Musician's Dystonia Research Articles

Video-based diagnosis support system for pianists with Musician's dystonia.

Musician's dystonia is a task-specific movement disorder that deteriorates fine motor control of skilled movements in musical performance. Although this disorder threatens professional careers, its diagnosis is challenging for clinicians who have no specialized knowledge of musical performance. To support diagnostic evaluation, the present study proposes a novel approach using a machine learning-based algorithm to identify the symptomatic movements of Musician's dystonia. We propose an algorithm that identifies the dystonic movements using the anomaly detection method with an autoencoder trained with the hand kinematics of healthy pianists. A unique feature of the algorithm is that it requires only the video image of the hand, which can be derived by a commercially available camera. We also measured the hand biomechanical functions to assess the contribution of peripheral factors and improve the identification of dystonic symptoms. The proposed algorithm successfully identified Musician's dystonia with an accuracy and specificity of 90% based only on video footages of the hands. In addition, we identified the degradation of biomechanical functions involved in controlling multiple fingers, which is not specific to musical performance. By contrast, there were no dystonia-specific malfunctions of hand biomechanics, including the strength and agility of individual digits. These findings demonstrate the effectiveness of the present technique in aiding in the accurate diagnosis of Musician's dystonia.

Efficacy and Safety of Zolpidem for Musician's Dystonia.

The efficacy and safety of zolpidem for treating musician's dystonia are not well understood. We aimed to retrospectively investigate the efficacy and safety of zolpidem for treating musician's dystonia. We retrospectively reviewed medical records between January 2021 and December 2023 to identify patients with musician's dystonia who had been prescribed zolpidem. Tubiana's Musician's Dystonia Rating Scale (range, 1-5; lower scores indicating greater severity) was used to evaluate musician's dystonia. Fifteen patients were included in this study. The mean effective dose of zolpidem was 5.3 ± 2.0 mg. The mean effective duration of zolpidem was 4.3 ± 1.2 h. With zolpidem administration, Tubiana's musician's dystonia rating scale score significantly improved from 2.2 ± 1.0 to 4.3 ± 0.8 (48.9% improvement, p < 0.001). Two patients (13.3%) discontinued the drug owing to unsatisfactory results or sleepiness. The results of this study suggest that zolpidem may be an alternative treatment option for musician's dystonia.

Musician's dystonia: an opinion on novel treatment strategies.

Musician's dystonia: an opinion on novel treatment strategies.

Gender Differences in Task Specific Dystonia: What Can we Learn from Musician's Dystonia?

Musician's Dystonia (MD) is a task specific, focal dystonia which usually occurs only at the instrument. The pathophysiology is not fully understood, but several risk factors like over-practice and genetic predisposition are known. Interestingly, 80% of those affected are men, which stands in contrast to the gender distribution in other focal dystonias, such as cervical dystonia. Our aim was to evaluate the difference in women and men with regard to risk factors leading to MD. We investigated known risk factors for MD in a large cohort of 364 MD patients by retrospectively collecting data on practice behavior and family history. In line with previous studies, we found a ratio of ~4:1 men to women. Age at onset of MD was significantly lower in women; however, subsequent analysis revealed that it was a positive family history (FH+) and not gender that was associated with a lower age at onset. Furthermore, we found that those with negative family history had accumulated more practice time until onset of MD. These results imply that the earlier age at onset in women did not depend on gender but was due to the higher proportion of a positive family history. In contrast, men were less likely to have a positive family history, suggesting that genetic factors may not be the primary reason for the higher prevalence of MD in men. Instead, differences in practice behaviors between men and women may contribute to this gender disparity.

The neurology of creativity: 2023 Hower lecture

AbstractThe neurology of creativity implies network activity; no singular cerebral area is invoked. A clinician‐scientist can develop a creative research project from a single patient, combined with critical scientific alliances, careful observations, and correlations. The developing nervous system poses additional complexity, as changes are expected over time in physiologic circumstances, to which must be added compensatory responses to underlying pathology. The arts represent an especially productive area to study the neurology of creativity, especially with functional imaging, tractography, and intracranial electrophysiology. Music activates widespread bilateral areas, including temporal, orbitofrontal, insular, fusiform, and cerebellar cortex. There are different neuronal clusters for different levels of sound volume, duration, timbre, and pitch. Heschl's gyrus and the arcuate fasciculus correlate with pitch. The orbitofrontal cortex is involved in expectancy generation and appears to be active with no music and then deactivates with music, as if the cortex has an editing function. This appears to correlate with the default mode network being key during improvisation, whereas the central executive network is invoked in effortful, repetitive playing. Furthermore, plasticity is associated with music, from the pathologic development of musicogenic seizures, to protection from musician's dystonia in pianists who begin lessons before age 9 years, to benefits of increased temporal cortex in older adults taking piano lessons after six months. Creativity, reducing negativity bias, and juggling life s priorities are key to countering burnout and building resilience.

An overview of rehabilitation approaches for focal hand dystonia in musicians: A scoping review

Objective To provide a comprehensive overview of rehabilitation treatment strategies for focal hand dystonia (FHD) in musicians, examining their evolution and effectiveness. Data Sources A systematic search of five databases, PubMed, PEDro, Cochrane Library, Trip, and Google Scholar, to identify relevant articles on FHD rehabilitation. The last search was performed on 20 December 2023. Methods Inclusion criteria were applied to 190 initially identified articles, resulting in 17 articles for review. Exclusions were made for duplicates, irrelevant titles, abstracts, and non-rehabilitation interventions. Results Ten different rehabilitation approaches were identified over 20 years. While no definitive intervention protocol exists, a multimodal approach is commonly recommended. Conclusions This scoping review underscores the diversity of rehabilitation strategies for FHD. It suggests the potential of multimodal approaches, emphasizing the need for further large-scale clinical efficacy studies.

Incobotulinum Toxin-A in Professional Musicians with Focal Task-Specific Dystonia: A Double Blind, Placebo Controlled, Cross-Over Study.

Musician's focal task-specific dystonia is a complex disorder of fine motor control, with incomplete understanding of its etiology. There have been relatively few trials of botulinum toxin in upper limb task-specific dystonia, and prior studies have yielded variable results, leading to skepticism regarding the utility of this approach in elite performers. We conducted a double-blind, placebo-controlled, randomized, cross-over study of incobotulinum toxin-A in 21 professional musicians with focal upper extremity task-specific dystonia affecting performance on their instrument, using a novel paradigm of initial injections followed by booster injections at two- and four-week intervals. The primary outcome measure was the change in blinded dystonia rating of the active arm by two expert raters using a Clinical Global Impression numeric scale at week 8 compared to enrollment. 19 men and 2 women with musicians' dystonia were enrolled over a six-year period. Nineteen patients completed the study. Analysis of the primary outcome measure in comparison to baseline revealed a change in dystonia severity of P = 0.04 and an improvement in overall musical performance of P = 0.027. No clinically significant weakness was observed, and neutralizing antibodies to toxin were not found. Despite its small sample size, our study demonstrated a statistically significant benefit of incobotulinum toxin-A injections as a treatment for musicians' task-specific dystonia. Tailoring the use of toxin with booster injections allowed refinement of dosing strategy and outcomes, with benefits that were meaningful to patients clearly visible on videotaped evaluations. In addition to its application to musicians' dystonia, this approach may have relevance to optimize application of botulinum toxin in other forms of focal dystonia such as blepharospasm, cervical dystonia, writer's cramp, and spasmodic dysphonia.

Muscle Ultrasound in Clinical Neurology: Diagnostic Uses and Guidance of Botulinum Toxin Injection

Muscle ultrasound (MUS) is increasingly used by neurologists, neuropediatricians, neurosurgeons, specialized radiologists and anaesthesiologists for the imaging-supported diagnosis of neuromuscular disorders. Especially, MUS is highly sensitive in detecting fasciculations in motor neuron diseases, and in revealing intensive care unit acquired weakness. Hereditary and inflammatory myopathies are associated with distinct patters of echo-intensity changes of affected muscles. Moreover, MUS can be used for guiding needle biopsy of muscle lesions, and for targeting intramuscular botulinum neurotoxin (BoNT) injection in neurological disorders with muscle hyperactivity. MUS-guidance of BoNT injection is especially recommendable in complex cervical dystonia, in task-related hand dystonia (writer’s cramp, musician dystonia), and in children and adolescents with cerebral palsy. Modern ultrasound technologies such as sono-elastography, tissue Doppler, and high-definition microvasculature imaging allow for novel diagnostic and therapeutic uses. Recently, an international expert group reported consensus guidelines for neuromuscular ultrasound training. The present review provides a concise overview of well-established diagnostic and therapeutic applications of MUS in clinical neurology, with specific focus at MUS for targeting intramuscular BoNT injections.

Focal Dystonia and the Stress Network: The Role of Stress Vulnerability and Adverse Childhood Experiences in the Development of Musician's Dystonia.

Musician's dystonia is often described as a neurological disorder, resulting from reduced inhibition in the basal ganglia and the cerebellum and dysfunctional cortical plasticity. However, several studies over the last decades support the hypothesis that psychological factors play an important role in the aetiology of dystonia, contradicting its classification as "purely neurological". Especially adverse childhood experiences (ACEs) such as neglect, maltreatment, or household dysfunction may influence the sensorimotor system, additionally to the impact they have on psychological traits. They are known to alter limbic networks, such as the amygdala, the hippocampus, and the stress response via the hypothalamus-pituitary-adrenal (HPA) axis and might also affect the cortico-striatal-thalamo-cortical loop that is vital for correct motor movement learning. Especially a higher activity of the basolateral amygdala could be important by increasing the consolidation of dysfunctional motor memories in stressful situations.Therefore, this chapter explores how musician's dystonia might be a result of dysfunctional stress-coping mechanisms, additionally to the already established neurological alterations.

Sensorimotor Incoordination in Musicians' Dystonia.

To acquire and maintain outstanding sensorimotor skills for playing musical instruments inevitably requires extensive training from childhood. However, on the way toward musical excellence, musicians sometimes develop serious disorders, such as tendinitis, carpal tunnel syndrome, and task-specific focal dystonia. Particularly, task-specific focal dystonia in musicians, which is referred to as musician's dystonia (MD), has no perfect cure and therefore often terminates professional careers of musicians. To better understand its pathological and pathophysiological mechanisms, the present article focuses on malfunctions of the sensorimotor system at the behavioral and neurophysiological levels. Based on emerging empirical evidence, we propose that the aberrant sensorimotor integration, possibly which occurs in both cortical and subcortical systems, underlies not only movement incoordination between the fingers (i.e., maladaptive synergy) but also failure of long-term retention of intervention effects in the patients with MD.

Embouchure Dystonia as a Network Disease.

While the pathophysiology of embouchure dystonia, a sub-entity of musician's dystonia, is still not fully understood, recent research has shown that it involves alterations of several brain functions and networks. Maladaptive plasticity in sensorimotor integration, sensory perception, and deficient inhibitory mechanisms at cortical, subcortical, and spinal level seem to contribute to its pathophysiology. Furthermore, functional systems of the basal ganglia and the cerebellum are involved, clearly pointing toward a network disorder. We therefore propose a novel network model, based on electrophysiological and recent neuroimaging studies highlighting embouchure dystonia.

Clinical Features of Common Types of Dystonia and Practical Approach for Occupational Dystonia

Dystonia is a movement disorder characterized by sustained muscle contractions that result in abnormal "patterned" movements and/or postural abnormalities. Based on the accompanying symptoms, dystonia can be classified as isolated (i.e., with dystonia only), combined (i.e., with other movement disorders such as myoclonus), or complex (i.e., with symptoms other than movement disorders such as mental retardation). Moreover, dystonia may affect single or multiple parts of the body and accordingly be classified as focal, segmental, multifocal, hemi, or generalized. The most common type of dystonia is isolated focal dystonia, often accompanied with a specific action (task-specific action). The "task-specificity" uniquely illustrates the nature of dystonia, and this phenomenon is most clearly observed in occupation-related dystonias that include musician's and athlete's dystonia. In this article, we first elucidate the general issues of common focal dystonia (cervical dystonia, blepharospasm, and focal hand dystonia) and then present several educational cases of occupational (task-specific) dystonia with some clinical pearls for practical management.

Musicians Focal Dystonia: The Practitioner's Perspective on Psychological, Psychosocial, and Behavioural Risk Factors and Non-motor Symptoms.

Musician's focal dystonia (MFD) is a painless, task-specific neurological movement disorder that impairs fine motor control when playing an instrument. The pathophysiology is not fully understood, and while the available treatment strategies can help with improving motor control, they are rarely able to fully and reliably rehabilitate playing skills. Recent studies suggest that apart from genetic factors, maladaptive neuroplasticity, and the repetitive nature of the instrumental technique, psychosocial, psychological, and behavioural factors might also play a role in the onset of MFD. However, the presence of some of these risk factors is supported primarily by anecdotal evidence, with only a few aspects examined empirically. To explore this area further, 14 semi-structured interviews were conducted with a convenience sample of practitioners (8 medical professionals and 6 musician-coaches) who frequently treated MFD sufferers. Throughout their career, these participants are estimated to have interacted with more than 2,000 musicians with MFD, creating a large, indirect sample. A detailed patient profile emerged from the data with three main components: 1) the negative impact of social environments, including traumatic experiences and low quality of instrumental teaching; 2) a perfectionist, anxious, overly sensitive, and acquiescent personality type; and 3) obsessive, controlling, and inadequate practice behaviours. Participants stated MFD needs to be treated holistically and that neglecting these aspects during treatment could jeopardise rehabilitation. Further objective, controlled research trials are needed to describe these factors in detail, quantify their potential impact as risk factors, and understand how they might hinder therapy.

Task-Specific Focal Dystonia in Musicians: Implications for OT

Abstract Date Presented 04/02/2022 Focal task-specific dystonia is a fine motor disorder that affects professional musicians, for whom this diagnosis is often career ending. This study explored musicians’ perceptions of the lived experience of focal task-specific dystonia. The findings of this study suggest client-centered and collaborative approaches to care, highlighting the importance of addressing emotional factors related to chronic conditions and occupational transition and the need for improved approaches to evaluation. Primary Author and Speaker: Jill Olson Moser Contributing Authors: Julie Bass

The Technical Ability and Performing Scale (TAPS): A newly developed patient-reported functional rating scale for Musician's focal dystonia

BackgroundMusician's Focal Dystonia (MFD) is the most common adult-onset dystonia involving the hand and can cause a professional music career to end. MFD affects about 1% of professional musicians and is a challenging clinical condition to treat. This work aimed to validate the Technical Ability and Performing Scale (TAPS), a newly-developed patient-reported functional rating scale for the clinical assessment of the MFD burden. MethodsSeventy-seven musicians with MFD (40.84 ± 13.14 years) who accessed “Sol Diesis Service” were consecutively enrolled. Each subject filled in the TAPS after playing six technical passages of different complexity for 45 s each. The clinicians also collected the Arm Dystonia Disability Scale (ADDS) and Tubiana-Chamagne Scale (TCS). Cronbach's α coefficient was used to assess reliability; concurrent validity was measured using correlation with validated tools (ADDS and TCS). ResultsOur results showed that the symptoms of dystonia appeared at around 33 years of age and lasted for at least three years. The Cronbach's α displayed good internal consistency (0.817) for Technical Ability (TA). The two TAPS scores, TA and Performing Score (PS), positively correlated with TCS total score and negatively with ADDS total score (concurrent validity). ConclusionsThe TAPS is a reliable and valid tool for the clinical assessment of the MFD burden. This patient-reported outcome measure may facilitate patient engagement in decision-making about their care and can help healthcare professionals to monitor the musician's change during the rehabilitative intervention.

Towards a Holistic Understanding of Musician's Focal Dystonia: Educational Factors and Mistake Rumination Contribute to the Risk of Developing the Disorder.

Musicians’ Focal Dystonia (MFD) is a task-specific neurological movement disorder, affecting 1–2% of highly skilled musicians. The condition can impair motor function by creating involuntary movements, predominantly in the upper extremities or the embouchure. The pathophysiology of the disorder is not fully understood, and complete recovery is extremely rare. While most of the literature views the condition through a neurological lens, a handful of recent studies point out certain psychological traits and the presence of adverse playing-related experiences and preceding trauma as possible contributors to the onset. The nature and the frequency of these factors, however, are under-researched. The present quasi-experimental study aimed to compare musicians with and without MFD in terms of the frequency of various adverse psychosocial and psychological factors to explore their contribution to the onset of the condition. Professional musicians with MFD (n = 107) and without MFD (n = 68) were recruited from online platforms, musicians’ unions, and organisations to fill out a survey. The survey was based on two previously conducted interview studies and included the Student-Instructor Relationship Scale (SIRS), the Mistake Rumination Scale (MRS), the Trauma History Screen, and self-constructed questions about the received music education, early success, and personal experiences. To identify potential risk factors, independent samples t-tests were conducted and found that there are significant differences in musicians with and without MFD in terms of mistake rumination, early success, and the received music education. A logistic regression showed that six factors contributed to the construct to various extents; we observed a significant model [χ2(80) = 22.681, p < 0.001], which predicted 71.2% of the cases correctly. This exploratory study shows that psychological and psychosocial factors might play a role in the development of MFD. Understanding these in more detail could inform preventative strategies and complement the current therapeutic approaches to support this vulnerable population better.

Influence of Adverse Childhood Experiences and Perfectionism on Musician's Dystonia: a Case Control Study.

Background:Musician’s dystonia (MD) is a task-specific movement disorder characterized by muscle cramps and impaired voluntary motor-control whilst playing a musical instrument. Recent studies suggest an involvement of adverse childhood experiences (ACEs) in the development of MD.Objectives:By investigating the prevalence of ACEs in MD patients with perfectionism as possible mediating factor this study aims to gain further insights into the etiology of MD.Methods:The Adverse Childhood Experiences Scale (ACE-S), the Childhood Trauma Questionnaire (CTQ) and Frost’s Multidimensional Perfectionism Scale (FMPS) were answered by 128 MD patients and 136 healthy musicians. Regression and mediator analyses were conducted to identify relevant predictors of MD and to investigate the role of perfectionism.Results:The CTQ total score (OR: 1.04; 95% CI [1.01, 1.08]) and the sub-score “emotional neglect” (OR: 1.13; 95% CI [1.02, 1.25]) were identified as two predictors of MD. Patients scored significantly higher on the sub-score emotional neglect, but no significant differences were observed for other forms of ACEs. Perfectionism had no mediating function on the association between ACEs and MD.Discussion:Though only slight differences between both groups were found, there is a trend towards higher rates of emotional neglect among dystonic musicians. A possible explanation for the association between musician’s dystonia and emotional neglect could be a lower stress resilience in musicians with a history of ACEs, which increases vulnerability to acquire dysfunctional movement patterns.These tendencies should be further investigated in future studies in which the MD and HM groups are more evenly matched in sex and age.HighlightsWe investigated the role of Adverse Childhood Experiences in the development of musician’s dystonia, comparing a large sample of healthy musicians and dystonia patients. Our findings suggest that experiencing emotional neglect might increase the probability to acquire musician’s dystonia. The findings offer new implications for etiology and treatment of dystonia.

Magnetic Resonance‐Guided Focused Ultrasound Thalamotomy for Focal Hand Dystonia: A Pilot Study

ABSTRACTBackgroundThe efficacy of magnetic resonance‐guided focused ultrasound (MRgFUS) thalamotomy for the treatment of focal hand dystonia (FHD) is not well known.ObjectiveWe aimed to prospectively investigate the efficacy of MRgFUS thalamotomy for the treatment of FHD.MethodsWe performed MRgFUS thalamotomy of the ventro‐oral (Vo) nucleus in 10 patients with FHD. We evaluated the scores of the Writer's Cramp Rating Scale (WCRS, 0–30; higher scores indicating greater severity), Tubiana Musician's Dystonia Scale (TMDS, 0–5; lower scores indicating greater severity), and Arm Dystonia Disability Scale (ADDS, 0%–100%; lower scores indicating greater disability) at baseline and 3 and 12 months post‐treatment.ResultsWCRS, TMDS, and ADDS scores significantly improved from 6.3 ± 2.7, 1.4 ± 0.5, and 58.7% ± 14.3% at baseline to 1.6 ± 3.1 (P = 0.011), 5.0 ± 0 (P = 0.0001), and 81.6% ± 22.9% (P = 0.0229) at 12 months, respectively. There was one prolonged case of dysarthria at 12 months.ConclusionWe show that MRgFUS Vo‐thalamotomy significantly improved FHD. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society

The Role of Focused Ultrasound in the Management of Movement Disorders: Insights after 5 Years of Experience.

The Role of Focused Ultrasound in the Management of Movement Disorders: Insights after 5 Years of Experience.

The development and use of an anatomy-based retraining program (MusAARP) to assess and treat focal hand dystonia in musicians–A pilot study

BackgroundMovement dysfunctions are commonly reported in musicians, and in extreme cases may result in a persisting loss of motor control. This condition, whereby motor control of the hand during previously highly trained movements on the instrument is lost, is termed focal hand dystonia. It is widely considered to be a consequence of prolonged repetitive daily practice, often in combination with exposure to a range of other risk factors. Current literature recommends retraining as a promising treatment intervention, although only scant scientific evidence exists on which components should be included in a retraining program, and how these may be best administered. MethodsA progressive muscle activation and movement exercise program was devised by one of the authors applying a series of anatomy-based off-instrument movement tasks. This series of fine motor control exercises, was used to both assess and retrain focal hand dystonia in a population of musicians. The standardized approach aimed to provide a systematic method of retraining musically relevant muscular synergies that could later be applied to the instrument, while still allowing individual modifications. Retraining sessions were mostly run online as a consequence of the coronavirus pandemic, although some early sessions were also able to be undertaken face to face. Both qualitative and quantitative measures were used in this case series to evaluate program efficacy, due to the typical heterogeneity of the focal hand dystonia participants. This included: blinded external neurological evaluation of video footage using the Tubiana grading system, written subjective feedback, exercise progressions, and performance outcomes. ResultsPilot testing of 4 patients indicated the utility of the program over approximately a 12- month time period. All subjects improved, 2 of whom have returned to pre-dystonia performance levels. These patients reported the importance of patience and persistence with daily exercise sessions in their recovery. ConclusionUsing off-instrument playing-relevant exercises to enhance fine motor control and muscle activation can be effective in retraining focal hand dystonia, regardless of additional treatments or level of performance. They should be regularly practiced and progressed in order for effects to be best progressed to instrumental applications. Further research may elucidate whether there are optimal outcomes with single or particular combinations of treatment approaches.