Writers Cramp

Dystonia Association South Africa

(Incorporating Essential Tremor, Tourette's Syndrome

and other Movement Disorders)

Reg No 004-729 NPO

P O Box 4351, Randburg, 2125 or 3rd Floor Standard Bank Building, Oak Avenue, Randburg 2194

Tel: +27 11 326 2112 Fax: +27 11 326 3041

e-mail dystonia@dystonia.org.za , Web www.dystonia.org.za
Office hours - 08.30 to 14.00 Monday to Friday
Urgent enquiries 082 357 6586

YEAR 2006/2007

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WRITERS' CRAMP

The so-called ”occupation” cramps are a form of focal dystonia. Writer’s cramp is a pure action dystonia in which abnormal tension or posturing develops in the hand only during the act of writing. Immediately upon cessation of writing, the spasm disappears. Thus, a delicate motor skill, perfected by years of practice and performed almost automatically, suddenly comes to require a conscious and laboured effort for its execution.

This condition was originally considered as psychiatric in origin, and was even classed as an “occupational neuroses”. Careful clinical analysis does not bear this out – and today patients can carry the diagnosis without any stigma attached to it.

Who are the victims?

This disorder begins in adult life and men and women are equally affected, most often between the ages of 20 and 50 years. It frequently affects persons who write a great deal as part of their work. Frequently the patients do not have any other neurological abnormalities, and psychological inventories not reveal a higher incidence of psychiatric illness than in the normal population. In 5%of the cases the condition is familiar, and another 5% of patients give a history of trauma to the affected arm preceding the onset of Writers' Cramp.

What happens?

The initial symptoms may include only clumsiness or sloppy writing, with discomfort rarely prominent. When the patient attempts to write, all the muscles of the thumb and fingers go into spasm, resulting in an abnormal posture of the fingers, hand and arm. Manipulation of the pen is slow and clumsy and fluidity of hand movement is lost. To continue writing, the patient exerts greater force. The end result is poorly legible script.

If this spasm is prolonged it may be painful and spread into the forearm or even the shoulder. Sometimes the spasm fragments into a tremor. Some patients complain of weakness, especially if the fingers splay away from the direction in which they were intended to go.

Although the disturbance in Writers' Cramp is usually limited to the specific act of writing, it may involve other equally demanding manual tasks. A few of the younger patients also develop Spasmodic Torticollis at a later date.

The general absence of pain and the presence of abnormal postures distinguish this condition from the more common painful “overuse syndromes”.

Why does this happen?

We are not sure, the nature of this condition being quite obscure! Normally, writing is accomplished by alternating activity in the flexors and extensors of the forearm. Electrophysiological studies prove that in patients with Writer's Cramp there is co-contraction in agonist-antagonist muscle pairs in the forearm – that means that flexors and extensors of the arm contract simultaneously. This finding suggests a disorder of reciprocal inhibition between the muscles of the forearms. There is no evidence of any structural brain or spinal cord disease. The role of the basal ganglia in this condition is not yet fully understood.

Is there any hope?

Spontaneous remission of this condition is rare, and the treatment is difficult.

Hypnosis and other forms of psychiatric-treatment are usually without effect (if not being a psychiatric condition!)

Learning to write with the opposite hand may help, but it takes about 6 – 12 months to learn a fluent script, and there is a 25% chance that this non-dominant hand will become afflicted with the same problem.

Writing aids have been popular, but used with mixed results. Sometimes the use of a very thick pen (constructed by an enthusiastic Occupational Therapist) held in the palm of the hand (to eliminate the need for fine finger movement) may help.

Drug treatment with anticholinergics and dopamine agonists has been disappointing, but few anecdotal reports may make an empiric trail worthwhile.

Botulinum toxin injections can effectively reduce the spasms in the forearm muscles. If the most dominant muscle is identified by needle EMG and injected, only a limited degree of weakness (If any) may be experienced, with stability to the hand while writing. Patients are usually very grateful for the relief of these uncomfortable spasms.

Dr Mariët Van Niekerk , MB.ChB. (UOVS) M.Med(Pret) (Neurol) FCP (SA) , Neurologist , Pretoria