Figure 6.

Dystonic tremor with writer’s cramp. (A) Severe: the patient is barely able to hold a pen with the right (dominant) hand because of involuntary hand posturing. He had been using non-dominant left hand to write but there is now evidence of dystonia—writer’s cramp and dystonic tremor—on this side too. The spiral drawings and handwriting with the left hand have a multidirectional axis with evidence of lighter ink pressure because there is dystonic extensor posturing of the fingers and wrist. (B) Mild: the patient had minimal tremor and mild dystonia that only became apparent with prolonged periods of writing. Note how the writing progressively deteriorates on the second and third lines. Spiral and straight line drawings were normal.