On Focal Dystonia (3a)

<— back to part 2

In the previous part, I recounted my experience with focal dystonia. In these subsequent installments, I would like to address more general issues, including the prevalence of dystonia in classical musicians and the psychology of dystonia. Finally, I will conclude by describing some possible steps towards overcoming the disorder. Originally, I had intended this to be a single post, but it appears that there are many details worth discussing, and hence, just like the Hobbit movies, I will expand it into three parts.

Who gets focal dystonia?

Although I have only browsed just over a dozen articles on focal dystonia in musicians, there is already significant variation in the estimate of musicians afflicted by this condition [I will provide a full reference list at the very end of this series of posts]. Several articles have stated that FD affects ~1% of professional musicians — I assume they mean classical musicians, but more about that later. However, Jabusch et al. (2005) claim that FD affects ~1% of “all musicians”, whatever that means. Given that a defining characteristic of FD is that it mostly affects extensively trained movements, perhaps they left  out the word “professional”?  To complicate things further, Butler & Rosenkranz (2006) report the prevalence of FD among professional musicians as 2-10% (citing three other papers), which is surely a non-trivial variation! However, this paper is also one of the very few to acknowledge that FD might be more common that is often reported, so it is worth keeping these figures in mind.

Some other interesting details:

• It is generally recognised that classical musicians are at the highest risk of developing FD. In Butler & Rosenkranz’s article, the researchers estimate that 95% of cases are attributed to classical musicians, implying that the remaining 5% accounts for jazz and pop musicians. This is an extremely significant number, and strongly suggests that there are specific occupational “hazards” in the training and development of a career in classical music.
• Consistently, it is shown that there is a much higher incidence of FD among males than females. I have yet to find a detailed explanation for this. Lim et al. (2001) speculate that this may be due to inherent gender biases in the classical music industry (“An explanation might be that males are represented at higher levels of music performance and that the gender bias may result from the type of instruments played”). However, the gender divide is slowly disappearing in classical music, so this argument is perhaps not so strong.
• Some researchers have acknowledged that genetics may influence one’s susceptibility to dystonia (e.g. family history of movement disorders). However, my siblings and I are the first generation in my family to have studied any musical instrument in a rigorous manner, and there are undoubtedly many others in the same situation, so this perspective is not particularly useful in my case. A brief review of the literature in the article by Lim et al. shows that the research in this area is inconclusive. The proportion of FD patients who also had family history of some type of dystonia or other movement disorders ranged from 0% at one end, to 25% at the other extreme.

“Classical conditioning”

(My apologies to Pavlov for misappropriating this term. And if this reference doesn’t ring a bell for you, then… oh, I think I just ruined the joke).

It is fair to say that classical musicians spend most of their lives practising. Many start their training early: for pianists and violinists especially, starting at the age of 4 or 5 is not uncommon. Furthermore, those who are particularly talented acquire new skills and techniques, learn repertoire, and in general ‘absorb’ music rapidly. Steven Frucht, in his 2009 article which gives diagnostic advice to the clinician, notes astutely that for accomplished musicians, “the idea that instrumental performance can be challenging is often foreign. Many are unaware of the mechanics involved in their own playing and may have never analysed their physical approach to the instrument.” We can observe the remarkable abilities of young violinists in, for instance, international competitions, where 12-year-olds effortlessly perform technically demanding works by Paganini and Wieniawski and more. Regardless of natural talent however, the common denominator is that to make any progress at all on a musical instrument, there must be a consistent and persistent investment of time and effort — that is, regular, even daily practice over many years. Furthermore, the way we practise is also a distinctive aspect of classical music training. In order to excel, disciplined study and practice is necessary. When a student is young, this discipline may often be imposed by parents and teachers, but later may well develop into an internal motivation to develop and succeed. Indeed, this seems to characterise the best musicians: for them, practice does not come as a chore, but becomes a necessary part of their artistry, as they continually refine their techniques and expand their palette of musical expression.

What defines mastery of a musical instrument, at least in my opinion, is the illusion of ease. This is not a difficult concept to grasp. After all, we admire top tennis players like Roger Federer or Serena Williams, for whom nothing seems to be impossible as they move effortlessly from one incredible shot to another. Similarly, who has not thought to themselves, after a performance from the likes of Martha Argerich, Frank Peter Zimmerman, Christian Lindberg, or John Coltrane, or [insert your favourite artist here], “how does it look so easy for them?” Admittedly, Coltrane is a bit of an anomaly. As I wrote above, FD affects classical musicians disproportionately. Altenmüller & Jabusch (2010) have also noted: “in contrast to pop or jazz music with improvised structures and great freedom of interpretation, musical constraints are most severe in classical music.” The ideal of perfection in classical music has often been considered an important factor contributing to FD. This is where we tread the fine line between pushing ourselves to develop our craft to its highest potential, or simply becoming harmfully fixated and obsessing over the most intricate details. On the one hand, playing any instrument at a high level requires a tremendous amount of careful, disciplined practice, simply in order to learn the hundreds of complex tasks necessary to performance. On the other hand, there is a limit to how much we can take before we feel the physical and emotional/mental consequences. A catchy phrase that has become popular in education is “work smarter, not harder.” Unfortunately, musicians (and I suppose athletes too) do not have that luxury. We must work very hard and very smart. I also think that recording technology has not helped in this regard. These days we are far too accustomed to “perfect” recordings of classical works, where it is possible to edit virtually every note, and not a scratch to be heard. This creates some unrealistic expectations for both performer and listener of what a performance should sound like, and perhaps unrealistic ideals of what is physically possible in performance. I say “perhaps”, because it is undeniable that the technical abilities of the top performers are extraordinary, but without the power of multiple takes and state-of-the-art audio editing, we are nonetheless all human.

These unique features of classical music training have certainly been understood by researchers of musician’s focal dystonia, and many suggest that there are specific psychological pressures associated with this kind of learning environment which contribute to the onset of the disorder. However, the good news is that a solid understanding of these psychological factors may prove to be one of the most helpful ways of overcoming focal dystonia.

to part 3b —>