writer's cramp

[shruti]

my uncle,58yrs old has been diagnosed with writer's cramp wich is considered as initial stage of parkinson's disease(generally). he has strted developing li'll shaking of hands...........wich is leading to poor handwriting or micrographia.

people kindly enlighten me with some treatment aspects in this regard.

regards
shruti

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[gcoe]

micrographia is quite different from writers cramp. Writers cramp is not a problem of Parkinson's disease. If your uncle has Parkinson's disease it is most likely not due to writers cramp. So I have written this as considering your uncle doesn't have writers cramp and that that is a false diagnosis. The shaking (tremor) usually disappears on the concentrating on moving so is usually not such a big problem as you hand writing causes the movement. The problem in micrographia is considered due to hypokinesia which is loss of the size of the movement - the size of the movement is affected due to failing of the scaling of the movement by the part of the brain that is affected. this is what produces the tiny hand writing and small steps in walking.

Two strategies you could try is having some large hand writing on the line above and getting your uncle to practice copying the large handwriting. this often has a temporary effect of increasing the handwriting for some time. But the exercise needs to be repeated, for example each day doing a bit of practice

An alternative strategy is to practice hand writing while not looking at the hand (eg keep the eyes closed):

http://www.bcm.edu/neurology/pdf/pos...n%20PD_MDS.pdf

there is usually a general loss of fine manipulation skills in the hand over and above micrographia. Keeping the hand strong and practising manipulation tasks each day may help slow down the decline in hand function. However there is a fine line between "fighting the disease" - that is where you exercise to overcome the impairments and where there needs to be some acceptance of the loss of function and thinking about alternative strategies. On the whole you are better off doing what he can to keep the function. And keeping fit generally is really important - exercising every day.

Is your uncle on levadopa or other Parkinson's medications?

[shruti]

Thanx so much for the suggestions,...

but i guess u misundrstud a bit......he hs been diagnosed with writer's cramp only not p.d by many neurologists and acc. to them its a precipitating factor for p.d....hez not hvng any levodopa or any such med.

he dsnt hv any bradykinesia or any movt. disorders.......only thing affecting him is hand functions and esp. handwriting. he complains of li'l hand shaking vry li'l while writing. and he hs also showed me his writing wich is actually deteriorating day by day...vry difficult to undrstnd,wich dsn implies that hez hvng sum movt. disordrs or p.d........ITZ GNRLLY CONSIDRD THT IT may (cud be vry rare)b an indicator of dvlping p.d in future.

[gcoe]

Yes I can see how I misunderstood what you were saying. It is true that a focal dystonia can precede PD but I understand that this is much more common in a younger person with early age onset PD.

The confusing bit is the micrographia. If he truly has micrographia that is a feature of PD and not writers cramp. For physical treatments it is quite important to be as clear as you can as the wrong treatment is probably going to waste your uncle's time.

Perhaps you could explain in your own words what you observe happens on writing and on other task he is having difficulty with.

[shruti]

dts right......i actully forgot to mention the big word "focal hand dystonia"...and micrograhia z the term used by me as per the decline in his writing skills.......rite now hez nt following any physical trtment.....since hez quite far away frm me(different state in india itself),im nt much able2lukaftr him nd his current condition......a daily exercise regime z actuaaly required,wich to certn xtent hez following.........rest spcfc pt trtment hs yet2b implemented...

[gcoe]

Dystonia is complex and I would not be comfortable prescribing specific exercises without a proper assessment. I think your uncle warrants an assessment from a neurological physiotherapist who has experience in dystonia.

If that is not possible here are some overall principles and a suggested resources:

• If one approaches it from a motor control point of view, the problem is excessive activity in the wrong muscles at the wrong time.
• Maintaining a supported posture with good alignment so he can relax for starters
• Try writing slowly and very gently. Patients often excessively co-contract their muscles in an attempt to control the dystonic movement but this can make matters worse. and keep the size of the writing larger than usual
• Practice performing lines, circles, ellipses and other geometrical shapes making them as smooth as possible. These more simplified shapes may are often easier to perform as an intermediary step.
• Having an optimal grip can reduce the effort required to hold the pen. Therefore an ergonomic pen which has a grip of 1.5 to 2 cm and is very comfortable to hold may help.
  
  Resources:
  
  The Dystonia Medical Research Foundation has some good tips under non drug therapies:
  
  http://www.dystonia-foundation.org/p...rapies/110.php

One take home message from the DMRF is not to get fixated just on physical treatments but paying attention to participation in life and personal satisfaction is important.

There is a guy who runs this site and sometimes contributes here who has a number of resources and suggestions on physiotherapy for various types of dystonia and it is definitely worth checking out his website. This has many suggestions and tips for dystonia generally and specific to focal dystonias. I think he also offers free consultation. Fernando takes a very holistic approach:

http://www.distoweb.com/

It has to be said however that there is virtually no evidence to date for physiotherapy for dystonia - no clinical trials. So it is hard to advocate for a particular approach. It is an area that desperately needs some good clinical research.

[SPPAWA]

Both Parkinson's and Dystonic events are produced by dysfunction within the same neural circuitry involving the basal ganglia.

What hand is affected?

Look at his pupils... Is one larger than the other one?

Basically, basal ganglionic functions are regulated by descending input from ipsilateral cortical centers. Therefore, at some level, these are inappropriately modulating output to the muscles of the hand during writing tasks for your uncle. These circuits exist on the brain C/L to the side of the lesion (in this case the hand). From a manual therapy approach, an attempt to increase afferentation to cortical centers through any sensory modality that will increase decending modulation to basal ganglionic circuits should be attempted. This does not necessarily mean electrotherapies or manipulation, although they may be used if parietal functions have been assessed and deemed the major deficient system.

Such effects can be seen in this video on youtube (I realize this is not a great "scientific" reference, however, for lack of other visual demonstration please humor me). YouTube - Dyskinesia and Blue Lenses What you are seeing is that a blue filter in lenses is changing the firing patters from the occipital cortex which is responding to differences in the frequency of light. Blue light is of a higher frequency than red light. Decreasing or (in this case) increasing firing from an occipital lobe will have an effect on modulating the overall activity in basal ganglionic and resultant thalmo-cortical circuitry which, as I'm sure you are aware, regulates output from primary motor centers. This is important, as this output is producing both the unwanted movement ie the choreioform movement in the video and focal dystonic event in your uncle's hand.

You can try these glasses which I have used successfully on some patients for similar dystonic events. You can try both the blue/red and dark/red combination's and simply test with a timed writing test improve his symptoms as he writes. NOTE *** rest periods inbetween ie. a day between trials is needed*** use a stopwatch to time*** Try each of the following:

1. Red/blue with Red to the right side.... Time a set writing task
2. Red/blue with Blue to the right side.... Time the same writing task
3 Red/dark with dark to the right side.... Time the same writing task
4. Red/dark with Red to the right side.... Time the same writing task.

If your uncle has a deficient visual sensory integration issue it will likely appear to improve with one of the above tests. Remember to do the same writing test to maintain consistency and NOTE which way the lenses were facing when his symptoms improved.

Pick's Reversible Frame Hemifield Stimulator Goggles

Pick's Reversible Frame Hemifield Stimulator Goggles

try both the above. tell me the hand. tell me if he has an anisochoria.

You can get back to me and I will discuss treatment options further if you are interested.

If you are really up to snuff on your neurology you will understand this article and be able to apply it to what I have said above:

Elsevier

Cheers,
SPPAWA