When Dystonia Strikes

April 1, 2024

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Among the most frustrating disorders for musicians to manage is task-specific focal dystonia. Dystonia causes muscles to contract, which makes them move involuntarily or get stuck in an abnormal position. It can affect the entire body or a certain part, and the movements can sometimes cause pain.

Though there are a number of unknowns, dystonia is thought to be related to a problem in the part of the brain called the basal ganglia. This is where the brain processes the information that helps muscles contract. The theory is that the neurotransmitters, the chemicals that do the “talking” in the brain, are abnormal in people with dystonia. (Dystonia, however, does not affect cognitive thinking and is not generally related to mental health issues.)

According to the Dystonia Medical Research Foundation, 1%-2% of professional musicians are affected by dystonia. Almost all afflicted performers are classically trained and, according to the data, most are male. Up to 25% have a family history of dystonia. Research has pinpointed different genetic mutations linked to dystonia. It can also be caused by a stroke, called secondary dystonia, and the symptoms are usually limited to one side of the body.

As a person develops and learns movement tasks, these movements are stored in the brain as sensory motor programs. Musician’s dystonia can be described as a “computer virus” that corrupts the sensory motor programs associated with playing the instrument.

Common Symptoms

The musicians most affected by dystonia are pianists, guitarists, and wind instrumentalists. By far, the two most common types of focal dystonia affecting musicians are embouchure dystonia and hand dystonia. Commonly symptoms appear in these areas:

• Pianists: right hand, fourth and fifth fingers
• String players: left hand
• Guitarists: either hand, third finger of right hand
• Percussionists: either hand
• Woodwinds: either hand, face, mouth
• Brass players: corners of mouth, jaw

Focal hand dystonia is strikingly more common in musicians than in other groups of professionals that require intricate hand movements—such as dentists, surgeons, and writers. At first, instrumentalists may perceive symptoms as the result of faulty technique or insufficient preparation. Dystonia may also be misdiagnosed as a psychological condition.

Focal Hand Dystonia

Focal hand dystonia typically manifests as loss of muscular control in highly practiced movements and can also be accompanied by tremors. 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 on the other. Dystonia may also be sensitive to sensory input with some pianists reporting symptoms only when playing on ivory keys (not plastic).

Embouchure Dystonia

Embouchure dystonia is most common in brass and woodwind players. It may affect muscles of the mouth, face, jaw, and tongue. Symptoms may be subtle at first—air leaks at the corners of the mouth and tremors (sometimes worse in higher registers) or involuntary and abnormal contractions of the face muscles.

Treatment

Doctors typically take an individualized approach and use a combination of methods to help patients manage pain and reduce muscle spasms. Different medications may be tried to treat dystonia, such as drugs that affect the specific neurotransmitters acetylcholine, GABA, dopamine, and anticonvulsants. Anticholinergics, which block and inhibit the activity of the neurotransmitter acetylcholine (chemical messenger) at both central and peripheral nervous system synapses, are sometimes used.

Botulinum toxin injections have also been used to 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. This is a better choice for hand dystonia than embouchure dystonia.

New Research and Therapy

A career-threatening malady, dystonia is, at its heart, a conditioned reflexive behavior. As such, the maladaptive change in the brain can potentially be reversed through specific patterns of finger movement. The goal is to establish new sensory motor programs to accomplish the tasks that have become challenging.

Altering posture or key positions may also help. Sensory tricks, like playing while wearing a latex glove or stimulation applied to affected areas, can lessen symptoms.

Researchers and therapists have seen significant results in a therapy called sensory motor retuning (SMR), where nonaffected fingers are immobilized in a splint while performing repetitive coordination exercises. This may facilitate freer, more independent movement patterns from a dystonic finger.

Last year, researchers from the Korea Advanced Institute of Science & Technology, led by neuroscientist and professor Daesoo Kim, presented findings on a new treatment for the condition at the Conference for Musicians with Dystonia. Kim’s research team found that abnormal muscle tension is caused by excessive stress. The researchers developed NT-1, a treatment that can block the development of the symptoms of dystonia from the brain, enabling patients to use their muscles in a normal way. 

Dystonia can be a symptom of other serious conditions. If you are experiencing uncontrolled muscle movement or contractions, see your doctor as soon as possible. For more information on musician’s dystonia visit the Dystonia Medical Research Foundation (www.dystonia-foundation.org/musicians).

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