Rehabilitation of musician's dystonia through retraining

Abstract

Focal dystonia is undoubtedly the most devastating condition to affect a musician. Playing a musical instrument requires the precise execution of complex movements, which must happen at speed with exact timing. Since the advent of the CD industry, greater perfection is required than ever before, thus increasing both the physical and psychological demands on the musician. Musicians are athletes and as such often experience a wide range of overuse injuries. The most devastating of these is undoubtedly focal dystonia. Focal dystonia not only affects the speed of neurological transmission, but can distort the movement so much that the musician has no control over which finger he is using. Very often no satisfactory treatment is available and although injections of botox and the administration of antichorinergic drugs can sometimes reduce symptoms, unless the musician gains complete recovery, focal dystonia often ends a career. Usually a musician has spent a lifetime gaining the skills required to play at professional level and therefore his very identity can be threatened when he can no longer play. My belief is that complete recovery can only occur if every movement is reprogrammed from its most simple level so that new neurological pathways can be activated or that the blurring induced by focal dystonia can be clarified. Every movement must be learned in its simplest form, at a very slow speed and the sufferer must learn to play again as if he was a beginner. This can only happen through detailed work with the assistance of an experienced pedagogue. In the course of writing a PhD on this subject I have retrained five pianists and a cellist without other medical intervention. The first three studies were conducted with ten one- hour sessions within a two-week period. Following this study, work was undertaken with two further dystonic pianists: the first of these lived in Sydney and visited New Zealand for two weeks of intensive retraining for 5 hours daily, and the second lived in London and so the study occurred through the medium of video conferencing. Finally I retrained a cellist over a three-week period with a number of follow-up sessions. As the playing of an even scale with the dystonic hand was difficult for all pianists, examples of scale playing were recorded pre and post retraining with each hand separately in three different keys at a range of tempi. These examples were assessed on a four point rating by a blinded listener, who was also asked to identify the hand as dystonic or nondystonic. Results of four of these pianists have been published in Medical Problems of Performing Artists. The cellist, who had problems with vibrato playing because of dystonia, recorded a number of examples pre and post retraining which were later assessed by a professional string quartet who rated the quality of vibrato on a four-point scale. The condition of all six subjects improved statistically, with one pianist returning to the concert platform as an international soloist, and another playing solo concerts again some years later. The cellist is still maintaining her orchestral career and her improved condition has been maintained four years after retraining. My research has shown that there are certain crucial factors that can assist the success of this retraining procedure. Retraining is most successful when the sessions are close together and when the sufferer abstains from all other playing while new movement patterns are established. This gradual process needs detailed monitored practice, so that new movements do not become distorted by past learning. The sufferer also needs to be trained to appreciate minimal improvements as they occur, so that motivation can be maintained. Because of the complexity of the retraining procedure, regularity of sessions is imperative for the success of rehabilitation. This presentation will outline pedagogical retraining as applied to these case studies and with the aid of video clips will show examples of the various problems that affect the musician’s ability to play