- Musician’s focal hand dystonia (sometimes colloquially called ‘musician’s cramp’) is characterised by an involuntary cramping or activation of certain fingers that occurs almost always exclusively when playing one’s instrument. It either interferes with one’s ability to play, or shuts it down completely. Common complaints that characterise the condition include an involuntary curling of a given finger into the palm, and an inability to return such a finger it to its resting position while playing. Sometimes, one or more other fingers also strain away from the palm in an effort to bring the offending digit back out from its clenched, bent position. And most confounding for the afflicted musician, focal hand dystonia is task specific – these symptoms leave the hand the moment he or she stops playing.
- Contrary to long-standing impressions, musician’s focal hand dystonia is reversible/resolvable. As with most things in life, certainty in all cases is an elusive comfort – however, given the current understanding of the mechanisms involved in focal hand dystonia at the cusp of musical practice, psychology, and kinesiology, most cases of dystonia are 100% reversible. In a ‘treatment’ regime, basic functional effectiveness on the instrument may initially respond best to counselling and a regimen of slowed down practice as proposed by Joaquin Fabra and Naotaka Sakai respectively, though for focal hand dystonia (as opposed to embouchure dystonia, for example) these are most useful as coping strategies and to prime a musician with hand dystonia to subsequently engage with a more active rehabilitation program. Full functional ability can be brought back via a protocol of exercises designed to use the brain’s tendency towards neuroplasticity to achieve a desired outcome. I have developed this approach drawing on the published findings of Candia et al, specifically papers on the subject published in 1999, 2002, and 2005. Generally, an accurate application of these exercises to stimulate desired neuroplasticity can take between 5 and 8 weeks. My own experience is testament to this.
- Voluntary movements of the fingers are controlled by an area of the brain called the somatosensory cortex. This area holds ‘representations’ of each finger – on an MEG or magnetoencephalography scan, neural activity in a fully functional musician’s somatosensory cortex shows up in five discrete points of light when they engage in an activity such as playing. In contrast, a dystonic hand shows up on an MEG scan as a blurred area of activity: not having accurately perceived each finger as functionally separate, the brain adapts by blurring the control areas in a mistaken attempt at greater efficiency. Here’s an image illustrating this, taken from <http://www.nature.com/nrn/journal/v3/n6/images/nrn843-f4.gif>:
- Neuroplasticity, as the term applies to dystonia, is the brain’s tendency to adapt itself to try and become more efficient at allowing you to perform a given voluntary task. We are all born with this biological tendency. It occurs in response to repeated voluntary movements. In the context of focal dystonia, neuroplasticity occurs in a way that is maladaptive to the task one is trying to perform (playing an instrument) because of repeated discrepancies between sensory feedback (the experience of playing ‘fluidly’) and cortical activity that enables playing (the control centre for each finger firing rapidly and accurately). Happily, just as the onset of dystonia is a consequence of inadvertent neuroplasticity, resolution of dystonia can be achieved through directed/induced neuroplasticity via the repetition of selective voluntary movements.
- Dystonia is a natural neuroplastic outcome of engaging in an activity that, unbeknownst to you, encourages your brain to reorganise its homunculus representation (its ‘control map’) of your fingers to try to be more efficient at accomplishing the task of playing. The maladaptive reorganisation of the ‘control map’ is a result of repeated discrepancies between neural activity that enables playing and sensory feedback from playing – what areas of your brain fire to make certain movements happen, versus what it hears and what it perceives your hand as having done to play those notes. Empirically speaking, it is still an open question as to how much a conscious, accurate perception of each operant finger movement can nullify the brain’s tendency to reorganise itself in this direction; the fact remains, as shown by Byl et al in a paper published in the journal Neurology in August, 1996, that engaging in a quick enough and repetitive enough activity can cause even monkeys to develop focal hand dystonia.
- According to the current understanding of the condition, genetic predisposition appears to be a factor in how readily an individual’s brain will reorganise itself based on contrasting somatosensory cortical activity and sensory feedback, i.e. how readily it will develop focal hand dystonia.
- If your hand has lost its ability to perform certain finger movements over a range of activities rather than just one, or if you experience persistent pain in your hand regardless of what you are doing (or not doing), chances are you do not have dystonia. In such cases, consult a qualified medical practitioner about repetitive motion injuries, carpal or cubital tunnel syndrome, or tendonitis.
- If you have focal dystonia and need to continue to play before you can get help, it’s important that you develop coping strategies that challenge your maladaptive cortical reorganisation as little as possible, because gritting your teeth and forcing your way through pieces that you used to play well will only reinforce the maladaptive reorganisation in your brain. Effective coping strategies include changing fingerings to accommodate the unwanted tendencies that one or more of your fingers have developed, playing problematic passages more slowly, and selecting repertoire that challenge your dystonia least.
- While waiting to get help to resolve your dystonia, you can take steps to retain your repertoire. Slow practice, practicing with the non-dystonic hand alone (usually the left for classical guitarists), and forgiving your right hand the mistakes it makes while you rehearse the sequence of notes and movements that make up a given piece are all good uses of your time. You could even learn new pieces while retaining your repertoire!
For further consultation, feel free to email me at yogi.ponappa@.