The effect of handwriting versus iPad writing on cervical alignment and pinch muscle strength among female university students: a cross-sectional study

Abstract

Objectives

This study aimed to examine the impact of handwriting versus iPad writing on cervical alignment and pinch muscle strength among female university students at the Faculty of Physical Therapy, Cairo University.

Methods

Thirty female students were divided into two equal groups: Group A engaged in handwriting, and Group B used iPad writing. The mean body mass index of the participants was 25.12 kg/m². Each participant was instructed to write for 15 min. Cervical range of motion (ROM) devices were used to assess cervical flexion, lateral bending, and rotation, whereas key pinch strength was measured to evaluate the strength of the dominant pinch muscles.

Results

Analysis of variance (ANOVA) indicated no significant differences in the pinch strength outcome variables between the handwriting and iPad writing groups, F (1, 28) = 12.54, P = 0.25; η² = 0.05. The handwriting group exhibited lower mean values within their group compared to the iPad group. Furthermore, a repeated-measures ANOVA comparing the groups revealed no significant difference in the mean cervical range of motion (ROM) in flexion between the two groups (P = 0.67). However, the mean values for the handwriting group increased post-writing compared to those for the iPad group. The repeated-measures ANOVA between groups also demonstrated no significant difference in the mean cervical range of motion values for rotation to the right after writing for either group (P = 0.34) or for the cervical range of motion for rotation to the left (P = 0.49); however, an increase in the mean values of cervical rotation to the right was observed for the handwriting group.

Conclusions

Using an iPad increases the degree of lateral bending and rotation to the left and right. In addition, the degree of right rotation increased in the iPad group. However, key-pinch muscle strength was lower in the handwriting group than in the iPad writing group.

Introduction

Proprioception and exteroception, which include self-awareness of external entities, along with precise hand-eye coordination and regulation of forces exchanged with writing instruments, are essential for handwriting. Nonetheless, proficiency in rapid typing on keyboards and touch screens is increasingly vital as this activity becomes less common and the writing process becomes more dematerialized [1]. The perception of the tool, spatial awareness of the physical medium, and fine motor control of the instrument are notably absent [2]. However, as revealed by the embodied cognition model, handwriting is a fundamental skill that significantly contributes to human development. Several neuroscientists and educators have observed that certain synaptic connections in specialized brain areas are established through complex interrelations, leading to coordinated physical and mental abilities [3]. Technology simultaneously extends and amputates the sensory experience. We propose the Finger Pen, a hand position designed to leverage recent advancements in writing technologies while maintaining the traditional practice of using the “hand for language” [4].

The index finger is constrained by the hand in the Finger Pen position, transforming it into a writing instrument characterized by the integration of “tool and gesture into a single organ.” Although tablets are extensively used across all age groups, pen and paper remain the sole means of developing the fine sensorimotor skills that are essential for handwriting [5].

Currently, a significant number of college students use digital devices for educational purposes [6]. Writing on digital screens and sending text messages are integral parts of daily academic activities. Furthermore, the prevalent use of mobile and multimedia technologies has led to increased reliance on smartphones [7]. Handwriting remains a vital communication skill that college students must master to achieve academic success in higher education. Texting involves the creation and electronic transmission of brief text messages between mobile devices. Initially, alphanumeric plain text was the primary format, which has since evolved to include multimedia messaging. Individuals who engage in texting often adopt an improper neck posture, commonly referred to as “text neck”, which may be associated with neck pain [8]. Among smartphone users, neck pain has adverse effects and appears to increase neck muscle activity [9]. To mitigate neck discomfort, users should avoid excessive neck flexion and recognize that maintaining a 0° neck flexion angle minimizes muscular activity and gravitational force [10].

Numerous studies have quantitatively evaluated the postural changes associated with tablet use by comparing these findings with those observed during desktop and laptop use. Tablet use, as opposed to desktop computer use, is associated with more asymmetrical and flexed spinal postures, elevated and flexed shoulders, and increased neck muscle activity. When a tablet is used while resting on the lap, there is an increase in the wrist radial deviation and wrist extension angle. Compared to desktop use, tablet use is more significantly correlated with a heightened risk of musculoskeletal issues, particularly in the absence of job variety [11]. Lee conducted a comparative analysis of handwriting versus modern technological writing methods among thirty-two students. The findings indicate that writing on a tablet is more challenging than handwriting. Furthermore, handwriting has been shown to have positive effects on cognitive function [12]. Wollscheid examined the impact of digital devices versus pen and paper on primary school students writing skills. Their results demonstrated that qualitative studies in cognitive psychology, as well as those from neuroscience and learning perspectives, favored handwriting [13].

According to Nijal, there were significant variations in cervical muscular endurance, postural angles, and range of motion [14]. Among the 428 college students, 35 participants exhibited a significant incidence of Text Neck, with 80% scoring between 15 and 20, resulting in a prevalence rate of 29.2%. These participants demonstrated altered physical characteristics, including angular variations in posture and endurance, which correlated with a higher incidence of neck pain.

Previous research has identified a gap in understanding which input writing models, iPad or handwriting, are suitable for assessing head and cervical alignment, as well as pinch strength, in this specific age group. Thus, the aim of this research is to investigate the differences in cervical alignment and pinch strength of the muscles between handwriting and writing on an iPad in female university students. Although previous research explored how prolonged use of digital devices affects general posture and musculoskeletal discomfort, very few studies have compared different modes of writing and the biomechanical impact of those modes on the body. This research will offer fresh contributions by concurrently assessing cervical alignment and fine motor strength within female university students. This study will provide useful information to inform ergonomic guidelines and prevention strategies; as such, it will help determine if writing digitally is associated with unique biomechanical risks compared to writing conventionally. The present study will add to the present understanding of the association between technology and musculoskeletal adaptations. Consequently, this study investigated the immediate effects of 15 min of handwriting versus iPad writing on cervical alignment and pinch muscle strength in female university students.

Subjects and methods

Design and setting

This was a cross-sectional observational study. The study was conducted between July and August 2025 at the Faculty of Physical Therapy, Cairo University.

Sample size calculation

G*Power software for Windows (version 3.1.9.7) was used to calculate the sample size relevant to the specific procedures [15]. As indicated by El-gohary and Marwan Mahmoud, when using a one-tailed t-test to distinguish between two dependent means, the requisite sample size for each group is 12, based on an effect size of 0.8, power of 0.8, and alpha (α) error of 0.05 prior to the power analysis [16]. We assumed a maximum failure rate of 20%. Consequently, a sample size of 15 per group was statistically justified.

Participants

In this study, 30 female university students participated, comprising 15 individuals using handwriting and 15 age-matched counterparts using iPads. All participants were right-hand-dominant writers and met the following criteria: aged 19–21 years, with a body mass index (BMI) ranging from 20 to 24 kg/m². Each group engaged in a 15-minute writing session with each device, conducted twice with a 5-minute intermission for muscle recovery [17–19]. Initially, thirty-seven participants were considered; however, seven were excluded based on the following criteria: (1) attendance at lectures without using an iPad or writing paper, (2) academic pursuits predominantly dependent on visual activities rather than writing, and (3) left-hand dominance. Additional exclusion criteria included traumatic hand injuries, congenital wrist abnormalities, surgical interventions involving the hand or shoulder, upper extremity deformities (such as claw deformities or excessive pronation/supination of the forearm), recent cervical spine trauma necessitating medical attention, neck pain exceeding 2/10 at the time of inclusion, and factors influencing neck angle, such as the use of spectacles. Written informed consent was obtained from all participants, who were subsequently screened for upper limb functional mobility, neck mobility, and neck pain prior to the study [20]. Clarifications were made regarding daily iPad use exceeding two hours, writing activities lasting over ten minutes per day, and the test period preceding the study. Participants underwent a familiarization session with the key pinch hand dynamometer and cervical range of motion (ROM) assessments before and after the writing tasks. The same therapist conducted the key pinch and cervical ROM measurements for both groups to ensure inter-measurement reliability, with three measurements averaged for the cervical ROM and pinch muscle strength.

Procedures

Prior to evaluating the devices, the participants were familiarized with two writing modes: handwriting and the iPad Pro. The work surface and seating arrangements were tailored to each participant’s anthropometric measurements in accordance with the ANSI/HFES standards [21]. The participants were seated with their thighs parallel to the ground, feet flat, and knees bent at a 90-degree angle. To maintain a neutral posture, the participants were advised to relax their necks and shoulders, sit close to the writing surface to facilitate natural arm movement, and keep their backs straight while supporting the paper with the non-writing hand. The paper was slightly tilted towards the dominant hand to reduce wrist strain. Each participant’s wrist was positioned neutrally before writing commenced. The length-tension relationship of muscles is associated with wrist flexor and extensor movements; flexion shortens the muscles, thereby decreasing tension, whereas extension lengthens them, increasing tension for optimal force production. The neutral position facilitates optimal force production by ensuring the best overlap between the actin and myosin filaments. Deviations from this position can affect the pinch strength and hand function [22]. Ergonomically, the tripod grip is prevalent, wherein the pen is held between the thumb and index finger, with the middle finger resting on it, providing a balanced control and minimising fatigue [23].

Participants were provided with an iPad Pro and a handwriting exercise that required them to compose text incorporating both geometrical and alphanumeric elements. Subsequently, each participant was tasked with completing an assignment for each ink within 15 min (900 s). The participants used a blue ink pen with a medium point of 0.6 mm and a line width of 0.3 mm to write on foolscap paper with a line spacing of 7 mm and a paper grammage of 54 g/m². This writing instrument, designed and manufactured for reliability and cleanliness, is currently the most popular globally and offers enhanced accuracy in handwriting tasks [24]. Each article required participants to write several paragraphs of 100 words. The participants are typed below each paragraph. They were permitted to adjust their seat height and backrest angle [25]. The iPad Pro features digital pen technology. The physical stylus digital pen technology employed in this study for iPad writing was selected to address the common features of available digital pen technologies. The iPad Pro provides an optimal writing and drawing experience with its ProMotion display and advanced features. This model is compatible with the Apple Pencil Pro, which offers a near-pen-like experience with low latency during generative writing, drawing, and writing tasks. Considerations included accuracy, weight, grips, length, form, tip size, and additional features such as touch sensitivity and electronic erasers [26].

Key pinch strength was assessed one minute prior to and one minute following the completion of the designated hand exercises. The assessment was conducted using a pinching gauge. All measurements were obtained with the participants seated, the wrist joint in the neutral position preferred by the participant, the forearm in a mid-position, the elbow flexed at 90°, and the shoulder in a mid-position. Participants were instructed to press their thumb pads against the lateral aspects of their index fingers while the examiner held the distal end of the pinch gauge (Fig. 1). All measurements were recorded in kilograms during a single session. To lessen any potential order effects that could compromise internal validity, the sequence of measurements was counterbalanced [27–29].

Fig. 1.

Measurement of key pinch muscle strength using a pinch hand dynamometer

The inclinometer range of motion of the cervical device was used to assess the ranges of motion in cervical flexion, extension, rotation, and lateral flexion. During all range of motion assessments, the participants maintained an erect posture, facing forward, with their arms resting on their laps and feet flat on the ground [14]. The CROM uses three distinct inclinometers attached to a frame resembling eyeglasses to evaluate rotation, flexion/extension, and lateral flexion in the cervical range of motion. In the transverse plane, the inclinometer was used for rotation, in the sagittal plane for flexion/extension, and in the frontal plane for lateral flexion. The flexion/extension and lateral flexion inclinometers were equipped with gravity needles, whereas the rotation inclinometer employed a magnetic needle. To generate the magnetic field necessary for needle movement during head rotation, the participants wore a magnetic necklace. Each inclinometer was equipped with a movable ring to establish the zero position prior to measurement. The inclinometer was subsequently adjusted according to the degree of cervical movement to be measured during writing (Fig. 2). The validity and reliability of this method were certified by Tousignant [30]. Furthermore, Sukari reported the precision and accuracy of these measurements in clinical tests of the cervical range of motion [31].

Fig. 2.

Cervical ROM measurement device during writing for (A) side bending, B flexion, and (C)rotation

Statistical analysis

Data were analyzed using GraphPad Prism version 9 [32]. Data are expressed as mean ± standard deviation (SD). The Shapiro-Wilk test was used to evaluate data normality. A paired t-test was used to test the outcome differences within the group pre- and post-activity. A two-way repeated measure analysis of variance (ANOVA) was used to evaluate the effects of group (handwriting vs. iPad use), time (pre- and post-activity), and the Group x Time interaction. The interaction effect determined whether the changes over time differed significantly between the groups. Independent samples t-tests were used to compare baseline characteristics and pre - or post-activity between the two groups (handwriting vs. iPad use). The level of statistical significance was set at P ≤ 0.05.

Results

Demographic data were collected from the participants (Table 1). The sample included 30 cases as baseline demographic data of the subjects (15 for the Handwriting 15 and iPad writing groups). The data for clinical measures of pinch muscle strength for the handwriting (A) and iPad writing (B) groups are shown in Table 2; Fig. 3. The mean values of the pinch strength within the handwriting group decreased after the activity compared to the mean value before the activity (P < 0.01, η² = 0.41). This decrease was significant; however, no significant difference was observed in the mean values of pinch strength for the iPad writing group (P = 0.15 η² = 0.14). Two-way repeated measures ANOVA showed no significant change in pinch strength between the handwriting and iPad writing groups, F (1.28) = 12.54, P = 0.25; η² = 0.05.

Table 1.

Baseline demographic data of the subjects (N = 30)

Variables	Group A (Handwriting) (N = 15)	Group B (iPad writing) (N = 15)	MD	95% CI		P	Effect size (η2)
	Mean ± SD	Mean ± SD		Lower	Upper
Age (years)	20.40 ± 1.24	21.00 ± 1.13	– 0.60	– 1.49	0.29	0.18 (ns)	0.06
Weight (kg)	61.20 ± 13.62	60.67 ± 12.70	0.53	– 9.31	10.38	0.91(ns)	0.0004
Height (cm)	159.80 ± 7.02	155.33 ± 7.92	4.47	– 1.13	10.06	0.11(ns)	0.09
BMI (kg/m2)	23.97 ± 5.17	25.12 ± 4.71	–1.15	– 4.85	2.55	0.53(ns)	0.02

Mean ± SD (standard deviation) is used to provide quantitative data, an independent t t-test was used, BMI Bod mass index, N number, P ≥ 0.05 is statistically non -significant (ns)

Table 2.

Pinch strength within both groups

Pinch strength (Kg)	Group A (Handwriting) (N = 15)	Group B (iPad writing) (N = 15)	MD (95% CI)	P a	Effect size (η2)	Group X Time interaction (F) p value
	Mean ± SD	Mean ± SD
Pre-activity	12.53 ± 2.80	12.07 ± 2.25	–0.47(–2.37–1.43)	0.62	0.008
Post-activity	9.67 ± 1.72	10.67 ± 2.82	1.00(–0.75–2.74)	0.25	0.05	F1,28=12.54
						< 0.01**
MD (95% CI)	–2.87(–4.84 to − 0.89)	–1.40(–3.36–0.56)
P b	< 0.01**	0.15
Effect size (η2)	0.41	0.14

Values are shown as mean ± standard deviation (SD); CI Confidence Interval, MD Mean Difference, P^a) value intergroups from independent-samples t-test; P^b) two-tailed value within group from paired-samples t-test; Significant P^b and P value ** (<0.01) η2: partial eta square; group × time interaction P value from two-way repeated measures ANOVA

Fig. 3.

The difference in the mean values of pinch strength within and between the two groups

Table 3; Fig. 4 show the difference in the mean values of cervical ROM for flexion after writing between the handwriting and iPad writing groups. This difference was highly significant (P < 0.001, η² = 0.89; P < 0.001, η² = 0.83). Repeated measures ANOVA between groups showed that the mean values for the iPad writing group were lower than those of the handwriting group after the writing activity. However, this difference was not significant for the mean values of cervical ROM during flexion, F (1.28) = 122.8, P = 0.67; η² = 0.006.

Table 3.

Cervical range of motion for flexion within both groups

Variables ROM (degrees)	Group A (Handwriting) (N = 15)	Group B (iPad writing) (N = 15)	MD (95% CI)	P a	Effect size (η2)	Group X Time interaction (F) p value
	Mean ± SD	Mean ± SD
Cervical ROM for flexion
Pre-activity	2.33 ± 4.17	3.67 ± 4.25	1.33(–182–4.48)	0.39(ns)	0.026
Post-activity	34.67 ± 11.87	32.67 ± 3.31	–2.00 (–11.23–7.23)	0.67(ns)	0.006	F1,28=122.8
						< 0.001***
MD (95% CI)	32.33(25.68–38.99)	29.00(21.51–36.49)
P b	< 0.001***	< 0.001***
Effect size (η2)	0.89	0.83

Values are shown as mean ± standard deviation (SD); CI Confidence Interval, MD Mean Difference, P^a) value intergroup from Independent - Samples T Test; P^b) Two-tailed value within group from Paired - Samples T Test; Significant P^b and P value ***(< 0.001), η2: partial eta square; Group X time interaction P value from Two-way repeated measures ANOVA

Fig. 4.

The difference in the mean values of cervical ROM for flexion within and between the two groups

Lateral flexion to both sides of the cervical area is shown in Table 4; Fig. 5. No significant difference was observed in the mean values for the cervical range of motion on the right side for the handwriting and iPad writing groups (P < 0.58, η² = 0.02, and P < 0.27, η² = 0.09). However, an observable increase in the mean values of the cervical range of motion for lateral flexion to the left was observed in the iPad writing group compared to the other group. This change was significant (P < 0.05, η² = 0.24 and P < 0.05, η² = 0.33). Two-way repeated-measures ANOVA showed no significant change in cervical ROM for lateral flexion to the right variable between the handwriting and iPad writing groups (F (1.28) = 0.882, P = 0.37; η2 = 0.03). In addition, no significant change was recorded in the cervical range of motion for lateral flexion to the left between the handwriting and iPad groups, F (1.28) = 8.80, P = 0.96, η² = 8.14.

Table 4.

Cervical range of motion for lateral flexion to right within both groups

Variables ROM (degrees)	Group A (Handwriting) (N = 15)	Group B (iPad writing) (N = 15)	MD (95% CI)	P a	Effect size (η2)	Group X Time interaction (F) p value
	Mean ± SD	Mean ± SD
Cervical ROM lateral flexion to right
Pre-activity	1.33 ± 3.52	2.00 ± 4.14	0.67(–5.51–3.54)	0.64(ns)	0.008
Post-activity	2.00 ± 4.14	4.00 ± 7.37	2.00(–2.47–6.47)	0.37(ns)	0.03	F1,28 = 0.882
						0.36(ns)
MD (95% CI)	0.67(–1.87–3.20)	2.00(–4.74–5.74)
P b	0.58(ns)	0.27(ns)
Effect size (η2)	0.02*	0.09
Cervical ROM lateral flexion to left
Pre-activity	0.67 ± 2.58	2.47 ± 3.78	1.80(–0.62–4.22)	0.14(ns)	0.08
Post-activity	18.46 ± 30.51	18.00 ± 22.42	–0.47(–21.07–20.15)	0.96(ns)	8.14 × 10− 5	F1,28 = 8.80
						< 0.01**
MD (95% CI)	15.33(–0.45–31.12)	15.53(2.76–28.31)
P b	0.05(ns)	< 0.05*
Effect size (η2)	0.24	0.33

Values are shown as mean ± standard deviation (SD); CI Confidence Interval, MD Mean Difference, P^a) value intergroup from independent-samples t-test; P^b) two-tailed value within group from paired-samples t-test; significant P^b and P value *(< 0.05) and **(< 0.01), η2: partial eta square; group X time interaction P value from two-way repeated measures ANOVA

Fig. 5.

The difference in the mean values of cervical ROM for lateral flexion to the right (A) and left (B) within and between the two groups

Table 5; Fig. 6 compare the handwriting and iPad writing groups for the mean values of the cervical range of motion for rotations to the right and left. According to the range of motion for rotation to the right, repeated-measures ANOVA revealed significant changes within both groups, as the mean cervical range of motion for rotation to the right increased after writing compared to before writing for both groups (P < 0.01, η² = 0.37 and P < 0.03, η² = 0.30). Regarding the mean values for the cervical range of motion for rotation to the left, repeated measures ANOVA revealed no significant changes within the handwriting group; however, a significant increase in the mean values was observed within the iPad writing group (P = 0.08, η² = 0.20 and P < 0.02, η² = 0.35). In addition, repeated measures ANOVA between groups showed that there was no significant difference in the mean values of cervical range of motion for rotation to the right, F (1.28) = 9.06, P = 0.34; η² = 0.03 and for cervical range of motion for rotation to the left, F (1.28) = 11.66, P = 0.49; η² = 0.02.

Table 5.

Cervical range of motion for rotation within both groups

Variables ROM (degrees)	Group A (Handwriting) (N = 15)	Group B (iPad writing) (N = 15)	MD (95% CI)	P a	Effect size (η2)	Group X Time interaction (F) p value
	Mean ± SD	Mean ± SD
Cervical ROM rotation to right
Pre-activity	5.33 ± 13.02	3.33 ± 4.88	–2.00(–9.35–5.35)	0.58(ns)	0.01
Post-activity	28.00 ± 36.88	17.33 ± 22.51	–10.67(–33.52–12.18)	0.34(ns)	0.03	F1,28 = 9.06
						< 0.01**
MD (95% CI)	22.67(5.86–39.47)	14.00(1.65–0.30)
P b	0.01*	0.03*
Effect size (η2)	0.37	0.30
Cervical ROM rotation to left
Pre-activity	4.00 ± 7.37	1.33 ± 3.52	–2.67(–6.99–1.65)	0.22(ns)	0.05
Post-activity	16.67 ± 32.22	25.33 ± 35.02	8.67(–16.50–33.84)	0.49(ns)	0.02	F1,28 = 11.66
						< 0.01**
MD (95% CI)	12.67(–1.75–27.09)	24.00(5.42–42.58)
P b	0.08(ns)	0.02*
Effect size (η2)	0.20	0.35

Values are shown as mean ± standard deviation (SD); CI Confidence Interval, MD Mean Difference, P^a) value intergroup from Independent - Samples T Test; P^b) Two-tailed value within group from Paired - Samples T Test; Significant P^b and P value *(< 0.05) and **(< 0.01), η2: partial eta square; Group X time interaction P value from Two-way repeated measures ANOVA

Fig. 6.

The difference in the mean values of cervical ROM for rotation to the right (A) & left (B) within and between the two groups

Discussion

The purpose of this study was to investigate the effect of handwriting and iPad writing on cervical alignment and pinch muscle strength among female university students. The study specifically sought to ascertain if there is a difference in postural alignment of the cervical spine and functional strength of the pinch muscles between the two writing techniques. The results of this cross-sectional study show that this goal was accomplished since there were discernible variations in neck position and pinch muscle strength between the two writing techniques (handwriting and iPad writing). Repeated-measures ANOVA showed that there was no significant difference in the mean values of key muscle pinch strength between the handwriting and iPad writing groups. However, the mean values of cervical ROM for flexion and right rotation were significantly higher for the handwriting group than for the iPad writing group. The results provide insight into the ergonomic and musculoskeletal consequences of different writing techniques in educational environments.

For college students to achieve academic success, proficiency in handwriting is an essential communication skill. Texting is defined as the process of composing and electronically transmitting brief text messages between mobile devices [33]. In addition to head position, the configuration of the grasp and placement of the fingers around the writing instrument may affect writing proficiency [34, 35]. Therefore, one of the objectives of the present study was to compare the modalities of writing tools among female college students in relation to their key pinch strength and cervical range of motion (ROM) while they were writing.

El-gohary and Marwan Mahmoud corroborated the present findings by examining the impact of texting and handwriting on the handgrip and key-pinch strengths of healthy female students both immediately and over time. This study evaluated the hand muscle and pinch strengths of 65 female students during writing tasks lasting ten and 15 min at two separate intervals. This conclusion aligns with our results regarding the mean values of the pinch muscle strength, as no significant differences were detected between the two groups [16].

The findings of this study are supported by those of Kietrys and Tapanya, who examined the influence of mobile devices, texting behaviors, and ergonomic stressors on cervical posture and trapezius muscle activity. They assessed the effects of neck flexion angle on the gravitational moment and neck muscle activity while using smartphones or other messaging devices while standing. The study involved young, healthy participants who were instructed to text for three minutes from four different perspectives. The results indicated that an increase in the neck flexion angle corresponded with a significant increase in the gravitational moment of the neck and erector spinae muscle activity in the cervical region. The optimal posture, characterized by minimal muscle activity, was identified as a neck position with 0° flexion. Based on these findings, it is recommended that individuals using electronic devices maintain a neck position of 0° flexion to mitigate mechanical disadvantages and alleviate neck pain [12, 36].

Almeida reported that using a pen increased hand and finger muscle activity during handwriting activities, which is consistent with our findings [37]. Different muscular actions are used owing to variations in the grasp patterns. Therefore, the most significant factor that may influence muscular activation, aside from grasp style, is the use of a pen and paper [38].

The findings of this study are consistent with those reported by Tatarescu, who conducted a comparative analysis of digital and paper-based handwriting [39]. Their research involved ten forensic students aged 18–20 years who participated in handwriting tasks for authorship identification. The study observed alterations in writing characteristics when using digital media, such as the iPad Pro, particularly regarding speed and letter shape. These changes were attributed to factors such as body alignment, wrist, and arm support [40]. According to Marullo, handwriting enhances cognitive functions, and these benefits can be integrated into precise writing [41]. The use of pen and paper fosters the development of fine sensorimotor skills that are essential for traditional handwriting. Prattichizzo found that free-finger motion is suitable for tasks requiring large workspaces and short durations, whereas a writing tool provides precise control [42]. Wells demonstrated that traditional methods surpass technological ones in terms of letter formation and orientation, with improved letter recognition associated with conventional handwriting input. Previous research has highlighted the superiority of handwriting in enhancing cognitive functions and sensorimotor skills, with minimal clinically important differences (MCID) observed with the prolonged use of modern technology. This study underscores the importance of maintaining a proper posture when using portable devices [43]. The results suggest that prolonged use of iPads may impact hand muscle strength and cervical alignment, which is of particular relevance to medical professionals and physiotherapists who treat young adults.

Our results align with those of Vongjaturapat and Chotikakamthorn, who investigated the differences in muscle activity between digital handwriting tools and pencils. They compared the electromyogram of five muscles: upper trapezius, biceps brachii, extensor digitorum communis, flexor digitorum superficialis, and first dorsal interosseous during elementary school practice of forming letters and words. Five digital handwriting devices were used in this study. The results showed that the iPad Pro caused the lowest muscle activity. They also approved digital handwriting tools as suitable for learning environments [44].

Corkett and Benevides presented findings that contrast with our results by examining the writing abilities of students with learning disabilities, comparing the use of iPads to traditional handwriting. They posited that iPads had a positive impact on students writing skills. The discrepancies between their findings and ours may be attributed to the younger age group of sixth-grade students in their study, as opposed to the older age group of 20 and 21 years in our study [45].

Study strengths

Several important strengths support the validity and applicability of the conclusions derived from this study. Firstly, the research examines less explored area of research, especially regarding cervical position and pinch muscle power, in which traditional handwriting is compared with digital writing on an iPad. Secondly, this study’s focus on a specific demographic group, university female students, aims to minimize variability in age, occupational exposure, and lifestyle characteristics. This improves the internal validity of the study and allows for a more detailed understanding of the relationship between writing style and musculoskeletal outcomes. Thirdly, objective measures of cervical alignment and pinch muscle strength increase the reliability of the findings and decrease subjective bias. Another strength of the study is the comparison approach that allows a direct comparison of two commonly used writing techniques under comparable conditions and therefore enhances the practical applicability of the findings especially in clinical and educational settings. Finally, the study provides clinically important information that can guide ergonomic suggestions and preventive measures to reduce hand muscle fatigue and neck strain associated with prolonged writing tasks.

Clinical implications

The results of this study have significant clinical implications for educators, students, and health professionals and highlight the need for specific ergonomic actions in the educational setting. This may imply that the difference in conventional handwriting and iPad use may have a detrimental effect on neck alignment and pinch muscle strength. We recommend that students who regularly use digital devices should be offered postural assessment and ergonomic advice from clinicians (specifically physiotherapists and occupational therapists). Prevention strategies include screen positioning, use of external devices (e.g., stylus pen, tablet stand) and planned breaks which may reduce the risk of cervical strain. The difference in pinch strength used between handwriting and iPad use also shows that writing with an iPad may not be activating the muscles required to the same degree as traditional writing, potentially affecting the development of hand strength and fine motor skills.

Limitations and future directions

One limitation of this study is its cross-sectional design, which restricts causal inference due to data being collected at a single time point, thereby reflecting only associations to determine the short-term effect of 15 min of writing on mood. Another limitation is the study population—female, right-hand-dominant students from a single institution—which may limit generalizability.

Future research should employ a randomized controlled trial (RCT) with blinding and standardized postural protocols to enhance rigor and obtain more causal evidence and long-term effects. We recommend future research with more diverse samples, including both sexes, different hand dominance profiles, multicenter recruitment, and longitudinal designs to strengthen external validity and temporal understanding.

Conclusion and recommendation

A statistically significant difference was observed between the groups in the mean values of cervical range of motion (ROM) for flexion, lateral flexion to the left, and rotation to the right and left. Notably, the mean cervical rotation to the left was higher in the iPad writing group than in the handwriting group after writing, highlighting abnormal head alignment related to the line of gravity passing anterior to the cervical region. This misalignment may contribute to disturbances in the musculoskeletal components surrounding the head and neck during iPad use. Consequently, realignment of the cervical region for iPad users and a controlled time interval for the handwriting group reduced fatigue in the pinching muscles. Based on these findings, follow-up studies should be conducted to extend the writing session time. Both groups were provided with a rehabilitation program aimed at enabling free head movement in all directions, improving cervical ROM, and enhancing pinch muscle strength.

Abbreviations

ANOVA

Analysis of variance

ANSI/HFES

American National Standards Institute / Human Factors and Ergonomics Society

BMI

Body mass index

CI

Confidence interval

CROM

Cervical range of motion

MCID

Minimal Clinically Important Difference

MD

Mean difference

RCT

Randomized controlled trial

ROM

Range of motion

SD

Standard deviation

η2

Partial eta square

Authors’ contributions

AEA: Conceptualization, data curation, formal analysis, Methodology, Software, Writing – original draft, and writing – review and editing. DMAE: Formal analysis, Methodology, Software, Writing – original draft, and Writing – review and editing. ROA: Investigation, Methodology, and Writing – review and editing. Kh.ME: Formal analysis and writing – review and editing. MAMA: Formal analysis and writing – review and editing. AAC: Formal analysis and writing – review and editing. RHA: Formal analysis, funding acquisition, and writing – review & editing. MSh: Formal analysis and writing – review and editing. MMAA: Formal analysis and writing – review and editing. All the authors have read and approved the final manuscript.

Funding

This work was supported by Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2026R199), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia. This work was also supported by the Deanship of Scientific Research, Vice Presidency for Graduate Research, King Faisal University, Saudi Arabia (Grant No. KFU261641).

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the ethical standards set out in the 1964 Declaration of Helsinki (revised 2013). The study was authorized by the Research Ethics Committee of the Faculty of Physical Therapy, Cairo University (P.T.REC/012/005837). Prior to the procedures, all participants were informed of the benefits and risks of the research, and they signed written informed consent. All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Informed consent for publication was obtained from all the individual participants included in the study.

Competing interests

The authors declare no competing interests.