Writer’s cramp
Writer’s cramp also known as focal hand dystonia, arm dystonia or finger dystonia, is a focal dystonia of the fingers, hand, and/or forearm causing difficulty in writing. A focal dystonia affects one area of the body. Symptoms usually appear when a person is trying to do a task that requires fine motor movements, such as writing or playing a musical instrument. Writer’s cramp symptoms may be isolated to only those tasks or affect the muscles in a more general way and spread to affect many tasks. Symptoms of writer’s cramp vary from person to person and include unusual positioning of the fingers, wrist or elbow and muscle spasms and cramping of the fingers, hand and/or forearm while writing. Sometimes uncontrolled involuntary movements or tremor may occur. Common symptoms include, for example, excessive gripping of a pen or utensil, flexing of the wrist, elevation of the elbow, and occasional extension of a finger or fingers causing the utensil to fall from the hand. These symptoms make it difficult for the person to write and for others to read their writing. For most people the dystonia only affects writing but for a number of people it may become more complicated. Other tasks that need fine motor movements, such as using a knife and fork or shaving, may also be affected.
Writer’s cramp can affect people of any age but is commonly diagnosed in people aged 30-50 years.
Writer’s cramp may be primary or secondary. Very rarely, individuals with DYT1 dystonia (which is primary and usually generalized) will have writer’s cramp as the only symptom.
A similar type of dystonia, musician’s cramp, can affect musicians particularly violinists and pianists
Forearm dystonia can also be seen in sportspeople such as golfers. Pain in focal hand dystonias is not common, unlike a repetitive strain injury (RSI).
A specialist neurologist (a neurologist with a special interest in movement disorders) will assess your symptoms, perform a neurological examination and take a detailed history for a possible diagnosis of dystonia. There are no special scans, X rays or blood tests available to diagnose writer’s cramp but these investigations may be ordered to exclude other conditions.
There is no known cure for writer’s cramp but there are treatment options to reduce the severity of symptoms 1.
Writer’s cramp cause
For most people no cause is found, although it can be related to repetitive movements performed over many years in some cases. Simple writer’s cramp is usually caused by over-use of the hand, poor writing posture or poor penhold. The resulting muscle strain can cause the writer to press down too hard on the paper and can lead to spasms and pain.
A genetic cause may be found if the writer’s cramp is part of a more generalized dystonia, usually in conjunction with early-onset generalized dystonia, which is associated with the DYT1 gene. It is generally accepted that writer’s cramp is in part related to a problem with the functioning and connections of various areas of the brain including the basal ganglia and cerebellum.
Writer’s cramp symptoms
Two basic 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 individual picks up a pen—or within writing a few words—dystonic postures of the hand begin to impede the speed and accuracy of writing.
Symptoms of simple writer’s cramp only appear during writing and include some or all of the following:
- Gripping the pen too hard.
- Extension of the finger during writing making the pen difficult to hold.
- Unusual postures of the wrist or elbow.
These can make writing very difficult. Sometimes tremor is also a symptom although this is unusual. In many cases, symptoms are exacerbated by tension.
In a minority of cases, difficulties in writing are caused by dystonic writer’s cramp which may occur together with a more generalized dystonia that can affect other parts of the body as well. In this case, the involuntary movements and muscle cramps can also be apparent when undertaking other non-writing tasks such as using a knife and fork or applying makeup etc.
In dystonic writer’s cramp, symptoms will be present not only when the person is writing, but also when performing other activities, such as shaving, using eating utensils, applying make-up.
Common symptoms include, for example, excessive gripping of a pen or utensil, flexing of the wrist, elevation of the elbow, and occasional extension of a finger or fingers causing the 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 generalized or segmental dystonia. Very rarely, individuals with DYT1 dystonia (which is usually generalized) will have writer’s cramp as the only symptom. If the writer’s cramp is secondary, there may be a greater frequency of pain.
Writer’s cramp diagnosis
Diagnosis of writer’s cramp is based on information from the 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
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 characterized 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.
Writer’s cramp treatment
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.
Oral medications
Oral medications for people with writer’s cramp include benzodiazepines, antispasmodics and, in particular, anticholinergics. These medications have varying and limited success in managing the symptoms. Since side effects can occur with all medications a balance is required between possible side effects and benefit.
A multitude of oral 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® (trihexyphenidyl), Cogentin® (benztropine).
Botulinum toxin A injections
Botulinum toxin A injections into the forearm and/or hand muscles that are thought to be responsible for the unusual posturing or cramping is one treatment for writer’s cramp. This treatment reduces the overactivity of the muscles by weakening them, especially when significant deviation of the wrist or finger joints is present. Often the injecting neurologist will be guided by recording the activity within the muscle before injecting them. This is called electromyography, or EMG. Although botulinum toxin A injection 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.
Botulinum toxin has been used successfully and safely worldwide for many years and has the most success in reducing symptoms. Most people tolerate this treatment but possible side effects such as weakness of the injected muscles must be considered and balanced against the benefit. Where many different muscle groups are involved in the writer’s cramp, treatment may be less effective.
Writer’s cramp exercises
Physiotherapy in writer’s cramp is complex. Physiotherapy cannot cure writer’s cramp but assessment and retraining techniques may provide relief and help you feel more in control of your symptoms. You should contact a physiotherapist who understands the condition or is willing to discuss your treatment with someone who is experienced in treating writer’s cramp.
Complementary therapies
Complementary therapies may be explored, and if pain is present regular relaxation practices may benefit an individual’s sense of overall well being. If you are considering having alternative therapies you should discuss them with your specialist beforehand to ensure they do not cause issues with your condition or treatment.
Surgery
Surgery is not usually considered in writer’s cramp unless the person also has other types of dystonia which have not responded to medical treatment and are impacting on their quality of life (see web site for details on surgery).
Writer’s cramp prognosis
In most cases writer’s cramp remains focal and the condition stabilizes within a five year period. Using a “thick” pen can help writing for some individuals while others may benefit from writing with their non-dominant hand or changing their writing technique. Writer’s cramp can affect the individual physically, emotionally, socially, at work and in daily living activities. This often causes depression and anxiety. These health symptoms can have as big an impact as the physical symptoms and should be discussed with your neurologist, primary care physician or mental health professional.
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