Focal D Hand Injuries

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ACOUSTIC MAGAZINE OCTOBER 2011

FEATURE

OCTOBER 2011 ACOUSTIC MAGAZINE 19

EATURE PREVENTING INJURIES IN GUITARISTS

PREVENTING INJURIESIN GUITARISTSFOCAL HAND DYSTONIA

By Katherine Butler www.londonhandtherapy.co.uk

D ystonia is a syndromewhere involuntaryprolonged musclecontractions can

ead to sustained twistingpostures.1,2,3 If symptoms startbefore 28 years of age thedystonia is classified as ‘earlyonset’, but if they start after28 years of age it is classifiedas ‘late onset’. Dystonia can befurther categorised into primarydystonia, where there are noobvious effects on the brain, orsecondary dystonia, where a partof the brain (the basal ganglia)may be affected.

Symptoms can be:

• ‘General’, where symptomsmanifest in all extremities

• ‘Hemi’, where symptoms arefocused on one side of the body

• ‘Segmental’, where a sectionof the body is affected, or

• ‘Focal’, where a single bodypart is affected.

Any part of the body canbe affected by focal dystonia,including the neck, eyelids, vocal

cords or hand.4,5

In this article we will look atfocal hand dystonia (FHD), aate-onset, primary dystonia

that is often task-specific andincludes musician’s and writer’scramp (Fig 1).

 Focal Hand DystoniaIn MusiciansFHD in musicians is a primarydystonia that is painless and isusually task-specific, focal and ofate onset. Symptoms can includeack of coordination, cramps and

tremors.6 Tey tend to be sp ecificto each individual and related tothe instrument played.

Patients can respond tosensory tricks, and if they do,this is usually a good indicatorof how successful hand therapywill be. Sensory tricks can beused to ‘fool’ the brain and give a‘nonsense’ message to the brain.Tis breaks the fixed messagefor a short time.4,7,8 Often thenovelty will not be effective forlong and the brain recalibrates tothe automatic dystonic pattern.Coban, Blu-ack, latex gloves

and splints can all be used assensory tricks (Fig 2).

It’s estimated that 2–10%of professional musicianshave focal hand dystonia,9,10,11 which is higher than the 0.1%of writer’s cramp sufferersin the general population.12 FHD is overwhelmingly morecommon in classical than inpop, rock or jazz musicians.e high percentage of FHDin this population reflects thespecific demands of continuousrepetition made upon them.Musicians who suffer from focalhand dystonia may be geneticallypredisposed to developing this

condition, and then excessiveplaying or overtraining may bringit on. Ongoing work to identifyabnormal genes in patients withfocal dystonia continues andresults of further studies areeagerly awaited.

Who Develops FHD?Many factors can ‘trigger’the development of FHD inmusicians, such as a suddenincrease in playing time, changein technique, return to playingafter a long break, trauma,

history of nerve entrapment,psychological aspects or changeof instrument. Repetitivemovements can inducestereotypical feedback messages,which lead to disorganisation inthe area of the brain that controlshand movement (sensory cortex)and a failure in coordinationbetween sensory and motormessages to and from the brain(sensorimotor integration).Tis can lead to uncoordinatedmovement (Fig 3).

reatmentsAt present there is no ‘cure’for dystonia, and many ofthe treatments availablehave significant limitations.Current treatments includeoral medication, Botulinumtoxin injections, surgery,rehabilitative therapies andsupportive approaches. Butlerand Rosenkranz13,14 publishedtwo papers that clearly outlinemany of the treatments that havebeen researched and trialled withpatients who are aected by FHD.

The rehabilitative

approaches include:• Sensory re-education• Sensory motor retuning (SMR)• Slow- down exercise therapy

(SDET)

Fig 1. Task-specific action-induced focal hand dystonia has different forms, including musician’s dystonia, which canaffect the hand and embouchure (a), and writer’s cramp (b).

a) b)

Fig 2a. A p last ic sp li nt b ei ng u se d a s a s enso ry tr ick . Fig 2b. A l ycr a fing er s le eve a nd p las ti c s pl int bei ng use d as a se ns or y t ri ck .

playing the piano. Te authorsconclude that proprioceptivetraining applied for only 15minutes significantly restoredthe pattern of sensory motororganisation in musicians’ dystoniaand improved motor performanceon the piano objectively andsubjectively for up to 24 hours.Tis intervention is a highlypromising tool for rehabilitationand it is hoped that furtherinvestigations into this excitingtreatment technique can continue.

Sensory re-education is atreatment technique used atLondon Hand erapy and

many patients respond well to it.Careful explanation and massiveamounts of encouragement arerequired for a patient to continuewith this treatment techniquelong enough for the sensorychanges to occur and for theeffects to be noticed whileplaying their instrument.

Sensory MotorRetuning (SMR)Te ‘compensating’ finger is fixedin a splint while the ‘dystonic’finger carries out exercises.23 Tese exercises are completedunder supervision and involveone or more of the other digits to

Figures 3a, b and c. Manipulatingembossed items such as dominoes(a), identifying sensory stimulation(b) and discriminating and matchingcommon household items (c).

Figure 3: Byl model of focal hand dystonia in humans showing impairment ofthe sensorimotor feedback loop.

sensorimotor integration fails

induces motorincoordination

disorganisation insensory cortex

induces stereotype & repetitivemovement feedback messaging

repetitive movements

showing impairment of the sensorimotorfeedback loop.

a)

b)

c)

• Multi-disciplinary approach• Limb immobilisation• Supportive approaches

In this paper some of the morecommonly used treatmenttechniques and current researchfindings will be explored.

SensoryRe-educationRepetitive motions can induceplasticity changes in the sensorycortex, which may degradethe hand representation andinterfere with motor control.15,16 Using sensory training to treatpatients with FD is raisedthrough this research. Sensoryre-education programmesfacilitate and positively influence

the relearning process andimprove function. Sensorydiscrimination training is taughtas part of the home exerciseprogramme.17,18,19 However, thesame number of repetitionsthat lead to the disorder maybe required to restore the handrepresentation, so cooperationis essential when using thistreatment technique.15,16

o facilitate normal sensationand perception, and reinforce handfunction, patients are asked to visualise healing, imagine normalsensory processing, motor controland task execution. Byl expectspatients to complete 1–2 hoursa day of sensory discriminationactivities at home.17 Teseactivities can include: matchingobjects/shapes or textures,braille reading, or identifying andmanipulating common householdobjects with vision occluded(Figure 3a, b and c).

Zeuner et al20 report on their

studies of the efficacy of learningto read Braille as a method ofsensory training for patientswith focal hand dystonia. Teauthors conclude that training inBraille reading improves spatialdiscrimination and decreases thelevel of disability in patients withfocal hand dystonia. Tey alsoshow that sensory training lastinglonger than eight weeks may leadto continued improvement.21

Rosenkranz et al22 presentproprioceptive (awareness ofwhere your body is in space)training as a sensory interventionin order to assist in increasingcontrol of movements while

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FEATURE PREVENTING INJURIES IN GUITARISTS

exercise for up to 2.5 hours perday for eight consecutive days.24,25

It is believed that SMRproduces functionalimprovement associated with

neuronal reorganisation. Candiaet al24 present results of 11professional musicians who took

part in a prospective case seriesthat had a follow-up comparisongroup of 3–25 months for

piano and guitar subjects and0–4 months for oboe and flutesubjects. SMR was seen as beinga valuable treatment technique

for pianists and guitarists aseach patient displayed improvedperformance without the splint.

reatments that alter movementpatterns may provide assistance

to patients with FHD.

Slow-Down ExerciseTerapy (SDE)An exercise called ‘slow-downmovement therapy’ (SDET) that

Sakai26 presents, works very wellwith guitarists, even though theinitial research was performed

using pianists. Te therapyfollows these five steps:• e patient chooses a piece

of music that causes a dystonichand movement.

• e performance speed is

reduced until there is nodystonic movement evidentand the metronome marking

is noted.

• At this slow tempo the patientrehearses the piece for half anhour per day for two weeks

and is allowed to play otherpieces freely.

• After two weeks the speed is

increased by 10%. If symptomsdo not appear with thisincrease in speed the patient

proceeds to practise for anadditional two weeks at thistempo. If the dystonic

movement does reappear thenthe speed is decreased.

• After two weeks the speed

is gradually increased again byanother 10%, and theprogramme continues.

SDE therapy teaches a patient to

reduce the speed of movementbelow the level where memoriesand emotions associated withdystonia exist. Movement patternsare then retrained. Tis treatment

technique is utilised in the clinicsetting with great effect. Manypatients find it encouraging being

able to play their instrument freelywhen not doing the slow-downexercises and appreciate mapping

their progress by looking at themetronome markings.

Hand Terapy & TeMulti-disciplinaryeam (MD)No single treatment modality

seems to be effective for the

treatment of FHD. When

treating musicians an MDapproach can be very helpfuland necessary. Tis team will

frequently include: the musician,neurologist, hand therapist,music teacher, instrument maker

and psychologist.MD treatments can include

traditional hand therapymodalities, encouraging

rest, psychological support,modifications to the instrument,Alexander technique or

Feldenkrais therapy, mirrortreatment techniques andretraining the whole body and

associated movement patterns. Abrief outline of each of the abovetreatments will follow.

raditional hand therapymodalities include splinting(Figure 4a, b and c), adaptive

devices, heat, ice, exercise,strengthening, rehabilitation andpreventative measures against

the development of FHD. Soft-

tissue massage may be requiredto decrease muscular tension.Education and liaison with the

teachers and other members ofthe MD are integral.

Dystonic movements occur

predominately while performingperceptual motor tasks involvingemotion. Tere is difficulty

changing emotional andmotor traces that have becomeassociated, and this may lead

to preservation of dystonicsymptoms. Emotional support orreferral for professional help may

be necessary for some patients.Modifications to the

instrument may assist in

decreasing symptoms through

eliminating postural triggers(Fig 5). Modications could

include: changing to a smallerinstrument, altering location ofthumb on neck of instrument

or altering tension or type ofstrings. Playing positions canalso be changed, ie standing up,

kneeling or lying down to play.Feldenkrais and Alexander

techniques can help patients gain

awareness of control, with simplemovements being practised andthen more complex patterns beingintroduced once muscle activity

and relaxation have been learnt.28

Chamagne29 particularlyfocuses on increasing shoulder

control. I use arm-swinging

Figs 4b and c. Splints can assist in retraining movement patterns and can block movements or act as a sensory trick.27

Fig 4a. Blocking splints made ofplastic.

b) c)

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FEATURE PREVENTING INJURIES IN GUITARISTS

exercises in the clinical settingfrequently and integrate them

into the patient’s home exerciseprogramme, and many peoplereport these as being veryeffective and helpful.

Mirror treatment techniqueswere first used with patientssuffering from phantom limb.30 When using this technique withdystonic patients, instant visual

feedback with mirrors can helppatients recognise dystonicand non-dystonic movements.

Te mirror is positioned so themusician can see the uninjuredhand looking like the injuredone. Te illusion is created and

the brain thinks there is activityin the injured hand.31 It is very

useful to use this techniquewith pianists in particular, asboth hands are performing

similar motions. Tis techniqueis not so easily translated toinstruments such as the guitar

as the hands perform suchdierent movements. However,this technique can be useful

in retraining basic movementpatterns in guitarists and isused frequently within the clinic

setting to assist guitarists in

Fig 5: Instrument modifications can include using supports that alter theposition of the guitar, and this can lead to a change in arm and hand positionsthat may assist in decreasing postural triggers.

retraining hand movements awayfrom the instrument.

Prevention Is BetterTan Cure!Animal studies show that highlyrepetitive motor movementscontribute to disorganisation in

the area of the brain that controlsthe hand.

Protect yourself:

• Vary the speed and force ofrepetitive movements.

• Maintain your instrument in

top playing condition to reduceexcessive energy outlay.

• Intersperse practice with

other activities.• Control stress and anxiety

before a performance andpractice sessions.

Conclusionse mechanisms by which FDdevelops in musicians need to

be identified. reatment mustassist in re-establishing the linkbetween sensory and movement

control and commands. Acomprehensive therapy andhome exercise programme

with sensory re-education as

a focus can improve sensoryprocessing and motor controlof the hand. SMR, slow-down

exercise therapy, and handtherapy techniques are of valuewhen treating FD in guitarists.A whole-body approach must

be adopted when treating thispatient group and regular reviewand assessment of the musician

playing their instrument is

essential. Scientic researchinvestigating preventativemeasures and appropriate

treatments for FHD is essential.Collaboration and an MDapproach to prevention,

treatment and research areimperative and will benefit all.Katherine Butler 

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References