Visit to Prince Court Medical Centre (1)

8th October 2008


Today I have an appointment with the neurologist, Dr Julia Shahnaz, to diagnose the cause of deterioration of my writing.
However,the appointment was rearranged because Dr Julia couldn't make it due to her car broke down.
So the appointment was changed to 3pm with Dr Hj Hamidon.

Masuk2 aje.kat dalam Prince Court Medical Centre
"E eh...mcm hotel la!" - kata nilam
haha.ape2 je la bdk ni.

So went to the specialist room.
Bagi doc referral letter
Then cerita2 kat doc
Then tunjuk la my writing yang dulu2 dengan sekarang (to see the difference)
Then kena tulis.Sambil tu doc examine.
Then kena test yang ketuk2 tuh.
Test strength of the hand.
Semua,dari grip,hold,push,pull.
Then doc tanya ada masalah laen tak setakat ni selain ini.
Nope - *geleng kepala*
Ok.
So doc pn bagitau.
I have a problem called task performing focal dystonia
atau dipanggil writer's cramp.

Writer's cramp

The so-called ”occupation” cramps are a form of focal dystonia. Writer’s cramp is a pure action dystonia in which abnormal tension or posturing develops in the hand only during the act of writing. Immediately upon cessation of writing, the spasm disappears. Thus, a delicate motor skill, perfected by years of practice and performed almost automatically, suddenly comes to require a conscious and laboured effort for its execution.

This condition was originally considered as psychiatric in origin, and was even classed as an “occupational neuroses”. Careful clinical analysis does not bear this out – and today patients can carry the diagnosis without any stigma attached to it.

Who are the victims?

This disorder begins in adult life and men and women are equally affected, most often between the ages of 20 and 50 years. It frequently affects persons who write a great deal as part of their work. Frequently the patients do not have any other neurological abnormalities, and psychological inventories not reveal a higher incidence of psychiatric illness than in the normal population. In 5%of the cases the condition is familiar, and another 5% of patients give a history of trauma to the affected arm preceding the onset of Writers' Cramp.

What happens?

The initial symptoms may include only clumsiness or sloppy writing, with discomfort rarely prominent. When the patient attempts to write, all the muscles of the thumb and fingers go into spasm, resulting in an abnormal posture of the fingers, hand and arm. Manipulation of the pen is slow and clumsy and fluidity of hand movement is lost. To continue writing, the patient exerts greater force. The end result is poorly legible script.

If this spasm is prolonged it may be painful and spread into the forearm or even the shoulder. Sometimes the spasm fragments into a tremor. Some patients complain of weakness, especially if the fingers splay away from the direction in which they were intended to go.

Although the disturbance in Writers' Cramp is usually limited to the specific act of writing, it may involve other equally demanding manual tasks. A few of the younger patients also develop Spasmodic Torticollis at a later date.

The general absence of pain and the presence of abnormal postures distinguish this condition from the more common painful “overuse syndromes”.

Why does this happen?

We are not sure, the nature of this condition being quite obscure! Normally, writing is accomplished by alternating activity in the flexors and extensors of the forearm. Electrophysiological studies prove that in patients with Writer's Cramp there is co-contraction in agonist-antagonist muscle pairs in the forearm – that means that flexors and extensors of the arm contract simultaneously. This finding suggests a disorder of reciprocal inhibition between the muscles of the forearms. There is no evidence of any structural brain or spinal cord disease. The role of the basal ganglia in this condition is not yet fully understood.

Is there any hope?

Spontaneous remission of this condition is rare, and the treatment is difficult.

Hypnosis and other forms of psychiatric-treatment are usually without effect (if not being a psychiatric condition!)

Learning to write with the opposite hand may help, but it takes about 6 – 12 months to learn a fluent script, and there is a 25% chance that this non-dominant hand will become afflicted with the same problem.

Writing aids have been popular, but used with mixed results. Sometimes the use of a very thick pen (constructed by an enthusiastic Occupational Therapist) held in the palm of the hand (to eliminate the need for fine finger movement) may help.

Drug treatment with anticholinergics and dopamine agonists has been disappointing, but few anecdotal reports may make an empiric trail worthwhile.

Botulinum toxin injections can effectively reduce the spasms in the forearm muscles. If the most dominant muscle is identified by needle EMG and injected, only a limited degree of weakness (If any) may be experienced, with stability to the hand while writing. Patients are usually very grateful for the relief of these uncomfortable spasms.

For the treatment,until now,botox can reduce the problem,however,it only lasts for about 4-5 months,so it would be a lifetime treatment,and it is not 100% guarantee. The probability that it can be effective is about 50%,while the effectiveness is only about 20-30% if it is effective.Certain people have good results,but some people will have bad results by having this treatment.Right now actually there is no actual cure for this disease at this moment.




Ok..after done semua tests tuh..
Doc kata kena scan MRI (brain scan)
sebab takut2 kalau ada apa2 problem in the brain
So pergi la....

Huiyo.Canggih2.
hehe.jakun sungguh.almaklumlah baru first time.
Tapi before that semua benda2 besi kat badan kena remove.
Sebab the scanner tak boleh dapatkan image brain if ada besi - gangguan
So baring la kat katil machine tuh.
Erk.Aduh.Nape sakit dalam telinga ni?Macam ada benda aje.
Then dia bagi headphone - untuk dengar music and listen instruction yang dia bagi.(macam countdown nak tangkap the image)
Dah pakai headphone,kurang la sikit sakit...

Tengah dengar lagu Love Like This
Then dia bagi instruction.
"The blablabla will start in 10 seconds"
Relax sahaja.
Tapi.Tibe2 dia kuarkan balik guey.
Bukak headphone
Erk.sakitnya telinga knn!

That H.A tanya
Check ade metal tak?Ade pakai subang x?
*geleng kepala*
Ade pernah accident tak?Pernah ada surgery kat area belah kanan tak?
*geleng kepala*
"Tapikan,It was really painful in my right ear".
Then dia suruh tunggu sekejap.
Check balik dlm imaging room
Try la baring balik.
Erk.sakit.mcm ade benda dalam telinga yang tertarik
Duduk balik.
Erk.Sakit.benda dalam telinga pun macam ikut aje.
So turun dulu..dduk kat changing room.

Then yang specialist in radiology datang...doc tuh tanya
Ada dental x?
- ada,tapi belah kiri..aaaaa(sambil nganga tunjuk dental tu)

Then dia check muka.Die tengok belah kanan is slightly bengkak than kiri.
Tp I said
-doc,tuh mmg nature.rahang kanan saya mmg besar sikit

Oh.ok.Then die pergi call dr.hamidon.
Ask what to do.
Nampaknya kena buat x ray dulu la sebab nak tengok ada benda ke tak..

Ok.Fara,now we have to do an x ray on your skull
-Why?
Because there might be an artifact or something in your right part of head.Come,I'll show you.
Die bawak masuk dalam imaging room.
Erk.a ah la...area sebelah kanan bwh otak memang takde image.sebab ade gangguan tu la.
Come,we go for an x ray dulu la yer.

Dah x-ray.
Image dah produce.
Surprisingly!

foreign particle(in the circle)

Dr Sumithra(radiologist) showed us the image.
She said itu memang benda.
and it might be metal since it disturbs MRI scanner.
agagaga.muncul benda lain pula!

Dr Hamidon dah turun kat area radiology.
Dia kata dia dah call the Otorhinolaryngology or Ear,Nose and Throat specialist (E.N.T)
Then Dr Hamidon pergi la tengok image brain...from MRI tuh

Since I'm using the my right hand,so the brain that controls it is the left part of brain.
And since the image of left area dapat nampak,so doc boleh check la...
Alhamdulillah...tak ada apa2 kat part brain yang control writing.

So Dr. Hamidon kata memang writer's cramp la tu..so..dia tanya nak try tak treatment botox tu?
-tak kisah
Kalau tak mau nanti dia boleh bagi my mom pakai.
-haha.tak payah la.boleh la try kot

Since dah lewat petang,so treatment buat esok la.
Tunggu la Dr Kuljit (E.N.T)
Sambil2 tuh bual2 la.

"Eee...farah ni macam2 yer.Hari tu dah kena...Hari ni check untuk lain tapi terjumpa skali benda lain yer" - Dr Hamidon
- Tuh la...mcm2 la. *geleng kepala*
"tapi yang musykil sebab tak tau bila n benda ape tuh" - Dr Hamidon
"tuh la..before this mmg tak pernah accident pun" - mama
"tuh la...tah2 alien kot...pasang microchip kat situ!" Dr hamidon
Hahaha.smpat lagi buat lawak.hihi~

Then Dr Kuljit came.
Die tengok x-ray tu..
Then he met me.Dia kate nak check tepi.
Than dia tekan2 kat area rahang dekat dengan telinga.
Kemungkinan2 kedudukan benda tu...
Then buat side x-ray pulak....

foreign particle (in red circle) yang bulat putih bawah tu cuma flash camera ya.

ahahaha.
klau based on the image...
dari pandangan hadapan n sisi..
mcm bentuk pil tablet

tapi ape benda ni yer????
Yang pasti memang metal sebab benda nih effect mri.
n mase kat machine mri tuh,telinga rasa sakit due to presence of electromagnetic...so benda tu maybe tertarik...
And in normal condition....tak rasa sakit pun...sbb statik aje

-So..how's it doc?
Apa2 pn we have to know what is it and have to remove it.Sebab besi...kita tak tahu kalau2 dah rust atau nanti takut ade corrosion kan...and takut dia masuk dalam blood vessel
erk.kecil2 cili padi! huhu

Since dah ptg...so further examination sambung esok...

So dr hamidon bagi surat kebenaran.Untuk my lecturers.

To whom it may concern.
This letter is to certify that the above named is currently under my follow up for writer's cramp.This condition is a form of task specific focal dystonia causing progressive deterioration of writing function. Brain MRI was done showed normal structures at the right hand region (incidental right metallic object right/internal auditory meatus). Thus far,there is no actual cure for this condition.Therefore I strongly suggest that she will be allowed to take her exams by other means possible than using handwriting(eg. using computers).
thank you.

wawawa.camne nak amek exam pakai computer niyh??
huhu...

-to be continued-