How physiotherapists diagnose and treat focal hand dystonia AKA writer’s cramp


How physiotherapists diagnose and treat focal hand dystonia AKA writer’s cramp

Have you ever had your hand cramp up when you’ve been writing with old school tech like a pen or pencil? Writing becomes painful and your words become harder and harder to read. Maybe you’re a musician and you’ve felt tremors in your hand or involuntary movements in your arm or hand muscles.

Left untreated and allowed to progress, these cramps and pains can worsen over time until they began to affect your ability to complete other tasks without pain. This is called focal hand dystonia, commonly known as writer’s or musician’s cramp but non-discriminatory when it comes to who it affects.

What is focal hand dystonia?

Focal hand dystonia is a neurological movement disorder resulting in involuntary movement or cramps in the hand or arm muscles due to an imperfection in the way nerve cells communicate signals from the brain. Dystonia is a movement disorder and focal defines it as occurring in one singular region as opposed to multifocal or generalised.

When focal hand dystonia affects your ability to write, physiotherapists refer to it as writer’s cramp. Hand dystonia can be caused by any repetitive movement that puts strain on that region and is common among writers, illustrators and often found in musicians.[1] Piano players and those on string instruments are most likely, but focal hand dystonia has been observed in telegraphists, golfers, hairdressers, surgeons, tailors, and cobblers alike.[2]

What are the symptoms of writer’s cramp?

Symptoms of writer’s cramp vary from person to person and are commonly task specific, but not always. Patients often present with a lack of dexterity, pain or discomfort locally and fatigue in the affected hand. Excessive tightness in the muscles needed to perform the task are common also.

It is common for symptoms to progress and include unusual positioning of the fingers, wrist or elbow and muscle spasms and cramping of the fingers, hand and/or forearm while writing. Sometimes uncontrolled involuntary movements or tremors may also occur.[3]

The mean age of onset of writer’s cramp is 38 years old and about 16% of focal hand dysonias will progress from their original site and become generalised over the long term.[4]

How does physiotherapy treat writer’s cramp?

Physiotherapy in writer’s cramp is complex. The aim of physiotherapy is to ease symptoms and improve function. Physiotherapy cannot cure writer’s cramp but assessment and retraining techniques may provide pain relief and help you feel more in control of your symptoms.

At the moment, the most common way to treat writer’s cramp is with a series of botulinum toxin injections to chemically denervate muscles. This can result in muscle weakness though and it is best to use a multi-modal approach to treatment.

Your first session will include a thorough review of your medical history, a physical examination and if possible a recreation of your posture/technique to evaluate the problem. Progress will be reviewed at follow-up sessions and your treatment program will be adjusted to fit your recovery.

There are several treatment approaches and will be dependent on your symptoms but the most positive interventions are:

Shockwave Therapy technology has been in use since the 1980’s and has been used to successfully treat a growing number of musculoskeletal conditions. A 2009 study looked at extracorporeal shock wave therapy’s effects on writer’s cramp and found that by targeting muscles in the hand and forearm they were able to improve some symptoms with no adverse effects.

  • Sensorimotor training

Movement practice as an intervention for focal dystonia of the hand is a common form of treatment and one that can take many shapes. Commonly, task-specific motor training is employed for treating writer’s and musician’s cramp to promote proper body alignment and prevent dystonic patterns during motor performance.[5]

Focal dystonia is complex and notoriously difficult to treat. You should contact a physiotherapist who understands the condition or is willing to discuss your treatment with someone who is experienced in treating writer’s cramp. If you have been suffering with any of the above symptoms, do not let them progress any further. Once dystonia becomes generalised, it becomes more difficult to treat and putting up with the pain now is only detrimental in the long run. Call Lane Cove Physio on (02) 9428 5772 or email us at to see one of our musculoskeletal physiotherapists ASAP.


[1] Aranguiz, R., Chana-Cuevas, P., Alburquerque, D. Leon, M. (2011). Focal dystonia in musicians. Neurologia, 26(1), 45-52. doi: 10.1016/j.nrl.2010.09.019

[2] Giorelli M, Zimatore GB. Hairdresser’s Dystonia: An Unusual Occupational Dystonia. Tremor Other Hyperkinet Mov (N Y). 2013;3:tre-03-204-4640-2. Published 2013 Dec 4. doi:10.7916/D87S7MGH

[3] Torres-Russotto D, Perlmutter JS. Focal dystonias of the hand and upper extremity. J Hand Surg Am. 2008;33(9):1657–1658. doi:10.1016/j.jhsa.2008.09.001

[4] Relative risk of spread of symptoms among the focal onset primary dystonias. Weiss EM, Hershey T, Karimi M, Racette B, Tabbal SD, Mink JW, Paniello RC, Perlmutter JS Mov Disord. 2006 Aug; 21(8):1175-81.

[5] Zeuner KE, Peller M, Knutzen A, Hallett M, Deuschl G, Siebner HR. Motor retraining does not need to be task specific to improve writer’s cramp. Mov Disord