in this study, with two independent variables: lower body
stabilization (with/without) and pencil (regular/assigned grip height/biaxial). Fourteen children with CP were randomly
divided into two groups. One group performed the writing task with the lower body stabilized, and then performed the same
writing task without stabilization one week later. The other group began their task sequence the other way around to
counterbalance the order effects. During each writing task, three pencils were distributed to the subject in a random order.
There was a 30-min rest in between the use of different pencils (Fig. 1).

2.2.1. Equipment
A wooden height-adjustable chair and a height-adjustable desk were used for the writing task. The chair has a straight
30 cm-high back, an adjustable pelvic belt to hold the pelvic in position, and two lower leg straps to keep the legs from
leaning or slipping. The desk has a surface 120 cm long and 60 cm wide.
Three different pencils were used in this study (Fig. 2). Two of them are identical regular pencils with triangular rubber
grips (the lowest margin of the grip is 2.8 cm from the pencil tip), except the second pencil has a line marked at 2.8 cm
1154 H.-Y. Cheng et al. / Research in Developmental Disabilities 34 (2013) 1152–1159

CP With Without 1st Pencil 2nd Pencil 3rd Pencil

1st Pencil 2nd Pencil 3rd Pencil
(N=7) Stabilization

Washout period- 1 week

Stabilization

Children
with CP Random Assignment Cross-over
(N=14)

CP Without With 1stPencil 2nd Pencil 3rd Pencil

1stPencil 2nd Pencil 3rd Pencil
(N=7) Stabilization Stabilization

Pencil 1st, 2 nd, 3 rd : The three pencils (control/assigned grip height/biaxial)

. in a random order of testing

Fig. 1. Flow chart of the crossover design.

Fig. 2. The writing tools. The pencil at the top was used for the previous two conditions, the pencil down at the bottom was the biaxial pencil.

distance from the pencil tip. Subject was requested to hold the pencil at the line when using that pencil. The third one is a z-
shaped biaxial pencil (Yoropen Corp., Taipei, Taiwan). The angle between the two axes is 238. The angle of the pencil enables
the writer to see clearly what she/he is writing, and therefore the fingers do not block the visual field. It also has a tripod
rubber grip 2.8 cm from the pencil tip. All of the pencils have a shaft diameter about 1.1 cm.

2.2.2. Protocol and assessment

Subjects were seated on the chair in front of the table. The chair and the table were height-adjusted to fit the subject. The
testing sheet was laid 10 cm away from the border of the desk. The distance between the eyes of the subject and the desk
surface was 35.37 (2.65) cm.
For condition without lower body fixation, the subject sat on the chair without any constraint. For condition with lower
body fixation, the subject was secured with the pelvic belt and the lower leg straps, with the pelvic in mid-position and the
lower legs abducted for about 10–208, feet flat on the floor.
Three digital cameras were used to capture postural information on body segments. Adhesive markers were
placed over the subject’s bilateral earlobes, shoulder acromion processes, the spinous processes of the 7th cervical
column (C7), the 10th thoracic column (T10), and the 4th lumbar column (L4). Photographs were obtained using three
digital cameras (Sony DSC-HX5 V) situated in the front, back, and right side of the subjects. Cameras were attached to
tripods placed in a distance/height of 300/120 cm (front), 200/55 cm (back) and 120/80 cm (right) from the subject.
Spirit levels placed on top of the cameras and on side of the lens were used to confirm the horizontal and vertical
alignments of the camera respectively. The correct placements of the subject, the desk, and the tripods were marked
with the masking tape.
Photographs were exported to a PC and further processed by AutoCAD software (Autodesk Inc., USA), to digitize the x and
y coordinates obtained from each anatomical landmark of the photographs. One of the authors undertook all the digitizing
process to eliminate inter-examiner error (test-retest measurement accuracy 98.17%). The x, y coordinate values were used
to calculate the following body angles used for data analysis:

Posterior view:
head-horizontal angle (HH)
head-shoulder angle (HS)
shoulder-horizontal angle (SH)
trunk lateral inclination angle (TLI)
Posterior superior iliac spine-horizontal angle (PSIS-H)
posterior superior iliac spine-C7/L4 angle (PSIS-C7/L4)
Anterior view:
visual focus-vertical angle (VFV)
pencil-desk angle, anterior view (PD-A)
Lateral view:
 H.-Y. Cheng et al. / Research in Developmental Disabilities 34 (2013) 1152–1159 1155

Fig. 3. The modified Archimedean spiral.

head forward inclination angle (HFI)

trunk forward inclination angle (TFI)
pencil-desk angle, lateral view (PD-L)

In addition, a biaxial electrogoniometer (SG110, Biometrics, Ltd., Cwmfelinfach, Gwent, UK), secured on the dorsal side of
the 3rd metacarpal bone and the forearm, was used to measure the degree of wrist-vertical deviation (W-V).
Surface EMG was used to monitor muscle activities. The skin overlying the target muscles was prepared with alcohol
swabs for the application of electrodes. Bipolar active electrodes (TSD 150A, Biopac System Inc., Santa Barbara, CA, USA) were
applied onto the following muscles: flexor carpi ulnaris (FCU), flexor digitorum superficialis (FDS), 1st inter digitorum (1st
ID), extensor carpi radialis (ECR), extensor digitorum communis (EDC), bilateral upper trapezius (left trapezius: LT, right
trapezius: RT). The reference electrode was placed on the olecranon of the left elbow. A 2-min resting EMG data was collected
as the baseline prior to the start of the writing task. BIOPAC MP150 (Biopac System Inc., USA) was used for data acquisition.
After the preparation, the subject had 3 min to practice handwriting with the designated pencil. Then the subject
completed a testing sheet for data collection purpose. The testing sheet has 25 modified Archimedean spiral mazes (5 rows of
5). The Archimedean spiral maze was modified from the original Archimedean spiral (Lin, 2007), which is the locus of points
corresponding to the locations over time of a point moving away from a fixed point with a constant speed along a line which
rotates with constant angular velocity. This modified version has a squared shape (2 cm  2 cm) to mimic the notebook for
Chinese handwriting (Fig. 3). The subject was asked to draw a line along the spiral maze in an outside-in manner, until the
center of the maze was reached. At the start of each row, the subject was requested to press down with the pencil tip on the
black dot for 5 s. They were asked to look at the black dot and use the same effort as they were about to write. Photographs
were taken at this time, along with the start of EMG and electrogoniometer data collection. Subject was then asked to
complete that row of mazes as soon as he/she could. Same procedure was repeated for each row. The root-mean-square
(RMS) value of the EMG within 500 ms before the movement initiation was calculated. Data collected from the 5 rows were
averaged for statistical analysis. Thirty minutes after the completion of the test sheet with the 1st pencil, the process was
duplicated for the 2nd and the 3rd pencils. The average maze finish time for each pencil was recorded.

2.3. Data processing and analysis

All data were analyzed using the statistical analysis software SPSS (SPSS Inc., version 17.0, Chicago, IL, USA). Descriptive
statistics were used to calculate the subjects’ demographics. Two-way analysis of variance (ANOVA) [stabilization (2
factors)  pencil (3 factors)] with repeated measures on pencil was performed for all variables. The predetermined alpha
level was set at 0.05. If any repeated measures ANOVA identified a significant difference among the means, multiple
comparisons between pairs of means were conducted to determine groups of significant differences using alpha level with
Bonferroni adjustment.

3. Results

Six boys and eight girls with a mean age of 12.31  4.13 years participated in this study. Their diagnoses were spastic
diplegia (N = 6), spastic quadriplegia (N = 6), and spastic hemiplegia (N = 2). Their MACS levels were 1 (N = 3), 2 (N = 6), and 3
(N = 5). The averaged grip height was 16.92  5.39 mm.
Inferential statistics for variable analysis are presented in Table 1. For the body angles, significant differences were found
in TLI, VFV and TFI angles for stabilization; in HH, SH, TLI, PSIS-H, PSIS-C7/L4, VFV, PD-A angles for pencil; and in PSIS-C7/
L4 angle only for stabilization and pencil interaction. Post hoc analyses for pencil indicated that differences existed between
regular/biaxial and assigned/biaxial for variables as HH (p = 0.090, p = 0.073), TLI (p < 0.001, p < 0.001), PSIS-C7/L4 (p = 0.001,
p = 0.001), and VFV (p < 0.001, p < 0.001); between regular/biaxial and regular/assigned for SH (p = 0.013, p = 0.048);
between regular/biaxial for PSIS-H (p = 0.049) and PD-A (p = 0.001). For the electrogoniometer (W-V deviation angle) and
EMG results, no significant difference was found in any variable. No statistical significant difference was revealed in the
 1156
Table 1
Inferential statistics for variable analyses.

Variables Without stabilization Mean (SD) With stabilization Mean (SD) Pstabilization Ppencil Pstabilization  pencil

H.-Y. Cheng et al. / Research in Developmental Disabilities 34 (2013) 1152–1159

Pencil Pencil

Regular Assigned Biaxial Regular Assigned Biaxial

Angle-photography/ HH 11.51 (9.02) 10.06 (7.45) 7.34 (5.95) 11.74 (8.16) 10.75 (8.12) 9.46 (4.93) 0.549 0.028* 0.741
electrogoniometry
HS 4.18 (7.51) 5.55 (7.03) 3.09 (6.84) 4.89 (9.28) 4.98 (9.16) 4.46 (7.05) 0.735 0.312 0.664
SH 7.17 (3.89) 4.51 (5.00) 4.12 (5.41) 6.66 (6.05) 5.83 (3.93) 4.83 (5.05) 0.736 0.007* 0.469
TLI 77.85 (5.14) 76.15 (6.19) 81.25 (5.71) 79.29 (3.25) 81.03 (3.09) 84.38 (2.40) 0.017* 0.000** 0.088
PSIS-H 4.62 (6.93) 3.15 (6.39) 3.66 (6.39) 0.22 (0.78) 0.11 (0.39) 0.02 (0.06) 0.051 0.024* 0.060
PSIS-C7/L4 82.51 (8.27) 79.29 (7.49) 84.91 (5.05) 79.51 (3.13) 81.14 (3.03) 84.40 (2.41) 0.735 0.000** 0.026*
VFV 65.17 (8.99) 67.68 (9.05) 78.92 (4.70) 69.43 (5.80) 71.18 (6.04) 82.11 (3.35) 0.013* 0.000** 0.846
PD-A 79.31 (6.18) 75.62 (9.60) 73.65 (6.62) 78.08 (6.28) 77.17 (8.35) 72.34 (8.04) 0.836 0.000** 0.357
HFI 21.52 (12.96) 23.37 (14.73) 22.78 (14.85) 26.28 (13.67) 25.31 (14.61) 24.43 (14.27) 0.178 0.831 0.540
TFI 48.12 (12.38) 48.28 (13.2) 48.03 (11.62) 43.83 (10.24) 44.20 (11.92) 44.02 (9.35) 0.023* 0.973 0.986
PD-L 5.12 (16.31) 5.17 (17.84) 5.63 (14.52) 1.52 (16.48) 1.74 (18.65) 2.32 (18.00) 0.258 0.893 0.980
W-V 27.36 (12.79) 29.84 (13.38) 28.57 (15.48) 28.15 (12.90) 29.57 (13.44) 28.54 (15.30) 0.724 0.600 0.747
EMG FCU 0.20 (1.02) 0.85 (1.13) 0.90 (2.61) 0.13 (1.72) 0.43 (0.99) 0.27 (1.39) 0.293 0.625 0.857
FDS 0.69 (0.89) 0.36 (0.76) 0.34 (1.22) 0.24 (0.85) 0.24 (0.49) 0.12 (0.83) 0.264 0.660 0.713
1st ID 0.06 (2.32) 0.25 (1.95) 0.17 (5.44) 0.24 (2.45) 1.05 (4.27) 1.64 (4.56) 0.119 0.690 0.895
ECR 1.32 (4.77) 0.44 (2.07) 0.37 (2.03) 0.02 (1.31) 0.77 (1.87) 0.35 (1.84) 0.882 0.655 0.327
EDC 0.15 (0.73) 0.06 (0.96) 0.12 (1.03) 0.10 (1.56) 0.19 (1.13) 0.24 (1.56) 0.770 0.904 0.872
L-T 0.16 (1.30) 0.35 (0.83) 0.27 (3.79) 0.19 (1.15) 0.24 (0.57) 0.18 (0.66) 0.850 0.584 0.981
R-T 1.53 (3.98) 2.06 (4.33) 0.54 (0.80) 0.34 (0.45) 1.11 (1.22) 0.77 (0.98) 0.334 0.229 0.316

HH: head-horizontal angle; HS: head-shoulder angle; SH: shoulder-horizontal angle; TLI: trunk lateral inclination angle; PSIS-H: posterior superior iliac spine-horizontal angle; PSIS-C7/L4: posterior superior iliac
spine-C7/L4 angle; VFV: visual focus-vertical angle; PD-A: pencil-desk angle, anterior view; HFI: head forward inclination angle; TFI: trunk forward inclination angle; PD-L: pencil-desk angle, lateral view; W-
V = wrist vertical deviation; FCU: flexor carpi ulnaris; FDS: flexor digitorum superficialis; 1st ID: 1st inter digitorum, ECR: extensor carpi radialis, EDC: extensor digitorum communis, L-T/R-T: left/right upper
trapezius. Unit: mV for muscle EMG; degree for angle.
* p < .05.
** p < .01.
 H.-Y. Cheng et al. / Research in Developmental Disabilities 34 (2013) 1152–1159 1157

average maze finish time for stabilization (F = .055, p = 0.439), pencils (F = .600, p = 0.946), or their interaction (F = .177,
p = 0.838).

4. Discussion

As the inclusive education promotes diversity and full participation, children with disabilities such as CP are included in
regular school setting. They are expected to join classroom activities, such as handwriting. However, many children with
spastic CP have abnormal muscle tone and motor control that interfere with their posture and handwriting. Most studies
investigated writing performance in children with CP, however little of them focused on body biomechanics during
handwriting. To the author’s knowledge, this study was the first to investigate the influences of lower body stabilization and
pencil parameters on body biomechanics during handwriting in children with CP.
According to the results, the time to complete the Archimedean maze did not differ significantly across the pencils. This
indicated that the speeds of writing with three pencils were not statistically significant. For the results of EMG, no
statistically significant differences were found for stabilization, pencil, and the interaction. Children with CP exhibit a great
diversity in their symptoms and clinical appearances (Arner, Eliasson, Nicklasson, Sommerstein, & Hägglund, 2008; DuBois
et al., 2004). Our subjects held the pencils in ways that were most comfortable and functional for themselves, therefore
exhibited great movement variability. These have made the comparison of EMG data difficult. No differences could be found
in stabilization conditions, in pencils, or in the interaction between these two variables. These findings could result from the
great varieties of pencil grip, along with the various motor control difficulties and coping strategies of each subject. Our
findings are similar to the results from previous literature. No significant EMG was found with different grips (Ferriell et al.,
2000).
This study also found that no significant difference existed in wrist angle for stabilization, types of pencils, and their
interaction. This indicated that wrist angle was not directly influenced by the stability of lower body, or by the pencil used. It
is reasonable that lower body stabilization may not influence wrist angle. Most subjects, as the examiners observed during
the maze depiction, laid their elbows on the desk to support their upper extremities. Therefore the effects of lower body
stabilization on the distal wrist were minimal. However, one would think that types of pencils should make a difference in
wrist angle, and the result was not as we expected. We attributed these to the effects were either too small to be detected, or
the varieties of hand grips among our CP subjects canceled out the effects of the pencils.
As for the results on photography, our results revealed significant differences in trunk lateral inclination, trunk forward
inclination and visual focus-vertical angles for stabilization. Since the pelvic belt and the lower leg straps held the pelvic and
the lower legs in position, the results indicated that proper pelvic and lower extremity positioning have a direct impact on
trunk stability, leading to less trunk inclination. Consequently, the head was held erect therefore the visual focus-vertical
angle improved. These findings were supported by previous literature indicating that the postural control was markedly
superior when the child was secured symmetrically by a belt anchored under the seat, and with orthosis that held lower legs
in abduction (Myhr & von Wendt, 1990; Stavness, 2006). This sitting position also improved the upper extremity function
(Stavness, 2006).
Body posture is generally considered to have an important influence on the efficiency of the writing process and product
in typically developing (Yeats, 1997) and children with CP (Rigby & Schwellnus, 1999). Postural problems are common for
children with CP. These problems include but not limited to the associated movements through the face and arms; rounded
back; and slouching onto a desk causing the face close to the page (Rigby & Schwellnus, 1999). All of these would hamper
bilateral control and trunk stability. As a result these children must devote a lot of attention and energy to the task of sitting
and controlling movements, which may distract them from the handwriting tasks. With the use pelvic belt and lower leg
straps, these postural adaptations can be controlled and therefore promote the handwriting quality and efficiency in children
with CP.
Significant differences were found in head-horizontal; shoulder-horizontal; trunk lateral inclination; posterior superior
iliac spine-horizontal; posterior superior iliac spine-C7/L4; visual focus-vertical; and pencil-desk anterior view angles for the
types of pencils. Compared to the results from the effects of stabilization, the types of pencil had even broader influences on
handwriting posture. For SH, post hoc analysis revealed that the difference existed between regular pencil and the other two
pencils. Since the difference between the regular pencil and the other two pencils was mainly in the grip height, this result
indicated that grip height would affect shoulder level during writing. For variables other than SH, post hoc analyses revealed
that the differences existed in between biaxial pencil and the other two pencils. The main difference between the biaxial
pencil and the other two was its biaxial design. Practically, the z-shape design of the biaxial pencil ensures that subject’s
fingers do not obstruct the field of vision, which in turn eliminates head and trunk inclination.
Significant difference was found in posterior superior iliac spine-C7/L4 on the interaction between stabilization and
pencil. Writing with a biaxial pencil was helpful in facilitating better body biomechanics, but was more helpful on average if
given in combination with lower body stabilization.
Researchers and clinicians have noted that inferior ergonomic factors related to body position and pencil use are
characteristic of nonproficient handwriters (Parush, Levanon-Erez, & Weintraub, 1998; Rosenblum, Dvorkin, & Weiss, 2006).
However, few studies have been done to investigate the biomechanical ergonomics in most handwriting evaluations. Most
writing studies emphasized on the hand itself and its performance. The results of this study offered scientific and
quantitative information on body posture and upper extremity biomechanics. To sum up, the results of this study indicate
1158 H.-Y. Cheng et al. / Research in Developmental Disabilities 34 (2013) 1152–1159

that proper stabilization of the lower extremity alone improve trunk and head inclination during handwriting. Using a pencil
with an assigned grip height of 2.8 cm can facilitate the subject’s shoulder to stay level. Along with the biaxial design, the
alignment of pelvic, trunk, shoulder, head, and visual focus were improved all together. Although these factors are beneficial
for body posture, they did not change the upper extremity muscle exertion to a statistically significant level.
There are couple limitations for this study. First of all, our subjects were spastic-type CP therefore attention must be paid
while we generalized the results. In addition, there were a limited number of subjects in each type, and this needs to be
improved with future follow-ups. Furthermore, this study only monitored the immediate effects of lower body fixation and
the use of different writing tools. Long term effects should be monitored in the future.
Lastly, instead of using the three-dimensional analysis, photographs were used to capture the posture changes therefore
no rotational information was available. Three-dimensional motion analysis devices were not used since prominent
reflexive markers or flock of birds would interfere with handwriting movements. Some markers have electrical cords which
would hinder the subjects from moving freely. For what we need to monitor (the joint angles in each anatomical plane), two-
dimensional picture would be a better choice plus it required less effort in modeling afterwards. In addition, three cameras
were used for data collection therefore the photographs from three directions would provide us ideas regarding how the
subject performed in three-dimensional space.

5. Conclusion

Children with handwriting problems typically have difficulties dealing with the written work, which in turn affect
academic progress and may lead to social and behavior problems (Feder & Majnemer, 2007). Furthermore, poor writing
biomechanics inevitably lead to health problems. This study suggested that a chair which provides proper positioning was
effective in improving trunk posture in children with CP during handwriting activity. In addition, a pencil with assigned grip
height or with a biaxial design, when compared with a regular one, could improve head, shoulder, trunk and pelvic
alignment, but not the upper extremity muscle exertion. Current results may provide guidelines for parents, teachers and
clinicians regarding writing tools and positioning. These findings can also be applied to children with similar handwriting
difficulties. Further analyses can focus on the design, modification and clinical application of assitive sitting and writing
devices for the use in children with handwriting difficulties.

Conflict of interest

The authors did not have any financial and personal relationship with other people or organization that could
inappropriately influence this work.

Acknowledgement

This work was supported by the Chang Gung Medical Research Program (CMRP), Taiwan (grant no. CMRPD190292).

References

Arner, M., Eliasson, A. C., Nicklasson, S., Sommerstein, K., & Hägglund, G. (2008). Hand function in cerebral palsy. Report of 367 children in a population-based
longitudinal health care program. The Journal of Hand Surgery, 33, 1337–1347.
DuBois, L., Klemm, A., Murchland, S., & Ozols, A. (2004). Handwriting of children who have hemiplegia: A profile of abilities in children aged 8–13 years from a
parent and teacher survey. Australian Occupational Therapy Journal, 51, 89–98.
Feder, K. P., & Majnemer, A. (2007). Handwriting development, competency and intervention. Developmental Medicince and Child Neurology, 49, 312–317.
Ferriell, B. R., Fogo, J. L., McDaniel, S. A., Schillig, L. R., Shehorn, A. R., Stringfellow, J. K., & Varney Ii, R. L. (2000). Determining the effectiveness of pencil grips: An
electromyographical analysis. Occupational Therapy in Health Care, 12, 47–62.
Goonetilleke, R. S., Hoffmann, E. R., & Luximon, A. (2009). Effects of pen design on drawing and writing performance. Applied Ergonomics, 40, 292–301.
Kavak, S. T., & Bumin, G. (2009). The effects of pencil grip posture and different desk designs on handwriting performance in children with hemiplegic cerebral
palsy. Jornal de pediatria, 85, 346–352.
Koman, L. A., Williams, R. M., Evans, P. J., Richardson, R., Naughton, M. J., Passmore, L., & Smith, B. P. (2008). Quantification of upper extremity function and range of
motion in children with cerebral palsy. Developmental Medicince and Child Neurology, 50, 910–917.
Lin, Y. Y. (2007). A study of consumers’ cognition of universal design pen. Taipei City, Taiwan: MS, Shih-Chine University.
McHale, K., & Cermak, S. A. (1992). Fine motor activities in elementary school: Preliminary findings and provisional implications for children with fine motor
problems. The American Journal of Occupational Therapy, 46, 898–903.
Murphy, S., Buckle, P., & Stubbs, D. (2004). Classroom posture and self-reported back and neck pain in schoolchildren. Applied Ergonomics, 35, 113–120.
Myhr, U., & von Wendt, L. (1990). Reducing spasticity and enhancing postural control for the creation of a functional sitting position in children with cerebral
palsy: A pilot study. Physiotherapy Theory and Practice, 6, 65–76.
Noda, W., & Tanaka-Matsumi, J. (2009). Effect of a classroom-based behavioral intervention package on the improvement of children’s sitting posture in Japan.
Behavior Modification, 33, 263–273.
Nwaobi, O. M. (1987). Seating orientations and upper extremity function in children with cerebral palsy. Physical Therapy, 67, 1209–1212.
Odding, E., Roebroeck, M. E., & Stam, H. J. (2006). The epidemiology of cerebral palsy: Incidence impairments and risk factors. Disability and Rehabilitation, 28, 183–
191.
Parush, S., Levanon-Erez, N., & Weintraub, N. (1998). Ergonomic factors influencing handwriting performance. Work, 11, 295–305.
Reid, D. T. (1996). The effects of the saddle seat on seated postural control and upper-extremity movement in children with cerebral palsy. Developmental
Medicince and Child Neurology, 38, 805–815.
Reid, S., Elliott, C., Alderson, J., Lloyd, D., & Elliott, B. (2010). Repeatability of upper limb kinematics for children with and without cerebral palsy. Gait and Posture,
32, 10–17.
 H.-Y. Cheng et al. / Research in Developmental Disabilities 34 (2013) 1152–1159 1159

Rigby, P., & Schwellnus, H. (1999). Occupational therapy decision making guidelines for problems in written productivity. Physical and Occupational Therapy in
Pediatrics, 19, 5–27.
Rosenblum, S., Dvorkin, A. Y., & Weiss, P. L. (2006). Automatic segmentation as a tool for examining the handwriting process of children with dysgraphic and
proficient handwriting. Human Movement Science, 25, 608–621.
Saw, S. M. (2003). A synopsis of the prevalence rates and environmental risk factors for myopia. Clinical and Experimental Optometry, 86, 289–294.
Stavness, C. (2006). The effect of positioning for children with cerebral palsy on upper-extremity function: A review of the evidence. Physical and Occupational
Therapy in Pediatrics, 26, 39–53.
Trevelyan, F. C., & Legg, S. J. (2006). Back pain in school children – Where to from here? Applied Ergonomics, 37, 45–54.
Yeats, B. (1997). Factors that may influence the postural health of schoolchildren (K-12). Work, 9, 45–55.
Yu, Y. C. (2011). Effects of biaxial pen on writing posture among kindergarten and early elementary school children. Tao Yuan, Taiwan: MS, Chang Gung University.