Performing Arts Medicine Abroad

Prolonged Neuromuscular
Rehabilitation for Musicians
Focal Dystonia
Raoul Tubiana, M.D., FRCS

ecause of the increasing number of musicians seen in my

hand clinics and because of the time needed for their
examinations, in 1975 with the assistance of my physiotherapist Philippe Chamagne, I established a monthly medical
clinic for musicians. Since then, we have seen more than
4000 musicians with medical problems of the upper extremity, about 600 of whom were diagnosed with a focal dystonia
(FD). This unusually high proportion of patients with FD is
probably the result of our early interest and publications in
this area.1,2
All 4000 patients were given a complete physical examination. From these examinations, we were struck by two obvious findings: 1) the frequency of problems of posture and
movements and of muscle imbalance (seen in most of the
patients with FD), and 2) the psychological repercussions of
their musical frustration.
We decided to attempt to correct the most significant
deformities through a rehabilitation program. We were
encouraged to pursue this program by the personal experience of Philippe Chamagne, who years earlier had suffered a
writers cramp and, due to his profession, was able to cure
himself after a prolonged rehabilitation.3 In 1991, we
reported an evaluation of our treatment results.4 Although
the results seemed to have improved over time, we concluded
this review as follows: These results must be reviewed with
caution because of the initial lack of patient selection and
because the therapy protocol was firmly established only after
a long trial period.5

Professeur Tubiana is Founder and Past President of the Institut de la Main

in Paris and Past President of the Intenational Federation of Societies for
Surgery of the Hand.
This paper has been presented as a Communication at the 10th European
Congress on Musicians Medicine, June 2003, in Turku, Finland.
Address correspondence and reprint requests to Prof. Raoul Tubiana, Institut de la Main, Clinique Jouvenet 6, Square Jouvenet, 75016 Paris, France.
Fax: (33 1) 42 15 40 42.
166

Medical Problems of Performing Artists

For these reasons, we re-evaluated our results in 2000, this

time using well-selected patients and a well-established therapy protocol.6 Also, we graded patient outcomes according to
a classification of six stages of dystonia severity, which provides an assessment of the instrumentalists musical capabilities at the onset of the treatment and after rehabilitation
(Table 1). Between 1992 and 1999, we saw 145 cases of musicians FD, and our results are the subject of this paper.

BACKGROUND AND MUSICIAN

EXAMINATION
The exact cause of FD, a neurologic movement disorder,
remains unknown. However, in our experience, several factors seem to influence the development of FD. In many of
these cases, the onset was found to coincide with a period of
especially intense musical activity or after a change in musical
behavior. Any changes in long-established musical habits can
lead to unaccustomed tension (both biomechanical and psychological). In some patients, other factors also may play an
etiologic role, including 1) chronic pain due to overuse/
misuse or nerve compression and 2) trauma.
The same individual or a family member may occasionally
have other types of dystonia, such as writers cramp, torticollis, or blepharospasm. Although in our experience, these
cases are rare, they nevertheless indicate that a certain susceptibility for developing FD may exist.
The most common inciting factors in our experience have
been biomechanical and psychological. Of course, FD should
not be attributed to a purely psychological origins; as Decourt
writes, This does not deny the emotional behavior common
in artists, and the apprehension they have of the socio-professional consequences may lead to an obsessional state
which one must take into account.7 It is well known that
stress can cause muscular tension, particularly in the trapezius and neck areas.
A complete physical examination is necessary to evaluate
the mechanical disturbances.

Examination without the instrument shows muscular imbalances or deficiencies that are not specific for FD but that are
often found in musicians with FD. Muscular imbalance is
extremely frequent at the level of the scapulothoracic girdle, in
those muscles responsible for positioning shoulder axis. Disturbance of the scapula-stabilizing muscles causes internal rotation of the arm and affects the dynamics of the upper limb.
Without proper support and positioning of the shoulder
girdle, fine control of hand movements is problematic. Most of
our patients showed a muscular disequilibrium between strong
peripheral muscles of the limb used for fine movement and
the often insufficiently used proximal stabilizing muscles.
A functional imbalance between the radial and ulnar
parts of the hand is also often seen. This typically may involve
a collapse of the fourth and fifth metacarpal heads. Also, limitation of abduction between the third and fourth fingers, as
noted by Wilson and Wagner,8 is occasionally found and is
perfectly apparent in the hand of Glenn Gould.9
It is commonly said about FD that neurological examination does not reveal any further abnormalities. However,
in our cases, proprioception is often altered. This problem is
easily tested by having the patient close his or her eyes, asking
the musician to place the distal phalanx of a finger of the one
hand in a flexed or extended position, and then to place the
finger on the contralateral hand in the same position.
Assessment of the musician playing his or her instrument is vital,
not only to reveal involuntary abnormal movements but also
to identify nonphysiologic postures and movement compensations. While playing, it is impossible for instrumentalists to
avoid momentary lapses from an ideal posture. However,
numerous repetitions of a complex movement in a nonphysiologic position cause overworking of muscles and may lead
to serious disorders. Because the majority of musicians with
nonphysiological postures are able to maintain the accuracy
of their movements, additional risk factors must exist provoking disturbances in fine motor control. In our opinion,
additional risks factors for the development of FD are disorders of proprioception, an excessive emotional susceptibility,
and/or sometimes a genetically determined predisposition.
Regarding psychological factors, it seems that most musicians
suffering from FD have totally invested themselves in their
profession; these people are intense perfectionists and have
great artistic ambition. One can then understand the despair
of the instrumentalist who can no longer control his or her
hand. In most of our patients, we have found an interdependence between biomechanical and psychological factors.
This extensive examination is important for designing the
therapeutic program, which is based on how and when the
instrumentalist uses movements as compensation during a
musical performance.

PROLONGED NEUROMUSCULAR
REHABILITATION AS TREATMENT OF
MUSICIANS FOCAL DYSTONIA
The goal of the treatment is to establish a new sensory
motor program obtain through a complete rehabilitation of

TABLE 1. Classification of Handicap

0
1
2
3
4
5

Unable to produce several notes

Several notes, then blockage
Short sequences with unsteady fingering
Cannot execute certain elements
Plays without normal speed
Return to concert performance

the neuromuscular system. Different methods exist that may

be tried in order to achieve this goal. We have chosen to treat
musicians FD with a rehabilitation program that includes
both physical and psychological components.
The treatment has been gradually refined. It consists of
the musician being made aware of any poor posture, deprogramming the nonphysiologic movements, and then teaching
movements that respect normal physiologic function. This reeducation is not restricted to the hand, but includes the
whole body. Prolonged rehabilitation tends to reestablish a
physiologic posture that supports the freedom of movements
by the musician with minimal expense of energy.
Once the neuromuscular program is established, it must
be communicated to the patient in simple, understandable
terms in order for the musician to recognize not only what is
being done but also why. This approach maximizes the rehabilitation potential.
The prospect of a long period of rehabilitation may itself
produce anxiety in the musician,10 not only for economic reasons but also for fear of being cut off from the musical community. Support therapy from a psychotherapist can help the
musician to adhere to the long rehabilitation program. In any
case, the instrumentalist must maintain some musical activity, whether playing with the other hand when possible or
teaching in a music school.
Chamagne has developed a progressive therapeutic program with four phases. The details of these rehabilitative
phases have been described in several previous publications.611,12 In summary, they are:
Phase 1: Restructuring the Body Image
Phase 1 is a preliminary phase in which the musician
develops an appreciation of proprioceptive elements and
learns techniques of stereognosis. Facing a mirror, the musician becomes aware of any poor posture. He or she must
become conscious of the effect of gravity. The musician must
ensure that the transverse axis through the shoulder joints
and pelvis is placed squarely over the feet, and he or she must
straighten the spine and position of the head and then find
this balance with the eyes closed.
Because a physiotherapist who specializes in the treatment
of musicians has close contact with the patient from the
beginning of the treatment and over the long-term, he or she
will also have a psychological effect on the patient. The physiotherapist will have the opportunity to hold a dialogue
explaining the mechanism of the deformities. Before attempting to correct the inappropriate postures and movements, the
December 2003 167

TABLE 2. Focal Dystonias in Musicians, by Instrument

Total
No.

Right
Hands

Left
Hands

Pianists
Guitarists
Violinists and
violists
Flautists
Piccolo player
Oboists
Saxophonists
Bag piper
Clarinetists
Accordionists
Percussionists
Organist
Horn player
Bassoonist

46
36

42
26

4
10

21
12
2
4
3
1
2
3
7
1
1
1

5
1
1
3
1
1
2
2
3
1

16
8
1
1
2

Total no.

145

91

Instrumentalists

Lips

Right
Foot

1
3

2
1
1

48

patient is first taught the basis of normal anatomy and physiology, for without this knowledge it is impossible to modify
patterns of movement that lead to the disorder.
Phase 2: Independence of Limb Movement
Once a balanced posture is achieved, the musician tries to
achieve complete independence of the functioning limbs,
without altering the basic posture previously attained. These
two first phases are directed at removal of bad habits, and
they are generally difficult for the musician. In fact, sometimes the rehabilitation ends at this stage if after several
months there is no sign of collaboration on the part of the
patient. However, if there is any improvement, rehabilitation
is continued.
Phase 3: Re-teaching Movement or Posture
Phase 3 takes into account specific areas of movement or
posture to be corrected or developed. Such areas may include a
lack of proximal support of the limb, strengthening of the wrist
and digital extensors, or strengthening of interosseous muscles.
Rehabilitation must consider the function of each digit on
the instrument. Frequently, in the dystonic musician, the
strong proximal muscles of the shoulder girdle are neglected at
the expense of the distal muscles, and the force of contact of
the digits on the keys is increased. The force of the digit on the
instrument is re-taught first on foam using different resistances.
Phase 4: Return to the Instrument
The final phase emphasizes the integration of the new posture and muscular balance into the movements needed at the
instrument, and it is done while the musician faces a mirror.
Orthotic devices are sometimes an useful adjunct in this phase.
It is important to develop the exteroceptive and proprioceptive
senses, first by simulating play without the instrument (shadow
playing) and then by actual playing with the instrument.
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Medical Problems of Performing Artists

Management of the return to playing is particularly important. The activity must be progressive, with a gradual increase
in the amount of time spent playing and also in the technical
difficulty and tempo of the music. It requires the avoidance
of positions and activities that provoke the dystonic symptoms. Progression to recovery is never linear; rather it is
through a series of successive levels.
Rehabilitation is prolonged and may take several years
(about 2 years on average in this series). The aim of the treatment is to give the instrumentalist an opportunity to play
musical passages using physiologic movements at a normal
speed, as well as to regain the instrumental sound that he or
she had attained prior to the dystonia. This is quite difficult
to achieve. The duration of rehabilitation depends mainly on
the patients motivation.

RESULTS OF PROLONGED REHABILITATION

OF MUSICIANS FOCAL DYSTONIA
We previously reported the detailed results of our rehabilitation program for musicians FD, for cases treated between
1992 and 1999, divided according to the instrument played.6
Between 1992 and 1999, we saw 1320 musicians with upper
limb problems, 145 of whom had FD (Table 2). FD was predominant in men (105 men, 40 women), and the average age
of onset was 33 years.
Because of our specialization at the Hand Institute, we
saw only a few cases of cervicofacial FD, which were those
associated with upper limb dystonia. However, Chamagne, in
the new Rehabilitation Center of Medecine des Arts, has
treated these patients according to the same basic principles
of prolonged rehabilitation and has seen encouraging results.
For our physical examination, we established a classification of six stages of FD severity, which provides an assessment
of the musicians musical capabilities at the onset of the treatment (Table 1). This same classification provides a basis for
evaluating the results following treatment.
In short, from a total of 145 musicians with FD treated
between 1992 and 1999, 35 failed to complete the rehabilitation. Of the 110 who finished the rehabilitation program, 25
showed no improvement, and 85 have shown more or less
improvement, including 39 patients who returned to perform (Table 3).
In our experience, the higher the functional grade at the
beginning of the treatment correlates with better results
after rehabilitation. Other factors influencing results
include the quality of the treatment, unfavorable psychological or morphologic conditions, and a delay between the
onset of the problems and treatment. Age appears to influence the results, in that the prospect of a long and uncertain
rehabilitation may be more difficult to tolerate for elderly
musicians.
Also, the degree of cooperation of the patient is of critical
importance. Artists who seem to react positively to rehabilitation are those who show a desire to understand how the
body functions and hence to understand better the mechanism of the problem.

The results of our prolonged rehabilitation treatment of

musicians FD are far from satisfactory in all cases and could
probably be improved in cases. However, they show that musicians FD is not incurable. Thirty-nine instrumentalists, among
them some of international renown who had been obliged to
interrupt their careers, returned to performance. After treatment, some musicians are still fatigued when concerts are
scheduled too closely, and periodic re-assessment of posture
and movement is mandatory in order to avoid recurrences.
We agree with Altenmller, when he says:13 Although the
neurobiological origins of this disorder are not yet clarified,
it is probable that musicians FD is in most cases part of a
cortical sensory-motor mis-learning syndrome, which in turn
is due to dysfunctional brain plasticity. It has now been
demonstrated that daily musical training can induce functional reorganization of the cerebral cortex.14,15 We believe
that through the flexibility offered by neural plasticity,16 it is
possible in some individuals to teach a new neuromuscular
reprogramming that respects normal physiology.
We do not believe that administration of botulinum A
toxin constitutes the treatment of choice for musicians FD.
Although local injections of botulinum A toxin are effective
in reducing the involuntary contraction of blepharospasms
or torticollis, they do not appear to be as promising an
option for musicians because of the musicians reluctance to
submit to repeated injections. In 1991, Cole and colleagues17
concluded a summary of their experience with botulinum
toxin with these words: FD in a musician is characterized by
both spasms and a disorder of coordination. Improvement in
the spasms can be accomplished, but the motor coordination
component is not addressed with the treatment.
We do not think that administration of botulinum A
toxin, without neuromuscular rehabilitation, should be an
option for musicians FD. We agree, however, that in some
severe localized contractions, administration of this toxin can
be a useful adjuvant to the rehabilitation treatment.
In closing, our experience leads to several conclusions:
The basis of therapy for musicians FD is a long rehabilitation program.
A multidisciplinary approach is the best way to treat this
condition.

TABLE 3. Results for 12 Pianists According to FD Scores

Initial
Grade

No. of
Subjects

0
1
2
3
4

6
5
13
12
6

2
3
2
2

1
1
6
5
2

1
0
2
5
4

Finally, considering the long-term investment required in

the rehabilitation, personal factors of the musician influence
the results. We have found that musicians with FD who
adhere to the long rehabilitation program and who re-evaluate the basic aspects of their playing and some aspects of their
professional behavior have the best chance for cure.

REFERENCES
1.
2.
3.
4.
5.
6.

7.
8.
9.
10.
11.

At the Musicians Clinic at the Hand Institute, four specialists currently run the program: a hand surgeon (Prof.
Tubiana), a neurologist (Prof. Rondot), a pediatrician (Prof.
Malek), and a physiotherapist (Ph. Chamagne). The physician typically will make the diagnosis, prescribe the therapy,
and control the evolution of the treatment. An experienced
physiotherapist institutes de-programming and re-programming of the musicians sensorimotor system. And finally, psychologists trained in the musicians problem help the musicians to lessen their frustration and assist them in developing
a new perspective. The collaboration of instrumental teachers is also desirable and may be of great help.

Final Grade
____________________________________
0
1
2
3
4
5

12.
13.

14.

15.
16.
17.

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