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Focal Task Specific Dystonia: The Titanic of Musician Oriented Repetitive Stress Disorders

Written by: Suzanne Higgins, OTR/L, MEd

Virtual Hand to Shoulder Fellow '20/'21

Music is an extraordinary art form, and a universal language that allows us to simultaneously engage in an emotional and intellectual experience regardless of the fact that we speak different languages, and come from different cultures. Whether it is background music at work, a date to a live concert, or the specific music we listened to in our formative years, music is central to our lives. The people who create and nurture this medium, often identified as special or admired if they are famous, are at 80% higher risk for developing injuries, particularly repetitive stress injuries (RSI), than the standard population. (Ivano, 2016).

As a musician myself, I can vouch for the challenge of maintaining a balanced lifestyle, both as a student in a demanding music program, and later as a professional musician and teacher. Many musicians involved in contemporary Jazz, Pop or Classical genres, struggle to meet economic requirements while also maintaining the prowess necessary to perform their craft. For orchestral and concert musicians, it is not uncommon to continue beyond formative years in a conservatory or college music program, with 4 to 5 hours of ongoing daily practice preparing new material, and sharpening needed technical virtuosity.

Many RSI injuries, that musicians may present with in hand therapy clinics, are not that different than RSI affecting the general population, and can be treated with standard protocols and specific ergonomic considerations. Focal Task Specific Dystonia (FTSD), however, is a different animal. FTSD tends to emerge in classical musicians of a mean age of 33 years old, with common triggering events including intensive practice of technically challenging musical passages, accompanied by anxiety or pressure to master material, often for a deadline such as a recital, competition, or audition. (Leijnse, Hallett & Sonneveld, 2015).

As a musician and hand therapist, this diagnosis stirs both curiosity and terror. Nothing could be more chilling to a performing musician, than the sudden loss of the fine motor control needed to play.

“Nothing I was doing seemed to change anything in my hand. It wasn’t fair, it wasn’t fair. I wondered if there was any point to living, if I wasn’t able to play. I gave serious thought to ending my life” Leon Fleisher Concert Pianist and conductor.

FTSD manifests as uncontrolled finger movements, co-contracture of agonist/antagonist musculature, and loss of automaticity. The disorder

affects 8% of professional classical musicians, (Horisawa et al, 2016), with 14% of musicians seeking treatment in Performing Arts Clinics eventually diagnosed with the condition. (Conti, Pullman & Frucht, 2008)

Unlike most RSI injuries, FTSD is associated with the central nervous system (CNS), specifically, with the basal ganglia, and related cortical circuits, including relays in the thalamus, and the cerebellum. Recent advances in neuroimaging have generated updated understanding of the pathophysiology, including maladaptive cortical plasticity leading to fine motor degradation, abnormal sensorimotor integration, and reduced inhibition across several levels of the motor pathway (Chang & Frucht, Mount Sinai Medical Center, 2013). The National Institutes of Health list symptoms of FTSD as:

Sustained or intermittent muscle contractions, causing abnormal movements, postures, or both. Symptoms are initiated/triggered by repetitive voluntary action and associated with overflow muscle activation. (National Institutes of Health, Albanese et al, 2013)

Included as triggers to developing FTSD, are psychosocial components such as perfectionism and anxiety, driving many classical musicians to push themselves too far, and too fast. As a music teacher, there is a fine balance of criticism and encouragement, with both external and internal input vital to the development of one’s unique expression in any art form. I can remember as a self-taught player, dissecting song forms from recordings, learning musical structure, and vibing with the emotional elements of sound, with absolute confidence. It was not until I studied classical guitar in a college level music program, that I discovered the concepts of pedagogy, scheduled practice, levels of proficiency, the pressures of competition, and self-conscious doubt.

It is interesting to note that the brain chemical Dopamine, which in healthy levels, is associated with both fine motor control and feel good emotions, has heredity links with focal dystonia, where lower levels of the brain chemical is associated with movement disorders, as well as anxiety and other psychological disorders. (Dystonia Medical Research Foundation,2019)

“Musicians should practice healthy emotions like they practice scales” Mic Goodrick Jazz Gui