At the end of 2017, I was studying in God and suddenly found that I, a medical student, can’t write? ! But playing the Rubik’s cube, using the mouse, typing, using chopsticks, all other fine movements of the hands are normal.
My first reaction was muscle fatigue, so just take a break. But after a series of exams, I couldn’t write well, and I couldn’t fill in the form when I went to the finance department to report the account. I realized that this may be an illness, and it has been more than half a year. However, the director’s diagnosis was only a glance away, and my heart was cold for only a moment.
Epidemiology
Writer’s cramp (WC) is a primary, task-specific, focal dystonia characterized by synchronous contraction of agonist and antagonist muscles during writing , resulting in hand spasms, abnormal posture and twisting movements, and eventually inability to write, which may be accompanied by tremors.
The European Dystonia Epidemiology Study Group reported an annual incidence of writing spasm in 8 European countries of 14/1 million; studies from Japan showed focal dystonia The prevalence rate was 62/1 million. However, because many patients do not seek medical care, the incidence of writing cramps is likely to be underestimated. The age of onset of this disease is 30 to 50 years old, and the incidence rate of males is significantly higher than that of females (male:female=1.3).
Clinical symptoms
Handwriting cramps are usually insidious at onset and progress over several months. Patients may complain of tightness, stiffness in the forearm when writing, or fatigue when writing for long periods of time. Hands, fingers and/or arms may have involuntary flexion or extension during writing. Decreased speed and spasms when writing for extended periods of time. Abnormal writing posture with tremor may occur in about 45% of patients.
Common dystonias include flexion, extension, supination, pronation, or a combination. Flexion-dominant disorders often result in increased pressure on the writing surface, the so-called “force through the back of the paper”; while extension-dominant disorders may lift the fingers/thumbs off the pen, making it difficult to place the pen on the paper, resulting in handwriting Vague.
As a medical student, I quickly figured out what was going on by doing research, but I noticed that the internet was full of prejudice about this disease. It should be emphasized that the results of MRI and EMG clearly demonstrate the “organic changes” of writing spasm as a neurological disease, and it is not a simple “psychological disease”.
Since a large number of patients are students or staff who depend on their writing function, the misunderstanding of the social environment and the pressure of work and study requirements often bring patients far more pain than the disease. How many people can bear it when they suddenly can’t write one day, but they are considered by their parents as “rebellious, nonsense, and an excuse for not wanting to read”?
Pathogenesis
Writing spasm is a task-specific focal dystonia, and its pathogenesis mainly includes structural dysfunction of the basal ganglia and its connecting circuits, and weakened inhibitory effects at all levels of the sensorimotor system. , cerebral cortical plasticity and homeostasis abnormalities, sensorimotor processing dysfunction and other four aspects.
In focal hand dystonia including writing spasm, repetitive hand patterns may be a contributing factor. The relationship between hand trauma and the development of writing cramps is unclear; although there have been reports of limb dystonia after peripheral trauma.
Diagnosis and Treatment
Experimental examinations mainly include blood electrolytes, drugs, trace elements and biochemical examinations, which are helpful for differential diagnosis. CT and magnetic resonance imaging (MRI) examinations are meaningful in the differential diagnosis of intracranial diseases. Electromyography is meaningful for differential diagnosis. Genetic analysis has important implications for the identification of certain inherited dystonic disorders.
The treatment of WC mainly includes botulinum toxin injection, internal medicine, surgery, magnetic (electrical) stimulation, exercise training and immobilization, sensory function training, and traditional Chinese medicine acupuncture.
1
Botox injections
The key to botulinum toxin treatment for WC is identifying the muscles that spasm when writing. WC usually affects the distal extremity flexor muscles, and may involve the wrist and arm muscles in a longer course of disease. Although many muscles can be affected by WC, the most severely affected muscles, especially the flexors, are usually selected for the actual injection. Multi-point injection is often used, each point is 2.5 to 5 U, and the total amount is 50 to 100 U. If the tremor is significant, the dose should be appropriately increased.
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Medical therapy
WC currently has no specific drug treatment. Clinical experience suggests that anticholinergics, benzodiazepines, baclofen and other drugs have certain effects. It has been reported that sertraline also has an effect. For some patients with dopamine-responsive dystonia with WC, low-dose dopamine can achieve good efficacy. Medications for WC are usually ineffective and only work in some patients.
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Surgery
In 1969, Siegfried performed the first stereotaxic ablation of WC. At present, this method has become an effective treatment. The commonly used damage targets are the ventromoral nucleus and ventromedial nucleus of the thalamus. Because the damage target is close to the internal capsule, sensory thalamus and other important structures, and the damage is an irreversible operation, there is a certain risk. Recently, deep brain stimulation (DBS) has also been used to treat WC.
In general, thalamic damage or DBS surgery is effective in the treatment of WC, but due to the risks, costs, and technical thresholds of surgery, the current clinical application is limited.
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Other Sex
In addition, low-frequency (≤1 Hz) repetitive transcranial magnetic stimulation, transcutaneous electrical nerve stimulation, exercise training, hand immobilization, Braille practice, and traditional Chinese medicine acupuncture have been reported, but clinical applications limited.
I still remember nearly four years of medical study at that time, which made me adapt to any situation where just a precise description of the symptoms of the disease can be used as the scientific name of the disease, and there is basically no treatment for such diseases by default. .
But I still want to say to my patients that there is nothing to be afraid of disease. If you encounter it, accept it calmly, and actively treat it. If it cannot be cured, then try to live with it.
Recalling the day of the diagnosis, before going out, I asked the director what to do when writing? The director waved his hand: If you can’t write, you won’t write anymore. In the future, the hospital will type.
The author says:
Strictly speaking, “writing spasm” is not a rare disease. The starting point of this topic is purely to respond to the needs of readers and friends.
However, in the process of collecting information, the author only saw the same posts without any good stuff in a certain related post bar with the catalogue of “Fantasy·Fantasy Novels”. A young colleague recorded his disease, diagnosis and treatment and mental journey in detail.
The author is shocked that this disease is not rare, but what is the difference between our cognition of it, the prejudice of patients, and rare diseases?
I sincerely hope that the development of medicine and technology will not only allow everyone to receive treatment and improvement, but also completely get rid of the “suffering of writing”.
References:
1. Zhihu: Writing spasm – a “rare disease” that needs attention.
2. Goldman JG. Writer’s cramp. Toxicon. 2015 Dec 1;107(Pt A):98-104. doi: 10.1016/j.toxicon.2015.09.024. Epub 2015 Sep 21 . PMID: 26391286.
3. Zakin E, Simpson DM. Botulinum Toxin Therapy in Writer’s Cramp and Musician’s Dystonia. Toxins (Basel). 2021 Dec 14;13(12):899. doi: 10.3390/toxins13120899. PMID: 34941736; PMCID: PMC8708945.
4. Yuan Gao. Research progress of writing spasm. Chinese Contemporary Medicine, Vol. 21, No. 22, Aug. 2014.
5. Popular Science China Science Encyclopedia: Writing Spasms
Source | Mace Medicine has a long way to go
Editor | Lan Ying
