Abstract
Study Design
Pre-Post, Mixed Factorial Trial.
Introduction
Focal hand dystonia is a challenging movement disorder to rehabilitate in musicians
and writers.
Purpose of the Study
To compare the neuromusculoskeletal characteristics of those with writers' cramp (WC)
and musicians' cramp (MC), and evaluate responsiveness to learning-based sensorimotor
training.
Methods
Twenty-seven individuals (14 musicians, 13 writers) participated in 8 weeks of supervised
therapy supplemented with a home program. Between-group differences on measures of
musculoskeletal (physical), sensory, and motor performance were evaluated at baseline
and post-intervention.
Results
Subjects with MC had a higher level of functional independence and better range of
motion, but less strength in the affected upper limb than those of subjects with WC.
Subjects with MC demonstrated greater accuracy on graphesthesia, kinesthesia, and
localization at baseline. No between-group differences in motor performance were noted
at baseline or post-intervention. Following individually adapted learning-based sensorimotor
training, both groups improved in musculoskeletal (physical) parameters, sensory processing,
and motor control; however, improvements on certain subtests differed by group. At
follow-up, differences in posture, ROM, strength, graphesthesia, and kinesthesia persisted
between the groups.
Conclusions
Subjects with WC have different physical and performance risk factors compared with
those of subjects with MC. Intervention paradigms are efficacious, but variable responses
to rehabilitation occur.
Level of Evidence
4.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Hand TherapyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Writer's cramp.Trends Neurosci. 1990; 13: 148-153
- Writers' cramp—focal dystonia.Brain. 1982; 105: 341-343
- The sensory consequences of repetitive strain injury in musicians: focal dystonia of the hand.J Back Musculoskeletal Rehabil. 1996; 7: 27-39
- Task-specific plasticity of somatosensory cortex in patients with writer's cramp.Neuroimage. 2003; 20: 1329-1338
- Sensory dysfunction associated with repetitive strain injuries of tendonitis and focal hand dystonia: a comparative study.J Orthop Sports Phys Ther. 1996; 23: 234-243
- The neural consequences of repetition: clinical implications of a learning hypothesis.J Hand Ther. 1997; 10: 160-174
- A primate model for studying focal dystonia and repetitive strain injury: effects on the primary somatosensory cortex.Phys Ther. 1997; 77: 269-285
- Differences in somatosensory hand organization in a healthy flutist and a flutist with focal hand dystonia: a case report.J Hand Ther. 2000; 13: 302-309
- Treatment effectiveness for patients with a history of repetitive hand use and focal hand dystonia: a planned, prospective follow-up study.J Hand Ther. 2000; 13: 289-301
- Abnormal somatosensory homunculus in dystonia of the hand.Ann Neurol. 1998; 44: 828-831
- Sensory discrimination capabilities in patients with focal hand dystonia.Ann Neurol. 2000; 47: 377-380
- Alteration of digital representations in somatosensory cortex in focal hand dystonia.Neuroreport. 1998; 16: 3571-3575
- Somatosensory representation of the digits and clinical performance in patients with focal hand dystonia.Am J Phys Med Rehabil. 2003; 82: 737-749
- Task-dependent modulation of silent period duration in focal hand dystonia.Mov Disord. 2005; 20: 1143-1151
- Impaired intracortical inhibition in the primary somatosensory cortex in focal hand dystonia.Mov Disord. 2008; 23: 558-565
- Movement-related cortical potentials in writer's cramp.Ann Neurol. 1995; 38: 862-868
- Impaired inhibition in writer's cramp during voluntary muscle activation.Neurology. 1997; 49: 1054-1059
- Task-dependent intracortical inhibition is impaired in focal hand dystonia.Mov Disord. 2005; 20: 545-551
- Primary writing tremor: motor cortex reorganization and disinhibition.J Clin Neurosci. 2005; 12: 102-104
- Subthreshold low-frequency repetitive transcranial magnetic stimulation over the premotor cortex modulates writer's cramp.Brain. 2005; 128: 104-115
- Abnormal somatotopic arrangement of sensorimotor interactions in dystonic patients.Brain. 2002; 125: 2719-2730
- Homeostatic-like plasticity of the primary motor hand area is impaired in focal hand dystonia.Brain. 2005; 128: 1943-1950
- Movement-related electroencephalographic desynchronization in patients with hand cramps: evidence for motor cortical involvement in focal dystonia.Ann Neurol. 2000; 47: 456-461
- Correlation of clinical neuromusculoskeletal and central somatosensory performance: variability in controls and patients with severe and mild focal hand dystonia.Neural Plast. 2002; 9: 177-202
- Abnormal cortical sensory activation in dystonia: an fMRI study.Mov Disord. 2003; 18: 673-682
- Animal models of focal dystonia.NeuroRx. 2005; 2: 513-524
- Human brain mapping in dystonia reveals both endophenotypic traits and adaptive reorganization.Ann Neurol. 2001; 50: 521-527
- Changes in brain anatomy in focal hand dystonia.Ann Neurol. 2004; 55: 736-739
- Learning-based animal models: task-specific focal hand dystonia.ILAR J. 2007; 48: 411-431
- Pathophysiology of writer's cramp.Hum Mov Sci. 2006; 25: 454-463
- Abnormality of motor cortex excitability in peripherally induced dystonia.Mov Disord. 2007; 22: 1186-1189
- Increased pre-SMA activation in early PD patients during simple self-initiated hand movements.Neurology. 2006; 253: 199-207
- Abnormalities of motor cortex excitability preceding movement in patients with dystonia.Brain. 2003; 126: 1745-1754
- Perceptual differences in sequential stimuli across patients with musician's and writer's cramp.Mov Disord. 2003; 18: 1286-1293
- The supplementary motor area in motor and perceptual time processing: fMRI studies.Cogn Process. 2006; 7: 89-94
- The effect of cutaneous input on intracortical inhibition in focal task-specific dystonia.Mov Disord. 2007; 22: 1286-1292
- Corticospinal excitability during motor imagery of a simple tonic finger movement in patients with writer's cramp.Mov Disord. 2005; 20: 1488-1495
- Differential modulation of motor cortical plasticity and excitability in early and late phases of human motor learning.J Neurosci. 2007; 27: 12058-12066
- The neurophysiology of dystonia.Arch Neurol. 1998; 55: 601-603
- Temporal processing of visuotactile and tactile stimuli in writer's cramp.Ann Neurol. 2003; 53: 630-635
- Abnormalities of spatial and temporal sensory discrimination in writer's cramp.Mov Disord. 2001; 16: 94-99
- Temporal discrimination of somesthetic stimuli is impaired in dystonic patients.Neuroreport. 1999; 10: 1547-1550
- Abnormal central integration of dual somatosensory input in dystonia. Evidence for sensory overflow.Brain. 2000; 123: 42-50
- Tonic vibration reflex and muscle afferent block in writer's cramp.Ann Neurol. 1995; 38: 155-162
- Abnormal sensorimotor integration in writer's cramp: study of contingent negative variation.Mov Disord. 1996; 11: 683-690
- Abnormalities of sensorimotor integration in focal dystonia. A transcranial magnetic stimulation study.Brain. 2001; 124: 537-545
- Impaired modulation of motor cortex excitability by homonymous and heteronymous muscle afferents in focal hand dystonia.Mov Disord. 2007; 22: 523-527
- Changes in the balance between motor cortical excitation and inhibition in focal, task-specific dystonia.J Neurol Neurosurg Psychiatry. 1995; 59: 493-498
- Abnormal cortical mechanisms of voluntary muscle relaxation in patients with writer's cramp: an fMRI study.Brain. 2003; 125: 895-903
- Somatosensory disinhibition in dystonia.Mov Disord. 2001; 16: 674-682
- Abnormal cortical motor excitability in dystonia.Neurology. 1996; 46: 1371-1376
- Lack of inhibitory interaction between somatosensory afferent inputs and intracortical inhibitory interneurons in focal hand dystonia.Mov Disord. 2006; 21: 824-834
- Intracortical excitability in the hand motor representation in hand dystonia and blepharospasm.Mov Disord. 2002; 17: 1017-1025
- Changes in short afferent inhibition during phasic movement in focal hand dystonia.Muscle Nerve. 2008; 37: 358-363
- Disorganized somatotopy in the putamen of patients with focal hand dystonia.Neurology. 2005; 64: 1391-1396
Peller M, Zeuner KE, Munchau A, et al. The basal ganglia are hyperactive during the discrimination of tactile stimuli in writer's cramp. Brain. E publication. Jul 19, 2006.
- Effects of focal hand dystonia on visually guided and internally guided force control.J Neurol Neurosurg Psychiatry. 2006; 77: 909-914
- Rate of force production and relaxation is impaired in patients with focal hand dystonia.Parkinsonism Relat Disord. 2006; 12: 363-371
- Selective impairment of hand mental rotation in patients with focal hand dystonia.Brain. 2006; 129: 47-54
- A systematic review on the diagnosis and treatment of primary (idiopathic) dystonia and dystonia plus syndromes: report of an EFNS/MDS-ES task force.Eur J Neurol. 2006; 13: 433-444
- Clinical analysis of musicians' focal hand dystonia. Review of 86 cases.Neurologia. 2005; 20: 108-115
- The hand that has forgotten its cunning-lessons from musicians' hand dystonia.Mov Disord. 2008; 23: 398-406
- Is focal hand dystonia associated with psychopathology?.Mov Disord. 1991; 6: 29-35
- Increased co-activation of the upper limb muscles in writer's cramp.J Neurol Neurosurg Psychiatry. 1985; 48: 782-787
- Hand cramps: clinical features and electromyographic patterns in a focal dystonia.Neurology. 1988; 38: 1005-1012
- Reciprocal inhibition between forearm muscles in patients with writer's cramp and other occupational cramps, symptomatic hemiparesis due to stroke.Brain. 1989; 112: 681-697
- Focal dystonia, with special reference to writer's cramp.Int J Clin Pract. 2005; 59: 1088-1090
- Physiology of dystonia.Adv Neurol. 1998; 78: 11-18
- Time-frequency analysis reveals decreased high-frequency oscillations in writer's cramp.Brain. 2007; 130: 198-205
- Temporal discrimination of two passive movements in writer's cramp.Mov Disord. 2006; 21: 1131-1135
- The two sides of associative plasticity in writer's cramp.Brain. 2006; 129: 2709-2721
- Focal dystonia: advances in brain imaging and understanding of fine motor control in musicians.J Hand Clin. 2003; 19 (xi): 523-538
- Constraint-induced movement therapy for focal hand dystonia in musicians.Lancet. 1999; 353: 42
- Effective behavioral treatment of focal hand dystonia in musicians alters somatosensory cortical organization.Proc Natl Acad Sci U S A. 2003; 100: 7942-7946
- Changing the brain through therapy for musicians' hand dystonia.Ann N Y Acad Sci. 2005; : 335-342
- What can studying musicians tell us about motor control of the hand?.J Anat. 2006; 208: 527-542
- Increased cortical representation of the fingers of the left hand in string players.Science. 1995; 270: 305-312
- The brain that plays music is changed by it.Ann N Y Acad Sci. 2001; 930: 315-329
- Reduced intracortical inhibition and facilitation of corticospinal neurons in musicians.Exp Brain Res. 2002; 144: 336-342
- Corticospinal control of the thumb-index grip depends on precision of force control: a transcranial magnetic stimulation and functional magnetic resonance imagery study in humans.Eur J Neurosci. 2007; 25: 872-880
- Pathophysiological differences between musician's dystonia and writer's cramp.Brain. 2005; 128: 918-931
- Sensorimotor reorganization by proprioceptive training in musician's dystonia and writer's cramp.Neurology. 2008; 70: 215-304
- Botulinum toxin in the treatment of writer's cramp: a double-blind study.Neurology. 1993; 43: 183-185
- Botulinum toxin in the treatment of writer's cramp.J Assoc Physicians India. 1999; 47: 694-698
- Effect of muscle activity immediately after botulinum toxin injection for writer's cramp.Mov Disord. 1999; 14: 307-312
- Long-term outcome of focal dystonia in string instrumentalists.Mov Disord. 2004; 19: 43-48
- Botulinum toxin injections in the treatment of musician's dystonia.Neurology. 2005; 64: 341-343
- Botulinum toxin for writer's cramp: a randomized, placebo-controlled trial and 1-year follow-up.J Neurol Neurosurg Psychiatry. 2007; 78: 264-270
- Limb immobilization for the treatment of focal occupational dystonia.Neurology. 2001; 57: 405-409
- A writing device improves writing in primary writing tremor.Neurology. 2005; 64: 1648-1650
- Sensory training for patients with focal hand dystonia.Ann Neurol. 2002; 51: 593-598
- Motor training as treatment in focal hand dystonia.Mov Disord. 2005; 20: 335-341
- Functional outcomes: the development of a new instrument to monitor the effectiveness of physical therapy.Eur J Phys Med Rehabil. 1997; 7: 31-41
- Sensory Integration and Praxis Test (SIPT) Manual.Western Psychological Association, Los Angeles, CA1989
- Stopwatch for measuring thumb-movement time.Percept Mot Skills. 1995; 81: 211-216
- Focal hand dystonia may result from aberrant neuroplasticity.Adv Neurol. 2004; 4: 19-28
- Abnormal reorganization in focal hand dystonia—sensory and motor training programs to retrain cortical function.NeuroRehabilitation. 2008; 23: 43-53
- Reorganization of human cerebral cortex: the range of changes following use and injury.Neuroscientist. 2004; 10: 129-141
- Biomechanical abnormalities in musicians with occupational cramp/focal dystonia.J Hand Ther. 1993; 6: 298-307
- Anatomical factors predisposing to focal dystonia in the musician's hand—principles, theoretical examples, clinical significance.J Biomech. 1997; 30: 659-669
- Disturbances of grip force behaviour in focal hand dystonia: evidence for a generalized impairment of sensory-motor integration?.J Neurol Neurosurg Psychiatry. 2005; 76: 953-959
- Strength deficits in primary focal hand dystonia.Mov Disord. 2006; 21: 18-27
JHT Read for Credit
Quiz: Article # 127
Record your answers on the return Answer Form found on the tear-out coupon at the back of this issue. There is only one best answer for each question.
- #1.The study suggests that
- a.subjects with musicians cramp have the same risk factors as those with writers cramp
- b.subjects with musicians cramp have the different risk factors as those with writers cramp
- c.the musicians cramp group improved in sensory processing and motor control, whereas the writers cramp group did not
- d.the writers cramp group improved in sensory processing and motor control, whereas the musicians cramp group did not
- a.
- #2.The study strongly suggests that the clinical management of dystonia (cramping)
- a.is a straight forward, easily followed process
- b.is essentially the same for patients with musicians cramp as for writers cramp
- c.should follow a pre-established protocol that is applicable to most patients
- d.must be patient specific in that no given protocol is likely to be effective for most patients
- a.
- #3.The treatment intervention can best be described as a form of
- a.computer assisted biofeedback
- b.controlled plastic cerebellar deformation
- c.learning based sensorimotor retraining
- d.delicate cortical manipulation
- a.
- #4.The article suggests that the described intervention is superior to drug therapy for cramping
- a.true
- b.false
- a.
- #5.The design of this study
- a.was hindered by the small sample size
- b.included a comparison of groups using an ICC correlation statistic
- c.included a control group
- d.was an RCT
- a.
When submitting to the HTCC for re-certification, please batch your JHT RFC certificate in group of 3 or more to get full credit.
Article info
Identification
Copyright
© 2009 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.
