Musicians’ Focal Dystonia

Introduction

This resource has been developed to raise awareness of Musicians’ Focal Dystonia (MFD), also known as Task-Specific Dystonia (TSD) in musicians. Although this disorder affects an estimated 1-2% of professional musicians, its possibly career-limiting effect and classification as a reportable occupational disease demands careful attention and awareness.

BAPAM is pleased to receive enquiries from individual performers in relation to their health and welfare, and will treat them in the strictest confidence.

In this Factsheet:

• What is Musicians’ Focal Dystonia (MFD)?
• Symptoms and recognition
• Risk factors and prevention
• How do you know if you have MFD and what can you do?
• What treatments are available?
• Recommendations for organisations

Background

Task-specific dystonia is a potentially career-ending movement disorder that affects one or two in every hundred professional musicians.  Under The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013, this condition is listed as a RIDDOR reportable disease when it affects the hand or forearm. This emphasises how important TSD is as an occupational health concern that must be managed and monitored systematically.

What is Musicians’ Focal Dystonia?

MFD/TSD is a neurological condition affecting movement control during highly specific, skilled tasks.

It manifests through:

• Involuntary muscle spasm leading to abnormal movements and postures of the affected part of the body, impairing control and precision.
• ‘Task-specific’ symptoms primarily affecting a highly practiced musical performance
• Various presentation patterns depending on the instrument and affected body part.

Common presentations include

• Upper limb involvement (hands, fingers, wrist or forearm) in guitarists, pianists and string players
• Embouchure-related symptoms in brass and wind players
• Foot-related symptoms in percussionists

Symptoms and Recognition

Primary symptoms include:

• Involuntary and abnormal movement while playing the musical instrument
• Loss of of co-ordination whilst carrying out a highly skilled and rehearsed activity
• Possible tremor
• Often painless initially
• Normal function likely to remain for non-musical tasks

When MFD affects fingers, hands or wrists, musicians may notice a loss of fluidity in their playing and a tendency for the affected area to pull into an abnormal posture during playing. Other muscles such as the shoulder are also occasionally affected. When MFD affects the embouchure, musicians often report being unable to position the instrument against the mouth, or to pitch or articulate notes correctly, experiencing escape of air or a tremor in the note when it is being held. The function of the affected part of the body may be normal for all other tasks, although the problem can also spread to fine dexterous tasks such as writing, typing, doing up buttons and so on. MFD can cause very significant and career-limiting disability. In attempting to control the problem, musicians often develop secondary symptoms, including abnormal muscle activity elsewhere in the body, which can lead to pain and further impairment. Affected musicians may also become anxious and frustrated about their impaired performance skills.

Risk factors and Prevention

Research to date has identified several risk factors and protective elements:

Risk factors

• Male gender (4:1 male to female ratio)
• Environmental triggers including peripheral trauma and instrumental changes
• Performance-related stress

Protective Factors

• Early musical training (before age 10)
• Systematic approach to practice and technique development

It is generally thought that MFD is associated with changes in parts of the brain which control skilled and repetitive movements, disrupting nerve signals to the affected areas. Various possible causes have been suggested, but evidence for any one particular cause is not yet conclusive.

MFD is not a degenerative disease or progressive condition, and is not normally the result of brain damage.

Onset of MFD is often associated with performance-related stress and practice habits. Healthy performance techniques may reduce the risk (and are likely to be beneficial in preventing a range of performance-related problems).

Prevention Strategies:

Evidence-based preventive measures include:

• Regular health surveillance and monitoring
• Implementation of structured practice programmes:

– Avoid over-practising, particularly to the point of causing pain or musculoskeletal strain
– Avoid marked changes in technique, especially rapidly and under pressure
– Take regular breaks and appropriate rest periods
– Do a physical warm-up before playing
– Do gentle stretches (once warmed up)

• Early intervention when symptoms first appear
• Stress management techniques

Detailed guidance on healthy performance practice is freely available on BAPAM’s website: Health Resources

Responsibilities and Duty of Care

The music sector includes various working arrangements, including direct employment, contracted services, educational provision and freelancing jobs, and others. Organisations have a duty under both statutory and common law to take reasonable care to protect those who might foreseeably be affected by their undertaking from risk of injury or ill health. While the scope of these duties may vary according to the nature of the working or educational relationship, the following are likely to be essential requirements for all organisations:

1. Suitable and sufficient risk assessments
2. Written warnings and information about TSD
3. Regular health surveillance programs, where residual risk remains
4. Clear referral pathways for suspected cases
5. Appropriate support for affected musicians

Organisations should be aware that failure to implement appropriate control measures may have substantial implications, particularly where earlier intervention could have prevented career-limiting progression of symptoms.

How do you know if you have MFD and what can you do?

MFD is uncommon and most musicians experiencing adverse performance-related symptoms will not have MFD. Young musicians (under 40) often experience musculoskeletal symptoms which may be corrected through changes in performance practice, whilst older musicians may develop age-related musculoskeletal problems which are widespread in the general population and managed by standard medical treatments. Seeking appropriate medical advice and getting an accurate diagnosis is therefore crucial.

Musicians experiencing some of the initial symptoms of MFD – such as clumsiness in playing, ‘disobedient’ fingers, or loss of embouchure control often assume that the problem arises from faults in their technique or from under-rehearsal. They may therefore try to deal with the changes by increasing practice time, which can lead to further symptoms. The problem may go unrecognised for some time due to lack of awareness on the part of the musician or their healthcare professional. Musicians may also keep the condition secret due to anxiety about the career implications.

Assessment and Diagnosis

Because MFD is uncommon and routine clinical examination may prove normal, musicians who have unexplained symptoms and are concerned they may have the condition should seek advice from a performing arts specialist which includes an assessment of them playing their instrument.

Diagnosis requires:

• Specialist neurological assessment
• Detailed clinical evaluation
• Instrument-specific performance assessment
• Distinction from other movement-related conditions

No simple diagnostic test is available, but electrical studies of nerve conduction and muscle contraction are sometimes used to reveal the affected (dystonic) muscles.

Affected individuals need rapid access to assessment by a neurologist and other specialists if necessary. We would suggest arranging an appointment in a clinic run by BAPAM (assessment is free) and also asking your NHS GP about a referral to a neurologist with a special interest in movement disorders.

What treatments are available?

Whilst some musicians may respond well to treatments and the condition can be managed, there is no known ‘cure’. Current evidence supports a multi-disciplinary approach including:

Medical interventions

Botulinum toxin injections (supported by recent clinical trials) can control excess activity in dystonic muscles, although the effects are often short-lived and some side effects may be experienced. Nerve conduction studies are used to pinpoint the best site for the injection if this is the chosen treatment strategy.

Rehabilitation

Instrument-specific retraining programmes

Behavioural techniques are designed to correct the faulty communication between the affected area of the body and the brain. Examples include sensory re-education (matching and palpating objects to enhance sensory discrimination), sensory motor re-tuning (constraint-induced movement therapy), mirror treatment (re-education of affected muscles using visual feedback from unimpaired areas) and slow down exercise treatment (manipulating speed of playing).

Psychological Support

Stress management, performance anxiety management and career counselling can all be useful adjunct treatment.  It is also helpful to optimise any other health conditions.

Some preliminary research on long-term outcomes suggests that the majority of musicians diagnosed with MFD remain within the profession, although they may not be able to return to levels of performance attained before the onset of symptoms.

Due to the complex and individualistic nature of the condition, the management approach needs to be multi-disciplinary, involving both medical and rehabilitative care. Accessing such care outside the NHS can prove challenging.

Recommendations for Organisations

BAPAM can provide expert occupational health advice to employers, unions, representative bodies, educational institutions or other interested parties. Please contact us if you would like to discuss your requirements and the cost of this service. 

Educational Institutions:

• Incorporate TSD awareness into curriculum
• Provide regular health surveillance
• Implement early warning systems
• Maintain clear referral pathways

Orchestras and Ensembles:

• Conduct regular risk assessments
• Provide written guidance and information
• Implement health surveillance programs
• Maintain occupational health support systems and referral pathways

Support for Freelance Musicians:

• Provide access to health information and guidance
• Establish clear reporting mechanisms
• Ensure access to appropriate medical support

Guidance for Individual Music Teachers

Music teachers hold a unique position in supporting student health by means of regular observation of developing technique, practices and potential symptoms. Musicians are particularly vulnerable during periods of intense technical development, practice and rehearsal. BAPAM would advise teachers to:

• Remain mindful of how students’ practice patterns and approach change with time
• Record any surprising changes in technical control or playing fluency
• Maintaining suitable notes of any observations potentially indicating symptoms
• Encourage open and honest discussion on healthy practice habits

Teachers are encouraged to develop in knowledge of performing arts health through continuing professional development and building relationships with reputable performing arts medical specialists. Their main responsibility when issues surface, though, is making sure students get prompt and suitable specialist assessments.

Compensation

MFD affecting the upper limb – but not embouchure – is a category of ‘task-specific focal dystonia of the hand and forearm’ in the UK. It is listed as a Prescribed Disease category A4 (see the Department for Work and Pensions publication Industrial Diseases Disablement: Technical Guidance, May 2015 available at www.gov.uk) under which an individual with employee status (but not freelance) in the UK may be eligible for DWP benefits related to disability or loss of earnings. At the time of writing, BAPAM is not aware of an instance of a claim being made in this respect. Any affected player should be advised and supported in pursuing such possible eligibility.