Timings:

Weikai:
Shauno:
Cherry: 3:15
Apurva: 3:01
Bradley: 3:24
Embouchure dystonia
1. What is it and how does it manifest? Wei Kai
2. Who are affected & what effects does it have on the patient? Shauno
3. How does the brain change? Cherry
4. Treatment options? Effectiveness? Apurva
5. Conclusion - Bradley

What is embouchure and how does it manifest?

a task-specific, focal dystonia that affects lower facial, jaw and
tongue muscle
manifestations: embouchure tremor, involuntary lip movements,
jaw closure, upper lip tightness and pulling, lips fatigue
generally, theres no symptoms at rest
leakage of air around the corners of the mouth piece = loss of air
seal
sensory symptoms and pain very rare
Different classification of symptoms e.g. Frucht: tremor of lips,
lateral pulling of lips, isolated involuntary movement of the jaw; Satoh et al:
masticatory, facial, lingual

the term embouchure refers to the mouthpiece of a woodwind or brass instrument, or the way in
which the mouth is applied to the instrument to produce a sound.
dystonia just refers to a disorder that causes involuntary contraction in the muscles. Just like
focal dystonia in piano and guitarists, embouchure dystonia strictly affects woodwind and brass
instrumentalists.
in general, embouchure dystonia is a unusual neurological disorder that affects motor control of
the facial muscles in woodwind and brass musicians it affects them not only physically but also
psychologically.Just as guitarists spend a lot of hours in building and perfecting their technique
in their hands, woodwind and brass players spend these hours in training their mouth muscles
to perform complex motor tasks.
So how do we know this exists? measures have been taken to ensure that this disorder is not
just something that was invented to compensate for lack of technique; evidence shows
noticeable changes in the brain activity when embouchure dystonia is present than when it is
not present; Cherry will further elaborate on this.
embouchure dystonia is very task-specific, what that means that the involuntary contractions of
the muscles will only trigger DURING practice or performing, there are no notable spasms
outside of playing.

so what happens with embouchure dystonia and how does it manifest?

so lets briefly discuss how one actually produces a sound so we can have a better
understanding of how the symptoms affect these musicians. lets take brass players for an
example. brass player's position both upper and lower lips inside the ring of the mouthpiece,
their lips will vibrate as the air passes through them. how they control the frequency or the pitch
of the note is due adjusting the tension and the size of their lip opening. In the higher register,
the mouth opening becomes smaller and the vibration in the lips become more rapid.
how this dystonia manifests is with embouchure tremors / upper lip tightness / jaw closure, lip
fatigue and loss of air seal. (elaborate on each of the symptoms).
according to a study done by Frucht (neurologist at the Columbia presbyterian medical centre
and the co-founder of Musicians with Dystonia). 26 subjects were clincally tested and
diagnosed with embouchure dystonia and only 2 were able to continue their professional
performance schedule.

What psychological effects does it have on the patient?

Altenmller, Eckart; Jabusch, Hans-Christian Focal hand dystonia
in musicians: phenomenology, etiology, and psychological trigger factors
http://search.proquest.com.ezproxy.auckland.ac.nz/docview/10411
63967?accountid=8424
Medical and Scientific Issues Embouchure Dystonia: Hope for the
Future?
http://search.proquest.com.ezproxy.auckland.ac.nz/docview/87860
6637?accountid=8424
When focal dystonia strikes musicians, careers end ; Dystonia, a
perplexing neurological affliction, is the third-most- common movement disorder
in the United States, behind Parkinson's disease and essential tremor.: [METRO
Edition] (Website Article)
http://search.proquest.com.ezproxy.auckland.ac.nz/docview/42785
2041?accountid=8424&OpenUrlRefId=info:xri/sid:primo
Image of Alison Young
http://www.alisonflute.com/
Image of Depression
http://gunnercooke.com/when-is-depression-termed-as-adisability/
embouchure dystonia may have a significant psychological
component
Anxiety disorders, social phobias, specific phobias occur more
often in musicians with dystonia.
musicians with Focal Dystonia - highly perfectionist tendencies
Harsh self-criticism
Anxiety - amplifies symptoms

 Depression
Strong link between Psychological and Physical symptoms patients may be able to reduce dystonic spasms by varying sensory input to
areas of the body near the site of the abnormality - finding ways to control the
emotions, and to reduce anxiety, fear, and perfectionism.
fear of not being able to be in control, the anticipation of making
errors, or the fear of losing the esteem of students or colleagues - set-up for
failure, negating all the positive outcomes experienced in practice.
Psychological Symptoms Speech
Psychological Symptoms - Career Ending - Example
(Shauno Isomura)
[Slide 1]
(As weikai mentioned, Embouchure dystonia has many kind of symptoms that is able to
be visually observed. However not only can embouchure dystonia cause physical
disabilities such as clamping, it could also greatly affect the mental health of a
musician.This is the Psychological symptoms of embouchure dystonia).
(As weikai mentioned, Embouchure dystonia has many kind of symptoms that is able to
be visually observed. However not only can embouchure dystonia cause physical
disabilities such as clamping, it can also cause psychological symptoms).

These could include Anxiety disorder, Social Phobia, Fear, Depression, and exaggerated
perfectionism. As opposed to the physical symptoms, few psychological conditions can
be pre-existent to the musician. Based on an investigation conducted by Eckart
Altenmuller and Hans-Christian Jabusch, out of 20 professional musicians diagnosed
with dystonia, 19 out of 20 musicians reported that they had some kind of psychological
condition before the onset of dystonia, however, clinical observations also suggest that
physical symptoms of dystonia could greatly amplify the psychological conditions of a
musician.
I think that there is a strong link between performing music and the human emotions
which is causing a loop between the psychological and physical causes. Psychological
symptoms such as perfectionism tendencies may cause over practice which may trigger
Physical symptoms such as Cramps and Tremors. On the other side, Physical
symptoms could trigger psychological symptoms such as Depression and Anxiety.
These psychological and physical symptoms of embouchure dystonia may cause a
devastating impact in the lives of being a musician. This may ultimately lead to ending
ones career - including losing a position in an orchestra or a band, losing the ability to
perform as a soloist, recording artist, chamber musician, accompanist, everything that
involves playing your instrument. Meaning the musician will lose almost everything they
have been building throughout their life as a musician.
[Next Slide]

Alison Young who was a professional flautist, recording artist, and a principle flautist in
the Houston Ballet Orchestra, she was affected by embouchure dystonia during a
orchestral rehearsal, she lifted her flute to her lips and suddenly she could not place her
fingers properly, In this case she showed a physical symptom in her flute playing. Her
dystonia got worse over time in addition to her over practice which possibly could come
from her perfectionism tendencies triggered from worries and fear of her dystonic
movements. Things got even worse and she ultimately had to quite her 20 year career
and lose her job in the orchestra where she played for through the past 13 years. This i
believe illustrates the devastating effect of Embouchure Dystonia put on a musician, she
had fallen in a loop where physical symptoms had triggered psychological symptoms
and psychological symptoms triggered physical symptoms. She says in an interview "I
didn't think I would want to have anything to do with classical music. The heartbreak was
too extreme. It was like the baby had died and I didn't want to be around children
anymore,"
[Next Speaker]
3:12

How does the brain change?

Haslinger, B. MD; Altenmller, E. MD; Castrop, F. MD; Zimmer, C.
MD; Dresel, C. MD: Sensorimotor overactivity as a pathophysiologic trait of
embouchure dystonia
during dystonia provoking oro-facial motor task i.e. instrument
playing, there was increased sensorimotor activation within the oro-facial
representations on fMRI
areas include premotor, primary motor, primary and secondary
somatosensory cortices
during neutral tasks (blowing into a tube), even though patients
appear asymptomatic, there was also increased activation in the cortical areas
mentioned above (although to a lesser extent)
suggesting that this is an intrinsic abnormality predisposing
underlying cause can be due to basal ganglia
hyperactivity/impaired sensory gating
(three cases of FD) sensorimotor overactivity can be due to 1)
reduced subcortical or intracortical inhibition 2) _______ 3) alteration in
sensorimotor integration
(structural, functional and molecular imaging)
in addition to sensorimotor cortex, also found abnormalities in
basal ganglia, thalamus and cerebellum
voxel based morphometry of T1 weighted MRI - allows for the
comparison of the amount of gray and white matter between two regions in the
brain - a bilateral increase in putaminal grey matter was found in patients with
musicians dystonia (which includes embouchure dystonia and focal hand
dystonia) and patients with orofacial dystonia - this is a consistent finding
amongst different forms of focal dystonia - cause or consequence?

 Hirata et al., 2004: on MEG (megnatoencephalography), altered

lip and digit representation on the somatosensory cortex and a decreased
cortical distance between hand and lip representations were found
Rosenkranz et al., 2005: Overuse and prolonged training in
professional brass and woodwind players may cause a redcued lateral inhibition
in somatosensory receptive fields, causing a net reduction of cuclidian distance
between adjacent neuronal networks -> less precise sensory-motor integration ->
may result in overshoot in motor activations of the lip and facial muscles
(sensory mapping of lip representation) synchronous stimulation
of hand and mouth in monkeys produces overlap of the representation of the chin
and cheek -> altering hand and mouth relationship in somatosensory cortex,
favoring dystonic development
patients showed decreased gap selection sensitivity in the upper
lips - upper lip of a brass player plays a major role in vibration and production of
rich sounds, while the lower lip only supports the upper lip. it is also quite
common for musicians playing a high register to position the lower jaw slightly
behind the upper jaw. this technique possibly results in their upper lips being
highly susceptible to intense mouthpiece pressure and compression
increase in sensory threshold (reduced sensitivity) of the upper lip
in patients
How does the brain change? I roughly divided my findings into changes in the activity and the
structures of the brain. In the study conducted by Haslinger et al, functional MRI was used to
compare the sensorimotor activation in brass players with embouchure dystonia and healthy
brass players. They asked all the subjects to buzz into a mouthpiece and while they were doing
so, they observed greater brain activity in subjects with embouchure dystonia on the MRI The
overactive areas are in yellow, which include the premotor, primary motor, temporal, primary
and secondary somatosensory cortices. What I found interesting was that they went on to ask
the subjects to blow into a tube and they called this a neutral task that is not dystonia-specific.
Logically, this task should not trigger the dystonic symptoms, and it didnt. However, the brass
players with embouchure dystonia had a very similar pattern of hyperactivity in the brain areas
that I mentioned before (red). What does this finding imply? The research group postulated that
this hyper-activation is an intrinsic trait that predisposes individuals to the development of
embouchure dystonia, and I presume that this could be true for other types of primary focal
dystonia.
Moving onto the structural abnormalities in the brain. It was discovered that there was a reduced
distance between the hand and lip representations in the motor and somatosensory cortices. In
the focal dystonia lecture earlier we learnt that there is a shorter distance between finger
representations in pianists and guitarists, which is consistent with this finding. The study also
found an increase in the putaminal gray matter volume, which is present in many different types
of focal dystonia. However, they havent been able to explain if this was a cause or
consequence of the dystonia. A similar increase in the gray matter volume was also seen in the
thalamus and cerebellum (but the link to embouchure dystonia is a bit less clear.)

This is a flautist with embouchure dystonia. She noted that just by putting her mouth next to the
flute would trigger serious muscle spasms not only in the embouchure but also in her tongue,
neck, sometimes even in her arms, legs and hands. This is a rather extreme case but it
illustrates a very important point that I mentioned earlier: embouchure dystonia could very well
be due to an intrinsic trait, which may explain why this lady is experiencing symptoms of
dystonia in various parts of her body at the same time.
(Such a predisposition is clinically supported by a small incidence of dystonia in other body parts like task-induced
FHD in some patients with ED.2)

3:15

Treatment options? Effectiveness?

Masayuki Satoh, Motoshi Narita, Hidekazu Tomimoto: Three
Cases of Focal Embouchure Dystonia: Classifications and Successful Therapy
Using a Dental Splint - dental splint that covered the two molars of the bilateral
upper and lower jaw; effectiveness dependent on the type of embouchure
dystonia (e.g. masticatory, facial or lingual - effective for masticatory)
anticholinergics
botulinum toxin injection
Fruct et al, 2001: Out of 26 patients, 6 tried acupuncture (no
effect), 2 tried herbal therapy (no effect), 1 tried chiropractic treatment (no effect),
10 tried massage (out of which only 1 derived mild benefit), 5 tried dental
prosthetics (no success), 7 underwent botulinum toxin injections (functionally
significant improvement in only one case - injections into the masseter, medial
pterygoids and temporalis alleviated jaw closure; injection of orbicularis oris,
mentalis, zygomaticus group, or depressor angularis ori produced unacceptable
weakness or minimal functional benefit)
Most effective treatment was embouchure retraining (mildly
effective for lateral lip movement but ineffective for lip tremor)
Sensory tricks: simple touches or stimulations near the area of
abnormal movement that can decrease the dystonia
Case study: Role for mindfulness: control of anxiety, fear and
perfectionism (area of more research?)
Mindfulness training can help develop superior self-regulation,
especially emotional regulation. Mindfulness is the present-moment and nonjudgemental acceptance of ones experience. Individuals trained in mindfulness
are more easily able to let go of negative emotional events.
http://www.specialistpainphysio.com/category/focal-dystonia/
Stand alone, mindfulness practice can change our interface with the world.
Combined with specific sensorimotor training and the creation of new habits, the
potency is magnified mindfulness can be used at all stages of dystonia, acute
through chronic.

 Musicians with focal dystonia display more anxiety and higher

levels of perfectionism

Embouchure dystonia is evidently an incredibly debilitating condition but, unfortunately, sufferers

have limited treatment options. For embouchure dystonia some of the same treatments that we
learned about when talking about focal dystonia have also been used, such as botilinum toxin,
anticholinergic drugs and retraining. In a study by Fruct et al in 2001, they looked at 26 patients
who suffered from embouchure dystonia and the various treatments they had tried. 6 tried
acupuncture, 2 tried herbal therapies, 1 tried chiropractic treatment, 10 tried massage, 5 tried
dental prosthetics and 7 tried botulinum toxins. Most of these treatments had limited or no
success, and some even caused additional problems.
Another study looked at three patients with embouchure dystonia and tried to treat all three with
dental splints on the last two molars. This treatment completely removed the symptoms
experienced in one of the patients but had little effect on the other two. The authors of this study
suggested that this may have been due to the different types of embouchure dystonia
experienced. They categorised each condition into masticatory, facial and lingual embouchure
dystonia. The patient who benefited from the splinting had a masticatory dystonia, suggesting
that treatment may be highly individualised.
Sensory tricks are another option that has been tried, which involves simple touches or
stimulations near the area of abnormal movement that can decrease the dystonia. Using mirrors
to provide visual feedback and focussing attention on non-dystonic muscles can also benefit
some patients over a period of time.
In order to effectively prevent embouchure dystonia it would be useful to know about what
causes this condition. Unfortunately, not much is yet known about this. A few studies have
suggested the involvement of genetic or personality factors, but for prevention, it is helpful to
focus on the things that can be changed for musicians. One of these factors is a greater
awareness of their playing style. In a study by Hirata et al in 2004, brass players showed
reduced gap detection sensitivity in the upper lip compared to the lower lip. This is because the
upper lip plays a greater part in sound production than the lower lip. This decreased sensitivity
could be the cause of brain changes seen in embouchure dystonia, as this asymmetry is not
seen in healthy musicians. However, brass players often make this worse by positioning the
lower jaw slightly behind the upper jaw when playing in a higher register, which leads to
increased susceptibility to mouthpiece pressure and compression. By becoming aware of this,
and making efforts to change their technique, brass players may be able to combat embouchure
dystonia. Alternatively, as we previously mentioned, musicians with focal dystonia display higher
levels of anxiety and perfectionism. It is possible then that mindfulness can not only be used as
a treatment but also as a preventive measure for the development of embouchure dystonia.
3:01

 patients showed decreased gap selection sensitivity in the upper

lips - upper lip of a brass player plays a major role in vibration and production of
rich sounds, while the lower lip only supports the upper lip. it is also quite
common for musicians playing a high register to position the lower jaw slightly
behind the upper jaw. this technique possibly results in their upper lips being
highly susceptible to intense mouthpiece pressure and compression
increase in sensory threshold (reduced sensitivity) of the upper lip
in patients

Conclusion

Possibly some brief information about preventive measures?

Bradley
Mindfulness
One treatment for such psychological conditions that is becoming popular is Mindfulness.
Mindfulness is the present-moment and non-judgemental acceptance of ones experience
(including emotions, thoughts and sensations). There have been numerous studies that show
that training (such as mindfulness meditation, body awareness and yoga) can reduce stress,
anxiety and depression and promote relaxation, all things that lead to a greater quality of life.
The ability to better control ones emotions makes it easier to respond to negative emotional
events. When confronted with such an event, rather than worrying about every detail that lead to
and will follow the event, those with mindfulness training are more easily able to let it go.
Sufferers of Dystonia display more anxiety, fear, and higher levels of perfectionism and as we
found out in some of our previous lectures, our emotions can affect our body. Perhaps the high
levels of these psychological conditions that are present in dystonia sufferers is negatively
affecting their physical recovery
Chronic pain specialist Richmond Stace, believes that mindfulness can be beneficial for
sufferers of Dystonia Stand alone, mindfulness practice can change our interface with the
world. Combined with specific sensorimotor training and the creation of new habits, the potency
is magnified mindfulness can be used at all stages of dystonia, acute through chronic.
Who is this information relevant to and why?
For health professionals: the ability to empathise with the situation of the musician who could be
facing the end of their performing career. Taking a thorough history in order to suggest treatment
options that will need to be individualised to suit the problems and needs of the patient.
For educators: the need to have an awareness of the preventative measures for embouchure
dystonia, which in most cases is just being able to catch the symptoms at an early stage to
prevent further harm. The skill to understand the challenges of the student at each stage of their

technical development and teach correct and safe technique that prevents unnecessary, often
harmful movements. Maybe the most important part is instilling in their students the knowledge
that conditions such as embouchure dystonia exist and fostering an environment where the
student feels safe to let the teacher know of any problems that they are having.
For students: Many musicians are both ambitious and perfectionists and will sacrifice other
aspects of their life to accomplish these sometimes impossible self-imposed tasks. Ironically, by
neglecting these other aspects, such as physical health (exercise and diet) and mental health
(stress and anxiety management) they are not functioning at their full potential. Letting
themselves show vulnerability when something is wrong and seeking help immediately when a
problem arises.
No one becomes a musician for the money, people become musicians because music is the
only way they feel they can truly communicate with the world. Its a horrible situation when
something like Embouchure Dystonia comes along and threatens to take away the one thing
that allows someone to fully express themselves. Treating embouchure dystonia is evidently a
nuanced and individualised process, and one that requires much time and patience from the
sufferer. Further research of both physiological and psychological treatments is required so that
we may move closer to achieving a high rate of recovery.
3:24

How common is embouchure dystonia?

How many people does this disorder affect? how common is it?
only about 1% of musicians are affected with medical problems are affected by this disorder
(Glenn Dalrymple and Glen Estrin, Medical Problems and Horn Playing: Some embouchure
problems of Horn Players).
Retraining

------------------------------------------(i)
Define the topic and/or key issues you are talking about. Provide one definition for the
key issue and suggest other definitions that have been used. State reasons for your
choice.
Briefly define focal dystonia
What are the treatment options for focal dystonia?
-Botulinum toxin
-Anticholinergic drugs
-Sensory therapy
-Physio
-Mindfulness
How do they compare?
-Side effects
-Different effects for different instruments - focus on piano and guitar (justify?)
How can we objectively assess the effectiveness of treatments for focal dystonia?
Why did we choose this topic? Why is objectivity important?
We initially tried to find studies that looked at brain imaging before and after retraining to look at
plasticity changes in the brain, but we were not able to find any of them. However, we did find
some methods of objectively assessing treatment outcomes such as....
-Arm dystonia disability scale
- Scale Quality Evaluation
- Dystonic Hand Identification Evaluation (DHIE)
-EMG
-MRI

-Subjective evaluation (e.g. questionnaire) - this may be most important because it is the
patients experience of the condition
-Combination of existing techniques - standardised method? Needs more research
Maybe suggest a way of objectively comparing treatment options - measuring dystonia?
Using references (10-15)
Use a case study, piece of research or real world experience you have read about or have
experience of, that illustrates the problem or issue or some aspect of it
Comment on the relevance of this topic to the population you have chosen or different
populations of musicians
Highlight the relevance of your topic for health professional educators as well as
performers
15 minute breakdown:
2 minutes: quick recap of relevant lecture content (dystonia and treatments)
http://www.specialistpainphysio.com/category/focal-dystonia/ Mindfulness and focal dystonia