What is it about?
The act of writing requires a stable pen grip as well as precise and highly repetitive fine flexion/extension movements at MPJ and IPJ. These movements are executed by the prehensile thumb, index, and middle fingers. In writers cramp, the digital and thumb flexor/extensors contract simultaneously (cocontraction) instead of the extensors relaxing to allow flexor action and viceversa. This impedes the delicate, precise and highly repetitive fine free movements essential for writing. The cocontraction is secondary to the presence of irritable, taut myofascial bands with myofascial trigger points (MTrPS). On initiation of writing, it is these shortened fibres that stretch first and according to Starling’s law these will also be the ones to contract while the surrounding fibres of normal length bunch around the taut bands. This preferential overuse of the taut bands shortened by MTrPs leads to resource exhaustion in these fibres while the normal fibres go into disuse atrophy. The preferential overutilization of irritable taut bands manifests clinically as painful cramps, a contradictory association of weakness with stiffness and progressive reduction of writing time, dystonia and tremors manifesting as Writer’s cramp(WC). Repeated provocation of pain eventually leads to the development of peripheral and central sensitization. Ultrasonography (USG) guided dry needling (DN) accurately targets specific digital muscles to release the MTrPs and resolving the taut bands. Serial resolution of MTrPs and taut bands relieves the pain and cocontraction, leads to utilization of the whole muscle in contraction rather than a preferential overuse of shortened taut bands. This participation normal muscles in activities reduces the disuse atrophy and allows gradual muscle strengthening essential for reversal of sustained repetitive strain injury (RSI). Muscle regeneration in the fibres having disuse atrophy was obvious on muscle ultrasonography as increased bulk of individual muscles These changes were obvious in our patient as confirmed by clinical findings of improved quality of writing as well as a remarkable progression to writing continuously for 2 hours in an exam. He also showed improved grip strength on hand held dynamometry. USG findings showed increased muscle bulk which has been sustained for 2 years . In conclusion, we have presented a different understanding of writers cramp that emphasizes the benefits of USGDN as the logical, physiologically appropriate, and minimally invasive therapeutic intervention for Writers cramp.
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Why is it important?
This publication provides a totally different perspective on treatment of writers cramp(WC) which is generally considered as a difficult condition to treat. We have looked at WC from the perspective of muscle rather than a neurological phenomenon. When we consider the cocontraction of WC from the perspective of a muscle spasm/ stiffness because of myofascial bands and MTrPS, it becomes remediable with dry needling. Ultrasound guidance makes the needling accurate, specific and safe since deeper structures are needled under vision. Unlike botox which causes muscle weakness and wasting because of its action at neuromuscular junction, dry needling actually increases muscle bulk. Once the myofascial bands responsible for cocontraction are relaxed? resolved the muscles can be strengthened with physiotherapy to prevent any recurrence of WC. Thus Dry needling offers a definitive cure for WC which has remained untreatable so far. Thus Dry needling offers a unique ,safe and a physiologically appropriate solution to WC
Perspectives
This publication highlights the importance of muscles in the pathophysiology of writers cramp. We have been working on a concept that all neuropathic conditions have a motor component making them neuromyopathies where the muscles become stiff initially and then later become painful. This is because the myofascial trigger points(MTrPs) which cause the stiffness are initially painless ( latent MTrPs) and later become painful and tender (active MTrPS). Since muscles are vital to locomotion it is only a matter of time become affected to add another dimension. Nerves are located in intermuscular compartments and spasm and stiffening of muscles can cause nerve entrapment syndromes to cause a myriad and complex symptomatology which is characteristic of neuropathies. Thus It is extremely important to take cognizance of muscle stiffness and in neuromyopathies and in all chronic pains which eventually become neuromyopathies. The muscle changes of neuromyopathy are exquisitely sensitive to Dry needling which specifically addresses MTrPs. Since dry needling addresses neuromyopathy, most neuropathies become not just treatable but actually remediable. This opens up several exciting possibilities in pains like post herpetic neuralgia, diabetic neuropathy, complex regional pain syndrome. We have been treating all these conditions with excellent results and patient gratification
Dr Lakshmi Champak Vas
Ashirvad Institute for Pain Management and Research
Read the Original
This page is a summary of: Myofascial Trigger Points as a Cause of Abnormal Cocontraction in Writer's Cramp, Pain Medicine, October 2015, Oxford University Press (OUP),
DOI: 10.1111/pme.12814.
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