Neurology -- Correspondence for Priori et al., 57 (3) 405-409

Correspondence published:

Reply to Dr. Lanska's letter: A Priori, "A Pesenti, A Cappellari, G Scarlato, S Barbieri" (6 November 2001)

Limb immobilization for the treatment of focal occupational dystonia: Douglas J Lanska (6 November 2001)

Reply to Dr. Lanska's letter 6 November 2001

A Priori
Universita di Milano Milano Italy,
"A Pesenti, A Cappellari, G Scarlato, S Barbieri"
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Re: Reply to Dr. Lanska's letter

a.priori{at}mailserver.unimi.it A Priori, et al.

We thank Dr Lanska for his comments on our article “Limb immobilization for the treatment of focal dystonia” [1] because it gives readers an interesting background on historical information. Historically speaking, the concept of rest as a general remedy in medicine originated of course from Hippocrates. In line with our findings, all the early observations reported by Dr Lanska stressed the need for absolute rest of the troublesome limb.
We were also prompted to conduct a more rigorous study into the possible benefits of immobilization on focal occupational dystonia by an anecdotal observation when one of our dystonic patients broke his forearm. On having the plaster taken off after several weeks rest, the patient surprisingly reported that his dystonia had improved. But anecdotal observations are not enough in modern medicine. Our systematic pilot study calls for a reappraisal of limb immobilization as an option for managing focal occupational dystonia according to modern research standards and prompts further studies. The next step is to refine the profile of the optimal patient to treat. The preliminary results of a larger systematic study are underway in our department to confirm those focal occupational dystonia responds variably to limb immobilization: certain patients respond better to treatment than others. In conclusion, evidence from history and from ordinary life suggests and our systematic study shows, that even doing nothing can be a good remedy. It is also a safe one that will not push medical expenses higher!
On the reappraisal of old ideas with modern methods we agree with Charcot that “Disease is very old, and nothing about it has changed. It is we who change, as we learn to recognize what was formerly thought imperceptible”. [2]
References:
1. Priori A, Pesenti A, Cappellari A, Scarlato G, Barbeieri S. Limb immobilization for the treatment of focal occupational dystonia. Neurology2001;57:405-409.
2. Jean Martin Charcot, (1825-93) (De l’expectation en médicine).

Limb immobilization for the treatment of focal occupational dystonia 6 November 2001

Douglas J Lanska
Veterans Administration Medical Center Tomah, WI
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Re: Limb immobilization for the treatment of focal occupational dystonia

douglas.lanska{at}med.va.gov Douglas J Lanska

Based on an uncontrolled trial in eight patients, Priori et al. reported that limb immobilization with a splint can be a “simple, effective, safe, and inexpensive treatment for focal occupational upper- limb dystonia,” including writer’s cramp. [1] Early authorities on writer’s cramp also advocated varying degrees of rest, and sometimes- applied splints or slings to ensure that the limb would not be used. In 1864, Solly recommended two months of “entire rest from the occupation that has produced the disease.” [2] In 1872, Hamilton said: “forced rest by fastening the hand upon a splint” which was later cited in a publication from 1885. [3] In 1885, Robins similarly reported the use of a sling [4,5]: “Your patient must have absolute rest, not necessarily of the whole body, but absolutely and entirely of the affected muscles, as far as those particular movements of coordination are concerned, whose abuse has brought on the attack… In some cases I have been accustomed to order the arm to be carried in a sling for a week or so, to remind the patient that all writing is to be shunned… [5].” In 1888, Gowers affirmed that rest is beneficial, especially if begun early: “The commencing symptoms often pass away with a brief rest; a month’s abstinence from writing at the onset will do more than a year’s rest if the disease has continued for six months.” [6] In 1892, Osler with typical directness noted that “Rest is essential. No measures are of value without this.” [7]
References:
1. Priori A, Pesenti A, Cappellari A, Scarlato G, Barbeieri S. Limb immobilization for the treatment of focal occupational dystonia. Neurology 2001;57:405-409.
2. Solly S. Lectures on scriveners’ palsy: lecture III. Lancet 1865;i:113-115.
3. Lewis MJ. The neural disorders of writers and artisans. In: Pepper W, Starr L. A system of practical medicine, vol. 5. Phildaelphia: Lea & Prothers, 1885-6: 504-543.
4. Robins RP. “Writers’ cramp” and its treatment, with the notes of several cases. Am J Med Sci 1885;89:452-462.
5. Robins RP. The treatment of writers’ cramp. Proc Phil Co Med Soc 1885;7:271-277.
6. Gowers WR. A manual of diseases of the nervous system, vol. II. London: J&A Churchill, 1888: 657-674.
7. Osler W. The principles and practice of medicine, designed for the use of practitioners and students of medicine. New York: D. Appleton and Co., 1892:963-965.