Writer's Cramp treatment. latest studies
March 15 2016

A new therapeutic proposal for writer's cramp: a case report.
Sao Paulo Med J. 2010. Movement Disorders Section, Department of Neurology, Pedro Ernesto University Hospital, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.
Writer's cramp is a kind of focal hand dystonia that appears when individuals are writing. Since pharmacological treatment has not shown the desired therapeutic response, a study on immobilization of the damaged musculature was performed on two individuals with writer's cramp, using splints with the objective of reducing the handwriting abnormalities. Two patients presenting writer's cramp who had previously undergone different therapies, including botulinum toxin, without an adequate response, participated in a body awareness program, followed by immobilization of the hand musculature damaged by dystonia, by means of splints, with handwriting training. At the end of the procedure, objective and subjective improvements in the motor pattern of writing could be observed. The immobilization of the dystonic musculature of the hand by means of splints and the motor training of handwriting helped to improve and consequently to reduce the dystonia component observed in the writer's cramp.

Physiotherapy of focal dystonia: a physiotherapist's personal experience.
Eur J Neurol. 2010. Bleton JP. Service de Neurologie, Université Paris Descartes INSERM, Hopital Sainte-Anne, Paris, France.
The approach of the physiotherapist to each form of dystonia is individual and has to be specific. There is not one single method but several strategies related to the different clinical forms. Although there is no standard programme applicable to all forms of cervical dystonia, we can distinguish a number of guidelines for the different clinical forms. In the myoclonic form, emphasis is placed on seeking to immobilize the head, and for the tonic form, on rehabilitating corrector muscles. Physiotherapy and botulinum toxin injections mutually interact in order to reduce the symptoms. Recent studies have shown the clinical benefits of physiotherapy. The physiotherapy of writer's cramp is designed as a re-learning process. The first step is to perform exercises to improve independence and precision of fingers and wrist movements. Then, the muscles involved in the correction of dystonic postures are trained by drawing loops, curves and arabesques. The aim of rehabilitation is not to enable patients with writer's cramp to write as they used to, but to help their dysgraphia evolve towards a fast, fluid and effortless handwriting. A reshaping of the sensory cortical hand representation appears to be associated with clinical improvement in patients with dystonia after rehabilitation.

Surgical treatment of dystonia
Eur J Neurol. 2010. Krauss JK. Department of Neurosurgery, Medical School Hannover, Hannover, Germany.
Surgical treatment of dystonia has experienced a tremendous change over the past decade. Whilst selective peripheral denervation is reserved for cervical dystonia refractory to botulinum toxin injections, deep brain stimulation (DBS) of the pallidum has gained a wide scope and presents an elementary column in the treatment of medically refractory patients, nowadays. There is consensus that idiopathic generalized, cervical and segmental dystonia are good indications for DBS, although there is still a paucity of studies providing high-level data according to EBM criteria. Efficacy is maintained on longterm. Several other forms of primary dystonia are still under investigation but it appears that patients with Meige syndrome and myoclonus-dystonia gain also marked benefit. Study of the outcome in secondary dystonia disorders is more complex, in general, but patients with tardive dystonia gain similar improvement than patients with idiopathic dystonia. Overall, the risk profile of pallidal DBS is quite low, and it has been shown to be cognitively safe. The effect of pallidal DBS on non-dystonic extremities has not received much attention, albeit there are hints for a pro-akinetic mechanism. Several questions remain to be solved including optimal programming of stimulation settings, battery drain with high stimulation energies and the elucidation of the mechanisms of DBS in dystonia.

Treating writer's cramp: 14 years' experience with botulinum toxin.
Rev Neurol. 2010. Somma-Mauvais H, Soulayrol S, Duvocelle A, Azulay JP, Gastaut JL.Pôle neurosciences cliniques, neurophysiologie clinique, hopital Nord, chemin des Bourrelly, Marseille cedex 20, France.
Writer's cramp is a focal dystonia; treatment remains disappointing. We report our 14-year experience with a population of 119 patients aged between 18 and 85 years (average age 43 years). The choice treatment for writer's cramp remains well-targeted injections of botulinum toxin. Physiotherapy is useful when the toxin injections are ineffective in completely improving writing. This requires close cooperation between the injector, the physiotherapist and the patient.

Focal hand dystonia: effectiveness of a home program of fitness and learning-based sensorimotor and memory training.
J Hand Ther. 2009. Byl NN, Archer ES, McKenzie A. Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, CA, USA.
Retraining the brain is one approach to remediate movement dysfunction resulting from task specific focal hand dystonia (FHD(TSP)). Document change in task specific performance (TSP) for patients with FHD (TSP) after 8 weeks of comprehensive home training (fitness activities, task practice, learning based memory and sensorimotor training). Thirteen subjects were admitted and evaluated at baseline, immediately and 6 months post treatment for task specific performance, functional independence, sensory discrimination, fine motor speed and strength. In Phase I, 10 subjects were randomly assigned to home training alone or supervised practice prior to initiating the home training. In phase II, 2 subjects crossed over and 3 new subjects were added (18 hands). The intent to treat model was followed. Outcomes were summarized by median, effect size, and proportion improving with nonparametric analysis for significance. Immediately post-intervention, TSP, sensory discrimination, and fine motor speed improved 60-80%. Functional independence and strength improved by 50%. Eleven subjects (16 hands) were re-evaluated at 6 months; all but one subject reported a return to work. Task-specific performance was scored 84-90%. Supervised practice was associated with greater compliance and greater gains in performance. Progressive task practice plus learning based memory and sensorimotor training can improve TSP in patients with FHD(TSP). Compliance with home training is enhanced when initiated with supervised practice.