Musician's Dystonia
"When I try to move the fourth finger of my right hand, my whole body seems to contort."
Robert Schumann (1810–1856)Musician's history
-Robert Schumann (1810–1856) – Composer / Pianist
-Leon Fleisher (1928–2020) – Pianist
-Gary Graffman (1928–2025) – Pianist
-David Leisner (b. 1953) – Classical Guitarist / Composer
-Reinhard Goebel (b. 1952) – Baroque Violinist
-Glenn Gould (1932–1982) – Pianist
-Joachim‑Ernst Berendt (1922–2000) – Jazz Critic / Saxophonist
-Billy McLaughlin (b. 1953) – Fingerstyle Guitarist
Definition
-Focal task-specific DTN of the musicians' arm (FTSDma)
-1st describe was William Gowers
Epidemiology
-Onset: typically 3rd–5th decade
-Often after ~30 yrs / ≥10,000 h of playing
>Early musical training (<10 yo, Suzuki method) may be protective
-Male predominance
-High-risk instruments: piano, guitar, violin, brass, woodwinds
Phenomenology
-If not visible, record & see slow-motion
-Hand & OMD (can affect speech, eating, drinking)
-FHD divided in 4 types
G1 Precision→ 2&3
G2 Power→ 3&4&5
G3 Precision→1&2
G4 Proximal
G1 - Precision
1) Pianist, isolated dystonic extension of the second digit (Ia pattern)
2) Guitarist, dystonic extension of 2 and flexion of 3 (pattern Ib)
3) Pianist, dystonic flexion of 2 (pattern Ic)
4) Pianist, dystonic flexion of 2 and extension of 3, (pattern Id)
5) Banjo player, dystonic flexion of 2 and 3 appears mild (pattern Ie)
6) Irish accordion player, extension of 3
7) Guitarist, dystonic extension of 2 and 3 (pattern Ig)
G2 - Power
1) Violinist, dystonic flexion of 4 and 5 (pattern IIa)
2) Pianist, dystonic flexion of the left third and fourth finger (pattern IId)
3) Pianist, dystonia affecting fingers 3-5 (pattern IIc)
4) Piccolo player, dystonic flexion of the left third finger at the middle phalanx (pattern IId)
*Botox at the flexor digitorum superficialis of 3
5) Pianist, extension of 3 and flexion of 4 and 5
6) Violinist, flexion of 4 (likely lumbrical-mediated)
7) Flexion of the 3rd finger (likely lumbrical-mediated) (pattern IIf)
8) Extension of 4 and 5
9) Jazz guitarist, flexion of 5 (pattern IIi)
G3 - Precision
1) Flexion/adduction of the thumb and extension of 2 while playing (pattern IIIa)
2) Flexion/adduction of the thumb and flexion of 2 while writing, producing a pincer-like posture of the thumb and index finger holding the pen (pattern IIIb)
3) Flexion of the thumb (particularly the distal phalanx) while playing (pattern IIIc)
4) Hybrid banjo/guitar, extension of the thumb and flexion/adduction of 2 while playing (pattern IIId)
5) Banjo player, dystonic extension of the thumb while playing (pattern IIIe)
G4 - Proximal
1) Pianist, isolated extension of the wrist as soon as his left hand touches the keyboard (pattern Va)
2) Guitarist, pronation of the wrist, which spread to the task of writing (pattern Vb)
3) Tennis coach, wrist flexion dystonia which spread to occur when he held his arms up (pattern Vc)
4) Percussionist, ulnar deviation of the left wrist while playing with “soft mallets” in a fast roll (pattern Vd)
5) Violinist, subtle loss of vibrato 2/2 biceps activation (VIa)
6) Violinist, dystonia of the bow arm (pattern VII)
*Botox injection
7) Athletics, dystonia of the throwing arm causes the ball to fly wildly off target (pattern EA)
Scales
-Tubiana & Chamagne Scale
Pathophysiology
-Maladaptive sensorimotor plasticity
-Power hand mismatch→ hand is evolutionarily designed to stabilize and exert force onto an object, rather than engaging in precision kinetics
Observations
-Manipulandum DTN→ instrument-specific
-Overflow DTN→ spread to adjacent muscles
-Can progress from focal→ segmental DTN
>Initially task‑specific, but may lose task specificity
-High spread risk in woodwind players (speech/swallowing involvement)
Differential Dx
-Overuse syndromes
-Entrapment neuropathies (e.g., ulnar neuropathy)
>Neuropathy may coexist but is rarely the primary cause
-Functional movement disorder
Treatment Options
-Non-pharm
>Pedagogical: relearning, changing technique, temporary switch
>Sensory: glove
>Constrain-induced technique
-Botox
>US-guided, selective
>Low-doses
-TMS: transient effects, not durable
-Surgery:
>VoA thalamotomy (Japan reports benefit)
>DBS: experimental, protocol-driven only