‘Chopping’ vs changing: focal dystonia resolution

As you may know, in recent months I have maintained my work on musician’s focal hand dystonia resolution on this other page, the idea being to keep anything I do in the realm of dystonia resolution neater and less mixed up with things of a more general ‘guitaristic’ or musical nature. While I will no longer be adding pages to the focal dystonia resolution section on this blog, since I still very much think of this space as my ‘home space’, and the site analytics tell me that this blog continues to get a regular readership that is interested in focal dystonia and its resolution, I will still cross-post things I write about FD on my ‘dystonia site’ over here. Here’s my latest post reacting to and evaluating recent surgical interventions in cases of musician’s dystonia from the blogroll on my dedicated FD page, https://musiciansdystoniaresolution.wordpress.com:

If you care to read the post on its original page, or if you want to visit my dystonia resolution site, click here. Meanwhile, here’s the text:

Over the last couple of years, a few stories have emerged from around the world of successful surgical interventions in guitarists with focal dystonia. Going by the news stories that covered procedures in Japan, China, and India, one must applaud all three for having been landmark applications of focused ultrasound (FUS) therapy, deep brain stimulation (DBS), and radio frequency ablation (RFA) respectively, to different forms of focal dystonia in a musician’s brain. The fact that in each case, surgeons were able to variously improve the functioning of a patient’s SM cortex in a real-world situation (guitar playing) via the application of either electrical impulses or selective destruction of brain cells (ablation) illustrates the extent to which brain surgery using a range of techniques can provide solutions to problems of fine motor control centred in the SM cortex.

While giving due credit to the advances in technology and neurosurgical capabilities that made the surgically invasive DBS and RFA, and the remote (and so physically non-invasive) FUS procedures possible, and lauding in particular the brilliant surgeons who performed the above-linked procedures successfully, I find myself having mixed reactions to the idea of neurosurgical intervention as an approach to overcoming task-specific musician’s focal hand dystonia in particular. That said, in the spirit of musing upon landmark achievements in brain surgery towards musician’s dystonia resolution, let me begin by listing some of the positive implications that come to mind:

1. DBS has long been known to be a treatment option for various forms of dystonia, most notably (and perhaps most impressively) generalized dystonias. That it has been proven a viable, if somewhat aggressive and no doubt relatively risky, way to overcome musician’s focal hand dystonia is worth knowing. (Why risky, one might ask. Well, sawing or drilling into the head, for starters…) I should note, of course, that the patient in the Chinese success story of the application of DBS to overcome hand dystonia had a generalized problem that affected all aspects of daily life, rather than just his ability to play the guitar – that is to say, his wasn’t a task-specific occupational dystonia. The seriousness and aggressiveness of the method (opening the skull to implant a ‘pacemaker’ in the brain) leads me to think that it will remain a last resort for most musicians with less existentially compromising task-specific occupational dystonias. It’s good to know that the big guns do work, though.
2. The recent application of RFA to ablate (destroy) a portion of an Indian guitarist’s thalamus, successfully clearing up a case of task-specific focal hand dystonia in his left (fretting) hand, is welcome news for any stringed instrument player struggling against a fretting hand dystonia. Left hand (aka fretting hand) task-specific focal dystonias are notoriously less responsive to conservative interventions, including SMR/CIMT, emotional therapy, and SDE, and resolving them via graduated exposure/systematic desensitization therapy, though effective, is a laborious and expensive process, involving a protracted phase of intensive sessions with a therapist. It seems to me that while the foundational steps for the RFA process remain highly invasive (drilling into the skull, once again…) it is noteworthy that RFA has been proven effective in resolving precisely the sort of task-specific musician’s focal hand dystonia that is least responsive to cheaper and more conservative conditioning-based therapies such as SMR and CIMT.
3. The experimental application of FUS to ablate the ventrooralis (Vo) nucleus of the thalamus of a dystonic guitarist at Tokyo Women’s Medical University last year is most impressive for the fact that it was entirely non-invasive. No cuts were made in the patient’s skull, and yet a ‘laser of sound’ was converged upon a specific point within the patient’s head to destroy a tightly defined section of the patient’s Vo nucleus, apparently successfully resolving a case of task specific musician’s focal hand dystonia in a guitarist’s right hand. I find myself reacting more tentatively than positively to this particular application of the technology and procedural approach (more on that below), but it is worth noting the possibly wonderful implication here – that where thalamic ablation via brain surgery is truly necessary, it may be possible to achieve a positive outcome without any of the risks inherent in opening up a patient’s skull in order to perform either RFA or DBS. The study that administered this application of FUS is still underway at the time of my writing this, and of course, one wishes the research team the best, and hopes that FUS proves viable as an alternative to traditional surgery in cases where ablation is necessary.

As I mentioned above, I have mixed feelings about some aspects and implications of the successful surgical interventions described in the three stories to which I have referred. Most of all, I am somewhat uneasy with the idea of recourse to some form of surgery being considered the default solution to task-specific focal hand dystonia in musicians, which is of course the form of dystonia that most musicians who are affected by focal hand dystonia experience. My reasons for this are:

1. Focusing on the thalamus may not be the most holistic approach to reversing a task-specific problem that arises from interaction between areas of the SM cortex. It also comes with a number of risks. Surgical interventions all focus on the thalamus. DBS involves the planting of an electrode in that part of the brain, and both RFA and FUS ablate (that is, they burn up or destroy) a small section of the same structure in brain. The function of the thalamus is to relay signals to the sensorimotor cortex. It is, in essence, primarily a relay station. While destruction of a section of this brain structure has been shown to alleviate dystonic symptoms, in cases where an individual affected by task-specific dystonia undergoes this form of treatment, one wonders at the possibility of  wider implications to long term neurological functioning resulting from the removal of a part of a brain structure that was relaying neural impulses normally in circumstances outside the one task where the individual experienced dystonia.  As much as MEG and MRI scans provide information on the precise location of the parts of the brain that activate to control finger movements in a specific task, even if we can track the pathways of neural activation through the thalamus and basal ganglia, our understanding of how neural impulses travel through the thalamus between the SM cortex and the body is rudimentary. Activity in certain areas of the SM cortex regulates finger movement, and certain other associated cortical activity in the brain of a musician with task-specific focal dystonia (i.e., synaptic activation in other areas of the SM cortex) causes brain cells that carry the homunculus representation of affected fingers to malfunction. Anyone who has read the research in the field will know of Altenmuller et al’s illustration of overlapping cortical representations of fingers – but we don’t know what triggers the said overlapping activations in an otherwise functionally normal SM cortex in cases of task-specific musician’s focal hand dystonia – a logjam somewhere in the thalamus or basal ganglia, problematic associative learning, or something else entirely. Nor, speaking to the surgical approach, do we know exactly though which parts of the thalamus a given precise and exclusive set of neural impulses (and no other cortical activity) would travel, to say nothing of how the flow of impulses up and down through the thalamus would change over time as the individual ages. Permanently constricting the flow of signals to and from the SM cortex in a brain that shows indications of focal dystonia only task-specifically amounts to applying a generalised solution to a specific and conditional problem; it may, in effect, be too aggressive, carrying with it the possibility of wider negative implications to the patient’s ability to execute or maintain functionality outside the previously dystonic (and now presumably surgically-restored) task.
2. Cortical adaptation as a result of neuroplasticity underlies the onset of an occupational focal dystonia; it also offers the most robust and stable form of resolution. At its heart, task-specific focal hand dystonia as experienced by musicians is the result of maladaptive learning – specifically, it is the inadvertently trained reflexive activations/hyperflexions of the digits traditionally thought of as ‘dystonic finger/s’. Underpinning the unfortunate maladaptation, as underpinning all learnt reflexive abilities in functional musical capability, is neuroplasticity – the brain’s endless capacity to adapt its structural predisposition under sufficiently (and specifically) stimulating conditions. Often frustratingly for dystonic musicians, creating the right conditions for successful retraining is more an exercise in designing an advanced psychological experiment than it is musical instrument practice. With that said, through incremental advances in our understanding of cortical reconditioning, increasingly more complex manifestations of task-specific musician’s focal hand dystonia are proving to be reversible. Specifically in cases of task-specific focal hand dystonia, affected musicians may be equally well if not better served (and quite possibly far safer) by looking first to conservative approaches to resolving dystonia before considering brain surgery. Resolution through somatosensory reconditioning would carry the advantages of affording: a) stable and lasting changes in the organization of the SM cortex towards, for example, better control of fingers on guitar strings, rather than a constriction of the path by which signals from a maladapted SM cortex travel to the affected digits, and b) since the brain’s natural process of optimisation towards being able to control given physical capabilities happens in the SM cortex, and not in other brain structures like the thalamus, the brain’s capacity to receive and relay sensory and motor impulses would not be artificially impaired in any way.

On balance, I believe that the risks, expense, and poorly-understood long term implications inherent in surgical intervention in cases of musician’s task-specific focal hand dystonia make it an option not to be considered lightly. With that said, for musicians affected with generalising forms of focal dystonia, or musicians affected in ways for which resolution has not yet been reliably understood by more moderate approaches (such as fretting hand dystonias or perhaps even embouchure dystonias), or for those for whom the prospect of returning to making music quickly is more valuable than the combined risk and cost of surgery, the surgical approach has shown itself to be a worthwhile last resort.

Recent insights in F(H)D Resolution (January-June 2016)

As you may know if you’ve read any of the other pages in this section, I formulated my behavioural therapy approach to resolving focal dystonia in the first half of 2015. I was my own first ‘test case’, so to speak, and it was the 100% success of my own experimental protocol, based on the research of Candia et al among others, that led me to start working with other musicians both in person and over Skype almost exactly a year ago. This May, I marked the passing of a year since my own return to performing, after having completely resolved my dystonia. I can’t over-emphasize how fortunate I feel for having studied psychology – I never thought I’d use it when I started playing seriously, but if I hadn’t studied it, I wouldn’t still be playing! Looking back over the past fourteen months of playing, I now feel quite secure in making the claim that resolution of musician’s focal hand dystonia through behavioural therapy in the form of applied SMR via CIMT (sensory motor reconditioning via constraint-induced movement therapy) can be both complete and permanent, though resolving dystonia through this approach is dependent on two factors – the dystonic musician’s hand must be initially responsive to CIMT (not 100% of all dystonic musicians are, and receptivity to this approach needs to be determined before beginning a retraining program), and the CIMT setup and exercise design need to be accurately tailored to the individual dystonic manifestation – inaccurate application leads to partial retraining, or no response.

Having worked and/or consulted with a number of musicians in the past year, I have seen a full range of retraining outcomes, ranging from 100% resolution in some instances, through partial resolution in other cases, to no response to treatment at all in a couple of cases. Early on, an unsuccessful outcome in a case involving a dystonic guitarist whose i (index) finger problem was completely unreceptive to behavioural therapy made me wonder if I my method for resolution of focal dystonia was only narrowly applicable to the more common manifestation of FD in guitarists’ right hands (a tightly curled m or a finger) – from the time I started working with dystonic musicians, all such cases have ended in successful outcomes. However, subsequent successes in resolving other dystonic manifestations have suggested some refinements in the way focal dystonia resolution through behavioural therapy may be approached, and yielded some specific insights into the neurological mechanisms that underpin dystonia resolution through SMR via CIMT, most notably with regard to factors that give rise to less common dystonic manifestations (such as i finger and/or right thumb curling, and left hand dystonias in guitarists, and what I call ‘complex’ dystonias, where more than one finger exhibits classic dystonic symptoms) – and crucially, how to apply behavioural therapy towards resolving them.

Starting from the most general, and proceeding to the most specific points I’d like to share, then, in the hope that some of this may be of interest to practitioners and affected musicians:

Some conjecture about the emotional vs physiological question
Ever since I first saw results with my method, I have been convinced that the onset of musician’s focal hand dystonia is not precipitated by emotional factors. That said, I’ll qualify my position by saying, a) I believe this only with respect to task-specific musician’s focal hand dystonia, and b) I believe a different (emotionally-driven) onset process may also lead to focal hand dystonia in some musicians – I am tempted to wonder if it plays a role in cases of dystonias that, though identical to others in manifestation, symptoms, and every other respect, mysteriously don’t respond to behavioural therapy.

The efficacy of SMR invites further disambiguation in conceptualizing the condition
From what I have seen of the discourse surrounding dystonia resolution online and in scholarly publications, and heard from dystonic musicians with whom I have worked and interacted, a lot of the attention paid to focal dystonia resolution in musicians has come out of a general theoretical and functional awareness of dystonia over its wide range of types and manifestations, and consequently, general approaches to alleviation of symptoms. While an understanding of the broad subject area (dystonia in general) would very likely contribute to a functional understanding of the specifics of the condition as it affects musicians (and its resolution), my observations of the condition as it affects musicians’ hands, as well as the mechanisms and processes involved in its resolution through behavioural therapy (which effectively restores fine motor control by precipitating desirable reorganization in cortical representations of the fingers) have led me to believe that when considering resolution through behavioural therapy, it is important to conceptualise the issue through the lens of as specific a description as possible.
In musicians, focal dystonia tends to affect the hands or the feet (the latter very rarely – it does happen to drummers, though), and the mouth (the embouchure). It is task-specific to begin with, and often remains so, either indefinitely, or for several months to some years, after which it may generalize to other tasks in some individuals. Incidentally, musicians may also be affected by other forms of dystonia that initially manifest as focal dystonia, but soon progress to affect more than just the hand or the mouth. It is my conjecture (pending the opportunity to further test this empirically) that the onset mechanisms of this kind of (spreading) dystonia are different from those responsible for the onset of focal dystonia – certainly, resolution in these cases doesn’t seem to be possible through SMR via CIMT.
In the interests of assessing the possibility of a given musician’s recourse to resolution through behavioural therapy, it seems useful to distinguish between hand dystonia and embouchure dystonia, because the methods for resolution through the application of behavioural therapy are easily applicable to the hand, but not to the muscles around the mouth. The term I have come to use to define the condition that I help people to overcome, based on affected musicians’ receptivity to behavioural therapy, is task-specific musician’s focal hand dystonia.
To take a tangent, this does raise the question of whether or not embouchure dystonia differs from focal hand dystonia merely in that behavioural therapy can’t easily be applied to the mouth, or if there is a different process involved in its onset, and (dys-) function. Certainly, a number of people have successfully treated embouchure dystonia by addressing emotional factors that they believed were responsible for the condition’s onset and functioning, while replication of those methods on the guitar or piano have not, in my experience, yielded much beyond coping strategies. Not having a working knowledge of the processes that underpin the playing of wind instruments, I am not qualified to address this, beyond conjecture about the nature of the connection between emotional states and a person’s control of their breath and facial muscles.

Task-specific musician’s focal hand dystonia affects systems, not individual fingers
From the earliest breakthroughs that identified behavioural therapy as a viable approach to resolving focal hand dystonia (Candia et al’s successful applications of SMR), it has been held that a dystonic hand has one or more ‘main dystonic finger/s’, and equally, one or more ‘main compensatory finger/s’. Accurately identifying these digits is a crucial step in formulating a behavioural therapy program for a dystonic hand. In line with the documented results of Candia et al’s early experimental SMR applications, I have observed in a number of instances that retraining the ‘main dystonic finger’ through SMR does not result in a complete resolution of dystonia. Following a retraining of the dystonic finger’s patterns of movement, similar evaluative and therapeutic methods need to then be applied to the compensating finger/s in subsequent phases of behavioural therapy. Where there is more than one compensating finger, the order in which they are addressed for CIMT is important, and can make the difference between a diminishing of dystonic symptoms and their morphing from one set of dystonic tendencies to another. So, while the terminology of SMR (‘main dystonic’ and ‘main compensatory’) are useful in designing SMR programs for individual phases of behavioural therapy, it may be more accurate to conceptualize affected/afflicted digits as forming ‘dystonic systems’.

Classic FD symptoms in the i (index) finger are usually symptomatic of a complex set of maladaptive cortical representations, involving more than two digits
In players of plucked string instruments, dystonia characterised by an involuntary and disruptive curling of the index finger appears to be functionally more complex than the other common problem encountered by musicians of this kind, namely, similar patterns of problematic activity in the middle, annular/ring, and/or little fingers. From limited experience with this manifestation, and indeed having only effected partial resolution in a few cases as a consequence of a limited period of contact with musicians with this problem, I have found that a curling i finger is symptomatic of two separate maladaptive changes in cortical representations of the right hand fingers, most often involving the thumb and the middle finger. For the purposes of applying behavioural therapy, each of these need to be treated as a separate dystonic system, and as always, the order of application of CIMT programs is important.

Fretting hand dystonias in chordophone players may be characterised by abnormal and disruptive flexion or extension
It is fairly self-evident, and widely demonstrable, that the direction of dystonic movements in a hand correlates with the kind of movements that were trained extensively prior to the condition’s onset. Given the direction of finger movements while playing most instruments, therefore, it isn’t surprising that focal hand dystonia is usually viewed as a problem of flexion (curling) in the affected fingers – so, a dystonic pianists’ fingers would flex or curl in to his or her palm. However, for musicians who play the guitar, and possibly other instruments that have a fingerboard, left hand dystonias often develop following periods of significant time and effort spent working on fast trills, or left hand patterns typical of virtuosic rock or metal-derived styles on the electric guitar, for example. Recent experiences with musicians whose dystonic fretting hands responded (unexpectedly at first) to CIMT protocols that assumed an abnormally extending main dystonic finger, and an abnormally flexing main compensatory finger, have shown that fretting hand dystonias are at least sometimes a problem of abnormal extension of the fingers, rather than of flexion. In such instances, retraining the former movement rather than the latter is more likely to effect resolution.

Understanding Focal Dystonia | My presentation to the Thailand Guitar Society

Earlier this week, I popped into Bangkok on my way home from Australia, to present to the Thailand Guitar Society about focal dystonia, and my approach to its resolution. Getting the chance to speak to guitarists and guitar teachers about this issue which has been popping up with increasing frequency around the world in recent years was a wonderful way to end a month of lovely experiences; my thanks to the Thailand Guitar Society and the Asian Guitar Federation – and in particular, Dr Paul Cesarczyk, Khun Sira Tindukasiri, and Ms Veda Aggarwal – for making it possible for me to share what I know. Below is a synopsis of my presentation.

To begin with, let me take a couple of minutes to tell you a little about dystonia in general. This is not immediately pertinent to focal hand dystonia as we know it in the context of the classical guitar, but I think a basic awareness of the issue might be helpful for context.

Dystonia, in essence, is characterised by abnormal, involuntary, and in some way disruptive flexion of one or more muscles or muscle groups. It can happen to a number of parts of the body, arise for a number of reasons, and have varying effects on the functional abilities of an affected person. As such, ‘dystonia’ itself is an umbrella term that covers a wide range of problems. The most commonly known forms of dystonia are generalised dystonia, and focal dystonia. Additionally, especially in recent years, some forms of dystonia have been known to arise as an adverse reaction to various drugs.

Generalised dystonia, though not pertinent to musicians for the most part, is the more commonly addressed form of dystonia in health and medicine. As the name suggests, it generalises across the body, often starting in one limb, and creeping over time to affect larger portions of the body. Often, this ends up disabling a person in the most basic of ways, such as walking or running. An example of this kind of dystonia is runner’s dystonia. A simple search for generalised dystonia on youtube will give you a number of very disturbing videos of otherwise perfectly healthy people, whose legs clench up and contort themselves in rather painful-looking ways when they try to walk.

Focal dystonia, which is much more pertinent to our context, differs from generalised dystonia in the sense that the dystonic tendency – the involuntary cramping of one or more muscles – is focalised to one body part. It doesn’t spread across the body – thankfully, I suppose – but is debilitating in that it can interfere with or completely shut down a person’s ability to perform one or more tasks. Non-musical examples of common focal dystonias are cervical dystonia (which manifests as a twitching of the neck one way or the other) and blepharospasm (rapid involuntary blinking), which most of us have probably seen in someone at some time in our lives. Musicians who experience dystonia typically experience focal dystonia, but with the difference that whereas other focal dystonias – like cervical dystonia and blepharospasm – are often non-task-specific, musician’s focal dystonia is commonly task specific, and tends to occur in the body part that is most important for musical performance. So, for example, guitarists, pianists, and other chordophone players tend to experience focal dystonia in one or the other hand, whereas wind instrument players tend to experience it in the muscles surrounding their mouth (embouchure dystonia). Drummers, for the same reason, have been known to contract focal dystonia in either of their hands or feet. In most of these cases, the affected person is perfectly functional in most aspects of their life, except when they try to play their instruments. Classical guitarists with focal dystonia, for example, are often able to type, drive, shuffle cards etc, and only experience dystonic symptoms when they play the guitar.

Recent research has shown that musician’s focal dystonia tends to be localised in whichever body part is involved in highly repetitive interactions of gross motor strength and fine motor coordination. In classical guitarists, that tends to be the right hand. For the rest of this talk, for our purposes, I’m going to speak of ‘dystonia’ or ‘focal dystonia’ in the context of how classical guitarists experience it most often, i.e., with task-specificity and in the right hand. As we move along, I’ll tell you how dystonia as classical guitarists experience it is not a disease or a disorder in the most commonly understood sense of those terms, but something that can be ‘learnt’, and equally, unlearnt.

To give you a sense of what a classical guitarist’s dystonia looks like, take a look at this video. This guitarist is experiencing focal dystonia in his a finger. For the purposes of illustration, the involuntary clenching of his a finger is most clearly visible from 00:55-01:30.

Before we go any further, and now that I have shown you what dystonia might look like in a classical guitarist, let’s step sideways for a moment and go over a very brief and basic psychology lesson. This will help with understanding how dystonia for classical guitarists develops, functions, and can be resolved.

Any voluntary act, including playing, is an outcome of neural activity in the brain. Neurons fire in parts of the brain that control the movement of particular body parts, and muscles contract and relax as a result. This activity takes place in a part of the brain called the somatosensory cortex. Control centres for each part of the body take up specific areas within the somatosensory cortex – or each part of the body is ‘represented’ on the somatosensory cortex. This representation of the body is called a homunculus representation, and fine motor functions, such as fretting and plucking strings, are possible because of it. A homunculus representation is key to our ability to perform precise and delicate actions, because it means that the parts of our bodies that require the most control from the brain are allocated more space within the somatosensory cortex. You might have come across this popular representation of a homunculus, which tells you what we’d look like if our bodies were built the way they’re normally represented in the somatosensory cortex. You see that it’s really all about the hands, the mouth, the face, and in comparison the rest of the body is controlled with very little brain power.

Source: http://www.madscientistblog.ca/wp-content/uploads/2010/12/penfieldhomunculus.jpg

 

In the context of voluntary movements, neural activity serves two purposes or processes – activation and inhibition. Activation is easy. It refers to muscles, and groups of muscles, contracting. Clenching your fist is a very basic example of hand activation – even babies with their grabbing reflex are experts at it. Inhibition, on the other hand, is complicated. Really, for the most part when we as guitarists talk about developing our hands for better finger separation, we’re talking about our brains getting better at inhibition.

Our brains learn – get better – at inhibition, and thereby at controlling and enabling fine motor movements like virtuosic playing, through a process or a tendency called neuroplasticity. Neuroplasticity essentially means that your brain is ‘plastic’, or changeable. It changes to become more efficient, in response to the tasks you require it to perform repeatedly. Repetition is key in this. Being efficient, the brain doesn’t waste time changing itself for every random function you ask of it – it only changes when it ‘sees’ from experience that some complex task is likely to be asked of it repeatedly.

Two processes direct the way the brain changes itself in response to one’s activities. One is the process of repetition itself. The areas that represent the appropriate fingers on the somatosensory cortex of a guitarist playing a tremolo, for example, fire repeatedly through p-a-m-i (or whatever other variation you might use to play a tremolo, of course). As the saying goes, practice makes perfect, and when tasked with repeatedly enabling you to move through p-a-m-i, the brain adapts by reinforcing the connections that make that sequence of neurons firing easier and better. The other process that guides neuroplasticity is sensory feedback, or perception. The brain, as it fires through p-a-m-i, also constantly processes the sensations your fingers register as they play. The qualitative nature of this second process – sensory feedback – is key in the brain adapting correctly to help a guitarist play better. That is, when sensory feedback is accurate, and congruent with the brain’s experience of a repetitive task, the brain will adapt to facilitate virtuosity. However, if there is a repetitive discrepancy between a given pattern of neural activity (brain cells firing in the somatosensory cortex), and sensory feedback, the guitarist’s brain’s tendency to change to adapt to the task it sees as regular, and worth getting better at, can take a wrong turn, resulting in focal dystonia. Altenmuller et al have illustrated this via MEG scan, where the representational areas of a musician’s dystonic hand are blurred on the somatosensory cortex, in contrast to those of a non-dystonic hand, which are not. In the context of guitarists, this can happen when our perceptions of our own highly repetitive complex right hand actions (think of some Giuliani or Barrios passages) are incorrect, and don’t actually conform to what our brains are doing to play those notes in the first place.

So that, basically, is how dystonia typically arises in classical guitarists. Of course, it is important to remember that the process I have described does not happen a lot more often than it does, because most musicians in the world don’t have dystonia (even though the number that do is significant enough for us to be talking about it today). In fact, reported rates worldwide tell us that about 1% of all classical musicians develop focal dystonia. Some factors that have been found to predispose a given musician to contracting dystonia are:

• Long spells of virtuosic practice. This is the number one contributing factor. Long hours spent playing loud and fast are more likely to predispose one to developing dystonia than anything else. This is particularly true when one is practicing passages that involve more than two fingers on the right hand moving rapidly in repetitive patterns.
• Age – most dystonic musicians are aged mid-20s to mid-40s when they develop it.
• Men are more likely to develop it than women.
• There is a genetic component to the extent that anyone is predisposed to developing it.
• A sudden increase in the amount and intensity of practice, as one often sees musicians doing before an exam, competition, or audition.
• Personality type – type A personalities and perfectionists are more likely to develop dystonia than other personality types.
• The age at which one started playing – people who begin learning an instrument after the age of 9 are 6 times more likely to develop focal dystonia than people who start learning at a younger age. Just going by the particular demands of playing guitar, and how many people consider younger children unable to start learning the instrument until their hands grow a bit, I’d say that puts guitarists especially at risk!

From that list of factors that predispose one towards developing focal dystonia, one might well say that classical musicians are at significantly higher risk for developing dystonia than other people – and the research bears that out as well. Eckart Altenmuller, whom I mentioned earlier, found that professional classical musicians are 800 times more likely to develop focal dystonia than other people. Another recent study (Rozanski et al, 2015) made a recommendation to the German Ministry of Labour and Social Affairs, and in fact, in Germany, musician’s focal dystonia is now recognized as an occupational disease, and professional musicians who develop it in Germany may get support for their treatment.

So with all of this said, how does one go about resolving focal dystonia? I do have my own approach, which I’ll share in a moment, but because a) different people respond differently to different approaches, and b) even the approaches that don’t work in isolation do help as priming or coping strategies when incorporated into other approaches, here’s a list of what’s out there:

• Emotional therapy/counselling – of the sort that is most identified with Dr Joaquin Fabra. In my experience, working on the emotional component of dystonia is not ultimately effective for guitarists, but it does help with laying the groundwork for another, more effective approach. This may be because it often helps the affected guitarist take the first step towards resolving dystonia, which is coping with any anxiety and stress issues that arise as a result of having focal dystonia – as you can imagine, not being able to play for reasons you don’t fully understand would give rise to considerable anxiety and stress, which in turn do get in the way of a dystonic musician applying himself or herself to a program aimed at resolving their dystonia.
• Botox injections – going back to our initial understanding of dystonia, recall that dystonia is characterised by unwanted contractions of particular muscles. Botox injections directly into these muscles inhibits their functioning. Yes, it is as drastic and unsustainable as it sounds, and I am not an advocate of this approach. I believe that there is a bit of a problem with over-medicalization of musician’s focal hand dystonia – especially considering there is no pathology involved in the condition – and botox treatments are a part of that.
• Retraining or developing alternative technique – various people have come up with alternative playing techniques to get around the problems posed by a dystonic hand. I don’t personally know of any cases of success through this route, other than David Leisner, but they are out there, so I’m mentioning the option.
• Slow-Down Exercises (SDE) – a pedagogy-based approach that proposes that dystonic tendencies have a temporal threshold, and that retraining can be done by playing under that threshold (very slowly, as with exaggerated slow practice), and that this threshold can gradually be raised to facilitate normal playing. I have not personally found this to be effective, but its principal proponent, Dr Naotaka Sakai, has apparently helped a number of pianists resolve focal dystonia and return to the stage.
• Deep Brain Stimulation (DBS) – brain surgery, which is as drastic as it sounds. There are obviously major concerns associated with this approach, which is more often used to address other, more serious forms of dystonia.
• Transcranial Magnetic Stimulation (tCMS) – a new and experimental approach, which to my knowledge has not quite made it out of the laboratory yet.
• Sensorimotor Retuning (SMR), as was first designed by Dr Victor Candia at the University of Konstanz about 15 years ago. This approach uses constraint-induced movement therapy (CIMT) to create conditions under which the dystonic musician can perform repetitive motions that will induce neuroplastic responses in the desired direction, i.e., to induce the re-separation of representational areas for each finger in a dystonic somatosensory cortex. CIMT, by the way, was first found to be effective in helping stroke victims recover lost motor functioning. Though effective and reliable, SMR as applied by Dr Candia was limited in its effect, in that it only normalised excessive activation in a dystonic hand. In the past year, I have used the same principles that guided Dr Candia to apply CIMT to dystonic musicians to design an addendum to the SMR program, which leads to a fully resolved, non-dystonic hand.

This, then, is essentially an overview of what dystonia is, how it can be developed and how it functions, and a quick look at what you can do about it. What I’d like you to take away from this tonight, more than anything is:

a. Focal hand dystonia for guitarists is a problem of learning, not a disease, or curse, or anything else…it’s an example of maladaptive neuroplasticity, whereby you essentially ‘learn your way into a corner’. Therefore, when people talk about recovering from dystonia, the word ‘cure’ is also not appropriate. Just as dystonia can be developed through actions over time, it can also be resolved.

b. I see that this doesn’t seem to be much of a problem in Thailand, going by the self-reportage we have of it here, but in the West, focal dystonia in musicians is very much a taboo subject, and is not spoken of. There seems to be a stigma associated with it, not unlike there is with mental health issues (not that that’s okay either). I suspect this has a lot to do with a lack of understanding of both its onset and resolution. I believe it’s important that we all, as musicians, do whatever we can to generate awareness of this being a part of living in the classical music industry or world – perhaps a small part, in terms of the number of people it touches, but a significant one nonetheless.

c. As more and more classical guitar scenes/cultures develop around the world, the incidence of focal hand dystonia in guitarists is probably going to go up, and Thailand today is a prime example of that – recall that lots of loud and fast playing at a high level is the number one predisposing factor. Competition culture, where young players often try really hard to perfect playing pieces that may be at the limit of their technical ability, doesn’t help at all. As teachers, it is incumbent on us to keep students developing holistically, and healthily. Key in all this is teaching young guitarists how to practice smartly, rather than for hours on end.

d. Dystonia, for all its serious implications for a musician’s career, is an occupational hazard (recall that Germany has even formally recognised this, as I told you earlier). It’s not irreversible, but its resolution through the application of the appropriate science is very recent, and not very well known. It’s important that people who have it know that behavioural therapy is a viable approach to resolving it.

I hereby declare war on dystonia

My new mission statement:

Having overcome focal dystonia myself, and now passed on what worked for me to a few people, some in person, some over Skype, I am preparing to make guiding people out of focal dystonia a significant part of my work.  It has taken several months of post-dystonic functionality, during which I have returned blissfully to playing and my encounter with dystonia has receded further and further into hazy memory, for me to realise that if I understand this condition and know how to help people undo it for themselves, the path I choose to travel should include sharing what I have learnt. My goal is to be able to help musicians facing the awful experience of dystonia overcome their problem and return to playing. I believe that the musical community is long overdue some sustainable advancement in this aspect of our lives and work, namely effective and truly accessible help for problems most other people have never heard of and don’t understand. The guidance to overcome dystonia, which is not really a medical condition at all, should not have to entail transcontinental travel and be priced out of reach of most people whose lives are affected by it. All the information you need is transferable over the internet, and regardless of where you live, the small bits of training equipment you’ll need to implement this information don’t amount to more than a sandwich or two in shipping charges.

Look in the drop-down tabs from the ‘Focal Dystonia’ section on my home page for some information on the condition. If you are a musician with focal hand dystonia, let me just say – chin up. Do not confuse the complexity of the condition with the size of its effect. It’s not a disease, curse, or syndrome, and it can be reversed. If you’d like to know more, drop me a line at yogi.ponappa@gmail.com.