Sometime’s it’s hard to figure out if you’ve just been playing too much lately or if there’s something wrong. There are lots of problems that cause a lot of pain, like a stretched or torn muscle, nerve issue, or temporomandibular joint disorder. You might have heard of something called musician’s focal dystonia, and this includes something called embouchure dystonia. This is a disorder that severely interferes with the normal function of the embouchure and the musician’s ability to control it, and it is almost always not painful.
First, what is dystonia?
Focal task-specific dystonia is a movement disorder characterized by the loss of fine motor control which only occurs when executing very specific movement patterns. When it is expressed in the execution of movement patterns to play a musical instrument, it is often termed musicians’ dystonia… It often involves the muscles that have been extensively trained in the finest level of motor control. (Iltis et al (2015:1)).
So, dystonia is a disorder that causes muscles (especially highly trained muscles) to malfunction. So what is embouchure dystonia?
Embouchure dystonia is a subcategory of musicians’ dystonia affecting the muscles of the lower face, jaw and tongue which control air flow into the mouthpiece of a wind instrument. This painless disorder typically has its onset in the fourth decade, is often restricted to a specific technical aspects of playing, may be limited to particular note frequency ranges, and has a variety of phenotypes including lip lock, tremor, lip pulling, jaw lock, and tongue-specific variants. (Iltis et al (2015:1))
Here’s a look at exactly how debilitating this can be, at the beginning of this video:
So, when an embouchure is affected by dystonia, the ability to control the embouchure is painlessly blocked by the brain. It’s important to note that this problem comes from the brain, not from the muscles themselves. There are several different types of embouchure dystonia, and there are some consistent elements in who it affects and how it begins. That’s the basic summary, but there’s a lot more to learn!
So why does embouchure dystonia happen?
There’s been some recent research that suggests that musicians with embouchure dystonia might be predisposed to it. Haslinger, Altenmuller, Castrop, Zimmer, and Dresel (2010) looked at the brains of 20 French horn players- half healthy, half with embouchure dystonia- with Functional Magnetic Resonance Imaging (fMRI) to look at the patterns that occurred in the musicians’ brains. There were two tests. In the first test, the subjects they buzzed into a mouthpiece, and in the second, they blew into a tube of a similar diameter. The healthy subjects had normal brain activity for both tasks. However, the dystonic musicians displayed overactive brain patterns (typical of dystonia) both while blowing into the mouthpiece and the tube, even though they didn’t outwardly display any symptoms with the tube. There’s no logical reason for this to happen, except if there was something in their brain that caused the dystonia. This type of neural dystonia representation is called “sensorimotor activity.” There is also a small percentage of musicians with dystonia (approximately 5-10%) that have more than one type of dystonia (such as writer’s cramp or other hand and finger dystonias), which is highly unusual. This also points to a predisposition.
In an earlier study, Hirata, Schulz, Altenmuller, Elbert, and Pantev (2004) looked at where the neural control centers for the lips and fingers were in embouchure dystonic musicians compared to their peers, healthy musicians. They found that there was significant asymmetry: the motor areas that control the fingers were shifted toward the lip representation centre, and the patients’ upper lips were significantly underrepresented compared to the lower lip. None of this was present in the healthy control group, and this also suggests that an abnormal sensorimotor organization might be going on in the brain before the dystonia even shows itself.
Apart from the heavy science and neurology behind dystonia, there is another study that looks at something that we as musicians talk and think about almost every day: voicing in the oral cavity and airstream shape.
In another recent study, Iltis et al. (2015) examined what was going on in the oral cavity while musicians are playing. They got eleven horn players (six healthy and five dystonic) to play an eleven-note harmonic sequence in an MRI. What they found is that the healthy elite players have a larger oral cavity in lower notes than dystonic players, and as they play higher frequencies, they reduce the size of the oral cavity more than the dystonic musicians do. It’s important to note that the resting positions of both groups were the same- the positioning of the tongue, teeth, jaw and oral cavity weren’t significantly different between the healthy and dystonic players. However, when they were playing, the horn players with dystonia just didn’t lift their tongues to focus the air as much as the healthy players. The result of this is that their embouchures had to compensate for the less focused air stream by vibrating at a higher frequency, putting more stress on their lips. Of course, it’s impossible to know from this study if this difference in oral cavity caused the dystonia, or if they are somehow compensating for their playing difficulties with this strategy, but it’s an important thing to consider. Don’t overwork your embouchure!
Like Iltis said in our definition of embouchure dystonia above, it usually effects high level musicians in their late thirties or early forties. Steven Frucht (2009), a prominent research at Columbia University in New York, completed a survey of eighty-nine musicians with embouchure dystonia and found that it affected brass players at three times the rate of woodwind players. He also noticed that only very rarely (2% of cases) was the onset of dystonia preceded by any sort of trauma to the embouchure, so it’s not precipitated by an injury. Interestingly, embouchure dystonia is also three times as common in men as it is in women.
What does it feel like?
In his survey, Frucht said that the initial symptoms reported by the patients were loss of embouchure control, loss of clarity of articulation, and involuntary movements of the lips, jaws and tongue. On average, after symptom onset it took about three years for professional performance to be impaired. In most of the musicians studied (69%) the symptoms began in a particular pitch range or with a specific technique (e.g. articulation), and then spread to other ranges or techniques.
Frucht also identified six different phenotypes, or symptomatic expressions, of embouchure dystonia:
- Tremor- Shaking in the muscles of the embouchure. Occurs most frequently in high brass (trumpet and horn);
- Lateral pulling- The embouchure involuntarily stretches or twitches to the side. Occurs most frequently in high brass;
- Lip locking- The lips seal shut when you attempt to blow. Occurs exclusively in low brass (trombone and tuba);
- Jaw- Tremors or locking of the jaw. Occurs mostly in woodwinds;
- Tongue- Spasms or inability to articulate. Occurs mostly in woodwinds;
- Meige- Facial tics not necessarily including the embouchure. Occurs most frequently in high brass.
Of those with jaw, tongue, and meige types of embouchure dystonia, 38% had their symptoms eventually spread to speaking, eating or drinking.
To see what it might look like, here’s a video of horn player Katie Berglof, who is going through rehabilitation for her embouchure dystonia. Keep an eye on her upper lip, on the left side. Her symptoms seem to be either tremors or lateral pulling, which are consistent with her being a horn player.
When musicians with embouchure dystonia play, there is a fundamental difference in their sound production. Lee, Furuya, Morise, Iltis, and Altenmuller (2014) measured the instability of tone musicians in seven brass musicians with embouchure dystonia compared to ten healthy musicians, and there was a significant fluctuation in the fundamental pitch of the dystonic players. This fluctuation manifested as an oscillation with peaks between about 5-25 Hz, whereas the healthy musicians had a consistent frequency without those peaks. In other words, a healthy musician has a strong, unwavering tone as compared to a dystonic musician, whose tone looks more like a sine wave.
From this we can see that embouchure dystonia isn’t one size fits all: it manifests in different ways in different people, and starts small and then often spreads.
Because embouchure dystonia starts small and spreads, it’s very important to get help early. A lot of musicians don’t realize what is happening, and think that they’re either tired or out of shape. If there’s no reason for either of those things to be the case, and you’re having painless unexplained loss of embouchure control, talk to your teacher or other professional. I’ve included a list of practitioners that help in rehabilitation, from Katie Berglof’s blog:
Unfortunately, there aren’t really any good treatments now except for long rehabilitation processes. The problem is neural, so to retrain the connection between your brain and your embouchure takes a long time and a lot of careful work. However, it is possible! Some ideas include altering the size or shape of your mouthpiece or its placement on your embouchure. Embouchure dystonia is extremely task specific, so if it’s not too highly advanced you can sometimes bypass the the dystonic behaviour with such sensory tricks. In Frucht’s survey, some musicians had limited success with touching their face frequently, or holding things between their molars, especially if they had the tremor type of dystonia. He notes that it’s important to have the retraining supervised by a musician who is experienced in it. Medical interventions like botox injections are in general not helpful, because of the highly specific nature of the embouchure muscles and the tasks they have to perform. According to Frucht, it provides a very small amount of relief only in a very few cases, and this relief does not last.
Katie Berglof shows some embouchure stretches that help increase flexibility and control that she does every day:
There is one recent case study of a trumpet player with jaw tremors who recovered completely from her dystonia (Satoh et al, 2011). She was an unusual case because she was only 28, and her symptoms had been affecting her playing for only two months instead of the years that most people go without seeking help. She could produce sound, but the tremor caused a loss in sound quality. She was fitted with dental splints, custom casts that covered each of her four molars and held her jaw open exactly the right amount to be able to play. They provided enough support to her jaw that the tremors disappeared within two months of consistent use, and she was gradually able to phase them out. At the time of the study’s publication, the symptoms had not returned for two years.
While that result is extremely promising, it’s important to note that her dystonia was caught very early. Two other musicians in the study with different types of embouchure dystonia eventually had to give up playing. Although the sample sizes in most studies are fairly small, many musicians affected with embouchure dystonia have to stop playing or cut back from a professional performance schedule. Some musicians actually switch instruments and continue their career on the other instrument! One of Frucht’s patients, a trumpet player, switched to bassoon and successfully auditioned for conservatories without any recurrence of symptoms. While this is certainly an unusual case, it’s one way for musicians affected with embouchure dystonia to continue doing what they love.
If you’re really interested in the subject, here are some lectures from prominent researchers in the field, Peter Iltis and Eckhart Altenmuller. They’re both authors of many of the studies discussed above.
Haslinger, B., Altenmuller, E., Castrop, F., Zimmer, C., & Dresel., C. (2010). Sensorimotor overactivity as a pathophysiologic trait of embouchure dystonia. Neurology, 74 (22), 1790-1797. doi: 10.1212/WNL.0b013e3181e0f784
Iltis, P., Frahm, J., Voit, D., Joseph, A., Schoonderwaldt, E., & Altenmuller, E. (2015). Divergent oral cavity motor strategies between healthy elite and dystonic horn players. Journal of Clinical Movement Disorders, 2 (15), 15-23. doi: 10.1186/S40734-015-0027-2
Lee, A., Furuya, S., Morise, M., Iltis, P., Altenmuller, E. (2014). Quantification of instability of tone production in embouchure dystonia. Parkinsonism and Related Disorders, 20 (11), 1161-1164. doi: 10.1016/j.parkreldis.2014.08.007
Satoh, M., Narita, M., & Tomimoto, H. (2011). Three cases of focal embouchure dystonia: Classifications and successful therapy using a dental splint. European Neurology, 66 (2), 85-90. doi: 10.1159/000329578
Thanks to Katie Berglof for allowing me to use materials from her blog, Living With Embouchure Dystonia! Best of luck in your rehabilitation.