Musicians with Dystonia: practice makes imperfect

by Carl Ellenberger, MD
The music of Robert Schumann remains vital and wondrous in the universe of classical music. Perhaps we should thank 'dysfunctional brain plasticity' for it. At the age of 19 when he was studying law against his wishes while also a piano student competing with his teacher's daughter Clara, with whom he was in love against her father's wishes, drinking too much, actively searching for his sexual identity, feeling anxious and depressed, and fighting loneliness after his teacher took Clara away for months, Schumann began to lose control of the middle finger of his right hand. He tried various remedies to no avail, including mechanical contraptions and also a cutting-edge medical treatment of 1831, "inserting the ailing extremity into the moist belly of a slaughtered animal." Thereafter, Schumann turned from performing to writing music and writing about music(1).

Background

At the intersection of two major domains, modern medicine and musical pedagogy, dystonia of musicians seems to have been largely appropriated by the medical domain, especially since the recent surge of interest in medical problems of performing artists. When Schumann sought medical help, he found a quack remedy. Quack remedies exist today, as do misguided ones, such as surgical cutting of ligaments and tendons. Though neuroscience now could offer him a better understanding of the problem thanks to accumulating observations of cases and neuroimaging, modern medicine could probably not restore Schumann's full ability as a pianist. Botox injections and various drugs and behavioral therapies may partially help some victims -- but often at the expense of side effects incompatible with playing an instrument.

One obstacle is that we face many diverse individual examples of the condition. Though we can easily divide them into two broad categories: extremity (arms and fingers) and embouchure dystonia, each musician has his or her own version and no single solution fits all cases like insulin improves diabetes. But we have achieved better understanding of the basic nature of all these problems: they originate in parts of the brain. Unfortunately, there they are subject to myriad influences, including genetic heritage, character, personality, life style, toxins not limited to alcohol, sleep patterns, emotions, life stress and performance anxiety.

Even some of the conventional statistics like prevalence are uncertain because they derive from self-selection of subjects, self-evaluation ("on a scale from 1 to 10"), and data collected retrospectively by interviews and questionnaires.  The diagnosis in many of these cases may not be certain. Swallow this 'conclusion' from an expert in the field:

"Taken together, epidemiological findings indicate that the amount of workload of the respective body part, the complexity of movements and the degree of spatial and temporal sensorimotor precision as well as the level of social constraints associated with the musical performance were related to musician’s dystonia."

So our understanding is still limited as we try to help.

What is Dystonia?

Dystonia of musicians may be a dead-end branch of the evolutionary tree, a maladaptation that happens when the human brain (of certain vulnerable humans; see below) is called upon time after time to do one of the most complex motor tasks of all, beyond the limits of capability of most of us, like playing a Schumann (not to mention Scriabin or Rachmaninov) etude.(2)

Dys (bad) tonia (muscle tone) means involuntary muscle contraction, the inability to not contract muscles when that would be appropriate, as when controlling each finger independently or shaping an embouchure. The resulting loss of control is not due to weakness. When a flexor muscle contracts, its opposite, an extensor muscle, must relax; if both the biceps and triceps contract at the same time, the forearm doesn't move or performs a clumsy writhing movement as both muscles try to prevail. The long-recognized generalized familial form of the condition, dystonia musculorum deformans, affects most muscles usually early in life. The focal form, often "task specific," usually involves small integrated groups of muscles used repetitively for years to perform the same particular task. Dystonia in musicians is task specific.

A common form of task-specific focal dystonia, writer's cramp, illustrates a key characteristic of task-specific dystonia: it usually appears only when writing with a pen or pencil, not for example, when typing or using a knife or fork. A violinist may experience dystonia, usually in the left hand, only when playing the violin, not the viola, as most violinists don't do very often. My teacher had it when he reached his 60's; he became unable to control his third and fourth fingers independently only when playing the piccolo not the flute. So it is clear that sensory input--signals sent back to the brain from muscles and joints as they contract and move--plays a role. The problem involves sensory-motor integration.(3)

In a minority of cases dystonia may spread from one task to another -- from playing the flute to typing, for example -- illustrating that some individuals may indeed have a genetic vulnerability. 

Writers can sometimes minimize cramping by using a fat pen -- that feels different in the hand than a thin one and sends slightly different signals back to the brain. Such a maneuver is called a 'sensory trick.' A similar one may be employed by victims of torticollis, involuntary head turning. If they gently touch the side of the chin on the side the head turns to, using no effort to overcome the rogue rotator muscles, the torticollis may stop--temporarily. Musicians can learn sensory tricks too (see below).

Typically, the disorder comes in varying degrees as well as different patterns and locations.

Who has Dystonia?

Well-known musician's with dystonia include pianists Leon Fleischer and Gary Graffman and violinist Peter Oundjian of the Tokyo Quartet, turned conductor. They and other victims, like Schumann, turned their careers around in mid-life and made other distinguished musical contributions. But musicians with lesser degrees of the problem, those unaware that they have it, and those who have not chosen to 'out' themselves for fear of losing engagements, may confound the statistics of its prevalence, now thought to be about 1 percent of all classical musicians.

Uncertainty also attends the observation that men are far (6:1) more often affected than women; a large "gender bias." Classical musicians are mainly affected not only because they practice Ericsson's 10,000 hours to compete for limited opportunities, but also probably because they are subject to more strict restraints than jazz and pop musicians. You don't, for example, play a difficult Chopin Etude in an easier key, rewrite an Elliott Carter quintet to make it playable up to tempo, or turn repeated failed articulations in the trumpet opening of Mahler 5 into your signature jazz style. You have to 'nail' the notes exactly as written, exactly at the right time, and without the advantage of three strikes.

Some musicians who believe they have dystonia may actually have one of a variety of other neurological problems that mimic dystonia. (That's why a neurologist with special competence is necessary, see below).

Embouchure dystonia(4), more recently recognized, is most difficult to overcome; few of its victims can continue their careers (some have; see below). Instrumentalists most affected by any type of dystonia seem to be: pianists > guitarists > violinists > flutists > clarinetists > trombonists, roughly in order of the perceived complexity of execution. Like many of the numbers above this data come from the German musical community(5).

What causes dystonia?

Ironically, in the past the cause of musician's dystonia was thought to be "overuse," that is, overuse of the machinery: muscles, tendons, joints, 'chops.' But now we know that to the extent that the term "overuse" applies, it more aptly refers to overuse of a part of the brain. Musicians who play casually or technically simple music are rarely affected because they don't have to practice 'over and over' for many hours. In one sense (and only one sense) the problem seems to me comparable to wheels making ruts in a road by using the same path over and over; eventually the ruts become too deep and your carriage can't go anywhere but to follow the ruts, even if they go to the wrong place.

I really don't intend to contribute the term, "brain ruts," to the discussion, but I will try to simplify a little pathophysiology. Also critical for 'muscle memory' that musicians speak about, impaired sensory-motor integration underlies dystonia(3): one parcel of the cerebral cortex sends command signals to the fingers or embouchure which, in responding, send signals back to another parcel. Both the initial motor message and the sensory reply are 'integrated' and routed to other parcels some of which record that activity. The recording -- a growing library of 'muscle memory' -- helps facilitate, or prompt, the same activity each time it occurs again, first by enhancing chemical transmission (neurotransmitters) in the connections activated, and eventually by building more anatomic connections to help perform that particular task. The enhanced neurotransmission may explain why you improve by multiple repetitions of a passage during one session; the enhanced anatomic connections probably explain why the passages you learn today stay with you longer--much longer if you're in your 'sensitive' adolescent learning period. Ultimately, innumerable repetitions build a network of lasting connections to enable fingering, for example, an F to F#. Of course numbers of cells and connecting elements involved number in millions.

One indicator of brain 'plasticity' is the enlargement of a specific area of cerebral cortex (gray mater on the brain surface) in response to the intensity and duration in which that area is called upon for use. For example, the areas of motor and sensory cortex activated by fingering a violin with the left hand in the right hemisphere of the brain, expand with practice to larger size than the corresponding areas in the left hemisphere because the fingers of the bowing right hand, while not unimportant, perform less complex individual tasks. 

Areas, and thus actual volume, of brain cortex expand (we see this by MRI) because as they develop more fibers (axons), connections (dendritic spines, synapses), brain cells, and support matrix. Motor and sensory cortical areas for fingers and lips lie adjacent to one another in the frontal and parietal lobes. They overlap to some degree and theoretically, at least, expansion of the network for one finger could invade the network of another and vice versa. I wonder whether facial movements of violinists and pianists -- obvious when filmed close up (see a video of Leon Fleisher playing, or conducting) -- reflect this proximity of the fingers and face in the cortex; activity in the finger area spilling over into the face and lip area. Obviously, this observation and theory predict the likelihood of embouchure dystonia is increased in musicians with finger dystonia and vice versa; some data suggests this may be true. Exactly what happens on a microscopic or cellular level to cause dystonia also remains uncertain. 

Studies have shown that at least some musicians with dystonia have a genetic vulnerability for it: their brain's neural firmware may have been abnormal from birth. And evidence suggests that their individual finger areas in the cortex are indistinct or overlapping, at least more than in the rest of us. Most of them, of course, would never have noticed their defect if they hadn't stressed it by long hard practice, though some -- more than among the general population -- might have experienced other forms of dystonia, such as writer's cramp, torticollis, blepharospasm (eye closing), etc, or noticed it among family members and/or ancestors. Exactly what this inherited firmware defect is, and the genes involved, have not yet been determined but evidence comes from thorough exploration of family histories and techniques like functional MRI and electrical recording.

Finally, every human symptom, like 'headaches, pain, dizziness and blackouts' (a neurologist's daily bread), can be caused or magnified by depression and anxiety, often unrecognized by the victim, and related to stress. Musician's dystonia is no exception. Enduring a divorce, a succession of failed auditions, or performance anxiety can contribute. There are good reasons to incriminate the increasingly rigorous orchestral audition as a causative factor. Perfection is the goal when you compete with hundreds of other candidates for one chair, but there are inevitable casualties in the process as evidenced by so many principal players felled by dystonia.

Origin of dystonia in musicians, photo from (5)

What to do?

"Treatment" doesn't seem to be quite the right word, at least in the sense of medical treatment. Neuroscience has provided a better understanding of musician's dystonia but treatments based on this knowledge so far -- Botox, medications, behavioral therapy -- have only raised hope and succeeded partially in a few isolated cases. Prescribed rest periods have rarely helped in my experience. 

That said, an important first step is to consult a physician -- in almost all cases a neurologist -- who has special competence and experience in evaluating musicians. (If a consultant does not request you to bring your instrument to the consultation, he is not one of them.) Such consultants are rare because the problem is rare and few neurologists have seen any patients who have it. This step is important because  a host of other neurological problems can mistaken for dystonia, like ulnar neuropathy, early Parkinsonism, etc. 

If the diagnosis is indeed dystonia, the neurologist will assess the possibility that the one potentially effective purely medical treatment might be helpful and to what degree it might help. (That degree is rarely 100%). That treatment is a very targeted injection into carefully targeted small muscles to weaken those that inappropriately contract when they shouldn't. Choosing the one or more small muscles is a very difficult task.(6)

For now I believe that good problem-solving music teachers may also offer promising strategies. Most are based on the principle of relearning (reprogramming, rebooting, or restarting in computer jargon) 'from scratch' in the realm of the particular problem; be it bowing, fingering in some wind players, embouchure shaping, and others. This slow, starting-over change in practice behavior might, as in aphasic stroke patients regaining ability to speak, generate alternative networks and pathways in the brain, a detour around the ruts in the road, if you will. 

This method was used successfully by trombonist David Vining who described his struggle with embouchure dystonia to Chamber Music Magazine(7). His strategy was to restart his trombone career by practicing musical passages while just blowing into the instrument without buzzing his lips. Only months after playing "air trombone" did he begin again to learn how to produce a sound as if he were a child learning it for the first time. Any wind player could try the same strategy.

That strategy falls into the realm of "sensory tricks" as mentioned above. Similarly, flutists have had variable/temporary success by applying tape to the lip plate or perhaps even by changing to an instrument with a different "feel," or installing variety of 'handles' on their instrument so that holding it sends different signals to the brain. String players, of course, can try instruments of different sizes and perhaps balance. (I am not aware of any attempts to play 'left-handed' like a baseball batter, or of pianists changing to the harpsichord or organ.)

One might ask whether musicians who learn 'bad' playing habits from the start may be more vulnerable to dystonia later. I am not aware of evidence addressing that question. That information would be difficult to obtain and bad habits for one teacher may be tolerable or normal habits for others. (Think of Glenn Gould.) Nevertheless, Vining believes that his initial intense approach to playing, that I have observed in other trombonists, employing more effort than necessary to create an embouchure, may have contributed to his problem. When he restarted after studying the Alexander and similar techniques, his new approach was more 'laid back' and relaxed. Certainly some bad habits can lead to other problems down the road like pain, fatigue and tendonitis. 

You might also ask how one might minimize from the beginning the risk of 'contracting' dystonia in the first place. The answer is, of course, we don't know, but that won't stop me from speculating. I would say to young musicians: relax, lay back, don't push, practice slowly and deliberately and stop before you become frustrated with any particular passage. You can always try it again tomorrow. Substitute regular daily practicing -- one or more sessions -- for long intense sessions in which you try to completely master a difficult passage all at one time. In the beginning, we learned to play fast passages slowly, gradually building up to the necessary tempo.  Take any passage that elicits dystonia and slow it down to a speed that avoids the problem and then play that repetitively. Every day. And others like it that employ the same fingers that you can play over and over without dystonia. Wear new ruts into the road.

If something like dystonia appears only after a period of playing, or if intense practicing seems to make a passage worse, stop playing and start again an hour or more later, or tomorrow. Avoid anger and frustration Take a break! If you tend to be tense when playing, by all means investigate one of the relaxation methods like the Alexander technique. 

We are at a similar point in understanding sleep disorders. We don't have a universal single/simple treatment that fits all. But we do know enough about the problem to begin to develop recommendations under the heading of "sleep hygiene." So what I recommend here is perhaps what we might call "practice hygiene." In both cases, especially dystonia, we are also talking about a process that takes months if not longer -- perhaps as long as it took to master your technique when you were in junior high school -- and an effort that never ends.

Personally, I have learned that dystonia can be more of a problem when one is insecure with any passage of music, because of inadequate practice or rehearsal, so that another aspect of 'rehabilitation' can be to learn potentially troublesome passages cold, starting slowly, even to the point of learning them by memory. Greater confidence minimizes the chance of any problem, including dystonia. Often when working on difficult passages I have to stop myself and think, 'relax, lay back," the planet will not stop rotating if you don't immediately get this right! Of course, a variety of relaxation techniques, good sleep habits, exercise -- all healthy life-style activities in general, can help to reduce stress and improve the chance of success. All easy enough to say, not necessarily to accomplish, especially with a audition approaching, and by no means a cure for every problem.

Readers with dystonia may have tried some of the above strategies that might apply to them. Because I suspect that we hear more about career-changing failures and too little from those who have succeeded, especially to the point of being able to continue playing, their stories could be helpful. Click on 'Comments' below.

Understanding the basic science underlying dystonia could be the first step in overcoming it by altering and adapting practice techniques. This is not a condition where doctor shopping or, "You're the doctor, treat me," often succeeds. When a competent neurologist has confirmed the diagnosis, one alternative might be, 'ask a good music teacher' -- a teacher experienced in solving all kinds of problems. Teachers, too should take heed, especially the demanding slave-driver types. (I can only wonder what contribution Schumann's old teacher, Fred Wieck, made to his distresses.) Or talk to colleagues who have overcome a problem and consider adapting their methods to your problem. For now, however, prognosis remains uncertain and careers continue to be altered.

Leave a Comment. Are there any success stories?

*Further reading:

1. Schumann: Music and Madness, Peter Ostwald, 1985, Victor Gollanz Ltd, London
2. Altenmuller EO. From Laetoli to Carnegie: Evolution of the Brain and Hands as Prerequisites of Music Performance in Light of Music Physiology and Neurobiology
3.  Haslinger B, et al. Sensorimotor overactivity as a pathophysiologic trait of embouchure dystonia. Neurology, 2010 Jun 1;74(22): 1790-7
4. Frucht SJ. Embouchure dystonia: a video guide to diagnosis and evaluation. J Clin Mov Disord. 2016 Jun 18;3:10.

5 Jabusch H Altermüller e: Focal dystonia in musicians: From phenomenology to therapy. Adv Cog Psychol. 2;207-220, 2005
6. Frucht SJ. Evaluating the musician with dystonia of the upper limb: a practical approach with video demonstration. J Clin Mov Disord. 2015;2:16
7. David Vining, see Chamber Music Magazine, Fall 2012, p. 81, and mountainpeakmusic.com

Watch Leon Fleisher tell his story on PBS