jwilzewske: rehabilitation

Showing posts with label rehabilitation. Show all posts

Tuesday, January 3, 2012

Guided imagery in music training and performance

I n order to have fast mobility and clarity on left-hand fingers, string players have to train their fingers to have these 3 elements when dropping their left-hand fingers on the fingerboard: speed; strength; and the fast release right after the drop. The 3 elements on the left-hand fingers take training to build up the strength of the muscles and the speed of the reflex of the fast release. Of course, any ‘tool’ that we gain from our technical training is ultimately to be used to create music that would touch listeners. Sometimes when musicians concentrate too much on technical elements, their music tends to be too mechanical, too careful, and lacks emotion. By contrast, when musicians concentrate on being musical, it actually helps the technical things. For example, whenever I feel my fingers stiffen in fast passages, I always find thinking something light and bubbly helps to increase my fingers’ lightness, mobility, and fast articulations. Whenever I try to sustain a long note [and yet try to musically project vitality and suspense, despite the temporary absence of pitch-change or the lack of overt dynamics changes while the note lasts], I remind myself about the struggles and tension of the music. Whenever I try to create smooth bow changes, I often picture a [calligraphy] paint brush changing its direction, instead of which muscle to move first!” — Jackie Lee, Heartland Music Academy, 2012.

I n reply to the previous post, I received the helpful advice above.

A nother CMT reader emailed me to ask whether there was any scientific research literature that establishes the effectiveness of visual or kinesthetic imagery in music teaching, especially for soloists or chamber performers.

T here’s lots of published research on guided imagery in the neurophysiology and physical medicine and rehab literature—and in the lit for research on aging and stroke. Quite a lot in the dance and sports medicine lit. But there are not very many published controlled research studies in music performance/pedagogy lit, so far as I can tell.

I will continue looking; please feel free to add comment below or email me if there is a reference that you like.

M eanwhile, here are some links to work that’s relevant to this.

T he left arm functions, to a large extent, by 'walking' on the fingers. In actual walking, torso balance shifts forward, and it is caught on top of the moving legs. For the cellist's left arm, a similar balance can be felt when the upper arm shifts and must be caught by another finger or the arm will fall over... This ‘walking’ image can be strengthened by imagining that the fingerboard is a staircase... Picturing this helps you feel that your balance is aligned in the Earth's gravity, even though your fingers look angled-back in relation to the surface of the fingerboard.” — Jeffrey Solow, cellist, quoted in Bruser, p. 121.

I n automatic or cyclical movements, actual and motor imagery (MI) durations are similar. When athletes imagine only the dynamic phases of movement or perform MI just before competing, however, the environmental and time constraints lead to underestimating the actual duration [and the benefits of the guided imagery are diminished, despite the speed and ease with which the imagery for brief or cyclical movements is called up]. Conversely, complex attention-demanding movements take longer to image [and so guided imagery for complex movements has impediments to its effectiveness, even if duration over/underestimation does not occur].” — Aymeric Guillot, 2005.

T he bilateral frontal opercular regions [in the brain] are crucial in both preparation for and during music execution and imagining. They may have ‘mirror neuron’ properties that underlie observation or imagining of one’s own performance. The motor areas are differentially activated during the preparation and execution or imagining the sequence.” — Rumyana Kristeva, 2003.

D uring execution of musical sequences in professional musicians, a higher economy of motor areas [in the brain] frees resources for increased connectivity between the finger sequences and auditory as well as somatosensory loops, which may account for the superior musical performance. Professionals also demonstrated more focused activation patterns during imagined musical performance.” — Martin Lotze, 2003.

Wednesday, May 19, 2010

Afflicted Fingerings, Biomechanics, and Energy Budgets

B and B-flat, vying; then C and C#: yow! … all of which as if to reveal some hidden perversity in the interval itself, to show some concealed possible corner of the second’s personality … what the Second does when he’s at home alone, when no one’s watching.”
— Jeremy Denk, More about Goldberg Variations, ThinkDenk blog, 11-MAY-2009.

M y hand shifts to make a gradual transition in this Bach sarabande. I never fail to be impressed by how deeply afflicted this piece is. I think of these passages as several competing storylines crossing each other... chains upon [Dutilleux-esque] chains of expressive dissonances in the French Suites.

Bach, French Suite, No. 1 in D minor, BWV 812, mm. 7-8

W hat fingerings might be best? Bach’s Inventions No. 1 and 2 have been the focus for studies by Yuichiro Yonebayashi, Hirokazu Kameoka, and Shigeki Sagayama at the University of Tokyo (link below). They represent the positions and forms of hands and fingers as Hidden Markov Model (HMM) states and model the resulting sequence of performed notes mathematically as HMM transitions. Or, for me just now, Bach’s French Suites, BWV 812-817, Markovian fingers, compelled by what other neighboring Markovian fingers just did.

F ingering would be no problem were it not that music notes are preceded and/or followed by other notes.”
— Yuichiro Yonebayashi, Hirokazu Kameoka, and Shigeki Sagayama.

O ptimal fingering is essentially a problem of finding an optimal sequence of [reasonably] smooth state-transitions, from one state of each finger to the next. But the issue is not just about ‘ease’ or ‘reliability’ or ‘evenness’, even though those are of course important. The matter has also to do with texture and emotion. In fact, a thoughtful composer who is also a pianist knows very well what biomechanical ‘cost function’ or budget for effort or attention or energy expenditure will likely prevail for performers. If the composer’s intent is to devise an especially afflicted expression, then the composer chooses a key-signature and sequences of notes specifically with the intention of beleaguering or defeating performers’ biomechanics cost functions and built-in instincts.

W hen pianos were first invented, they were similar in size to harpsichords. Hand size was rarely a limiting factor throughout the eighteenth century because the keys were short and narrow and the repertoire usually contained intervals no larger than the octave. However, at the beginning of the nineteenth century, the piano gradually expanded in range and key size. The use of cast iron frames led to an exponential increase in string tension, resulting in heavier and deeper actions that exacerbated problems for small-handed players. Nineteenth-century concert pianos typically featured actions with 6 millimeters of travel depth, requiring 23 gm of weight for full key depression and string tension in the middle register that ranged from 12 to 15 grams. By the end of the century, string tension had risen to 80 kg in the middle register, resulting in a heavier action with 9 mm of travel depth, requiring 45 g for full key depression. Today’s Steinway grands feature even heavier actions and larger hammers: 90 kg of string tension and 10.5 mm of travel depth, requiring 50 to 60 g of key depression force.”
— Lora Deahl & Brenda Wristen, American Music Teacher, JUN-2003.

I sometimes use 2-3-5 LH for triads and 1-2-3 for RH triads, leaving the thumb ready for 7ths or other contingencies. Also, my RH likes 1-3-5 or 1-2-5 when straddling black notes or for inversions or big gaps. But these produce tension in the hand—not just physical stretching but—I realize this now—brain stretching, too. Brain regions controlling the index finger and middle finger—fused under the influence of years of neuroplasticity—get anxious. They are apprehensive of more affliction that’s surely in-store.

T his Bach is undoubtedly about middle age and loss. Written in 1722 or a little earlier—two years after the sudden death of his first wife, Maria Barbara; now soon after his marriage to Anna Magdalena. Bach at 37—he hardly knew over-the-hillness first-hand, but he surely knew about loss. I realize that I am playing this differently now in my late 50s than I did 20 years ago, but I am not sure how to explain the difference in words.

I t has been more than 10 years since I played French Suites. The elapsed time is long enough to have lost any muscle memory I once had. Whole strategies and insights have vanished—and my old marked-up copy misplaced in one move or another along the way. Maybe my explanation for what is different is just that: beginning again, after some sort of catastrophe. Feels like physical therapy/rehab for someone who has suffered a stroke? You full-well know what your appendages ought to do, and you know the self-possessed sensations that you intend, but the body doesn’t cooperate—or even feel like your own self, really.

W hen working out your fingerings—even for a piece that is vexingly familiar and yet alien, like this one is for me right now—you often start at the beginning of a passage and plot your strategy forward from there. Sometimes, though, I prefer to first find the points that demand a specific finger. These points mark constraints such that you must have the requisite finger to proceed into the next phrase; such points are often the highest or lowest points in a passage. In the RH, you don’t usually want to end up with fingers 1 or 2 on the highest note (LH lowest note), nor do you want to end up on 4 or 5 on the lowest note of a RH passage (highest in the LH)—especially if the thing is going to immediately reverse direction. Once you’ve identified those constraints, you can work outward, both upstream and downstream, to plan your optimal fingerings.

I mark each place that involves a finger substitution, a change of fingering on a repeated note, or crossings (4-over-5; 2-over-1; 3-over-1; 4-over-1; 1-under-2; 1-under-3; 1-under-4; 5-under-4). I used to do this in pencil, and sometimes I still do this. But in the last couple of years I prefer to do it with e-markups in MusicReader™ software, which I use with my AirTurn™ pedal.

I mark more non-standard fingerings—the more afflicted the passage, the more non-standard it gets. For example, a passage may have a D minor scale in the RH, but it may continue to the octave E. One conventional fingering would cross to 1 on the high D and place 2 on the E. If it were then to return, you would have another crossing (1 - 4 on D to C) almost immediately. In this instance, a non-standard fingering such as 1-2-3-4-1-2-3-4 may be more effective. Bach as ‘rehab’; rehab as [self-] ‘discovery’...

Tuesday, October 7, 2008

Progress in Treating Musicians’ Focal Dystonia: 2008 Update

I have a young student (teenage) who is having progressively more problems with his left hand, with violin. I have heard of musician’s cramp in older people—Leon Fleisher and all that. But I have never heard of it happening in kids. Does it happen and, if so, how common is it? Is there anything new in terms of available options for treating it? Would switching to a different violin help? Would switching to a viola or cello help?”
— Anonymous, email to CMT, Beijing.

Joseph Jankovic, a Professor of Neurology at Baylor College of Medicine (Houston) with whom I am acquainted, has recently collaborated on dystonia research with colleagues in Beijing (link below). Because I do not (yet) read Chinese it is only through personal contacts or through publications that appear in English that I become aware of neurologists in China who are specializing in dystonia diagnosis and management. But it is clear that there are a number of Chinese medical centers where you (your student) might go and receive expert care for this condition.

I don’t have any strong advice on this topic (musicians’ focal dystonia). And I don’t have any first-hand experience in diagnosing/treating/managing the condition. But I will gather together below some up-to-date information about current research, plus some links that you may find helpful in seeking expert assistance. As to the part of your question concerning the epidemiology of focal dystonia and the incidence of dystonia in kids, here is a quote that pertains to the experience in the U.S. (Maybe figures like these prevail in other parts of the world but, to my knowledge, no detailed epidemiologic statistics have so far been published.)

A s many as 1 in 200 (0.5%) [of professional] musicians may be affected during their career, and at performing arts medical centers 8% to 14% of musicians seeking medical attention are ultimately diagnosed with dystonia. Symptoms usually begin in the fourth decade of life, a period when performers are at the peak of their careers, and once present rarely remit.”
— Anna Conti, Seth Pullman, and Steven Frucht, The Neurological Institute, Columbia University Medical Center, New York, October 2008.

Dystonia is a movement disorder that causes the muscles in the body to contract or spasm involuntarily. These muscle ccontractions force the body into twisting, repetitive movements, and abnormal postures.

Multiple parts of the body can be affected, or sometimes just one such as hands, arms, neck, face, eyes, or vocal cords;
Symptoms are usually chronic and progressive;
Varying degrees of disability and pain, from mild to severe, interfering with performing on your instrument;
Affected body parts specifically are ones that are intensively utilized in your performing—ones that are the focus of intense attention, cognitive effort, and repetitive rehearsal.

There is still no cure for focal dystonia. There is no single treatment or therapy that is appropriate for every person who has focal dystonia. Treatment may include oral medications or Botox® / Myoblock® injections or behavioral retuning/conditioning exercises or, more recently, repetitive transcranial magnetic stimulation (rTMS). The more that research enables us to understand Torsin genes and other elements involved in the development of the condition, the likelier it is that more effective and specific therapies can be devised to treat dystonia.

Focal dystonia is a condition characterized by a loss in motor control of one or more body parts. A single muscle or group of muscles is involved: for example, muscles in the hand and forearm tense and tighten, with the result of making the hand (or part of it) curl. Musicians who have intensively practiced their instruments over a number of years are a group most affected by this condition; usually the diagnosis is made when the person is in her/his 20s to 40s. The reason is that focal dystonia generally arises with repetitive movement of the affected body part(s) over a significant period of time. The condition was long known as an ‘occupational hand cramp.’ It can easily be misdiagnosed as simple overuse or stress of the hand. Although it may not be obvious at symptomatic presentation, the level at which the problem is caused is not the hand (or other affected part), but the brain. If kids are intensively trained and accumulate a high level of repetitive movement history at a younger age, there is no biological reason why they would not experience dystonic symptoms at age 15 which, in earlier generations, might have been more usual at age 25 or 35.

Focal dystonia is almost certainly the most prevalent and the most disabling professional disorder in musicians. It decreases the technical level of performances. For many musicians, it ends their performing career. The musician is progressively unable to control the movement of the affected body part(s) when performing. Yes, there is meaningful life for musicians after focal dystonia, when dystonia treatments are unsuccessful. There are roles in music teaching/coaching, music theory, composing, conducting, recording and producing. There are roles as agents, presenters, and executives in government arts and NGO agencies. All sorts of things. But the mourning over the loss of what could have been is monumental. These are musicians—of all ages—whose gifts in other areas may be wonderful, but whose gifts as performers have been foreclosed upon by the misfortune of neurophysiology and genetics. The motivation to discover the underlying causes and discover better therapies is powerful!

The Chicago-based Dystonia Medical Research Foundation (DMRF) routinely issues research grants to investigators, as do other foundation and governmental granting agencies. Some are studying repetitive transcranial magnetic stimulation (rTMS) for the treatment of focal dystonia (e.g., Drs. Victor Candia; Teresa Kimberley and others).

Musicians With Dystonia [founded under the auspices of the Dystonia Medical Research Foundation (DMRF) in 2000 by professional French Horn player Glen Estrin and Steven Frucht, a neurologist at Columbia-Presbyterian Medical Center in New York] also works to encourage and sponsor original research concerning causes and treatments for focal dystonia. The group is dedicated to serving the special needs of musicians affected by focal dystonia, particularly hand and embouchure dystonias. As division of DMRF, the Musicians with Dystonia group supports innovative research in all populations of affected musicians, regardless of age.

The Musicians Medical Advisory Committee of the DMRF encourages grant applications from researchers addressing physician education programs (so that new innovations are made broadly available in practice, to the widest possible number of affected musicians), not just basic science or theoretical neuroscience studies.

Victor Candia is a fine example of a musician who is conducting practical applied research on dystonia. Victor was born in 1966 in Chile, and for 10+ years he taught classical guitar at music conservatories in Germany. In 1991, he developed severe focal dystonia of his left hand, which ended his career as a professional guitarist. He then studied Psychology at the University of Konstanz, Germany, from 1992 to 2000, where he designed and conducted research studies in musicians with dystonia. After completing his doctoral degree, in 2004 he joined the faculty at the Collegium Helveticum of the University and ETH Zürich, where he conducts research on neurophysiology of emotions, brain plasticity, and focal dystonia. Candia and his colleagues have studied treating focal dystonia with ‘sensorimotor retuning’ (SMR) and other methods, examining the efficacy of those techniques in performing artists. Remodeling cortical networks through sensory-motor retuning (SMR) have achieved long-term reduction in the symptoms of focal hand dystonia. The SMR treatments must be continued over time for the benefits to be sustained—but this finding is itself a very important practical result of Victor’s work. It is not only a matter of ‘what’ to do, but also a matter of ‘how’ and ‘how long’ to do it.

Recent fMRI magnetoencephalographic studies confirm that SMR modifies the ‘representational cortex’ that the brain has for the fingers and the fingers’ relations to each otehr, whereby the representation of the affected hand is reorganized so that it more closely resembles the organization of the non-affected side. Candia and others also observe differences in abnormal ‘tactile acuity’ between patients who have musicians’ dystonia and those with writers’ cramp. Using two-point finger discrimination, Candia’s group has found that dystonic musicians show a dramatic, quantitatively/statistically significant perceptual asymmetry between their hands, while writers’ cramp patients do not. To further evaluate the occurrence of collateral disturbances in focal dystonia, they assessed the clinical histories of more than 100 affected musicians. Solid results. Not anecdotes and qualitative ‘case reports’. Not soft conjectures. Solid, quantitative, actionable answers!

An important finding from Candia’s recent published studies was that dystonic musicians who play a similar first and second instruments consistently report a continuous worsening of their symptoms. In addition, collateral disturbances appeared with a shorter delay when more than one instrument was played. So for the Beijing teacher whose question was the reason for this CMT post, the answer is that substituting viola or cello would probably not yield lasting relief and may, in fact, make the process more rapid or severe. Taken together, the evidence suggests:

that neurological dysfunction can be substantially reversed by context-specific re-training of the affected part(s) [great news!];
reversal of dysfunction may be a slow process over many weeks or months [our hopes and fears, realistically calibrated!];
specific symptomatic and etiological differences among various forms of focal hand dystonia might result from different behavioral experiences and how and where those experiences are stored represented in the brain [helpful for diagnosticians and teachers!]; and
the spread of dystonic symptoms can in many instances be prevented by avoiding any training exercises that entail movement patterns that are similar to the main affected task, and by establishing ‘quotas’ on practice/rehearsal (limiting the amount of performance task-associated movements per day).

Karin Rosenkranz and colleauges in London at Sobell Dept of Motor Neuroscience and Movement Disorders the Institute of Neurology at UCL are also iconic examples of pragmatic research on dystonia. They have recently been working on sensorimotor retuning treatments for focal dystonia. The sensorimotor organization (SMO) of the motor hand area is abnormal in focal hand dystonia and appears to contribute directly to symptoms. In healthy musicians SMO is changed by training with spatial ‘proprioceptive’ stimulation. They tested whether similar interventions reverse the abnormal SMO in musicians’ dystonia and writers’ cramp, anticipating possibly developing them for improved therapies. In six non-musicians, six professional musicians, six patients with musicians’ dystonia, and six patients with writer’s cramp, SMO was explored by measuring changes in ‘short-interval-intracortical-inhibition’ (SICI) during short periods of mechanical hand muscle vibration before and after two training types:

AttVIB, involving attention to 15 minutes vibration of the abductor pollicis brevis muscle (APB); and
AttIndex, involving attention to neural stimulation of the index finger.

In normal, non-dystonic non-musicians, they found that baseline SMO is ‘spatially differentiated’ in the brain. That is, they found that SICI is reduced in projections to the vibrated parts, but enhanced in projections to the non-vibrated muscles. AttVIB increased and AttIndex reduced the effect of subsequent APB-vibration on SMO.

In healthy, non-dystonic musicians, the baseline SMO is not differentiated as much. AttVIB restored a more differentiated SMO pattern, while AttIndex diminished the effect of APB vibration. But in focal hand dystonia, they found that SMO is completely spatially de-differentiated. AttVIB tended to restore a more differential SMO in musicians’ dystonia (but not in writer’s cramp), while AttIndex failed to induce any changes in both groups.

W hether the vibration retuning intervention is effective or not apparently depends on the musician’s prior sensorimotor organization (SMO). In musicians’ focal hand dystonia, it’s possible to retrain an abnormal SMO toward a more spatially differentiated pattern.

Steven Frucht and colleagues at The Neurological Institute of New York at Columbia University Medical Center are another group active in conducting research to identify the neurophysiology and genomics of focal dystonia and to evaluate new practical treatments. Have a look at their website (and links below) to see what’s new in their efforts, and to see whether any of the clinical trials that they are conducting may be relevant to you or to your student.

Neuronetics rTMS clinical trials centers, U.S., 2008

The Dystonia Medical Research Foundation has a number of DVDs and videos that you may find useful. They also have a nice Treatments page that provides information on the approaches that are available right now (both medical and non-medical ones), plus a referral service to help you find a neurologist in your area who is experienced in managing focal dystonia in musicians.

Check out DMRF’s Musicians with Dystonia webpage.

Besides recent advances in sensorimotor retuning and other behavioral interventiosn, repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are promising, novel, noninvasive cortical stimulation methods for treatment of dystonia and other movement disorders. They avoid surgical risks and provide advantages in terms of targeting specific neural circuits modulating action of the affected muscles. Repetitive transcranial magnetic stimulation (rTMS) delivered at 0.5 Hz to 5 Hz repetitions and suprathreshold (e.g., ~2 Tesla) intensity produces a progressive facilitation of motor-evoked potential (MEP) amplitude that outlasts the end of stimulation. This effect is related to a short-term enhancement of cortical excitatory interneurons in the brain.

In patients with upper limb dystonia there’s an characteristic abnormal recovery from MEP facilitation after ‘supra-threshold’ 5 Hz rTMS, which suggests an abnormal pattern of short-term cortical plasticity in the brain. The abnormal recovery pattern is diagnostic (‘pathognomonic’) of focal dystonia—so if there’s any diagnostic uncertainty prior to the procedure, it may be resolved beyond a shadow of any doubt after the procedure. rTMS is an outpatient procedure, and each treatment takes only about 30 minutes. But it’s not a particularly pleasant procedure. Not as invasive as ECT, to be sure; but not without discomfort. Depending on the intensity of the frequency and the coil-type that is used to apply the magnetic field, many patients do experience headaches and other unpleasant sensations during and after rTMS. The most critical clinical concern is the risk of seizures during rTMS. Treatable, surely, but not a trivial adverse event if it materializes for you!

After rTMS treatment, the movement-enhancing effects of rTMS in focal dystonia patients last longer than in normal non-dystonic people. rTMS may only need to be repeated once a week or once every two weeks. Multiple mechanisms likely contribute to the clinical effects of rTMS in movement disorders, including normalization of cortical excitability, rebalancing the brain’s distributed neural network activity, and inducing dopamine release in the brain. It remains unclear how to individually adjust rTMS variables for the most beneficial effects on symptoms of dystonia. Nonetheless, the noninvasive nature of rTMS, the minimal side effects it has for most people, the positive effects it has demonstrated in preliminary clinical studies, and the growing evidence for mechanisms of action all make rTMS attractive for ongoing research investigation and for your consideration in the future, for yourself or for your students.

There is already considerable published evidence that rTMS is clinically effective, and rTMS is now being used in depression and other neurological conditions. But rTMS is slow in achieving recognition and regulatory approval as an accepted option in the therapeutic armamentarium for use in dystonia. Its beneficial effects are admittedly of short duration (days) and inconstant from one patient to the next and within any particular patient over time. These factors mean that presently in many countries rTMS is not ‘covered’ or reimbursed by insurers or health systems.

In the U.S., rTMS devices are still investigational with regard to dystonia treatment—only available to patients enrolled in clinical trials. Some rTMS devices are approved by the U.S. Food and Drug Administration (FDA) for stimulation of peripheral nerves but can be used off-label by physicians to treat other neurological disorders not approved by FDA. But insurers won't pay for rTMS treatments when they are given off-label. So in the U.S. and in other countries, generally patients who want to try rTMS for their dystonia will have to pay for the treatments out-of-pocket.

The same is also true for use of Botox/Myoblock treatments for dystonia in some countries. Until now, there has been inadequate control of the stimulation site. It is possible that the rTMS stimulation site could/should be varied on an individual basis. It seems logical to propose the use of fMRI functional imaging for such a purpose, but its use should be adapted to each individual patient’s symptoms and affected body part(s). Even after localizing the site by using fMRI or other measurments, the rTMS coil has to be placed accurately by the clinician. Procedural consistency is a major issue in producing decisive, actionable research results and journal publications that will convince payors and regulators. Stimulation protocols are currently defined by several parameters: the frequency of the rTMS stimulation (>5 Hz) or inhibition (<1 Hz), and the intensity and the number of stimuli influencing the amplitude and duration of the effect. Unfortunately, the effect has so far been variable in each patient. Paradoxical (non-beneficial and adverse) reactions have been observed in more than 15% of normal individuals treated with rTMS. In other words, don’t undertake rTMS lightly. It is entirely possible that, for you, it might make you worse than you are right now.

Medications used to treat dystonia are a brute-force, nonspecific ‘systemic’ option. Sledge hammer precision. Not ideal, but not to be ignored, particularly in extreme situations. Meds include:

Trihexyphenidyl
Benztropine
Anticonvulsants
Procyclidine
Muscle relaxants
Levodopa/carbidopa
Bromocriptine

Botox® or Myoblock® injected directly into the muscles affected by dystonia weakens the muscle. This may help improve symptoms of dystonia for 3 to 4 months, but the relief is in general not permanent. And the weakening may itself prevent concert-level performance, Leon Fleisher’s good results notwithstanding. The botulinum toxin preparation used in China is mostly CBTX-A® (Lanzhou Biological Products Institute, 888 Yanchanglu, Lanzhou, Gansu Lanzhou, Gansu 730046, China; Phone : ‎+86 931 8340311), which is a little less potent than Botox® (and therefore may need to be repeated more often) but much less expensive (Allergan Inc.)

Trihexyphenidyl and other anti-cholinergics that are sometimes used to treat dystonia may produce chorea or other movement disorders that are more severe than the dystonia. So it is best to be cautious. None of these options is ‘benign’; all of them have significant limitations/risks as well as strengths/benefits. You need to consult a neurologist who is expert in the treatment of dystonia in musicians to make a proper choice. [Besides the links above for the Beijing-based CMT commenter/emailer] the links below may help you to find such a person near your location, who can help you review the options and decide.

Meds that themselves sometimes cause dystonia as a side-effect include the following:

Levodopa/carbidopa
Bromocriptine
Antipsychotic meds
Metoclopramide
Dilantin
Calcium channel blockers
Selective serotonin reuptake inhibitors
Ergotamines
Antihistamines (esp. cetirizine Zyrtec)

Focal dystonia has a prevalence of 29.5 per 100,000 people in the general population as reported by Nutt and coworkers at the Mayo Clinic some years ago, but, then and now, dystonia often goes un-diagnosed or mis-diagnosed. Almost certainly the 1-in-200 remark at the top in the blockquote from Anna Conti, Seth Pullman, and Steven Frucht is the relevant figure with regard to musicians—both professional ones and serious amateurs. Curiously childhood- and adolescent-onset primary dystonia is more common in Jews of Eastern European or Ashkenazi ancestry, compared to the general population. Possibly there are genetic factors that will be found to be important in dystonia in Chinese and other populations. Although most cases of focal dystonia in musicians come to the attention of neurologists when the patients are in their 20s or later, it is more and more common to see the condition diagnosed at earlier ages. Possibly this is a correlate of the trend in many countries toward larger numbers of kids receiving intensive training as elite-level musicians, especially in China. But to-date there are no journal articles or other research publications that report on this.

Thank you very much for the question. I hope this post is useful to you. Please feel free to comment or email me again on this topic, or let other CMT readers know what results you have had with interventions you try.

Dystonia Medical Research Foundation (Chicago)
Movement Disorder Society
European Dystonia Federation (Helensburgh, U.K.; Brussels, Belgium)
Dystonia bulletin-board
Care4Dystonia.org
Performing Arts Medicine Association
Schwarzer MAGS2 rTMS
Neuronetics NeuroStar rTMS
Nexstim eXimia rTMS
MagVenture rTMS
rTMS page at Wikipedia
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Wednesday, September 5, 2007

Mortensen: Artistic Expression and Absence of Tension

Lars Ulrik Mortensen, Fintan Damgaard photo

CMT: There is nearly as much beauty in watching Lars Ulrik Mortensen play as there is in hearing him play. The near total absence of tension in his hands and arms is impressive. Almost zero tension, even in extremely rapid and difficult passages.

DSM: He’s a phenomenally gifted artist, it’s true. I think also that careful videography and biomechanics analysis of his playing could be valuable for other performers and teachers. There’s a great deal to be gained by dissecting and understanding how he does what he does.

CMT: Beyond the ordinary pedagogical aspect, I believe too that videography and analysis of Mortensen’s technique might hold significant therapeutic value for harpsichordists who develop focal dystonia or other injuries. And not just harpsichordists—pianists as well!

W hat is the ideal in music? It is to create phrasing that arises organically from as many details as possible. The overall lines are the sum of the details; the detailed rhythm, intonation and rhythmic swing… The aim is to create the impression that the music materializes in the here and now—not because it says so in the notes, or because it is something that we are doing for our own pleasure. It is something we do to communicate, to involve the listener.”
— Lars Ulrik Mortensen, 2007

DSM: What do you think of the notion that if you can play keyboard instrument ‘A’ well, you can probably play keyboard instrument ‘B’ well? I tend to think this is refuted by the ‘A-B’ pair ‘piano-harpsichord’.

CMT: Yes, well, many harpsichordists may have hardly the musculature to depress the piano keys, or lack the stamina to do it through an entire program.

DSM: And pianists may inadvertently tend to man-handle harpsichord keys.

CMT: In other words, the ‘the muscle memory’ you’ve spent many years acquiring in pursuing mastery of your primary instrument can’t readily be unlearned. The neural and musculoskeletal pathways are ‘set’.

DSM: In similar fashion, you don’t see highly accomplished brass players switching between brass instruments. The embouchure for each is very different from the others, and switching to another one tends to cause injury or difficulties when returning to your primary instrument.

CMT: Is it the sheer hand strength required to play the piano that’s the issue? By contrast to piano, the harpsichord’s played with the fingers only—or mostly. The only role for anatomy that’s proximal to the proximal interphalangeal joint is to position the fingers over the keys. There’s very little force exerted from the hand, arm, shoulder, or back—nothing beyond what it takes to get the key down accurately.

DSM: The piano, on the other hand, takes considerable strength to play—a large proportion of the weight of the back, shoulder, arm, hand, and fingers is projected down into the keys. The forces are considerable.

CMT: But the big difference is how you get the key down, don’t you think? How you get the piano key down determines the attack—the rate at which the hammer rises to strike the string. How you release the piano key is somewhat less critical. You don’t find people afflicted with pianists’ cramp complaining about their release. The problem is primarily with the attack.

DSM: Moreover, a pianist never really touches the string directly. The hammer mechanism is a step removed. With the harpsichord, it’s the opposite—it’s ‘pedal to the metal’ all the time. As the harpsichord key does down, your finger communicates directly with the string through the plectrum—you feel the plectrum stretch the string, you feel the string as it’s released.

CMT: And there’s a very long decay until you release the harpsichord key. With harpsichord, your release is critical—you have to maintain finger independence even more rigorously than with piano. What’s remarkable with Mortensen’s playing is not only the absence of tension in his hands but also the amazing finger independence that he has. Watch his fourth and fifth digits and you’ll see what I mean...

DSM: So with piano, the action is mainly downward, using your whole upper body—essentially ‘into’ the keyboard. And, with harpsichord, the action is mainly upward, more or less ‘out’ of the keyboard—using your finger from the tip to the proximal interphalangeal joint.

CMT: Learning how to play a keyboard instrument is a long process of training neural pathways. I wonder if there’s any difference between keyboard instruments—between piano and harpsichord, say—with regard to susceptibility to focal dystonia or other injuries.

DSM: To date, there’s really no research literature addressing that. The rarity of the cases makes the systematic study of possible statistical associations of that kind very difficult. There are, though, some recent papers in the journal MPPA that touch on it, albeit in an anecdotal way.

CMT: I wonder, too, whether—since the finger action is so different between harpsichord technique and piano technique—switching instruments might be helpful for a player who has developed a disability that is specific to one keyboard instrument. Are harpsichord and piano sufficiently different, do you think, so that the injured central and peripheral neuroanatomy involved with focal dystonia affecting the performance on one instrument would be distinct from the neuroanatomy pertinent to performance on the other instrument?

DSM: Again, there’s no published research literature concerning that possibility. Interestingly, the percentage of left-handed professional musicians isn’t significantly different from the percentage of ‘south-paws’ in the overall population, except for keyboard musicians. The percentage of ‘lefties’ among piano, organ and harpsichord players is very low—primarily because of the right-dominant literature. For a left-handed musician to play piano is comparable to writing with her/his right hand—awkward, uncomfortable. Consequently, lefties tend to play non-keyboard instruments professionally. So my hunch would be that the neuroanatomical pathways that are relevant to harpsichord playing and piano playing overlap a great deal. It would be surprising that switching instruments would offer respite from something like dystonia, unless there were a different laterality-dominance.

CMT: There is the example of Leon Fleisher and the left-handed piano literature. And Reinhard Goebel gave up being Konzertmeister of Musica Antiqua Köln in 1990 at the age 38 because of focal dystonia. He obtained a left-handed instrument, re-learned the violin left-handed, and resumed playing from the second violin desk (second-chair not because of diminished ability, but more probably to prevent collisions with the bows of the other violins). The literature was, obviously, the same as before. But the pathways were sufficiently different so that the switch was successful.

C ould anything be more absolute than Bach’s faith in God? Well, the means that Bach employs to express his unswerving faith in God are revealed more by way of hints. If the word ‘God’ makes sense in the case of Bach; providence or meaning may be better words. His trust in authority does not give rise to the need to shout out some truth or other, but rather to suggest it. There is a very wide framework for interpretation in Bach, but he is much more challenging, because he is less blunt. He appeals much more to my temperament than the broad statements of the Romantics.”

— Lars Ulrik Mortensen, 2007

DSM: Mortensen is the artistic director of Concerto Copenhagen. He studied with Karen Englund and Jesper Bøje Christensen at The Royal Danish Academy of Music in Copenhagen and with Trevor Pinnock in London. From 1988 to 1990 he was a member of London Baroque, and from 1990 to 1993 he was a member of Collegium Musicum 90. He has recorded for Archiv Produktion, Harmonia Mundi, Kontrapunkt and DaCapo. His recording of Bach’s Goldberg Variations won him a Diapason d’Or. He directed the European Union Baroque Orchestra in 2003. He was professor of harpsichord and performance practice at the Hochschule für Musik und Theater in Munich from 1996 to 1999. This year he received the Léonie Sonning Music Prize, Denmark’s premier music award.