and Further Forward
MARK S. SCHWARTZ
The rare (one prevalence estimate is 69 per million; Nutt, Muenter, Aronson, Kurland, & Melton, 1988) and very disabling disorder writer's cramp is typically resistant to treatment. When a person with writer's cramp starts to write or attempts to continue writing after just a few words, there is excess gripping of the pen or pencil, with a subsequent inability to write at all.
The hand may pronate, with ulnar deviation of the wrist and elevation of the elbow. Sometimes
the thumb and index finger flex, so that they ride up the pen. Less commonly, the index finger or
thumb, or both, extend to lift off the pen, which may fall from the grip…. Sudden jerks of the
hand and arm may cause unintended strokes of the pen, or drive the nib through the paper. Tremor
is common. (Marsden & Sheehy, 1990, p. 148)
Injury to the hand or arm immediately before symptom onset occurs in 5–10% of persons with writer's cramp. However, the onset is insidious in most patients. There are hints of inheritance in a small percentage of persons. Spontaneous remission for months or years reportedly occurs in about 5%, but relapse is also common. For about half of patients, writing difficulty is the only symptom. For many, there is progression to other manual acts. It is surprising that persons with writer's cramp can write shorthand without difficulty (Marsden & Sheehy, 1990).
Experts remain in disagreement about the etiology of writer's cramp. Some of this disagreement may result from the health care specialties of the investigators and the types of patients who seek their help. These divergent views result in different classifications of subtypes. Marsden and Sheehy (1990), for example, distinguish a "dystonic" from a "simple" type. In the dystonic type, there is involvement of other manual actions from the beginning. Persons with simple writer's cramp can complete other manual motor tasks without difficulty. These authors also distinguish a type they term "progressive" writer's cramp,