Can Focal Dystonia Be Prevented?

“Begin slowly and increase gradually any unaccustomed use of the hands.”
–Michael Charness, MD (The Musician’s Way, p. 237)

Guitarists Billy McLaughlin and Liona Boyd, pianists Leon Fleischer and Gary Graffman – all are musicians whose careers were upended by the mysterious condition known as focal dystonia.

Focal dystonia is a movement disorder characterized by painless, involuntary muscle contractions that occur when a person does a particular activity.

The images shown here portray a guitarist’s hand and a trombonist’s embouchure during dystonic contractions.

Among the approximately 1% of professional musicians who develop focal dystonia, the effects are debilitating. Some who retrain can continue to perform, but few regain their pre-dystonia dexterity.

Possible Causes
Focal dystonia results from changes in the movement centers of the brain. Researchers haven’t pinned down exact causes, but the condition appears to arise from a combination of individual behavior and genetic predisposition.

That is, people afflicted with focal dystonia generally engaged in a skillful, repetitive activity across a span of years – the playing of instruments being a prime example.

Over time, usually decades, the program in the brain that they depend on to control their movements gets corrupted, and they lose command of certain task-specific actions.

For instance, pianists with focal dystonia might experience curling of the right 4th and 5th fingers when they play passages on a keyboard but those fingers will function normally when they do other activities.

Researchers also find that “focal dystonia appears more often in the more intensely used hand” (Jabusch and Altenmüller, 2006). Hence, pianists are more likely to be affected in the right hand, violinists in the left, although any muscle group could be involved, even arm and shoulder muscles.

Some musicians diagnosed with focal dystonia seem to develop it without any precipitating factor aside from long-term repetitive movement.

For others, the condition surfaces months or years following a change of instrument or technique, subsequent to a dramatic increase in playing time, or after they begin doing a new, skillful repetitive activity – say, a fingerstyle or classical guitarist starts playing with a pick.

In those types of situations, the process via which a musician’s brain acquires a new movement program corrupts the pre-existing one, and then dystonic contractions result (e.g., the fingerstyle guitarist would experience dystonia in the right hand when fingerpicking).

On top of that, physician Raoul Tubiana reports that the musicians he diagnosed with focal dystonia displayed awkward postural and movement habits.

It’s conceivable, then, that physical misuse contributes to provoking focal dystonia, maybe because musicians who move awkwardly foster more convoluted and corruption-prone wiring in their brains. But that’s just speculation on my part.

Given that focal dystonia can run in families, a genetic component seems certain.

According to the Dystonia Medical Research Foundation, “At present, researchers have recognized multiple forms of inheritable dystonia and have identified at least 13 genes or chromosomal locations responsible for the various manifestations.” Note that the forms of dystonia referred to in that quote don’t include focal dystonia, for which no culpable genes have yet been found.

Sensible Precautions
In light of the above information, it’s possible that some musicians could be genetically predestined to acquire focal dystonia no matter how gracefully they play owing to the ways in which prolonged repetitive motion affects their brains.

Still, the published research also implies that if we emphasize certain behaviors and avoid others, we can probably reduce the chances of focal dystonia arising.

So here are 7 precautions we can take that could help us sidestep focal dystonia as well as protect us from other music-related maladies.

1. Never push through fatigue or injury
If we continue to play or sing despite tired muscles or the impairment of injury, our brains have to concoct new movement programs to compensate, which could catalyze focal dystonia.

2. Increase playing or singing time in stages
Various sorts of injuries can occur when performers abruptly ramp up their music making, so we should always increase systematically – no more than 10-20% per week. I.e., we need to govern our practice schedules, let go of perfectionism, and regulate how much work we accept.

3. Acclimate gradually to any unfamiliar instrument
Let’s say that a saxophonist wants to take up the flute: How much time can he spend practicing the flute without damaging the sax-playing wiring in his brain? No one can say. For now, arts medicine experts recommend that we introduce such new skillful movements gradually. The same advice applies to the process of acclimating to a replacement instrument.

4. Initiate technical changes in increments
Some musicians with focal dystonic initiated extensive technical changes prior to their symptoms appearing. Again, researchers advise us to make modifications step by step.

5. Curb new hand-intensive or repetitive tasks
Becoming skillful at any repetitive task obliges us to establish fine motor programs. With that in mind, we should introduce new repetitive movements slowly and avoid unnecessary ones. For instance, instrumentalists who acquire notebook computers but have never handled touchpads or pointing sticks might want to use mice and restrict contact with those other more exacting interfaces.

6. Commit to healthy practice habits
All of us should limit repetition, minimize stress and tension, take frequent breaks, manage our workloads, and the like. See “The 12 Habits of Healthy Musicians.”

7. Adopt good use
When we employ good use in our musical activities, we act with optimum efficiency, which not only helps us ward off injury but also liberates our creative powers.

For more information regarding musicians’ wellness and injury prevention, see Chapters 12 & 13 of The Musician’s Way – dozens of photos are included that depict musicians employing good vs. poor postural habits.

Related posts
The 12 Habits of Healthy Musicians
Balanced Shoulders, Open Heart
Heeding the Signs of Injury
Sitting Tall
The Total Warm-Up

© 2011 Gerald Klickstein


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5 Responses to “Can Focal Dystonia Be Prevented?”

  1. Mark@Mussicians Wanted said:

    Sep 28, 11 at 03:51

    This is another great post on your blog. Thanks for sharing some safety precautions on focal dystonia. Its really a great help.

  2. mrG said:

    Sep 28, 11 at 09:58

    Dare I propose an eighth advice? I would add, “There is more to music than dexterity” and offer as evidence the many very compelling performances in all genres that do not depend on super-human motor control.

    I suppose it comes down to what it is we wish to do with this thing called music. If the purpose is to bridge a connection, dexterity is certainly not the most important element. When Sri Chimnoy lifted the front of an automobile on the steps of the UN and proclaimed that his method could achieve any physical goal, many musicians bought in on the plan, John McLaughlin and Carlos Santana among them, and their playing did quickly go beyond astounding, however in both of those cases and many more the mind-trick of speed and clarity soon lost its lustre. Because it failed to connect. Both men say they are still grateful for that training and still respect Sri Chimnoy and his methods, but I think they came to the same conclusion as Anthony Braxton just before he abandoned hyper-complex jazz to study world musics, as he put it in his Guelph keynote, that while these avenues of personal mastery may be interesting, “‘Interesting’ just isn’t interesting enough.”

    Personally I think it is sad when musicians like Liona walk away because of a nervous twitch, no matter how bad it may be; I believe someone can stutter and still have something important to say!

  3. Jon said:

    Sep 21, 13 at 06:33

    Excellent post. And yes, I am quite certain that Musician’s Focal Dystonia can be solved and prevented by focussing on efficiency of body mechanics, mental direction/intention, and a positive neuro-asociation to playing the instrument.

  4. Gerald Klickstein said:

    Sep 21, 13 at 19:27

    Thanks for reading and commenting, Jon.

    Although many musicians with focal dystonia could probably have prevented their symptoms by engaging in different playing/movement habits, according to my research, we can’t conclude that all incidences of FD could have been averted if musicians played differently.

    Some musicians may be genetically wired such that they would get FD no matter how they played – repetitive movements of any sort would be enough.

    And given that the vast majority of musicians who move in quirky ways and engage in unhealthy playing habits don’t get FD, genetic factors must play a significant role, and I wouldn’t want us to blame musicians with FD for their genetic predisposition.

    That said, we educators should do all we can to ensure that musicians know about FD and that they take sensible precautions to minimize the likelihood that it would arise.

  5. Jon said:

    Sep 25, 13 at 12:30

    I agree completely! I should have written “Musician’s Focal Dystonia can be solved and prevented in many cases”.

    Genetics certainly must play an important role as you say.