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Stiff muscles, involuntary jerks in hands. Tests to do?

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Hello.
I have a quite unusual problem.
Well,I know this is kind of weird,but the thing is, eversince I was in fifth grade,I've been regurlarly (2 or 3 times per year)changing my handwriting on a SUPERFICIAL level.
And by that I mean this:I would only change its general style by changing and experimenting with details like:
Slant,how I make dots,the amount of pressure I exert on the pen,how I shape 1 or 2 (maximum)letters at a time,etc.I kept doing that for 8 years .It was like a hobby for me.
By that 8th year,unlike most people by age 17,I ended up not really having a signature handwriting.Instead I had:
-One way of shaping the letters of the alphabet.
-Many styles that I had to consciously choose from before each writing session.
-An insignificant yet steadily increasing loss of control over my hand movement.
I got so frustrated and I decided to RADICALLY change my handwriting,and by that I mean that I ve changed the way I shape letters,and started from scratch.The thing is :
I didn't take time to establish that new handwriting style.I literaly just decided about the new shape that I wanted and got immediately back to studying.Trying to change all of those letters at once,handwriting turned into a conscious awkward endeavor,and I stared to make more and more mistakes as I handwrite.Eversince,my situation only kept getting worse.Today,after two years,I suffer from the following symptoms:
I start out writing okay,but my handwriting gets really messy as I go along.
-My arm muscles feel stiff/rigid when I handwrite.
-My handwriting is awkward instead of flowing.
-Inconsistent shape and size of letters.
-My hand doesn't follow my will,it often involuntarily jerks.
-Mispellings(of words I can spell),either because of substitution or omission of letters.Sometimes I write a completely different word instead of the intended one.Or even combine two letters,etc.
-In general,I feel like I have little control over my hand.
-I can only press on the pen too hard. Or not hard enough.
-I have to focus on writing mechanisms instead of content.
-Unnatural stops and starts between letters,lack of connection between letters.
-Unfinished letters.
-I have a hard time translating my ideas into writing.
-I have to unreasonnably focus to put my words into writing.Even when it's only a matter of few sentences.
At first,I explained the mistakes and the rest of the symptoms I was experiencing as some sort of psychological response(like it was all in my head) ,because of the wrong timing at which i changed my writing as I was going through a lot of exams stress anxiety.But since these symptoms persisted fo as long as 2years by now,and are only getting worse.I was wondering if it were a disease showing through the deterioration of my handwriting.I already saw a neurologist here in my country,he got me to do a BASIC test and told me the test was normal and there's nothing to worry about.
So my first question is:Are there any neurological disorders that can not show in an elementary test and that need further tests?Is it all in my head or there must be a disease behind what I'm experiencing?What do you think could be the problem doctor?What type of diagnosis should I ask for the next time I go see my doctor.Please help.
PS:please make sure you include the mispellings symptom in your diagnosis because it is affecting my grades and the quality of my life dramatically.

Category: Neurologist, Medical

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Category: Pediatric Neurologist
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Hello,
Thank you for your query at DoctorSpring.com
I understand your concern.
I also want to apologise for the delay in the reply. I have been traveling and hence, I was not able to access internet for some time.
From your history, it does seem like you have low muscle tone in your arms, which is affecting your writing.
Did you get any CT SCAN/ MRI recently and if so, do you have the reports?
Do you have any involuntary jerks involving the entire extremity? Any pins/needles sensation? Any tingling in the arms?
Regarding studying, do you have difficulties remembering your subjects? Do you have troubles memorizing stuff? Any muscle twitching/ tremors?
Do you feel any weakness in doing other household activities?
Kindly get back to me with the answers to the above questions.
Regards,
Dr. Sudhir Kumar


Patient replied :

-Hello Doctor,thanks for answering .

ANSWERS TO YOUR QUESTIONS:
1)No I haven't ,I only had one basic examination (the eyes movement ,the reflexes,the strength..)and it was normal.
2)In what comes to the type of jerks I suffer from:
-For example,the next intended movement is my hand writing a certain letter,instead it will escape my control ,go a different direction ,and end up drawing a weird line or somthing else(and other varieties of this).
-Also,I can be intensely focused and my hand will still mispell a word ,or just in general move against my will.
-That being said,I have normal control of all my other fine and gross movements(handwriting is the only area where there is this lack of control).
3)I experience an unconfortamble sensation especially in my forearm in the muscle near my elbow.Almost some sort of tingling.Along with that I experience stiffness of my muscles whenever I handwrite.
4)Yes ,I do have trouble memorizing ,I do have trouble concentrating too.
5)Talking always about my right arm,it feels somewhat weak and unhealthy even when I m doing other activities.My body in general feels weak,and quite sometimes,my muscles feel sore for no reason at all,or because of little physical activity,especially after I wake up from sleep or a nap.
MORE INFORMATION:
-I m not living a healthy lifestyle currently.
-I m going through a lot of stress.
-I m 19 and I m a female.
-I have anemia.
-I ve always had this problem with my handwriting :only being capable of pressing too hard or not hard enough,and that's a main reason that kept me switching between the 2 all of these years.

Questions:
-What seems to be the problem Doctor?
-What tests to ask for next time I go see my neurologist?
-I don t understand what you meant by :"involving the entire extremity"in your second question.
PS:
Please help me doctor and show me what to do next,I am by my own studying in a foreign country .I really don't know what to do next,and I m starting to run out of money.Please help me.Here is my email if you want to send me further information:[email protected] you so much.



Hello,
Thank you for your follow-up.
You need a detailed neurological evaluation, and also a CT SCAN of the brain is required to come to a diagnosis.
Your symptoms are more psychosomatic, however, it could also be due to a vitamin b12 deficiency ( cobalamin deficiency ). The symptoms of trouble in concentrating and memory can also be explained by a significant cobalamin deficiency.
There is a specific area of brain, involved in writing, called as Exner's area of brain, usually located in left side of brain, in people who are right-handed. Any damage or abnormality of this part of brain can cause difficulty in writing, a condition known as agraphia.
You would need detailed evaluation of brain structure and brain functions. For brain structure, MRI of brain can be done. Brain function can be well studied by doing a PET scan of the brain.
Another possibility to exclude would be a condition called as writer's cramp, a type of focal dystonia, where only the hand-writing is poor and writing causes pain/stress in forearm/hand. There are no mis-spellings, or wrong words, etc in patients with writer's cramp.
Kindly get back to me with your CT reports and the vitamin b12 levels.
Hope this was helpful,
Regards.


Patient replied :

Hello Doctor,
Please answer the following questions:
1)Is it possible for an individual to have some sort of neurological disorder,and still have a normal elementary neurological examination?(please give me a yes or no answer).
2)Supposed I certainly have a neurological problem,what are ALL the disorders that could possibly be behind this problem?(Please name them all).What are the other symptoms of each one of them?
3)Should I get an MRI or PET or CT scan?please tell me exactly the name of the test(s) to get next because I couldn t grasp that from your last response.
4)Given my age and the details of my situation,what is the percentage of me having a neurological problem?
5)What type of specialist or tests should I go for to determine whether I have a writer's cramp or not?
6)Can repetitive mispellings be ONLY due to psychological reasons?
7)What type of experts you can recommend that can help me with the psychological dimension of my problem?


Hello Doctor,
Please answer the following questions:
1)Is it possible for an individual to have some sort of neurological disorder,and still have a normal elementary neurological examination?(please give me a yes or no answer).-----Yes
2)Supposed I certainly have a neurological problem,what are ALL the disorders that could possibly be behind this problem?(Please name them all).What are the other symptoms of each one of them?- There are multiple possibilities and would fill the entire page. However, after MRI and PET scan, the possibilities can be minimised. Some common conditions are brain stroke, brain tumor, degenerative diseases of brain, etc. Other symptoms may include weakness of arm or leg on the right side, headache, seizures, etc.
3)Should I get an MRI or PET or CT scan?please tell me exactly the name of the test(s) to get next because I couldn t grasp that from your last response.- Yes, you should get them done. The test names are- 1. MRI scan of brain, 2. PET-CT scan of brain
4)Given my age and the details of my situation,what is the percentage of me having a neurological problem?- 60-70%
5)What type of specialist or tests should I go for to determine whether I have a writer's cramp or not?- You should see a neurologist. Usually no tests are needed to confirm this.
6)Can repetitive mispellings be ONLY due to psychological reasons?- Yes, if someone has anxiety/depression, it can happen.
7)What type of experts you can recommend that can help me with the psychological dimension of my problem?- Psychiatrist and psychologist evaluation.


Patient replied :

Hello doctor,
Please answer my questions about writer's cramp:
1)Can an EMG test provide a definitive diagnosis?
2)Is there a way of providing a definitive diagnosis of whether I have it?
3)What causes such a condition?(please list all possible reasons).
4)What are ALL the possible treatment options?
5)Are they guaranteed to work?
6)Please list them in order,starting with the one with the greatest likelihood of working,all the way to the one with the least likelihood.
7)Do any of these options have any side effects?
8)Which one of these methods would you recommend trying first?Which ones after that?
9)How long could it take to cure from it?
10)Can I heal if I still use my hand to do a lot of handwriting on a daily basis while treating it ?Or do I need to allow it rest?
11)Can I heal from it if under a lot of stress?
Thank you for answering soon.


Hello,
The answers are given individually:

1)Can an EMG test provide a definitive diagnosis?--Clinical examination is enough. EMG is not usually needed for diagnosis.
2)Is there a way of providing a definitive diagnosis of whether I have it?- A clinical examination by a neurologist would confirm it.
3)What causes such a condition?(please list all possible reasons).- The cause is unknown.
4)What are ALL the possible treatment options?- The best treatment is botox injections.
5)Are they guaranteed to work?- Botox works in more than 90% people.
6)Please list them in order,starting with the one with the greatest likelihood of working,all the way to the one with the least likelihood.- Botox has the best chance to work. Medications such as trihexiphenydyl has a lower success rate of 3-40%.
7)Do any of these options have any side effects?- Botox is safe, may cause temporary weakness of muscles. Trihexiphenidyl may cause dryness of mouth.
8)Which one of these methods would you recommend trying first?Which ones after that?- Botox would be my preference.
9)How long could it take to cure from it?- Effect starts within 7-10 days and lasts for three months. You may need repeat botox injection after three months.
10)Can I heal if I still use my hand to do a lot of handwriting on a daily basis while treating it ?Or do I need to allow it rest?- You can continue to write and rest is not needed.
11)Can I heal from it if under a lot of stress?- Stress would delay the healing.


Dr. Sudhir Kumar
Category: Pediatric Neurologist
Experience: 
Senior Residency, Fellowship: DM, Neurology, CMC, Vellore, 2001
Junior Residency: MD, Internal Medicine, CMC, Vellore, 1998
Medical School: MBBS, Christian Medical College, Vellore, 1995
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