Hand orthosis as a writing aid in writer's cramp

Development of an Ergonomic Writing Assistive Device for Finger Pain Reduction in the Elderly

The decreased muscle mass and increased prevalence of musculoskeletal diseases in the elderly means that this population often experiences difficulty with writing. Although various commercial writing assistive devices exist to reduce pain and improve writing efficiency, low satisfaction with their design prevents them from being widely adopted. In this study, we developed a new ergonomic writing assistive device that overcomes these shortcomings and reduces finger pain. Twenty elderly people with normal writing skills participated in a performance evaluation of our designed device. We used two commercial writing assistive devices and the developed writing assistive device to write a given experimental sentence three times each for each device. For each device, finger-related muscles activity and finger pressure were measured during the experiment, and satisfaction level was evaluated using the modified QUEST 2.0 after the experiment. As a result, the activity in abductor pollicis brevis (18.16%) and first dorsal interosseous muscle (14.17%) was significantly higher when using the NDWAD (newly developed writing assistive device) than when using commercialized WADs (writing assistive devices) (p < 0.05). Finger pressure in the thumb (0.59 N), index finger (1.09 N), and middle finger (0.46 N) was significantly lower when using NDWAD than when using WADs (p < 0.05). The satisfaction level of NDWAD (4.47) was higher than that of WADs. Therefore, we confirmed that our design reduced finger pressure and improved user satisfaction. Consequently, the NDWAD developed in this study can be used as a writing aid not only for the elderly, but also for patients with writing disabilities.

[Non-motor disorders in patients with muscular dystonia]

Non-motor disturbances represented by sensory, affective, obsessive-compulsive disorders, cognitive dysfunction, sleep disturbances are often found in patients with dystonia and have a negative impact on their quality of life. The prevalence of sensory and affective disorders and sleep disturbances is above 50% in patients with cervical dystonia and is 25% in patients with blepharospasm, writing spasm; cognitive dysfunction is found in more than 25% of patients with focal dystonia. The relationship of non-motor, in particular psychiatric disorders, with the impairment of social and everyday life and worsening of quality of life in whole was shown. Common pathophysiological mechanisms of non-motor disorders as well as approaches to treatment of these disorders are discussed. The authors present the results on the positive effect of botulinum toxin therapy that reduces cognitive dysfunction, sensory disorders and depressive syndrome. Non-medication treatment of non-motor disorders in patients with dystonia is considered.

Why orthotic devices could be of help in the management of Movement Disorders in the young

Background

Movement Disorders (MD) are a class of disease that impair the daily activities of patients, conditioning their sensorimotor, cognitive and behavioural capabilities. Nowadays, the general management of patients with MD is based on rehabilitation, pharmacological treatments, surgery, and traditional splints. Although some attempts have been made to devise specific orthoses for the rehabilitation of patients affected by MD, especially the younger ones, those devices have received limited attention.

Main body

This paper will principally discuss the case of upper limb rehabilitation in Childhood Dyskinesia (CD), a complex motor disease that affects paediatric patients. Through a critical review of the present solutions and a discussion about the neurophysiological characteristics of the disease, the study will lead to the formulation of desirable features of a possible new upper-limb orthosis.

Conclusions

Design principles will be derived to provide specialised orthoses for the dynamic control of posture and the stabilisation of voluntary movements: those include using biomechanical actions and enhanced proprioception to support the sensorimotor rehabilitation of the children affected by CD. A similar approach could be advantageously applied in other MD-related conditions, especially with hyperkinetic and/or hypertonic traits.

Writer's cramp

Writer's cramp is the most common form of focal, task-specific dystonia. Symptoms frequently evolve in the setting of repetitive hand movements and increased writing demands, and clinical presentations demonstrate a variety of different dystonic patterns of the upper extremity such as while writing or holding a writing utensil. However, why writer's cramp develops still remains much of a mystery. Clinical evaluation of patients with writer's cramp and various theories regarding its pathophysiology are reviewed. Treatment can be challenging and often involves a combination of pharmacologic (e.g., oral medications, botulinum toxin injections) and non-pharmacologic approaches (e.g., neurosurgical or neurostimulatory interventions, rehabilitation therapies, adaptive devices). Management strategies for writer's cramp using both of these approaches will be discussed.

Sensitive Training Through Body Awareness to Improve the Writing of Patients with Writer's Cramp

The aim of this article is to evaluate if body awareness is important to improve the writing ability before using the splints. Twelve patients with writer's cramp were evaluated by a specialist in movement disorders. The Burke-Fahn-Marsden Scale (BFM), the Jedynak Protocol and the Analog Pain Scale were used. The rehabilitation training was administered over an eight-week period, in two phases of four weeks each, twice a week. Each session would last 60 minutes. A significant improvement was shown, not only in the motor, but also in the pain perception, through the BFM scale, the Jedynak Protocol and the Analog Pain Scale. Therefore, we conclude that the motor training, thanks to the body awareness and immobilization by splints of the affected dystonic musculature, led to an important improvement in the writer's cramp writing.

Adult-onset dystonia

Dystonia is defined as involuntary sustained muscle contractions producing twisting or squeezing movements and abnormal postures. The movements can be stereotyped and repetitive and they may vary in speed from rapid to slow; sustained contractions can result in fixed postures. Dystonic disorders are classified into primary and secondary forms. Several types of adult-onset primary dystonia have been identified but all share the characteristic that dystonia (including tremor) is the sole neurologic feature. The forms most commonly seen in neurological practice include cranial dystonia (blepharospasm, oromandibular and lingual dystonia and spasmodic dysphonia), cervical dystonia (also known as spasmodic torticollis) and writer's cramp. These are the disorders that benefit most from botulinum toxin injections. A general characteristic of dystonia is that the movements or postures may occur in relation to specific voluntary actions by the involved muscle groups (such as in writer's cramp). Dystonic contractions may occur in one body segment with movement of another (overflow dystonia). With progression, dystonia often becomes present at rest. Dystonic movements typically worsen with anxiety, heightened emotions, and fatigue, decrease with relaxation, and disappear during sleep. There may be diurnal fluctuations in the dystonia, which manifest as little or no involuntary movement in the morning followed by severe disabling dystonia in the afternoon and evening. Morning improvement (or honeymoon) is seen with several types of dystonia. Patients often discover maneuvers that reduce the dystonia and which involve sensory stimuli such as touching the chin lightly in cervical dystonia. These maneuvers are known as sensory tricks, or gestes antagonistes. This chapter focuses on adult-onset focal dystonias including cranial dystonia, cervical dystonia, and writer's cramp. The chapter begins with a review of the epidemiology of focal dystonias, followed by discussions of each major type of focal dystonia, covering clinical phenomenology, differential genetics, and diagnosis. The chapter concludes with discussions of the pathophysiology, the few pathological cases published of adult-onset focal dystonia and management options, and a a brief look at the future.

Physiotherapy of focal dystonia: a physiotherapist's personal experience

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.

Paramedical treatment in primary dystonia: a systematic review

Dystonia is a disabling movement disorder with a significant impact on quality of life. The current therapeutic armamentarium includes various drugs, botulinum toxin injections, and occasionally (neuro)surgery. In addition, many patients are referred for paramedical (including allied health care) interventions. An enormous variation in the paramedical treatment is provided, largely because evidence-based, accepted treatment regimes are not available. We have conducted a systematic review of studies that explored the effect of various paramedical interventions in primary dystonia. Only studies that have used clinical outcome measures were included. There were no class A1 or A2 studies and therefore, level 1 or 2 practice recommendations for a specific intervention could not be deducted. Many papers were case reports, mostly with a very limited number of patients and a clear publication bias for beneficial effects of a particular paramedical intervention. Some potentially interesting interventions come from class B studies, which include physical therapy in addition to botulinum toxin injections (BoNT-A) in cervical dystonia; sensorimotor training and transcutaneous electrical nerve stimulation (TENS) in writer's cramp; and speech therapy added to BoNT-A injections in laryngeal dystonia. Good quality clinical studies are therefore warranted, which should have the aim to be generally applicable. A design in which the paramedical intervention is added to a current gold standard, for example, BoNT-A injections in cervical dystonia, is recommended.

Geste antagonistes in idiopathic lower cranial dystonia

Geste antagonistes, or sensory tricks, are well described in focal dystonia affecting the neck, hand, and face. Improvement in dystonic movements is typically maintained while the trick is performed, but disappears when the geste ends. We investigated the phenomenological features of geste antagoniste maneuvers in 19 patients with idiopathic lower cranial dystonia who were prospectively evaluated over a period of 6 years. Of the 19, 10 were men, mean age of onset was 49.8 years, and the most commonly involved lower cranial area was the jaw (10 patients). In most patients, dystonia was task-specific. Taking advantage of the improvement with a sensory geste, we manufactured oral appliances that mimicked the geste in 8 patients, and 3 continue to use it.

Botulinum toxin for writer's cramp: a randomised, placebo-controlled trial and 1-year follow-up

BACKGROUND

Botulinum toxin type A (BoNT-A) has become the treatment of choice for most types of focal dystonia.

OBJECTIVE

To investigate the efficacy of BoNT-A injections in patients with writer's cramp in a double-blind, randomised, placebo-controlled trial and to evaluate the follow-up results.

METHODS

Forty participants were randomised to treatment with either BoNT-A or placebo injections in two sessions. Trial duration was 12 weeks. The primary outcome measure was the patients' choice to continue with the treatment, despite its possible disadvantages. Secondary outcome measures included several clinical rating scales on the levels of impairment and disability. Assessments were made at baseline and 2 months (secondary outcomes) and 3 months (primary outcome). Duration of follow-up was 1 year.

RESULTS

39 patients completed the trial. Fourteen of 20 patients (70%) receiving BoNT-A reported a beneficial effect and chose to continue treatment, versus 6 of 19 patients (31.6%) in the placebo group (p = 0.03). The changes on most of the clinical rating scales were significantly in favour of BoNT-A. Side effects reported were hand weakness, which was mostly mild and always transient, and pain at the injection site. After 1 year, 20 of 39 patients were still under treatment with a positive effect.

CONCLUSION

Treatment with BoNT-A injections led to a significantly greater improvement compared with placebo, according to patients' opinion and clinical assessment scales. Weakness in the hand is an important side effect of BoNT-A injections, but despite this disadvantage, most patients preferred to continue treatment. About 50% of our patients were still under treatment after 1 year.

Treatment of dystonia

Dystonia, defined as a neurological syndrome characterised by involuntary, patterned, sustained, or repetitive muscle contractions of opposing muscles, causing twisting movements and abnormal postures, is one of the most disabling movement disorders. Although gene mutations and other causes are increasingly recognised, most patients have primary dystonia without a specific cause. Although pathogenesis-targeted treatment is still elusive, the currently available symptomatic treatment strategies are quite effective for some types of dystonia in relieving involuntary movements, correcting abnormal posture, preventing contractures, reducing pain, and improving function and quality of life. A small portion of patients have a known cause and respond to specific treatments, such as levodopa in dopa-responsive dystonia or drugs that prevent copper accumulation in Wilson's disease. Therapeutic options must be tailored to the needs of individual patients and include chemodenervation with botulinum toxin injections for patients with focal or segmental dystonia, and medical treatments or deep brain stimulation for patients with generalised dystonia.

Treatment of dystonia

Dystonia may be a sign or symptom, that is comprised of complex abnormal and dynamic movements of different etiologies. A specific cause is identified in approximately 28% of patients, which only occasionally results in specific treatment. In most cases, treatment is symptomatic and designed to relieve involuntary movements, improve posture and function and reduce associated pain. Therapeutic options are dictated by clinical assessment of the topography of dystonia, severity of abnormal movements, functional impairment and progression of disease and consists of pharmacological, surgical and supportive approaches. Several advances have been made in treatment with newer medications, availability of different forms of botulinum toxin and globus pallidus deep brain stimulation (DBS). For patients with childhood-onset dystonia, the majority of whom later develop generalized dystonia, oral medication is the mainstay of therapy. Recently, DBS has emerged as an effective alternative therapy. Botulinum toxin is usually the treatment of choice for those with adult-onset primary dystonia in which dystonia usually remains focal. In patients with secondary dystonia, treatment is challenging and efficacy is typically incomplete and partially limited by side effects. Despite these treatment options, many patients with dystonia experience only partial benefit and continue to suffer significant disability. Therefore, more research is needed to better understand the underlying cause and pathophysiology of dystonia and to explore newer medications and surgical techniques for its treatment.

Botulinum toxin therapy of writer's cramp

The pathophysiology and management of writer's cramp is one of the most challenging amongst the various forms of focal dystonias. Frequently, the dystonic postures are confounded by compensatory muscle activity. Correct identification of target muscles for botulinum toxin (BT) injections determines the treatment success. The dosages of different preparations vary, with 1 unit of Botox roughly equalling 3.5 units of Dysport. Electromyographic guided injections yield better results and may also decrease the amount of toxin required. Weakness of target muscles interfering with other non-writing activities is a frequently encountered adverse effect. Studies have shown that BT is a safe long-term therapy option.