Dystonia Can Derail a Career

September 1, 2021

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Researchers identify dystonia as a neurological disorder characterized by excessive muscle contractions that can result in involuntary, slower movements and abnormal postures. There are several different forms of dystonia, but focal dystonia affects one specific area of the body. This disorder can be disabling to musicians because it causes a loss of muscular control in highly practiced movements. For example, in the hands it can cause fingers to curl or jut out.

By nature, the fingers are weak and if trained for prolonged periods of time, dystonia can occur. For instance, in pianists and guitar players it may affect the ring finger of the right hand. Glenn Gould struggled with dystonia as did the composer Robert Schumann. In his case, Schumann avoided dystonic moves and hardly used his middle finger of his right hand. American pianist Leon Fleisher, afflicted early in his career, famously played music written for the left hand only—a repertoire composed for pianist Paul Wittgenstein, who lost his right arm in World War I.

Movement Behind the Brain

Musicians describe focal dystonia as your brain sending garbled signals to your hands and fingers, causing them to do things out of your control, often rendering performance impossible. Initial symptoms include subtle loss of control in difficult passages, lack of precision, involuntary curling or sticking of fingers, and involuntary flexion of the bowing thumb.

The problem is almost always painless and task specific. For example, with doublers, it may only occur on one particular instrument, but not the other. It’s also subject to sensory input, with some pianists reporting symptoms only when playing on ivory keys (not plastic). Embouchure dystonia affects brass and woodwind players, which may cause the lips to tremble or the jaw to lock, or otherwise affect the face, mouth, and tongue.

Renowned neurologist Eckart Altenmüller, a leading authority on music and neurophysiology (and a classical flutist), cites several causes that contribute to focal dystonia. Two major factors are overuse of the same fingering and fatigue—often the result of forcing yourself to overcome a particular muscular weakness. There is also much evidence to suggest that psychological pressure contributes to the onset of dystonia. When our body perceives stress, the adrenal glands release the hormone cortisol, which destabilizes motor memories and weakens self-repair neuronal circuits in the brain.

Treatment and Research

According to the Dystonia Medical Research Foundation, 1% to 2% of professional musicians are affected by dystonia, though many may go undiagnosed. At present, there is no cure for dystonia, so the focus is on treatment. Sometimes, anticholinergic drugs, which affect the transmission of messages from the brain to the muscles, can help. Botulinum toxin injections can compel the body to create new programs by blocking nerve impulses to contracting muscles. They work by temporarily weakening the muscles so the spasm is reduced. Therefore, they are a better choice for hand dystonia than embouchure dystonia.

The ultimate goal of treatment is to establish new sensory motor programs to accomplish the tasks that have become challenging. Altering posture or key positions could help. Sensory tricks, like playing while wearing a latex glove or stimulation applied to affected areas, can lessen symptoms.

Sensory re-education attempts to reverse the changes in the cortex that have caused the dystonia through repetitive exercises and/or visualization. In sensory motor retuning (constraint induced movement therapy) nonaffected fingers are immobilized in a splint while performing repetitive coordination exercises. This may facilitate freer, more independent movement patterns from a dystonic finger.

On a positive note, more research is being conducted to explain neuromuscular mechanisms behind motor control of musicians’ dystonia and to develop novel neurorehabilitation techniques. Individual clinics focus on causes, diagnosis, and management. There are several specialized clinics around the country and in Canada, dedicated exclusively to dystonia, as well as foundations that promote awareness, education, and support.

Instrumentalists with dystonia commonly exhibit symptoms in the following ways:

• Pianists: right hand, 4th and 5th fingers
• String players: left hand
• Guitarists: either hand, 3rd finger of right hand
• Percussionists: either hand
• Woodwinds: either hand, face, mouth
• Brass players: corners of mouth, jaw

Most affected musicians describe symptoms in musical terms. A musician may notice:

• Subtle loss of control in fast passages
• Lack of precision
• Curling of fingers
• Fingers “sticking” to keys
• Involuntary flexion of bowing thumb in strings

If you exhibit symptoms of focal dystonia, seek a diagnosis as soon as possible. To ease muscle contractions, a specialist might recommend a combination of medications, therapy, or surgery. Physical therapy and/or occupational therapy can help ease symptoms and improve function.

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