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 Guitarist, The Advancing Guitarist (Goodrick,1987)
As a former music teacher, I cannot help but think of parents asking me if their children are talented. I also recall the fierce ways fellow guitar players in the guitar program I attended, would vie with each other with this idea of being the best one. Whereas developing strengths is important in any field, the myth of fame in the performing arts is perhaps an unhealthy driver of anxiety, and habitual tension that correlates negatively in the pursuit of excellence.
With regard to current medical treatments, some promising methods for treating FTSD include botulinum toxin injection (BoNT) to relax muscles (Değı̇rmencı̇,2019), Stereotactic ventro-oral thalamotomy involving creating microlesions in the thalamus through exposure to short intervals of high temperatures to reduce CNS abnormal (Horisawa et al., 2019) , and deep brain stimulation (DBS) to cause blockade over affected CNS area. (Cho et all, 2009)
Rehabilitation and retraining after medical intervention is usually interdisciplinary, with hand therapy addressing inefficient or erroneous biomechanical movements and postures, sensory motor/integrative therapies, selective immobilization, manual therapies, kinesio taping, TENS, stress reduction techniques, postural alignment/conditioning, ergonomics/adaptive equipment, etc.
As a hand therapist treating the musician for this disorder, which is often devastating to their career, it is important to be aware of vulnerabilities an injured musician might be feeling. An individualized collaborative approach can help the patient to feel more empowered as they deal with symptoms interfering with an art form they have spent most of their life developing. Successful therapy might also include patient as expert in discipline, consultations with other practitioners involved, as well as connecting with music teacher, and observing lessons/practice where possible.
In conclusion, FTSD is a multifactorial dx, with elements of psychosomatic, heredity, and neurophysiologic mechanisms, and is strongly correlated to repetitive stress. At this time, methodologies for hand therapy treatment continue to refine as research of focal dystonia mechanisms evolve. Ongoing research to further understand specific mechanisms of the disorder, as well as the formulation of definitive clinical tests, will help advance global treatments for this mysteriously debilitating disorder. As to the psychosocial aspects of FTSD, It is noteworthy to examine the nature of relationship, and what draws one to their art, as a vital link to the vitality of contribution, and ongoing health and resilience as a performing musician.
Recent evidence based studies outlining current treatment methodologies:
1. Weak muscle group strengthening - Musician’s Dystonia in Pianists: Long-Term Evaluation of Retraining and Other Therapies (Vugt et all, 2014)
2. Sensory motor retuning - Musician’s Dystonia in Pianists: Long-Term Evaluation of Retraining and Other Therapies (Vugt et all, 2014)
3. Slow-down exercise - Slow-down Exercise for the Treatment of Focal Hand Dystonia in Pianists. (Naotaka, 2006)
4. Biomechanical for rebuilding new motor pathways: approach with corrections for proper body positioning and technique proximal awareness of postural alignment and release of tension - Effects of Pianism Retraining on Three Pianists with Focal Dystonia. (De Lisle et all, 2006)
5. Selective Immobilization: cortical mapping AROM target fingers while inhibiting other digits - Motor Training as Treatment in Focal Hand Dystonia. ( Zeuner et al, 2005)
6. TENS: to normalize agonist/antagonist muscles - Effects of transcutaneous electrical nerve stimulation on motor cortex excitability in writer's cramp. (Tinazzi et al. 2005)
7. Kinesio tapeing: Induce muscle stretching/stimulate sensory processing - Kinesio Taping reduces Pain and Modulates Sensory Function in Patients with Focal Dystonia: a Randomized Crossover Pilot Study. (Pelosin et al 2013)
References
Albanese A, Bhatia K, Bressman SB, Delong MR, Fahn S, Fung VS, Hallett M, Jankovic J, Jinnah HA, Klein C, Lang AE, Mink JW, Teller JK. Phenomenology and classification of dystonia: a consensus update. Mov Disord. 2013 Jun 15;28(7):863-73. doi: 10.1002/mds.25475. Epub 2013 May 6. PMID: 23649720; PMCID: PMC3729880.
Chang FC, Frucht SJ. Motor and Sensory Dysfunction in Musician's Dystonia. Curr Neuropharmacol. 2013 Jan;11(1):41-7. doi: 10.2174/157015913804999531. PMID: 23814536; PMCID: PMC3580790.
Cho, Chul Bum, Hae Kwan Park, Kyung Jin Lee, and Hyoung Kyun Rha. “Thalamic Deep Brain Stimulation for Writer’s Cramp.” Journal of Korean Neurosurgical Society 46, no. 1 (July 2009): 52–55. https://doi.org/10.3340/jkns.2009.46.1.52
Conti, Anna M., Seth Pullman, and Steven J. Frucht. “The Hand That Has Forgotten Its Cunning--Lessons from Musicians’ Hand Dystonia.” Movement Disorders: Official Journal of the Movement Disorder Society 23, no. 10 (July 30, 2008):
1398–1406. https://doi.org/10.1002/mds.21976.
Değı̇rmencı̇, Yıldız. “A Glance into Botulinum Toxin Outpatient Clinic in Movement Disorders Practice: Self Experience.” Hareket Bozuklukları Pratiğinde Botulinum Toksin Polikliniğine Bakış: Kişisel Deneyim. 21, no. 3 (September 2019): 162–65. https://doi.org/10.18678/dtfd.559329
De Lisle, Rae, Dale B. Speedy, John M.D. Thompson, and Donald Maurice. “Effects of Pianism Retraining on Three Pianists with Focal Dystonia.” Medical Problems of Performing Artists 21, no. 3 (January 1, 2006): 105–11.
Dystonia Medical Research Foundation. ON-Target DMRF’s Drug Discovery Efforts Pursue New and Improved Treatment. Dystonia Dialogue Newsletter of the Dystonia Medical Research Foundation. Spring 2019; 42(1) p.12-17
Fleisher, Leon, and Anne Midgette. My Nine Lives: A Memoir of Many Careers in Music. New York: Doubleday, 2010.
http://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=742573.
Goodrick, M. The Advancing Guitarist: Applying Guitar Concepts and Techniques Advancing Guitarist. Hal Leonard, 41664th edition. Jan 1, 1987. ISBN-10:0881885894, ISBN-13: 978-0881886897
Horisawa, Shiro, Shinichi Goto, Takeshi Nakajima, Takakazu Kawamata, and Takaomi Taira. “Bilateral Stereotactic Thalamotomy for Bilateral Musician’s Hand Dystonia.” World Neurosurgery 92 (August 2016): 585.e21-585.e25. https://doi.org/10.1016/j.wneu.2016.05.017.
Horisawa, Shiro, Taku Ochiai, Shinichi Goto, Takeshi Nakajima, Nobuhiko Takeda, Atsushi Fukui, Tomoko Hanada, Takakazu Kawamata, and Takaomi Taira. “Safety and Long-Term Efficacy of Ventro-Oral Thalamotomy for Focal Hand Dystonia A Retrospective Study of 171 Patients.” Neurology 92, no. 4 (January 22, 2019): E371–77. https://doi.org/10.1212/WNL.0000000000006818.
Ivano, J Edmonton Researcher says 80% of professional musicians suffer from injuries. Global News, a division of Corus Entertainment Inc
2016, posted December 20, 2016. Downloaded from https://globalnews.ca/news/3137609/edmonton-researcher-shows-80-of-professional-musicians-suffer-from-injuries/
Leijnse, J., M. Hallett, and G. Sonneveld. “A Multifactorial Conceptual Model of Peripheral Neuromusculoskeletal Predisposing Factors in Task-Specific Focal Hand Dystonia in Musicians: Etiologic and Therapeutic Implications.” Biological Cybernetics 109, no. 1 (February 2015): 109–23. https://doi.org/10.1007/s00422-
014-0631-5.
McBride Smith, S. Edna Golandsky on Taubman Technique. Clavier Companion 4, no. 5 (October 9, 2012): 50.
Naotaka Sakai, “Slow-down Exercise for the Treatment of Focal Hand Dystonia in Pianists,” Medical Problems of Performing Artists 21, no. 1 (January 1, 2006): 25.
Pelosin, E. et all. Kinesio Taping reduces Pain and Modulates Sensory Function in Patients with Focal Dystonia: a Randomized Crossover Pilot Study. Neurorehabilitation and Neural Repair 27(8) p722–731. DOI: 10.1177/1545968313491010
Tinazzi, M. Effects of transcutaneous electrical nerve stimulation on motor cortex excitability in writer's cramp. Movement Disorders 21(11), p 1908-1913
Vugt, F.t. van, L. Boullet, H.-C. Jabusch, and E. Altenmüller. “Musician’s Dystonia in Pianists: Long-Term Evaluation of Retraining and Other Therapies.” Parkinsonism and Related Disorders 20, no. 1 (January 1, 2014): 8–12. https://doi.org/10.1016/j.parkreldis.2013.08.009.
Zeuner, E. et al. Motor Training as Treatment in Focal Hand Dystonia. Movement Disorders 20(3), March 2005; p 335-341