Evaluation of embouchure dysfunction: Experience of 139 patients at a single center

Treating the musician rather than the symptom: The holistic tools employed by current practices to attend to the non-motor problems of musicians with task-specific focal dystonia

Musicians Focal Dystonia (MFD) is a task-specific movement disorder affecting highly skilled musicians. The pathophysiology is poorly understood, and the available treatments are unable to fully and reliably rehabilitate the affected skill. Recently, the exclusively neurological nature of the condition has been questioned, and additional psychological, behavioral, and psychosocial contributing factors were identified. However, very little is known about how these factors influence the recovery process, and how, if at all, they are addressed in ongoing practices. For this study, 14 practitioners with substantial experience in working with musicians with MFD were interviewed about the elements in their approach which are directed at the cognition, emotions, attitudes, and behaviors of their patients and clients. A wide variety of tools were reported in three areas: (1) creating a supportive learning environment and addressing anxiety and perfectionism, (2) using body-oriented methods to optimize the playing behaviors and (3) consciously channeling the focus of attention to guide the physical retraining exercises and establishing new habits. The study also revealed that in-depth knowledge of the instrumental technique is profitable to retrain the impaired motor patterns. Therefore, the importance of including music educators in developing new therapeutic approaches will also be highlighted.

Towards a Holistic Understanding of Musician's Focal Dystonia: Educational Factors and Mistake Rumination Contribute to the Risk of Developing the Disorder

Musicians' Focal Dystonia (MFD) is a task-specific neurological movement disorder, affecting 1-2% of highly skilled musicians. The condition can impair motor function by creating involuntary movements, predominantly in the upper extremities or the embouchure. The pathophysiology of the disorder is not fully understood, and complete recovery is extremely rare. While most of the literature views the condition through a neurological lens, a handful of recent studies point out certain psychological traits and the presence of adverse playing-related experiences and preceding trauma as possible contributors to the onset. The nature and the frequency of these factors, however, are under-researched. The present quasi-experimental study aimed to compare musicians with and without MFD in terms of the frequency of various adverse psychosocial and psychological factors to explore their contribution to the onset of the condition. Professional musicians with MFD (n = 107) and without MFD (n = 68) were recruited from online platforms, musicians' unions, and organisations to fill out a survey. The survey was based on two previously conducted interview studies and included the Student-Instructor Relationship Scale (SIRS), the Mistake Rumination Scale (MRS), the Trauma History Screen, and self-constructed questions about the received music education, early success, and personal experiences. To identify potential risk factors, independent samples t-tests were conducted and found that there are significant differences in musicians with and without MFD in terms of mistake rumination, early success, and the received music education. A logistic regression showed that six factors contributed to the construct to various extents; we observed a significant model [χ2 (80) = 22.681, p < 0.001], which predicted 71.2% of the cases correctly. This exploratory study shows that psychological and psychosocial factors might play a role in the development of MFD. Understanding these in more detail could inform preventative strategies and complement the current therapeutic approaches to support this vulnerable population better.

Musculoskeletal and psychological assessments used in quantitatively based studies about musicians' health in brass players: A systematic literature review

OBJECTIVE

Brass players are exposed to high musculoskeletal strains during their instrumental play. Various assessments can be used to measure these strains, whereby a targeted therapy can also be supported. The aim of this study was to review literature concerning assessments used in quantitatively based studies about the analysis of musculoskeletal loads of brass players.

DATA SOURCES

The Cochrane Library, PubMed, CINAHL, PEDro as well as the journal "Medical Problems of Performing Artists" were searched for relevant studies.

STUDY SELECTION

Two reviewers independently applied the inclusion and exclusion criteria to select potential studies. A third reviewer was involved in the case of discrepancies.

DATA EXTRACTION

Two reviewers independently extracted the data.

DATA SYNTHESIS

A total of 73 studies conducted between 2004 and 2019 were included. Within a total of 30 studies, 18 assessments could be found that collect 2-dimensional or 3-dimensional kinematic data using video- or image-based analysis of posture, sonographic, optoelectronic and various electromagnetic systems. In 7 studies kinetic data were measured by force-transducers, pressure platforms, stabilizer and dynamometer. Fifteen studies used clinical examinations and additional assessments to screen individual body regions and 9 studies derived electromyography measurements from a total of 25 muscles. Thirty-one partially validated questionnaires were used to record musculoskeletal pain of brass players.

CONCLUSIONS

A variety of assessments can be used to optimize analysis and treatment procedures in research and clinical work. Future studies should both examine quality criteria of the various assessment methods and validate clinical examinations and questionnaires.

Dystonia in Performing Artists: Beyond Focal Hand Dystonia

Overuse of specific muscles in perfecting movements in performing arts makes an artist prone to many medical conditions. Musicians' hand dystonia is focal task-specific dystonia (FTSD) of hand among musicians that has been extensively studied. However, embouchure, lower limbs, and laryngeal muscles can also be affected among musicians. Embouchure dystonia (ED) refers to dystonia of the perioral and facial muscles that occurs in musicians while playing embouchure instruments. It is essential to identify ED since the dystonia might become persistent and non-task-specific if the musician continues to play the instrument. Task-specific dystonia of lower limbs among musicians has been exclusively reported among drummers. The diagnosis rests on electromyogram (EMG) of the involved muscles during the task. Singer's dystonia (SD) refers to task-specific laryngeal dystonia that occurs only while singing. The diagnosis of SD is based on laryngeal EMG and spectrographic analysis. Cortical hyperexcitability, loss of inhibition, and aberrant plasticity are central to the pathogenesis in both ED and musicians' hand dystonia. The pathophysiological studies in SD are limited. This review aims to discuss the lesser known dystonias among performing artists - ED, FTSD of lower limb, and SD.

Distinct roles of brain activity and somatotopic representation in pathophysiology of focal dystonia

Two main neural mechanisms including loss of cortical inhibition and maladaptive plasticity have been thought to be involved in the pathophysiology of focal task-specific dystonia. Such loss of inhibition and maladaptive plasticity likely correspond to cortical overactivity and disorganized somatotopy, respectively. However, the most plausible mechanism of focal task-specific dystonia remains unclear. To address this question, we assessed brain activity and somatotopic representations of motor-related brain areas using functional MRI and behavioral measurement in healthy instrumentalists and patients with embouchure dystonia as an example of focal task-specific dystonia. Dystonic symptoms were measured as variability of fundamental frequency during long tone playing. We found no significant differences in brain activity between the embouchure dystonia and healthy wind instrumentalists in the motor-related areas. Assessment of somatotopy, however, revealed significant differences in the somatotopic representations of the mouth area for the right somatosensory cortex between the two groups. Multiple-regression analysis revealed brain activity in the primary motor and somatosensory cortices, cerebellum, and putamen was significantly associated with variability of fundamental frequency signals representing dystonic symptoms. Conversely, somatotopic representations in motor-related brain areas were not associated with variability of fundamental frequency signals in embouchure dystonia. The present findings suggest that abnormal motor-related network activity and aberrant somatotopy correlate with different aspects of mechanisms underlying focal task-specific dystonia.

Quantitative, clinically relevant acoustic measurements of focal embouchure dystonia

BACKGROUND

Focal embouchure dystonia impairs orofacial motor control in wind musicians and causes professional disability. A paucity of quantitative measures or rating scales impedes the objective assessment of treatment efficacy.

OBJECTIVES

We quantified specific features of focal embouchure dystonia using acoustic measures and developed a metric to assess severity across multiple domains of symptomatic impairment.

METHODS

We recruited 9 brass musicians with and 6 without embouchure dystonia. The following 4 domains of symptomatic dysfunction in focal embouchure dystonia were identified: pitch inaccuracy, sound instability and tremor, sound breaks, and timing variability. Musicians performed sustained tones and sequences, and then acoustic variables within each domain were quantified. A composite brass acoustic severity score composed of these variables was validated against clinical global impressions of severity.

RESULTS

Musicians with dystonia performed worse in acoustic domains of pitch inaccuracy (median: dystonia = 100%, control = 62%), instability (median shimmer: dystonia = 3%, control = 2%), and breaks (median: dystonia = 0.34%, control = 0.05%). Tremor in embouchure dystonia was 5 to 8 Hz, intermittent, and variable in amplitude. Rhythmic variability did not differ between groups. Participants with embouchure dystonia had different patterns of impairment across variables. Composite severity scores strongly predicted clinical global impression of severity (R2  = 0.95).

CONCLUSIONS

Acoustic variables distinguish musicians with embouchure dystonia from controls and reflect different types of symptomatic impairments. Our composite acoustic severity score predicts severity of clinical global impression for musicians with different patterns of symptomatic impairment and may provide a foundation for developing a clinical rating scale. © 2018 International Parkinson and Movement Disorder Society.

Occupational Health and the Performing Arts: An Introduction

OBJECTIVE

Workplace hazards in the performing arts cause injuries, disabilities, and deaths every year. Occupational health professionals are familiar with most of these hazards and are particularly qualified to contribute to efforts to reduce them. This article reviews current health issues in the performing arts and highlights opportunities for occupational health contributions.

METHODS

Recognized experts in performing arts medicine were consulted and articles illustrating performing arts health issues were reviewed. Literature sources included medical databases, unindexed art-health publications, and popular press articles.

RESULTS

Resources discussing hazards and health issues in theater, dance, voice, and instrumental musicians were located and reviewed.

CONCLUSIONS

Treatment providers have a history of involvement with segments of the performing arts. The occupational health approach to workplace health issues can effectively complement these efforts. Sources of further information on performing arts health concerns are available.

Medical treatment of dystonia

Therapeutic strategies in dystonia have evolved considerably in the past few decades. Three major treatment modalities include oral medications, botulinum toxin injections and surgical therapies, particularly deep brain stimulation. Although there has been a tremendous interest in the later two modalities, there are relatively few recent reviews of oral treatment. We review the medical treatment of dystonia, focusing on three major neurotransmitter systems: cholinergic, GABAergic and dopaminergic. We also provide a practical guide to medication selection, therapeutic strategy and unmet needs.

Embouchure dystonia: a video guide to diagnosis and evaluation

Background

Embouchure dystonia is an unusual focal task-specific dystonia affecting the muscles that control the flow of air into the mouthpiece of a brass or woodwind instrument. The complexity of the embouchure and the relative rarity of the condition pose barriers for recognition and management of the disorder.

Methods

Case review and video survey.

Results

This paper presents four video compilations that illustrate the rich phenomenology of embouchure dystonia, in order to enhance recognition and diagnosis.

Conclusion

The phenomenology of embouchure dystonia is discussed.

Electronic supplementary material

The online version of this article (doi:10.1186/s40734-016-0035-x) contains supplementary material, which is available to authorized users.