Focal Hand Dystonia Affecting Musicians.

Part I: An Overview Of
Epidemiology, PathoPhysiology And Medical Treatments

Focal Hand Dystonia Affecting Musicians. Part I:

An Overview Of Epidemiology, PathoPhysiology And
Medical Treatments
Katherine Butler BAp(Sc) Occupational Therapy, AHT (BAHT), A MusA(Flute) The Princess Grace Hospital, London, UK
Dr Karin Rosenkranz MD Sobell Department, Institute of Neurology, Queen’s Square, London, UK

In 1911, Oppenheim coined the term ‘dystonia’ to describe disordered motor

control, characterised by an association of hypotonia and tonic muscle spasm.
Focal hand dystonia is one form of this disorder, in which symptoms are often
task-specific and occur during skilled movements such as writing (writer’s
cramp) or playing a musical instrument (musician’s cramp). Much research
has been conducted on the pathophysiology of dystonia, but the underlying
mechanisms still remain unclear. Hypotheseses about functional central
nervous system alterations continue to gain more support. Scientific treatment-
based publications on focal dystonia are sparse, and progress in evidence-
based treatment options are necessary in order to assist this patient group.
This paper will review the literature, documenting dystonia classification
criteria, manifestations, pathophysiology and medical treatment techniques for
musicians affected by focal hand dystonia.

INTRODUCTION

ystonia is a syndrome legs, trunk, neck, face, eyelids or vocal

D characterised by involuntary,
prolonged muscle contractions that
can lead to sustained twisting postures
(Fahn 1998, Fahn et al 1998, Fahn et al 1987).
Three criteria can be utilised to assist in
classifying this syndrome: age at onset,
aetiology and distribution of symptoms
(Fahn et al 1987 and 1998). An onset before
28 years of age is classified as early
onset dystonia, and after this age as late-
onset dystonia. Aetiology can be divided
into either idiopathic (no obvious effects
on the brain) or symptomatic (often the
basal ganglia are affected, resulting in
more generalised symptoms). Some
literature uses the term primary or
secondary for the same classification
(Fahn 1998). Thirdly, dystonia can be
classified according to its distribution of
symptom manifestation: in generalised
dystonia, symptoms may manifest in
all extremities including the trunk; in
hemidystonia, the symptoms are focused
on one side of the body; segmental
dystonia affects a segment of the body or
adjacent body parts; and focal dystonia
affects a single body part.
Any part of the body can be affected
by focal dystonia, including the arms,
cords (Berardelli et al 1998; Deuschl and
Hallett 1998). Focal dystonia tends to
be named according to the affected
region: such as blepharospasm (eyelids),
spastic torticollis (cervical dystonia),
lingual dystonia, spastic dystonia and
oromandibular dystonia. This paper will
focus on focal hand dystonia, a late-
onset primary dystonia that is often
task-specific and includes writer’s or
musician’s cramp. The symptoms may
affect a single finger up to the hand/
wrist; they do not tend to generalise and
remain fairly task-specific (Bressman et al
1998) (Figures 1a and 1b).
FOCAL HAND DYSTONIA IN
MUSICIANS
Musicians with focal hand dystonia
display varying symptoms which tend to
be specific to that individual person and
can include incoordination, cramping
and tremor (Jankovic and Shale 1989). The
symptoms musicians display depend
upon the instrument played, rather than
hand dominance. Dystonia in pianists
often manifests as a curling in of the
Figures 1a and 1b: Task-specific,
action-induced Focal Hand Dystonia
has different forms, including writer’s
cramp and musician’s dystonia (hand
and embouchure)
fourth and fifth fingers of the right
hand, whereas guitarists often show
a curling in of the third finger of the
right hand. Flautists tend to be affected
in the left hand, whereas violinists
and clarinettists can have involuntary
contractions in either hand (Altenmüller
1998; Brandfonbrener 1995; Hochberg et al
1983). Although focal dystonia manifests
as a motor problem, interestingly this
can be influenced by a ‘sensory trick’ (eg
playing the musical instrument while
wearing a latex glove). Many entities
appear to ‘trigger’ the manifestation of
focal hand dystonia in musicians, such as
a sudden increase in playing or practice
time; a dramatic change in technique; a
return to studies after a long break from
the instrument; a trauma (not necessarily
recent); current or a history of nerve

PAGE 72 The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3


entrapment; psychological trauma
or a change of instrument
(Brandfonbrener 1995).
EPIDEMIOLOGY
Dystonia in musicians might be
considered as a more common problem
than is often realised. The prevelance
among professional musicians can
be estimated as 2-10% (Jabusch 2006;
Branfonbrener 1995; Lim et al 2001), which is
higher than that of writer’s cramp (0.1%)
in the general population (Nutt et al 1988).
This high number certainly reflects the
specific demands made upon musicians.
More male than female musicians are
affected with ratios ranging from 2:1 to
6:1 (Lederman 1991; Brandfonbrener 1995;
Lim et al 2001), with only 6% reporting
a history of either writer’s cramp or
musician’s dystonia in their families.
A recent survey of 116 patients with focal
hand dystonia, the largest series to be
published, showed that the mean age
at onset of symptoms is about 33 years
(range 17-63 years) (Jabusch 2006). About
half the patients were in professional
soloist positions, 17% were tutti players
in orchestras, 17% held teaching
positions and 15% were students. These
results showed that classical musicians
are predominately affected by musician’s
focal hand dystonia (95%) with only a
minor number of jazz and pop musicians
affected. In this series, 28% were
keyboard instrumentalists, 26% were
woodwind players, 20% played plucked
instruments, 15% were bowed string
players, and 11% were brass players
(Jabusch 2006).
There are reports of predisposing
medical conditions, which may include:
ulnar neuropathy (Charness et al 1996; Ross
et al 1995), local trauma or peripheral
nerve injury (Brandfonbrener 1995) and
biomechanical limitations (Leijnse 1997a
Focal Hand Dystonia Affecting Musicians. Part I: An Overview Of
Epidemiology, PathoPhysiology And Medical Treatments
and b; Leijnse et al 1992 and 1993; Wilson et
al 1993). However, these studies do not
focus specifically on musician’s cramp
but also include other types of focal
hand dystonia, which may influence
the findings.
FOCAL HAND DYSTONIA IN
MUSICIANS – PATHOPHYSIOLOGY
It is thought that focal task-specific
hand dystonia develops due to a
functional disturbance at several levels
of the central nervous system. This
is mainly expressed as an imbalance
between inhibition and excitation
of neurons. There is evidence for
alteration in sensory and motor
cortical representation, which may
result in altered integration of sensory
information from the periphery
into adjacent and required motor
programmes.
There follow some of the theories
postulated for the development of
this functional disturbance. Due to
overlapping, it is difficult to identify if
focal hand dystonia is due to a sensory,
central or motor disturbance. However,
the points will be outlined following the
sensory motor loop to allow a clearer
overview.
Figures 2a and 2b: Focal Hand Dystonia
SENSORY ALTERATION
in musicians showing motor
inco-ordination or loss of voluntary
Animal studies showed that repetitive
control in pianist’s and cellist’s right
performance of a hand gripping
small and ring fingers.
movement can actively degrade cortical
representation in the primary sensory
cortex (Byl et al 1996a and b; Wang et al
1995). The changes are not only at the
cortical level, but also involve other
brain regions, which are also involved
in sensory processing (Lenz and Byl
1999; Sanger and Merzenich 2000). Similar
alterations have been found with
The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3 PAGE 73
Focal Hand Dystonia Affecting Musicians. Part I: An Overview Of
Epidemiology, PathoPhysiology And Medical Treatments
increasing severity in healthy musicians
and musicians with dystonia. An
increased cortical representation of the
left hand in healthy string players (Elbert
et al 1995), and a blurring/overlapping of
cortical representation in musicians with
focal hand dystonia (Elbert et al 1998), echo
the animal study findings.
DISTURBANCE OF SENSORIMOTOR
INTEGRATION
Animal studies have shown that cortical
abnormalities lead to deficient motor
preparation (Feve et al 1994; Van der Kamp
et al 1995; Yazawa et al 1999). The same
phenomenon was displayed in a study
of affected musicians. Due to disturbed
sensory representations, the motor
cortex receives altered information
(Rosenkranz et al 2000), and deficiencies
in sensorimotor integration can lead to
loss of motor control (Abbruzzese et al
2001; Siebner et al 1999). Both functional
and structural changes occur in any
musician’s brain, as they adapt to
the demands of their activity. These
plastic changes are necessary in order
to achieve a high performance level;
however it is argued that they may render
the musician susceptible to development
of dysfunctional motor control
syndromes such as focal hand dystonia
(Pascual-Leone 2001).
MOTOR DISTURBANCE
Studies with transcranial magnetic
stimulation of the motor cortex have
shown that cortical output again seems
to be higher in patients with dystonia,
which may contribute to the excessive
motor output that occurs during
voluntary movement (Mavroudakis et
al 1995; Ikoma et al 1996). Mapping of
cortical sites, from which specific muscle
responses can be elicited by brain
stimulation in patients with writer’s
PAGE 74 The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3
cramp, also showed an alteration in
size and location (Thompson et al 1996),
suggesting some reorganisation of
cortical excitability in dystonia. Ridding
et al (1995) found that there was less
intracortical inhibition in patients with
focal, task-specific primary dystonia
when tested at rest. They proposed that,
under normal circumstances, one role
of the inhibition was to ‘focus’ the motor
command within the cortex so that the
correct muscles were activated by the
right amount in any task. A deficiency
in this cortical inhibitory system could
therefore contribute to the overflow of
activity in dystonia. Indeed, reduced
excitability of this inhibitory system could
also account for the increased cortical
output again noted from above.
In conclusion, it is not clear if sensory
changes drive motor alteration, or
whether repetitive movements drive
sensory changes that lead to motor
remapping. Due to the close interlinks
within the loop, it is difficult to
differentiate where the alteration has
occurred. Functional disturbances of the
basal ganglia have been found in primary
dystonia (Ceballos-Baumann and Brooks
1997 and 1998; Berg et al 2000; Naumann
et al 1998 and 1996), however, no studies
were found that specifically related to
musicians in this regard. Musicians
appear to be a special group of people
as the tasks they perform are extremely
specific. Therefore, it is likely that, in
musicians with focal hand dystonia,
higher order motor areas are involved.
For an in-depth presentation of the
pathophysiology of focal dystonia, see
Lim et al (2001).
GENETICS
There appears to be conflicting evidence
to support a genetic contribution to
development of focal hand dystonia
in musicians. Early onset dystonia,
which can manifest itself as focal or
generalised dystonia, is commonly
attributed to the gene DYT1 (Bressman
1998; Bressman et al 1998). A family history
of movement disorders or writer’s
cramp has been described in about 10%
of musician patients (Altenmüller 1998;
Hochberg et al 1990). Brandfonbrener
(1995) found no positive family history.
There is no specific genetical study
on larger samples of musicians with
focal hand dystonia, but one study does
analyse ten Ashkenazi Jewish patients
with focal hand dystonia (eight with
musician’s cramp, two with writer’s
cramp) and no common mutation could
be found, thus arguing against a genetic
role in the etiology of musician’s cramp
(Gasser et al 1996).
PSYCHOLOGICAL FACTORS
Once established, the symptoms of
musician’s cramp can be aggravated
by psychological stress, such as
performance situations. However,
psychological factors are not thought
to significantly contribute to the
development of dystonia (Sheehy and
Marsden 1982). There is evidence that
blepharospasm may have an association
with obsessive-compulsive disorder
(Bihari et al 1992a and b), and thus
psychological status is included as a
possible risk factor for development of
focal dystonia. It could be argued that
to be a musician of outstanding ability
requires a certain personality in order to
achieve the standard.
It is thus understandable that musicians
with focal dystonia often despair when
they cannot control their hands to
perform tasks that they have practised
for hours everyday. This can, in turn,
cause development of secondary
psychological difficulties.

DYSTONIA DIFFERENTIAL
DIAGNOSIS
Dystonia can be distinguished from most
common painful conditions, in which
muscle pain usually continues after
task completion, as pain is usually not
evident with focal dystonia. If a patient
is trying to override contractions by
abnormally positioning joints and soft
tissues, pain may result (Kember 1997).
Muscle ache may occur after a prolonged
spasm. When making a diagnosis of
focal hand dystonia, other pathologies
such as ganglions, Dupuytren’s disease,
trigger finger, meningiomas (Wynn Parry
1998), compression neuropathies and
compartment syndrome affecting the
intrinsic muscles of the hand must be
excluded (Amadio and Russotti 1990).
TREATMENTS
Current literature that focuses on
medical-based treatments for focal hand
dystonia will be reviewed. Dystonia is
difficult to treat (Fahn et al 1987) and is
recalcitrant to intervention (Byl and Topp
1998). At present there appears to be no
one cure for dystonia and many of the
treatment modalities have significant
limitations. It is therefore important
that patients are educated regarding the
limitations of treatment (Lim et al 2001).
Many years ago, Gowers (1893) observed
that patients with writer’s cramp could
benefit from a freer approach to writing,
and if possible should be encouraged to
learn to use the other hand. However, he
comments that in about half of the cases
the other hand can become similarly
affected. The option of swapping hands
is not as convenient for musicians,
as they are often required to use two
hands to play their instrument. Many
articles identify a need for investigation
Focal Hand Dystonia Affecting Musicians. Part I: An Overview Of
Epidemiology, PathoPhysiology And Medical Treatments
into treatment approaches. Progress
in scientifically analysed and reported
treatment options for this condition are
necessary, in order to offer affected
patients evidence-based options.
Current treatments include:
• oral medications
• Botulinum toxin (BTX) injections
• surgery
• rehabilitative therapies and
• supportive approaches.
Medical-based treatment options will be
discussed in this article. Rehabilitative
therapies and supportive approaches are
the focus of Part II.
ORAL MEDICATIONS
Oral medications do not cure focal hand
dystonia, but can be used as palliative
treatments. Anticholinergic drugs
influence neurotransmission in the
basal ganglia, and can thus be useful
for treating patients with focal dystonia
(Altenmüller 1998). Trihexiphenidyl is,
at present, the most effective oral
medication; however the side effects,
even when using small doses, limit its
long-term use (Altenmüller 1998). The
side effects can include a dry mouth,
fatigue and slight memory impairment.
Dopaminergic medication appears to be
less effective in treating focal dystonia
than trihexiphenidyl (Muller et al 1996).
BOTULINUM TOXIN (BTX)
BTX type A is the most widely studied
and utilised treatment of focal hand
dystonia. BTX injections are seen as
the treatment of choice for cervical
dystonia and blepharospasm, and
good results have been reported for
The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3 PAGE 75
writer’s cramp, oromandibular and
spasmodic dystonia (Sojer et al 2001).
Intramuscular BTX injections weaken
the muscle by reducing the release of
acetylcholine (a neurotransmitter) at the
neuromuscular junction (Kedlaya et al
1999; Singer and Weiner 1995; Coffield at al
1994). BTX injections must be repeated
regularly (Marion 1999), as the effects are
reversible and may only last one to three
months. It is important to administer
enough, but not too much BTX, otherwise
muscle weakness and impairment can
occur (Altenmüller 2001; Cole et al 1991 and
1995; Ross et al 1997).
Musicians who are affected by focal
dystonia in a single digit are most
effectively treated by administration
of BTX (Altenmüller 1998). However, in
most musicians, rather more complex
movement patterns than just single
fingers are impaired. As BTX injections
are limited due to the associated
weakness of nondystonic muscles (Priori
et al 2001), and the as yet unknown long-
term effects of these injections on the
sensorimotor system, there is a need to
develop new treatments for musicians
with focal dystonia. Furthermore,
these injections only blur the obvious
symptoms without tackling the origin
(Cole et al 1991).
SURGERY
There is controversy surrounding
the use of surgery as a treatment
technique for patients with focal
dystonia. Winspur (1998) believes that
any surgery (eg tendon transfers and
nerve transpositions) is contradicted
when treating such patients as it only
causes further scrambling of disturbed
motor programmes. He believes
that attention to technique, change
in instrument, resolving mechanical
problems, and instrument adjustments
should all be considered before surgery.
Focal Hand Dystonia Affecting Musicians. Part I: An Overview Of
Epidemiology, PathoPhysiology And Medical Treatments
Lozano and Linazasoro (2000) comment
that peripheral surgical techniques
can alleviate focal dystonic symptoms
for many patients. Others report no
improvement in focal dystonic symptoms,
even when clearly entrapped nerves
are released (Charness et al 1996).
Marion (1999) states that surgery is
only indicated in very severe cases
and requires thorough planning and
discussion of indications, while Singer
and Weiner (1995) state that only a
surgeon with extensive training and
experience in operating on patients with
focal dystonia should do so. Objective
scientific studies need to be completed to
state if surgery would benefit this patient
group.
CONCLUSIONS
Musicians with focal hand dystonia
can display varying symptoms that are
very specific to each individual. This
condition appears to be more common
in the musician than in the general
population, probably due to the repetitive
specific and detailed hand use required
to play a musical instrument. Focal
hand dystonia is thought to develop due
to functional disturbance at several
levels of the central nervous system.
It is unclear if sensory changes drive
motor alteration, or whether repetitive
movements drive sensory changes
that lead to motor remapping. The
tasks musicians perform are extremely
specific, and therefore it is probable
that musicians with focal hand dystonia
have involvement of the higher motor
area. Dystonia is very difficult to treat
and medical-based treatments are
quite limited in effectiveness. Oral
medications have numerous side effects
and are purely palliative. Botulinum
toxin injections frequently require
re-administration and only treat the
PAGE 76 The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3
symptoms without tackling the origin of
the problem. Surgery can be viewed as
a contraindication and should only ever
be entered into extremely cautiously by
a senior consultant with experience in
operating on musicians with dystonia.
Thus, rehabilitative approaches are seen
as being the treatment options that
should be trialled first with this patient
group, and these will be covered in the
next paper.
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Katherine Butler
Clinical Specialist in Hand Therapy
30 Devonshire Street
in association with The Princess Grace Hospital
London W1G 6PU
Tel + 44 20 7908 3660
Fax + 44 20 7908 3661
Email: Katherine.Butler@HCAHealthcare.co.uk
© British Association of Hand Therapy Ltd
Focal Hand Dystonia Affecting Musicians. Part II:
An Overview Of Current Rehabilitative Treatment Techniques

Focal Hand Dystonia Affecting Musicians. Part II:

An Overview Of Current Rehabilitative Treatment
Techniques
Katherine Butler BAp(Sc) Occupational Therapy, AHT (BAHT), A MusA(Flute) The Princess Grace Hospital, London, UK
Dr Karin Rosenkranz MD Sobell Department, Institute of Neurology, Queen’s Square, London, UK

Focal Hand Dystonia is a complex and difficult condition to treat. Many treatment many interlinking techniques that can
techniques have been trialled with musicians who suffer from this condition. be employed to assist in achieving this
Current treatments include: oral medications, Botulinum toxin (BTX) injections, goal. Sensory re-education is a treatment
surgery and rehabilitative therapies. The medical-based treatments have that focuses on sensory discrimination.
been discussed in a prior paper, and thus rehabilitative therapy treatment The treatments that combine both
options and the related clinical implications are the focus of this paper. These sensory and motor aspects of focal
include: sensory re-education, sensory motor retuning, rest, splintage and limb hand dystonia include: sensory motor
immobilisation. Future research areas relating to focal hand dystonia and the retuning, rest, splintage, occupational
musician are highlighted. therapy and physiotherapy and the use
of a multi-disciplinary approach. Another
treatment option is limb immobilisation,
INTRODUCTION which interrupts motor performance
and decreases sensory afferents from
ocal hand dystonia occurs in REHABILITATIVE THERAPIES the limb. Other treatment approaches
F 2-10% of professional musicians that can complement the ones above
and often has devastating consequences Rehabilitative therapies and supportive include: assistive devices, instrument
for their careers. Treating these patients approaches for the treatment of focal modification, Feldenkreis therapy,
is difficult and requires, in almost hand dystonia include: Alexander technique, biofeedback
every case, an individual approach. The therapy, counselling and psychotherapy.
specific presentation of the dystonic • sensory re-education In order for treatment(s) to have any
symptoms, personal circumstances • sensory motor retuning (constraint- success, high patient compliance and
such as psychological involvement induced movement therapy) motivation is required, and associated
and professional circumstances (time • rest and splintage complications need to be reviewed (ie
pressure on recovery due to concert • limb immobilisation the musical instrument must be well
schedule, risk of losing position/job) all • occupational therapy and physiotherapy maintained, and associated medical
need to be considered and must influence • multi-disciplinary team approach conditions such as nerve compression or
therapeutic decisions. There are other • assistive devices/modifications to trigger finger{s} must be ruled out).
pressures that must also be considered. instrument
Often the patient’s expectations of • Feldenkreis therapy/Alexander SENSORY RE-EDUCATION
rehabilitation are unrealistic, in that they technique
are aiming for full recovery so that their • biofeedback therapy The integral role of the somatosensory
performance level is the same as pre- • counselling and psychotherapy. input is emphasised by the fact that a
focal hand dystonia onset. Full recovery reduction in involuntary movements
can only be achieved in certain cases. In Research on focal hand dystonia has and an increase in control can be
most cases, some restriction of motor highlighted a dysfunction of integration gained by performing sensory tricks, for
abilities will remain. Making the most of sensory information from the example playing the musical instrument
of this situation requires collaboration periphery into adequate motor whilst wearing a latex glove (Berardelli
of several disciplines including the commands in the brain. et al 1998; Hallett 1995; Lederman 1991).
medical profession, music teachers, This seems to be especially the case in Recent studies in primates suggest that
instrument makers, hand therapists and, musician’s hand dystonia (Rosenkranz repetitive motions can induce plasticity
on occasion, psychotherapists. The first et al 2005). The aim, when treating a changes in the sensory cortex, which
article outlined the medical treatments musician affected by focal hand dystonia, may degrade the hand representation
for this condition. This article considers is to re-establish integration of sensory and interfere with motor control (Blake et
the different rehabilitative strategies in proprioceptive afferent and cutaneous al 2002; Byl et al 1997, 1996a and b). Through
detail and the use of a multi-disciplinary information into a controlled, appropriate, this research, the possibility of utilising
team approach. adjacent motor command. There are specific sensory training to re-wind

The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3 PAGE 79

Focal Hand Dystonia Affecting Musicians. Part II:
An Overview Of Current Rehabilitative Treatment Techniques

sensory dedifferentiation and therefore

successfully treat patients with focal
dystonia is raised. Sensory discrimination
training is thus emphasised during
treatment sessions, and is an integral
part of the home exercise programme
(Byl and McKenzie 2000; Byl et al 2000; Byl
and Topp 1998). The same amount of
repetition may be needed to restore the
hand representation as that which led to
its degradation, thus patient compliance
is integral to the effectiveness of this Figures 1 a and b: Cellist utilising latex glove as a sensory trick
treatment (Byl et al 1996a, b).

The sensory discrimination activities
include: identifying various textures and
temperatures of sensory stimulation on
the skin; discriminating and matching
coins, beads, buttons and small animal
figures; identifying matched pairs of
objects in a game or out of a bag of rice,
beans or noodles; asking the vision-
occluded patient to locate where they are
being touched (Byl and McKenzie 2000);
vibration sensitivity; backward masking;
manipulating embossed letters; work
on detecting mismatched letters on a
keyboard and palpation of directional
lines on a cube (Byl and McKenzie 2000;
Byl and Topp 1998). To facilitate normal
sensation and perception and reinforce
normal hand functioning, patients are
asked to spend time at home meditating,
ie visualising healing, imagining normal
sensory processing, motor control, and
effective target task execution (Byl et al
2000; Byl and McKenzie 2000; Byl and Topp
1998).
High patient compliance and
commitment is required to perform
the number of repetitions of sensory
retraining tasks that are necessary to
restore the somatosensory function, and
in turn improve motor control and stress-
free motor movements. It is expected
that patients complete at least one to two
hours of sensory discrimination activities
at home each day (Byl and McKenzie 2000).
This treatment approach is supported
by a case report of a flautist with focal
hand dystonia who displayed changes
in cortical topographical representation
of the hand, clinical somatosensory
discrimination and fine motor control
after carrying out a comprehensive
rehabilitation programme that
emphasised sensory retraining, i.e.
specific, repetitive, goal-directed sensory
activities (Byl et al 2000). Patients with
writer’s cramp have displayed similar
results where, due to continual training
through braille reading, a decrease in
disability levels and an improvement in
spatial discrimination were noted (Zeuner
et al 2002).

Figures 2a, b and c: Sensory discrimination activities can include: identifying sensory stimulation, discriminating and matching
common household items (a, b) and manipulating embossed items such as dominoes (c).

PAGE 80 The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3


REST AND SPLINTAGE
Rest has been considered a therapeutic
approach for the treatment of dystonia
for more than 100 years (Gowers 1893;
Poore 1887; Hoppmann 2001). This
treatment approach has limitations
for musicians earning their living from
playing. If a period of rest can be taken
(eg a holiday), it may calm symptoms
down, but in any case after a period of
not playing, musicians must return with
slow graded progression in duration,
tempo and complexity of playing, with
psychological support (Tubiana 2000).
(See Appendix 1 for graded return to
playing programme) (Warrington 2003).
Some benefit from splintage has been
displayed in patients with writer’s
cramp (Tas et al 2001; Singer and Weiner
1995). Lederman (1998) reports on four
bagpipers with focal dystonia, one of
whom devised some splints that he found
helpful in decreasing the dystonic finger
movements.
SENSORY MOTOR RETUNING
(CONSTRAINT-INDUCED MOVEMENT
THERAPY)
Constraint-induced movement therapy
(CIMT) is a behavioural therapy approach
that has been trialled and proven to be
effective with stroke patients (Taub et al
1993 and 1999). The nonaffected limb is
immobilised in a cast, thus encouraging
the affected limb to be used. These
principles have been generalised and
trialled for treatment of patients with
focal hand dystonia. They have been
labelled sensory motor retuning (SMR)
(Candia et al 1999). The intervention
involves fixing the ‘compensating’ finger
for the dystonic movements in a splint,
while the ‘dystonic’ finger carries out
repetitive co-ordination exercises.
Exercises are completed under therapist
Focal Hand Dystonia Affecting Musicians. Part II:
An Overview Of Current Rehabilitative Treatment Techniques
Figures 3a and b: Immobilisation splint
supervision and involve one or more
of the other digits to exercise up to 2.5
hours per day for eight consecutive
days. (See Appendix 2 for exercises and
exercise schedule) (Candia et al 2002 and
2003). Candia et al (2002 and 2003) have
published findings of two studies where
improvements in both objective and
subjective measurements, utilising a
dexterity displacement device and patient
self-rating dystonia evaluation scale,
were noted. The first study (Candia et al
1999) was based on five musicians and
the results supported the authors’ beliefs
that SMR produces short-term functional
improvements associated with neuronal
reorganisation. The second study (Candia
et al 2002) involved 11 professional
musicians and evaluated the long-term
effects of SMR. The results suggest that
SMR is a valuable treatment technique
for pianists and guitarists, as each of
these subjects displayed improved
spontaneous repertoire performance
without the splint. The wind players
did not display any improvement, and
the authors offer two explanations for
this: either finger-mouth co-ordination
affects brain mechanisms, or SMR is not
effective in treating performers with focal
dystonia who exert a fairly constant and
firm force whilst playing.
The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3 PAGE 81
LIMB IMMOBILISATION
Prolonged immobilisation of the forearm
and hand for four to five weeks has
been tested as a treatment for patients
with musician’s cramp (Priori et al 2001).
Directly after the removal of the splint,
patients displayed weakness and
clumsiness, but after they regained
voluntary movement improvements
lasted for up to 24 weeks in 50% of
the patients. The authors claim that
immobilisation allows for plastic
changes to occur at the cortical level
(Pesenti et al 2001), and that prolonged
immobilisation, used in conjunction with
post-splintage rehabilitation, may lead
to better therapeutic results for patients
affected by focal hand dystonia (Priori et
al 2001). A larger sample group, studied
under controlled conditions, is needed
in order to validate this treatment for
general use. Information regarding ideal
length of immobilisation, number of
joints to splint, rehabilitation regimes
post-splintage, and clinical features
that would indicate patients who would
benefit from the treatment need to be
scientifically stated.
Focal Hand Dystonia Affecting Musicians. Part II:
An Overview Of Current Rehabilitative Treatment Techniques
OCCUPATIONAL THERAPY AND
PHYSIOTHERAPY
Physiotherapy and occupational therapy
play an important role in performing arts
medicine (Hoppmann 2001). Splinting,
adaptive devices, heat, ice, exercise,
electrical modalities, rehabilitation and
preventative measures can be useful in
treating the injured instrumentalist. Chen
and Hallett (1998) state that they use
occupational therapy as one treatment
option for patients with writer’s cramp,
whilst Berg and Naumann (1998)
comment that they prefer treating this
patient group with occupational therapy
in conjunction with botulinum toxin.
Hochberg et al (1990) prefer to see if
conservative hand therapy treatment,
such as strengthening exercises
for weak hand muscles (interossei,
lumbricals, abductor pollicus longus
and brevis) is effective before they utilise
pharmacological intervention.
MULTI-DISCIPLINARY APPROACH
No single treatment modality seems
to be effective for the treatment of
focal dystonia. In the multi-disciplinary
approach, many treatments can be
integrated, and occupational therapy and
physiotherapy play an important role.
The choice of treatments depends on
the patient’s symptoms. Each treatment
programme is individual and changes
according to the short- and long-
term goals of the affected patient and
those treating them. When assessing
and treating a patient with focal hand
dystonia, a whole body approach must
be emphasised (Kember 1997; Byl 2000).
Treatments such as soft tissue massage,
neural mobilisation, splintage, intrinsic
muscle strengthening and sensory
discrimination exercises may be
useful (Byl 2000). Other evaluations and
treatments, such as finding positions
PAGE 82 The British Journal of Hand Therapy autumn 2006 Vol 11 No 3
where the patient can perform the given
task normally, referring the patient to a
teacher who is trained in working with
injured musicians, and evaluating and
making necessary recommendations/
alterations to the workplace and
instrument may also be helpful (Byl 2000).
Further recommendations may relate
to the musician’s general approach
to life, for example: instruction in
diaphragmatic breathing, ensuring the
patient is well hydrated and has a healthy
diet and encouraging involvement
in a cardiovascular conditioning
programme (Byl 2000). A comprehensive
physiotherapy programme that includes
an aggressive sensory re-education
element, accompanied by exercises that
facilitate fitness and musculoskeletal
health, can improve sensory processing
and motor control of the hand (Byl and
McKenzie 2000).
Tubiana and colleagues propose a
four-stage treatment programme
for patients with focal dystonia. It is
based on relaxation, deprogramming
acquired bad habits and a complete
rehabilitation of the neuromuscular
system (Chamagne 1983 and 1996; Tubiana
and Chamagne 1983; Tubiana 1998). The
stages are: reconstructing the patient’s
body image, relaxation training and
muscle differentiation, individual muscle
retraining, and technical retraining on
the instrument. Tubiana and colleagues
believe that re-education involves the
whole body and the mind, not just the
upper limb. Tubiana and Chamagne
report that trust and co-operation in
the therapeutic relationship is essential
for treatment success. Patients must
be dedicated to participating in the
retraining programme. Brockman et al
(1993) present the results of 483 patients
who utilised this treatment programme:
95 returned to concert performance,
286 had partial improvement, and 57
reported no improvement. For a detailed
review of this treatment approach, refer
to Chamagne (2000).
These findings indicate that a multi-
disciplinary approach to the treatment
of patients with focal hand dystonia is
probably the most effective. However, the
treatments are slow and time-consuming
and success does rely on the patient
being motivated and performing the
exercises regularly and carefully. Muscle
strengthening, appropriate modification
to instruments, medications and
botulinum toxin injections are utilised
by Hochberg et al (1990) to treat patients
with focal hand dystonia.
SUPPORTIVE APPROACHES
ASSISTIVE DEVICES/ MODIFICATIONS TO
INSTRUMENT
Singer and Weiner (1995) comment,
but do not provide a scientific base,
that a writing aid may benefit patients
with writer’s cramp. Koller and Vetere-
Overfield (1989) present a patient who
had tried various medications over
a five to six-year history of writer’s
cramp, who found benefit from a small
writing block that was advertised as
an aide for people with arthritis. The
authors say that a writing device can be
viewed as a ‘sensory trick’ and should
be trialled before pharmacological or
botulinum toxin intervention, as it is
non-invasive and has no adverse effects.
A similar approach should be tested
with musicians, where a change in
instrument may be able to decrease or
improve symptoms. Hochberg et al (1990)
comment that modifications to musical
instruments can eliminate postural
triggers, decreasing focal dystonic
symptoms and have profound benefits
for the patient. Possible modifications
 Focal Hand Dystonia Affecting Musicians. Part II:
An Overview Of Current Rehabilitative Treatment Techniques

include: changing to a smaller

instrument, using a neck support,
altering location of thumb supports,
altering bridge and string height and
extending or altering finger supports.

FELDENKREIS THERAPY AND

ALEXANDER TECHNIQUE

Nelson (1989) and Hoppmann (2001) state

respectively, that Feldenkreis therapy
and Alexander technique can be utilised
as treatments for patients with focal
hand dystonia. They believe patients gain
an awareness of control, with simple
movements being practised initially,
and then more complex patterns being
introduced once control of muscle activity
and relaxation techniques have been
learnt. No scientific studies were found
to support or refute the use of these
techniques for musicians with focal hand
dystonia.
BIOFEEDBACK THERAPY
It is felt that biofeedback, when used in
conjunction with occupational therapy
(Hochberg et al 1990) or physiotherapy
(Singer and Weiner 1995), may be useful
to re-educate muscles that have been
affected by focal dystonia. Biofeedback
can be used to help patients eliminate
muscle co-contraction, and patients are
asked to hold and palpate the target
instrument but are not permitted to
play it until involuntary movements
are controlled (Byl and McKenzie 2000).
However, in a controlled study on
spasmodic torticollis patients, subjective
improvements in symptoms were noted
in both control and treatment groups
(Byl 2000). These subjective results were
not associated with significant changes
in objective measures, thus the authors
conclude that the sole use of EMG
biofeedback for treating torticollis is not
supported. More research is needed into
Figures 4a and b: Instrument modifications can include wrapping the end of a bow in
Coban and adding a Blu Tack bow ‘build-up’.
the effectiveness of biofeedback as a
treatment for focal hand dystonia.
COUNSELLING AND PSYCHOTHERAPY
Lim et al (2001) comment that dystonic
movements occur predominately
while performing perceptual-motor
tasks involving emotion. It is noted
that there is difficulty in changing
emotional and motor traces that have
become associated, and this may lead
to preservation of dystonic symptoms.
Psychosocial and somatic aspects are
interacting in patients with focal dystonia,
and thus psychotherapeutic support in
addition to botulinum toxin is indicated
for some patients (Erbguth 1997). Tubiana
(2000) comments that treating therapists
often have a psychological action that is
inseparable from the rehabilitation, due
to developing a therapeutic rapport with
the patient after spending long amounts
of time with them throughout their
treatment regime. Emotional support
can be imperative when a musician is
affected by such a disabling condition as
focal dystonia. Referral to professional
help for clinical depression may be
necessary (Hoppmann 2001). Kolle (2000)
states that a psychological approach to
treatment of patients with focal dystonia
can play a role in rehabilitation, as it
can examine the patient’s goals and
unconscious problems. If social problems
are evident due to the dystonia, then
support therapy may be useful. Short
duration behavioural therapy could be
appropriate if patients are experiencing
difficulty in adhering to therapy regimes
and in overcoming fears and returning
to performance. Relaxation therapy may
assist patients with difficulties relating to
perception of their surroundings and self.
PREVENTION OF FOCAL HAND
DYSTONIA
The key to treatment is prevention
(Sataloff et al 1991; Slade et al 1999),
therefore to decrease chances of a
musician developing an injury they
should try to avoid: irregular practice
with highly intense periods of practice
and performance, unnecessary changes
in instrument or technique, learning a
lot of new repertoire at the same time,
unrelated hand-over activity, trauma
to the hands and emotional stress.
Musicians should instigate sensible
practice techniques with regular breaks
and reasonable total playing/practice
time; utilise strong but flexible bodies
that are well conditioned; perform
warm-up and cool-down exercises

The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3 PAGE 83

Focal Hand Dystonia Affecting Musicians. Part I: An Overview Of
Epidemiology, PathoPhysiology And Medical Treatments
and gradually increase the intensity
and duration of their playing. A holistic
approach must be adapted, where
locomotor problems are corrected and
playing technique, lifestyle, psychosocial
and emotional factors are carefully
assessed and re-instructed and/or
modified as necessary (Wynn Parry 1998).
Stress and anxiety before a performance,
temporal-spatial constraints of the
instrument and playing, overuse and
hours practised should all be controlled,
thus hopefully minimising the possible
risk of developing focal hand dystonia
(Lim et al 2001).
Tubiana and Chamagne (2000) and
Altenmüller (1998) believe that freedom
of interpretation in musicians who
improvise, and freedom from external
pressures in amateur musicians, may be
preventative factors in the development
of focal dystonia. Newmark and
Lederman (1987) carried out research
on musicians at a conference. Most of
the players (73%, 79/109 with only two
being professional musicians) did not
usually perform routine practice. had
a rapid increase in playing time and
were predisposed to over-use injuries.
81% (48/79) of those with a significant
practice increase developed new playing
related complaints, whilst 63% (27/79)
experienced problems even without a
significant increase in playing time. The
authors comment that musicians should
view themselves as athletes, be more
attentive to their physical limitations and
condition their bodies accordingly, in the
hope of preventing over-use injuries.
They hope that teachers, performers and
physicians learn from the experiences
of their respondents and implement a
carefully planned increase to playing time.
Animal studies show that highly
repetitive motor movement contributes
to degradation in the somatosensory
PAGE 84 The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3
cortex. However, when the speed and
force of the repetitive motor tasks are
varied and interspersed with other
regular activities, the degradation of
hand cortical representation and loss of
motor control can be minimised (Byl et al
1997). Thus, it is important to maintain
instruments in top playing condition, with
the hope of decreasing excessive energy
outlay for desired level of performance
(Hoppmann 2001). Musicians need to
intersperse practice and playing with
other activities in order to decrease the
chances of developing focal dystonia and
other conditions.
FUTURE RESEARCH
Controlled studies are needed to
assess whether therapeutic benefit is
accompanied by functional changes in
the brain. Objective parameters need to
be established, in order to measure the
effectiveness of treatments. Finger force
and velocity pre- and post-therapeutic
intervention may be useful objective
measurements. The longevity and degree
of treatment effectiveness needs to be
assessed. Assessment of the musician’s
repertoire and performance levels before
onset of focal dystonia, and following
treatment, need evaluation. Circulation of
standardised research-based treatment
regimes to musicians, music teachers
and the treating multi-disciplinary team
should ensure a validated knowledge
base with working guidelines.
There is limited evidence surrounding
the effectiveness of treatments
such as hydrotherapy, acupuncture,
chiropractics, dietary changes, exercise
and magnetic devices for the treatment
of focal hand dystonia. It is necessary
for scientific research projects into the
effectiveness and long-term benefits of
these modalities to be completed.
With regard to sensory re-education,
future developments may lean
towards the use of computerised
sensory stimulators to increase
sensory retraining efficiency. Byl
and McKenzie (2000) suggest there
is a need for computer technology
‘…to provide intense, goal-directed,
suitable, motivating, repetitive, and
discriminatory sensory stimulation to
patients.’ The challenge is to negotiate
with compensatory bodies and maintain
motivation levels with patients, so that
sensory discriminative task performance
continues until enough cortical sensory
remapping has occurred to allow
normal motor control (Byl and Topp 1998).
Availability of computerized equipment,
that increases the intensity of repetition
and the gradation of the sensory
decisions, may shorten retraining times
and make tasks more interesting (Byl and
Topp 1998).
CONCLUSION
An increased focus on health issues
relating to the performing artist has
occurred in recent years, highlighting
the frequency and debilitating effects of
focal hand dystonia affecting musicians.
Use of splints, biofeedback, mechanical
aids, technical retraining, botulinum
toxin injections and oral medications
may provide some relief of symptoms.
However, there is a need to identify
the mechanisms accurately by which
focal dystonia develops in musicians.
More research into the pathophysiology
needs to be undertaken to support the
development of strategies for prevention
and treatment of this condition. As a first
step towards this goal, an impairment
of sensory-motor control has been
identified in musician’s dystonia and
treatment strategies that aim at re-
establishing physiological sensory-motor

integration in the brain are shown to be
effective in reducing dystonic symptoms
(Candia et al 2003).
A comprehensive hand therapy
programme with an aggressive sensory
re-education element, accompanied
by exercises that facilitate fitness and
musculoskeletal health, can improve
sensory processing and motor control
of the hand. Dialogue between health
care professionals, teachers and
performers needs to be free, so that
effective treatment and preventative
measures can be facilitated and
implemented. Prevention is the primary
aim of performing arts medicine. Mutual
education is imperative for informing
and overcoming barriers amongst all
people that come into contact with, and
are affected by, focal hand dystonia.
Encouragingly, recent investigation
into focal dystonia is more frequently
of a scientific nature, rather than
the descriptive methods of the past.
Collaboration and a multi-disciplinary
team approach to prevention, treatment
and research are imperative and will be
of benefit to all.
Appendix 2 - Exercises and exercise schedule
The ‘focal dystonic digit’ and the digit(s)
that perform compensatory movements for
the dystonic one are identified. A splint that
immobilises the main compensatory finger
and in turn permits independent movement
of the dystonic finger is then fabricated.
Sequential exercises are then performed,
in which the subject makes movements of
two or three digits in extension, including
the focal dystonic digit. These exercises
are performed for a 10-minute period, in
a continuous ascending and descending
order (e.g. D2, D3, D4, D3, D2 etc. with D4
being the focal dystonic finger and D5 the
immobilised main compensatory finger).
The patient then rests for two minutes.
Following the rest, a different sequence of
Focal Hand Dystonia Affecting Musicians. Part II:
An Overview Of Current Rehabilitative Treatment Techniques
Appendix 1
Graded return to play programme
PRACTICE SESSIONS PER DAY
Two sessions shadow playing
Two sessions on instrument
Two sessions
Two sessions
Two sessions
Three sessions
Three sessions
Four sessions
Four sessions
Three sessions
Three sessions
Two sessions
Two sessions
Start with Simple, Slow and Soft music
Double minutes of playing every few days
Drop back a level if pain is elicited
Gradually progress repertoire difficulty
A five-minute break is encouraged every 20 minutes at the higher levels of playing
movements of two or three fingers, including
the focal dystonic finger, are completed. Five
blocks of exercises are performed in an hour.
Initially, the exercise task is paced by a
metronome and begins at a medium tempo
(60bpm). The tempo is then increased and
gradually decreased, as some musicians with
dystonia find slow, controlled movements
more difficult than fast ones.
After completing the first five blocks of
exercises, the splint is removed and patients can
rest for 10 minutes. Following this, four more
10-minute blocks of exercise with two-minute
rest breaks between the blocks are completed.
A variety of possible finger movements are
performed in the different exercise blocks.
The British Journal of Hand Therapy Autumn 2006 Vol 11 No 3 PAGE 85
MINUTES OF PLAYING
3-5 minutes
3-5 minutes
5-10 minutes
15 minutes
20 minutes
15 minutes
20 minutes
20 minutes
30 minutes
45 minutes
60 minutes
90 minutes
120 minutes
Subjects then have a rest of about 40
minutes. The patient is then encouraged
to play their instrument without the splint.
They are invited to play a piece of music
of their choice for 15-30 seconds. If they
cannot do this, they are encouraged to
try a second time. After two successful
repetitions, they are asked to play a new,
longer segment of the piece, until they
have played for 15 minutes (excluding rest
breaks). After a five-minute break, if the
patient is not too fatigued, the splint is
reapplied and a second series of alternating
digital manoeuvres, each of five-minute
duration, is performed. This regimen
continues for eight consecutive days.
Focal Hand Dystonia Affecting Musicians. Part II:
An Overview Of Current Rehabilitative Treatment Techniques
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