On Focal Dystonia (1)

By now, a fair number of people are aware that I am enrolled in a Bachelor of Science (Advanced Mathematics) degree at the University of Sydney. This knowledge has invariably (and to my great relief) been greeted with enthusiasm and kind support, and I am immensely grateful for this. However, I have never really fleshed out the details behind the circumstances – which I intend to do now with this blogpost. Many of my friends and colleagues at the Sydney Conservatorium will know that my retreat from violin performance is due to onset of focal dystonia in my left hand, a neurological condition which severely compromises coordination in the affected area(s). It has occurred to me that it might be useful (and not only to musicians) to describe in detail the symptoms of this condition, how it affects instrumental playing, the treatment I received, and finally, the steps I am taking to recover.

The word dystonia can refer to a variety of movement disorders, so clearly the keyword here is focal. Generally speaking, focal dystonia is a task-specific loss of coordination, and it apparently afflicts musicians frequently enough such that it is often also called “musician’s cramp” (Altenmüller & Jabusch, 2009). The well-known condition writer’s cramp is indeed a type of focal dystonia (Frucht, 2009). An instrumentalist can execute hundreds of intricate movements – think about the many varied and highly-detailed tasks which an accomplished violinist, pianist, trombonist or percussionist (to name only a few) must perform! These tasks are often trained from an early age, and in practice, often subject to many hours of repetition on a daily basis. It is an intricate system that nonetheless must endure a tremendous amount of physical and mental strain in the rehearsal room and ultimately on the concert platform. Hence there is a cruel irony in the fact that…

Focal dystonia … presents itself as muscular incoordination or loss of voluntary motor control of extensively trained movements while a musician is playing the instrument.

… Typically, musician’s dystonia occurs without pain, although muscle aching can present after prolonged spasms. Lack of pain distinguishes it from repetitive strain injury or occupational fatigue syndrome.

This definition, from a 2009 paper by Drs. Altenmüller and Jabusch, highlights the first important point I want to make about focal dystonia: The harder you try, the worse it gets.

To understand this, let’s unpack the definition a bit more: 1) dystonia is a loss of voluntary motor control – i.e. the musician experiences uncontrollable spasms; 2) the movements affected are extensively trained; 3) the involuntary spasms occur only when trying to play the instrument (in my case, for example, my left hand coordination was not at all compromised in other daily tasks like picking up objects or typing on a computer keyboard). As you can imagine, this creates the agonising situation where the musician knows exactly how a specific movement must be done, but when he or she tries to execute the motion on the instrument, somehow the body “refuses” to do it, and instead involuntary spasms occur. Although it has quite debilitating physical symptoms, focal dystonia is neurological disorder, and represents a “corruption of complex motor programs” acquired through extensive training (Frucht, 2009, p. 137). There is a substantial body of research that demonstrates how the “mapping” of the affected areas (usually the hands in the case of musicians, and embouchure in the specific case of wind and brass players) in the brain is distorted. In hindsight, this is quite a natural explanation. String players and pianists, and to some extent woodwind players, require complex patterns of fingerings, and even in relatively simple pieces, the work done by the fingers is not trivial! (NB. I have deliberately avoided discussing wind, brass and percussion players, since I clearly don’t have the expertise to make an informed comment in this area. No doubt, each of these instrumental groups have unique, respective problems). Furthermore, the independence of finger action when playing these instruments is extremely important even in the early stages. Thus the brain develops a highly delicate representation of each finger. A 2003 study conducted by Candia, Wienbruch et al. describes this neurophysiological aspect in great detail, and furthermore shows that successful treatment of focal hand dystonia does in fact reorganise digit representation in the somatosensory cortex.

I do not intend to turn this blogpost into a neuroscience paper (nor do I have the relevant qualifications), so I will leave it here as far as scientific details are concerned. Hopefully I have provided a clear framework in which I may now discuss my own experience with focal hand dystonia.

Click here for part 2 —>

References

Altenmüller, E. & Jabusch, H-C. (2009). Focal hand dystonia in musicians: phenomenology, etiology, and psychological trigger factors. Journal of Hand Therapy 22(2), 144-154.

Candia, V., Wienbruch, C., Elbert, T., Rockstroh, B. & Ray, W. (2003). Effective behavioral treatment of focal hand dystonia in musicians alters somatosensory cortical organization. Proceedings of the National Academy of Sciences 100(13), 7942-7946.

Frucht, S. (2009). Focal task-specific dystonia of the musicians’ hand—a practical approach for the clinician. Journal of Hand Therapy 22(2), 136-142.