What is it?
Writer’s Cramp is a focal dystonia of the fingers, hand, and/or forearm. Symptoms usually appear when a person is trying to do a task that requires fine motor movements. The symptoms may appear only during a particular type of movement, such as writing or playing the piano, but the dystonia may spread to affect many tasks.
Two types of writer’s cramp have been described: simple and dystonic. People with simple writer’s cramp have difficulty with only one specific task. For example, if writing activates the dystonia, as soon as the person picks up a pen or within writing a few words, dystonic postures of the hand begin to impede the speed and accuracy of writing.
In dystonic writer’s cramp, symptoms will be present not only when the person is writing, but also when performing other-task specific activities, such as shaving, using eating utensils, applying make-up.
Common symptoms of simple writer’s cramp include excessive gripping of the pen or utensil, flexing of the wrist, elevation of the elbow, and occasional extension of a finger or fingers causing the pen or utensil to fall from the hand. Sometimes the disorder progresses to include the elevation of shoulders or the retraction of arm while writing. Tremor is usually not a symptom of writer’s cramp. The symptoms usually begin between the ages of 30 and 50 years old and affect both men and women.
Cramping or aching of the hand is not common. Mild discomfort may occur in the fingers, wrist, or forearm.
A similar cramp may be seen in musicians as the violin is bowed, in certain athletes such as golfers, or in typists.
Dystonic writer’s cramp may occur in conjunction with generalised or segmental dystonia. Very rarely, people with DYT1 dystonia (which is usually generalised) will have writer’s cramp as the only symptom. If writer’s cramp is secondary, there may be a greater frequency of pain.
Writer’s Cramp is believed to be due to abnormal functioning of the basal ganglia, which are deep brain structures involved with the control of movement. The basal ganglia assist in initiating and regulating movement. What goes wrong in the basal ganglia is still unknown. An imbalance of dopamine, a neurotransmitter in the basal ganglia, may underlie several different forms of dystonia, but much more research needs to be done for a better understanding of the brain mechanisms involved with dystonia.
Writer’s cramp may occur with no family history. Cases of inherited writer’s cramp have been reported, usually in conjunction with early-onset generalised dystonia, which is associated with the DYT1 gene.
Diagnosis of writer’s cramp is based on information from the affected individual and the physical and neurological examination. At this time, there is no test to confirm diagnosis of writer’s cramp, and, in most cases, laboratory tests are normal.
Sometimes an electromyogram (EMG) will be done to show which muscles are overactive and to what degree.
The hands can be affected by many conditions. Arthritis, tendon problems, and muscle cramps can all cause pain in the hands. Carpal tunnel syndrome is the result of nerve compression.
Writer’s Cramp is often mistaken for over-use conditions. Over-use syndromes or repeated-use syndromes are usually characterised by pain, whereas writer’s cramp is more likely to cause problems with coordination.
Focal hand dystonia is responsible for only about 5% of all conditions affecting the hand.
No single treatment strategy is appropriate for every case of writer’s cramp. one of the most effective methods is adapting tasks to try to avoid triggering the dystonic movements, this may involve occupational therapy or using assistive adapted devices.
A multitude of drugs has been studied to determine benefit for people with writer’s cramp, but none appear to be uniformly effective.
About 5% of people’s symptoms improved with the use of anticholinergic drugs, such as Artane (benzhexol), Cogentin (benztropine), but the degree of improvement is usually unsatisfactory and at the expense of side effects.
Botulinum Toxin Injections
Botulinum toxin injections into selected muscles are helpful in treating writer’s cramp, especially when significant deviation of the wrist or finger joints is present. Botulinum toxin is a therapeutic muscle-relaxing agent that helps reduce the uncontrollable muscular contractions associated with dystonia. It is injected into specific muscles where it acts to weaken muscle activity sufficiently to reduce a spasm but not enough to cause paralysis.
Every muscle in the hand plays a specific role in normal hand movement, unlike the neck in which the structure of muscles is more complex, and several muscles work together to achieve movement. Therefore if the appropriate hand muscle is injected at the correct dose, the BTX will weaken that muscle enough to relieve symptoms without affecting the overall function of the hand.
Although this treatment is not effective for all people, significant improvement in writing and reduction of pain is seen in at least two-thirds of those persons treated.
Since writer’s cramp generally affects only a local area of the arm under certain activities such as writing, surgical treatments are not usually considered.
The conservative approach to treating writer’s cramp includes minimize writing with the affected hand and using other methods of communication such as typing or dictating. Using a tape recorder to take notes may be helpful. Notes can then be transcribed later in a less stressful situation.
Physical methods to help hand dystonia include learning to hold a pencil differently or using a special wax mould to help hold a pencil.
The trick to reduce dystonia symptoms in the hand when writing at a desk is to use the shoulder and arm rather than the wrists and fingers. Sometimes a minimal change in writing style can make a difference. It is important to be comfortable. About 60% of people with writer’s cramp can reduce their symptoms by writing vertically on a board.
Learning to write with the opposite hand may or may not be helpful. In about 50% of people with writer’s cramp, the dystonia will “jump” to the opposite hand. Or, in some cases, writing with the left hand will trigger symptoms in the right hand, or vice versa. This “mirror dystonia” is a clear indication that dystonia of the hand is a motor problem stemming from the brain, not a problem with the hands themselves.
Physiotherapy may help to improve local arm flexibility (diminished by dystonic spasms and strength of the unaffected muscles).
Dystonia and its emotional offshoots affect every aspect of a person’s life – how we think, the way we act, and how we cope. By educating yourself with information, you have taken the first step in dealing with dystonia.
Stress is an inevitable part of life, and, although it clearly does not cause dystonia, it can aggravate dystonia symptoms. Stress-reduction programmes such as relaxation techniques, and meditation may be beneficial.
Sometimes depression can be a byproduct of dystonia. Depression may aggravate symptoms and make them worse, but, often, treating depression can result in an improvement of dystonia. It is important to remember that depression is a disorder; it is treatable and not a reflection of one’s self.
Many people are experiencing similar symptoms. Reassurance from family, friends, and others who have dystonia is beneficial. Sharing experiences at support group meetings offers encouragement, camaraderie, and the latest information about new treatments and medical advances.