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.
The Well-Tempered Guitar 