Rehabilitation of focal hand dystonia in musicians: a systematic review of the studies

R. Chiaramonte, M. Vecchio [REV NEUROL 2021;72:269-282] PMID: 33851716 DOI: https://doi.org/10.33588/rn.7208.2020421 OPEN ACCESS
Volumen 72 | Number 08 | Nº of views of the article 32.927 | Nº of PDF downloads 274 | Article publication date 16/04/2021
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ABSTRACT Artículo en español English version
INTRODUCTION Focal hand dystonia in musicians is a task-specific movement disorder characterized by an involuntary loss of control and coordination of finger movements during instrumental playing.

MATERIALS AND METHODS Literature searches with the keywords ‘dystonia’ AND ‘musician’ AND ‘finger’ OR ‘treatment’ OR ‘therapy’ OR ‘rehabilitation’ were conducted in PubMed, EMBASE, Cochrane Library and Web of Science to perform the systematic review about the several strategies used to treat dystonia in musicians. The search was performed independently by two authors (R.C. and M.V.) from 6 April 2020 till 6 June 2020. The research identified a total of 423 articles. Seventy-seven selected articles were analysed by the reviewers. Thirty-six publications met the inclusion criteria and were included in the systematic review.

RESULTS The systematic review was performed to identify the main used treatments for dystonia in musicians. We defined the several techniques to better guide the physician to delineate a rehabilitation protocol adopting the better strategies described in the current literature. CONCLUSION. This systematic review tried to provide to the reader a complete overview of the literature of all possible different treatments for dystonia in musicians. A correct protocol could permit to improve the motor performance and the quality of life of musicians.
KeywordsDystoniaFingersMusiciansQuality of lifeRehabilitationSystematic review CategoriesTrastornos del movimiento
FULL TEXT Artículo en español English version


Focal hand dystonia in musicians

Focal hand dystonia in musicians is a task-specific movement disorder characterized by an involuntary loss of control and coordination of finger movements during instrumental playing correlated to extensive and forceful use of the digits [1]. It is correlated to a co-contractions of agonist and antagonist muscles due to maladaptive cortical reorganisation and altered sensory perception with abnormalities in temporal and spatial discrimination [2,3].

The dystonia in musicians became a field of investigation only in the last 40 years, even if some authors asserted that previously famous composers were affected. In 1999 Richard J. Lederman [4] in his paper ‘Robert Schumann’ hypothesized that Schumann was affected by this disease. In 1988, Frank Wilson [5] had written ‘musician in full flight is an operational miracle, but a miracle with peculiar and occasionally unpredictable vulnerabilities’ and in 1989 he had published a pioneering article [6] on dystonia in musicians in which he sustained ‘although the relationship of music and medicine is measured in millennia, it is only within the past few years that it has developed genuine vitality’.

Nowadays, we know that the prevalence of dystonia in musicians is 0.2% to 0.5% [1]. Every instrument group is affected, but guitarists, pianists and woodwind players are most commonly affected, representing 70% of patients [1].

The musicians have a sudden or insidious deterioration of sensorimotor skills, often only during instrument playing. Musicians often report incoordination while playing that is frequently accompanied by involuntary flexion or extension of fingers during music passages that emphasize rapid, forceful finger movements [7]. They presented involuntary spasms, cramping sensations, abnormal hand posture, finger curling, loss of coordination during specific task [1]. It more often involves digits 3, 4 and 5 (D3, D4, D5) of the hand and is thought to be related to the intense and prolonged practice of rapid, alternating, and highly precise finger movement patterns [1].

Disability condition and the role of treatment

The dystonia in musicians can be disabling to compromise the professional career. This condition does not need to be severe to exercise a significant impact on musician’s career. Multiple strategies were explored to manage dystonia in musicians with highly variable outcomes. Rehabilitation goals include improvement of control of the movement and of sensibility perception. No specific program of therapy has been defined. The treatment is needed because cortical changes, together with emergent neurological dysfunction, can be redressed by context-specific treatment [8]. In addition, the use of a movement intervention capable of producing measurable changes in the cortical organization of sensory areas underscores the tight relationship between sensory and motor systems [8].

For musicians with dystonia, maintaining a good motor performance is hard and it has consequences on their careers. The presence of dystonia in musicians may constitute a negative factor in their quality of life.


This study aimed to perform a systematic review of the several strategies for dystonia in musicians to investigate the different therapy intervention, aimed at normalising movement patterns, in musicians affected by dystonia. Unfortunately, the current literature does not show robust evidences that indicate which treatments work better, when they should start, their best duration or intensity. Until now, there are no specific guidelines.

This review defined the several techniques for the treatment of dystonia in musicians to better guide the physician to delineate a therapeutic protocol adopting the better strategies described in the current literature.

Materials and methods

Search strategy

The search was carried out on the following medical electronic databases: PubMed, EMBASE, Cochrane Library and Scopus Web of Science. The review was conducted from 6 April 2020 till 6 June 2020. We searched for the following terms and keywords: ‘dystonia’ AND ‘musician’ AND ‘finger’ OR ‘therapy’ OR ‘treatment’ OR ‘rehabilitation’.

Selection criteria and data extraction

From 1989 to 2020, searches in the database produced for the keywords ‘dystonia’ AND ‘musician’ AND ‘finger’ yielded 60 references and for the search ‘dystonia’ AND ‘musician’ AND ‘treatment’ OR ‘therapy’ OR ‘rehabilitation’ respectively 159, 135 and 66 references, whose titles and abstracts were screened by the reviewers.

The selected papers remained for full-text screening were 77 and the eligibility of the study inclusion was assessed independently. Thirty-six publications met the inclusion criteria and were included in the systematic review. Forty-one articles were excluded for the following reasons: 20 studies were about different topics than ours, 8 described a different disorder from finger dystonia, 13 treated on a different professional category than musicians (Figure).


Figure. Flowchart of the process of initial literature search and extraction of studies meeting the inclusion criteria.


We included original articles about finger dystonia in musicians. We excluded animal studies and participants with other disorders. We also excluded all of the remaining duplicates.

Two reviewers independently screened the titles and abstracts from the initial search to identify relevant records and to identify eligible studies based on title and abstract. In the case of conflicting opinions, a consensus was reached after discussion between the authors. Selected full texts were then reviewed and included in the systematic review following the PRISMA protocol [9] and in accordance with the PICOS [10] (population, intervention, comparison, outcome, and study design) criteria, shown in Table I: participants were aging adult musicians; intervention was based on rehabilitation therapy; comparator was any comparator; outcomes included clinical assessments, diagnostic scales and instrumental tools; and study design was RCTs, case series and case report, retrospective studies.


Table I. Treatment of dystonia in musicians: characteristics and outcomes of studies included in the systematic review.
Study design

Dystonia location

Dystonia duration


Intervention/ treatment

Outcome measures

Intervention frequency

Clinical results

Berque et al, 2010

Case series

D2, D3, D4, D5

~ 9.2 y

2 guitars,

2 flutes,

2 bagpipes,

1 oboe player,

1 accordion

CIMT and SDE at slow speed

Video recordings, FAM, change in metronome speed

Up to 30 min/d for 12 m.

Only the first w of retraining involved CIMT, for 2 h/d.

Each subject would play each sequence continuously for 10 min, with a 2-min rest between sequences. A 10-min of rest was given after the first series of 5 sequences was completed. Speed of metronome was modified every 2 min since the abnormal movement pattern occurring

Significant ↓ in the number of abnormal movements per second of instrumental playing over the 12-month period.

Berque et al, 2013

Case series

D2, D3, D4, D5

~ 11.6 y

2 guitarist,

2 flutes players

CIMT and SDE at slow speed

Video recordings, FAM, TCS, ADDS, change in metronome speed

Up to 30 min/d for 12 m

Significant ↓ in the number of abnormal movements per second of instrumental playing over 36 m.

Betti et al, 2018

Case study

D1, D2, D3

~ 3 y

1 guitarist


Movement time (time interval between onset and offset),

MGA (maximum distance reached by the 3D coordinates of the thumb and index finger)

TMGA (time at which the distance between the 3D coordinates of the thumb and index finger was maximum from movement onset)

TMGV (time at which the tangential velocity of the 3D coordinates of the thumb and index finger was maximum from movement onset)

TMWH (time at which the 3D coordinates of the wrist were maximum from movement onset)

TMWD (time at which the deceleration of the 3D coordinates of the wrist was maximum from movement onset)

DG (time interval between the onset of the wrist movement and the onset of fingers’ opening)

Motor threshold

1 Hz of rTMS for 5 d

Significant difference in Finger Flexion Task, TMGV, TMWD, DG.

Bravi et al, 2019


D1, D2, D3, D4, D5

8.7±9.7 y

1 harpsichord,

1 guitarist,

1 violinist,

3 pianist,

1 clarinettist

Correction Kinesiotaping versus sham Kinesiotaping


No significant differences in effects between Correction Kinesiotaping and Sham Kinesiotaping were reported by the experts, either for general performance or for fingers’ posture. Musicians estimated that Correction Kinesiotaping was ineffective in improving their musical abilities

Butler et al, 2018


D3, D4, D5

~ 2.5 m

4 pianist,

2 guitarist,

1 flutist

Sensory–motor task-specific dystonia rehabilitative program


Six therapy sessions over a 6-m period.

Forearm muscles stretch to decrease myofascial tension, shoulder exercises to increase freedom of movement in the shoulder girdle, hand strengthening exercises to increase proprioceptive awareness and strength of intrinsic hand muscles.

Improvements occurred across measures and were typically larger at the 6-m

Buttkus et al, 2010

Case report

Finger flexion dystonia

~ 15 y

1 piano

A: Retraining strategies

B: Retraining strategies

+ tDCS

MIDI-based scale analysis.

20’ per d, 5 d consecutively for 6 w

Beneficial effect of retraining on fine motor control enhanced by cathodal tDCS

Byl et al,

Case series


1-5 y

12 p, whose 5 musicians (not specified the instruments)

Sensory training with biofeedback, mirror therapy, mental practice techniques

A battery of sensory, motor, physical and functional performance tests

Once a w for 6 m

Significant gains in pain, posture, balance, neural tension, strength and range of motion of fingers

Byl et al,

Case series

D3, D4, D5

2 flutists,

1 bagpipe

SDE and motor training

Magnetoencephalography and clinical sensory and motor tests

task-specific motor control: Purdue Pegboard test, digital reaction time, line tracing accuracy and time

Sensory discrimination: localization, 2-point discrimination, graphesthesia, stereognosis, kinesthesia

musculoskeletal performance: ROM, posture, neural tension,

independence: functional independence, work status

1p: 2 times a w for 12 w and reinforced daily at home.

1 p: 1 d for 2 w

1 p: 1 w for 17 w

Improved an average of 86.8% on somatosensory hand representation, 117% on target-specific performance, 23.9% on fine motor skills, 22.7% on sensory discrimination, 31.9% on musculoskeletal skills, and 32.3% on independence.

Byl et al,


>3 y

8 musicians

Home program of fitness and learning-based sensorimotor and memory training

Functional independence and strength

8 w

Task practice plus learning based memory and sensorimotor training can improve MD

Candia et al, 1999

Case series

3 pianists,

2 guitarists


Non-invasive neuroimaging technique (magnetic source imaging), DES
Significant ↑ in the smoothness of movements after treatment

Candia et al, 2002

Case series

D2, D3, D4, D5

~ 7 y

6 pianists,

2 guirarists,

2 flutes,

1 oboe


DES, Dexterity and Displacement Device

2 h per day over a period of 8 consecutive days

1-month follow-up

SMR is of value for the treatment of focal hand dystonia in pianists and guitarists

Candia et al, 2003

Case series


~ 3 m

11 pianists

Behavioural treatment

Oldfield handedness questionnaire and DES

8 consecutive d for 1.5 to 2.5 h
per sessions

Significant ↑ in DES scores and in smoothness of movement

Candia et al, 2005

Case series


101 musicians:

pianists, guitarist, flautists, oboist

SMR, hand splint


8 consecutive d for 1.5 to 2.5 h per session

Pianists and guitarists visibly improved the performance.

The wind players did not improve

Chen et al, 1998


Frontalis or abductor digiti minimi

69 m

1 musician,

81 y

Botulinum toxin injections

5-point scale of benefits, VAS

23 injections, 130 U.

Benefits of botulinum injections for 6 m

Cohen et al, 1989


D1, D2, D2, D4, D5

~ 7 y

1 pianist,

2 guitarist,

1 clarinet

Botulinum toxin injections


Every 2 w increasing doses (up to 20 U the first w, up to 40 U the second w, and up to 80 U the third w)

Benefit lasted between 1 and 6 m and was reproducible.

Cole et al,



~ 6.5 y

1 bagpipes player,

1 pianist

Botulinum toxin injections

MRC scale, videotaped performance

3 injection with 5 and 10 U respectively for each patient

The efficacy of botulinum toxin lasted for 1 to 4 months

Furuya et al, 2014


D2, D3, D4

~ 7.9 y

20 pianists


Rhythmic variability of the key strokes at pretest, post-test, and testing baseline

5 sessions

Therapeutic effects of behavioral training assisted by bihemispheric, noninvasive brain stimulation restored fine motor control

Horisawa et
al, 2013


D1, D2, D3, D4, D5

8.3 ± 8.2 y

1 koto player,

7 guitars,

2 shamisen,

3 pianists,

1 flutist

1 violinist

Ventro-oral thalamotomy

Tubiana’s musician’s dystonia scale


Ventro-oral thalamotomy remarkably improved MD and the effect persisted for a

long time

Jabusch et al, 2004

Case report

D3, D4, D5

~ 10 y

1 Pianist



After administration of THC or placebo, the patient played the piano for 3 h with short intermissions every 45 min.

Significant ↑ of motor control.

After administration of placebo, motor control of the affected hand showed no improvement

Jabusch et al, 2005


Flexor digitorum superficial, profundus, flexor carpi radialis, flexor pollicis longus, extensor digitorum, extensor indicis, interosseus palmaris

~ 9 y

144 musicians:

keyboard players, woodwind players, guitarists

Botulinum toxin, Dysport (n. 71 p, 48%),

Trihexyphenidyl (n. 69 p, 49%)

Pedagogical retraining (n. 24 p, 17%)

Ergonomic changes (n. 51p, 35%)

Nonspecific exercises on the instrument (n.78 p, 54%)

Standardized questionnaire about the nature and duration of therapies

Trihexyphenidyl per 9±7 m:

dosage 10 mg/day±1-13


In 18 p one injection

In 53 p (37%): 5.7±12 injections per patients; range, 2–25

Duration:16±29 m.

Interval between treatment sessions of 4.2±12 m.

Dosage per treatment session:128±218 U.

Ergonomic changes for 35 m

Pedagogical retraining for 28 m

In 77 p (54%): alleviation of symptoms:

In 33% with trihexyphenidyl,

49% with BT,

63% with ergonomic changes

50% with pedagogical retraining,

56% with unmonitored technical exercises,

Jabusch et al, 2009

Case series

19 pianists

Instruments practice

Standardized questionnaire about the nature and duration of therapies and musical instrument digital interface-based scale analysis

27 m

Maintenance of motor skills was significantly influenced by practice quantity

Karp et al, 1994


5±1 y

4 pianists,

4 guitarists,

2 drum players,

2 violinists,

2 trump players,

2 flute players,

1 clarinettist,

1 organist,

1bagpipes player

Botulinurn injections

Performance scale, MRC

The initial dose of BT was 2.5 to 20 U per muscle. The mean dose of BT used in a session was 26 ± 2 U. Benefit from each session lasted a mean of 6 ± 1 m. Weakness lasted a mean of 3 m.

BT injection is safe and effective for the long-term management of focal hand dystonia.

Lungu et al, 2011


>20 y

2 pianists,

1 guitarist,

1 drum player,

1 trumpet player


Self-reported scales of benefit and weakness

Period between injections 19.9±12.4 m

The patients received a higher mean dose at the end of the follow-up period compared to the initial treatment (49.9 vs. 24.9 U)

Botulinum injections are safe and effective after more than a decade of treatment

et al, 2009


1-10 y

14 p

Sensorimotor training

Sensory discrimination and fine motor speed

8 w

Effectiveness of the treatment

Pesenti et al, 2001


2.8 ± 0.4 y

4 guitarists,

1 violinist,

3 pianists,

1 accordionist,

1 harpist

Motor fatigue

Handgrip test

Handgrip contraction lasts a mean of 2.13 ± 0.47 min

In dystonic musicians, a fatiguing contraction significantly improved motor performance. Five minutes after the contraction ended the benefit progressively disappeared.

Priori et al, 2001


3.62 ± 2.36 y

4 guitarists

1 pianist

2 drummers

Limb Immobilization

ADDS, TCS, Self-rating

Patients wore the splint throughout the 24 h and removed it only once a w for brief (10 min) local hygiene. Duration 4.5 w

Four w after removal of the splint, all the patients had regained normal voluntary control of the hand with normal strength

et al, 2008

Case series


5 pianists

Proprioceptive training


15 m/d

Proprioceptive training improves hand motor function

et al, 2008

Case series


~ 7.8 y

1 trumpet/ pianist,

1 violinist/ pianist

1 violinist,

2 frenchhorn / pianists,

1 clarinettist

Proprioceptive training

BFM scale

Time spent playing h/d 3.33

Behavioral proprioceptive training improves hand motor function

Ross et al, 1996


D2, D3

~ 5.8 y

6 pianists,

2 drummers,

1 horn player,

1 saxophonist,

1 guitarist



Smaller muscles injected with 5–15 U.

Larger muscles injected with 60–100 U.

The dose was administered in one injection site, and the concentration of botulinum toxin was always 5 U/0.1 cc.

BT had success to treat MD

Rosset-Llobet et al, 2011

Case report

D3, D4, D5

10 y

1 pianist


Performance score, EMG, brain NMR

Every day for a y.

The patient returned to high-level piano playing, and after 8 y of follow-up, performance remains normal

Rosset-Llobet et al, 2015


D2, D3, D4

10.8 y

16 guitarists,

10 guitarists



2-w course of neurorehabilitation based on sensory motor

retuning therapy coupled with either real or sham tDCS for the

first 30 min of each daily 1-h therapy session (total 10


Both groups significantly

improved their dystonia severity score during the 2 w of therapy.

Schuele et al, 2004

Case series

Forearm flexors

~ 10.6

12 strings,

20 keyboards,

25 guitars,

25 woodwinds,

2 brass


questionnaire about the nature and duration of therapies, self-rating scale, six-step self-sating Score

Mean duration of treatment: 23 m Mean interval between injections 3.8 m.

Number of injections per patient 7.4

Number of muscles injected per treatment: 2.5 (range 1 to 6).

Total dose per treatment was 126.9 U (range 5 to 420) at the initial visit and 112.2 U (range 3 to 1,000) at the last visit.

Average dose per muscle group at last visit was 55 U for shoulder muscles (only 2 patients), 47.4 units for forearm flexors, 31.4 for forearm extensors, and 17.7 for hand muscles

In 58 p: improvement after the injections.

In 36% of p: long-term benefit

Van Vugt et al, 2013


~ 10.1 y

54 pianists

BTXA (53%), trihexyphenildyl (51%)

questionnaire about the type and effectiveness of therapies

BT (53%), 4.1±3.0 injection session for 25.4±21.8 m, 24.1±17.6 U per session

Trihexyphenidyl (51%),

21.5±17.8 m (5.02±3.7 mg/d)

Retraining (87%)

41.0±38.9 sessions in 38.2±29.5 m (1.4±1.1 sessions per m)

Hand therapy (42%)

Relaxation techniques (38%)

Physiotherapy (30%)

Psychotherapy (23%)

Acupuncture (21%)

Body techniques (21%).

50% of patients improved task performance following participation in a variety of intervention strategies, but subjectively, 80% of subjects reported improvement after retrained and BT more than Trihexyphenidyl.

Vecchio et al, 2012

Case report


~ 4 m

1 guitarist

Levocarnitine + BT

EMG, CT, MRI, transcranial magnetic stimulation, Fahn dystonia scale

levocarnitine (3 g daily for 3 months) + BT injected into the superficial (20 IU) and deep fl exor (20 IU) muscles

The contractions diminished 5 d later the BT injection. The beneficial effect of BT lasted for about 8 m

Yoshie et al, 2015

Case report

D3, D4, D5

~ 4 m

1 pianist

Slow-Down Exercise


30 min per d for 12 m.

Effectiveness of slowdown exercise. Behavioral intervention can reverse the reorganization of sensorimotor neural networks

Zeuner et al, 2005

Case series

14.6±7.0 y

1 guitarist,

9 writers

Motor training program and splint.

Kinematic Analysis, EEG, Transcranial Magnetic Stimulation

Finger flexor splints and others extensor finger splints. In addition, they were instructed to train each finger individually by making clockwise and counter clockwise circles, the letters II and mm on a piece of paper.

During the first week, they practiced 25 min per d, 5 min with each finger, in the remaining 3 w 50 min/d with 10 min per finger.

Improvement after training

ADDS: arm dystonia disability scale; BFM: Burke-Fahn-Marsden; BT: botulinum toxin A; CIMT: constraint-induced movement therapy; CT: clinical trial; d: day; D: finger; DES: dystonia evaluation scale; DG: delay grasping; DSR: dystonia severity rating; f: females; FAM: frequency of abnormal movements scale; FHD: focal hand dystonia; h: hours; HC: healthy controls; m: males; MGA: maximum grip aperture; MIDI: MIDI-based scale analysis; min: minutes; MRC: Medical Research Council; n.: number; OS: observational study; p: patients; ROM: range of motion; RS: retrospective study; RT: retrospective study; rTMS: repetitive transcranial magnetic stimulation; SDE: motor control retraining; SICI: ahort interval intracortical inhibition; SMR: sensory motor retuning; TCS: Tubiana and Chamagne scale; tDCS: transcranial direct current stimulation; THC: Δ9-tetrahydrocannabinol; TMGA: time of maximum grip aperture; TMGV: time of maximum grip velocity; TMWD: time of maximum wrist deceleration; TMWH: time of maximum wrist height; U: units; VAS: visual analogue scale; w: week; y: year/s.



Description of the studies

The number of studies produced at each stage of the search for the systematic review is shown in figure.

A total of 36 studies were included in our systematic review with the sample characteristics and details of the design of each included study in Table I.

Variations of experimental conditions across the studies

The selected 36 articles were described on the basis of the several treatments used for dystonia in musicians. Characteristics of the studies are shown in table I.

All study groups were not homogeneous for relevant general clinical features as affected fingers, duration of disease, kinds of diagnostic measures, severity of symptoms, rehabilitation therapy, time of starting therapy, duration of treatment (Table I).

Rehabilitation treatment

We showed all methods of the current literature used for the treatment of dystonia in musicians in Table II.


Table II. Treatments of focal hand dystonia in musicians.

Aim of the therapy


Behaviour treatment

Finger exercises with feedback

Improvement of somatosensory cortical organization

Candia et al, 1999;

Candia et al, 2002;

Candia et al, 2003;

Candia et al, 2005

Constraint-induced therapy + slow-down exercise therapy

Splint and slow-down exercise

Reversing of the reorganization of sensorimotor neural networks

Berque et al, 2010;

Berque et al, 2013;

Rosset et al, 2016

Immobilization of fingers

Immobilization with splints and combinations of specific finger exercises

Reducing co-contraction

Candia et al, 1999;

Candia et al, 2002;

Priori et al, 2001;

Zeuener et al, 2005


Passive method for muscle activity normalization

Decrease in pain, but no improvement in motor abilities

Bravi et al, 2019

Motor Fatigue exercises

Fatiguing handgrip contraction

Improvement in motor performance, finger coordination and movement accuracy

Pesenti et al, 2001

Pharmacologic therapy

Oral anticholinergic medication

Improvement in motor control

Jabush et al, 2004;

Jabush et al, 2005


Improvement in motor control

Jabush et al, 2004

Botulinum toxin injections

Control of muscle spasms

Chen et al, 1998;

Cohen, 1989;

Cole et al, 1994;

Jabush et al, 2005;

Karp et al, 1994;

Lungu et al, 2011;

Ross et al, 2005;

Schuele et al, 2005;

Van Vugt et al, 2014

Botulinum toxin injections + levocarnitine

Beneficial effect in MD

Vecchio et al, 2012

Proprioceptive training

Vibratory stimulation

Enhancing of sensorimotor organization and proprioceptive awareness

Bluter et al, 2018;

Rosenkranz et al, 2008

Sensory re-education and SMR

Exercises of palpating and visualising size, weight and texture of different objects, intensive sensory training or sensory deprivation. Positive reinforcement was provided by verbal, visual, tactile, or auditory feedback

Improvement in sensory discrimination. Promotion of somatosensory reorganization and subsequent motor improvement. Redefining spatial and temporal processing capacities in the sensory and motor cortices
in order to restore task-specific skills

Byl et al, 2000;

Byl et al, 2003,

Byl et al, 2009;

McKenzie et al, 2009;

Zeuener et al, 2005

Surgical treatment

Ventro-oral thalamotomy

Improvement of finger movement

Horisawa et al, 2013

Task-specific motor training + Neuromodulation

Hand activities in the prone, supine, sitting, and standing position.

Promotion of body alignment and prevention of dystonic patterns. Normalising movement patterns

Buttkus et al, 2010;

Byl et al, 2000;

Furuya et al, 2014;

Jabush et al, 2009;

Zeuner et al, 2005


Stimulating electrode over the primary motor cortex.

Support to training, increase rehabilitation effectiveness

Betti et al, 2018;

Buttkus et al, 2010;

Furuya et al, 2014;

Rosset-Llobet et al, 2015

MD: musician’s dystonia; SMR: sensory motor returning; tDCS: repeated transcranial direct current stimulation.


Botulinum injection is the most used therapy in literature [11-20]. Sensory re-education and sensory motor returning [21-25] and the combination of task specific motor training and neuromodulation [21,25-28] were used in five studies. Behaviour treatment [8,29-31], immobilization of fingers with splints in combination with specific finger exercises [25,29,30,32], transcranial direct current stimulation [26,27,33,34] were used in several articles too. Other treatments were less used, such as the constraint-induced therapy in combination with slow-down exercises [1,35,36], oral anticholinergic medication [14,37], proprioceptive training [38,39]. In only one study the following therapies were described: kinesiotaping [40], motor fatigue exercises [41], oral intake of D9-tetrahydrocannabinol [37], surgical treatment [42]. The outcomes of the different types of therapy are resumed in Table I.


Treatment of musicians’ dystonia

Hand dystonia seems to be related to the excessive performance of repetitive activities and has been treated in different ways. Treatment is based on using multiple strategies for the management of the dystonia, with variable results. Although a specific therapy has not been defined, several positive outcomes are shown.

Task-specific motor training and neuromodulation

Task-specific motor training combined with neuromodulation was employed in dystonia in musicians to promote proper body alignment and prevent dystonic patterns during motor performance [26-28,34].

Sensory re-education and sensory motor returning

Significant improvement in motor control, accuracy, sensory discrimination and physical performance was described after specific exercises of sensory re-education and sensory motor returning [21-25,35,43]. Sensory motor returning (SMR) could be used both as only intervention [30,31,36] or in combination with other approaches [1,35]. Candia et al [30] developed a novel treatment intervention, a combination of sensory motor retuning (SMR), behavioural treatment and constraint-induced therapy. By immobilising one or several digits ‘compensating’ for the dystonic movements, the ‘dystonic’ finger was required to carry out repetitive exercises in coordination with the remaining free digits [30]. Even if improvement in motor performance were described, the program was not sufficient to return musicians to professional levels of performance [22].

Behaviour treatment

Candia and his collaborators had a particular interest for the treatment of focal dystonia in musicians [8,29,31]. Since behavioural mechanisms apparently underlie both the cortical disorder and the involuntary incoordination of movement, it was thought to be possible that a behavioural intervention could be of value in reducing or eliminating these conditions [29].

Constraint-induced therapy, slow-down exercise therapy and immobilization

In two studies of Candia et al [29,30] and of Berque [1,35], splints were used to immobilise the wrist and the adjacent fingers to the dystonic one. The finger that trained was not splinted and retraining included combinations of specific finger exercises during playing the instruments [29,30].

Zeuner et al [25] and of Priori et al [32], described their task specific motor training with good outcome for dystonia in musicians. Priori et al [32] concluded that limb immobilisation was a simple, effective and safe treatment for focal dystonia, but the duration of the outcomes were variable.

However, prolonged immobilization could be associated with transient side effects and variable outcomes in writer’s cramp and musician’s dystonia [32,41].

A combination of intensive constraint-induced therapy and specific motor control retraining at slow speed is described as a successful strategy for the treatment of dystonia in musicians [1,35,36], but in this way, it is difficult to establish which aspect of treatment had the more beneficial effect [1].

A 1-year period of this intensive constraint-induced therapy and motor control retraining at slow speed could be a successful strategy with longterm, lasting effects for the treatment of dystonia in musicians [35].

Yoshie et al [44] confirmed the effectiveness of slowdown exercise for the treatment of focal hand dystonia and of behavioural intervention, these treatments could reverse the reorganization of sensorimotor neural networks in dystonic patients [44].

Proprioceptive training

Rosenkranz et al [39,45] tested the effect of vibratory stimulation on the pattern of sensorimotor organization in healthy non-musicians, healthy musicians, patients with musician’s dystonia, and patients with writer’s cramp. The proprioceptive training improved the dystonic pattern [39,45].

Bluter et al [38] described a rehabilitation program that included proprioceptive exercises. This intervention was feasible, with high retention, adherence and acceptability [38].

Repeated transcranial direct current stimulation (tDCS)

tDCS might be a safe and noninvasive tool to assist retraining and might improve retraining effects in pianists [26,27,33]. This technique does not interfere with the neurorehabilitation procedure and can increase therapy effectiveness in rehabilitation patients [34]. The study of Buttkus et al [26] and Furuya et al [27] has a sample very small (only a musician) to obtain significant results.

Comparison between tDCS with and without training revealed that tDCS alone is not effective for improving motor performance in musician’s dystonia [27].


Use of kinesiotape over affected muscles, a passive method for muscle activity normalization, led to significant decrease in pain and somatosensory temporal discrimination threshold in comparison to sham tape in cervical and focal hand dystonia [46]. The study of Pelosin et al [46] did not specify if the participants were musicians, for this reason the study was not included in the review.

According to Bravi et al [40], musicians estimated that correction kinesiotaping was ineffective in improving musical abilities.

Motor fatigue exercises

According to the study of Pesenti et al [41], in dystonic musicians, after a fatiguing handgrip contraction lasting a few of minutes on the affected side, motor performance variably improved for a short time. Although the fatiguing task led to a subjective feeling of clumsiness of the arm and forearm, it improved finger coordination and movement accuracy in the affected fingers [41].

Pharmacologic therapy

Oral anticholinergic medication and Δ9-tetrahydro­canna­binol

The results after anticholinergic medication administration were discouraging, with improvement being reported in only 33% of patients [14].

In the study of Jabusch et al [37], the results provide evidence that after single dose of 5 mg of D9-tetrahydrocannabinol (THC), motor control of the affected hand was significantly improved in a pianist suffering from focal dystonia. After administration of placebo, motor control of the affected hand showed no improvement [37].

Botulinum toxin injections

Uncontrollable muscle spasms can sometimes be controlled with repeated injections of botulinum toxin into the affected muscles to reduce the intensity of the contractions and relieve the discomfort of cramping [13,14,19]. One of the first article on the use of botulinum toxin injection in musicians’dystonia was the study of Cohen et al [12]. It provides preliminary evidence that botulinum toxin is helpful in treating many patients with hand cramps. Several studies [15,16,18] provided the evidence that botulinum toxin offers long-term benefit for some instrumental musicians with playing-provoked, focal limb dystonia [18].

Unfortunately, this type of treatment does not restore normal motor control, and patients often cannot return to previous jobs that require fine motor skills [14]. Improvement in performance was associated with some degree of weakness [12]. After the BT injection, 49% of patients reported an improvement and 57% received more than one injection [14]. Repeated injections are necessary [14].

Proper selection of the muscles to be injected and the use of electromyography are fundamental aspects to be taken into consideration. According to the study of Ross et al [17], the most common patterns of toxin spread were from flexor digitorum sublimis to profundus, extensor carpi radialis to extensor digitorum communis, and extensor indicis proprius to extensor pollicis brevis. Spread to adjacent uninjected muscles was a major factor contributing to suboptimal outcome for the consequent finger weakness [17]. In the study of Chen et al [11], frontalis and abductor digiti minimi were treated with botulinum toxin type F, with good outcomes. In the study of Vecchio et al [20] a guitarist with uncontrolled movement of the right index finger assumed levocarnitine (3 g daily for 3 months) to decrease cramps and botulinum toxin injected into the superficial (20 IU) and deep flexor (20 IU) muscles of the right index finger under electromyographic and ultrasonographic guidance. The contractions diminished 5 days later and the beneficial effect of botulinum toxin lasted for about 8 months [20].

Surgical treatment

According the study of Horisawa et al [42], the ventro-oral thalamotomy improved musician’s dystonia and the effect persisted for a long duration.

Multidisciplinary team and psychological support

After a period of not playing, musicians must return playing with slow graded progression in duration and complexity of movements, often with psychological support.

The multidisciplinary team was proposed by several authors, including the participation a psychotherapeutic approach in many cases [14,34].

Summary of findings and Implication in rehabilitation

The rehabilitation for dystonia in musicians is variable in methodology and quality, intensity and duration. Also, there are no different specific protocols on the basis of the gravity of the disorder. The focus of therapy for mild, moderate and severe dystonia did not differ significantly for clinicians, even because musicians lose their virtuosity during the exhibitions even when the symptomatology is mild. Another non-homogeneous and very variable feature of the therapy is its beginning after the beginning of the disorder.

Musicians are extraordinarily motivated to pursue treatment, and they persevere in their search for an effective therapy. The treatment for dystonia in musicians could be very important to stimulate and promote the improvement of fine movements, to avoid the end of important carers with consequence worsening of quality of life, to sustain the mood of the subjects. The musicians need a complete recovery of the motor performance to recovery the lost virtuosity during their concerts.


A lack of uniformity among the papers (measured parameters and assessment scale) may affect the outcomes of considered articles. The absence of information about some clinical characteristics, that could influence motor performance, represents another limitation, such as comorbidities affecting movements, the use of drugs, psychologic traits such as performance anxiety. Furthermore, in some articles the sample was very small. Several studies did not assess participants educational status, it could be a confounding factor and could influence the results.


Dystonia in musicians is a condition that leads to reduced performance levels and often the end of a musician’s career. So, it is essential found a therapeutic solution. Several treatments, also in combination, could be promising tools with therapeutic potential. This systematic review tries to provide to the reader a comprehensive overview of the literature of all possible different treatments for dystonia in musicians.

Unfortunately the Wilson’s theory [6], according whom are ‘required months of lessons concentrating on rebuilding a ‘healthy’ movement strategy on the instrument before movements began to become normal’, seems optimistic; many musicians have compromised their careers, as reported by Oliver Sacks in Musicophilia [47], such as the virtuosos of the piano Gary Graffmann, who definitively stopped his activity, Leon Fleisher who continued to play with only one hand and who claimed ‘dystonic once, dystonic forever’ [47].

We believe that the development of different options of treatment and rehabilitation in musician’s cramp demonstrate, in some way, that there is no established and certainly effective therapy that restores complete professional functionality to the musician. Anyhow, a correct strategy could permit to improve motor performance and the quality of life of musicians. We would like to have created a guide for choosing a rehabilitation protocol combining more treatments and personalising the rehabilitation intervention.

Further researches in this area are required, such as large-scale, controlled trials to compare the different rehabilitation strategies and find a better protocol for this disorder.



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Rehabilitación de la distonía focal de mano en músicos: una revisión sistemática de los estudios

Introducción. La distonía focal de la mano en los músicos es un trastorno del movimiento relacionado con una tarea específica, que se caracteriza por una pérdida involuntaria del control y la coordinación de los movimientos de los dedos al tocar un instrumento.

Materiales y métodos. Se llevaron a cabo búsquedas bibliográficas con las palabras clave ‘dystonia’ (distonía) Y ‘musician’ (músico) Y finger’ (dedo) O ‘treatment’ (tratamiento) O ‘therapy’ (terapia) O ‘rehabilitation’ (rehabilitación) en PubMed, EMBASE, Cochrane Library y Web of Science para realizar la revisión sistemática sobre las diversas estrategias usadas para tratar la distonía en los músicos. La búsqueda se realizó de forma independiente por dos autores (R.C. y M.V.) entre el 6 de abril de 2020 y el 6 de junio del mismo año. La investigación identificó un total de 423 artículos. Los encargados de la revisión analizaron 77 artículos que fueron previamente seleccionados. Treinta y seis publicaciones cumplieron con los criterios de inclusión y se incluyeron en la revisión sistemática.

Resultados. La revisión sistemática se realizó para identificar los principales tratamientos utilizados para la distonía en músicos. Se definieron las diversas técnicas existentes para orientar mejor a los médicos a la hora de diseñar un protocolo de rehabilitación que adopte las mejores estrategias descritas en la bibliografía actual.

Conclusión. Esta revisión sistemática intenta proporcionar al lector una mirada completa sobre todos los posibles tratamientos diferentes para la distonía en los músicos. Un protocolo correcto podría permitir mejorar el rendimiento motor y la calidad de vida de los músicos.

Palabras clave. Calidad de vida. Dedos. Distonía. Músicos. Rehabilitación. Revisión sistemática.


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