Focal hand dystonia, tremors, and retraining
Observations on Focal Hand Dystonia and Tremors in Pianists -Teresa Dybvig
An involuntary movement is any unwanted movement that the musician feels he or she cannot control. Focal hand dystonia is one type of involuntary movement. Tremors are another. Most significantly, over the decades I have seen that pianists with dystonia and pianists with tremors share a constellation of habits. Therefore, I have come to think in terms of pianists with involuntary movements rather than pianists with either tremors or dystonia.
To clarify, when I say “pianists with involuntary motions” I refer to a condition that occurs later in life, after the pianist has been playing for several years, for which there is no other known cause. So I do not include conditions like Parkinson’s Disease, which are know to cause involuntary movements. Likewise, dystonia and tremors that have been present since birth are different situations.
Over the years I have seen that pianists (and other instrumentalists) with focal hand dystonia or tremors share certain incoordinate habits of alignment, balance, and movement. When these habits are changed to more coordinate habits, the involuntary movement that characterizes the involuntary movement ameliorates or disappears altogether.
It is noteworthy that all the pianists I see with involuntary movements have similar habits. Usually every student who comes to me to learn healthy movement walks in the door with a unique combination of healthy and unhealthy habits. So it is extraordinary when every student with a particular problem evinces the same habits.
The habits may have come into being because of a genetic predisposition, bringing anxiety into practice (Jabusch and Altenmüller 2004), technical advice followed, technical advice ignored, or the innocent desire to play glorious music that made demands upon the body that it was not yet equipped to handle. What is important is that these habits, although sometimes stubborn, are only habits. We can change them.
Some neurologists tell musicians that a diagnosis of dystonia, or essential tremor, or idiopathic tremor, means that their best playing is behind them. These musicians hear that even if one of the medications that address involuntary movements helps them, they still will not return to their previous level of performance. My experience supports a more optimistic prognosis. I have seen that pianists with dystonia and other involuntary movements who retrain can become even better pianists than they were before their injury appeared. Those who persist can play real music without experiencing the involuntary movement after 20 to 50 hours of lessons. Sometimes they are so happy to play without the involuntary movement that they stop lessons at this point. Others continue to take lessons so they can play increasingly complex repertoire well and without trouble. They become greedy in the best way.
Some medical experts consider retraining an important component of treating musicians with involuntary movements. One of my students told me that when Dr. John Chong of Toronto diagnosed her with dystonia, he advised her to find a Taubman teacher and learn to play differently. Dr. Eckart Altenmüller (2003), director of the Institute of Music Physiology and Musicians’ Medicine in Hannover, Germany; Raoul Tubiana (2003), director of the Parisian l’Institut de la Main; and Altenmüller together with Hans-Christian Jabusch (2006), also at Hannover, all advocate retraining as part of treatment programs to help musicians with dystonia.
Other music medicine researchers are not fans of retraining. I don’t know why, but I have some ideas. For one, those of us who do the retraining have such a different educational background that we barely speak the same language as physicians. Piano teachers who help students retrain often encounter doctors who can’t seem to imagine what a huge difference a small change in movement can make. Likewise, musicians do not tend to think quantitatively, or do quantitative research.
Sometimes medical professionals are right to be skeptical. Retraining from involuntary movements requires knowledge, precision, and experience that are hard to come by. So even though I find a generalized attitude against retraining frustrating, I can understand why it exists. If music medicine researchers understood that there are different approaches to retraining, fascinating research could be done to determine which approaches were most effective. Then we could begin to see a real change for musicians with involuntary movements!
The best retraining from involuntary movements includes attention on mindset and body movement in addition to piano technique. My students who improve the fastest are the ones who work on all at the same time. One of my students even told me that she wished she had done six months of body movement study (in her case, Alexander or Feldenkrais) before we even started lessons. I recommend Feldenkrais Relaxercise lessons to all my students with involuntary movements (and most of my other students too!) at their first or second lesson.
Successful retraining from involuntary movements also includes retraining both hands, even if only one hand has the involuntary movement. That way, the hands reinforce one another in the omni-available motor memory, and we reduce the chance that the involuntary movement will “spread” from one hand to the other.
I always try to retrain within repertoire whenever possible. To do this, we spend the bulk of every lesson coaching a new skill, and then practice experiencing it consciously in music (usually we need to start with easier music than the pianist has been playing). Some pianists with involuntary movements find it impossible to make changes while playing, so we spend some time coaching alignment, balance, and movement before starting to play repertoire.
Sometimes students considering retraining worry that they will find it hard. They might. Retraining requires clear thinking, honesty, persistence, and the ability to laugh at your own foibles. But to judge from my students, they will probably also find it empowering and rewarding. Some people ask me how old they will be when they are playing again. Obviously, they will be as old as they would be if they didn’t retrain, but they will have pursued the more proactive course. Some are so discouraged by what they hear from their doctors that they decide that giving up is the most realistic course. But think about it: there is nothing inherently more realistic about pessimism. Just because your doctor has not had good experience with retraining, or does not know how to guide you through retraining, does not mean that retraining isn’t a solution. It is just not your doctor’s solution.
Altenmüller, Eckart (2003). Focal dystonia: advances in brain imaging and understanding of fine motor control in musicians. Hand Clinics 19: 1-16.
Jabusch, Hans-Christian, and Altenmüller, Eckart (2004). Anxiety as an aggravating factor during onset of focal dystonia in musicians. Medical Problems of Performing Artists 19: 75-81.
Jabusch, H., and Altenmüller, E. (2006). Focal dystonia in musicians: from phenomenology to therapy. Advances in Cognitive Psychology 2(2):207-220.
Tubiana, Raoul. (1997). Upper limb disorders in musicians. Maîtrise Orthopédique 69.
- Mary Ellen HaupertAssociate Professor of Music and PianistMary Ellen HaupertAssociate Professor of Music and Pianist
I wouldn't be an active musician today if it wasn't for Teresa Dybvig's careful guidance through the challenge of recovery. Today I don't even consider myself a person with dystonia.
- G.C.Pianist and Piano teacherG.C.Pianist and Piano teacher
Almost 6 years ago I was diagnosed with dystonia, and my doctor recommended I try the Taubman Technique instead of other invasive solutions which were not even guaranteed to permanently cure me. Soon I began studying with Teresa Dybvig. I rarely feel the involuntary movement any more. Some days I wake up and I don't even remember which hand had the dystonia. I was able to complete my Masters degree in piano performance, and am now continuing to perform. The retraining process was difficult at times, but very rewarding overall. I am very happy and feel very fortunate to not have had to abandon my musical career in piano.
- Linda CodyAccompanist and TeacherLinda CodyAccompanist and Teacher
Please consider attending a workshop this summer. There are answers and solutions that work! It is a process of unlearning and relearning. It takes patience, but it is so worth it. I have had teammates from several different countries travel to the workshops, because Terry has been the only person who knew how to help them. In every single case, there has been progress.
- H.H.Pianist and College Music InstructorH.H.Pianist and College Music Instructor
Retraining is a challenging experience, but I have learned that with persistence and patience you can make incredible changes and experience the joy of playing again.
- G.T.Pianist and TeacherG.T.Pianist and Teacher
I came to Dr. Teresa Dybvig with an involuntary movement in my fourth and fifth fingers of the right hand in 2006. Four years later, I am performing solo repertoire again and feel technically equipped to play anything I want. A friend recently heard me play the Liszt Tarantella and said, "I would never have guessed you were injured." The process of retraining with Terry is a profound one; it is physical, mental, and spiritual. Without getting into all the niceties of the work, I feel not only transformed physically in my use of fingers, hands, and arms, and the relationship of these playing parts to the body, but also my approach to the music. If you have an involuntary movement and want to walk the path of recovery to performing at your absolute best, I recommend wholeheartedly Dr. Dybvig as your guide.