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Winkler S, Lohs A, Zinn-Kirchner ZM, Alotaibi M, Caffier PP. Tribute to the Flute: A Literature Review of Playing-Related Problems in Flautists. J Multidiscip Healthc 2024; 17:649-671. [PMID: 38375525 PMCID: PMC10875341 DOI: 10.2147/jmdh.s448301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024] Open
Abstract
Playing musical instruments places unusually high demands on specific parts of the human body. Relative to the instruments they play, musicians may experience instrument-related symptoms, as recorded in flute players. The objective was to provide an overview of the study findings addressing medical problems in flautists to better understand their complaints and pave the way for more personalized healthcare. Several electronic databases (PubMed, Embase, Cochrane Library) were systematically searched in July 2022. Furthermore, the references of all included articles were reviewed for additionally relevant sources. The resulting set of studies was summarized in a table, with quality assessment according to the SIGN grading system. From an initial 433 hits, the search yielded 95 studies with a total of 32,600 musicians, including at least 2134 flautists. Among the latter, evidence was found for musculoskeletal, neurological, dermatological, temporomandibular, and hearing complaints, overuse and reflux symptoms, velopharyngeal insufficiency, as well as upper and lower airway impairment. Other specialists may be consulted equally often and should be sensitive to the particular medical problems in flautists. Future studies would ideally contain specific outcome analyses on an international scale and consider flautists as an individual subgroup within a larger number of total participants.
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Affiliation(s)
- Silvia Winkler
- Berlin Center for Musicians Medicine (BCMM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, D-10117, Germany
- Department of Audiology and Phoniatrics; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, D-10117, Germany
| | - Anne Lohs
- Department of Audiology and Phoniatrics; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, D-10117, Germany
| | - Zahavah M Zinn-Kirchner
- Berlin Center for Musicians Medicine (BCMM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, D-10117, Germany
- Department of Audiology and Phoniatrics; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, D-10117, Germany
| | - Moonef Alotaibi
- Department of Audiology and Phoniatrics; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, D-10117, Germany
- King Fahad Medical City, Department of Otorhinolaryngology, Head and Neck Surgery, Riyadh, Kingdom of Saudi Arabia
| | - Philipp P Caffier
- Berlin Center for Musicians Medicine (BCMM), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, D-10117, Germany
- Department of Audiology and Phoniatrics; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, D-10117, Germany
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Nelkenstock R, Iltis PW, Voit D, Frahm J, Passarotto E, Altenmüller E. Movement patterns in tuba playing: comparison of an embouchure dystonia case with healthy professional tuba players using real-time MRI imaging. Front Neurol 2023; 14:1106217. [PMID: 37234782 PMCID: PMC10206072 DOI: 10.3389/fneur.2023.1106217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 04/07/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction Musculoskeletal problems in professional brass musicians are very common and often involve the muscles of the embouchure. In rare cases, embouchure dystonia (EmD), a task-specific movement disorder with a wide symptomatic and phenotypic variability, occurs. Following trumpeters and horn players, professional tuba players with and without EmD have now been studied using the latest real-time MRI technology to better understand the underlying pathophysiology. Materials and methods In the present study, the tongue movement patterns of 11 healthy professional artists and one subject suffering from EmD were compared. The tongue position in the anterior, intermediary and posterior oral cavity were converted into pixel positions based on seven previously generated profile lines, using the established software MATLAB. These data allow a structured comparison of tongue movement patterns between the patient and the healthy subjects, as well as between individual exercises. The main focus of the analysis was on an ascending 7-note harmonic series performed in different playing techniques (slurred, tongued, tenuto and staccato). Results Playing the ascending harmonics, a noticeable ascending tongue movement could be observed in the anterior part of the oral cavity in healthy tubists. In the posterior region, there was a slight decrease in oral cavity space. In the EmD patient, hardly any movement was observed at the tongue apex, but in the middle and posterior regions of the oral cavity there was an increase in size the higher the tone became. These distinct differences are relevant for the characterization and a better understanding of the clinical presentation of EmD. Concerning different playing techniques, it was apparent, that notes played slurred or staccato resulted in a larger oral cavity when compared to notes played tongued or tenuto, respectively. Conclusion By using real-time MRI videos, the tongue movements of tuba players can be clearly observed and analyzed. The differences between healthy and diseased tuba players demonstrate the great effects of movement disorders in a small area of the tongue. In order to better understand the compensation of this motor control dysfunction, further studies should investigate further parameters of tone production in all brass players with a larger number of EmD patients additional to the observed movement patterns.
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Affiliation(s)
- Robert Nelkenstock
- Institut für Musikphysiologie und Musikermedizin, Hochschule für Musik, Theater und Medien, Hannover, Germany
| | - Peter W. Iltis
- Department of Kinesiology, Gordon College, Wenham, MA, United States
| | - Dirk Voit
- Biomedizinische NMR, Max-Planck-Institut für Multidisziplinäre Naturwissenschaften, Göttingen, Germany
| | - Jens Frahm
- Biomedizinische NMR, Max-Planck-Institut für Multidisziplinäre Naturwissenschaften, Göttingen, Germany
| | - Edoardo Passarotto
- Institut für Musikphysiologie und Musikermedizin, Hochschule für Musik, Theater und Medien, Hannover, Germany
| | - Eckart Altenmüller
- Institut für Musikphysiologie und Musikermedizin, Hochschule für Musik, Theater und Medien, Hannover, Germany
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Mantel T, Lee A, Furuya S, Morise M, Altenmüller E, Haslinger B. Reliability and Validity of the Embouchure Dystonia Severity Rating Scale. J Mov Disord 2023; 16:191-195. [PMID: 37258280 DOI: 10.14802/jmd.22213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/05/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVE Embouchure dystonia (ED) is a task-specific movement disorder that leads to loss of fine motor control of the embouchure and tongue muscles in wind musicians. In contrast to musicians' hand dystonia, no validated severity rating for ED exists, posing a major obstacle for structured assessment in scientific and clinical settings. The aim of this study is to validate an ED severity rating scale (EDSRS) allowing for a standardized estimation of symptom severity in ED. METHODS The EDSRS was set up as a composite score of six items evaluating audio-visual disease symptoms during the performance of three standardized musical tasks (sustained notes, scales, and fourths) separately for each body side. For validation, 17 musicians with ED underwent standardized audiovisual recordings during performance. Anonymized and randomized recordings were assessed by two experts in ED (raters). Statistical analysis included metrics of consistency, reliability, and construct validity with the fluctuation of the fundamental frequency of the acoustic signal (F0) (extracted in an audio analysis of the sustained notes). RESULTS The EDSRS showed high internal consistency (Cronbach's α = 0.975-0.983, corrected item-total correlations r = 0.90-0.96), interrater reliability (intraclass correlation coefficient [ICC] for agreement/consistency = 0.94/0.96), intrarater reliability over time (ICC per rater = 0.93/0.87) and good precision (standard error of measurement = 2.19/2.65), and correlated significantly with F0 variability (r = 0.55-0.60, p = 0.011-0.023). CONCLUSION The developed EDSRS is a valid and reliable tool for the assessment of ED severity in the hands of trained expert raters. Its easy applicability makes it suitable not only for routine clinical practice but also for scientific studies.
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Affiliation(s)
- Tobias Mantel
- Department of Neurology, Technical University of Munich, Munich, Germany
| | - André Lee
- Department of Neurology, Technical University of Munich, Munich, Germany
- Institute for Music Physiology and Musicians' Medicine, Hannover University of Music, Drama, and Media, Hanover, Germany
| | - Shinichi Furuya
- Institute for Music Physiology and Musicians' Medicine, Hannover University of Music, Drama, and Media, Hanover, Germany
- Sony Computer Science Laboratories Inc. (Sony CSL), Tokyo, Japan
- NeuroPiano Institute, Kyoto, Japan
| | - Masanori Morise
- Meiji University, School of Interdisciplinary Mathematical Sciences, Tokyo, Japan
| | - Eckart Altenmüller
- Institute for Music Physiology and Musicians' Medicine, Hannover University of Music, Drama, and Media, Hanover, Germany
| | - Bernhard Haslinger
- Department of Neurology, Technical University of Munich, Munich, Germany
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Furuya S, Oku T. Sensorimotor Incoordination in Musicians' Dystonia. ADVANCES IN NEUROBIOLOGY 2023; 31:61-70. [PMID: 37338696 DOI: 10.1007/978-3-031-26220-3_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
To acquire and maintain outstanding sensorimotor skills for playing musical instruments inevitably requires extensive training from childhood. However, on the way toward musical excellence, musicians sometimes develop serious disorders, such as tendinitis, carpal tunnel syndrome, and task-specific focal dystonia. Particularly, task-specific focal dystonia in musicians, which is referred to as musician's dystonia (MD), has no perfect cure and therefore often terminates professional careers of musicians. To better understand its pathological and pathophysiological mechanisms, the present article focuses on malfunctions of the sensorimotor system at the behavioral and neurophysiological levels. Based on emerging empirical evidence, we propose that the aberrant sensorimotor integration, possibly which occurs in both cortical and subcortical systems, underlies not only movement incoordination between the fingers (i.e., maladaptive synergy) but also failure of long-term retention of intervention effects in the patients with MD.
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Affiliation(s)
- Shinichi Furuya
- Sony Computer Science Laboratories Inc. (Sony CSL), Tokyo, Japan.
- NeuroPiano Institute, Kyoto, Japan.
| | - Takanori Oku
- Sony Computer Science Laboratories Inc. (Sony CSL), Tokyo, Japan
- NeuroPiano Institute, Kyoto, Japan
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Yoshida K. Botulinum Toxin Therapy for Oromandibular Dystonia and Other Movement Disorders in the Stomatognathic System. Toxins (Basel) 2022; 14:282. [PMID: 35448891 PMCID: PMC9026473 DOI: 10.3390/toxins14040282] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 01/02/2023] Open
Abstract
Various movement disorders, such as oromandibular dystonia, oral dyskinesia, bruxism, functional (psychogenic) movement disorder, and tremors, exist in the stomatognathic system. Most patients experiencing involuntary movements due to these disorders visit dentists or oral surgeons, who may be the first healthcare providers. However, differential diagnoses require neurological and dental knowledge. This study aimed to review scientific advances in botulinum toxin therapy for these conditions. The results indicated that botulinum toxin injection is effective and safe, with few side effects in most cases when properly administered by an experienced clinician. The diagnosis and treatment of movement disorders in the stomatognathic system require both neurological and dental or oral surgical knowledge and skills, and well-designed multicenter trials with a multidisciplinary team approach must be necessary to ensure accurate diagnosis and proper treatment.
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Affiliation(s)
- Kazuya Yoshida
- Department of Oral and Maxillofacial Surgery, National Hospital Organization, Kyoto Medical Center, 1-1 Mukaihata-cho, Fukakusa, Fushimi-ku, Kyoto 612-8555, Japan
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Krishnan S, Saraf U, Chandarana M, Divya KP. Oromandibular dystonia – A systematic review. Ann Indian Acad Neurol 2022; 25:26-34. [PMID: 35342238 PMCID: PMC8954320 DOI: 10.4103/aian.aian_242_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/10/2021] [Accepted: 09/04/2021] [Indexed: 11/04/2022] Open
Abstract
Oromandibular dystonia (OMD) is a clinical problem which is commonly encountered in the practice of movement disorders. OMD results from a variety of genetic and acquired etiologies and can occur as an isolated manifestation, or as part of an isolated generalized or a combined dystonia syndrome. There are only very few systematic reviews on this condition which often causes significant disability. We review here the etiology, clinical features, diagnostic approach and management of OMD.
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Herrmann N, Just M, Zalpour C, Möller D. Musculoskeletal and psychological assessments used in quantitatively based studies about musicians' health in brass players: A systematic literature review. J Bodyw Mov Ther 2021; 28:376-390. [PMID: 34776167 DOI: 10.1016/j.jbmt.2021.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 06/06/2021] [Accepted: 07/12/2021] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Noëla Herrmann
- Department of Physiotherapy, Faculty of Business Management and Social Sciences, Osnabrück University of Applied Sciences, Germany
| | - Melissa Just
- Department of Physiotherapy, Faculty of Business Management and Social Sciences, Osnabrück University of Applied Sciences, Germany
| | - Christoff Zalpour
- Department of Physiotherapy, Faculty of Business Management and Social Sciences, Osnabrück University of Applied Sciences, Germany
| | - Dirk Möller
- Department of Physiotherapy, Faculty of Business Management and Social Sciences, Osnabrück University of Applied Sciences, Germany.
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Abstract
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.
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Mantel T, Altenmüller E, Li Y, Lee A, Meindl T, Jochim A, Zimmer C, Haslinger B. Structure-function abnormalities in cortical sensory projections in embouchure dystonia. NEUROIMAGE-CLINICAL 2020; 28:102410. [PMID: 32932052 PMCID: PMC7495104 DOI: 10.1016/j.nicl.2020.102410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/29/2020] [Accepted: 08/30/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Embouchure dystonia (ED) is a task-specific focal dystonia in professional brass players leading to abnormal orofacial muscle posturing/spasms during performance. Previous studies have outlined abnormal cortical sensorimotor function during sensory/motor tasks and in the resting state as well as abnormal cortical sensorimotor structure. Yet, potentially underlying white-matter tract abnormalities in this network disease are unknown. OBJECTIVE To delineate structure-function abnormalities within cerebral sensorimotor trajectories in ED. METHOD Probabilistic tractography and seed-based functional connectivity analysis were performed in 16/16 ED patients/healthy brass players within a simple literature-informed network model of cortical sensorimotor processing encompassing supplementary motor, superior parietal, primary somatosensory and motor cortex as well as the putamen. Post-hoc grey matter volumetry was performed within cortices of abnormal trajectories. RESULTS ED patients showed average axial diffusivity reduction within projections between the primary somatosensory cortex and putamen, with converse increases within projections between supplementary motor and superior parietal cortex in both hemispheres. Increase in the mode of anisotropy in patients was accompanying the latter left-hemispheric projection, as well as in the supplementary motor area's projection to the left primary motor cortex. Patient's left primary somatosensory functional connectivity with the putamen was abnormally reduced and significantly associated with the axial diffusivity reduction. Left primary somatosensory grey matter volume was increased in patients. CONCLUSION Correlates of abnormal tract integrity within primary somatosensory cortico-subcortical projections and higher-order sensorimotor projections support the key role of dysfunctional sensory information propagation in ED pathophysiology. Differential directionality of cortico-cortical and cortico-subcortical abnormalities hints at non-uniform sensory system changes.
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Affiliation(s)
- Tobias Mantel
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, Munich, Germany
| | - Eckart Altenmüller
- Hochschule für Musik, Theater und Medien Hannover, Emmichplatz 1, Hanover, Germany
| | - Yong Li
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, Munich, Germany
| | - André Lee
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, Munich, Germany; Hochschule für Musik, Theater und Medien Hannover, Emmichplatz 1, Hanover, Germany
| | - Tobias Meindl
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, Munich, Germany
| | - Angela Jochim
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, Munich, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, Munich, Germany
| | - Bernhard Haslinger
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstrasse 22, Munich, Germany.
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Franz L, Travan L, Isola M, Marioni G, Pozzo R. Facial Muscle Activity Patterns in Clarinet Players: A Key to Understanding Facial Muscle Physiology and Dysfunction in Musicians. Ann Otol Rhinol Laryngol 2020; 129:1078-1087. [PMID: 32486834 DOI: 10.1177/0003489420931553] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Facial muscle activity is crucial to controlling musical performance in wind instrument playing. Facial muscle dysfunctions are common in wind instrument players, dramatically affecting their professional musical activity and potentially leading to disabling symptoms.The aim of this pilot study on a cohort of healthy clarinetists was to use surface electromyography to identify the facial muscle activity patterns involved in stabilizing the mouthpiece, controlling emission and articulation during musical tasks in physiological conditions, also comparing muscle activity between less and more experienced clarinetists (students vs postgraduates/professionals). METHODS Surface electromyographic measures of the sternocleidomastoid, masseter, mentalis, mylohyoid and buccinator muscles were obtained from eight healthy clarinet players (four students and four postgraduates/professionals) performing two standardized musical tasks. RESULTS Overall, mean IEMG activity was significantly lower for the sternocleidomastoid than for the other muscles (P = .000), and for the mouthpiece-stabilizing muscles (masseter and mentalis) than for those directly involved in controlling emission and articulation (buccinator and mylohyoid muscles) (P = .000).Regardless of the musical task, the mean IEMG values were significantly higher in the students for the masseter (P = .0007), buccinator (P = .0001) and mylohyoid (0.000), while they were significantly higher in the postgraduates/professionals for the mentalis (P = .000). No significant differences emerged between the two groups for the sternocleidomastoid (P = .207). CONCLUSIONS These preliminary data reflect a significantly higher overall facial muscle activity in the less-experienced group, potentially resulting in an overload, whereas the more expert players had more optimized muscle activity patterns.
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Affiliation(s)
- Leonardo Franz
- Department of Neuroscience DNS, Otolaryngology Section, University of Padova, Padova, Italy
| | - Luciana Travan
- Department of Medicine, Anatomy Section, University of Udine, Udine, Italy
| | - Miriam Isola
- Department of Medicine, Statistics Section, University of Udine, Udine, Italy
| | - Gino Marioni
- Department of Neuroscience DNS, Otolaryngology Section, University of Padova, Padova, Italy
| | - Renzo Pozzo
- Department of Medicine, Exercise and Sport Science Section, University of Udine, Udine, Italy
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Hellwig SJ, Iltis PW, Joseph AA, Voit D, Frahm J, Schoonderwaldt E, Altenmüller E. Tongue involvement in embouchure dystonia: new piloting results using real-time MRI of trumpet players. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2019; 6:5. [PMID: 31754440 PMCID: PMC6852982 DOI: 10.1186/s40734-019-0080-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022]
Abstract
Background The embouchure of trumpet players is of utmost importance for tone production and quality of playing. It requires skilled coordination of lips, facial muscles, tongue, oral cavity, larynx and breathing and has to be maintained by steady practice. In rare cases, embouchure dystonia (EmD), a highly task specific movement disorder, may cause deterioration of sound quality and reduced control of tongue and lip movements. In order to better understand the pathophysiology of this movement disorder, we use real-time MRI to analyse differences in tongue movements between healthy trumpet players and professional players with embouchure dystonia. Methods Real-time MRI videos (with sound recording) were acquired at 55 frames per second, while 10 healthy subjects and 4 patients with EmD performed a defined set of exercises on an MRI-compatible trumpet inside a 3 Tesla MRI system. To allow for a comparison of tongue movements between players, temporal changes of MRI signal intensities were analysed along 7 standardized positions of the tongue using a customised MATLAB toolkit. Detailed results of movements within the oral cavity during performance of an ascending slurred 11-note harmonic series are presented. Results Playing trumpet in the higher register requires a very precise and stable narrowing of the free oral cavity. For this purpose the anterior section of the tongue is used as a valve in order to speed up airflow in a controlled manner. Conversely, the posterior part of the tongue is much less involved in the regulation of air speed. The results further demonstrate that healthy trumpet players control movements of the tongue rather precisely and stable during a sustained tone, whereas trumpet players with EmD exhibit much higher variability in tongue movements. Conclusion Control of the anterior tongue in trumpet playing emerges as a critical feature for regulating air speed and, ultimately, achieving a high-quality performance. In EmD the observation of less coordinated tongue movements suggests the presence of compensatory patterns in an attempt to regulate (or correct) pitch. Increased variability of the anterior tongue could be an objective sign of dystonia that has to be examined in further studies and extended to other brass instruments and may be also a potential target for therapy options.
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Affiliation(s)
| | | | - Arun A Joseph
- 3Biomedizinische NMR, Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
| | - Dirk Voit
- 3Biomedizinische NMR, Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
| | - Jens Frahm
- 3Biomedizinische NMR, Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
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12
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Uehara K, Furuya S, Numazawa H, Kita K, Sakamoto T, Hanakawa T. Distinct roles of brain activity and somatotopic representation in pathophysiology of focal dystonia. Hum Brain Mapp 2019; 40:1738-1749. [PMID: 30570801 DOI: 10.1002/hbm.24486] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/25/2018] [Accepted: 11/21/2018] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Kazumasa Uehara
- Department of Advanced Neuroimaging, Integrative Brain Imaging Center (IBIC), National Center of Neurology and Psychiatry, Tokyo, Japan.,Musical Skill and Injury Center (MuSIC), Sophia University, Tokyo, Japan.,Research fellow of the Japan Society for the Promotion of Science, Tokyo, Japan
| | - Shinichi Furuya
- Department of Advanced Neuroimaging, Integrative Brain Imaging Center (IBIC), National Center of Neurology and Psychiatry, Tokyo, Japan.,Musical Skill and Injury Center (MuSIC), Sophia University, Tokyo, Japan.,Sony Computer Science Laboratories Inc. (Sony CSL), Tokyo, Japan
| | - Hidemi Numazawa
- Department of Advanced Neuroimaging, Integrative Brain Imaging Center (IBIC), National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Kahori Kita
- Department of Advanced Neuroimaging, Integrative Brain Imaging Center (IBIC), National Center of Neurology and Psychiatry, Tokyo, Japan.,Musical Skill and Injury Center (MuSIC), Sophia University, Tokyo, Japan.,Center for Frontier Medical Engineering, Chiba University, Chiba, Japan
| | - Takashi Sakamoto
- Department of Neurology, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Takashi Hanakawa
- Department of Advanced Neuroimaging, Integrative Brain Imaging Center (IBIC), National Center of Neurology and Psychiatry, Tokyo, Japan.,Musical Skill and Injury Center (MuSIC), Sophia University, Tokyo, Japan
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13
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Frucht SJ. Billiards-related dystonia: A new task-specific dystonia. Parkinsonism Relat Disord 2019; 60:12-13. [DOI: 10.1016/j.parkreldis.2019.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 02/07/2019] [Accepted: 02/16/2019] [Indexed: 11/28/2022]
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14
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Mainka T, Erro R, Rothwell J, Kühn AA, Bhatia KP, Ganos C. Remission in dystonia - Systematic review of the literature and meta-analysis. Parkinsonism Relat Disord 2019; 66:9-15. [PMID: 30898428 DOI: 10.1016/j.parkreldis.2019.02.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/20/2019] [Accepted: 02/14/2019] [Indexed: 11/27/2022]
Abstract
In isolated, sporadic dystonia, it has been occasionally reported that some patients might undergo symptom remission. However, the exact clinical characteristics of patients with remission remain understudied. Given the important prognostic and pathophysiological implications of dystonic remission, we here provide a systematic review of the literature and a meta-analysis to assess demographic and clinical features associated with this phenomenon. We also provide a list of operational criteria to better define dystonic remission. Using PubMed and Embase, we conducted a systematic literature search in March 2018. 626 records were screened, 31 studies comprising data of 2551 cases with reports predominantly from patients with cervical dystonia (n = 1319) or blepharospasm/Meige syndrome (n = 704) were included in qualitative analysis. Five studies reporting remission in cervical dystonia were eligible for meta-analysis. Complete remission was reported in 11.8% and partial remission for 4.4% of cases. Remission rates were higher in cervical dystonia than in blepharospasm/Meige (e.g. complete remission 15.4% vs. 5.8% respectively). Remission occurred on average 4.5 years after onset of dystonic symptoms. However, the majority of patients (63.8%) relapsed. Meta-analysis for cervical dystonia showed that patients with remission were significantly younger at symptom onset than patients without remission (mean difference -7.13 years [95% CI: 10.58, -3.68], p < 0.0001). Based on our findings, we propose that the degree, the conditions associated with the onset, and the duration of remission are key factors to be considered in a unifying definition of dystonic remission.
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Affiliation(s)
- Tina Mainka
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Roberto Erro
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy
| | - John Rothwell
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Andrea A Kühn
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, United Kingdom
| | - Christos Ganos
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany.
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15
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Horisawa S, Oka M, Kawamata T, Taira T. Bilateral pallidotomy for embouchure dystonia. Eur J Neurol 2018; 25:e108-e109. [DOI: 10.1111/ene.13706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/03/2018] [Indexed: 11/28/2022]
Affiliation(s)
- S. Horisawa
- Department of Neurosurgery; Neurological Institute; Tokyo Women's Medical University; Tokyo Japan
| | - M. Oka
- Department of Neurosurgery; Neurological Institute; Tokyo Women's Medical University; Tokyo Japan
| | - T. Kawamata
- Department of Neurosurgery; Neurological Institute; Tokyo Women's Medical University; Tokyo Japan
| | - T. Taira
- Department of Neurosurgery; Neurological Institute; Tokyo Women's Medical University; Tokyo Japan
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16
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Lee JE, Kim JS. Task-specific hand tremor during embouchure in a flutist. Neurol Sci 2018. [PMID: 29542025 DOI: 10.1007/s10072-018-3317-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Jee-Eun Lee
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
| | - Joong-Seok Kim
- Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul St. Mary's Hospital, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
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17
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Morris AE, Norris SA, Perlmutter JS, Mink JW. Quantitative, clinically relevant acoustic measurements of focal embouchure dystonia. Mov Disord 2018; 33:449-458. [PMID: 29460980 PMCID: PMC5839997 DOI: 10.1002/mds.27298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 12/13/2017] [Accepted: 12/17/2017] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Aimee E Morris
- Medical Scientist Training Program, University of Rochester, Rochester, New York, USA
| | - Scott A Norris
- Department of Neurology, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Joel S Perlmutter
- Departments of Neurology, Radiology, Neuroscience, Occupational Therapy, and Physical Therapy, Washington University in Saint Louis, Saint Louis, Missouri, USA
| | - Jonathan W Mink
- Departments of Neurology, Neuroscience, and Pediatrics, University of Rochester, Rochester, New York, USA
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18
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Basal ganglia mechanisms in action selection, plasticity, and dystonia. Eur J Paediatr Neurol 2018; 22:225-229. [PMID: 29396175 PMCID: PMC5815934 DOI: 10.1016/j.ejpn.2018.01.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/08/2018] [Indexed: 02/02/2023]
Abstract
Basal ganglia circuits are organized to selected desired actions and to inhibit potentially competing unwanted actions. This is accomplished through a complex circuitry that is modified through development and learning. Mechanisms of neural plasticity underlying these modifications are increasingly understood, but new mechanisms continue to be discovered. Dystonia, a movement disorder characterized by involuntary muscle contractions that cause abnormal postures and movements. Emerging evidence points to important links between mechanisms of plasticity and the manifestations of dystonia. Investigation of these mechanisms has improved understanding of the action of currently used medication and is informing the development of new treatments.
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19
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Avivi-Arber L, Sessle BJ. Jaw sensorimotor control in healthy adults and effects of ageing. J Oral Rehabil 2017; 45:50-80. [DOI: 10.1111/joor.12554] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2017] [Indexed: 12/22/2022]
Affiliation(s)
- L. Avivi-Arber
- Faculty of Dentistry; University of Toronto; Toronto ON Canada
| | - B. J. Sessle
- Faculty of Dentistry; University of Toronto; Toronto ON Canada
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20
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Haslinger B, Noé J, Altenmüller E, Riedl V, Zimmer C, Mantel T, Dresel C. Changes in resting-state connectivity in musicians with embouchure dystonia. Mov Disord 2016; 32:450-458. [PMID: 27911020 DOI: 10.1002/mds.26893] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 10/21/2016] [Accepted: 11/09/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Embouchure dystonia is a highly disabling task-specific dystonia in professional brass musicians leading to spasms of perioral muscles while playing the instrument. As they are asymptomatic at rest, resting-state functional magnetic resonance imaging in these patients can reveal changes in functional connectivity within and between brain networks independent from dystonic symptoms. METHODS We therefore compared embouchure dystonia patients to healthy musicians with resting-state functional magnetic resonance imaging in combination with independent component analyses. RESULTS Patients showed increased functional connectivity of the bilateral sensorimotor mouth area and right secondary somatosensory cortex, but reduced functional connectivity of the bilateral sensorimotor hand representation, left inferior parietal cortex, and mesial premotor cortex within the lateral motor function network. Within the auditory function network, the functional connectivity of bilateral secondary auditory cortices, right posterior parietal cortex and left sensorimotor hand area was increased, the functional connectivity of right primary auditory cortex, right secondary somatosensory cortex, right sensorimotor mouth representation, bilateral thalamus, and anterior cingulate cortex was reduced. Negative functional connectivity between the cerebellar and lateral motor function network and positive functional connectivity between the cerebellar and primary visual network were reduced. CONCLUSIONS Abnormal resting-state functional connectivity of sensorimotor representations of affected and unaffected body parts suggests a pathophysiological predisposition for abnormal sensorimotor and audiomotor integration in embouchure dystonia. Altered connectivity to the cerebellar network highlights the important role of the cerebellum in this disease. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Bernhard Haslinger
- Klinik und Poliklinik für Neurologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Jonas Noé
- Klinik und Poliklinik für Neurologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Eckart Altenmüller
- Institut für Musikphysiologie und Musikermedizin, Hochschule für Musik, Theater und Medien Hannover, Hannover, Germany
| | - Valentin Riedl
- Abteilung für diagnostische und interventionelle Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Claus Zimmer
- Abteilung für diagnostische und interventionelle Neuroradiologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Tobias Mantel
- Klinik und Poliklinik für Neurologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Christian Dresel
- Klinik und Poliklinik für Neurologie, Klinikum rechts der Isar, Technische Universität München, München, Germany
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21
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Konaka K, Mochizuki H. [Questionnaire survey of musician's dystonia among students of a music college]. Rinsho Shinkeigaku 2016; 55:263-5. [PMID: 25904257 DOI: 10.5692/clinicalneurol.55.263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Musician's dystonia is known as a task specific dystonia. Though it is thought to occur during a long course of repetitive performance, the actual circumstances that precipitate this condition are not clear. According to factual reports this disease is not commonly known, probably because many of these patients may not have been visiting a hospital. We prepared a questionnaire and did a survey among the students of a music college. This is the first questionnaire survey aimed at finding out the prevalence of musician's dystonia among the students of music. Among the 480 participants of this survey, 29% of the students had knowledge of this disorder and 1.25% of the students had dystonia while performing music.
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Affiliation(s)
- Kuni Konaka
- Department of Neurology, Osaka University Graduate School of Medicine
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22
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Frucht SJ. Embouchure dystonia: a video guide to diagnosis and evaluation. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2016; 3:10. [PMID: 27330823 PMCID: PMC4912816 DOI: 10.1186/s40734-016-0035-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/01/2016] [Indexed: 11/13/2022]
Abstract
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.
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23
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Mantel T, Dresel C, Altenmüller E, Zimmer C, Noe J, Haslinger B. Activity and topographic changes in the somatosensory system in embouchure dystonia. Mov Disord 2016; 31:1640-1648. [PMID: 27273329 DOI: 10.1002/mds.26664] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Revised: 04/04/2016] [Accepted: 04/07/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Embouchure dystonia is a highly disabling focal task-specific dystonia affecting professional brass players. OBJECTIVE This study was designed to analyze activity changes along with topographic representations in primary and nonprimary centers for somatosensory processing in patients with embouchure dystonia. METHODS We used event-related functional magnetic resonance imaging with automized tactile stimulation of dystonic (upper lip) and nondystonic (forehead and dorsal hand) body regions in 15 professional brass players with and without embouchure dystonia. Statistical analyses included whole-brain between-group comparisons of stimulation-induced activation and region-of-interest-based single patient analyses of topographic activation characteristics. RESULTS Affected musicians revealed increased stimulation-induced activity in contralateral primary and bilateral secondary somatosensory representations of dystonic and nondystonic body regions as well as in the cerebellum ipsilateral to the left dystonic upper lip. Changes of somatotopic organization with altered intracortical distances and between-group differences of the centers of representations were found in the right primary and the bilateral secondary somatosensory cortex and in the left cerebellum. Positional variability of dystonic and nondystonic body regions was reduced with an emphasis on face representations. CONCLUSIONS The present findings are supportive of the concept of an abnormal processing of somatosensory information in embouchure dystonia affecting multiple domains. The underlying neurophysiological mechanisms (eg, changes in inhibition, maladaptive plasticity, changes in baseline activity) remain unclear. The involvement of nondystonic body areas can be viewed in the context of possible compensation or an endophenotypic predisposition. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Tobias Mantel
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Christian Dresel
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Eckart Altenmüller
- Institute for Music Physiology and Musicians' Medicine, Hochschule für Musik, Theater und Medien Hannover, Hannover, Germany
| | - Claus Zimmer
- Department of Neuroradiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Jonas Noe
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Bernhard Haslinger
- Department of Neurology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Termsarasab P, Frucht SJ. Evaluation of embouchure dysfunction: Experience of 139 patients at a single center. Laryngoscope 2015; 126:1327-33. [PMID: 26511602 DOI: 10.1002/lary.25723] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 09/08/2015] [Accepted: 09/15/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Our aims are to 1) illustrate the complexity and phenomenological richness of the embouchure; 2) delineate the main clinical features of non-dystonic embouchure problems (NED) versus embouchure dystonia (ED); and 3) provide a practical framework for physicians who may encounter a patient with embouchure dysfunction. STUDY DESIGN We performed retrospective chart and video review and report 139 instrumentalists with embouchure dysfunction evaluated over a 15-year period. RESULTS Included in this group are 109 ED patients (20 newly reported and 89 previously published) and 30 NED patients. Non-dystonic embouchure problems included the overuse syndrome, infraorbital neuropathy, and orbicularis oris tears, among others. CONCLUSIONS Based on this experience, the largest series presented to date, we propose a practical guide to help evaluate patients with embouchure dysfunction in the office. LEVEL OF EVIDENCE 4. Laryngoscope, 126:1327-1333, 2016.
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Affiliation(s)
- Pichet Termsarasab
- Department of Neurology, Movement Disorders Division, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Steven J Frucht
- Department of Neurology, Movement Disorders Division, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
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25
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Iltis PW, Frahm J, Voit D, Joseph A, Schoonderwaldt E, Altenmüller E. Divergent oral cavity motor strategies between healthy elite and dystonic horn players. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2015; 2:15. [PMID: 26788351 PMCID: PMC4711099 DOI: 10.1186/s40734-015-0027-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 10/13/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND This paper describes the use of real-time magnetic resonance imaging in visualizing and quantifying oral cavity motor strategies employed by 6 healthy, elite horn players and 5 horn players with embouchure dystonia. METHODS Serial images with an acquisition time of 33.3 ms were obtained from each performer during execution of an 11-note harmonic series encompassing 2.5 octaves on a magnetic resonance imaging-compatible horn. A customized MATLAB toolkit was employed for the extraction of line profiles from magnetic resonance imaging films allowing comparative analyses between elite and dystonic horn players. RESULTS The data demonstrate differing motor strategies, particularly in moving from the 6th through 9th harmonics. The elite horn player strategy features elevation and anterior displacement of the tongue during ascending sequences, whereas dystonic players showed significantly less movement. The elite horn players thus narrowed the air channel on higher notes, presumably affording faster airflow for vibration of the lips at higher frequencies. CONCLUSIONS We postulate that failure to employ this strategy by dystonic horn players may require greater tension in the embouchure muscles to compensate for slower air speed. Though this may simply be an expression of or adaptation for dystonia, the possibility that it may be a contributing factor in the development of embouchure dystonia is suggested.
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Affiliation(s)
- Peter W Iltis
- Department of Kinesiology, Gordon College, Wenham, MA USA ; Hochshule für Musik, Theater und Medien, Hannover, Germany
| | - Jens Frahm
- Biomedizinische NMR Forschungs GmbH am Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
| | - Dirk Voit
- Biomedizinische NMR Forschungs GmbH am Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
| | - Arun Joseph
- Biomedizinische NMR Forschungs GmbH am Max-Planck-Institut für biophysikalische Chemie, Göttingen, Germany
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26
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Frucht SJ. Evaluating the musician with dystonia of the upper limb: a practical approach with video demonstration. JOURNAL OF CLINICAL MOVEMENT DISORDERS 2015; 2:16. [PMID: 26788352 PMCID: PMC4711181 DOI: 10.1186/s40734-015-0026-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 09/02/2015] [Indexed: 12/04/2022]
Abstract
Focal task-specific dystonia is an unusual movement disorder that may affect musicians specifically when they perform on their instruments. Muscles of the lower face, lower limb and upper limb may be involved depending on the nature of the instrument. We illustrate the rich phenomenology of focal task-specific dystonia affecting the upper limb in musicians, and present a practical approach for evaluating patients in the office.
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Affiliation(s)
- Steven J Frucht
- Mount Sinai Medical Center, Division of Movement Disorders, 5 East 98th Street, New York, NY 10029 USA
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27
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Furuya S, Tominaga K, Miyazaki F, Altenmüller E. Losing dexterity: patterns of impaired coordination of finger movements in musician's dystonia. Sci Rep 2015; 5:13360. [PMID: 26289433 PMCID: PMC4542337 DOI: 10.1038/srep13360] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/24/2015] [Indexed: 11/23/2022] Open
Abstract
Extensive training can bring about highly-skilled action, but may also impair motor dexterity by producing involuntary movements and muscular cramping, as seen in focal dystonia (FD) and tremor. To elucidate the underlying neuroplastic mechanisms of FD, the present study addressed the organization of finger movements during piano performance in pianists suffering from the condition. Principal component (PC) analysis identified three patterns of fundamental joint coordination constituting finger movements in both patients and controls. The first two coordination patterns described less individuated movements between the “dystonic” finger and key-striking fingers for patients compared to controls. The third coordination pattern, representing the individuation of movements between the middle and ring fingers, was evident during a sequence of strikes with these fingers in controls, which was absent in the patients. Consequently, rhythmic variability of keystrokes was more pronounced during this sequence of strikes for the patients. A stepwise multiple-regression analysis further identified greater variability of keystrokes for individuals displaying less individuated movements between the affected and striking fingers. The findings suggest that FD alters dexterous joint coordination so as to lower independent control of finger movements, and thereby degrades fine motor control.
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Affiliation(s)
- Shinichi Furuya
- Institute for Music Physiology and Musicians' Medicine, Hanover University of Music, Drama and Media, Emmichplatz 1, Hanover, Germany 30175.,Department of Information and Communication Sciences, Sophia University, Tokyo, Japan, 1020081
| | - Kenta Tominaga
- Department of Engineering Science, Osaka University, Osaka, Japan, 5608531
| | - Fumio Miyazaki
- Department of Engineering Science, Osaka University, Osaka, Japan, 5608531
| | - Eckart Altenmüller
- Institute for Music Physiology and Musicians' Medicine, Hanover University of Music, Drama and Media, Emmichplatz 1, Hanover, Germany 30175
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Iltis PW, Schoonderwaldt E, Zhang S, Frahm J, Altenmüller E. Real-time MRI comparisons of brass players: A methodological pilot study. Hum Mov Sci 2015; 42:132-45. [DOI: 10.1016/j.humov.2015.04.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 04/21/2015] [Accepted: 04/27/2015] [Indexed: 10/23/2022]
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Furuya S, Altenmüller E. Acquisition and reacquisition of motor coordination in musicians. Ann N Y Acad Sci 2015; 1337:118-24. [PMID: 25773625 DOI: 10.1111/nyas.12659] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Precise control of movement timing plays a key role in musical performance. This motor skill requires coordination across multiple joints and muscles, which is acquired through extensive musical training from childhood. However, extensive training has a potential risk of causing neurological disorders that impair fine motor control, such as task-specific tremor and focal dystonia. Recent technological advances in measurement and analysis of biological data, as well as noninvasive manipulation of neuronal activities, have promoted the understanding of computational and neurophysiological mechanisms underlying acquisition, loss, and reacquisition of dexterous movements through musical practice and rehabilitation. This paper aims to provide an overview of the behavioral and neurophysiological basis of motor virtuosity and disorder in musicians, representative extremes of human motor skill. We also report novel evidence of effects of noninvasive neurorehabilitation that combined transcranial direct-current stimulation and motor rehabilitation over multiple days on musician's dystonia, which offers a promising therapeutic means.
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Affiliation(s)
- Shinichi Furuya
- Institute for Music Physiology and Musicians' Medicine, Hanover University of Music, Drama and Media, Hanover, Germany; Department of Information and Communication Sciences, Sophia University, Tokyo, Japan
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30
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Lee A, Furuya S, Morise M, Iltis P, Altenmüller E. Quantification of instability of tone production in embouchure dystonia. Parkinsonism Relat Disord 2014; 20:1161-4. [DOI: 10.1016/j.parkreldis.2014.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 06/17/2014] [Accepted: 08/07/2014] [Indexed: 10/24/2022]
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31
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Chan C, Ackermann B. Evidence-informed physical therapy management of performance-related musculoskeletal disorders in musicians. Front Psychol 2014; 5:706. [PMID: 25071671 PMCID: PMC4086404 DOI: 10.3389/fpsyg.2014.00706] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/19/2014] [Indexed: 12/26/2022] Open
Abstract
Playing a musical instrument at an elite level is a highly complex motor skill. The regular daily training loads resulting from practice, rehearsals and performances place great demands on the neuromusculoskeletal systems of the body. As a consequence, performance-related musculoskeletal disorders (PRMDs) are globally recognized as common phenomena amongst professional orchestral musicians. These disorders create a significant financial burden to individuals and orchestras as well as lead to serious consequences to the musicians’ performance and ultimately their career. Physical therapists are experts in treating musculoskeletal injuries and are ideally placed to apply their skills to manage PRMDs in this hyper-functioning population, but there is little available evidence to guide specific injury management approaches. An Australia-wide survey of professional orchestral musicians revealed that the musicians attributed excessively high or sudden increase in playing-load as major contributors to their PRMDs. Therefore, facilitating musicians to better manage these loads should be a cornerstone of physical therapy management. The Sound Practice orchestral musicians work health and safety project used formative and process evaluation approaches to develop evidence-informed and clinically applicable physical therapy interventions, ultimately resulting in favorable outcomes. After these methodologies were employed, the intervention studies were conducted with a national cohort of professional musicians including: health education, onsite injury management, cross-training exercise regimes, performance postural analysis, and music performance biomechanics feedback. The outcomes of all these interventions will be discussed alongside a focussed review on the existing literature of these management strategies. Finally, a framework for best-practice physical therapy management of PRMDs in musicians will be provided.
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Affiliation(s)
- Cliffton Chan
- Discipline of Biomedical Science, Sydney Medical School, The University of Sydney Sydney, NSW, Australia
| | - Bronwen Ackermann
- Discipline of Biomedical Science, Sydney Medical School, The University of Sydney Sydney, NSW, Australia
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O'Gorman CM, Bower JH, Matsumoto JY, Kantarci OH, Kumar N. When Drinking Makes the Tremor Worse: A Task-Specific Orolingual Tremor. Mov Disord Clin Pract 2014; 1:237-239. [PMID: 30363876 DOI: 10.1002/mdc3.12041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 04/17/2014] [Accepted: 04/18/2014] [Indexed: 11/07/2022] Open
Affiliation(s)
| | - James H Bower
- Department of Neurology Mayo Clinic Rochester Minnesota USA
| | | | | | - Neeraj Kumar
- Department of Neurology Mayo Clinic Rochester Minnesota USA
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Steinmetz A, Stang A, Kornhuber M, Röllinghoff M, Delank KS, Altenmüller E. From embouchure problems to embouchure dystonia? A survey of self-reported embouchure disorders in 585 professional orchestra brass players. Int Arch Occup Environ Health 2013; 87:783-92. [PMID: 24337629 DOI: 10.1007/s00420-013-0923-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 11/24/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Data concerning embouchure problems in professional brass players are scarce. Embouchure problems can potentially lead to focal dystonia. The aim of this study was to investigate the frequency of distinct embouchure problems in professional brass players. Furthermore, the frequency of "cramping", a distinct symptom of embouchure dystonia, was evaluated in the context of established embouchure dystonia risk factors. METHODS Five hundred and eighty-five professional brass players participated in a cross-sectional study concerning embouchure problems. A self-administered questionnaire was developed to evaluate embouchure fatigue, embouchure disorders and their consequences. To study the association between risk factors and cramping (a symptom of embouchure dystonia), a log-binomial regression analysis was conducted, enabling estimation of prevalence ratios (PR) and 95 % confidence intervals (95 % CI). RESULTS Thirty percent (95 % CI 25.9-33.3) reported embouchure fatigue. The relative frequency of embouchure disorders was 59 % (95 % CI 54.6-63.6), with 26 % (95 % CI 22.4-29.5) reporting embouchure cramping. Embouchure disorders resulted in sick leave in 16 % (95 % CI 12.7-20.6). Female brass players (PR 2.0, 95 % CI 0.98-3.98) and musicians with a prior change in their embouchure (PR 2.4, 95 % CI 1.38-4.05) or breathing technique (PR 2.2, 95 % CI 1.25-3.72) and musicians with embouchure fatigue (PR 1.9, 95 % CI 1.18-2.93) presented more frequently with embouchure cramping than musicians with other or without risk factors. CONCLUSION This study shows a high relative frequency of embouchure problems in professional brass players. Given that embouchure dystonia is often preceded by embouchure problems, these findings may assist in gaining further insight into the characteristics of embouchure dystonia and the development of preventive strategies.
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Affiliation(s)
- Anke Steinmetz
- Department of Orthopaedics, Traumatology and Physical Medicine, University of Halle, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany,
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Ramdhani RA, Frucht SJ. Adult-onset Idiopathic Focal Lower Extremity Dystonia: A Rare Task-Specific Dystonia. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2013; 3. [PMID: 23450825 PMCID: PMC3583069 DOI: 10.7916/d8571bqx] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 11/26/2012] [Indexed: 12/01/2022]
Abstract
Background Adult-onset focal lower extremity (LE) dystonia is rare, but there have recently been a number of case series that have reported an idiopathic variant triggered during ambulation. Methods We describe nine patients with idiopathic, focal task-specific LE dystonia. We conducted a comparative analysis that included our cohort and several recently published case series to further characterize the disorder. Results A total of 48 patients (37 female, 11 male) were compared. The average age of onset was 48 years; 36 patients had distal extremity involvement (75%), 5 proximal (10%), and 7 both proximal and distal (15%). Among 33 patients in which the dystonic side was known, 20 were affected on the left (61%). Inversion of the foot with flexion of one or more toes was the most prevalent pattern in those with distal extremity involvement. Discussion This is a novel task-specific dystonia triggered during ambulation that is often misdiagnosed as an orthopedic or psychogenic issue.
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Affiliation(s)
- Ritesh A Ramdhani
- Movement Disorders Division, Mount Sinai School of Medicine, New York, New York, United States of America
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Altenmüller E, Baur V, Hofmann A, Lim VK, Jabusch HC. Musician's cramp as manifestation of maladaptive brain plasticity: arguments from instrumental differences. Ann N Y Acad Sci 2012; 1252:259-65. [PMID: 22524368 DOI: 10.1111/j.1749-6632.2012.06456.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Musician's cramp is a task-specific movement disorder that presents itself as muscular incoordination or loss of voluntary motor control of extensively trained movements while a musician is playing the instrument. It is characterized by task specificity and gender bias, affecting significantly more males than females. The etiology is multifaceted: a combination of a genetic predisposition, termed endophenotype, and behavioral triggering factors being the leading features for the manifestation of the disorder. We present epidemiological data from 591 musician patients from our outpatient clinic demonstrating an influence of fine-motor requirements on the manifestation of dystonia. Brass, guitar, and woodwind players were at greater risk than other instrumentalists. High temporospatial precision of movement patterns, synchronous demands on tonic and phasic muscular activation, in combination with fine-motor burdens of using the dominant hand in daily life activities, constitute as triggering factors for the disorder and may explain why different body parts are affected.
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Affiliation(s)
- Eckart Altenmüller
- Institute for Music Physiology and Musicians' Medicine, University of Music, Drama and Media, Hannover, Germany.
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Avivi-Arber L, Martin R, Lee JC, Sessle BJ. Face sensorimotor cortex and its neuroplasticity related to orofacial sensorimotor functions. Arch Oral Biol 2011; 56:1440-65. [DOI: 10.1016/j.archoralbio.2011.04.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 04/05/2011] [Accepted: 04/06/2011] [Indexed: 12/20/2022]
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Kang SY, Kim H, Ma HI, Kim YJ, Kwon SB, Hwang SH, Sohn YH. Highly task-specific oromandibular dystonia in a telephone operator. Eur J Neurol 2011; 18:e136. [PMID: 21914046 DOI: 10.1111/j.1468-1331.2011.03468.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Shamim EA, Chu J, Scheider LH, Savitt J, Jinnah HA, Hallett M. Extreme task specificity in writer's cramp. Mov Disord 2011; 26:2107-9. [PMID: 21714006 DOI: 10.1002/mds.23827] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 04/27/2011] [Accepted: 05/12/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Focal hand dystonia may be task specific, as is the case with writer's cramp. In early stages, task specificity can be so specific that it may be mistaken for a psychogenic movement disorder. METHODS We describe 4 patients who showed extreme task specificity in writer's cramp. They initially only had problems writing either a single letter or number. Although they were largely thought to be psychogenic, they progressed to typical writer's cramp. CONCLUSIONS Early recognition of this condition may provide an opportunity for early initiation of treatment.
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Affiliation(s)
- Ejaz A Shamim
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.
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Aránguiz R, Chana-Cuevas P, Alburquerque D, León M. Focal dystonia in musicians. NEUROLOGÍA (ENGLISH EDITION) 2011. [DOI: 10.1016/s2173-5808(11)70008-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Aránguiz R, Chana-Cuevas P, Alburquerque D, León M. Focal dystonia in musicians. Neurologia 2010; 26:45-52. [PMID: 21163218 DOI: 10.1016/j.nrl.2010.09.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 08/27/2010] [Accepted: 09/18/2010] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION A special group of focal dystonia is that known as occupational, which include dystonic disorders triggered by repetitive motor activity, closely associated with the professional activity of a specific task that the affected person performs. In this sense, musicians are a population particularly vulnerable to this disorder, which is presented during the execution of highly trained movements. OBJECTIVE This article reviews the pathophysiology of focal dystonia and its therapeutic implications. DEVELOPMENT The pathophysiological basis of focal dystonia in the musician is still not well established. However, due to the contribution of neurophysiological studies and functional neuroimaging, there is growing evidence of anomalies in the processing of sensory information, sensory-motor integration, cortical and subcortical inhibitory processes, which underline this disease. Clinically, it is characterised by the appearance of involuntary muscle contractions, and is associated with loss of motor control while practicing music. It is a gradual appearance and sometimes there may be a history of musculoskeletal injuries or non-physiological postures preceding the appearance of the symptoms. The neurological examination is usually normal, although subtle dystonic postures can develop spontaneously or with movements that involve the affected segments. The dystonia remains focal and is not generalised. CONCLUSIONS Treatment is based on using multiple strategies for the management of the dystonia, with variable results. Although a specific therapy has not been defined, there are general principles that are combined in each situation looking for results. This includes, among others, pharmacological interventions, management with botulinum toxin, and sensory re-training techniques.
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Affiliation(s)
- R Aránguiz
- Centro de Trastornos del Movimiento, Universidad de Santiago de Chile (CETRAM-USACH), Hospital Geriátrico de Santiago de Chile, Santiago de Chile, Chile.
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