Writer's Cramp

Vol.
8, March 2005
FORENSIC DO CUM ENT EX AMINAT ION/Writers Cramp: 52-21-011023/050325
WRITERS CRAMP:
ITS AFFECT ON FORENSIC HANDWRITING EXAMINATIONS 1
A study to assess whether illegible writing can be compared.
by Nevzat Alkan, M.D.2, Nurten Uzun, M.D.3,
Meral Erdemir Kiziltan, M.S.3, and Joel S. Harris, B.Sc.4
REFERENCES: Alkan, N.2 , Uzun, N.3, Kiziltan, M.E.3 , and Harris, J.S.4,
"Writers Cramp: Its Affect On Forensic Handwriting Examinations,
The Forensic Scientist OnLine Journal, Vol. 8, March 2005, pp. 1-21.
ABSTRACT: A lesser known health condition affecting the writing habits
of persons in the Turkish city of Istanbul is assessed. The effects of
writers cramp on handwriting is assessed through a study of handwriting
produced by 49 persons suffering from the disease. The patients ages
ranged from 23 to 81 years. Samples were evaluated to determine at what
stage in the writing process writers cramp begins to affect legibility. A
series of standard handwriting examination tests were applied to the
samples to determine limitations which might hamper a handwriting
comparison. The handwriting features in the samples were examined for
evidence of class characteristics which might be unique identifiers of
writing affected by writers cramp. The writing features in these samples
were compared with handwriting produced by persons suffering from other
diseases or related conditions. This comparison may help to characterize
and distinguish writing affected by different diseases. The affects and
misuse of special supports and Botulinum Toxin Type A (Botox)
injections for improving legibility in writers cramp writing and how it can
be used to commit fraud will be discussed. The results of this study may
assist handwriting experts examining illegible handwriting evidence.
KEYWORDS: Writers cramp, handwriting, signatures, fraud, class
characteristics.
1.0 BACKGROUND
1.1 Assessing Handwriting Evidence
Handwriting evidence, like other forensic evidence, must be assessed
to identify any factors which might limit the potential of arriving at
definitive conclusions during the primary comparison [1,2]. These
standard, a priori, handwriting tests [3-7] include: comparison of writing
styles (i.e. handwriting verses hand printing), comparison of text, image
clarity (affect of writing instrument, reproduction processes, legibility),
natural writing movement (i.e. line quality), contemporaneity (questioned
and specimens prepared within a similar time frame), writing materials
(questioned and specimen prepared on a similar writing surface and with
the same writing equipment, i.e. ball point pen verse felt-tip marker, to
distinguish image clarity), quantity of specimen and questioned material
(adequate text available for comparison), writing conditions (influences
affecting the writing), alterations (evidence of physical or chemical
changes to the writing), common authorship (determine whether specimen
1
Presented at the Fifty-Fourth Annual Meeting of the American Academy of

Forensic Sciences, February 9-16, 2002, Atlanta, Georgia.
2
Istanbul University, Istanbul Medical Faculty, Department of Forensic Medicine
Istanbul Tip Fakultesi, Adli Anabilim Dali, 34390 Capa Istanbul Turkey. Tel
( B u s . ) : 0 0 9 0 - 2 1 2 - 6 3 5 - 1 1 7 9 ; F a x . : 0 0 9 0 - 2 1 2 - 5 2 6 - 7 3 2 6 ; E m a i l:
alkan@istanbul.edu.tr.
3
Istanbul University, Cerrahpasa Medical Faculty, Department of Neurology.
4
Shunderscon Communications Inc., Ottawa, Ontario, Canada.
and/or questioned text were homogeneously prepared documents

attributed to one source).
Some of these tests (comparison of writing style and text) may be
quickly applied at the time of submission. This will quickly determine
if the case can be accepted and other tests applied or whether it should
be returned to the investigator. Subsequent test must be satisfied
before the primary handwriting comparison can proceed. The failure
of the evidence to satisfy a particular test may halt the examination
process until such time as the problem is corrected. For examples this
may require the submission of additional specimens that contain
comparable text, writing style, or were contemporaneous. Although
it is common to request additional specimen writings when limitations
are identified in the original submission, this is not always possible.
However, it may be more difficult to request specimen writing
prepared under some external (writing surface, writing positions,
writing materials) or internal (health related contributions, i.e. injury,
illness, fatigue, emotional state, effects of drugs and alcohol, aging,
etc.) writing condition. Many studies [10-21] have attempted to
identify writing characteristics in handwriting produced under the
influences of alcohol and/or drugs and if these characteristics can be
used in a handwriting examination and comparison. Other studies [2234] have attempted to identify handwriting characteristics unique to
different diseases and what affect these modifications have on a
handwriting comparison. It is valuable to apply standard tests which
can identify when, and by what means, a handwriting may have been
affected by external and internal factors. This information may help
to assess limitations which might affect any subsequent handwriting
comparison. In some cases the investigator will advise the scientist of
conditions under which the questioned and specimen material may
have been prepared. However, there are some conditions which do not
have specific associated physical disabilities such as persons who are
visually impaired, or suffer from Parkinson or Alzheimers disease.
Psychiatric, neurological and orthopedic diseases are considered to be
the principal health related factors affecting the greatest change in
handwriting. While some of these diseases influence the handwriting
texturally, others cause formal changes in the writing and still others
induce both textural and formal changes in the writing [35-38].
Writers cramp is a lesser known health condition that does not
display the debilitating physical and neurological affects attributed to
such diseases as Parkinson or Alzheimers. Consequently it has not
received the same attention for its affect on handwriting. Writers
cramp is a phrase liberally used to refer to a cramp in the hand which
affects the ability to write legibly for any duration, without some
periodic resting. The use of the term cramp, which denotes a
temporary condition, usually occurring after strenuous production,
may be inappropriate because the disease has been found to be
permanent for those who suffer from it. Writers cramp, however, is
a common disease which afflicts many persons and may develop as a
result of the writing process [39]. This disease is not reported in
standard document examination reference texts [40-44] and therefore
is not widely recognized, or assessed, during routine handwriting
examinations. Writing which is illegible may potentially disclose class
characteristic associated with writers cramp writing thereby
Copyright 2005 Shunderson Communication, Inc. All Rights of Reproduction Reserved
The Forensic Scientist OnLine Journal
distinguishing it from illegible writing due to a lack of skill. Once the

cause of the illegible writing style has been established, it may be possible
to conduct a handwriting comparison. There are no validated studies
identifying handwriting characteristics due to writers cramp nor how such
a condition might affect a handwriting comparison. Writers cramp is in
fact a form of task-specific focal dystonia (inflection, repeating motions
and permanent contractions that lead to postural disorders) which may
dramatically influence handwriting legibility.
This study assesses handwriting samples prepared by persons suffering
from writers cramp to determine the following:
S the stage at which the handwriting legibility begins to deteriorate;
S evidence of handwriting class characteristics associated with
writers cramp;
S to compare handwriting affected by writers cramp with other
diseases affecting handwriting;
S whether a handwriting comparison can be conducted on writing
affected by writers cramp;
S to compare handwriting affected by writers cramp with writing
prepared with the assistance of preventive supports;
S the effects of Botox on improving writing legibility; and,
S the misuse of Botox in the commission of fraud by persons
suffering from the writers cramp.
The results of this study may help document examiners to recognize
and identify the causes of abnormal handwriting and may provide
methods of conducting a handwriting comparison on such samples.
1.2 What Is Writers Cramp
Writers cramp affects the upper extremities of the human body and
is a task-specific extremity focal dystonia [45]. Focal dystonia of the hand
affects tasks that require fine motor movements. The symptoms may
appear only during a particular type of movement, such as writing or
playing the piano, but the dystonia may spread to affect many tasks. Two
types of writer's cramp have been described: simple and dystonic. People
with simple writer's cramp have difficulty with only one specific task. For
example, if writing activates the dystonia, then within writing a few words,
dystonic postures of the hand begin to impede the speed and accuracy of
writing. In dystonic writer's cramp, symptoms will be present not only
when the person is writing, but also when performing other-task specific
activities, such as shaving, using eating utensils, applying make-up [46].
In 1/3 of patients with the simple type of writers cramp, there is a
progression toward the more acute dystonic type, but there might not be
any marked increase in the degeneration in the writing.
1.3 Symptoms and Their Relation to Handwriting
Writers cramp begins as an involuntary rigorousness in the fingers
and thenar muscles shortly after the writing process has begun (generally
after a few sentences). This rigorousness gradually spreads back towards
the wrist, forearm, biceps, and shoulder muscles throughout the duration
of the writing process. A persons writing hand may be affected by many
conditions, arthritis, tendon problems, and muscle cramps, some of which
may cause pain. Carpal tunnel syndrome is the result of nerve
compression. Writer's cramp is often mistaken for over-use conditions,
but they are unrelated problems. Over-use syndromes or repeated-use
syndromes are usually characterized by pain, whereas writer's cramp is
more likely to cause problems with coordination. Focal hand dystonia is
responsible for only about 5% of all conditions affecting the hand.
However, there are instances when the involuntary rigorousness may be
accompanied by pain, which forces a halt to the writing process and
therefore the cause of the pain. When handwriting is restarted after a
period of rest the same rigorousness re-occurs. In 1/3 of patients this
aching spasm is accompanied by a tremor in the line quality.

People suffering from this disease may develop a fear of writing
(graphophobia). In 5% of documented cases other family members
were found to also suffer and demonstrate similar symptoms. Writers
cramp is usually unilateral and may turn to a segmental and
generalized dystonia by spreading over time [47-49]. Dystonia cases
have also been reported to occur during other activities related to
coordination and use of the hands, i.e.guitar, trumpet or viola playing
and golf [50-52]. The disease, however, remains prominent amongst
persons in occupations involving excessive handwriting such as
teachers, students, accountants and bank personnel. Job activities such
as tailors and shoe makers also experience the occurrence of writers
cramp. Those persons within these groups repeatedly use their upper
extremities more frequently, and they are often determined to have
some trap neuropathies and muscular-joint diseases except for writers
cramp [53].
In writers cramp, pen holding generally becomes tight and
exaggerated due to some symptoms that start as soon as taking the pen
in hand or after writing out some words. Separately, some cases like
wrist hyper-extension, hyper-flexion, forced supination or pronation
are encountered. Handwriting shows a saltatory, scattered and
irregular characteristic. In the late periods of the disease, handwriting
cannot continue after a few lines and becomes illegible (Figures 1 to
3). Patients can classically write on the black board. Some of them
will support the affected arm with the good arm in order to write on
the black board or may use a writing instrument that possesses a
broader delivery point for the ink, thereby requiring less movements
to form letters but also affecting the detail and size of writing prepared.
Some patients utilize the unaccustomed hand to write when writers
cramp becomes a factor. In 25% of patients trying to write with their
unaccustomed hand, writers cramp will also develop over the course
of time [54-57].
Symptoms common to simple writer's cramp include excessive
gripping of the pen, flexion, and sometimes deviation of the wrist,
elevation of the elbow, and occasional extension of a finger or fingers
causing the pen to fall from the hand. Sometimes the disorder
progresses to include the elevation of shoulders or the retraction of the
arm while writing. Interestingly tremor is usually not a symptom of
writer's cramp. The symptoms of writers cramp usually begin between
the ages of 30 and 50 years old and affects both men and women.
Cramping or aching of the hand is not common. Mild discomfort may
occur in the fingers, wrist, or forearm. A similar cramp may be seen
in musicians as the violin is bowed, in certain athletes such as golfers,
or in typists. If writer's cramp causes any type of impairment, it is
because muscle contractions interfere with normal function. Features
such as cognition, strength, and the senses, including vision and
hearing are normal. While dystonia is not fatal, it is a chronic disorder
and prognosis is difficult to predict.
Related problems associated with over-use of the hand are
different, and more commonly occurring, than writers cramp.
Over-use can be quite painful, but it is still unclear as to where the
pain is coming from the location of the pathology is unclear. Using
different movements and muscles as well as better posture may reduce
strain on the hand. Writers cramp is not to be confused with carpal
tunnel syndrome which may involve a pinched nerve in the carpal
tunnel of the hand. Most persons suffering from carpal tunnel
syndrome develop symptoms in both hands.
There is a condition called primary writing tremor in which the
hand shakes (consistently in one direction) during writing. Whether
this tremor is closely related to either writer's cramp or essential
tremor is unclear.
1.3 Causes of Writers Cramp
Copyright 2005 Shunderson Communications, Inc. All Rights of Reproduction Reserved
Vol. 8, March 2005
The reasons for writers cramp are not completely known, however,
heredity and peripheral factors are considered to be responsible. The
cause of writer's cramp is believed to be due to abnormal functioning of
the basal ganglia, which are deep brain structures involved with the control
of movement. The basal ganglia assists in initiating and regulating
movement. What goes wrong in the basal ganglia is still unknown. An
imbalance of dopamine, a neurotransmitter in the basal ganglia, may
underlie several different forms of dystonia, but much more research needs
to be done for a better understanding of the brain mechanisms involved
with dystonia. Cases of inherited writer's cramp have been reported,
usually in conjunction with early-onset generalized dystonia, which is
associated with the DYT1 gene [58].
Some investigators have proposed that there is a psychiatric basis for
the disease, but the fact that patients do not undergo hypnosis or other
psychiatric remedies points to the neurological roots [59,60]. Although
there are no demographic studies accurately recording the occurrence of
writers cramp around the world, it has been found to commonly occur in
the Turkish population and is believed to develop in persons who write
excessively, including repeatedly overwriting entries. This has lead to
early diagnosis of the disease. Many persons suffering from the disease try
to reduce its affect by adopting different writing methods (i.e. holding the
pen with their thenars and making use of special pen holders [61-63], or
to use their unaccustomed hand which does not suffer from the associated
muscle spasm. Examples of mechanical pen holders developed to assist
sufferers of this disease when writing signatures or extended text are
presented in Figures 4 and 5.
1.4 Treatment
Treatment for dystonia is designed to help lessen the symptoms of
spasms, pain, and disturbed postures and functions. Most therapies are
symptomatic, attempting to cover up or release the dystonic spasms. No
single strategy will be appropriate for every case. The goal of any
treatment is to achieve the greatest benefits while incurring the fewest
risks. It is to allow the patient to lead a fuller, more productive life by
reducing the effects of dystonia. Establishing a satisfactory regimen
requires patience on the part of both the affected individual and the
physician. The approach for treatment of dystonia is usually three-tiered:
oral medications, botulinum toxin injections, and surgery. These therapies
may be used alone or in combination. Complementary care, such as
physical therapy, may also have a role in the treatment management
depending on the form of dystonia. For many people, supportive therapy
provides an important adjunct to medical treatment. Although there is
currently no known cure for dystonia, we are gaining a better
understanding of dystonia through research and are developing new
approaches to treatments[64].
A multitude of drugs have been studied to determine the benefit for
people with writer's cramp, but none appear to be uniformly effective. In
about 5% of persons affected symptoms improve with the use of
anticholinergic drugs, such as Artane (trihexyphenidyl), Cogentin
(benztropine), but the degree of improvement is usually unsatisfactory and
at the expense of side effects [65].
Since the 1980s botulinum toxin (BTX) has been used on focal
dystonias to reduce the effects of writers cramp. Botulinum toxin (BTX)
injections into selected muscles are helpful in treating writer's cramp,
especially when significant deviation of the wrist or finger joints is
present. Every muscle in the hand plays a specific role in normal hand
movement, unlike the neck in which the structure of muscles is more
complex, and several muscles work together to achieve movement.
Therefore if the appropriate hand muscle is injected at the correct dose, the
BTX will weaken that muscle enough to relieve symptoms without
affecting the overall function of the hand. The toxin causes stroke, by
producing chemo-denervation in the patient thereby effectively preventing
the acetyl colin release in muscle nervous connections. The drug needs to
be administered to the responsible muscles since those especially in

the fingers, thenars and forearms contract and impede handwriting.
However, overdoses or increased doses of the toxin may result in side
effects such as an increased muscle weakness, affecting muscle and
subsequently control of the writing instrument. Deficient doses may
result in only minor reduction in muscle relaxation. A suitable dose
must be determined and this may require some trial and error. BTX
may last 3-4 months and as many as 8 months to one year in some
reported cases and pending the dosage. Ancillary side effects include
possible temporal muscular weakness in the injected tissue [66-70].
Although this treatment is not effective for all people, significant
improvement in writing and reduction of pain is seen in at least
two-thirds of those persons treated.
Since writer's cramp generally affects only a local area of the arm
under certain activities such as writing, surgical treatments are not
usually considered. The conservative approach to treating writer's
cramp includes minimizing writing with the affected hand and using
other methods of communication such as typing or dictating. Using a
tape recorder to take notes may be helpful. Notes can then be
transcribed later in a less stressful situation. Physical methods to help
hand dystonia include learning to hold a pencil differently or using a
special wax mold to help hold a pencil. The trick to reduce dystonia
symptoms in the hand when writing at a desk is to use the shoulder and
arm rather than the wrists and fingers. Sometimes a minimal change in
writing style can make a difference. It is important to be comfortable.
Learning to write with the opposite hand may or may not be helpful.
In some case studies of the disease, the dystonia will "jump" to the
opposite hand. This is referred to as mirror dystonia. In some
cases, writing with the left hand will trigger symptoms in the right
hand, or vice versa. This "mirror dystonia" is a clear indication that
dystonia of the hand is a motor problem stemming from the brain, not
a problem with the hands themselves. Physical therapy may help to
improve local arm flexibility (diminished by dystonic spasms and
strength of the unaffected muscles).
2.0 PURPOSE
To assess handwriting samples produced under the influence of
writers cramp for evidence of:
S the stage at which the handwriting legibility begins to
deteriorate;
S evidence of handwriting class characteristics associated with
writers cramp;
S to compare handwriting affected by writers cramp with other
diseases affecting handwriting;
S whether a handwriting comparison can be conducted on writing
affected by writers cramp;
S to compare handwriting affected by writers cramp with writing
prepared with the assistance of preventive supports;
S the effects of Botox on improving writing legibility; and,
S the misuse of Botox in the commission of fraud by persons
suffering from the writers cramp.
3.0 MATERIALS AND METHODS
3.1 Sampling Pool
Forty-nine patients admitted to Cerrahpasa Medical Faculty,
Department of Neurology, Electromyography Lan, Istanbul, Turkey
with pre-diagnosed writers cramp or a combination of writers cramp
and tremor were evaluated between 1997 and 2001.
3.2 Methods of Evaluation
1. Biographical and demographic profiles were developed for each

patient and included information on: gender, education, occupation,
age, hand dominance, presence of tremor in the hand, related diseases,
trauma history, length of time suffering from writers cramp or other
handwriting disorder, writing characteristics.
2. Electromyocgraphic and kinetiologic features of patients and their
respective short and long term handwriting activities were assessed.
Principally, the presence of radiculopathy and trap neuropathy was
electromygraphically examined; the kinetiologic examination of the
3.
upper extremities with symptoms was made during the rest,

posture, kinetic and target by means of surface electrodes; and the
existence of any spontaneous and involuntary motion was
investigated. Additionally, we reached for some evidence on
behalf of writers cramp by means of rhythmic changes that occur
during long-term handwriting.
4. Letter shapes, combinations, movements and arrangements in

each of the handwriting samples were visually and
microscopically examined.
4.0 OBSERVATIONS
Figure 1: 42-year old male high school teacher suffering writers cramp for 10 years.
Figure 2: 40 year old male patient suffering writers cramp for 10 years.
Figure 3: 25-year old male university student suffering from writers cramp for one year.
Vol. 8, March 2005
Figure 4: Examples of two different writing supports to assist persons suffering from writers cramp [71-73]. Note the strap in the second example that
fits over the back of the hand.
Figure 5: Examples of writing produced using the mechanical supports shown in Figure 4. Top is an example of the normal writing of a person suffering
from writers cramp. The example below is the same writer repeating the text using the support mechanism.
Figure 6: A 22-year old female university student suffering from writers cramp for one year. Top is an example of the student writing her name for the
first time on a sheet of paper. The example below is the same student writing her name for the seventh time.
Figure 7: 29-year old male financial consultant suffering for approximately one and a half years from writers cramp. Top image of writing was produced
under normal conditions. The example below is from the same writer following treatment with Botox.
remaining 47 (96%) suffering this disease in the right hand.
5.0 RESULTS AND DISCUSSION

5.1 Statistical Distribution of Sampling Pool
The 49 patients with diagnosis of writers cramp disclosed biographic,
demographic and electrophysiologic data:
Gender:
Ages:
Education:
Professions:
Length of
Disease:
Dominant
Hand:
11 (22%) were female patients and 38 (77%) were male;

23 to 81 years with a mean of 47 years of age;
High school, university graduates or students;
Architects, musicians, state officials, teachers, accountants,
bank personnel or doctors.
Subjects suffered from writers cramp for periods ranging
from 2 months to 11 years with a mean average of 3.8
years;
All patients suffered from writers cramp in the dominant
hand. In two subjects (4%) this was the left hand with the
Other
Conditions:
19 (40%) patients also displayed tremors and one patient

had a history of cerebrovascular disease. Another patient
has diabetes mellitus, and one patient had multiple
sclerosis. There was also one patient with a history of
bilateral trauma.
5.2 Physiological Effects

Patients demonstrated difficulty in handwriting, pain in the influenced
extremity, convulsions, tremors, writing deformations, and writing and
signing disabilities. Patients held the pen tightly and used excessive
downward pressure when writing. Most patients had adopted the use
dimensionally wider pens, supported the affected hand with the
unaccustomed hand, adopted the use of the unaccustomed hand to write,
disclosed postural changes in the fingers and hand of the affected hand
when writing. The literature describing the affects of writing on a desk in
Vol. 8, March 2005
a conventional writing position verses writing on a black board were

verified, with the disease affecting writing more at the desk than while
standing at a black board.
In 11 patients similar difficulties attributed to writers cramp were
defined in other activities such as eating and shaving. Polyneuropathy was
detected in the diabetic patient.
5.3 Effects on Handwriting
In 26 (53%) patients handwriting was initially normal but became
deformed after one or more lines of writing. In 23 (47%) patients the
writing was deformed from the beginning of the writing process and
worsened with increased writing.
In 21 (62%) of 34 patients, who had been suffering from writers
cramp for less than 5 years, a normal writing style was observed that
gradually digressed to a deformed style as the amount of writing increased.
The other 13 (38%) possessed a more advanced, deformed writing style,
from the outset of the writing process. Interestingly, in the group suffering
for longer than 5 years, 4 (27%) of 15 patients had writing styles that
began normally, and gradually became deformed with increased writing
with the other 11 (73%) displaying a deformed writing style from the
beginning of the writing process (see Figure 6).
7 (37%) of 19 patients displayed tremor in association with writers
cramp which began as a normal writing style and then became deformed
with time. The remaining 12 (63%) patients demonstrated both tremor and
a deformed writing style from the outset of the writing process. Tremor
was also observed in 11 (58%) patients with less than 5 years and 8 (42%)
with more than 5 years of writers cramp.
In 8(16%) of the total group, handwriting was determined to be a
puerile characteristic. Of this group 2 (25%) patients in the group had an
entirely deformed writing style at the beginning of writing and 6 (75%)
displayed a writing style that was initially normal becoming increasingly
deformed with time. 5 (63%) patients within this group suffered for less
than 5 years and the remaining 3 (37%) suffered for over 5 years.
5.4 Legibility
Legibility, like many terms used to describe handwriting, is a
subjective assessment [74,75] that has never been scientifically validated
based on a standard criteria on what is legible writing and what is not. It
is generally accepted that any writing which cannot be deciphered or
whose letters are not recognizable and diverge to such an extreme away
from a core shape, might be labeled as illegible. It is unclear what the basis
is for labeling a handwriting as legible or illegible. Is this assignment
based on legibility or readability? This is where the subjectivity becomes
a factor restricting determination of a validated standard. However, if the
writing is considered only within the subject and not within a larger group
it may be possible to demonstrate changes in legibility relative to different
writing samples. This is the approach that will be used when assessing the
effects of writers cramp on legibility. Evidence will be sought that shows
changes in character construction which might signify the onset of a loss
of legibility due to the disease in the ability to decipher the text. It is not
possible at this time to assign a numerical value to this change in legibility
within or between writers. Due to the absence of any validated standards
identifying what is legible and what is illegible writing, there may be
disagreement between different document examiners looking at the same
evidence. Therefore the handwriting samples will be examined for
evidence of changes in the formation of letters to determine if these
changes are gradual or rapid and to what degree these letters may be
deciphered.
In Figure 5 a sample sentence has been handwritten three consecutive
times without a break between entries.. Although the entries were
prepared by Turkish nationals, the script is based on the Latin alphabet.
It is unclear whether any of the first letters at the beginning of the
sentences are reproduced at the end of the sentence (Figure 8) due to an

inability to decipher all of the later writing. Therefore it is difficult to
observe changes in legibility between the same letter prepared at different
stages in the writing process. The letters at the beginning of the sentence
generally disclose shapes more consistent with copy book forms while
some of the letters at the end of the sentence cannot be deciphered (Figure
9). This suggests the progressive deterioration of legibility.
In the first sentence it might be argued that the legibility of the writing
becomes harder to decipher after the t (Figure 8). This would support
prior profiles on writers cramp writing which states that one symptom of
writers cramp is a decrease in the legibility of the writing soon after a few
words have been written. It may be possible to confirm this based on the
legibility at the end of the first sentence verses the beginning of the next
and so on. Based on the literature a person suffering from writers cramp
might begin to write legibly (following a period of inactivity) followed by
a reduction in legibility as the writing process continues and at different
rates and degrees based on the person and the extent they are afflicted with
the disease. If a new sentence is started the decline in legibility should
continue. It is difficult to decide whether the first 5 letters of the second
sentence are of similar legibility to those same letters in the first sentence.
However there is a decline in legibility of the h in the second sentence
compared to the first (Figure 10). This may suggest there was no rest
between writing each sentence. It may also be argued that both the B
g/y and last letter of the first word are of similar legibility suggesting a
break in writing. It is difficult to draw conclusions based on the limited
amount of writing sample provided.
Additional handwriting samples where repeated sentences are
generated may identify class characteristics unique to persons suffering
from writers cramp by which document examiners can recognized the
occurrence of this disease in handwriting evidence. The change in the
letter movement from smooth, rounded strokes and no angular disruptions
from the intended path to a letter movement that has angular disruptions
from the intended path, may be a better gauge of the change in legibility
as opposed to assigning legibility based on the ability to read the text.
Some examiners might argue that there may be some letters at the end
of the second sentence which might be more recognizable (and therefore
more legible) than the same letters at the end of the first sentence. Since
there is no information on whether a rest period occurred between writing
subsequent sentences, it is not possible to determine how time and
legibility are affected in respect of the amount of writing prepared. It is
unclear if writers cramp is cumulative and does not entirely recede during
periods of rest, nor how the length of the rest period might reduce the
affects of the disease on the next writing activity.
In the third sentence (Figure 11) there is evidence that the last two
letters of the first word are less legible than the same letters in the first two
sentences. This again may suggest a rest period between the preparation
of the second and third sentences. Here the legibility begins to diminish
after the formation of the g which may suggest a progressive increase in
the stage of the writing at which the writing movement deteriorates. The
more rapid decline in legibility based on the position in the sentence may
be due to the inability of the rest period to completely reduce the affects
of writers cramp to the same degree as in prior periods of inactivity.
Based on these limited samples it may not be possible to draw broad
conclusions, however, there is evidence that handwriting quality
diminishes soon after the writing process begins, confirming the literature
in regards to the effects of writers cramp on writing. Whether writing
legibility improves after periods of inactivity and the relationship between
the length of inactivity verses the degree of illegibility could not be
Figure 8: There is no evidence of repeating of letter shapes at the beginning of the sentence with those at the end to demonstrate changes in legibility with
the amount of writing prepared.
Figure 9: The letters B, y, h, s and t at the beginning of the sentence (left) compared with the letters at the end of the sentence (right) which
are not decipherable.
Figure 10: The initial letters at the beginning of the first (top) and second sentence (bottom) show similar agreement in legibility compared with the
letters at the end of each sentence.
Figure 11: Decline in legibility of the last two letters of the first word compared to the same letters in first two sentences. This suggest continuous
decline in legibility or a possibility that any rest period taken had a less positive affect in reducing the effects of writers cramp.
interpolated based on the limited amount of writing provided.

Another example where the same sentence has been repeatedly written
is in Figure 5A. The text was deciphered to read, This is a sample of my
best handwriting. It is difficult to compare and comment on any degrees
of differences in legibility between the first three sentences in Figure 5A.
In each sentence there are examples of the same letter which display a
more conventional shape than in other sentences, including the h and
d in the last word of the third sentence. This is an example of a chronic
sufferer of writers cramp. In Figure 12, writing samples for Figure 1 and
Figure 5A are compared. There is evidence to suggest that the writings in
Figure 1 are less legible than those in Figure 5A. There are no good
examples of recognizable conventional letter shapes throughout the three
sentences as occurs in Figure 5A. This may be due to the writer in Figure
1 suffering from the disease longer that the writer of the samples in Figure
5A.
This example demonstrates the variation in the onset of declining
legibility as reported in the literature. There is more agreement in the
decline of legibility in the bottom group of sentences in Figure 12 than in

the top group, where the most dramatic decline begins with the last word.
In the absence of information on how long this person has been suffering
from the disease it is not possible to compare the legibility of the letter
shapes in this example with that in Figure 1 where the decline in legibility
is more dramatic. No conclusion can be drawn to show a relationship
between the stage in the writing process at which legibility declines verses
the length of time a person has been suffering from the disease. It might
not be possible to distinguish this sample as evidence of a person suffering
from writers cramp verses a person with no affects of a disease but who
possesses poor writing skills.
In Figures 2 and 3 the letter construction is poorer from the outset of
the writing, suggesting again agreement with the literature that some
sufferers of writers cramp demonstrate dramatically diminished legibility
in their writing almost immediately upon putting pen to paper. Examples
of different writing from five persons suffering from the disease are shown
in Figure 13.
Vol. 8, March 2005
Figure 12: The example at the top (Figure 1) shows a decline in letter formation after only a few letters have been constructed compared with the bottom
examples (Figure 5A) which show a dramatic decline only in the last word of the sentence.
Figure 13: Examples of different stages of illegibility in a sentence by 5 different writers suffering for different lengths of time. Note the different stages
when legibility diminishes. The bottom example is from Figure 6B, a person suffering for only a few years.
5.5 Class Characteristics

Class characteristics in handwriting refer to characteristics identified
in handwriting which are common to a group of writers. Determining the
existence of class characteristics requires the examination and comparison
of many handwriting samples from a representative pool of writers within
any one group. In the present study only a few examples of writing can be
considered, therefore it may not be possible to identify class characteristics
unique to writing produced by persons suffering from writers cramp.
However, it is possible to inter-compare these writing samples with writing
samples prepared by persons affected by a number of health factors.
5.6 Tremor
tremor which may be used as a general standard when analyzing writing

suspected to be affected by health related condition [Figure 14]. The
handwriting samples in Figures 1, 2, 3 and 5 to 7, were examined for the
presence of tremor in the strokes.
In Figure 14 different examples of tremor are clearly shown. The
example of tremor due to senility from Harrison at the bottom is consistent
with Buquet and Rudlers last example. There are no repeating redirections in this example compared with those in the example for
alcoholism or Parkinson.
In the samples of writing affected by writers cramp, tremor is not so
easily identified and may in fact be confused with a slow writing
movement associated with the affects of the disease (Figure 15). Again
there are no examples of the repeating misdirections observed in the
examples in Figure 14.
Buquet and Rudler [76] give examples of three different types of
Figure 14: Examples of tremor (Courtesy Buquet and Rudler [76]) and an example of extended writing by a person suffering from senility (Courtesy
Harrison [77]).
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Vol. 8, March 2005
Figure 15: The handwriting examples produced under the conditions of writers cramp show few decisive examples as evidence of tremor, when
compared to the standards in Figure 14.
The examples in Figure 15 show the following:
1. Examples of uneven line quality that may not be consistent with
tremor;
2. Examples of smooth, uninterrupted line quality;
3. Possible isolated examples of uneven line quality which my be due to
a slow writing movement and not tremor.
4. Possible examples of tremor.
5. Uneven writing movement, not an example of tremor.
5.7 Parkinsons Disease

Figure 16 shows a comparison of sample handwritings produced by
persons suffering from Parkinson disease with samples of handwriting
affected by writers cramp. The legibility of the writing in the Parkinson
patients is better than that produced under writers cramp. The rapid
change in legibility may be the single most identifiable characteristic
distinguishing writers cramp writing from that of writing affected by
other factors. Walton [78] reported from his study that waver was mainly
found on long downstrokes or on the sides of lower case letters. The
comparison sample of writers cramp demonstrates the degree of
11
Figure 16: Comparison of handwriting (top) produced by Parkinson patients (Courtesy Walton) and sufferers of writers cramp (bottom).
Figure 17: Two different examples of writing (top) prepared while intoxicated (Courtesy Buquet and Rudler [79]) compared with samples of writing
prepared under writers cramp (bottom).
12
Vol. 8, March 2005
difference in legibility where it is difficult to isolate any class

characteristics unique to one letter movement.
5.8 Intoxication
Figure 17 shows a comparison of writers cramp writing with that
produced by persons under the influence of alcohol. Writing produced
while intoxicated has been characterized by an increase in the size of the
letters compared to writing produced by the same person while sober.
There is also a decrease in legibility. These distortions result in letters of
varying size and shape which fall outside the boundaries of the writing
area. Writers cramp writing does not show dramatic increases in size
together with distorted movements. Writers cramp may restrict the
writers movements preventing the creation of wild distortions. The
writing, although decreasing in legibility, remains within the writing areas.
The person has not lost control as can happen when intoxicated. However,
the person loses the ability to direct the fingers to form recognized
standard letter formations. Therefore, while legibility declines in both
writers cramp writing and writing while intoxicated, the decline in
writers cramp writing stays within the control of the writer who is able to
place letters within the areas of interest. In the example in Figure 17, the
left side is more legible than that on the right. This may be related to the
degree of alcohol consumption in which case the writer on the right was
totally intoxicated.
5.9 Handwriting Comparisons
Handwriting examinations and comparison must be based on accepted,
validated methods. This requires research to identify all those possible
external and internal conditions which may affect writing and therefore the
ability to conduct a handwriting comparison. Studies such as this one on
writers cramp draw attention to possible causes for changes in
handwriting and may assist the expert in recognizing and distinguishing
conditions under which writing was prepared. However, it is not clear as
to whether a handwriting comparison can be conducted on writing
produced by persons suffering from writers cramp. Let us consider
Figures 1 and 5, respectively. Both these examples display repeated lines
of writing each purported to have been prepared by one writer. In a real
case scenario the forensic document examiner would be expected to
demonstrate the common origin of specimen writing that was submitted as
collected specimens and not prepared in front of a witness. We can treat
these two examples in the same way, as collected, unknown and
unquestioned writings to be used as specimens.
Standard a priori tests [80] are applied to handwriting evidence to
identify any limitations which might prevent a handwriting comparison or
which might affect the strength of opinion assigned following a
handwriting comparison. These tests were described at the beginning of
this paper with reference to the literature. Some basic criteria must be met
before a handwriting comparison can be conducted, whether to confirm
common source of specimens or to compare questioned with specimen
writings. The tests may be applied in an order such that the successful
completion of one test permits the next test to be applied. At any given
instance, failure to satisfy a test may disqualify a handwriting comparison
and may necessitate the investigator resubmitting the evidence with
additional specimens meeting the criteria for comparison.
Writing style and comparable text are two tests which can be quickly
applied to handwriting evidence and may be used as a preliminary screen
at the processing stage of any submission of evidence for a handwriting
examination. The failure to satisfy both tests may disqualify the
submission before any further tests are applied. If we consider writing
style we are determining whether the writing to be compared was prepared
in the same style, i.e. hand printing with hand printing and handwriting
with handwriting. In Figure 1, the three lines of writing disclose
disconnected and connected letter combinations (Figure 18). Some of the
letters may be lower case hand printed forms as seen with the h and the
t (1), while other letters resemble disconnected printed forms with some
cursive components s (2) or cursive writing, possible g(3) and
possible upper case B (4) written as a lower case letter. These letters
show the characteristic features associated with cursively formed letters.
There are also examples of connected letter combinations as seen in the
possible ge and ng (5). The h in the third example (1b) shows a
loop in the first staff which may be consistent with cursive writing rather
than hand printing. In Figure 5 (Figure 18) there is less variation in the
writing style which shows a consistent cursive writing style. In summary
there is evidence that all three sentences were prepared with the same
writing style comprising disconnected cursive and hand printed letters and
connected letter combinations.
Comparable text requires that the same letters exist in the different
documents or bodies of writing to be compared. While some letters such
as the a, d and g may demonstrate an internal consistency around
the body of the a, it is still not possible to conduct a complete
handwriting comparison because these are different letters with other, noncomparable components. Therefore, the same letters and possibly letter
combinations must be demonstrated in the different writings to be
compared; otherwise, it will not be possible to determine similarities or
dissimilarities in letter construction. In Figures 1 and 5 there is evidence
that each sentence is a duplication of text and therefore there is
comparable text between the three sentences to allow for a comparison of
writing movements (Figure 18).
Legibility may also be considered as an initial screening test before
other tests can be applied to the evidence. Legibility may also be tested
under the test for comparable text. If we refer back to Harris and Hilton
[81,82], what may appear illegible, may, with time, slowly become more
legible as the scientist becomes familiar with the writing and deciphers the
text. It may be possible to identify deliberate disguise presented as
illegible writing but it may not be possible to assign a naturally prepared
writing as illegible without representative specimens of writing prepared
at different times. There are no validated standards upon which to
determine what is considered illegible writing because of the subjectivity
of assessment. The literature states that a writer can prepare a text that is
of less artistic quality than what they are normally capable of doing [83]
but that same writer cannot write a more artistic or skilled writing than
what they are capable of. This again has not been validated but has been
reported in different literature and is part of the training received for
handwriting examination. In Figure 18, the entries in Figure 5 may be
considered more legible than those entries in Figure 1 based on the ease
of deciphering the two texts. Therefore this assessment may require
additional time to determine and then it still remains a subjective
assessment. If comparable text is a criteria test for conducting a
handwriting examination then, it therefore must also require that the text
be legible or resemble a recognized alphabet such that the letters can be
identified and therefore compared. While it may be possible to look for
similarly formed writing movements to satisfy the condition of comparable
text, if these movements can not be attributed to a letter form, no matter
how divergent from the copybook model, it may not be possible to confirm
that two similar formed movements, presumed to be letter formations are
in fact the same letter. This also would take into account internal
consistency between letters of similar core structure such as the a, d,
g, and p. However, as stated earlier, while some comparisons may be
conducted on these similar constructed letters, there are other components
which cannot be compared. Therefore two illegible movements, defined
as not being recognized to match any alphabet letter shape, may show
similarities, but may in fact be two different letters. In Figure 18 the
bottom example is not illegible as the letter shapes can be deciphered and
therefore an assessment for comparable text is possible. In the top
example, however, some of the letters are less decipherable as a result of
the progressive affect of the disease of writers cramp. Examples from
Figure 1 have been isolated and shown in Figure 19. It must be kept in
13
Figure 18: Examples of comparable writing style and text in samples handwriting from Figure 1 and 5 under the influence of writers cramp. Numbers
correspond to letters and letter combinations repeating in the specimens.
B
Figure 19: Selected letters from Figure 1 together with assigned decipherment of the letter. Attempt to demonstrate whether all the letters in the example
are decipherable and therefore can demonstrate comparable text necessary for a handwriting comparison.
14
Vol. 8, March 2005
mind that these examples were prepared in Turkish and the expert should
be familiar with the written and spoken language before attempting to
conduct a handwriting comparison. The Turkish written language is based
on the Latin alphabet. A letter has been assigned as a possible
decipherment together with examples from the three sentences to
determine if there is evidence of common text.
It may be possible to follow a writing movement and demonstrate that
it is reproducible without assessing what that movement represents. If the
writing is illegible then it may not be possible to identify the writing style
or the presence of comparable letter shapes. However, it is difficult to
assign an optimum condition as to what is illegible and how all other
writing measures against this optimum standard. As the literature stated,
illegible writing may become more legible as the reader becomes familiar
with the style. In Figure 1 (Figure 19) there are some letters which cannot
be deciphered as representing any standard letter shape and therefore
confirmed as the same letter form in all three sentences. These
movements, however, show some agreement. Is this then evidence that the
same movement was prepared despite an inability to determine what letter
it represents? In the last two columns of Figure 19, the letters are not
decipherable and their shapes vary between the three sentences. If the
letter can not be deciphered and attributed to a particular recognized form
it is not possible to assess natural variation around a core writing
movement. These are examples of limitations which may ultimately affect
the primary handwriting comparison and must be taken into consideration.
The top example in Figure 19 disclosed similar text at the beginning of
each sentence which may allow for a comparison, while the latter text is
not entirely decipherable. Subsequently, as is the case in other situations,
such as suspected disguise and forged writings, some of the entries may be
shown to be comparable and can be assessed while others must be
disregarded. This does not preclude conducting a complete handwriting
comparison on those entries which have been retained. In this example
parts of the writing may allow for a handwriting comparison but may not
necessarily allow for the scientist to extrapolate the results of this
comparison to include the remaining entries at the ends of these sentences.
There are also examples of letters which do not resemble standard letter
forms but their formation has been duplicated, and therefore these may be
comparable (Figure 19). Therefore there is evidence of legible writing
features which allows for a comparison of the same letter in the different
sentences.
Image Clarity refers to the condition of the image submitted for
examination. Genuine documents are preferred over photocopies or other
form of reproduced document. However, even with original documents
there may be limitations affected by the writing instrument. While it has
never been validated, ball point pen writing instruments are considered to
capture more writing movements on paper than any other writing
instrument. Felt-tip marking instruments, due to the fluid and diffusive
nature of the ink, will diffuse horizontally and vertically upon contact with
the paper, and therefore do not retain the shape of the writing movements
to the same degree as the more viscous ball point pen inks. Image clarity
will impact on the assessment of writing movement to determine if the
writing was naturally prepared. There has been considerable discussion
on whether handwriting comparisons can be conducted from photocopies
or digital images [84]. In our two examples we are not dealing with
original documents and therefore it was difficult to confirm the writing
instrument used and whether it may hamper the assessment of all writing
characteristics. Image clarity may be measured against the detail captured
by a ball point pen which can be microscopically observed. Although
there have been no validation studies determining the degree of
handwriting detail that can be captured and clearly defined on a document
from different writing instruments, ball point pens are considered the
optimum writing device. Examination for detail and clarity may include
pen ball striations, distinguishing two retraced or superimposed strokes,
or other fine minutia. In Figure 19, the top example displays more detail
compared with that in the lower example. This may be due to the writing
instrument, or whether an original or copy was used. Some of the retraced

strokes in the bottom example are not clearly distinguishable compared to
the top example. While the fine detail in the bottom example of Figure 19
is not as clear, many writing movements are clearly defined and should not
affect the handwriting comparison.
Writing Movement refers to evidence that the entries were naturally
prepared and therefore demonstrate genuine examples of the writers letter
formations. Naturally prepared writing is a core requirement for any
handwriting comparison. In the absence of naturally prepared writing it
may not be possible to arrive at any conclusion as to authorship. Naturally
prepared writing is characterized by evidence of a smooth, uninterrupted
path in the written stroke, tapered terminations at the ends of strokes and
gradations in pen pressure. There are no validation studies to confirm
whether all three criteria must be identified before a handwriting sample
may be determined as naturally prepared. There are examples in the
literature of these characteristics as a reference for determining the
presence of naturally prepared writing. In Figure 20, examples from
Figures 1 and 5 disclose evidence of tapered terminations at the ends of
strokes (1), smooth line quality (2), and gradations in pen pressure (3).
Similarly there are also examples of uneven line quality, where the strokes
are not smooth and continuous (4). However, other features such as blunt
termination, which indicate a slow writing movement and which may or
may not be natural to the writer, were not found in either example. Also
uniform pen pressure which cannot always be distinguished when a broad
felt tip marker is used, was also not found in either of the examples.
This examination is of particular importance when dealing with
possible writers cramp writing. The writing may appear to be illegible
but this may be a natural illegible result of the disease and not due to a
deliberate attempt at disguise. It is important to note that in both examples
the line quality periodically displays interruptions in the smooth path of
the stroke, there are still associated examples of tapered terminations. This
presents a contradiction which has not been thoroughly validated. There
are two conflicting pieces of information, indicative of two writing
conditions, one natural and the other unnatural. The occurrence of both
these characteristics may be considered a class characteristic of writers
cramp writing. Here the writing may appear illegible, and stroke lines
uneven, but there is also associated tapered terminations.
There is evidence that the writing was naturally prepared but
influenced by some uncontrolled health condition.
Contemporaneity: This refers to whether the writing to be compared
was produced within the same time frame. In this example the entries
were purportedly written one after the other and there is no information
suggesting each successive entry was prepared at a different time. This
assessment arises when comparing questioned with known writings which
may have been prepared several years apart.
Alterations: There is no evidence that the entries were altered. This
assessment should be addressed for any handwriting examinations in an
effort to explain what has occurred during the preparation of the
document.
Conditions of Preparation: This is what is being assessed and
defined, whether writers cramp writing can be identified and
distinguished from other writing conditions that may alter a persons
natural writing movements. One problem is to distinguish illegibility due
to disguise and that due to as a result of an illness.
Common Authorship: As mentioned this must be determined for
specimens submitted as standards for comparison with a questioned
document. This becomes important when the specimens provided were
not witnessed but are unquestioned and unknown. In an attempt to
determine whether a handwriting comparison can be conducted on writers
cramp writing we are using the repeated writing from Figure 1 to intercompare for evidence of common authorship. To conduct such a
comparison the same a priori tests applied to questioned and known
writing for the purposes of comparison must be applied to known writing
for the purposes of assessing for common authorship. We will consider
15
Figure 20: Examples from Figures 1 and 2 showing tapered terminations (1), smooth line quality (2), gradations in pen pressure (3) and uneven line
quality (4).
Figure 21: Examples of repeated letter formations and inconspicuous features found in common in Figure 1 of writing produced under the influence
of writers cramp.
each of these examples separately. In Figure 21 we can show examples of comparable
2. Possible
text with
u:naturally
variationprepared
in initialwriting
and terminal
which shows
movements:
the same writing
movements repeated in each of the three sentences.
1
2
3
1. B: terminal below staff and disconnected; shape of lower body, not
as rounded as upper bulb; base intersects baseline; Some variation in
shape of staff;
3. G: adjustment in terminal staff; narrow lower loop intersects

midway up staff; variation on terminal eyelet at top of second staff
and initial staff show variation.
1
16
Vol. 8, March 2005
4. Uncertain what this letter is, some agreement in the first two
sentences, third sentence there are dissimilarities.
1
11. g: Angular base; variation in terminal.

1
2
5. B: close resemblance, may be another letter. Agreement in terminal

eyelet; open base, not close to initial staff; some variation in staff.
12. Another example of inconspicuous features relative heights.

1
6. Length of base of s longer relative to ha combination.

1
In summary, there is evidence a handwriting comparison may be

conducted on writing produced under the influence of writers cramp.
However, several tests must be applied to the evidence to identify any
limitations.
5.10 Remedies
5.10.1 Botox (Botulinum Toxin Type A)
7. Letter shape not repeated throughout all three sentences.

1
Another factor which may affect determining the presence of writers

cramp is that some persons writing will be improved in the course of time
(up to one year) with botulinum toxin. Botulinum toxin may cause marked
improvements especially in writing velocity, legibility and pen control,
and as a result there is an increase in the ability to routinely use signatures.
Figure 22 is an example of writers cramp writing before and following
injection with Botox.
5.11 Writers Cramp and Fraud
8. Initial stroke good agreement in sentences 1 and 2; remainder of letter

formation not totally accounted for. Possibly a cursive z.
1
9. Disagreement in letter shape in all three sentences.

1
10.
g: narrow angular loop; terminal eyelet; variation in initial stroke.
A study performed in Turkey on 10 patients with writers cramp

reported that signing qualities improved markedly in 3 and partially in 4
patients after botulinum toxin injection. In fact, handwriting and signing
characters sporadically show deformations and improvements during many
diseases. This occurrence is more distinct in neurological diseases.
In writers cramp the periodic remission of the disease by means of
drug injection may cause the emergence of patients who tend to take
advantage of the situation. In other words these persons may use the
disease and the Botox treatment to commit fraud. Someone who has a
history of disability due to writers cramp may regularly display illegible
writing. However, in another situation they may display vastly improved
writing after receiving Botox to control the dystonia. The use of Botox
to control the dystonia may present opportunities to commit a fraud. This
can arise when a patient receiving Botox prepares writing which they later
wish to deny as their own. To support their alibi they provide writing
samples demonstrating that they are sufferers of the condition. These
specimens may be illegible and difficult to compare with the better quality
questioned writing. There was no information on the minimum dose of
Botox needed to reduce writers cramp and how long legibility would
remain improved. Generally the literature reports 4 months as the standard
period of improvement from a dose of Botox to treat writers cramp.
Although Botox is generally considered a prescription drug it can be
obtained illegally through the black market. This may make it difficult to
establish whether a suspect writer had access to the drug through a trail of
medical prescriptions. One route may be to test for metabolites of the drug
which may not only show that the suspect had injected the drug, but may
also provide a relative time of injection which may be compared with the
17
Figure 22: Writing prepared by a 29-year old male financial consultant suffering for approximately one and a half years from writers cramp. Top image
of writing was produced under normal conditions. Note the deformation of letter shapes after the second name. The example below is from
the same writer following treatment with Botox. The deformation does not show after the second word and is absent from the sentence when
compared with the same sentence in the absence of Botox.
Figure 23: In the top and bottom entries the only comparable letter is the upper case N. These examples show few similarities between the two
writings and does show the types of problems which can be encountered when attempting to compare writing produced by the same person
under different writing conditions.
date of the fraud.

Using the example in Figure 22, a handwriting comparison was
conducted between the writing produced under writers cramp with
writing produced after treatment with Botox (Figure 23). Unfortunately
this is not the best example because there is evidence of two different
writing styles and a limited amount of comparable text between the two
writings. The top example is affected by writers cramp and discloses a
mix of connected cursive letters and disconnected hand printed and cursive
letter forms. There is also a limited amount of comparable text as the entry
produced under Botox is primarily disconnected block letters and does not
duplicate the text of the first entry. Therefore a proper handwriting
assessment may be precluded on the limitations between the two writings.
Some observations related to similarities and dissimilarities were noted
and have been numbered in Figure 23 described below.
6. The N discloses a number of similar features. The initial staff is
longer than the terminal staff; disconnected at the intersection of the
base of second staff with the base of diagonal crossing stroke. The
base of this intersection is a longer distance above the baseline
compare with the initial staff. The terminal of diagonal stroke forms
a horizontal adjustment into the intersection with the terminal staff.
18
7A
7B
2. The base line alignment of the letters on the left show some agreement
with letters positioned above the baseline and the later letters touching
or closer to the baseline (t).
7a
7b
In this comparison it may be argued that a handwriting examination

may not be possible due to two fundamental problems, a lack of
Vol. 8, March 2005
comparable writing styles and text. It is unclear if the style differences and
the use of disconnected hand printed block letters is easier to write more
clearly because the style is less complex and possibly less demanding than
cursive writing. Conversely, if the writing style used to prepare the
samples is the natural writing style of the writer treated with Botox, then
this may be a good example of two different writing styles prepared by the
same person under different conditions. While it is inappropriate to draw
broad conclusions based on this limited comparison, this is an example of
the dramatic differences in writing movements within the same writer
suffering from writers cramp before and after Botox treatment. Therefore
there is the potential to take advantage of this disease and its treatment to
commit fraud. Based on this example further studies are warranted. In
summary a proper handwriting comparison cannot be conducted on these
examples to determine whether it is possible to draw any definitive
conclusions as to authorship. Subsequent research will seek examples of
frauds where writers cramp was used as a defense and where there is a
possibility Botox was involved.
Although the example in Figure 23 is of limited value for
demonstrating comparison, it does highlight the need to ensue specimens
duplicate the amount, style and if possible the conditions under which the
questioned signatures were prepared. Forensic document examiners must
not only be aware of the causes of illegible writing but also understand the
potential for fraud to be committed under these conditions.
It was still possible to conduct a limited handwriting comparison,

demonstrate similarities and dissimilarities and arrive at a qualified
conclusion. As with any forensic examination it is necessary that the
evidence be assessed to identify any limitations which might affect the
handwriting comparison.
The potential to commit fraud remains a driving focus on the subject
of writers cramp. The successful use of botulinum toxin type A to
reduce the affects of writers cramp may have created an opportunity to
commit fraud. It may be possible for a single sufferer of the disease to
write a questioned or fraudulent text while under treatment with Botox and
then later deny the writing using examples of writers cramp writing
prepared in the absence of Botox. Unfortunately this was not fully
explored with the examples provided nor was it possible to design a test
to validate this possibility. Additional information is required to
determine the potential of Botox acting rapidly to improve a writers
cramp sufferer such that there is no resemblance between the treated and
untreated writing. Also there may be ways to identify metabolites in a
person suspected of committing such frauds.
This study draws attention to a less well known disease that may have
dramatic affects on writing legibility and may also be manipulated to
successfully perpetrate a fraud.
5.12 Writing Supports
[1].
Harris, J. S., Morin, T., Nott, H.R. and Loncar, J., War Crimes
Cases in Canada and the Scientific Examination of Questioned
Document Evidence, presented at the 53rd Annual Meeting of the
American Academy of Forensic Sciences, Seattle, Washington,
February 2001.
[2].
Harris, J. S., Identifying Digitized Handwriting, presented at the

54th Annual Meeting of the American Academy of Forensic
Sciences, Atlanta, Georgia, February 2002.
[3].
Harrison, W. R., Suspect Documents: Their Scientific Examination,

Nelson-Hall Publishers, Chicago, 1981.
[4].
Conway, J. V. P., Evidential Documents, Charles Thomas,

Publisher, New York, 1959.
[5].
Hilton, O., The Scientific Examination of Questioned Documents,

CRC Press, 1993, London.
[6].
Ellen, D., The Scientific Examination of Documents: Methods and

Techniques, Ellis Horwood Ltd., 1989, England.
[7].
Huber, R. A. and Headrick, A. M., Handwriting Identification:

Facts and Fundamentals, CRC Press, New York, 1999.
[8].
Singh, I. and Chattopathy, P. K., Effect oif Alcohol on

Handwriting, Current Topics in Forensic Science, Proceedings of
the 14th Meeting of the International Association of Forensic
Sciences, August 26-30, 1996, Tokyo, Japan, Vol. 4, 1997, p. 390396.
[9].
Stinson, M. D., A Validation Study of the Influence of Alcohol on

Handwriting, Journal of Forensic Sciences, Vol. 42, No. 3, 1997,
p. 411-416.
As shown in Figures 4 and 5, mechanical writing supports may be

used to generate increased legibility in writing for persons suffering from
writers cramp. The example in Figure 5 (bottom) was produced using
one of the mechanical assists described in Figure 4. Note the strap in the
second example that fits over the back of the hand. Both devices reduce
the action of the hand on the writing instrument, thereby allowing the
writer to guide the pen and reduce the tight grip and heavy downward
pressure characteristic of persons suffering from this disease. The reader
is invited to conduct a handwriting comparison between the writers
cramp writing and the assisted writing samples in Figure 5A and B to
determine limitations and whether a definitive conclusion as to authorship
is possible.
7.0 REFERENCES
6.0 CONCLUSIONS
Legibility remains the only indicator that writers cramp may be
affecting the writing. Based on the handwriting samples provided there is
evidence that legibility diminishes soon after the writing process begins in
persons suffering from writers cramp. This confirms what has been
reported in the literature.
The deformation of letters in writers cramp writing is different from
that found in other diseases such as Parkinson and Alzheimer or under the
influence of alcohol. This may help the expert to distinguish between
illegible writing due to poor skill and that which results from dytonia. It
may also be possible to distinguish between writing styles and
characteristics resulting from a number of diseases.
A handwriting examination and comparison was conducted on writing
samples prepared by the same writer while affected by writers cramp. The
example selected was used to conduct a common authorship examination.
Although this is not the same as comparing questioned with known
writings, common authorship examinations are necessary and require the
same detailed comparison as that applied when comparing specimens with
questioned writing. However, this example may display writings that were
prepared consecutively and within a very short period of time. This would
be of value for writing that is not affected by the disease, but because of
the dramatic changes in legibility cause by this disease the close
preparation time were of importance. The writing in subsequent examples
disclosed marginally more deformation of letters from the first sentence.
[10]. Watkins, R. I. and Gorajczk, J., The Effect of Alcohol

Concentration on Handwriting, presented at the 48th Annual
Meeting of the American Academy of Forensic Sciences, February
1996, 15 pp.
19
[11]. Buquet, A. and Rudler, M., Handwriting and Exogenous

Intoxication, International Criminal Police Review, No. 48,
Sept/Oct, 1987, pp. 9-20.
[12]. Galbraith, N. G., Alcohol: Its Effect on Handwriting, Journal of
Forensic Sciences, Vol. 31, No. 2, 1986, p. 580-588.
[27]. Tarver, J. A., Micrographia in the Handwriting of Parkinsons

Disease Patients, presented at the Joint Conference of the
Southwestern Association of Forensic Document Examiners Fall
Seminar and the American Society of Questioned Document
Examiners 46th Annual Meeting, Denver, Colorado, Sept. 1988, 25
pp.
[13]. Beck, Jan, Handwriting of the Alcoholic, Forensic Science

International, Vol. 28, 1985, p. 19-26.
[28]. Behrendt, J. E., Alzheimer Disease and Its Effect on Handwriting,

Journal of Forensic Sciences, Vol. 29, No. 1, 1984, p. 87-91.
[14]. Zaki, N. N. and Ibraheim, M. A., Effect of Alcohol and Cannabis

Sativa Consumption on Handwriting, Neruobehavioral Toxicology
and Teratology, Vol. 5, No. 2, 1983, p. 225-229.
[29]. Lindblom, B., Identifying Characteristics in the Handwriting of the

Visually Impaired, Canadian Society of Forensic Sciences Journal,
Vol. 16, No. 4, 1983, p. 174-191.
[15]. Foley, R. G. and Lamar, A., The Effects of Marijuana and Alcohol
Usage on Handwriting, Forensic Science International, Vol. 14,
No. 3, 1979, p. 159 -164.
[30]. Wing, A. M. and Baddeley, A. D., A Simple Measure of

Handwriting As An Index of Stress, Bulleting of the Psychonomic
Society, Vol. 11, No. 4, 1978, p. 245-246.
[16]. Doud, D., Some Pitfalls in Testimony Relating to Alcohol

Consumption and Handwriting, presented at the 34thd Annual
Meeting of the American Society of Questioned Document
Examiners, Colorado Springs, Colorado, July, 1975, 4 pp.
[31]. Hilton, O., Influence of Age and Illness on Handwriting

Identification Problems, presented a the 33rd Annual Meeting of the
American Society of Questioned Document Examiners,
Washington, D.C., July, 1975, 5 pp.
[17]. Anderson, G., Varying Effect of Alcohol on Handwriting,

presented at the 26th Annual Meeting of the American Academy of
Forensic Sciences, Dallas, Texas, February, 1974, 9 pp.
[32]. Downing, R. W., Ebert, J. N., Boruchow, J. K. and Valentine, J. H.,

Temporal Changes in Handwriting Size Level of Premorbid Social
Functioning and Intellectual Level During Treatment in Acute
Schizophrenics, Journal of Nervous and Mental Disease, Vol. 14,
No. 6, 1966, p. 526-533.
[18]. Hilton, O., A Study of the Influence of Alcohol on Handwriting,

Journal of Forensic Sciences, Vol. 14, No. 3, 1969, p. 309-316.
[19]. Puri, K. S., Effects of Intoxication on Handwriting, Journal of
Criminal Law and Police Science, Vol. 56, No. 3, 1965, p. 372-374.
[20]. Duke, D. M. and Coldwell, B. B., Blood Alcohol Levels and
Handwriting, presented at the joint conference of the American
Society of Questioned Document Examiners 23rd annual meeting
and the Royal Canadian Mounted Police Crime Detection
Laboratories, Ottawa, Ontario, August, 1965, 10 pp.
[33]. Todd, I., Abnormal Handwriting, Identification News, Vol. 16,

No. 2, 1966, p. 7-11.
[34]. Russell, W. R. and Espir, M. L. E., Cerebral Dominance and
Handedness Summary and Conclusions, Traumatic Aphasia,
Chapters 4 and 15, 1961.
[35]. Roberson, E.W., Fundamentals of Document Examination, NelsonHall Publishers, Chicago, 1991.
[21]. Obermedizibalrat, V., Types of Reaction in the Handwriting of

Persons Under the Influence of Alcohol, Kriminalistik, Vol. 18,
No. 1, 1964, p. 38-42.
[36]. Op. cit., Hilton, O.
[22]. Walton, J., Handwriting Changes Due to Aging and Parkinsons

Syndrome, Forensic Science International, Vol. 28, No. 3, p. 197214.
[38]. Alkan, N., Due to Aging Handwriting and Signature Changes,

Thesis: Forensic Medicine Specialization, Istanbul Medical Faculty,
Department of Forensic Medicine, 1996.
[23]. De Bonoso, G. R. D., Alterations in Handwriting Caused by

Alzheimers Disease and Abuse of Drugs, presented at the 51st
Annual Meeting of the American Society of Questioned Document
Examiners, September 1993, 14 pp.
[39]. Sassoon, R., Writers Cramp, Visible Language, Vol. 24, No. 2,
1990, p. 198-213.
[24]. Carney, B. B., A New Tremor In Handwriting, presented at the

51st Annual Meeting of the American Society of Questioned
Document Examiners, September 1993, 10 pp.
[41]. Op. Cit., Hilton.
[25]. Tull, P., Handwriting and Signatures of the Visually Impaired,

Journal of Forensic Document Examination, Vol. 5, Fall 1992, pp.
35-54.
[43]. Op. Cit., Huber.
[26]. Hooten, A, A Study of Dating Multiple-Sclerosis Onset by

Handwriting, Journal of Forensic Document Examination, Vol. 5,
Fall 1992, pp. 55-63.
[45]. Rothwell, J.C., The Physiology of Dystonia, in: Handbook of

Dystonia, Tsui, J.K.C. and Calne, D.B., Editors, Published by
Marcel Dekker, New York, 1995, pp. 59-76.
20
[37]. Op. Cit., Ellen, D.
[40]. Op. Cit., Conway.
[42]. Op. Cit., Harrison.
[44]. Op. Cit., Ellen.
Vol. 8, March 2005
[46]. Gowers, W. R., A Manual of Diseases of the Nervous System,

Publisher: Churchill Livingston, London, 1988, p. 656.
[47]. ibid
[48]. Rosenbaum, F. and Iankovic, J., Focal Task-Specific Tremor and
Dystonia: Categorization of Occupational Movement Disorders,
Neurology, 1988, vol. 38, pp. 522-527.
[49]. Vitti, R. J., Vingerhoets, F. J. G. and Tsui, J.K.C., Limb Dystonia,
in: Handbook of Dystonia, Tsui, J.K.C. and Calne, D.B., Editors,
Published by Marcel Dekker, New York, 1995, p. 143.
Botulusmis Toxin: A Review of Ten Patients, The Journal of

Neurologic Sciences, Vol. 16, pp. 2-11, 1999 (Turkish).
[67]. Brin, M.F., Iankovic, J., Comella, C., Blitzer, A., Tsui, J. and
Pulmann, S.L., Treatment of Dystonia Using Botulinum Toxin,
In: Kurlan, R., (Ed.), Treatment of Movement Disorders,
Philadephia, J.B. Lippincott, Chapter 6, pp. 220-225, 1995.
[68]. Yoshimura, D. M., Aminoff, M. J., and Olney, R. K., Botulinum
Toxin Therapy for Limb Dystonias, Neurology, Vol. 42, pp. 627630, 1992.
[50]. McDaniel, K.D., Cummings, J.L., and Shain, S., The Yips: A
Focal Dystonia of Golfers, Neurology, Vol. 39, pp. 192-195, 1989.
[69]. Tsui, J. K. C., Bhatt, M. and Calne, D. B., Botulinum Toxin in the
Treatment of Writers Cramp: A Double-Blind Study, Neurology,
Vol. 43, pp. 183-185, 1993.
[51]. Newark, J., Hochberg, F.H., Isolated Painless Manual

Coordination in 57 Musicians, J. Neuro Neruosurg Psychiatry,
Vol. 50, pp. 291-295, 1987.
[71]. Karp, B. I., Cole, R. A., Cohen, L. G., Grill, S., Lou, J. S., ad
Hallett, M., Long-Term Botulinum Toxin Treatment of Focal Hand
Dystonia, Neurology, Vol. 44, pp. 70-76, 1994.
[52]. Lockwood, A. H., Medical Problems in Musicians, New England

Journal of Medicine, Vol. 320, pp. 220-227, 1989.
[71]. Ranawaya, R. and Lang, A., Usefulness of a Writing Device in

Writers Cramp, Neurology, Vol. 41, 1136-1138, 1991.
[53] Jonathan B Strober, Writer's Cramp, at

http://www.emedicine.com/neuro /topic614.htm
[72]. Quinn, N., Aid in Writers Cramp, Neurology, Vol. 39, 14041405, 1989.
eMedicine,
[54] Ibid.
[73]. Koller, W. C. and Vetere-Overfield B., Usefulness of a Writing

Aid in Writers Cramp, Neurology, Vol. 39, pp. 149-150, 1989.
[55]. Tolosa, E. S. and Marti, M. J., Adult Onset Idiopathic Torsion

Dystonia, In: Watts, R.L. and Koller, W.C., Editors, Movement
Disorders. Neurologic Principles and Practice, New York:
McGraw-Hill, Chapter 31, pp. 433-441, 1997.
[56]. Sheehy, M.P. and Marsden, C.D., Writers Cramp: a Focal
Dystonia, Brain, Vol. 10, No. 5, pp. 461-480, 1982.
[74]. Op. Cit. Hilton, p.146.

[75]. Op. Cit. Harrison p. 308.
[76]. Op. cit., Buquet and Rudler.
[77]. Op. Cit., Harris.
[57]. Marsden, C. D. and Sheehy, M.P., Writers Cramp, Trends in

Neuroscience, Vol. 13, No. 4, pp. 148-153, 1990.
[78]. Op. cit., Waller.
[58]. Op. Cit., Strober.
[79]. Op. cit., Buquet and Rudler.
[59]. Zacher, A., Writers Cramp-Focal Dystonia or Psycogenic

Movement Disorder? - A Critical Review of the Literature,
Fortschr Neurol Psychiat, Vol. 57, pp. 328-336, 1989.
[80] Op. Cit., Harris.
[60]. Besson, J. A. O. and Walker, L.E., Hypnotherapy for Writers

Cramp, Lancet, pp. 71-2, 1983.
[82]. Op. Cit. Harrison p. 308
[81]. Op. Cit. Hilton, p.146.
[83]. Op. Cit., Harrison.

[61]. Ranawaya, R. and Lang, A., Usefulness of a Writing Device in
Writers Cramp, Neurology, Vol. 41, 1136-1138, 1991.
[84]. Op. Cit., Harris.
[62]. Quinn, N., Aid in Writers Cramp, Neurology, Vol. 39, 14041405, 1989.
[63]. Koller, W. C. and Vetere-Overfield B., Usefulness of a Writing
Aid in Writers Cramp, Neurology, Vol. 39, pp. 149-150, 1989.
[64]. Lees, A. J., Kleedorfer, B., and Foster, H., Treatment of Writers
Dystonia, Lancet, pp. 1525, 1989.
[65]. Op. Cit., Strober.
[66]. Gulsen, P. Y., Sahin, H., Hanagasi, H., Kaptanoglu, G., Yazici, J.
Gursoy, G. and Emre, M., The Treatment of Wriers Cramp With
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Vol.

FORENSIC DO CUM ENT EX AMINAT ION/Writers Cramp: 52-21-011023/050325

Presented at the Fifty-Fourth Annual Meeting of the American Academy of

and/or questioned text were homogeneously prepared documents

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The Forensic Scientist OnLine Journal

distinguishing it from illegible writing due to a lack of skill. Once the

aching spasm is accompanied by a tremor in the line quality.

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Vol. 8, March 2005

be administered to the responsible muscles since those especially in

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1. Biographical and demographic profiles were developed for each

upper extremities with symptoms was made during the rest,

4. Letter shapes, combinations, movements and arrangements in

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Vol. 8, March 2005

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The Forensic Scientist OnLine Journal

5.0 RESULTS AND DISCUSSION

11 (22%) were female patients and 38 (77%) were male;

19 (40%) patients also displayed tremors and one patient

5.2 Physiological Effects

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Vol. 8, March 2005

a conventional writing position verses writing on a black board were

sentences are reproduced at the end of the sentence (Figure 8) due to an

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The Forensic Scientist OnLine Journal

interpolated based on the limited amount of writing provided.

decline of legibility in the bottom group of sentences in Figure 12 than in

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5.5 Class Characteristics

tremor which may be used as a general standard when analyzing writing

Buquet and Rudler [76] give examples of three different types of

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5.7 Parkinsons Disease

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difference in legibility where it is difficult to isolate any class

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Vol. 8, March 2005

instrument, or whether an original or copy was used. Some of the retraced

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3. G: adjustment in terminal staff; narrow lower loop intersects

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Vol. 8, March 2005

11. g: Angular base; variation in terminal.

5. B: close resemblance, may be another letter. Agreement in terminal

12. Another example of inconspicuous features relative heights.

6. Length of base of s longer relative to ha combination.

In summary, there is evidence a handwriting comparison may be

7. Letter shape not repeated throughout all three sentences.

Another factor which may affect determining the presence of writers

Writer's Cramp

Writer's Cramp