It's an Epidemic! Are You Next?

When pianists Gary Graffman and Leon Fleisher cancelled concerts in the 1960’s and ‘70’s due to problems with their right hands, it came as a surprise to many in the classical music industry.  Both musicians were at the peak of their careers performing in major concert halls around the world and concerto appearances with top orchestras.  Then, closer to home, guitarist and composer, David Leisner, stricken with right-hand problems, began canceling his busy concert schedule in the 1980’s.  All three musicians exhausted every possible option towards receiving a diagnosis of their hand problems with the hope of discovering a treatment or cure. They sought out physicians, physical therapists, psychiatrists, massage therapists, acupuncturists, and many others.  From professional musicians to talented amateurs, hand problems seem to be occurring in increasing numbers.  Is this era particularly problematic with regards to musicians with hand problems?  Or, is the information age just making us more aware of the problem? 

I’ve not come across a study that chronicled the percentages of contemporary musicians with hand problems compared with previous generations – did earlier musicians just walk away from their instruments if they incurred a hand problem?  As it turns out, Graffman, Fleisher and Leisner had developed focal dystonia.  With the advent of the internet, you can make contact with focal dystonia (FD) sufferers from around the world in dedicated chat rooms for musicians with FD as well as see video of them on Youtube.  Are we more susceptible than musicians before us?  If we examine possible causes of hand problems, including focal dystonia, we might someday find some answers.  First of all, a guitarist who practices Tarrega’s Lagrima and Adelita for a half-hour per day is an unlikely candidate for FD.  Musicians who get FD are typically practicing difficult concert repertoire for hours per day.  Graffman and Fleisher have stated that they were trying to be the fastest, loudest pianists of the land when they developed their hand problems.  David Leisner was working on the 12 Etudes by Villa-Lobos. 

What is focal dystonia?  A simple explanation is that it is where a person has involuntary or spastic, and usually painless, movement or contraction with their fingers.  For guitarists who have the problem manifest in their right hand, typically either their index finger sticks outward and they cannot move it, certainly not in a way that allows them to pluck a string under control; or, the middle, ring, pinky, or all three curl into the palm and they cannot return the fingers to the strings.  Another, probably earlier stage of the problem, is where the player has uncontrolled trembling and twitching with their fingers and they have extreme difficulty in locating the correct string to play.   If the musician has FD with their left hand, it seems that their fingers won’t obey mental directions and either point outwards, won’t lift off the string, or curl into the palm.   

Our bodies typically link muscles together in order to accomplish daily activities.  For example, if you are holding a pencil, it takes very little muscle action to maintain your grip.  However, it you are sitting in a chair, and a pencil lies 4 feet away, when you lean over to grab it, you will activate almost every muscle in your body, from muscles in your toes, legs, abdomen and back all the way up to your neck.  Our bodies link the muscles together in order to maintain balance, or to gain strength by combining muscle groups to share the work load.  The problem with musicians is that for fine motor movements, we often use too many muscles, and most of these extra muscles are opposing necessary muscles. 

One intriguing issue that FD brings up with regards to guitarists is that we tend to develop debilitating hand problems with the right hand more so than the left.  Consider that the left hand needs to move with extremely contrasting motions, along with sustained pressure, while the effort needed to simply pluck a string with the right hand is relatively minimal.  So, on a basic level, it seems that it should be the left hand that would be ripe for developing problems, not the right.  But the issue of speed is more of a factor with the right hand than the left.  Attempting to play quickly with the right hand under tension is likely a major factor.  I think this helps explain what may be the most likely cause of FD:  where musicians tense up opposing muscle groups in the arms – tensioning both the flexors and extensors simultaneously.  After perhaps years of doing this, the impulses from the brain begin to be scrambled and dystonia may occur.   

First and foremost, all the FD musicians that I’ve worked with or seen play have had problems with excess muscle tension.  There are three muscle areas that have been problematic:  the upper trapezius (between the shoulder and the neck); the deltoid (shoulder muscle that lifts the arm); and perhaps most important, the forearm extensor muscles.  It is interesting to note that most movements in playing an instrument, in fact just about anything we do with our hands, focuses on pulling our fingers inward towards our palms. This motion is brought about by contracting our flexor muscles, which are on the bottom of our forearms.  (Take a look at one of your forearms and notice that the flexor muscles are much larger than the extensor muscles.)  If our right index finger, for example, needs to move inward to our palm in order to pluck a string, the flexor muscle for that finger should contract, and the corresponding extensor muscle should release.  If this happens correctly, the index finger will move easily.  However, if the musician inadvertently contracts the extensor and flexor muscles simultaneously, then the flexor has to work more vigorously to overcome the added resistance that the extensor is creating, and strain develops. 

Two interesting approaches that the medical community favors in treating FD is the use of Botox to temporarily paralyze the arm, and arm/hand isolation – where the FD arm and hand are bound in a cast to keep the musician from moving the afflicted area for a time period of about a month.  Both of these techniques are supposed to help the brain forget the old way of playing so that the musician can, hopefully, relearn how to play without the FD symptoms.  I think there is validity to both of these techniques; however, if the player doesn’t radically change their approach to playing, the old problems will resurface.  Another problem with the use of Botox is that the effect wears off after awhile, and it takes ever increasing amounts of a very expensive drug to get the same result (and women in Beverly Hills need all the Botox that they can get!).  

For musicians who have developed FD, three issues need to be examined.  First, they must learn how to relax non-essential muscles and get complimentary muscle groups, like the flexors and extensors to coordinate properly.  Posture is a huge factor here, as proper posture allows the player to utilize the structure of their body to support itself, which allows many back, abdomen, and shoulder muscles to relax.  Frequently, I’ll point out how the player is even tensing their legs and feet unnecessarily.   Lately, I’ve been using a small bio-feedback monitor (Myotrac EMG Biofeedback Systems) to help all of my students learn how to control certain muscles. 

Secondly, develop new ways to play.  This is extremely critical in that the player has created an association between playing their instrument and dystonic movements.  In this regard, it is important to focus on improving hand positions and finger movement by mimicking playing with super-light touching.  One example is to sit with the guitar resting well away from the body – close to the left knee, standing up while playing, or even lying on a bed or floor, and then tapping a string with the fingers affected by FD, without any attempt to play notes.  This is to help the player develop different memories on how to move so that they can create new mental pathways to their fingers.  Another common problem with FD guitarists, at least the ones I’ve seen who have it in their right hand, is that they have too little movement in their large knuckle joints and tend to move almost exclusively with the middle joints of their fingers.  This is easy to fix with the super-light string touching exercise. 

Along the line of developing a new way to play, David Leisner has accomplished this by how he uses back muscles in a way that he never did before.  His use of the back muscles is similar to a technique that ballet dancers are taught in order to hold their arms in proper position for long periods without strain.  David is a rarity, having successfully overcome FD on his own.

Finally, practice habits need to be changed.  Micro-relaxation moments need to be programmed into pieces, and ease of movement needs to be associated with each piece.  Commonly, FD musicians tend to push their fingers incessantly without regard to how it feels to play. 

If the reader should suspect that he or she is potentially developing FD, perhaps first and foremost, you need to see someone, a physician or specialist, who has experience with musicians who have contracted FD.  Continuing to play in the manner that has caused FD will only make things worse.  Fortunately, focal dystonia has received substantial interest in the medical and research communities and there is help available. 

Ultimately, one of the most debilitating issues that a musician faces when they find that they have developed FD is psychological.  Where a player might have basked in the glory of successful performances and widespread recognition, or just the pleasure of bringing a virtuoso piece up to tempo, they now face a frustrating, demoralizing period where everything that they have known in their musical life is now in question.  

The scope of this essay is not to comprehensively examine focal dystonia or offer a cure, but to introduce the problem to unsuspecting readers.  I believe more musicians than perhaps ever have developed this problem due to our society’s emphasis on virtuosity.  I doubt that Claudio Arrau would have ever developed this problem...