The Pen Test

Since James Parkinson first reported the syndrome of findings in 1817 that would later bear his name, clinicians have proposed examination techniques to define function and disability in Parkinson’s disease (PD). Currently there are a variety of methods used in general neurology and movement disorders clinics. These techniques are aimed at describing limitations and severity measures and have proven very useful in following response to medication and in gauging progression of disease.

Techniques to define impairment and response to medication range in complexity from observations by physicians of function in typical activities of daily living, such as buttoning one’s shirt, to more technologically sophisticated electronic/ digital analyses and reporting. Techniques typically used in the clinician’s office include observation of facial expression, eye blink frequency, arm swing during walking exercises, number of steps required in turning 180 degrees, extremity passive range of motion to assess cogwheel rigidity; tremor assessment, at rest, in posture, or in kinetic activity, such as in drawing an Archimedes spiral; voice amplitude, festination of speech; posture stress tests, and assessment of ability to tap the feet or fingers. Techniques, such as “speeded tapping” and metronome tapping although useful, require more sophisticated equipment that is not readily available. Objective, measurable, and easily reproducible testing for the general neurology clinic is not easily accessible, cost effective, or reimbursable.

The Pen Test Proposal

In attempting to assess fine finger movements and control by a more objective technique, I am proposing a timed pen rotation test that is performed with limited technological load and expense. It can easily be added to the clinical examination armamentarium without adding a tremendous allotment of clinic time for the neurologist.

The test involves the use of a contoured pen (Figure 1) for ease of handling. It is recommended to use the same type of pen at each visit to assure relative test standardization. The patient should hold the pen in vertical position (Figure 2). A timer is required. I prefer to use an electronic timer (as shown in Figure 3). Newer phones typically have a timer allowing easy access without the purchase of additional equipment.

The Test Technique

Explain the test to the patient. Details are usually only required the first time the test is performed. At subsequent visits, the patient will typically reach for the pen with a knowing grin. However, patients with concurrent dementia may require an explanation each visit.

• Inform the patient that you will be timing them as they turn the pen in their hand three times.
• Ask them to relax as they perform the test, as anxiety will certainly affect the timed outcome. I typically offer the patient a few moments to feel the pen in their hand and to turn it a few times.
• Warn the patient that you are about to begin the test. Announce, “Ready. Set. Begin.”
• Observe the turns of the pocket clip in three total rotations and record the time.
• Repeat this at least twice.
• Record the time of day and time of last medication dosage.
• Record and compare times at subsequent visits. As an example, the table below displays observations in a right hemibody predominant PD patient before and after treatment:

A Useful Technique

The Pen Test represents a useful technique in evaluating fine motor skills in patients diagnosed with Parkinson’s disease, focal motor dystonia, multiple sclerosis, myasthenia gravis, etc. The test can be used to gauge response to medication in subsequent clinic visits. The pen test is very time efficient and reliable in assessment of fine motor function.

Dr. Jones has no conflicts of interest and receives no funding or grant monies from outside sources.

Daniel A. Jones, MD is currently a solo practicing neurologist in Columbus, Ohio. He is board certified by the American Board of Neurology and Psychiatry and American Board of Sleep Medicine.