Writer's Cramp

Vol. 8, March 2005

1Copyright 2005 Shunderson Communication, Inc. All Rights of Reproduction Reserved

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

WRITERS CRAMP:ITS AFFECT ON FORENSIC HANDWRITING EXAMINATIONS1

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 habitsof persons in the Turkish city of Istanbul is assessed. The effects ofwriters cramp on handwriting is assessed through a study of handwritingproduced by 49 persons suffering from the disease. The patients agesranged from 23 to 81 years. Samples were evaluated to determine at whatstage in the writing process writers cramp begins to affect legibility. Aseries of standard handwriting examination tests were applied to thesamples to determine limitations which might hamper a handwritingcomparison. The handwriting features in the samples were examined forevidence of class characteristics which might be unique identifiers ofwriting affected by writers cramp. The writing features in these sampleswere compared with handwriting produced by persons suffering from otherdiseases or related conditions. This comparison may help to characterizeand distinguish writing affected by different diseases. The affects andmisuse of special supports and Botulinum Toxin Type A (Botox)injections for improving legibility in writers cramp writing and how it canbe used to commit fraud will be discussed. The results of this study mayassist handwriting experts examining illegible handwriting evidence.

KEYWORDS: Writers cramp, handwriting, signatures, fraud, classcharacteristics.

1.0 BACKGROUND

1.1 Assessing Handwriting Evidence

Handwriting evidence, like other forensic evidence, must be assessedto identify any factors which might limit the potential of arriving atdefinitive conclusions during the primary comparison [1,2]. Thesestandard, a priori, handwriting tests [3-7] include: comparison of writingstyles (i.e. handwriting verses hand printing), comparison of text, imageclarity (affect of writing instrument, reproduction processes, legibility),natural writing movement (i.e. line quality), contemporaneity (questionedand specimens prepared within a similar time frame), writing materials(questioned and specimen prepared on a similar writing surface and withthe same writing equipment, i.e. ball point pen verse felt-tip marker, todistinguish image clarity), quantity of specimen and questioned material(adequate text available for comparison), writing conditions (influencesaffecting the writing), alterations (evidence of physical or chemicalchanges to the writing), common authorship (determine whether specimen 1Presented at the Fifty-Fourth Annual Meeting of the American Academy ofForensic Sciences, February 9-16, 2002, Atlanta, Georgia.2Istanbul University, Istanbul Medical Faculty, Department of Forensic MedicineIstanbul 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:[email protected] University, Cerrahpasa Medical Faculty, Department of Neurology.4Shunderscon Communications Inc., Ottawa, Ontario, Canada.

and/or questioned text were homogeneously prepared documentsattributed to one source).

Some of these tests (comparison of writing style and text) may bequickly applied at the time of submission. This will quickly determineif the case can be accepted and other tests applied or whether it shouldbe returned to the investigator. Subsequent test must be satisfiedbefore the primary handwriting comparison can proceed. The failureof the evidence to satisfy a particular test may halt the examinationprocess until such time as the problem is corrected. For examples thismay require the submission of additional specimens that containcomparable text, writing style, or were contemporaneous. Althoughit is common to request additional specimen writings when limitationsare identified in the original submission, this is not always possible.However, it may be more difficult to request specimen writingprepared 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 toidentify writing characteristics in handwriting produced under theinfluences of alcohol and/or drugs and if these characteristics can beused in a handwriting examination and comparison. Other studies [22-34] have attempted to identify handwriting characteristics unique todifferent diseases and what affect these modifications have on ahandwriting comparison. It is valuable to apply standard tests whichcan identify when, and by what means, a handwriting may have beenaffected by external and internal factors. This information may helpto assess limitations which might affect any subsequent handwritingcomparison. In some cases the investigator will advise the scientist ofconditions under which the questioned and specimen material mayhave been prepared. However, there are some conditions which do nothave specific associated physical disabilities such as persons who arevisually impaired, or suffer from Parkinson or Alzheimers disease.Psychiatric, neurological and orthopedic diseases are considered to bethe principal health related factors affecting the greatest change inhandwriting. While some of these diseases influence the handwritingtexturally, others cause formal changes in the writing and still othersinduce both textural and formal changes in the writing [35-38].

Writers cramp is a lesser known health condition that does notdisplay the debilitating physical and neurological affects attributed tosuch diseases as Parkinson or Alzheimers. Consequently it has notreceived the same attention for its affect on handwriting. Writerscramp is a phrase liberally used to refer to a cramp in the hand whichaffects the ability to write legibly for any duration, without someperiodic resting. The use of the term cramp, which denotes atemporary condition, usually occurring after strenuous production,may be inappropriate because the disease has been found to bepermanent for those who suffer from it. Writers cramp, however, isa common disease which afflicts many persons and may develop as aresult of the writing process [39]. This disease is not reported instandard document examination reference texts [40-44] and thereforeis not widely recognized, or assessed, during routine handwritingexaminations. Writing which is illegible may potentially disclose classcharacteristic associated with writers cramp writing thereby

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2 Copyright 2005 Shunderson Communications, Inc. All Rights of Reproduction Reserved

distinguishing it from illegible writing due to a lack of skill. Once thecause of the illegible writing style has been established, it may be possibleto conduct a handwriting comparison. There are no validated studiesidentifying handwriting characteristics due to writers cramp nor how sucha condition might affect a handwriting comparison. Writers cramp is infact a form of task-specific focal dystonia (inflection, repeating motionsand permanent contractions that lead to postural disorders) which maydramatically influence handwriting legibility.

This study assesses handwriting samples prepared by persons sufferingfrom 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 recognizeand identify the causes of abnormal handwriting and may providemethods of conducting a handwriting comparison on such samples.

1.2 What Is Writers Cramp

Writers cramp affects the upper extremities of the human body andis a task-specific extremity focal dystonia [45]. Focal dystonia of the handaffects tasks that require fine motor movements. The symptoms mayappear only during a particular type of movement, such as writing orplaying the piano, but the dystonia may spread to affect many tasks. Twotypes of writer's cramp have been described: simple and dystonic. Peoplewith simple writer's cramp have difficulty with only one specific task. Forexample, if writing activates the dystonia, then within writing a few words,dystonic postures of the hand begin to impede the speed and accuracy ofwriting. In dystonic writer's cramp, symptoms will be present not onlywhen the person is writing, but also when performing other-task specificactivities, such as shaving, using eating utensils, applying make-up [46].In 1/3 of patients with the simple type of writers cramp, there is aprogression toward the more acute dystonic type, but there might not beany 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 fingersand thenar muscles shortly after the writing process has begun (generallyafter a few sentences). This rigorousness gradually spreads back towardsthe wrist, forearm, biceps, and shoulder muscles throughout the durationof the writing process. A persons writing hand may be affected by manyconditions, arthritis, tendon problems, and muscle cramps, some of whichmay cause pain. Carpal tunnel syndrome is the result of nervecompression. Writer's cramp is often mistaken for over-use conditions,but they are unrelated problems. Over-use syndromes or repeated-usesyndromes are usually characterized by pain, whereas writer's cramp ismore likely to cause problems with coordination. Focal hand dystonia isresponsible for only about 5% of all conditions affecting the hand. However, there are instances when the involuntary rigorousness may beaccompanied by pain, which forces a halt to the writing process andtherefore the cause of the pain. When handwriting is restarted after aperiod 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 memberswere found to also suffer and demonstrate similar symptoms. Writerscramp is usually unilateral and may turn to a segmental andgeneralized dystonia by spreading over time [47-49]. Dystonia caseshave also been reported to occur during other activities related tocoordination and use of the hands, i.e.guitar, trumpet or viola playingand golf [50-52]. The disease, however, remains prominent amongstpersons in occupations involving excessive handwriting such asteachers, students, accountants and bank personnel. Job activities suchas tailors and shoe makers also experience the occurrence of writerscramp. Those persons within these groups repeatedly use their upperextremities more frequently, and they are often determined to havesome trap neuropathies and muscular-joint diseases except for writerscramp [53].

In writers cramp, pen holding generally becomes tight andexaggerated due to some symptoms that start as soon as taking the penin hand or after writing out some words. Separately, some cases likewrist hyper-extension, hyper-flexion, forced supination or pronationare encountered. Handwriting shows a saltatory, scattered andirregular characteristic. In the late periods of the disease, handwritingcannot continue after a few lines and becomes illegible (Figures 1 to3). Patients can classically write on the black board. Some of themwill support the affected arm with the good arm in order to write onthe black board or may use a writing instrument that possesses abroader delivery point for the ink, thereby requiring less movementsto form letters but also affecting the detail and size of writing prepared.Some patients utilize the unaccustomed hand to write when writerscramp becomes a factor. In 25% of patients trying to write with theirunaccustomed hand, writers cramp will also develop over the courseof time [54-57].

Symptoms common to simple writer's cramp include excessivegripping of the pen, flexion, and sometimes deviation of the wrist,elevation of the elbow, and occasional extension of a finger or fingerscausing the pen to fall from the hand. Sometimes the disorderprogresses to include the elevation of shoulders or the retraction of thearm while writing. Interestingly tremor is usually not a symptom ofwriter's cramp. The symptoms of writers cramp usually begin betweenthe ages of 30 and 50 years old and affects both men and women.Cramping or aching of the hand is not common. Mild discomfort mayoccur in the fingers, wrist, or forearm. A similar cramp may be seenin 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 isbecause muscle contractions interfere with normal function. Featuressuch as cognition, strength, and the senses, including vision andhearing are normal. While dystonia is not fatal, it is a chronic disorderand prognosis is difficult to predict.

Related problems associated with over-use of the hand aredifferent, and more commonly occurring, than writers cramp.Over-use can be quite painful, but it is still unclear as to where thepain is coming from the location of the pathology is unclear. Usingdifferent movements and muscles as well as better posture may reducestrain on the hand. Writers cramp is not to be confused with carpaltunnel syndrome which may involve a pinched nerve in the carpaltunnel of the hand. Most persons suffering from carpal tunnelsyndrome develop symptoms in both hands.

There is a condition called primary writing tremor in which thehand shakes (consistently in one direction) during writing. Whetherthis tremor is closely related to either writer's cramp or essentialtremor is unclear.

1.3 Causes of Writers Cramp

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The reasons for writers cramp are not completely known, however,heredity and peripheral factors are considered to be responsible. Thecause of writer's cramp is believed to be due to abnormal functioning ofthe basal ganglia, which are deep brain structures involved with the controlof movement. The basal ganglia assists in initiating and regulatingmovement. What goes wrong in the basal ganglia is still unknown. Animbalance of dopamine, a neurotransmitter in the basal ganglia, mayunderlie several different forms of dystonia, but much more research needsto be done for a better understanding of the brain mechanisms involvedwith dystonia. Cases of inherited writer's cramp have been reported,usually in conjunction with early-onset generalized dystonia, which isassociated with the DYT1 gene [58].

Some investigators have proposed that there is a psychiatric basis forthe disease, but the fact that patients do not undergo hypnosis or otherpsychiatric remedies points to the neurological roots [59,60]. Althoughthere are no demographic studies accurately recording the occurrence ofwriters cramp around the world, it has been found to commonly occur inthe Turkish population and is believed to develop in persons who writeexcessively, including repeatedly overwriting entries. This has lead toearly diagnosis of the disease. Many persons suffering from the disease tryto reduce its affect by adopting different writing methods (i.e. holding thepen with their thenars and making use of special pen holders [61-63], orto use their unaccustomed hand which does not suffer from the associatedmuscle spasm. Examples of mechanical pen holders developed to assistsufferers of this disease when writing signatures or extended text arepresented in Figures 4 and 5.

1.4 Treatment

Treatment for dystonia is designed to help lessen the symptoms ofspasms, pain, and disturbed postures and functions. Most therapies aresymptomatic, attempting to cover up or release the dystonic spasms. Nosingle strategy will be appropriate for every case. The goal of anytreatment is to achieve the greatest benefits while incurring the fewestrisks. It is to allow the patient to lead a fuller, more productive life byreducing the effects of dystonia. Establishing a satisfactory regimenrequires patience on the part of both the affected individual and thephysician. The approach for treatment of dystonia is usually three-tiered:oral medications, botulinum toxin injections, and surgery. These therapiesmay be used alone or in combination. Complementary care, such asphysical therapy, may also have a role in the treatment managementdepending on the form of dystonia. For many people, supportive therapyprovides an important adjunct to medical treatment. Although there iscurrently no known cure for dystonia, we are gaining a betterunderstanding of dystonia through research and are developing newapproaches to treatments[64].

A multitude of drugs have been studied to determine the benefit forpeople with writer's cramp, but none appear to be uniformly effective. Inabout 5% of persons affected symptoms improve with the use ofanticholinergic drugs, such as Artane (trihexyphenidyl), Cogentin(benztropine), but the degree of improvement is usually unsatisfactory andat the expense of side effects [65].

Since the 1980s botulinum toxin (BTX) has been used on focaldystonias 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 ispresent. Every muscle in the hand plays a specific role in normal handmovement, unlike the neck in which the structure of muscles is morecomplex, and several muscles work together to achieve movement.Therefore if the appropriate hand muscle is injected at the correct dose, theBTX will weaken that muscle enough to relieve symptoms withoutaffecting the overall function of the hand. The toxin causes stroke, byproducing chemo-denervation in the patient thereby effectively preventingthe acetyl colin release in muscle nervous connections. The drug needs to

be administered to the responsible muscles since those especially inthe fingers, thenars and forearms contract and impede handwriting.However, overdoses or increased doses of the toxin may result in sideeffects such as an increased muscle weakness, affecting muscle andsubsequently control of the writing instrument. Deficient doses mayresult in only minor reduction in muscle relaxation. A suitable dosemust be determined and this may require some trial and error. BTXmay last 3-4 months and as many as 8 months to one year in somereported cases and pending the dosage. Ancillary side effects includepossible temporal muscular weakness in the injected tissue [66-70].Although this treatment is not effective for all people, significantimprovement in writing and reduction of pain is seen in at leasttwo-thirds of those persons treated.

Since writer's cramp generally affects only a local area of the armunder certain activities such as writing, surgical treatments are notusually considered. The conservative approach to treating writer'scramp includes minimizing writing with the affected hand and usingother methods of communication such as typing or dictating. Using atape recorder to take notes may be helpful. Notes can then betranscribed later in a less stressful situation. Physical methods to helphand dystonia include learning to hold a pencil differently or using aspecial wax mold to help hold a pencil. The trick to reduce dystoniasymptoms in the hand when writing at a desk is to use the shoulder andarm rather than the wrists and fingers. Sometimes a minimal change inwriting 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 theopposite hand. This is referred to as mirror dystonia. In somecases, writing with the left hand will trigger symptoms in the righthand, or vice versa. This "mirror dystonia" is a clear indication thatdystonia of the hand is a motor problem stemming from the brain, nota problem with the hands themselves. Physical therapy may help toimprove local arm flexibility (diminished by dystonic spasms andstrength of the unaffected muscles).

2.0 PURPOSE

To assess handwriting samples produced under the influence ofwriters cramp for evidence of:

S the stage at which the handwriting legibility begins todeteriorate;

S evidence of handwriting class characteristics associated withwriters cramp;

S to compare handwriting affected by writers cramp with otherdiseases affecting handwriting;

S whether a handwriting comparison can be conducted on writingaffected by writers cramp;

S to compare handwriting affected by writers cramp with writingprepared 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, Turkeywith pre-diagnosed writers cramp or a combination of writers crampand tremor were evaluated between 1997 and 2001.

3.2 Methods of Evaluation



1. Biographical and demographic profiles were developed for eachpatient 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 otherhandwriting disorder, writing characteristics.

2. Electromyocgraphic and kinetiologic features of patients and theirrespective short and long term handwriting activities were assessed.Principally, the presence of radiculopathy and trap neuropathy waselectromygraphically 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 theexistence of any spontaneous and involuntary motion wasinvestigated. Additionally, we reached for some evidence onbehalf of writers cramp by means of rhythmic changes that occurduring long-term handwriting.

4. Letter shapes, combinations, movements and arrangements ineach of the handwriting samples were visually andmicroscopically 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 thatfits 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 sufferingfrom 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 thefirst 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 producedunder normal conditions. The example below is from the same writer following treatment with Botox.

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: 11 (22%) were female patients and 38 (77%) were male;Ages: 23 to 81 years with a mean of 47 years of age;Education: High school, university graduates or students;Professions: Architects, musicians, state officials, teachers, accountants,

bank personnel or doctors.Length ofDisease: Subjects suffered from writers cramp for periods ranging

from 2 months to 11 years with a mean average of 3.8years;

DominantHand: All patients suffered from writers cramp in the dominant

hand. In two subjects (4%) this was the left hand with the

remaining 47 (96%) suffering this disease in the right hand.

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

had a history of cerebrovascular disease. Another patienthas diabetes mellitus, and one patient had multiplesclerosis. There was also one patient with a history ofbilateral trauma.

5.2 Physiological Effects

Patients demonstrated difficulty in handwriting, pain in the influencedextremity, convulsions, tremors, writing deformations, and writing andsigning disabilities. Patients held the pen tightly and used excessivedownward pressure when writing. Most patients had adopted the usedimensionally wider pens, supported the affected hand with theunaccustomed hand, adopted the use of the unaccustomed hand to write,disclosed postural changes in the fingers and hand of the affected handwhen 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 wereverified, with the disease affecting writing more at the desk than whilestanding at a black board.

In 11 patients similar difficulties attributed to writers cramp weredefined in other activities such as eating and shaving. Polyneuropathy wasdetected in the diabetic patient.

5.3 Effects on Handwriting

In 26 (53%) patients handwriting was initially normal but becamedeformed after one or more lines of writing. In 23 (47%) patients thewriting was deformed from the beginning of the writing process andworsened with increased writing.

In 21 (62%) of 34 patients, who had been suffering from writerscramp for less than 5 years, a normal writing style was observed thatgradually 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 sufferingfor longer than 5 years, 4 (27%) of 15 patients had writing styles thatbegan normally, and gradually became deformed with increased writingwith the other 11 (73%) displaying a deformed writing style from thebeginning of the writing process (see Figure 6).

7 (37%) of 19 patients displayed tremor in association with writerscramp which began as a normal writing style and then became deformedwith time. The remaining 12 (63%) patients demonstrated both tremor anda deformed writing style from the outset of the writing process. Tremorwas 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 apuerile characteristic. Of this group 2 (25%) patients in the group had anentirely deformed writing style at the beginning of writing and 6 (75%)displayed a writing style that was initially normal becoming increasinglydeformed with time. 5 (63%) patients within this group suffered for lessthan 5 years and the remaining 3 (37%) suffered for over 5 years.

5.4 Legibility

Legibility, like many terms used to describe handwriting, is asubjective assessment [74,75] that has never been scientifically validatedbased on a standard criteria on what is legible writing and what is not. Itis generally accepted that any writing which cannot be deciphered orwhose letters are not recognizable and diverge to such an extreme awayfrom a core shape, might be labeled as illegible. It is unclear what the basisis for labeling a handwriting as legible or illegible. Is this assignmentbased on legibility or readability? This is where the subjectivity becomesa factor restricting determination of a validated standard. However, if thewriting is considered only within the subject and not within a larger groupit may be possible to demonstrate changes in legibility relative to differentwriting samples. This is the approach that will be used when assessing theeffects of writers cramp on legibility. Evidence will be sought that showschanges in character construction which might signify the onset of a lossof legibility due to the disease in the ability to decipher the text. It is notpossible at this time to assign a numerical value to this change in legibilitywithin or between writers. Due to the absence of any validated standardsidentifying what is legible and what is illegible writing, there may bedisagreement between different document examiners looking at the sameevidence. Therefore the handwriting samples will be examined forevidence of changes in the formation of letters to determine if thesechanges are gradual or rapid and to what degree these letters may bedeciphered.

In Figure 5 a sample sentence has been handwritten three consecutivetimes without a break between entries.. Although the entries wereprepared 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 aninability to decipher all of the later writing. Therefore it is difficult toobserve changes in legibility between the same letter prepared at differentstages in the writing process. The letters at the beginning of the sentencegenerally disclose shapes more consistent with copy book forms whilesome of the letters at the end of the sentence cannot be deciphered (Figure9). This suggests the progressive deterioration of legibility.

In the first sentence it might be argued that the legibility of the writingbecomes harder to decipher after the t (Figure 8). This would supportprior profiles on writers cramp writing which states that one symptom ofwriters cramp is a decrease in the legibility of the writing soon after a fewwords have been written. It may be possible to confirm this based on thelegibility at the end of the first sentence verses the beginning of the nextand so on. Based on the literature a person suffering from writers crampmight begin to write legibly (following a period of inactivity) followed bya reduction in legibility as the writing process continues and at differentrates and degrees based on the person and the extent they are afflicted withthe disease. If a new sentence is started the decline in legibility shouldcontinue. It is difficult to decide whether the first 5 letters of the secondsentence 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 sentencecompared to the first (Figure 10). This may suggest there was no restbetween writing each sentence. It may also be argued that both the Bg/y and last letter of the first word are of similar legibility suggesting abreak in writing. It is difficult to draw conclusions based on the limitedamount of writing sample provided.

Additional handwriting samples where repeated sentences aregenerated may identify class characteristics unique to persons sufferingfrom writers cramp by which document examiners can recognized theoccurrence of this disease in handwriting evidence. The change in theletter movement from smooth, rounded strokes and no angular disruptionsfrom the intended path to a letter movement that has angular disruptionsfrom the intended path, may be a better gauge of the change in legibilityas opposed to assigning legibility based on the ability to read the text.

Some examiners might argue that there may be some letters at the endof the second sentence which might be more recognizable (and thereforemore legible) than the same letters at the end of the first sentence. Sincethere is no information on whether a rest period occurred between writingsubsequent sentences, it is not possible to determine how time andlegibility are affected in respect of the amount of writing prepared. It isunclear if writers cramp is cumulative and does not entirely recede duringperiods of rest, nor how the length of the rest period might reduce theaffects of the disease on the next writing activity.

In the third sentence (Figure 11) there is evidence that the last twoletters of the first word are less legible than the same letters in the first twosentences. This again may suggest a rest period between the preparationof the second and third sentences. Here the legibility begins to diminishafter the formation of the g which may suggest a progressive increase inthe stage of the writing at which the writing movement deteriorates. Themore rapid decline in legibility based on the position in the sentence maybe due to the inability of the rest period to completely reduce the affectsof writers cramp to the same degree as in prior periods of inactivity.Based on these limited samples it may not be possible to draw broadconclusions, however, there is evidence that handwriting qualitydiminishes soon after the writing process begins, confirming the literaturein regards to the effects of writers cramp on writing. Whether writinglegibility improves after periods of inactivity and the relationship betweenthe 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 withthe 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) whichare 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 theletters 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 continuousdecline 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 mybest handwriting. It is difficult to compare and comment on any degreesof differences in legibility between the first three sentences in Figure 5A.In each sentence there are examples of the same letter which display amore conventional shape than in other sentences, including the h andd in the last word of the third sentence. This is an example of a chronicsufferer of writers cramp. In Figure 12, writing samples for Figure 1 andFigure 5A are compared. There is evidence to suggest that the writings inFigure 1 are less legible than those in Figure 5A. There are no goodexamples of recognizable conventional letter shapes throughout the threesentences as occurs in Figure 5A. This may be due to the writer in Figure1 suffering from the disease longer that the writer of the samples in Figure5A.

This example demonstrates the variation in the onset of declininglegibility as reported in the literature. There is more agreement in the

decline of legibility in the bottom group of sentences in Figure 12 than inthe top group, where the most dramatic decline begins with the last word.In the absence of information on how long this person has been sufferingfrom the disease it is not possible to compare the legibility of the lettershapes in this example with that in Figure 1 where the decline in legibilityis more dramatic. No conclusion can be drawn to show a relationshipbetween the stage in the writing process at which legibility declines versesthe length of time a person has been suffering from the disease. It mightnot be possible to distinguish this sample as evidence of a person sufferingfrom writers cramp verses a person with no affects of a disease but whopossesses poor writing skills.

In Figures 2 and 3 the letter construction is poorer from the outset ofthe writing, suggesting again agreement with the literature that somesufferers of writers cramp demonstrate dramatically diminished legibilityin their writing almost immediately upon putting pen to paper. Examplesof different writing from five persons suffering from the disease are shownin Figure 13.

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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 bottomexamples (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 stageswhen 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 identifiedin handwriting which are common to a group of writers. Determining theexistence of class characteristics requires the examination and comparisonof many handwriting samples from a representative pool of writers withinany one group. In the present study only a few examples of writing can beconsidered, therefore it may not be possible to identify class characteristicsunique to writing produced by persons suffering from writers cramp. However, it is possible to inter-compare these writing samples with writingsamples prepared by persons affected by a number of health factors.

5.6 Tremor

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

tremor which may be used as a general standard when analyzing writingsuspected to be affected by health related condition [Figure 14]. Thehandwriting samples in Figures 1, 2, 3 and 5 to 7, were examined for thepresence of tremor in the strokes.

In Figure 14 different examples of tremor are clearly shown. Theexample of tremor due to senility from Harrison at the bottom is consistentwith Buquet and Rudlers last example. There are no repeating re-directions in this example compared with those in the example foralcoholism or Parkinson.

In the samples of writing affected by writers cramp, tremor is not soeasily identified and may in fact be confused with a slow writingmovement associated with the affects of the disease (Figure 15). Againthere are no examples of the repeating misdirections observed in theexamples in Figure 14.

Figure 14: Examples of tremor (Courtesy Buquet and Rudler [76]) and an example of extended writing by a person suffering from senility (CourtesyHarrison [77]).

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Figure 15: The handwriting examples produced under the conditions of writers cramp show few decisive examples as evidence of tremor, whencompared 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 withtremor;

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 bypersons suffering from Parkinson disease with samples of handwritingaffected by writers cramp. The legibility of the writing in the Parkinsonpatients is better than that produced under writers cramp. The rapidchange in legibility may be the single most identifiable characteristicdistinguishing writers cramp writing from that of writing affected byother factors. Walton [78] reported from his study that waver was mainlyfound on long downstrokes or on the sides of lower case letters. Thecomparison sample of writers cramp demonstrates the degree of



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 writingprepared under writers cramp (bottom).

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difference in legibility where it is difficult to isolate any classcharacteristics unique to one letter movement.

5.8 Intoxication

Figure 17 shows a comparison of writers cramp writing with thatproduced by persons under the influence of alcohol. Writing producedwhile intoxicated has been characterized by an increase in the size of theletters compared to writing produced by the same person while sober.There is also a decrease in legibility. These distortions result in letters ofvarying size and shape which fall outside the boundaries of the writingarea. Writers cramp writing does not show dramatic increases in sizetogether with distorted movements. Writers cramp may restrict thewriters movements preventing the creation of wild distortions. Thewriting, 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 recognizedstandard letter formations. Therefore, while legibility declines in bothwriters cramp writing and writing while intoxicated, the decline inwriters cramp writing stays within the control of the writer who is able toplace letters within the areas of interest. In the example in Figure 17, theleft side is more legible than that on the right. This may be related to thedegree of alcohol consumption in which case the writer on the right wastotally intoxicated.

5.9 Handwriting Comparisons

Handwriting examinations and comparison must be based on accepted,validated methods. This requires research to identify all those possibleexternal and internal conditions which may affect writing and therefore theability to conduct a handwriting comparison. Studies such as this one onwriters cramp draw attention to possible causes for changes inhandwriting and may assist the expert in recognizing and distinguishingconditions under which writing was prepared. However, it is not clear asto whether a handwriting comparison can be conducted on writingproduced by persons suffering from writers cramp. Let us considerFigures 1 and 5, respectively. Both these examples display repeated linesof writing each purported to have been prepared by one writer. In a realcase scenario the forensic document examiner would be expected todemonstrate the common origin of specimen writing that was submitted ascollected specimens and not prepared in front of a witness. We can treatthese two examples in the same way, as collected, unknown andunquestioned writings to be used as specimens.

Standard a priori tests [80] are applied to handwriting evidence toidentify any limitations which might prevent a handwriting comparison orwhich might affect the strength of opinion assigned following ahandwriting comparison. These tests were described at the beginning ofthis paper with reference to the literature. Some basic criteria must be metbefore a handwriting comparison can be conducted, whether to confirmcommon source of specimens or to compare questioned with specimenwritings. The tests may be applied in an order such that the successfulcompletion of one test permits the next test to be applied. At any giveninstance, failure to satisfy a test may disqualify a handwriting comparisonand may necessitate the investigator resubmitting the evidence withadditional specimens meeting the criteria for comparison.

Writing style and comparable text are two tests which can be quicklyapplied to handwriting evidence and may be used as a preliminary screenat the processing stage of any submission of evidence for a handwritingexamination. The failure to satisfy both tests may disqualify thesubmission before any further tests are applied. If we consider writingstyle we are determining whether the writing to be compared was preparedin the same style, i.e. hand printing with hand printing and handwritingwith handwriting. In Figure 1, the three lines of writing disclosedisconnected and connected letter combinations (Figure 18). Some of the

letters may be lower case hand printed forms as seen with the h and thet (1), while other letters resemble disconnected printed forms with somecursive components s (2) or cursive writing, possible g(3) andpossible upper case B (4) written as a lower case letter. These lettersshow the characteristic features associated with cursively formed letters.There are also examples of connected letter combinations as seen in thepossible ge and ng (5). The h in the third example (1b) shows aloop in the first staff which may be consistent with cursive writing ratherthan hand printing. In Figure 5 (Figure 18) there is less variation in thewriting style which shows a consistent cursive writing style. In summarythere is evidence that all three sentences were prepared with the samewriting style comprising disconnected cursive and hand printed letters andconnected letter combinations.

Comparable text requires that the same letters exist in the differentdocuments or bodies of writing to be compared. While some letters suchas the a, d and g may demonstrate an internal consistency aroundthe body of the a, it is still not possible to conduct a completehandwriting comparison because these are different letters with other, non-comparable components. Therefore, the same letters and possibly lettercombinations must be demonstrated in the different writings to becompared; otherwise, it will not be possible to determine similarities ordissimilarities in letter construction. In Figures 1 and 5 there is evidencethat each sentence is a duplication of text and therefore there iscomparable text between the three sentences to allow for a comparison ofwriting movements (Figure 18).

Legibility may also be considered as an initial screening test beforeother tests can be applied to the evidence. Legibility may also be testedunder the test for comparable text. If we refer back to Harris and Hilton[81,82], what may appear illegible, may, with time, slowly become morelegible as the scientist becomes familiar with the writing and deciphers thetext. It may be possible to identify deliberate disguise presented asillegible writing but it may not be possible to assign a naturally preparedwriting as illegible without representative specimens of writing preparedat different times. There are no validated standards upon which todetermine what is considered illegible writing because of the subjectivityof assessment. The literature states that a writer can prepare a text that isof less artistic quality than what they are normally capable of doing [83]but that same writer cannot write a more artistic or skilled writing thanwhat they are capable of. This again has not been validated but has beenreported in different literature and is part of the training received forhandwriting examination. In Figure 18, the entries in Figure 5 may beconsidered more legible than those entries in Figure 1 based on the easeof deciphering the two texts. Therefore this assessment may requireadditional time to determine and then it still remains a subjectiveassessment. If comparable text is a criteria test for conducting ahandwriting examination then, it therefore must also require that the textbe legible or resemble a recognized alphabet such that the letters can beidentified and therefore compared. While it may be possible to look forsimilarly formed writing movements to satisfy the condition of comparabletext, if these movements can not be attributed to a letter form, no matterhow divergent from the copybook model, it may not be possible to confirmthat two similar formed movements, presumed to be letter formations arein fact the same letter. This also would take into account internalconsistency between letters of similar core structure such as the a, d,g, and p. However, as stated earlier, while some comparisons may beconducted on these similar constructed letters, there are other componentswhich cannot be compared. Therefore two illegible movements, definedas not being recognized to match any alphabet letter shape, may showsimilarities, but may in fact be two different letters. In Figure 18 thebottom example is not illegible as the letter shapes can be deciphered andtherefore an assessment for comparable text is possible. In the topexample, however, some of the letters are less decipherable as a result ofthe progressive affect of the disease of writers cramp. Examples fromFigure 1 have been isolated and shown in Figure 19. It must be kept in



Figure 18: Examples of comparable writing style and text in samples handwriting from Figure 1 and 5 under the influence of writers cramp. Numberscorrespond to letters and letter combinations repeating in the specimens.

B g a e ? ?

1

2

3

Figure 19: Selected letters from Figure 1 together with assigned decipherment of the letter. Attempt to demonstrate whether all the letters in the exampleare decipherable and therefore can demonstrate comparable text necessary for a handwriting comparison.

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mind that these examples were prepared in Turkish and the expert shouldbe familiar with the written and spoken language before attempting toconduct a handwriting comparison. The Turkish written language is basedon the Latin alphabet. A letter has been assigned as a possibledecipherment together with examples from the three sentences todetermine if there is evidence of common text.

It may be possible to follow a writing movement and demonstrate thatit is reproducible without assessing what that movement represents. If thewriting is illegible then it may not be possible to identify the writing styleor the presence of comparable letter shapes. However, it is difficult toassign an optimum condition as to what is illegible and how all otherwriting measures against this optimum standard. As the literature stated,illegible writing may become more legible as the reader becomes familiarwith the style. In Figure 1 (Figure 19) there are some letters which cannotbe deciphered as representing any standard letter shape and thereforeconfirmed as the same letter form in all three sentences. Thesemovements, however, show some agreement. Is this then evidence that thesame movement was prepared despite an inability to determine what letterit represents? In the last two columns of Figure 19, the letters are notdecipherable and their shapes vary between the three sentences. If theletter can not be deciphered and attributed to a particular recognized formit is not possible to assess natural variation around a core writingmovement. These are examples of limitations which may ultimately affectthe primary handwriting comparison and must be taken into consideration.The top example in Figure 19 disclosed similar text at the beginning ofeach sentence which may allow for a comparison, while the latter text isnot entirely decipherable. Subsequently, as is the case in other situations,such as suspected disguise and forged writings, some of the entries may beshown to be comparable and can be assessed while others must bedisregarded. This does not preclude conducting a complete handwritingcomparison on those entries which have been retained. In this exampleparts of the writing may allow for a handwriting comparison but may notnecessarily allow for the scientist to extrapolate the results of thiscomparison to include the remaining entries at the ends of these sentences.There are also examples of letters which do not resemble standard letterforms but their formation has been duplicated, and therefore these may becomparable (Figure 19). Therefore there is evidence of legible writingfeatures which allows for a comparison of the same letter in the differentsentences.

Image Clarity refers to the condition of the image submitted forexamination. Genuine documents are preferred over photocopies or otherform of reproduced document. However, even with original documentsthere may be limitations affected by the writing instrument. While it hasnever been validated, ball point pen writing instruments are considered tocapture more writing movements on paper than any other writinginstrument. Felt-tip marking instruments, due to the fluid and diffusivenature of the ink, will diffuse horizontally and vertically upon contact withthe paper, and therefore do not retain the shape of the writing movementsto the same degree as the more viscous ball point pen inks. Image claritywill impact on the assessment of writing movement to determine if thewriting was naturally prepared. There has been considerable discussionon whether handwriting comparisons can be conducted from photocopiesor digital images [84]. In our two examples we are not dealing withoriginal documents and therefore it was difficult to confirm the writinginstrument used and whether it may hamper the assessment of all writingcharacteristics. Image clarity may be measured against the detail capturedby a ball point pen which can be microscopically observed. Althoughthere have been no validation studies determining the degree ofhandwriting detail that can be captured and clearly defined on a documentfrom different writing instruments, ball point pens are considered theoptimum writing device. Examination for detail and clarity may includepen ball striations, distinguishing two retraced or superimposed strokes,or other fine minutia. In Figure 19, the top example displays more detailcompared 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 retracedstrokes in the bottom example are not clearly distinguishable compared tothe top example. While the fine detail in the bottom example of Figure 19is not as clear, many writing movements are clearly defined and should notaffect the handwriting comparison.

Writing Movement refers to evidence that the entries were naturallyprepared and therefore demonstrate genuine examples of the writers letterformations. Naturally prepared writing is a core requirement for anyhandwriting comparison. In the absence of naturally prepared writing itmay not be possible to arrive at any conclusion as to authorship. Naturallyprepared writing is characterized by evidence of a smooth, uninterruptedpath in the written stroke, tapered terminations at the ends of strokes andgradations in pen pressure. There are no validation studies to confirmwhether all three criteria must be identified before a handwriting samplemay be determined as naturally prepared. There are examples in theliterature of these characteristics as a reference for determining thepresence of naturally prepared writing. In Figure 20, examples fromFigures 1 and 5 disclose evidence of tapered terminations at the ends ofstrokes (1), smooth line quality (2), and gradations in pen pressure (3).Similarly there are also examples of uneven line quality, where the strokesare not smooth and continuous (4). However, other features such as blunttermination, which indicate a slow writing movement and which may ormay not be natural to the writer, were not found in either example. Alsouniform pen pressure which cannot always be distinguished when a broadfelt tip marker is used, was also not found in either of the examples.

This examination is of particular importance when dealing withpossible writers cramp writing. The writing may appear to be illegiblebut this may be a natural illegible result of the disease and not due to adeliberate attempt at disguise. It is important to note that in both examplesthe line quality periodically displays interruptions in the smooth path ofthe stroke, there are still associated examples of tapered terminations. Thispresents a contradiction which has not been thoroughly validated. Thereare two conflicting pieces of information, indicative of two writingconditions, one natural and the other unnatural. The occurrence of boththese characteristics may be considered a class characteristic of writerscramp writing. Here the writing may appear illegible, and stroke linesuneven, but there is also associated tapered terminations.

There is evidence that the writing was naturally prepared butinfluenced by some uncontrolled health condition.

Contemporaneity: This refers to whether the writing to be comparedwas produced within the same time frame. In this example the entrieswere purportedly written one after the other and there is no informationsuggesting each successive entry was prepared at a different time. Thisassessment arises when comparing questioned with known writings whichmay have been prepared several years apart.

Alterations: There is no evidence that the entries were altered. Thisassessment should be addressed for any handwriting examinations in aneffort to explain what has occurred during the preparation of thedocument.

Conditions of Preparation: This is what is being assessed anddefined, whether writers cramp writing can be identified anddistinguished from other writing conditions that may alter a personsnatural writing movements. One problem is to distinguish illegibility dueto disguise and that due to as a result of an illness.

Common Authorship: As mentioned this must be determined forspecimens submitted as standards for comparison with a questioneddocument. This becomes important when the specimens provided werenot witnessed but are unquestioned and unknown. In an attempt todetermine whether a handwriting comparison can be conducted on writerscramp writing we are using the repeated writing from Figure 1 to inter-compare for evidence of common authorship. To conduct such acomparison the same a priori tests applied to questioned and knownwriting for the purposes of comparison must be applied to known writingfor the purposes of assessing for common authorship. We will consider



Figure 20: Examples from Figures 1 and 2 showing tapered terminations (1), smooth line quality (2), gradations in pen pressure (3) and uneven linequality (4).

Figure 21: Examples of repeated letter formations and inconspicuous features found in common in Figure 1 of writing produced under the influenceof writers cramp.

each of these examples separately. In Figure 21 we can show examples of comparable text with naturally prepared writing which shows the same writingmovements repeated in each of the three sentences.

1. B: terminal below staff and disconnected; shape of lower body, notas rounded as upper bulb; base intersects baseline; Some variation inshape of staff;

1 2 3

2. Possible u: variation in initial and terminal movements:

1 2 3

3. G: adjustment in terminal staff; narrow lower loop intersectsmidway up staff; variation on terminal eyelet at top of second staffand initial staff show variation.

1 2 3

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4. Uncertain what this letter is, some agreement in the first twosentences, third sentence there are dissimilarities.

1 2 3

5. B: close resemblance, may be another letter. Agreement in terminaleyelet; open base, not close to initial staff; some variation in staff.

1 2 3

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

1 2 3

7. Letter shape not repeated throughout all three sentences.

1 2 3

8. Initial stroke good agreement in sentences 1 and 2; remainder of letterformation not totally accounted for. Possibly a cursive z.

1 2 3

9. Disagreement in letter shape in all three sentences.

1 2 3

10. g: narrow angular loop; terminal eyelet; variation in initial stroke.

1 2 3

11. g: Angular base; variation in terminal.1 2 3

12. Another example of inconspicuous features relative heights.

1 2 3

In summary, there is evidence a handwriting comparison may beconducted on writing produced under the influence of writers cramp.However, several tests must be applied to the evidence to identify anylimitations.

5.10 Remedies

5.10.1 Botox (Botulinum Toxin Type A)

Another factor which may affect determining the presence of writerscramp is that some persons writing will be improved in the course of time(up to one year) with botulinum toxin. Botulinum toxin may cause markedimprovements 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 followinginjection with Botox.

5.11 Writers Cramp and Fraud

A study performed in Turkey on 10 patients with writers crampreported that signing qualities improved markedly in 3 and partially in 4patients after botulinum toxin injection. In fact, handwriting and signingcharacters sporadically show deformations and improvements during manydiseases. This occurrence is more distinct in neurological diseases.

In writers cramp the periodic remission of the disease by means ofdrug injection may cause the emergence of patients who tend to takeadvantage of the situation. In other words these persons may use thedisease and the Botox treatment to commit fraud. Someone who has ahistory of disability due to writers cramp may regularly display illegiblewriting. However, in another situation they may display vastly improvedwriting after receiving Botox to control the dystonia. The use of Botoxto control the dystonia may present opportunities to commit a fraud. Thiscan arise when a patient receiving Botox prepares writing which they laterwish to deny as their own. To support their alibi they provide writingsamples demonstrating that they are sufferers of the condition. Thesespecimens may be illegible and difficult to compare with the better qualityquestioned writing. There was no information on the minimum dose ofBotox needed to reduce writers cramp and how long legibility wouldremain improved. Generally the literature reports 4 months as the standardperiod of improvement from a dose of Botox to treat writers cramp.Although Botox is generally considered a prescription drug it can beobtained illegally through the black market. This may make it difficult toestablish whether a suspect writer had access to the drug through a trail ofmedical prescriptions. One route may be to test for metabolites of the drugwhich may not only show that the suspect had injected the drug, but mayalso provide a relative time of injection which may be compared with the



Figure 22: Writing prepared by a 29-year old male financial consultant suffering for approximately one and a half years from writers cramp. Top imageof writing was produced under normal conditions. Note the deformation of letter shapes after the second name. The example below is fromthe same writer following treatment with Botox. The deformation does not show after the second word and is absent from the sentence whencompared 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 twowritings and does show the types of problems which can be encountered when attempting to compare writing produced by the same personunder 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 withwriting produced after treatment with Botox (Figure 23). Unfortunatelythis is not the best example because there is evidence of two differentwriting styles and a limited amount of comparable text between the twowritings. The top example is affected by writers cramp and discloses amix of connected cursive letters and disconnected hand printed and cursiveletter forms. There is also a limited amount of comparable text as the entryproduced under Botox is primarily disconnected block letters and does notduplicate the text of the first entry. Therefore a proper handwritingassessment may be precluded on the limitations between the two writings.Some observations related to similarities and dissimilarities were notedand have been numbered in Figure 23 described below.

6. The N discloses a number of similar features. The initial staff islonger than the terminal staff; disconnected at the intersection of thebase of second staff with the base of diagonal crossing stroke. Thebase of this intersection is a longer distance above the baselinecompare with the initial staff. The terminal of diagonal stroke formsa horizontal adjustment into the intersection with the terminal staff.

7A 7B

2. The base line alignment of the letters on the left show some agreementwith letters positioned above the baseline and the later letters touchingor closer to the baseline (t).

7a 7b

In this comparison it may be argued that a handwriting examinationmay not be possible due to two fundamental problems, a lack of

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comparable writing styles and text. It is unclear if the style differences andthe use of disconnected hand printed block letters is easier to write moreclearly because the style is less complex and possibly less demanding thancursive writing. Conversely, if the writing style used to prepare thesamples is the natural writing style of the writer treated with Botox, thenthis may be a good example of two different writing styles prepared by thesame person under different conditions. While it is inappropriate to drawbroad conclusions based on this limited comparison, this is an example ofthe dramatic differences in writing movements within the same writersuffering from writers cramp before and after Botox treatment. Thereforethere is the potential to take advantage of this disease and its treatment tocommit fraud. Based on this example further studies are warranted. Insummary a proper handwriting comparison cannot be conducted on theseexamples to determine whether it is possible to draw any definitiveconclusions as to authorship. Subsequent research will seek examples offrauds where writers cramp was used as a defense and where there is apossibility Botox was involved.

Although the example in Figure 23 is of limited value fordemonstrating comparison, it does highlight the need to ensue specimensduplicate the amount, style and if possible the conditions under which thequestioned signatures were prepared. Forensic document examiners mustnot only be aware of the causes of illegible writing but also understand thepotential for fraud to be committed under these conditions.

5.12 Writing Supports

As shown in Figures 4 and 5, mechanical writing supports may beused to generate increased legibility in writing for persons suffering fromwriters cramp. The example in Figure 5 (bottom) was produced usingone of the mechanical assists described in Figure 4. Note the strap in thesecond example that fits over the back of the hand. Both devices reducethe action of the hand on the writing instrument, thereby allowing thewriter to guide the pen and reduce the tight grip and heavy downwardpressure characteristic of persons suffering from this disease. The readeris invited to conduct a handwriting comparison between the writerscramp writing and the assisted writing samples in Figure 5A and B todetermine limitations and whether a definitive conclusion as to authorshipis possible.

6.0 CONCLUSIONS

Legibility remains the only indicator that writers cramp may beaffecting the writing. Based on the handwriting samples provided there isevidence that legibility diminishes soon after the writing process begins inpersons suffering from writers cramp. This confirms what has beenreported in the literature.

The deformation of letters in writers cramp writing is different fromthat found in other diseases such as Parkinson and Alzheimer or under theinfluence of alcohol. This may help the expert to distinguish betweenillegible writing due to poor skill and that which results from dytonia. Itmay also be possible to distinguish between writing styles andcharacteristics resulting from a number of diseases.

A handwriting examination and comparison was conducted on writingsamples prepared by the same writer while affected by writers cramp. Theexample selected was used to conduct a common authorship examination.Although this is not the same as comparing questioned with knownwritings, common authorship examinations are necessary and require thesame detailed comparison as that applied when comparing specimens withquestioned writing. However, this example may display writings that wereprepared consecutively and within a very short period of time. This wouldbe of value for writing that is not affected by the disease, but because ofthe dramatic changes in legibility cause by this disease the closepreparation time were of importance. The writing in subsequent examplesdisclosed marginally more deformation of letters from the first sentence.

It was still possible to conduct a limited handwriting comparison,demonstrate similarities and dissimilarities and arrive at a qualifiedconclusion. As with any forensic examination it is necessary that theevidence be assessed to identify any limitations which might affect thehandwriting comparison.

The potential to commit fraud remains a driving focus on the subjectof writers cramp. The successful use of botulinum toxin type A toreduce the affects of writers cramp may have created an opportunity tocommit fraud. It may be possible for a single sufferer of the disease towrite a questioned or fraudulent text while under treatment with Botox andthen later deny the writing using examples of writers cramp writingprepared in the absence of Botox. Unfortunately this was not fullyexplored with the examples provided nor was it possible to design a testto validate this possibility. Additional information is required todetermine the potential of Botox acting rapidly to improve a writerscramp sufferer such that there is no resemblance between the treated anduntreated writing. Also there may be ways to identify metabolites in aperson suspected of committing such frauds.

This study draws attention to a less well known disease that may havedramatic affects on writing legibility and may also be manipulated tosuccessfully perpetrate a fraud.

7.0 REFERENCES

[1]. Harris, J. S., Morin, T., Nott, H.R. and Loncar, J., War CrimesCases in Canada and the Scientific Examination of QuestionedDocument Evidence, presented at the 53rd Annual Meeting of theAmerican Academy of Forensic Sciences, Seattle, Washington,February 2001.

[2]. Harris, J. S., Identifying Digitized Handwriting, presented at the54th Annual Meeting of the American Academy of ForensicSciences, 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 andTechniques, 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 onHandwriting, Current Topics in Forensic Science, Proceedings ofthe 14th Meeting of the International Association of ForensicSciences, August 26-30, 1996, Tokyo, Japan, Vol. 4, 1997, p. 390-396.

[9]. Stinson, M. D., A Validation Study of the Influence of Alcohol onHandwriting, Journal of Forensic Sciences, Vol. 42, No. 3, 1997,p. 411-416.

[10]. Watkins, R. I. and Gorajczk, J., The Effect of AlcoholConcentration on Handwriting, presented at the 48th AnnualMeeting of the American Academy of Forensic Sciences, February1996, 15 pp.



[11]. Buquet, A. and Rudler, M., Handwriting and ExogenousIntoxication, International Criminal Police Review, No. 48,Sept/Oct, 1987, pp. 9-20.

[12]. Galbraith, N. G., Alcohol: Its Effect on Handwriting, Journal ofForensic Sciences, Vol. 31, No. 2, 1986, p. 580-588.

[13]. Beck, Jan, Handwriting of the Alcoholic, Forensic ScienceInternational, Vol. 28, 1985, p. 19-26.

[14]. Zaki, N. N. and Ibraheim, M. A., Effect of Alcohol and CannabisSativa Consumption on Handwriting, Neruobehavioral Toxicologyand Teratology, Vol. 5, No. 2, 1983, p. 225-229.

[15]. Foley, R. G. and Lamar, A., The Effects of Marijuana and AlcoholUsage on Handwriting, Forensic Science International, Vol. 14,No. 3, 1979, p. 159 -164.

[16]. Doud, D., Some Pitfalls in Testimony Relating to AlcoholConsumption and Handwriting, presented at the 34thd AnnualMeeting of the American Society of Questioned DocumentExaminers, Colorado Springs, Colorado, July, 1975, 4 pp.

[17]. Anderson, G., Varying Effect of Alcohol on Handwriting,presented at the 26th Annual Meeting of the American Academy ofForensic Sciences, Dallas, Texas, February, 1974, 9 pp.

[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 ofCriminal Law and Police Science, Vol. 56, No. 3, 1965, p. 372-374.

[20]. Duke, D. M. and Coldwell, B. B., Blood Alcohol Levels andHandwriting, presented at the joint conference of the AmericanSociety of Questioned Document Examiners 23rd annual meetingand the Royal Canadian Mounted Police Crime DetectionLaboratories, Ottawa, Ontario, August, 1965, 10 pp.

[21]. Obermedizibalrat, V., Types of Reaction in the Handwriting ofPersons Under the Influence of Alcohol, Kriminalistik, Vol. 18,No. 1, 1964, p. 38-42.

[22]. Walton, J., Handwriting Changes Due to Aging and ParkinsonsSyndrome, Forensic Science International, Vol. 28, No. 3, p. 197-214.

[23]. De Bonoso, G. R. D., Alterations in Handwriting Caused byAlzheimers Disease and Abuse of Drugs, presented at the 51stAnnual Meeting of the American Society of Questioned DocumentExaminers, September 1993, 14 pp.

[24]. Carney, B. B., A New Tremor In Handwriting, presented at the51st Annual Meeting of the American Society of QuestionedDocument Examiners, September 1993, 10 pp.

[25]. Tull, P., Handwriting and Signatures of the Visually Impaired,Journal of Forensic Document Examination, Vol. 5, Fall 1992, pp.35-54.

[26]. Hooten, A, A Study of Dating Multiple-Sclerosis Onset byHandwriting, Journal of Forensic Document Examination, Vol. 5,Fall 1992, pp. 55-63.

[27]. Tarver, J. A., Micrographia in the Handwriting of ParkinsonsDisease Patients, presented at the Joint Conference of theSouthwestern Association of Forensic Document Examiners FallSeminar and the American Society of Questioned DocumentExaminers 46th Annual Meeting, Denver, Colorado, Sept. 1988, 25pp.

[28]. Behrendt, J. E., Alzheimer Disease and Its Effect on Handwriting,Journal of Forensic Sciences, Vol. 29, No. 1, 1984, p. 87-91.

[29]. Lindblom, B., Identifying Characteristics in the Handwriting of theVisually Impaired, Canadian Society of Forensic Sciences Journal,Vol. 16, No. 4, 1983, p. 174-191.

[30]. Wing, A. M. and Baddeley, A. D., A Simple Measure ofHandwriting As An Index of Stress, Bulleting of the PsychonomicSociety, Vol. 11, No. 4, 1978, p. 245-246.

[31]. Hilton, O., Influence of Age and Illness on HandwritingIdentification Problems, presented a the 33rd Annual Meeting of theAmerican Society of Questioned Document Examiners,Washington, D.C., July, 1975, 5 pp.

[32]. Downing, R. W., Ebert, J. N., Boruchow, J. K. and Valentine, J. H.,Temporal Changes in Handwriting Size Level of Premorbid SocialFunctioning and Intellectual Level During Treatment in AcuteSchizophrenics, Journal of Nervous and Mental Disease, Vol. 14,No. 6, 1966, p. 526-533.

[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 andHandedness Summary and Conclusions, Traumatic Aphasia,Chapters 4 and 15, 1961.

[35]. Roberson, E.W., Fundamentals of Document Examination, Nelson-Hall Publishers, Chicago, 1991.

[36]. Op. cit., Hilton, O.

[37]. Op. Cit., Ellen, D.

[38]. Alkan, N., Due to Aging Handwriting and Signature Changes,Thesis: Forensic Medicine Specialization, Istanbul Medical Faculty,Department of Forensic Medicine, 1996.

[39]. Sassoon, R., Writers Cramp, Visible Language, Vol. 24, No. 2,1990, p. 198-213.

[40]. Op. Cit., Conway.

[41]. Op. Cit., Hilton.

[42]. Op. Cit., Harrison.

[43]. Op. Cit., Huber.

[44]. Op. Cit., Ellen.

[45]. Rothwell, J.C., The Physiology of Dystonia, in: Handbook ofDystonia, Tsui, J.K.C. and Calne, D.B., Editors, Published byMarcel Dekker, New York, 1995, pp. 59-76.

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 andDystonia: 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.

[50]. McDaniel, K.D., Cummings, J.L., and Shain, S., The Yips: AFocal Dystonia of Golfers, Neurology, Vol. 39, pp. 192-195, 1989.

[51]. Newark, J., Hochberg, F.H., Isolated Painless ManualCoordination in 57 Musicians, J. Neuro Neruosurg Psychiatry,Vol. 50, pp. 291-295, 1987.

[52]. Lockwood, A. H., Medical Problems in Musicians, New EnglandJournal of Medicine, Vol. 320, pp. 220-227, 1989.

[53] Jonathan B Strober, Writer's Cramp, at eMedicine,http://www.emedicine.com/neuro /topic614.htm

[54] Ibid.

[55]. Tolosa, E. S. and Marti, M. J., Adult Onset Idiopathic TorsionDystonia, In: Watts, R.L. and Koller, W.C., Editors, MovementDisorders. 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 FocalDystonia, Brain, Vol. 10, No. 5, pp. 461-480, 1982.

[57]. Marsden, C. D. and Sheehy, M.P., Writers Cramp, Trends inNeuroscience, Vol. 13, No. 4, pp. 148-153, 1990.

[58]. Op. Cit., Strober.

[59]. Zacher, A., Writers Cramp-Focal Dystonia or PsycogenicMovement Disorder? - A Critical Review of the Literature,Fortschr Neurol Psychiat, Vol. 57, pp. 328-336, 1989.

[60]. Besson, J. A. O. and Walker, L.E., Hypnotherapy for WritersCramp, Lancet, pp. 71-2, 1983.

[61]. Ranawaya, R. and Lang, A., Usefulness of a Writing Device inWriters Cramp, Neurology, Vol. 41, 1136-1138, 1991.

[62]. Quinn, N., Aid in Writers Cramp, Neurology, Vol. 39, 1404-1405, 1989.

[63]. Koller, W. C. and Vetere-Overfield B., Usefulness of a WritingAid in Writers Cramp, Neurology, Vol. 39, pp. 149-150, 1989.

[64]. Lees, A. J., Kleedorfer, B., and Foster, H., Treatment of WritersDystonia, 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

Botulusmis Toxin: A Review of Ten Patients, The Journal ofNeurologic Sciences, Vol. 16, pp. 2-11, 1999 (Turkish).

[67]. Brin, M.F., Iankovic, J., Comella, C., Blitzer, A., Tsui, J. andPulmann, 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., BotulinumToxin Therapy for Limb Dystonias, Neurology, Vol. 42, pp. 627-630, 1992.

[69]. Tsui, J. K. C., Bhatt, M. and Calne, D. B., Botulinum Toxin in theTreatment of Writers Cramp: A Double-Blind Study, Neurology,Vol. 43, pp. 183-185, 1993.

[71]. Karp, B. I., Cole, R. A., Cohen, L. G., Grill, S., Lou, J. S., adHallett, M., Long-Term Botulinum Toxin Treatment of Focal HandDystonia, Neurology, Vol. 44, pp. 70-76, 1994.

[71]. Ranawaya, R. and Lang, A., Usefulness of a Writing Device inWriters Cramp, Neurology, Vol. 41, 1136-1138, 1991.

[72]. Quinn, N., Aid in Writers Cramp, Neurology, Vol. 39, 1404-1405, 1989.

[73]. Koller, W. C. and Vetere-Overfield B., Usefulness of a WritingAid in Writers Cramp, Neurology, Vol. 39, pp. 149-150, 1989.

[74]. Op. Cit. Hilton, p.146.

[75]. Op. Cit. Harrison p. 308.

[76]. Op. cit., Buquet and Rudler.

[77]. Op. Cit., Harris.

[78]. Op. cit., Waller.

[79]. Op. cit., Buquet and Rudler.

[80] Op. Cit., Harris.

[81]. Op. Cit. Hilton, p.146.

[82]. Op. Cit. Harrison p. 308

[83]. Op. Cit., Harrison.

[84]. Op. Cit., Harris.

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