How to Practise When You Can’t Practise (On Focal Dystonia – final)

<— back to part 3b

Re-learning and Recovery

(*My apologies for not writing sooner, it has been a very busy time at Uni with many assessments due recently!)

There are some words which (bad) writers of popular science like to throw around in order to sound impressive. Quantum is perhaps among the most frequently abused terms, for instance. Another would be statistically speaking. (Did you really analyse the sample distributions, and compute the variance and correlation coefficients? Didn’t think so). Another buzzword, and the one pertinent to our discussion here, is neuroplasticity. Fortunately, unlike quantum field theory and statistics, we don’t have to pretend to understand neuroplasticity, since there are many cases where it is clearly visible, and I believe its core concepts are readily grasped by the general public. In addition, popular science titles like The Brain That Changes Itself by the neuroscientist Norman Doidge certainly increase public awareness and understanding of this issue. We can observe directly that the brain is capable of remarkable change and adaptation.  One of the most dramatic and convincing examples of this is the phenomenon of “phantom limbs” — the ability to feel pain or itching or other sensations in missing limbs. If you are interested, I will save you from googling for unreliable sources, and link this journal article by Ramachandran & Ramachandran (2000). The important and (at the time) revolutionary idea is that the brain is not a static organ. The brain map can be reorganised — new neural networks can be created, and the physical topography of the brain is susceptible to change. This is reassuring for those with dystonia. It means that there is a possibility of “unlearning” the dystonic movements, and creating new neural pathways to replace the old, misbehaving ones. Many dystonia researchers now recognise re-training as a viable treatment option, and from a musician’s point of view, I believe it is also the most useful and least harmful. Medical treatments can work very well for some individuals — and depending on the severity of the symptoms, may even be essential — but the prospect of taking botox injections several times a year, for example, is not exactly pretty. However, re-training requires considerable time investment and dedication… then again, isn’t this exactly like learning a musical instrument!

The first and arguably most difficult step is simply to recognise a need for re-training, if one desires to play the instrument again. Of course, this involves getting through the denial phase, in which one tries to practise “through” the dystonia (as I, and likely many others, have done), and inevitably to no avail. If you recall the main points I raised in the preceding section on the psychological aspects of focal dystonia, you’ll see that getting through this initial stage is in itself a challenge. One must learn to accept the circumstances imposed by the disorder, and resolve to find a new way. In my experience, I have felt the need to redevelop my left-hand technique from “first principles”, to borrow an important scientific term. This means that I return to the most basic aspects of violin playing, and derive more advanced concepts and techniques from these foundations. In the early stages, my “practice” would often involve simply holding the violin, and I would ask myself questions such as these:

  1. When playing, where does the instrument “sit”? (Generally speaking, on the collarbone)
  2. How is the violin supported? (In my view, it’s not as simple as you might think!)
  3. What is the most natural position for the left hand for me? (Everyone has a different hand)
  4. Where does the thumb sit in relation to the other fingers? What is the best set-up for me?
  5. What are the most natural ways of shifting (moving around the fingerboard)?

These are of course specific to violin playing. But it is necessary to consider some important questions from the neurological perspective too:

  1. Where is the dystonia localised? — There is more to this question than meets the eye. When I first realised I had the condition, I noticed that I could not control the middle finger. However, when I visited Dr. Altenmüller in February 2014, he showed that the behaviour of my middle finger was explained by involuntary flexion of the muscle controlling the ring finger, and hence that was where he administered the botox treatment.
  2. What is the trigger for the dystonic movements — i.e. what are the specific circumstances under which the dystonia manifests? In my case, when the condition was at its worst, simply placing the fingers of the left hand onto the fingerboard would trigger the incoordination. I later managed to narrow the trigger down to the specific sensation of pressing onto the strings themselves.
  3. Having now identified the trigger(s), can I remove myself from the specific circumstances to re-train the movements anew? — Yes, absolutely. In my case, I found it beneficial to stop playing the violin entirely for a while. After a period of complete rest, I started to practise violinistic movements away from the violin, then transitioning onto the instrument. I also practised various general finger coordination exercises which I collected from a mix of consultations with a physiotherapist, reading articles about dystonia, and talking with other musicians who have had similar issues.

I will mention briefly here a technique which has been described as sensory trick in various articles (for instance, see Butler & Rosencrantz, 2006a, pp79-80). Essentially, it plays on the specificity of the medium which sets off the incoordination. String players with FD will find that it may be possible to play “normally” while wearing a latex glove. A logical extension of this exercise is to cut off the tip for one of the digits of the glove, thus exposing a particular finger to the string. In this way, one can very gradually “teach” the hand, one finger at a time, not to react negatively to the sensation of the strings. Such a strange result demonstrates once again that the brain is a highly complex and sensitive organ!

Unfortunately, this final part of the blog series must necessarily be incomplete. My recovery from focal dystonia is still very much a work in progress, and no doubt I will continue to learn and discover new things. In between the homework and studying for my new Science degree at USyd, I try to allocate some time every day to violin practice, or failing that, I will then devote a significant part of the weekend to “catch-up”. Progress is slow, and I have had to learn to be very patient in all that I do concerning violin practice. There is a lot to think about, much to experiment with, and there are many hurdles to overcome. There will be days when you feel that everything has improved, and other days when you feel that nothing is working. In short, the recovery process is not so much a straight line, as it is better described by a function such as y = A(sin nx + x), , where x ≥ 0, and A and n are arbitrary constants chosen such that your graph looks pretty. Sorry, I couldn’t resist.

y = (1/2)(sin 2x + x)
(Click on the graph for full size)

(In the graph above, A = ½ and n = 2, if you were curious). Throughout all the ups and downs, it is important to keep in mind the overall progress. While there is still a long way to go, I have certainly made significant improvements since last year.

To conclude, I’d like to share some key pieces of information with respect to recovery from focal dystonia. Hopefully it will be useful to those afflicted by dystonia, and possibly also to musicians affected by any other occupational disorder or injury:

  • Being incapacitated as a performing musician will take an emotional or psychological toll. Be prepared and unafraid to deal with these consequences, and most importantly, do not feel ashamed to seek help!
  • Understand the condition — read about it, do research, consult professionals. Decide whether medical intervention is the right approach for you.
  • Share your experience with friends and colleagues. You never know where you might obtain valuable advice, and even important contacts.
  • In the beginning stages of recovery, practise little but often — that is, enforce a maximum of 15-20 minutes for each practice session, and even less if the dystonic movements are particularly troublesome. However, try to maintain regular practice nonetheless (hence, “little but often”).
  • Think about playing more than you actually play. Analyse the mechanics of playing your instrument. Mindless practice is simply wasted time. This probably applies to all musicians, with or without injury!
  • Be content with small victories. This is not the same as accepting defeat, or being complacent; rather it is a reminder to be realistic with your practice goals! If you’ve just suffered an injury, you cannot expect yourself to be playing Paganini caprices after a few days.
  • Continuing on from the point above, make very specific practice goals, and make comparative goals. The opposite of this is a blanket statement like “get left hand back to normal”, which is worse than useless for someone with focal dystonia. In my case, a realistic, specific goal might simply be: “to gain a level of control over the middle finger on the D string that was better than the situation on Thursday.” Another good one would be: “to reproduce the relaxed hand position attained yesterday and apply it to Sevcik finger-action exercises.”

My final bit of advice is to recognize that positive realistic thinking is of utmost importance. When combined with flexible problem-solving skills, I believe one can make excellent progress. It is no exaggeration to say that focal dystonia has been life-changing for me, and certainly not in the cheesy motivational documentary sort of way. Having spent most of my life up to now being heavily involved in classical music, suddenly enrolling in a Science degree is quite a dramatic, but definitely a welcome change in direction. In fact, these new experiences have only further enriched my thinking, expanded my knowledge and understanding of the world, and increased my curiosity and love of learning. I have also managed to maintain some presence in the musical community through teaching students and writing music, both of which I find immensely rewarding. It is tempting to think what might have happened, if I had never contracted focal dystonia. But I’m fairly convinced that the Me in that alternate universe is travelling a path far less interesting than the one I am experiencing right now.

You can now download a PDF file of my complete series of my blogposts on focal dystonia.

Selected References on Focal Dystonia

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.

Altenmüller, E., & Jabusch, H.-C. (2010). Focal Dystonia in Musicians: Phenomenology, Pathophysiology, Triggering Factors, and Treatment. Medical Problems of Performing Artists, 25(1), 3-9.

Butler, K., & Rosenkranz, K. (2006). Focal Hand Dystonia Affecting Musicians. Part I: An Overview of Epidemiology, Pathophysiology And Medical Treatments. Journal of Hand Therapy, 11(3), 72-78.

Butler, K., & Rosenkranz, K. (2006a). Focal Hand Dystonia Affecting Musicians. Part II: An Overview of Current Rehabilitative Treatment Techniques. Journal of Hand Therapy, 11(3), 79-87.

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.

Farias, J. (2012). Intertwined: How to induce neuroplasticity. A new approach to rehabilitating dystonias. Galene Editions.

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

Ioannou, C. I., & Altenmüller, E. (2014). Psychological characteristics in musician’s dystonia: A new diagnostic classification. Neuropsychologia, 61, 80-88.

Jabusch, H.-C., Zschucke, D., Schmidt, A., Schuele, S., & Altenmüller, E. (2005). Focal Dystonia in Musicians: Treatment Strategies and Long-term Outcome in 144 Patients. Movement Disorders, 20(12), 1623-1626.

Lim, V., Altenmüller, E., & Bradshaw, J. L. (2001). Focal dystonia: Current theories. Human Movement Science, 20, 875-914.

Münte, T. F., Altenmüller, E., & Jäncke, L. (2002). The musician’s brain as a model of neuroplasticity. Nature Reviews, 3, 473-478.

Sacks, O. (2008). Musicophilia: Tales of Music and the Brain. London: Picador.

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