Musician's Dystonia (Musician's Cramp)


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Musician's dystonia (also known as Musician's cramp)

Dystonia is a neurological movement disorder. It is caused by the brain sending incorrect information to the muscles and is characterised by involuntary, prolonged muscle contractions, which cause affected parts of the body to be twisted into abnormal postures. It can affect a range of parts of the body including the neck, eyes, voice and hand.  

Dystonia has a variety of causes – but dystonias affecting the hand are often caused by performing repeated hand movements. Such dystonias are known as “focal task-specific dystonias”. They can affect any profession which requires repeated movements but are more common among musicians than any other professional group. It is estimated that they affect approximately 1-2% of all professional musicians. Hand dystonia affecting musicians is often called musician’s dystonia or musician’s cramp.

Men are more commonly affected by musician’s dystonia than women with estimates of the ratio ranging from 2:1 to 6:1. Research has identified musicians who have intensively practiced their instruments over a number of years are a group most affected by this condition; usually the diagnosis is made when the person is in her/his 20s to 40s.

Triggers

The musician’s dystonia can be triggered in many ways including but not limited to the following:
•    A sudden increase in playing/practice
•    Dramatic change in technique
•    Return to playing following a protracted break
•    Trauma
•    History of nerve injury
•    Change of instrument

Cause

Musician’s dystonia can easily be misdiagnosed as simple overuse or stress of the hand. Although it may not be obvious at first sight, the dystonia is caused not by strain of the hand but by the brain. The cause is believed to be that the repetitive hand movement results in remapping of the receptive fields in the cortex of the brain. The cortex contains "maps" of the human body and, under normal circumstances, discrete body parts (such as individual fingers) occupy their own distinct areas on these maps. However, in musician’s dystonia these maps cease to be distinct. Brain imaging studies have confirmed this finding, showing that individuals with musician’s dystonia have finger representations in their brains that are abnormally fused compared to those who don’t have dystonia. As a result, the instructions from the brain do not necessarily go to the correct muscles.

It has been noted that the symptoms can be lessened through sensory tricks such as playing instruments wearing a latex glove, thereby altering the sensory input received by the brain.

Symptoms

The symptoms of musician’s dystonia include the hands or fingers failing to respond to commands or responding in unintended ways. Fingers may begin to curl, clench or shake involuntarily instead of touching the intended key. The finger may also freeze or shoot out to the side. Although stress does not cause hand dystonia, it can aggravate the symptoms. The condition may not be painful, but the emotional stress and frustration endured by musicians who have dystonia can be significant. Usually the affected part(s) will respond normally in other activities and only become uncontrollable during the trigger activity of playing a musical instrument.  

Part of the hand affected

The part of the hand affected depends upon the instrument played, rather than hand dominance. For instance:
•    In pianists, the dystonia often manifests in either the 4th or 5th fingers of the right hand.
•    Guitarists often display curling in the 3rd finger of the right hand.
•    Flautists tend to develop dystonia in their left hand.
•    Violinists and clarinettists may display symptoms in either hand.

This is attributed to the fact that it is the body part/area which performs the most complex movement patterns on the instrument in question.

Treatments

The situation for musicians with hand dystonia is not without hope. In some cases, regular injections into the affected muscle can reduce the unwanted muscle activity. In others, a variety a medications can also be helpful. However, quite often, the side effects of these treatments can affect the high level of performance required from the hand to play professional music.   
Many musicians have recovered from dystonia and returned to playing, by using alternative techniques such as Sensory Re-Education and Sensory Motor Retuning.

Sensory Re-education

As explained above, musician’s dystonia can be caused by changes within the cortex which may degrade the map in the brain representing the hand and so interfere with the brain’s control of the hand. In sensory re-education, the aim is to reverse this process. However this technique often requires a similar quantity of repetition to restore the correct hand representation as that which caused the problem. Therefore commitment and home exercise programmes are essential to ensure the treatment is effective.
The types of activity used to achieve sensory re-education include:

  • Identifying numerous different textures and temperatures of sensory stimulation on the skin
  • Discriminating and matching beads, scrabble figures, dominoes, coins and buttons etc.

In addition, to accentuate normal hand functioning, musicians with focal dystonia may be asked to utilise visual healing techniques such as imagining normal and effective hand activity. For instance, they may reflect on a time when playing was normal and then remember how easy it was to play and then go on to visualise how the instrument feels etc.

Sensory Motor Retuning (Constraint Induced Movement Therapy)

This is a behavioural therapy technique that involves immobilisation of the non-affected fingers, to enable the affected fingers to be retuned. The non-affected fingers are fixed in a splint, leaving the dystonic fingers free to perform repetitive co-ordination exercises. The splints can be moulded to the musicians hand while holding a normal playing posture (see below). The fingers which need to be splinted are identified by immobilising each finger that participates in the abnormal movement pattern in turn. In many cases, immobilising one or two other fingers facilitates a freer and more independent movement pattern of the main dystonic finger with reduced unwanted muscle contractions.

Complementary therapies

Some musicians use techniques such as the Alexander technique or Feldenkries therapy in order to gain global physiological awareness of their body whilst playing. However, it is important to note that there is no research to substantiate or refute that they help with managing musician’s dystonia. Also, the field of complementary therapies is unregulated and therapies are often expensive so a therapist should be chosen with care.

Rehabilitation often necessitates a Multi Disciplinary Team approach providing input from specialist such as Physiotherapist, Occupational Therapist, Orthotist, Psychologist, Specialist Nurse, and Neurologist. Availability of these resources on the NHS may be limited.

 

DISCLAIMER
The Dystonia Society provides the information on this page as general information only.  It is not intended to provide instruction and you should not rely on this information to determine diagnosis, prognosis or a course of treatment.  It should not be used in place of a professional consultation with a doctor.
The Dystonia Society is not responsible for the consequences of your decisions resulting from the use of this information, including, but not limited to, your  choosing to seek or not to seek professional medical care, or from choosing or not choosing specific treatment based on the information.  
You should not disregard the advice of your physician or other qualified health care provider because of any information you receive from us.  If you have any health care questions, please consult the relevant medical practitioner.

January 2012.

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