Botulinum toxin and occupational therapy in the treatment of writer's cramp

Objectives: To analyze the long term effect of botulinum toxin (BTX) inject ions and the efficacy of a structured occupational therapy program in patie nts with writer's cramp (WC). Study Design: We retrospectively investigated 28 patients with WC; 26 recei ved BTX, 15 took part in a structured occupational training program, contai ning modification of the way of writing and employment of different writing devices. Two of these 15 patients had occupational therapy only, the other s had the training program in addition to the BTX injections. The efficacy was evaluated using a self-assessment rating scale. Results: The mean follow-up was 20.2 months. Twenty-three percent of BTX-tr eated patients reported a marked, 35% a moderate and 42% only minimal or no response after BTX at the best time, Patients with relatively localized fo rms of WC, i.e., involvement of finger or wrist muscles had a better respon se to BTX than patients with more complex forms of dystonia affecting vario us muscle groups. Thirty-three percent of the patients taking part in the o ccupational therapy training program reported a marked or moderate improvem ent after occupational therapy, whereas 47% reported only limited benefit b ut still an important additional effect to BTX. No benefit was reported by 20%. In patients with combined treatment, the reported improvement after oc cupational therapy was additive to BTX indicating that occupational therapy potentiates the effect of BTX. Conclusion: BTX is a very useful and effective therapy in a substantial pro portion of patients with WC. A short structured occupational therapy progra m further improves the effect of BTX and may be the only form of treatment in single cases of WC patients.