{"id":2337,"date":"2016-04-26T10:06:02","date_gmt":"2016-04-26T14:06:02","guid":{"rendered":"http:\/\/sites.music.mcgill.ca\/mpbs\/?page_id=2337"},"modified":"2016-04-28T11:36:21","modified_gmt":"2016-04-28T15:36:21","slug":"focal-dystonia-in-the-hands-a-symptom-and-solution-guide","status":"publish","type":"page","link":"https:\/\/sites.music.mcgill.ca\/mpbs\/focal-dystonia-in-the-hands-a-symptom-and-solution-guide\/","title":{"rendered":"Focal dystonia in the hands: a symptom and solution guide"},"content":{"rendered":"

\"Title<\/p>\n

[toggle title=”What’s all the fuss?”]<\/p>\n

Focal dystonia is a neurological movement disorder, characterized by involuntary, uncontrollable, unwanted contracture of muscles which surround and usually accompany voluntary, intended contractions. These involuntary contractions characterize the debilitating effects of focal dystonia and act as the prime obstacle faced by those carrying out specific tasks that require a normal, efficient muscular function. The dystonic contractions can occur in any part of the body, but musicians, especially string players and keyboardists, are susceptible to developing dystonia of the hands, in which case the dystonic loss of extremely precise and fine motor control required for playing an instrument makes functional technique, and therefore proper performance on that instrument impossible (Altenm\u00fcller, Finger, & Boller, 2015, p. 94-95; Watson, 2009, p.260). Focal dystonia is not a disease that typically affects musicians who are beginners. It takes years to develop, and many of those who suffer from its ill-effects are often experienced musicians who have been practicing and performing at a high level for many decades, most of the time in mid-career (Watson, 2009, p. 262). Unfortunately, because of the slow developing nature of this disease, many musicians who have become affected by it never realized what was happening until the techniques used to make music were either too adversely affected, or actually worsened through further practice in desperate attempt to overcome the symptoms ( Altenm\u00fcller, Finger, & Boller, 2015, p. 94).<\/span><\/p>\n

Focal dystonia concerns the neurophysiological connections between the brain and the contraction of muscles, and the affected areas are concentrated around muscles which have been trained over extended periods to the finest levels of motor control. Thus, the site and particular nature of dystonia for different musicians seems to be contextually correlated with the specific requirements imposed by the technique of each respective instrument. This is especially true when fine motor activities, when repeatedly and intensively practiced, are limited or deprived of flexibility- that is, to be aided by larger muscular movements. Examples of this include the left hand of the violinist, and the right hand of the classical guitarist, as represented in the section below. Focal dystonia is also highly task-specific, and the symptoms involving involuntary contraction, loss of control, and fatigue may not even appear during activities other than the one which the dystonia adversely affects. For instance, a person who experiences dystonic contractions in a certain area of the body while playing an instrument, may not have the same problem while using the same muscle groups to use a tool. Sometimes, this task specificity can also mean that dystonic symptoms don’t appear when playing another instrument, or when doing near entirely similar activities. For example, a brass player with embouchure dystonia may not have problems playing with another instrument or mouthpiece, an affected string player may show no sign of dystonia while playing a different instrument requiring slightly different motions, and keyboardist may not experience any problems while typing (Watson, 2009, p. 261-263).<\/span><\/p>\n

In summary, focal dystonia develops over long periods of time through the intense practice of very specific, precise motions which engage very specific sets of muscle groups. The onset of symptoms is often gradual, with the notable characteristic of usually being painless. This painlessness, coupled with involuntary contracture is a generalized dystonic symptom. Likewise, the gradual deterioration of a precise, task-specific fine motor skill which was feasible in the past, the sense of fatigue only when applying that same skill, and the lack of improvement or even worsening of the condition with additional practice are all indicators that should hopefully serve as benchmarks to what focal dystonia feels like and how it develops. Writer’s cramp, tremors, embouchure dystonia, and musician’s hand dystonia are all essentially the same condition and operate on the same neurophysiological mechanism which we shall explore further. Controversially, traditional medicine has suggested that there is no known permanent \u201ccure,\u201d though in many cases, musicians have been able to recover by means of retraining the brain-muscle connections related to the dystonia (Solomon, 2007, p. 5). The dichotomy that exists between the conventional medical view of a proper cure for the disease (usually involving drug treatment), and long-term methods which involve retraining of the motor control in question will also be explored and examined.<\/span><\/p>\n

 <\/p>\n

The case in point<\/span><\/strong><\/span><\/p>\n

Here are two examples of professional musicians who have suffered from focal dystonia:<\/span><\/p>\n

Dominic Frasca<\/a><\/span> is a guitarist who specializes in contemporary music, using a ten string guitar and, in addition to a classically trained right hand finger picking technique, a vast array of extended techniques in order to perform nearly impossible technical feats. He developed severe dystonia of the right and left hands through the over-practice of these extended techniques, which has been reported as being sometimes up to fourteen hours per day. He was able to recover by taking a complete break from guitar playing, taking up Olympic weight training, and after a two-year period, subsequently retraining his technique (Griesgraber, 2005).<\/span><\/p>\n

Reinhard Goebel<\/a><\/span><\/span> was a baroque violinist who gradually developed dystonia in his left hand after years of practicing for at least eight hours a day, forcing him to completely relearn the violin, playing left-handed (backwards). He was able to play in this backwards configuration for nearly a decade, but switched back despite the dystonia because he felt he couldn’t achieve his former musicality while bowing left-handed. Eventually, he quit playing violin completely and became a conductor. Interestingly, Goebel speaks about being able to relax the muscles in his hand, and thus reducing dystonic symptoms by taking Alzheimer’s medication, but claims that the medicine was negatively affecting his mental health and personality, as well as other aspects of his life (Todes, 2009).<\/span><\/p>\n

The symptoms observed in these two cases are representative of a majority of dystonic patterns typically characteristic of guitarists and violinists who experience focal dystonia:<\/span><\/p>\n

The technical approach to the classical guitar, which including the rapid, sequential rippling motion of the right hand fingers and thumb, is most commonly affected by focal dystonia, with the tendency over time for these contractions to become less independent, and therefore less properly coordinated. The individual finger contractions which make up the fluid plucking action of the right hand become smeared together, in addition to involuntary contractions of the thumb. Put simply, more fingers than what is intended \u201cwant\u201d to pluck the strings of the guitar at the same time, and the sensibility of space, or timing between subsequent strokes of the fingers becomes uncontrollable, less deliberate, and less coordinated. Severe instances of such a dystonia would pose huge technical problems to the player in regard to what the music calls for, because every individual pluck, be it by the thumb or one of the fingers, should ideally have its own preparation stage, impulse (which coincides with contact with the string), and resolution towards the preparation of the next stroke. A good video example highlighting the recovery process of a patient of musician’s dystonia specialist Dr. Joaquin Fabra is shown below. Additionally, a simplification of a single dystonic contraction can be observed in the images in Figure 1.<\/span><\/p>\n

 <\/p>\n

[Video highlighting the improvements in a guitarist recoving from focal dystonia in the right hand. Pay close attention to the contrast between the before and after footage showing this musician’s progress, especially in regard to the ill effects the disease has on actual musical fluidity and expression in this particular case.]<\/strong><\/span><\/p>\n