Focal Dystonia: A Musician Overcomes a Movement Disorder With a Change of Mindon December 4, 2020 at 3:00 pm

Neuroscientist Joaquin Farias trained as a professional musician in his youth. He played the harpsichord, flute and piano. When he was 21, something changed — he felt as though he could not properly control his fingers. “It felt like I was moving my fingers under water,” he says. His muscles would freeze up and he could no longer play his instruments with the correct finger pressure.

Farias was affected by dystonia, a movement disorder that, in his case, was specific to his musical endeavors. “It was not there when performing other tasks,” he says. Known also as musician’s focal dystonia, the disorder often prompts the end of a professional musician’s career.

Farias was told that there was no cure. Unwilling to accept the prognosis, he self-directed his recovery through trial and error, eventually overcoming the disabling condition. He credits his success to both his intellectual and creative pursuits, combining his academic study of neuropsychology and biomechanics with his knowledge from his musical training. “I think that musicians know a lot about the brain, but they don’t know what they know,” he says.

The Musician Who Healed Himself

“I understood early that the process was not muscular but had something to do with my brain,” Farias says. For example, musicians know that if you train the left hand, the right hand improves and that playing a new musical piece slowly is critical to learning it fluently — both strategies that he would use to help his recovery. He developed exercises to improve control over pressure, speed and timing. He experimented with moving in a pool to reduce the influence of gravity and practiced clay modeling to explore depth perception. He also performed movements backwards, blindfolded and with different musical keyboard touch sensitivities to challenge habitual responses. Farias noticed some improvement right away, and after two years, he fully recovered his lost function.

Some of these techniques were later corroborated by others. For example, a study by neuroscientist Naotaka Sakai of Utsunomiya University in Japan showed that patients with musician’s dystonia who practiced a piece very slowly recovered normal or near-normal movement.

After graduating with his doctorate in sports medicine, Farias developed a neuroplasticity training program to help other dystonia patients recover, using his toolbox of strategies to teach them how to retrain their brains. According to the testimonials of Farias’ patients, some recover lost function within minutes. Others practice a home-based recovery plan that leads to significant improvements within weeks, months or in some cases years.

Dysfunction, Compensation and Relearning

Neuroscientist and physiotherapist Nancy Byl of the University of California, San Francisco, describes Farias as a “patient-sensitive interventionist”and regards neuroplastic retraining strategies as worthwhile because they are non-invasive and have no adverse effects. Byl believes that learned reinforcement of dysfunctional movement is an important underlying factor in musician’s focal dystonia — one of a combination of factors that interact to produce symptoms.

Playing a musical instrument changes the brain, particularly the way body parts are mapped in the brain. The complex sensory and motor demands for learning during repetitive practice of skilled hand movements are high, and the brain remodels itself to meet these demands. These brain changes also put professional musicians at risk for developing dystonia. Hand representations in the brain are usually well-defined. Excessive, repetitive movements like those needed to develop and maintain musical skills can cause hand maps to grow larger and the representations for distinct parts of the hand to degrade.

Neuroplasticity — the brain’s remarkable ability to change itself — follows a use-it-or-lose-it principle: Neural circuits that are repeatedly activated are strengthened. Those that are used less become dormant. Repeated expression of dysfunctional movement reinforces the neural pathways of abnormal movement and weakens those controlling normal movement. This is why dystonia becomes progressively worse over time. Neuroplastic retraining for musician’s focal dystonia works to bypass neural pathways that cause abnormal movement and strengthen those that control normal movement. Different therapists use different tools to implement these strategies.

Byl explains that neuroplastic brain changes can be good or bad, depending on what is reinforced. “The challenge is to stop the abnormal movements,” she says. “Patients, particularly musicians, have a difficult time [stopping] practice and performance. They learn compensatory strategies that are temporarily helpful but ultimately degrade in effectiveness.”

Sakai and colleagues found that neural activity in the brains of musicians with focal dystonia is different — compensating in an effort to maintain appropriate voluntary movement when habitual neural pathways are silenced. Farias says the reason for all the compensations is the lack of function in dystonic muscles an associated brain regions. Brain change that leads to recovery starts the day the patient says no to the compensatory movements and yes to the dormant ones.

But how do you refuse movement that seems involuntary? One way is through immobilization. Musician’s dystonia can affect different parts of the hand, depending on the instrument played and fingers most commonly used. Constraint therapy can encourage normal movement by immobilizing non-dystonic fingers and practicing normal movements with the dystonic finger. A study by behavioral neuroscientist Edward Taub and colleagues at the University of Alabama at Birmingham showed that patients with musician’s dystonia improve after such therapy.

A range of other targeted exercises can also stop dysfunctional movements and strengthen neural circuits underlying normal movement. Byl and colleagues showed that practicing specific tasks, engaging in physical fitness and relearning how to integrate sensation and movement are helpful. This is partly because learning-based activities and physical exercise increase dopamine and endorphins, which help remodel the nervous system.

Byl explains that mental imagery is crucial to restoring normal movement during the early stages of such training. “Recovering the memory of performing the task normally is fundamental,” she says. “The reward of feeling ‘normal’ voluntary motor control is critical to successful retraining.” Sport psychologist Leslee Fisher and colleagues of the University of Tennessee showed that guided imagery of normal movement is an effective rehabilitation strategy for dystonia. This is not surprising, given that imagining normal movement of a body part is known to activate the corresponding brain area involved in actual movement of that part.

Drink From as Many Sources as You Can

Farias’ work is a striking example of cross-pollination between different disciplines — of drawing inspiration from otherwise divergent fields. He believes that being open-minded to various influences inspires creative solutions to complex problems.

“Over-specialization makes you blind to the big picture,” he says. “To solve complex problems, drink from as many sources as you can. You can get insight in the places that you never thought.”

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