Common Overuse Injuries in Musicians-Focal Dystonia

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Being a professional musician is like being a professional athlete. Maintaining physical and mental well-being directly influences musical performance. This month’s newsletter is the second in a series that will focus on overuse injuries in musicians.

What is Focal Dystonia?

Dystonia is a condition of intermittent or sustained involuntary muscle contractions that interfere with the ability to perform a certain task. The brain sends the wrong movement signal to the muscles causing uncontrollable and sometimes painful muscle spasms or poor movement patterns. There are many different types of dystonia. Focal task specific dystonia (FTSD) is the type that may be experienced by musicians. “Focal” means the dystonia affects a single body part or region where as generalized dystonia can affect half, most, or all of the body. “Task specific” means the dystonia was likely brought about because of the repetitive nature of a certain task such as playing a musical instrument. Additionally, the symptoms may only present while playing an instrument and may not appear when attempting to do a different task with the same muscle group.
FTSD has additional subcategories that are sometimes seen in musicians such as focal hand dystonia, embouchure dystonia, and laryngeal dystonia. A pianist experiencing focal hand dystonia may report a few fingers in one hand curling into the palm when attempting to play. The dysfunctional movement may be overt or subtle. It can be difficult to control and result in an inability to play passages quickly and cleanly. Embouchure dystonia presents in woodwind and brass instrumentalists. They report experiencing an inability to shape the mouth properly or buzz well into a mouthpiece. They may also report air leaks, a loss in range, and poor tone quality. Laryngeal dystonia can affect singers by limiting the vocal range or creating an airy quality to the voice.

What causes focal task specific dystonia?

The cause of FTSD is unknown. A doctor will rule out other possible causes of dystonia such as Parkinson’s disease, Huntington’s disease, Wilson’s disease, trauma to the brain, or the effects of medication or recreational drug use. However, if none of these issues prove to be the cause then the source of the issue may remain unknown. Health care professionals may look to a musician’s practice and performance experience for insight.  There is a correlation between excessive repetitive movements and the appearance of FTSD which explains why it may be seen in musicians along with writers, typists, hair stylists, painters, and athletes.

Why would repetitive movement be a problem?

Scientists aren’t sure, but brain studies suggest that something about the repetitive movement physically changes the brain which may then lead to the brain sending the wrong movement signals to the muscles.

How do I know if I have FTSD?

A doctor will ask questions about your symptoms, inquire about repetitive activity, do a physical assessment, and order laboratory and imaging tests to rule out other causes of dystonia. Beyond that, there are no specific tests that determine whether or not a person has FTSD.

Am I at risk of developing FTSD?

There are a number of factors to consider, though all or none may be present for someone experiencing FTSD:

  • Occupation

FTSD can affect any profession requiring repetitive movement, but it affects 1-2% of musicians which is more than any other professional group. 

  • Genetics

Twenty-five percent of people with FTSD also have a family member with the condition pointing to a possible genetic component. 

  • Mental State

Some people with FTSD also experience anxiety or perfectionism.

  • Anatomy

Anatomy, such as hand size, can play a role.

  • Prior incident

Some musicians report a physical injury, emotional stress, or period of increased practice time prior to the onset of the FTSD, but some report no preceding event at all.

How is it treated?
Not easily. There is no cure for FTSD so treatment focuses on relieving the symptoms of the condition, adapting to the condition, or attempting to retrain the brain and muscles.
Medical treatments include botulinum toxin injections or oral medications. Botulinum toxin can relieve muscle contractions and pain, but in exchange a patient may lose fine motor control that is needed to play an instrument. Oral medications provide only some relief and have side effects.
Surgery on the brain is an option in some extreme cases, but again, the quality of movement is not guaranteed. One surgery called thalamotomy involves the removal of part of the thalamus, a section in the brain responsible for involuntary movement. Another surgery is deep brain stimulation where an electrical device is implanted into the part of the brain to stimulate improved movement.   
Physical therapy is a conservative treatment that includes splinting and immobilization of the affected part, exercises to retrain the brain, and adaptation of the task so that it can be completed in a different way. 
Alternative therapies like Alexander technique and Feldenkrais have also been attempted with modest results.
Regardless of the treatment plan, the chance of a musician returning to previous functionality is low. Success stories do happen, but only after years of retraining.  
What can I do to prevent FTSD?
Take a close look at your practice and performance approach. Do you take breaks when your body needs it, or do you push through despite being mentally, emotionally, and physically tired? Do you give yourself a reasonable amount of time to learn the music, or do you push yourself to learn it faster than is a comfortable pace? When you practice, are your strategies always exactly the same, or do you mix it up and try many ways to learn the task? If you feel physically uncomfortable while playing or singing are you looking for ways to relieve the discomfort or do you push through it anyway? Do you manage your performance anxiety well, or does it deeply affect you? All of these considerations will help you take a healthier approach to your musicianship.

Professional musicians challenge their bodies to create their music. That’s why learning about overuse injuries and how to manage or prevent them is important for the success and longevity of participation in music performance. Watch for next month’s newsletter when a new music-related overuse injury is discussed.

Dystonia information (n.d)

Snaith, A., & Wade, D. (2014). Dystonia.
Stahl, C. M., & Frucht, S. J. (2016). Focal task-specific dystonia: A review and update.
Sadnicka, A. et al. (2018). A unifying motor control framework for task-specific dystonia.
Focal Dystonia (n.d)
Konczak, J. & Abbruzzese, G., (2013). Focal dystonia in musicians: linking motor symptoms to somatosensory dysfunction.

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