A version of this article originally appeared last month as part 2 of a 3-part series on focal dystonia over at Ovation Press String Visions
Back in September, many of you might have read Gerald Klickstein’s great article about Focal Dystonia. In this article, Klickstein introduced the condition of focal dystonia, presented its possible causes, and discussed prevention. Since this disease is so debilitating to the musicians that develop it, it is also important to be aware of the treatment methods available.
What is Focal Dystonia?
Focal Dystonia, sometimes referred to as occupational or writer’s cramp, is a neurological disorder in which opposing muscles do not relax during muscular contraction. People with the disorder usually experience muscle spasms or loss of motor function after constant, repetitive use of a specific area. The symptoms are typically triggered directly by the instigation of a particular occupation, such as playing a musical instrument, and do not impact other activities. According to a study by Jabusch & Altenmüller, approximately 1% of professional musicians develop focal dystonia during their careers.
Treatment of Focal Dystonia
Even though focal dystonia is a rare condition for musicians, it is one of the most difficult to treat. Many of the available treatments and therapies have low rates of success, and can take a number of years to complete. Dr. Alice Brandfonbrener, one of the founders of the field of Performing Arts Medicine, describes it as “an essentially untreatable and career-ending, or greatly-modifying, disease.” Musicians with focal dystonia are often misdiagnosed by standard medical professionals, and must visit a clinic specifically for performing artists to receive proper treatment.
Some of the more common treatments include Botulinum Toxin (Botox) injections, ergonomic adjustments, technical and pedagogical retraining, and neuromuscular rehabilitation. Injections of Botox may be used to temporarily decrease symptoms and help the person regain the use of the affected body part long enough to complete a performance, but the dosage must be carefully regulated, and periodic, repeated injections are necessary, in order to be successful.  The recovery of Leon Fleisher from focal dystonia, following treatment using Botox injections, is one of the most highly publicized cases of the successful use of this treatment method for focal dystonia in musicians.
Ergonomical modifications to the musician’s setup, such as support straps, finger splints, and individualized chin and shoulder rests, tend to alleviate symptoms and reduce some of the tension that initially triggered the dystonia, but these alone are not enough to cure it. Many musicians are forced to methodically re-learn their technique or “trick” their body with new positioning or adaptations, in a manner that will not elicit the same behavioral responses.  
One of the most successful treatments–in conjunction with ergonomical adjustments–involves pedagogical and technical retraining, in which the patient slowly re-works his technique at a tempo that does not awaken his typical dystonic response. This method has proven useful in a number of different studies.    With the assistance of a knowledgeable teacher or somatic instructor, the patient’s awareness can be drawn to different aspects of his playing, so that he becomes more attuned to how he plays. Technical exercises, in moderation, can also be useful, because they give the patient an opportunity to examine his own playing technique in action and make necessary, minor adjustments to reduce tension.
Many musicians fail to respond to standard treatments for focal dystonia and may require numerous years of therapy before they are able to resume their careers, if they are fortunate enough to recover from the disorder. Please keep in mind that focal dystonia is very rare, but its onset and persistence can be catastrophic for a musician whose chosen career involves playing his instrument for his livelihood. Visit your primary medical care provider for an appropriate diagnosis if you think you may be experiencing an injury, since many conditions have similar symptoms but very different treatments and outcomes.
Despite the recent advances that have been made in the treatment of focal dystonia, more research must be conducted to improve the success rates of current treatments, and to explore new methods of therapy for this debilitating and life-altering disorder.
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 Dystonia Medical Research Foundation. (2006). Retrieved March 5, 2008, from http://www.dystonia-foundation.org.
 Brandfonbrener, A.G. (1995). Musicians with focal dystonia: a report of 58 cases seen during a ten-year period at a Performing Arts Medicine clinic. Medical Problems of Performing Artists, 10(4), 121-127.
 Jabusch H-C, & Altenmüller, E. (2006). Focal dystonia in musicians: from phenomenology to therapy. Advanced Cognitive Psychology, 2 (2-3), 207-220.
 Horvath, J. (2002). Playing (less) Hurt. Kearney, NE: Morris Publishing.
 Sakai, N. (2006). Slow-down exercise for the treatment of focal hand dystonia in pianists. Medical Problems of Performing Artists, 21(1), 25-28.
 Tubiana, R. (2003). Prolonged neuromuscular rehabilitation for musician’s focal dystonia. Medical Problems of Performing Artists, 18(4), 166-169.
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