Hyderabad-based, 48-year-old Venky was surprised when two of the cheques issued by him bounced due to a signature mismatch.
When enquiring with the bank staff about the signatures, he was shown his original signature, which did not match the current one.
The letters in the latter half of his signature had reduced in height and the legibility of his writing had worsened too. When he tried writing at home, the same thing happened.
A visit to the neurologist
Venky, subsequently, visited a neurologist and showed him the difference in his writing.
“I also observed mild shivering of his right hand, while he spoke to me. He mentioned that the shivering was mild, occurred when he was anxious, and did not interfere with daily activities,” said Dr Sudhir Kumar, consultant neurologist at Apollo Hospital Hyderabad via a Twitter post.
3. Venky decided to consult a Neurologist for evaluation. I reviewed his history.
He showed me his writing. Attached below are the samples- (above is normal, the one below is what his writing looked like).
I also observed mild shivering of his right hand, while he spoke to me. pic.twitter.com/LgPGVDrmBa— Dr Sudhir Kumar MD DM🇮🇳 (@hyderabaddoctor) March 5, 2023
His detailed clinical examination was otherwise normal. “I was already suspecting a disease and discussed with him further options,” said the doctor.
The options were to try and improve handwriting with training, practice, and occupational therapy or opt for the definitive test to confirm the diagnosis.
Venky opted for training as he was inconvenienced by the issue. After a month, he informed the doctor that his writing had improved.
“However, six months later, Venky returned for a review. His right hand shivering had increased in severity. In addition, his walking had slowed down. He was unable to keep pace when walking in a group. This time, he wanted to confirm the diagnosis,” said the doctor.
He was diagnosed with micrographia due to Parkinson’s disease (PD).
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Diagnosing Parkinson’s Disease
Micrographia is a medical condition characterised by abnormally small handwriting or the tendency to write smaller than normal. It is a neurological disorder that can occur due to various reasons, such as Parkinson’s disease, essential tremors, multiple sclerosis, or other nervous system disorders.
“As the shaking of hands only occurs in essential tremors and Parkinson’s disease, I asked for a further scan. I recommended 18F-DOPA PET scan, which confirmed my suspicion — Parkinson’s disease,” said Dr Sudhir to South First.
18F-DOPA PET scan is a medical imaging technique used to evaluate the function and activity of dopamine-producing neurons in the brain.
This test involves the injection of a small amount of a radioactive tracer called 18F-DOPA into the bloodstream. This tracer binds to dopamine-producing cells in the brain, allowing doctors to see how these cells are functioning.
The test is commonly used in the diagnosis and management of Parkinson’s disease, a neurological disorder characterised by the degeneration of dopamine-producing neurons in the brain.
The 18F-DOPA PET scan can help doctors identify areas of the brain where dopamine production is reduced, which can help confirm a diagnosis of Parkinson’s disease.
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Micrographia and PD
Parkinson’s disease, or PD, is a chronic, progressive, neurological disorder that affects movement. It is caused by the degeneration of dopamine-producing neurons in the brain, leading to a shortage of dopamine, a neurotransmitter that helps control movement.
Dr Sudhir also explained that micrographia can be an early feature of Parkinson’s Disease.
“It is of two types — constant, where letters are small from the beginning, and progressive, where letters are of normal height at the start and become smaller later. Progressive micrographia is more common in early stages of PD, whereas constant micrographia is more common in later stages of PD,” explained Dr Kumar.
Micrographia is found in more than 50 percent of patients with Parkinson’s disease.
Micrographia can occur even with essential tremors, but there are some key differences in their presentation that can help differentiate essential tremors from Parkinson’s disease.
Essential tremors typically cause a rhythmic shaking of the hands or other parts of the body, which can make handwriting difficult or illegible. Essential tremors typically worsen with movement and can be exacerbated by stress, caffeine, or other triggers.
Parkinson’s disease can also cause tremors, but they are typically more pronounced at rest and improve with movement. Parkinson’s disease may also cause other symptoms such as rigidity, slowness of movement (bradykinesia), and postural instability.
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Micrographia treatment
The treatment of micrographia depends on the underlying cause of the condition. In most cases, treating the underlying neurological condition is the primary approach to managing micrographia. Some treatment options for micrographia include:
Medication: Medications may be prescribed to manage the underlying neurological condition causing micrographia. For example, levodopa is a class of medication that is commonly used to treat Parkinson’s disease, which can improve micrographia symptoms in some patients.
Physical therapy: Physical therapy may be helpful in improving fine motor skills and reducing tremors. Therapists may use exercises to help improve muscle strength, coordination, and flexibility.
Occupational therapy: Occupational therapy can help people with micrographia develop strategies to improve their handwriting and fine motor skills. This may include exercises, adaptive equipment, or modifications to the environment.
Deep brain stimulation: This is a surgical procedure that involves implanting electrodes in the brain to help regulate abnormal movements.
Behavioral therapy: In some cases, anxiety or stress may be contributing to micrographia. Behavioural therapy, such as cognitive-behavioural therapy, may help manage stress and anxiety and improve handwriting.
It is important to work with a healthcare professional to determine the best treatment options for micrographia, based on individual needs and circumstances.
