Writer’s Cramp - Home Management and Exercises
This condition is also called ‘Mogiographia’ or ‘Scrivener’s Palsy’. When focal hand dystonia (abnormal muscle tone resulting in muscular spasm) affects writing it is called ‘Writer’s Cramp.’ It is a disorder of the hand caused by cramps or spasms of certain muscles or groups of muscles of the hand and /or forearm which interfere with while performing normal fine motor activities such as writing or playing with an instrument. Initially ‘Writer’s Cramp’ usually affects a person’s ability to write legibly for long periods of time, especially in one stretch. Dystonia results in sustained contraction of muscles leading to involuntary movements. ‘Writer’s Cramp’ is a focal dystonia of the muscles of the fingers, hand and/or forearm that is specific to the task of writing and it is the most common task specific focal dystonic disorder. Symptoms usually start to appear when a person tries to do a specific fine activity such as writing or playing with a musical instrument. The writing may become painful and the written matter may be illegible.
Types of Writer's Cramp
Two types- Simple and Dystonic
- Simple Type- When focal hand dystonia affects writing it is called Simple ‘Writer’s Cramp’. It is usually caused by over use of hand, poor writing posture, incorrect way of writing or using poor pen hold. These factors may cause muscle spasm leading the writer to press down unnecessarily hard on the paper resulting in pain. In Simple ‘Writer’s Cramp’ the distonic postures of the hand begin to impede the speed, accuracy and legibility of writing as soon as the person puts up the pen on the paper or within a short span of time after he starts writing.
- Dystonic Type- In this type the difficulty in writing may occur together with a more generalized dystonia that affects other parts of the body as well. In distonic type the symptoms such involuntary movements and muscle cramps may appear not only when the individual is writing but also they appear while performing other fine activities such as shaving, cutting nails, tying shoes, washing utensils, applying make ups, putting buttons etc. The dystonic type may be seen in musicians who play violin or guitar and also in athletes who play golf. This type is also commonly found in typists and in those who operate computer frequently
What is ‘Writer’s Cramp’?
Hand writing is a motor skill. Early in life the techniques of writing letters are learned and the movements which are responsible for carrying out the technique of writing are stored in the memory area of the brain. Once the techniques of writing are stored in the brain, it becomes ‘automated’. Once the technique of writing becomes ‘automated’ the person need not remember them while writing as the writing comes automatically. Thus he concentrates more or less fully in the matter which is to be written. In ‘Writer’s Cramp’ the ‘automation’ of the technique of writing is disrupted and hence his concentration falls not only on the matter to be written but also on the technique of writing. In such cases the dystonia (abnormal muscle tone resulting in muscular spasm) creeps in, which affects the muscles of the fingers, hand and/or forearm. Dystonia causes involuntarily movements and sustained muscle contractions with abnormal postures. Focal dystonia affects only one specific part of the body and a specific activity. ‘Writer’s Cramp’ is a typical type of focal dystonia that affects the hand and it is specific to the task of writing. ‘Writer’s Cramp’ is the most common focal primary distonic disorder. As with other types of dystonia, this automatic disruption becomes worse when the person who writes is under the influence of stress, strain or anxiety.
- Psychological- The following are some of the situations which may lead to ‘Writer’s Cramp’ psychologically.
- Bad experiences-while learning the techniques of writing in the early school days.
- Negative comments- by someone regarding ones handwriting. Eg. Illegible writing.
- Tension or worries- before or during examinations, not necessarily about writing.
- Too conscious about one’s own handwriting.
- Too high an expectation of writing. Someone who has good, legible and beautiful handwriting in the earlier days may find it mentally difficult to adjust with the changes needed to write in the later years of life. Some may even find it difficult to accommodate to the changes needed to speed up writing in the examination.
- At times of unexpected intense personal or family problems- like death, divorce, losing a job etc.
- Over use of hand- continuous and unlimited writing.
- Holding the pen towards its tip, while writing.
- Holding the pen vertically upwards instead of in a slanting position, while writing.
- Holding the pen too tightly, while writing.
- Pressing the pen forcefully on the paper, while writing.
- Inconvenient and unconventional pen holds- Those with long fingers may find it difficult to hold the pen in a convenient and comfortable way. The same problem creeps in if the pen is too small or too big to hold.
- Holding the pen too hard- Inconvenient and unconventional pen holds result in muscular strain. In such cases the writer holds the pen too hard and presses down forcefully on the paper resulting in pain.
- Bad writing posture- uncomfortable positions of elbow and wrist makes the pen hold uncomfortable leading to muscular strain and pain.
- An injury to the hand or arm- may make the pen hold uncomfortable making the pen hold uncomfortable leading to symptoms of Writer’s Cramp.
- Position of paper- An incorrect paper position makes the writer to assume an unsuitable body position while writing leading the wrist to have a twisted position. This may lead to symptoms of Writer’s Cramp. It is better to have the paper slightly to the right if the writer is right handed and slightly to the left if he is left handed.
- Loss of precision muscle contraction- eg. Dropping holdings from the hand frequently, happening of unexpected minor injuries to hand etc.
- Cramping pain or trembling- with sustained and excessive use of hand. eg. Activities like holding a book for a long time, turning pages of a book continuously for a long time.
- Keeping the hand in comfortable positions-The affected person may keep his hand in pocket while standing or may keep his hand under the thighs while sitting or may keep his hand under the pillows while sleeping to reduce the tremor and keep the hand still.
- Stress, anxiety, lack of sleep, sustained use, excessive use, cold temperature etc- may worse the symptom. Symptoms due to secondary effects of constant and continuous muscle and brain activity may be present. Eg. Disturbed sleep, feeling of exhaustion, mood variations, mental stress, lack of concentration, blurred vision, short-tempered, depression, problems with the digestive system etc.
- Difficulty in carrying out activities of daily living- especially the activities of hand.
- Tremor-Some have tremor in the affected arm or hand while the writing is initiated or even while the writing is going on. The tremor may continue even after the writing is stopped. The tremor may continue even after the arm is outstretched.
- Exageration of symptom-Symptoms may get exaggerated with the attempts to write.
- Neurological Examination usually reveals no abnormality.
- Electromyography (EMG) may show simultaneous contraction of agonists and antagonists.
- Nerve conduction studies – to rule out a trapped nerve or an injured nerve.
- MRI studies are indicated if a structural lesion is suspected.
- Functional assessment.
- Lab. Investigations- Usually normala
The symptoms may progress and then plateau for years or may stop progressing entirely. Progression may be delayed by treatment or adaptive life style changes. But in such cases the symptoms progress rapidly if one continues to use the hand. In some cases the symptoms may lead to total disability.
Since most of the patients suffering from do not seek medical help, it is very difficult to know the real incidence pattern. Anyway it is considered to be more prevalent between the ages of 30 and 50. Men are found to be more afflicted by Writer’ Cramp than women. More common amongst those occupation demands continuous and excessive writing
- Drugs like Anticholinergics and L-dopa have been used. But none appear to be uniformly effective to all.
- 2. Botulinum Neurotoxin injections to the selected muscles are helpful to relieve or reduce the symptoms. Significant improvement in writing and reduction of pain is seen in the majority of the patients.
- Avoid continuous and unlimited writing- It is advisable to stretch out the hand in between at times of interval.
- Hold the pen approximately about 1/3 above the tip, while writing.
- Hold the pen in a slanting position, while writing.
- Hold the pen in a relaxed manner, while writing. Hold the pen in such a way that the pressure applied should be a minimum.
- Avoid pressing the pen forcefully onto the paper, while writing.
- 8. Avoid a pen which is too big or too small. Using such pens will be inconvenient and less comfortable causing strain to the muscles resulting in symptoms. Hence selecting a pen of medium size which is comfortable to him to hold must be chosen.
- Good writing posture – Good writing posture must be chosen while writing. It is good and proper that the elbow, the forearm and the wrist are properly positioned and supported. Avoid hanging down of forearm or the elbow down the table while writing.
- Position of paper-The paper must be placed on the table in a convenient and comfortable position. It is better to have the paper on the right side if the writer is right handed and slightly to left if he is left handed. The paper must be held in position with the other hand or in any other way.
- Physiotherapy Treatment-
1. Includes strengthening exercises, stretching exercises, precision training exercises, relaxation exercises, grip exercises etc. to the small muscles of the hand. (Please refer my earlier articles which deal with physiotherapy treatment for Carpal Tunnel Syndrome.)
2. Heat modalities like Ultra Sound Therapy (UST), Wax Bath Therapy, Infra Red Radiation (IRR) are helpful to relieve the pain.
3. Transcutaneous Electrical Nerve Stimulation (TENS) is found to be highly beneficial.
12. Psychological Backup- A person inflicted by Writer’s Cramp is usually in a depressed mood as he thinks that the people around may have ill feeling towards his negative way of writing. This feeling of depression increases the stress experienced by the person in question and adversely affects his ability to write further. As a result he loses even his self confidence. In such circumstances a psychological boosting up is essential to keep up the morale of the patient. In such cases it is advisable that the patient must come forward and explains to his co-workers about his inability to write properly so that they can be a help group to boost up his morale.
13. Photographing or Video graphing- The writer who has Writer’s Cramp may be photographed or video graphed by another person while he is writing. He may be shown the photographs or videos so that he himself may be able to understand the negativities in his way of writing. Hence he may be able to correct them to a great extend.
14. Writing on a slanting surface- To some it is found to be helpful if writing on a slanting as it can relieve the pressure on the wrist and helps to reduce tremor to a great extend. The paper must be held in position without moving as the writing progresses.
15. Switching over to the other hand- Some prefer to switch over to the other hand to evade the symptoms. But it is found that it is not a solution as the problems may affect the other hand also in the course of time.
16. Distraction Technique- Instead of straight away rushing into writing words or sentences or putting signature on a paper, some people felt it helpful if he does some motions in the air or writing something on a scribbling paper with closed eyes.
17. Relaxation- The symptoms may be reduced to a great extend if the patient is relaxed prior to writing. Breathing Exercise Exercises may be done at regular intervals as the writing is progressing so that he can write in a relaxed mood. Relaxation may also be attained by outstretching the arm, shrugging the shoulders, shaking or moving the wrists, making the fists and releasing etc. in between as the writing progresses.
18. Re-education of writing- He may be encouraged to write something or draw pictures in a casual way on scribbling papers at leisure times. He may draw parallel lines, small circles, zigzag lines, writing between parallel lines etc.