Can Focal Dystonia Be Prevented?

September 26, 2011, 7:34 AM ·


“Begin slowly and increase gradually any unaccustomed use of the hands.”
–Michael Charness, MD (The Musician’s Way, p. 237) 

Violinist Peter Oundjian, guitarist Liona Boyd, pianists Leon Fleischer and Gary Graffman – all are musicians whose careers were upended by the mysterious condition known as focal dystonia (FD).

FD is a movement disorder characterized by painless, involuntary muscle contractions that occur when a person does a particular activity.Left hand of a violinist with focal dystonia

The image at right shows a violinist's left hand during dystonic contractions.

Among the approximately 1% of musicians who develop FD, the effects are debilitating. Some who retrain can continue to perform, but few regain their pre-dystonia dexterity.

Possible Causes
FD results from changes in the movement centers of the brain. Researchers haven’t pinned down exact causes, but the condition appears to arise from a combination of behavior and genetic predisposition.

That is, people afflicted with FD generally engaged in a skillful, repetitive activity across a span of years – the playing of instruments being a prime example.

Over time, usually decades, the program in the brain that they depend on to control their movements gets corrupted, and they lose command of certain task-specific actions.

For instance, violinists with FD might experience curling of the left 3rd and 4th fingers when they play, but those fingers will function normally when they do other activities.

Researchers also find that FD "appears more often in the more intensely used hand” (Jabusch and Altenmüller, 2006). Hence, violinists are more likely to be affected in the left hand, pianists in the right, although any muscle group could be involved, even arm or shoulder muscles.

Some musicians diagnosed with FD seem to develop it without any precipitating factor aside from long-term repetitive movement.

For others, the condition surfaces months or years following a change of instrument or technique, subsequent to a dramatic increase in playing time, or after they begin doing a new, skillful repetitive activity.

In those types of situations, the process via which a musician’s brain acquires a new movement program corrupts the pre-existing one and then dystonic contractions result.

On top of that, physician Raoul Tubiana reports that the musicians he diagnosed with FD displayed awkward postural and movement habits.

It’s conceivable, then, that physical misuse contributes to provoking FD in some individuals, maybe because musicians who move awkwardly foster more convoluted and corruption-prone wiring in their brains. But that’s just speculation on my part.

Given that FD can run in families, a genetic component seems certain.

According to the Dystonia Medical Research Foundation, “At present, researchers have recognized multiple forms of inheritable dystonia and have identified at least 13 genes or chromosomal locations responsible for the various manifestations.”

Note that the forms of dystonia referred to in that quote don’t include FD, for which no culpable genes have yet been discovered.

Sensible Precautions
In light of the above information, it’s possible that some musicians could be genetically predestined to acquire FD no matter how gracefully they play owing to the way that prolonged repetitive motion affects their brains.

Still, the published research also implies that if we emphasize certain behaviors and avoid others, we can probably reduce the chances of FD arising.

So here are seven precautions we can take that could help us sidestep FD as well as protect us from other music-related maladies.

1. Never push through fatigue or injury
If we continue to play despite tired muscles or the impairment of injury, our brains have to concoct new movement programs to compensate, which could catalyze FD.

2. Increase playing or singing time in stages
Various sorts of injuries can occur when performers abruptly ramp up their music making, so we should always increase systematically – no more than 10-20% per week.

3. Acclimate gradually to any unfamiliar instrument
Let’s say that a violinist wants to take up the guitar: How much time can she spend practicing the guitar without damaging the violin-playing wiring in her brain? No one can say. For now, arts medicine experts recommend that we introduce such new skillful movements gradually. The same advice applies to the process of acclimating to a replacement instrument.

4. Initiate technical changes in increments
Some musicians with FD initiated extensive technical changes prior to their symptoms appearing. Again, researchers advise us to make modifications step by step.

5. Curb new hand-intensive or repetitive tasks
Becoming skillful at any repetitive task obliges us to establish fine motor programs. With that in mind, we should introduce new repetitive movements slowly and avoid unnecessary ones. For instance, string players who acquire notebook computers but have never handled touchpads or pointing sticks might want to use mice and restrict contact with those other more exacting interfaces.

6. Commit to healthy practice habits
All of us should limit repetition, minimize tension, take frequent breaks, manage our workloads, and the like - see my articles about injury prevention for musicians on The Musician's Way Blog.

7. Adopt good use
When we employ good use in our musical activities, we act with optimum efficiency, which not only helps us ward off injury but also liberates our creative powers.

*  *  *

For more information regarding musicians’ wellness and injury prevention, see Chapters 12 & 13 of The Musician’s Way – dozens of photos are included that depict musicians employing good vs. poor use.

A version of this article first appeared on The Musician's Way Blog.

© 2011 Gerald Klickstein



September 26, 2011 at 05:24 PM ·

Very interesting post.  Thanks for sharing all that info.

September 26, 2011 at 06:17 PM ·

 SCARY!  thank you for the information; one more reason for attending to our bodies all the time.

September 26, 2011 at 06:50 PM ·

I have a theory that focal dystonia is more prevalent in people with natural facility as opposed to those whose facility is cultivated by very conscious technical choices that they can clearly articulate.

It is just a theory.

September 26, 2011 at 08:33 PM ·

Thanks for your comments, all.

Although FD may seem scary, my view is that by staying informed and taking reasonable precautions, we can go forward knowing that we're doing all we can to stay well.

September 27, 2011 at 10:28 AM ·

 indeed a very excellent and helpful write-up. i wonder if it is underlying cause for the so called yips,,,

or is dystonia a byproduct of the modern society where the better you get at something, the more perfect you are expected to be, and when it is challenging to be more perfect, the fuse blows?

i wonder if any of our ancestors had dystonia throwing spears at dinner...

September 27, 2011 at 12:51 PM ·

Thanks, Al.

According to the Mayo Clinic, you're correct that yips is probably a manifestation of FD:

Regarding FD and perfectionism, researchers do find a connection (see the Jabusch/Altenmuller article linked above); i.e., perfectionism can drive players to over-practice and push through fatigue & injury (Fleischer attributes his FD to chronic over-practicing).

FD isn't new, though - conditions that we'd probably call FD today appear in the historical medical literature for centuries and are labeled with various names; e.g., 'writer's cramp.'

That said, our current understanding of FD arose within the past 20 years or so, esp. the past decade.

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