Entire Thesis

Table of Contents
Introduction
Chapter 1: Description of facial musculature utilized in creating the embouchure
Chapter 2: Focal-Task Specific Embouchure Dystonia
Chapter 3: Embouchure Overuse Syndrome
27
Conclusion
30
References
35
Introduction
The strain on the human body caused by rigorous practicing is a common problem amongst
professional performers. This manifests itself in many ways, however this thesis will focus
primarily on embouchure strain in brass players, specifically trombonists. For a time,
playing-related injuries were seldom discussed, mainly because of the stigma that is attached
to it. In some brass playing communities, musicians. As a result, musicians often suffer in
silence rather than seek treatment for their injuries.1
The main problem with ignoring the symptoms of possible injury is the longer the symptoms
are left untreated, the more damage is caused to the embouchure, which means that the injury
could become irreversible. This has caused many promising brass musicians to enter into
premature retirement, at the cost of their careers. This causes a great deal of psychological
and financial stress to many musicians who depend solely on their career as a means of
financial support to themselves and families. This is what lead to the research of two of the
most common embouchure ailments that trombone players in particular suffer from, and how
they can possibly be prevented and treated. The embouchure injuries to be discussed are
Focal Task-Specific Embouchure Dystonia and Embouchure Overuse-Syndrome.
The first chapter of the research essay defines what an embouchure is and how it used in
brass playing. It discusses the anatomy of the embouchure in detail, as well as the physiology
of the facial muscles and how these muscles work together to create the embouchure. The
second chapter deals with Focal Task-Specific Embouchure Dystonia, a mysterious
neurological disorder that is notoriously difficult to diagnose and treat. The chapter will
discuss the process of identifying the cause, symptoms, diagnosis, treatment as well as
possible prevention of the disorder. In the third chapter, the cause, symptoms, treatment and
prevention of Embouchure Overuse Syndrome will be discussed, an injury that affects both
professional trombone players and amateurs alike.
1 Bache, S. & Edenborough, F. December 27 2008. A Symphony of Maladies

British medical journal (BMJ). 337(7684):1458-1460.
Chapter 1: Description of facial

musculature utilized in creating the
embouchure
In order to better understand FTSED and Embouchure Overuse Syndrome, the brass
instrumentalists embouchure should be briefly discussed. According to The MerriamWebster Dictionary, the embouchure is defined as the position and use of the lips, tongue,
and teeth in playing an instrument.2 Another definition of an embouchure is The mode of
applying the lips and mouth to the mouthpiece of a wind instrument as expertly advised and
the mode actually adopted or developed by a player for a particular mouthpiece of a wind
instrument.3 Brass pedagogues have altered the definition of what an embouchure is to
include the lips and the surrounding facial muscles only.
The functions of the tongue and oral cavity have been considered separately from the
embouchure, though they work interdependently with the embouchure during sound
production. A useful source which provides a thorough discussion of both woodwind and
brass embouchures is Grove Music Online. It defines the embouchure generally as the
coupling mechanism, during the playing of an instrument, between the air supply of the
player and the instrument.4 Steven Fruchts description of an embouchure is the set pattern
of perioral (surrounding the mouth) and jaw muscles used to initiate and control the
amplitude and force of airflow into the mouthpiece of a woodwind or brass instrument. 5
2
Merriam-Webster Free Online Dictionary 2013. embouchure. Available:
http://www.merriam-webster.com/dictionary/embouchure [23 April 2013].
3
Porter, M. 1973. The embouchure. London: Boosey & Hawkes.
4
Webster, G.B., Kelly, F. & Voorhees, J. 2013. Embouchure. Available:
http://www.oxfordmusiconline.com/subscriber/article/grove/music/51269.
The facial muscles are like elastic sheets that are stretched in layers over the cranium, facial
bones, the openings they form, and the cartilage, fat, and other tissues of the head. The
muscles of the face are in the classification of voluntary muscles. Voluntary muscles are
defined as muscles which are controlled by the will of the individual.6 The muscles of the
face are made up of delicate muscles fibres, with the breadth of a single muscle fibre
averaging1/400th of an inch (which is 0.00635 centimetres.). Unlike most body muscles, the
facial muscles are joined to each other rather than to a bone.
A brass players embouchure adjustment uses the musculature of the entire lower part of the
face (Figure 1). Dr Peter Iltis and Dr Michael Givens from the Department of Movement
Science at Gordon College state that no fewer than seven pairs of musclesshape the
aperture of the lips.7 These muscles are:
Orbicularis oris
Zygomaticus minor
Zygomaticus major
Levator anguli oris
Depressor anguli oris
Levator labii superioris
5
Frucht, S. & et al 2001. The Natural History of Embouchure Dystonia. Movement disorders.
16(5):899-906.
6
Kleinhammer, E. 1963. The Art of Trombone Playing. Illinois: Summy-Birchard.
7
Givens, M.W. & Iltis, P.W. 2005. EMG Characterization of Embouchure Muscle Activity:
Reliability and Application to Embouchure Dystonia. Medical problems of performing
artists. 20(1):25--34.
Depressor labii inferioris
Mentalis
Buccinator
Fig.1 Scheme of embouchure musculature (lateral view): (M) modiolus; (1) orbicularis oris
(upper lip portion); (2) levator labii sup. alaeque nasi; (3) levator labii superioris; (4)
levator anguli oris; (5) zygomaticus minor; (6) zygomaticus major; (7) buccinator; (8a)
risorius (masseteric strand); (8b) risorius (platysma strand); (9) depressor anguli oris; (10)
5
depressor labii inferioris; (11) mentalis; (12) orbicularis oris (lower lip portion). [online]
http://www.oxfordmusiconline.com/subscriber/article/img/grove/music/F001861 [Accessed
on 23 April 2013]
According to Banschbach, 8 there are three main muscles which play a major role in the
action of the embouchure. These three main muscles are: the orbicularis oris (a heavy
sphincter muscle that surrounds the mouth), the mentalis (a v-shaped muscle in the chin), and
the buccinator (a muscle in the cheeks with four fibrous bands flowing forward into the lip
muscle.) The orbicularis oris is the muscle that firmly closes the mouth. Some of the fibres of
the orbicularis oris reach across the lips from side to side. Other fibres come from the other
facial muscles which join the orbicularis oris, or the lips themselves.
The superficial group of muscles form the embouchure. These superficial muscles are also
known as muscles of facial expression.9 The muscles are attached to the overlying skin, and
their function is to give a conscious or unconscious indication of recognition, as well as
provide signals of what mood a person is in depending on their current situation.10 The
embouchures central muscle is called the orbicularis oris. Some of the muscle fibres of the
orbicularis oris are attached to the bones of the upper and lower jaw and others are attached
to the deep layers of the skin. The graphic demonstration of the orbicularis oris muscle in
action is seen when a person pouts their lips. This function is called a purse-string action.11
The muscles that are used to form and control the shape of the embouchure radiate out from
the orbicularis oris. These muscles are attached from the orbicularis oris to various anchor
points on the bones of the face and jaw. The upper lip is raised by the levator labii supeioris,
a muscle that runs up to the bone under the eye and on the side of the nose. The levator
anguli oris is a small, deep triangular muscle used to raise the corners of the mouth. It is
8
Banschbach, D. 2009. To Your Health- Brass Embouchure: The Glory and the Pain.
International musician. 107(4):18-19.
9
Watson, A.H.D. 2009. The Biology of Music Performance and Performance-Related Injury.
Maryland, Toronto, Plymouth: The Scarecrow Press.
10
Ibid., 198.
11
Ibid.
pulled upward and backward by muscles that run from the zygomatic arch of the cheek,
othwewise known as the zygomaticus major and minor. A comparable set of muscles act on
the lower lip. These all run from the lower jaw and they can depress the lip (depressor lalii
inferioris and mentalis) or the corner of the mouth (depressor anguli oris). The modiolis is
the region at the corner of the mouth where the levator and depressor anguli oris and the
zygomatic muscles all merge with the orbicularis oris. The risorius is small muscle which
contributes to the embouchure by pulling the corner of the mouth backward, in addition to the
other muscles. It is also known as the smiling muscle. Two additional muscle which aid the
risorius are the buccinator and by the platysma. The platysma is described as a thin, flat sheet
of muscle. It runs beneath the skin of the neck, to which it is attached.12 The upper fibres of
the platysma pass over the lower edge of the jaw-line. These muscle fibres are joined with the
muscles that contribute to the embouchure.The function of the mentalis is to push the lower
lip up against the upper lip. The buccinator is a sheet of muscle that forms the inner wall of
the cheek and extends forward to the opening of the mouth, where it contributes to the
embouchure. It is located deep into the temporalis and masseter muscles that attaches to one
end to the bone above the upper teeth, and at the other end of the outer surface of the lower
jaw below the teeth roots.
The name buccinator is derived from a Latin word for a trumpeter.13 It has four fibrous bands
that are arranged in the lip muscle in the following manner: the top band is in the upper lip
and the lower band is in the lower lip; the middle bands crisscross at the corner of the mouth
so that the lower most band passes into the upper lip, and the upper most band passes into the
lower lip. At the back, it merges with the outer muscle layer of the pharynx so that the
muscular wall of the throat is continuous all the way to the lips. This ensures that the airways
can resists the high pressures generated in the playing of many wind instruments, namely the
trombone. The basic structure of the embouchure musculature could be illustrated in the
following way: if you drew an oval for the mouth and put a V at the bottom, then drew four
lines leading into the ends of the oval with the middle lines criss-crossing, this would be the
12
Ibid., 199
13
basic structure of the embouchure musculature. One could physically feel the position of the
embouchure formation by firmly pronouncing the letter m. When saying the m, the teeth
are separated and the lower jaw is brought down and out so that the front teeth are opposed to
each other.14
In brass players, these muscles perform complicated movements that are analogous to the
complex motor tasks of the hands in pianists and string instrumentalists. Muscles of the
embouchure, however, are only one part of the complex task of tone production on a brass
instrument, a process succinctly summarized as follows: Several factors are involved in
producing a tone on a brass instrument: air quantity, speed and direction (which are affected
by the back of the tongue, the angle of the instrument as it is held to the mouth, mouthpiece
placement and teeth alignment); the push-pull of the muscles surrounding the centre of the
lips; the harmony of the facial mask; the efficiency of the lips as they meet naturally; the
structure of the teeth, the ability to achieve correct intonation without lipping notes into
tune; and a concept of sound focusing on pitch centre, fullness and intensity, and sheer
beauty of tone. 15
The role of the embouchure varies depending on the instrument being played, but in all cases
its shape must be precisely regulated using not only the orbicularis oris, but also the other
muscles that surround it. For brass players, the basic pursing of the lips is also achieved by
the orbicularis oris. Brass players tend to generate extreme intraoral pressures in the upper
registers. The tension in the orbicularis oris will determine the frequency at which the lips
vibrate to generate the sound. This action involves not just contraction of the fibres of the
orbicularis oris itself, but of the muscles radiating out from it. In order to gain the degree of
control over the embouchure needed to allow precise control over pitch in all registers, the
muscles that contribute to it must be strengthened over time and be kept in good physical
condition by constant training to maintain good performance standards. For brass players, the
14
Fink, R.H. 1977. The trombonist's handbook : a complete guide to playing and teaching the
trombone. Athens: Accura Music.
15
precise shape of the embouchure depends not only on register but also on the instrument, as
mouthpieces vary greatly in size and shape.
Chapter 2: Focal Task-Specific

Embouchure Dystonia
Focal Task-Specific Embouchure Dystonia, also commonly known as FTSED, is a
neurologically-based movement disorder that affects one or more muscles of the face in wind
musicians, particularly brass players.16 The term for dystonia is derived from the Greek dys,
meaning abnormal and tonia, which describes a normal muscular contraction.17 Focal TaskSpecific Embouchure Dystonia is characterized by abnormal random or sustained involuntary
muscle contractions which are initiated during playing and can cause embouchure
dysfunction. 18 In 1911, Hermann Oppenheim created the term dystonia. In his original
definition of dystonia, he described it as a state in which muscle tone is hypertonic at one
occasion and in tonic muscle spasm in another, usually but not exclusively elicited upon
16
Givens, M.W. & Iltis, P.W. 2005. EMG Characterization of Embouchure Muscle Activity: Reliability and
Application to Embouchure Dystonia. Medical problems of performing artists. 20(1):25--34.
17
Thomas, D. 2010. Embouchure Dystonia and the Overuse Syndrome: A Primer for
Musicians. D.M.A. Austin: University of Texas.
18
Fletcher, S.D. 2008. The Effect of Focal Task-Specific Upon Brass Musicians: A Literature Review and Case
Study. Doctor of Musical Arts. University of North Carolina.
10
volitional movements.19 In his observation of the disorder, Oppenheim placed emphasis on

noticing the chronic muscle cramps that seemed to occur without the presence of provoking
movements. After having made his initial observation, Oppenheims view of dystonia was
replaced by an emphasis on the disfigured and sustained postures that took place. This
seemed to characterize the condition of dystonia. 20 The understanding of dystonia and the
disorders related to it has expanded and advanced in a significant way since the early
definitions of the disorder were made.
Focal dystonias tend to affect an isolated part of the body and task-specific dystonias occur
only when a specific muscle is engaged in a certain action. Focal task-specific dystonia can
occur with any part of the body that engages in a controlled, repetitive motion. For brass
players, the embouchure is most susceptible to the neurological disorder. In fact, focal taskspecific embouchure dystonia is one of the most devastating occupational disorders that
affect wind musicians today. Steven Frucht, a neurologist from the Columbian Presbyterian
Medical Centre and co-founder of Musicians with Dystonia, conducted a study on the effects
of Focal Task-Specific Embouchure Dystonia upon musicians, and found that only two of
twenty six patients diagnosed with Embouchure Dystonia were able to continue their fulltime performance schedule.21 In this same study, it was discovered that once Embouchure
Dystonia was diagnosed, the symptoms did not improve. A separate study was conducted by
Richard Lederman of the Medical Centre for Performing Artists at the Cleveland Clinic
Foundation. In this study, it suggested that Focal Task-Specific Embouchure Dystonia is one
of the rarest and least-studied disorders that affected musicians today. 22 Glen Dalrymple, a
19
Calne, D.B., Fahn, S., C. & Marsden, D. 1987. Classification and Investigation of Dystonia. In Movement
Disorders 2. S.C. Fahn & D. Marsden, Eds. 2nd ed. London: Butterworth and Co. 332.
20
Ibid., 333.
21
22
Lederman, R.J. 2001. Embouchure Problems in Brass Instrumentalists. Medical Problems of performing artists.
16(2):53-57.
11
retired physician and horn player stated that that only 1% of musicians with medical
problems are diagnosed with FTSED. This reflects on the rarity of the disorder. 23
In wind players, the role of the embouchure is very important in the tone production of the
instrument. It requires the precise coordination of no fewer than seven pairs of muscles which
have been previously mentioned.24 Embouchure dystonia has been described in all varieties of
wind instrumentalists, but brass players are most susceptible the disorder.25 Focal taskSpecific Embouchure Dystonia is characterized by tremor or spasm of one or more of the
facial muscles. The instability of the muscles causes the vibrating interface of the lips to
malfunction. This leads to an uncontrolled tone production. Dr Seth D. Fletcher, a senior
lecturer of music at the University of Nebraska, provides examples of Focal Task-Specific
Embouchure Dystonia among brass musicians. These include a horn player who is unable to
sustain a note due to a rapidly shaking embouchure, and a tubists jaw clamping shut
uncontrollably when attempting to play octave leaps.26
Focal task-specific embouchure dystonia is a rather misunderstood debilitating occupational
disorder, and because of this there is no consistently effective method of treating embouchure
dystonia that has been identified to date. However, attempts have been made to treat the
disorder with botulinum toxin (otherwise known as BOTOX), embouchure retraining
23
Dalrymple,G. & Estrin, G. 2004. Medical problems and Horn Playing: Some Embouchure Problems of Horn
Players- Overuse Injury and Focal Embouchure Dystonia. The Horn Call. 34(2):53.
24
Givens, M.W. & Iltis, P.W. 2005. EMG Characterization of Embouchure Muscle Activity: Reliability and
Application to Embouchure Dystonia. Medical problems of performing artists. 20(1):25--34.
25
Ibid., 25.
26
Fletcher, S.D. 2008. The Effect of Focal Task-Specific Embouchure Dystonia Upon Brass
Musicians: A Literature Review and Case Study. Doctor of Musical Arts. University of North
Carolina.
12
programs, and various medications. The disadvantage of utilizing these forms of treatment is
that they are only effective for a short period of time. Unfortunately, Focal Task-Specific
Embouchure Dystonia is often a career-ending disorder, as there is no known cure and
medical research and insight into the nature of the disorder is limited.
Focal Task-Specific Embouchure Dystonia is a disorder that is both unknown and often
misunderstood among brass performers, pedagogues and students, despite the potential
severity of it. Neurological disorders such as FTSED are not often a common area of research
and as a result of this deficiency of research in the medical community, many musicians who
are struggling with the unexplained embouchure dysfunctions of this disorder are often left
with no cure. Many brass musicians have been misdiagnosed, and therefore any treatment
that they may have received in the past proved to be unsuccessful.27 Dr Frucht described one
of his patients being diagnosed with FTSED as having been evaluated by as many as 30
other individuals before learning the true nature of his affliction.28 . If the knowledge of
FTSED among brass instrumentalists and general practitioners could increase, it would
decrease the possibility of misdiagnoses of this nature. It is this kind of information that gives
impetus to research further into this topic.
Focal Task-Specific Embouchure Dystonia is classified as a neurological disorder. A
neurological disorder is defined as a disorder that affects the central nervous system.29 This
includes the brain, spinal cord and nerves that go throughout your body. By definition, the
central nervous system is the control unit of the human body, and it is responsible for
regulating conscious and unconscious bodily functions, and the swift transmission of
27
Ibid.
28
Frucht, S, & et al. 2001. The Natural History of Embouchure Dystonia. Movement Disorders. 16(5):900.
29
The Free Dictionary 2013. neurological disorder. Available:
http://www.thefreedictionary.com/neurological+disorder [18 August 2013].
13
information. The nervous system consists of three main parts: the central nervous system
(CNS), the peripheral nervous system (PNS), and the autonomic nervous system (ANS).30
The central nervous system is comprised of the brain and the spinal cord. Its primary function
is to produce the appropriate reactions to sensory signals of the brain. The central nervous
system is comprised of the brain and the spinal cord. Its primary function is to generate
appropriate reactions to the sensory signals, from inside or outside the body. The peripheral
nervous system includes the entire nervous system outside of the brain as well as the spinal
cord. This includes the 12 pairs of cranial nerves and 31 pairs of spinal nerves that link the
central nervous system with the rest of the body. The autonomic nervous system is located in
both the central nervous system and the peripheral nervous system. The autonomic nervous
system is responsible for the involuntary or automatic functions of the body.31
The central nervous system consists of four main building blocks that form it. These
building blocks comprise of neurons, blood vessels, glia (nervous system cells that support
and protect neurons) and sensory organs. Nerve cells, or neurons, are the most important
component of the nervous system because they transmit essential information in the form of
electric impulses. There are two main types of neurons that exist. These are sensory neurons
and motor neurons. The sensory neurons link to form ascending pathways and motor neurons
link to form descending pathways. A neuron is made up of a main cell body that contains the
nucleus. It has the dendrites which surround the cell body and are responsible for passing
received impulses to the cell body. It also consists of an axon which sends impulses on to
other cells.32 The nervous system consists of blood vessels which supply the necessary
nutrients to its cells and remove wastes from it as well. Glial cells act as a glue that
30
Carolina
31
Ibid., 10.
32
Blakemore, C. & Jennett, S. Eds. 2001. The Oxford Companion to the Body. 1st ed. Oxford:
Oxford Univerisity Press.
14
connects and protects, and they are the most numerous cells in the nervous system. In the
final process, the sensory organs and free nerve endings in the skin have receptors that
transmit ascending information to the central nervous system.33 How can this information be
analyzed during into brass performance is not yet known, as a full neurological investigation
in this specific process has not yet been undertaken, although attempts to understand this
process through electromyography have been made.
According to Scott Theirl, a board certified chiropractic neurologist at the Functional
Restoration Clinic in New York City34, muscle movement is a four-step process. Firstly, a
person decides what they want to move. Secondly, a person decides how the specific
movement should be made. Thirdly, the movement is initiated, and finally, the person senses
the movement of the specific area that took place.35 The discussion of the central nervous
system previously mentioned provides the bare essentials of human biology, yet it assists in
providing more information on the central nervous system since FTSED is defined by
medical professionals as a neurological disorder. Although it is not expected for brass players
and pedagogues to fully comprehend this area of research, since as medical professionals and
scientists find it too daunting a task for them as well, a basic knowledge of neurology may
benefit brass instrumentalists not only in recognizing and managing FTSED, but also in
general performance practices and brass pedagogy as well.
Dystonia is classified into two main groups. The classification of these two groups is based
on the cause of the dystonia. The first group is known as the idiopathic dystonias. It is
comprised of dystonia that is the primary condition of the patient. In the case of idiopathic
dystonia, the disorder causes the patients symptoms. The second group is called
33
Ibid.
34
Theirl, S. 2013. Functional Neurology. Available:
http://www.yourbestbrain.com/ [28 August 2013].
35
Carolina
15
symptomatic dystonia. The symptoms of dystonia in this group occur as a result of another
condition, which means that the dystonia is caused by an outside factor. A third category of
psychological etiology was also included in this classification for the greater portion of the
twentieth century. Despite an extensive amount of research which disproved the notion of a
psychological element to dystonia, evidence shows that as late as the 1990s, some
psychologists have considered some forms of dystonia to be psychosomatic in nature.36 The
word psychosomatic means mind (psyche) and body (soma). A psychosomatic disorder is a
disease which involves both mind and body. The symptoms of some physical diseases are
thought to be exacerbated by mental factors which include stress and anxiety. The current
mental state of an individual can affect how severe a physical disease can be at any given
time.37
The term distribution of dystonic movements refers to how much and what parts of the
body are affected by the condition. The distribution of dystonia is discussed in the following
terms which are: focal, segmental, multifocal, generalized, and hemidystonic. Focal refers
to a single part or area of the body that is affected with dystonia. Other common types of
focal dystonia include blepharospasm, which affects the eyelids, torticollis, which affects the
neck and some occupational cramps.38 Focal Task-Specific Hand Dystonia is another
common focal dystonia that affects musicians such as pianists, guitarists, string players and
wind instrumentalists.
Segmental dystonia affects two or more body parts that are adjoined and multifocal dystonia
affects two or more parts of the body which arent interconnected. Generalized dystonia
36
Calne, D.B., Fahn, S.C. & Marsden, D.C. 1988. Concept and Classification of Dystonia. Advances in
Neurology. 51(10):457-537.
37
Kenny, T. 2011. Psychosomatic disorders. Available: http://www.patient.co.uk/health/PsychosomaticDisorders.htm [22 August 2013].
38
Calne, D.B., Fahn, S.C. & Marsden, D.C. 1988. Concept and Classification of Dystonia. Advances in
Neurology. 51(10):457-537.
16
affects either one or both legs as well as another specific region of the body. Hemidystonia is
the dystonia which affects an entire half of the body. 39
From these methods of dystonia classification, one can derive a clear definition of what
FTSED is. The word focal refers to a specific area of the body that is affected by the
disorder. In this particular case, it refers to the embouchure. The term task-specific refers to
the characteristic nature of the dystonic movements, which are present only when a specific
task is executed. The embouchure is defined as the coupling mechanism, during the
playing of an instrument, between the air supply of the player and the instrument.40 And
finally, dystonia is a neurologically based movement disorder that causes involuntary
muscle contractions characterized by twisting and repetitive movements.
Focal Task-Specific Embouchure Dystonia affects the nervous system by disrupting its ability
to allow the brain and the muscles to communicate. The body undergoes a complex process
in order to control muscle movements and this complicated process involves many areas in
the brain. The area of the brain that is believed to be most affected by dystonia is called the
basal ganglia. According to the Dystonia Medical Research Foundation, the basal ganglia are
a deep region of the brain that monitors the speed of movement and controls unwanted
movements.41 The primary function of the basal ganglia is to send signals to the muscles. It
instructs the muscles when to move and when to stop moving. Focal Task-Specific
Embouchure Dystonia causes a disruption in the basal ganglias function of instructing the
39
Ibid., 40.
40
41
Dystonia Medical Research Foundation 2010. Frequently Asked Questions: Symptoms.
Available: http://www.dystonia-foundation.org/pages/faq_symptoms/101.php [8 October
2013].
17
muscles to move. As a result, unwanted muscle movements and contractions occur, which is
characteristic of embouchure dystonia.42
Researchers have discovered that there is a sensory component linked to the symptoms of
focal dystonia affecting musicians. The brain sends irregular messages to the muscles, and in
response to this, the affected muscles send chaotic messages back to the brain. As a result, the
nervous system is disrupted by a self-continuing cycle of abnormal communication.43 This
newly-discovered information has provided a new perspective to treating the disorder by
suggesting that the brain and muscles could be retrained to communicate through physical
therapy. Rehabilitation therapy is a relatively new yet active area of research that is likely to
develop over time. As research into this form of treatment continues, the new findings could
provide direction for new therapies which may assist in effectively treating Focal TaskSpecific Embouchure Dystonia.44
Symptoms of Focal Task-Specific Embouchure Dystonia
The initial signs of Focal Task-Specific Embouchure Dystonia are understated and
completely unnoticed. In some cases, the symptoms of FTSED are similar to those found
when a brass musician is either fatigued or under-practiced.45 These symptoms include:
unclear articulation, poor tone quality in an isolated register

difficulty with lip slurs
42
2013].
43
Ibid.
44
Ibid.
45
Frucht, S. & et al 2001. The Natural History of Embouchure Dystonia. Movement
disorders. 16(5):899-906.
18
Air leaks on the corners of the mouth, which become worse in the higher register,
accompanied by muscle tremor.

Involuntary, abnormal contractions of the muscles in the face which leads to unsteady
and uncontrolled tone production. The muscle most affected by embouchure dystonia
is the buccinator muscle. The dystonia of this muscle produces an involuntary
muscular contraction called a lateral pull which is easy to identify.46

Involuntary puckering and excessive elevation of the corners of the mouth.
Involuntary closing of the mouth.
With FTSED, these first signs are often limited to one range or specific style of playing. 47
The mysterious nature of the initial symptoms of FTSED can lead the afflicted brass musician
to experience feelings of self-doubt, intense frustration and depression. Certain symptoms can
however serve as signs and warnings that embouchure dystonia may in fact be the cause. A
greater awareness of Focal Task-Specific Embouchure Dystonia is necessary so that the
symptoms can be identified as soon as possible, and proper diagnosis and treatment can be
given.48
According to Steven Frucht, the symptoms of embouchure dystonia can be divided into three
main categories. These are: embouchure tremor, involuntary lip movements and involuntary
jaw movement. The categories were derived from the observation of symptoms done by
Frucht after the condition had been present in the patient for an extended period of time.
Some of the symptoms mentioned of FTSED will now be explained in detail. As it has been
previously mentioned, the initial symptoms are usually described as an unexplainable
difficulty in performing. Initial reports of other patients include loss of embouchure control,
lip fatigue, lip tremor and involuntary facial movements. Although most patients attest to
experiencing physical discomfort during playing, Focal Task-Specific Embouchure Dystonia
46
Ibid.
47
Ibid., 899
48
Fletcher, S.D. 2008. The Effect of Focal Task-Specific Embouchure Dystonia Upon Brass Musicians: A
Literature Review and Case Study. Doctor of Musical Arts. University of North Carolina
19
does not give any painful warning sign.49 In the case of FTSED, the symptoms are
experienced only when a musician performs. However, it is possible for symptoms to spread
beyond the embouchure-related dystonia. Frucht conducted a study in which 27% of patients
who suffered from Focal Task-Specific Embouchure Dystonia experienced a spread of the
dystonia from the embouchure to other oral tasks. There is no known clinical explanation
behind the isolation and spread of these symptoms. 50
Embouchure tremor can be described as a trembling of the lips and various embouchure
muscles, which results in a wobble in the brass instrumentalists sound. The tremor usually
begins at the start of sound production, however it may occur at random during performance.
In some instances of Focal Task-Specific Embouchure Dystonia, the initial production of
sound is good and the muscle tremor increases the longer a note is sustained. The vibrations
are very rapid and immediately noticeable. In most cases of FTSED, both lips are involved in
the tremor. While involuntary lip movements and involuntary jaw closure tend to affect
specific instrumentalists, embouchure tremor affects all types of brass players.51
Involuntary lip movements can be described as either a lateral pull or a closure of the lips,
which is also known as lip lock.52 A lateral pull is defined as an uncontrollable, rapid
movement away from the embouchure shape that is noticeable at the onset of the sound or
shortly afterwards. Lateral pull affects either one or both lips and/or one or both corners of
the mouth. At the moment of tone production, a sealing of the lips takes place which causes
the airflow to obstruct because of uncontrollable lip closure. This results in an increased
effort to force air through the lips that produces a lack of clarity and delayed articulation in
the onset of a note. Lateral pull has been identified as an ailment that is prone to affect
49
Dystonia Medical Research Foundation 2010. Frequently Asked Questions: Symptoms. Available:
http://www.dystonia-foundation.org/pages/faq_symptoms/101.php [8 October 2013].
50
Frucht, S. & et al 2001. The Natural History of Embouchure Dystonia. Movement disorders. 16(5):901
51
Ibid.
52
Ibid.
20
trumpet and horn players, while lip lock is most often detected in trombone and tuba
players.53
The final category of symptoms, which is involuntary jaw movement, is more likely to spread
to other activities than the types of symptoms. Like embouchure tremor, involuntary jaw
movement isnt instrument-specific. Involuntary jaw closure usually happens at the initial
onset of sound production and it produces rapid variations in pitch which are extremely
recognizable.54
There are a few other observations that have been made concerning the symptoms of Focal
Task-Specific Embouchure Dystonia. The majority of cases reported of FTSED occurred
predominantly in patients aged between 35 and 45 years old. Another observation of the
disorder is that the symptoms often begin in a specific register of the instrument. The
symptoms often begin as an initial problem with articulation, for example the individual may
find difficulty in playing staccato notes. Once the initial onset of symptoms has begun, the
disorder develops and advances to various stages of severity. 55
Causes of Focal Task-Specific Embouchure Dystonia
There are several possible causes of Focal Task-Specific Embouchure Dystonia that exist.
These include genes, brain lesions, injury and trauma and behavioral causes.56 An increasing
amount of current research suggests that the disorder develops as a result of a disorder in the
brains sensory feedback system due to overuse, which is called the somatosensory cortex. 57
Described as use-dependent cortical reorganization, the premise is that the motor cortex is
53
Ibid.
54
Ibid.,9013
55
Ibid.,903
56
Hallet,M.2013.TheNeurophysiologyofDystonia.Available:http://archneur.jamanetwork.com/article.aspx?
articleid=773761[27August2013].
21
rewired due to over-stimulation from the senses. 58 To gain a clearer understanding of the
sensory overload that may play a role in triggering FTSED, a description of the basic
neurology behind motor and sensory function relating to brass performance is essential.
Neurons are the basic functional units of the brain. They are specialized cells that transmit
information to muscle, gland or other nerve cells. The human brain contains between one
billion and one trillion neurons, which enable and facilitate all functions of the brain. 59 The
process of neural communication is created by the transmission of electrical impulses that
create connections with other cells. The neuron is comprised of three parts, namely the cell
body, axon and dendrites. The cell body contains the nucleus, the axon sends electrical
signals, and the dendrites receive signals from other neurons. The point in which the axon of
one neuron connects to the dendrite of another is called a synapse.60 A neural pathway is a
chain of synapses. The more times a neural pathway has been travelled and the more attention
focused on the path, the stronger the pathway becomes, similar to a dirt path that has been
worn in a field of grass. The concentrated and repetitive practice required in instrumentalists
assists in creating strong synapses and pathways from the motor cortex, the area of the brain
57
Altenmller, E., Bradshaw, J., L. & Lim, V., K. 2001. Focal Dystonia: Current
Theories. Human movement science. 20(6):889.
58
Begley, S. & Schwartz, J., M. 2002. The Mind and the Brain: Neuroplasty
and the Power of Mental Force. New York: ReganBooks.
59
The Society for Neuroscience. 2002. Brain Facts: A Primer on the Brain
and Nervous System. Washington D.C: Society of Neuroscience.
60
Ibid.,5.
22
which controls movement, to the specific muscles utilized in playing.61 A potential cause of
Focal Task-Specific Dystonia in musicians is a dysfunction of these pathways.62
The daily schedule of a professional musician often requires of them to practice or perform
on their instruments for several hours a day. It happens that these hours of practice become a
vehicle for overuse, and as a result, intense focus on the sensory input causes the impulses in
the sensory pathway to become unstable and overactive, which can become problematic.63
Signals from the sensory input can interfere and fuse with motor cortex output, this causes
uncontrollable involuntary movements, or in this case, Focal Task Specific Embouchure
Dystonia.
Diagnosis of Focal Task-Specific Embouchure Dystonia

The very nature of the disorder is elusive, which makes obtaining a correct diagnosis difficult
for musicians suffering from FTSED. Although any physician is qualified to diagnose
dystonia, it is recommended and preferred to seek such an opinion from a neurologist. As a
common medical practice, a physician who suspects dystonia will typically refer a patient to
the appropriate specialist. Because of the difficulty of diagnosing dystonia in musicians,
several opinions are required before a sufficient diagnosis is given. The diagnosis of Focal
61
Begley, S. & Schwartz, J., M. 2002. The Mind and the Brain: Neuroplasty
and the Power of Mental Force. New York: ReganBooks. (106-110)
62
Byl, N.N. & et al. 1997. A Primate Model for Studying Focal Dystonia and
Repetitive Strain Injury: Effects on the Primary Somatorysensory Cortex.
Physical therapy. 77(3):269-284.
63
Fletcher, S.D. 2008. The Effect of Focal Task-Specific Upon Brass Musicians: A Literature
Review and Case Study. Doctor of Musical Arts. University of North Carolina.
23
Task-Specific Embouchure Dystonia consists of a three-stage process. In the first stage, the
recognition of abnormal movements associated with dystonia takes place. The second stage
involves the classification of these movements according to age of onset and location, which
is then followed by determining the patients history with the problem. In the third and last
stage, a thorough investigation is undertaken into the cause of the dystonia.64
The normal process of diagnosing embouchure dystonia involves examining the patients
symptoms while performing the task in question, which in the case of the musician would be
playing the instrument. The diagnosis of focal dystonia in musicians is particularly difficult,
in comparison to other forms of dystonia. There are several reasons for this, such as the
subjectivity of early symptoms and the different ways in which the disorder manifests with
regard to the instrument being played.65
Treatment of Focal Task-Specific Embouchure Dystonia

Currently, there is no known cure that exists for FTSED, or any other form of dystonia.
Treatment for embouchure dystonia is used to rather alleviate the symptoms associated with
the disorder. There has been no medical treatment found to be universally successful for
FTSED. To date, all medical treatments have yielded only minimal success. 66 Traditional and
64
Calne, D.B., Fahn, S., C. & Marsden, D., C. Eds. 1988. Advances in Neurology: Dystonia 2.
2nd ed. New York: Raven Press.
65
Wilson, F.R. 2000. Current controversies on the Origin, Diagnosis and Management of Focal
Dystonia. In Medical Problems of the Intsrumentalist Musician. P.C. Amadio & R. Tubiana,
Eds. London: Martin Dunitz. 313.
66
Adler, C., H. 2000. Strategies for Controlling Dystonia: Overview of
Therapies that may Alleviate Symptoms. Postgraduate medicine.
108(5):151-160.
24
non-traditional methods have been used to treat FTSED. The traditional methods include:
botulinum toxin injections (otherwise known as BOTOX), trihexyphenidyl administered
orally, psychotherapy, chiropractic treatment, prolonged rest, physical therapy and surgery.
Non-traditional treatments include biofeedback, acupuncture, herbal therapy, massage
therapy, dental prosthetics, constraint induced movement therapy, aquatic therapy and dietary
changes.67 The most effective treatment for embouchure dystonia is a re-training of the
embouchure, also known as muscle re-training therapy. Each of these therapies will be
discussed in more detail.
BotulinumtoxinisthemostcommonmedicaltreatmentforFTSED.Accordingtothe
NationalSpasmodicDysphoniaAssociation,botulinumtoxin(BTX)isderivedfromthe
bacteriumClostridiumbotulinum.Itisanerveblockerthatbindstothenervesthatleadto
themuscleandweakenstheoveractivemusclesinvolved.Itpreventsthereleaseof
acetylcholine,whichisaneurotransmitterthatactivatesmusclecontractions.68Ifthemessage
isblocked,musclespasmsaresignificantlyreducedoreliminated.69Itishoweverimportant
formusiciansreceivingtreatmentforFTSEDtoreturnforinjectionsevery2to3months,as
thetreatmentissymptomatic.70Asmallamountisinjecteddirectlyintothespecificareaof
muscleswhichexhibitdystonicmovementsandweakensthem.Althoughbotulinumtoxinis
prescribedwiththeintentionofrelievingthesymptomsofFTSED,ithasnoabilitytocure
67
Altenmller, E., Bradshaw, J. & Lim, V. December 2001. Focal Dystonia:
Current Theories. Human movement science. 20(6):897-900.
68
National Spasmodic Dysphonia Association 2013. Botulinum Toxin.
Available: http://www.dysphonia.org/botulinum-toxin.php [3 October
2013].
69
Denton, T. 9 July 2010. Embouchure Dystonia Research. Available:
http://www.dentonlt.com/dystonia.
25
thedisorder.AccordingtoastudyconductedbyStevenFrucht,onlyoneoutofsevenpatients
withFTSEDshowedsignificantimprovementwithbotulinumtoxininjections.71Thegeneral
unsuccessfulnessofthistreatmentislargelyduetothedifficultyinachievingtheproperlevel
ofdosage.Althoughinsufficientdosageisanissue,administeringtoomuchbotulinumtoxin
cancauseadverseeffectssuchashighlyimpairedmusclefunction,amistakethatisoften
madewhentreatingFTSEDthroughadministeringtheseinjections.
TrihexyphenidylisanorallyadministeredmedicationwhichisusedtotreatParkinsons
diseaseandmuscletremorssuchasFTSED.72Itimprovesmusclecontrolandreduces
stiffnessofthemusclesofthebody.73Trihexyphenidyl,otherwiseknownasArtane,has
showntobeeffectiveintreatingchildonsetsegmentaldystoniawhenadministeredwithin5
yearsofonset.Despitethis,ithasproventobeineffectiveintreatingotherdystonias,suchas
FTSED.74AlthoughitisoneofthemostpromisingoraltreatmentsforFTSED,manypatients
arentabletocontinuewiththemedicationforalongperiodoftime.Thisisduetotheside
70
Altenmller, E. 2010. Review - Focal Dystonia in Musicians: Phenomenology,
Pathophysiology, Triggering Factors, and Treatment. Medical problems of performing artists.
25(1):3-9.
71
16(5):899-906.
72
MedlinePlus 2013. Trihexyphenidyl. Available:
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682160.html [6 October 2013].
73
Mayo Foundation for Medical Education and Research 2013. Trihexyphenidyl (Oral Route).
Available: http://www.mayoclinic.com/health/drug-information/DR602899 [6 October 2013].
26
effectsthatthemedicationproduces,suchasfatigue,drymouthandslightmemory
impairment,evenwithlowdosagesof46milligramsaday.75
Twononmedicalapproachestotreatmentwhichhaveproventobeeffectivearethe
AlexanderTechniqueandtheFeldenkraismethod.WilliamandBarbaraConableprovidean
accuratedefinitionoftheAlexanderTechniqueintheirbook,HowtoLearntheAlexander
Technique:AManuelforStudents.TheAlexanderTechniqueisapracticalmethodfor
improvingeaseofmovement,balance,support,flexibilityandcoordination.Itsaimisto
heightenkinestheticsensitivityandimprovespecificactionsoruseofaparticularbodypart
throughimprovingusofthewholebody.76TheFeldenkraismethodisaimedatimproving
selfimage,learningandmovementthroughapracticalandphilosophicalapproach.Itsmain
goalsaretargetedtowardsmental,physicalandoverallhumanimprovement.77
DavidVining,aProfessoroftromboneattheNorthernArizonaUniversitySchoolofMusic,
documentshisrecoveryfromEmbouchureDystoniainhiswebsitewww.davidvining.net.78
Viningskeytothesuccessofhisrecoverywasthediscoverythatinordertoretrainthe
74
Balash, Y. & Giladi, N. 2004. Efficacy of Pharmacological Treatment of Dystonia: EvidenceBased Review Including Meta-Analysis of the Effect of Botulinum Toxic and Other Cure
Options. European journal of neurology. 11(6):365.
75
Altenmller, E., Bradshaw, J. & Lim, V. December 2001. Focal Dystonia: Curent
Theories. Human movement science. 20(6):897-900.
76
Conable, W. & Conable, B. 1995. How to Learn the Alexander Technique: A Manuel for
Students. Columbus, Ohio: Andover Press.
77
Feldenkrais, M. 1977. Awareness through Movement: Health Exercises for Personal Growth.
1st ed. San Francisco: HarperSanFrancisco.
27
embouchure,onemuststartwithanunderstandingthatyouplaytrombonewiththeentire
body,notjusttheembouchure.ThisiswhatinspiredhimtotrytheAlexanderTechnique,
whichledhimtoatechniquecalledBodyMapping.By definition, Body mapping is "a
somatic (mind-body) discipline based on the scientific fact that the brain contains neural
maps of bodily functions and structures that govern our body usage."79
Aftermuchresearchandtrialanderrorashedescribesit,Viningwasabletofinda
concoctionofnonmedicaltherapiesthatassistedtowardshisrecovery.Theseareobviously
speciallydesignedforhim,aseverycaseofFTSEDdifferent.Inadditiontoresearching
varioustherapies,ViningalsosoughtprofessionaladvicefromAdjunctprofessorof
tromboneattheUniversityofNorthTexasandbrasspedagogueJanKagarice.Kagarice has
experience in treating many musicians who have suffered from Focal Task-Specific
Embouchure Dystonia, having struggled with a neuromuscular disease herself. She currently
serves as the chair of the International Trombone Associations Committee on Focal Task
Specific Dystonia.80 Here is a list of 7 retraining strategies that Vining formed himself. These
include:
1. Alexander Technique lessons
2. Feldenkrais lessons
3. Body Mapping
4. Working with brass pedagogue and FTSED specialist Jan Kagarice was beneficial for him,
as she has a wealth of knowledge in Embouchure Dystonia. She provided assistance in
78
Vining, D. 2010. My Recovery from Embouchure Dystonia. Available:
http://www.davidvining.net/narrative.html [7 October 2013].
79
Dinn, M. 2008. Body mapping. Canadian Music Educator. 50(1):9.
80
Berglof, K. 2012. Living With Embouchure Dystonia: list of practitioners.
Available: http://embouchuredystonia.blogspot.com/2012/08/list-ofpractictioners.html [23 October 2013].
28
cultivating healthy breath support and better understanding of what chemical processes take
place in the brain.81
5. Learning about neuroplasticity and applying some of these concepts to his own retraining
regimen (which involved playing a lot of air trombone)
6. Cultivating a new way of playing
7. Reinforcing all of these concepts many times on my own before attempting them in front
of others.82
81
82
Ibid.
29
Chapter 3: Embouchure Overuse

Syndrome
Embouchure Overuse Syndrome is a classified overuse and repetitive strain (RSI) syndrome
that affects both wind players as a result of practicing ones instrument for many more hours
than normal. Embouchure Overuse Syndrome can also be triggered by practicing with a
greater intensity than one is normally accustomed to. This often happens when a wind player
practices repertoire that requires a higher level of technical facility, dexterity and endurance
than what they are used to.83 84 Poor technique and an inconsistent practice regime are risk
factors which contribute to lip injuries such as Embouchure Overuse Syndrome.85
In order to blow a wind instrument, a conscious amount of effort is used to keep the mouth
open when creating space to produce the embouchure, no matter how small the space is. After
an extended period of time, this action starts to work against the stimulus that comes from the
central nervous system, which is trying to close it. Since the muscles which are trying to keep
the mouth open are weaker than the muscles which are trying to close it, they become more
and more fatigued and the mouth slowly closes. This could also describe the term that
musicians use as normal tiring of the embouchure muscles. Where pain occurs in the lips it
requires still more effort to keep the mouth open, however slightly, so that rapid tiring
occurs. In addition to this, the mouthpiece also causes blood flow to the lip muscles to be
restricted.
83
84
Lewis, L. 2006. Embouchure Overuse Syndrome in Brass Players. Available:
http://www.polyphonic.org/article/embouchure-overuse-syndrome-in-brass-players/ [17
October 2013].
85
Thomas (2010).
30
Symptoms of Embouchure Overuse Syndrome

The symptoms of Embouchure Overuse Syndrome are similar to those of muscular fatigue.
These shared symptoms include tightness, swelling and bruising in the muscle, as well as
pain and redness in the affected area which is sensitive to touch and use. Embouchure
Overuse Syndrome also causes the embouchure to become stuck in a painful, injured state
which can cripple its ability to function normally once it has been affected by the ailment.
86
Overuse affects the tone on the brass instrument, which causes an airy or unresonant
sound. Embouchure Overuse Syndrome affects the range, flexibility and endurance on the
instrument by limiting it due to pain and discomfort of the embouchure. If left untreated,
chronic Embouchure Overuse, otherwise known as repetitive stress could eventually lead to
the disability of the muscles and joints that are involved in creating and maintaining the
embouchure.87
Treatment for Embouchure Overuse Syndrome

Unlike Focal Task-Specific Embouchure Dystonia, Embouchure Overuse Syndrome is 100%
reversible and treatment of the ailment is effective once embouchure dysfunction has been
identified. Rest is considered to be the first and best treatment option for overuse, and the
time period of rest needed depends on the severity of the injury, as every individual case is
different. According to an ICSOM survey in which over 2000 professional players
participated, rest proved effective for 84% of the injured musicians who were willing to take
a break from playing.88 According to Dr Richard Norris book titled Musicians Survival
Manual, rest does not necessarily mean completely putting away the instrument. It is
86
Lewis, L. October 2007. To Your Health-Embouchure Overuse Syndrome: What Every Wind
Player Should Know. International Musician. 105(10):15.
87
Carlbrese, L. & Lederman, R.J. 1986. Overuse Syndrome in Musicians. Medical Problems of
Performing Artists. 1(1):7-11.
31
recommended that an injured musician combines periods of rest with mental practice sessions
that are interspersed throughout the practice day.89
Sports medicine recommends Rest, Ice, Compress and Elevation for injured muscle fibres
(RICE). The first three forms of treatment apply to the embouchure. An effective way of
reducing swelling and bruising caused by Embouchure Overuse Syndrome is to place a cold
ice pack on the lips. This causes the blood vessels to contract, which reduces the
inflammation. Later use of a warm compress on the lips helps to stimulate blood flow in the
muscle fibres, as muscle fibres need a fresh flow of blood to invigorate them. Once an injury
has been diagnosed and treated, post-treatment retraining and rehabilitation must be sought
after by the injured brass musician. This is a process that shouldnt be ignored, as physical
therapy and a review of proper instrumental technique is essential in avoiding another injury.
A sample program described by Dr Norris for instrumentalists recovering from Embouchure
Overuse Syndrome includes practice sessions that are approximately 50 minutes in length
followed by at least 10 minutes of rest.90
Prevention of Embouchure Overuse Syndrome

Dr Richard Norris suggests in his book that proper rest and thorough planning of practice
time are the best methods of prevention. A proper warm-up is essential, which aids in
building your lip muscles up towards strenuous materials and practice sessions. It is strongly
advised not to ignore fatigue or pain, and dont attempt to play through it, as some
uninformed musicians in the brass community are told to do. Any sudden, lengthy increase in
88
Ellis, A., Fishbein, M., Middlestat, S., Ottati, V. & Straus, S. 1988. Medical Problems Among
ICSOM Musicians: Overview of a National Survey. Medical problems of performing artists.
3(1):1-8.
89
Norris, R.N. 1993. The Musician's Survival Manual: A Guide to Preventing and Treating
Injuries in Instrumentalists. 1st ed. San Antonio: International Conference of Symphony and
Opera Musicians.
90
Ibid.
32
playing or intensity should always be followed by a day or two off or very careful, physically
paced playing until the embouchure has recovered.
Conclusion
Grove Music Online defines the embouchure as the coupling mechanism, during the playing
of a wind instrument, between the air supply of the player and the instrument.91 The
embouchure is formed by muscles of the superficial group. The superficial muscles are
known as muscles of facial expression. They are attached to the overlying skin, and we use
them to give conscious or unconscious indications of recognition and of mood or to provide
signals that reveal how we feel about what is going on around us. Doctors Peter Iltis and
Michael Givens state that there are no fewer than seven facial muscles that form the
embouchure. 92 These muscles are the orbicularis oris, zygomaticus minor, zygomaticus
major, levator anguli oris, depressor anguli oris, levator labii superioris and depressor labii
inferioris, mentalis and buccinator. The three core muscles that are used to form the action of
the embouchure are the orbicularis oris, mentalis and the buccinator.93
91
Webster, G.B., Kelly, F. & Voorhees, J.
2013. Embouchure. Available: http://www.oxfordmusiconline.com/subscriber/article/grove/m
usic/51269.
92
Reliability and Application to Embouchure Dystonia. Medical problems of performing
artists. 20(1):25--34.
93
33
The orbicularis oris is the central muscle of the embouchure. Some of the muscle fibres of
the orbicularis oris are attached to the bones of the upper and lower jaw and others are
attached to the deep layers of the skin.94 The buccinator is a sheet of muscle that forms the
inner wall of the cheek. This muscle extends forward to the opening of the mouth, where it
contributes to the embouchure. It is located deep into the temporalis and masseter muscles
that attaches to one end to the bone above the upper teeth, and at the other end of the outer
surface of the lower jaw below the teeth roots. The buccinator has four fibrous bands that are
arranged in the lip muscle in the following manner: the top band is in the upper lip and the
lower band is in the lower lip; the middle bands crisscross at the corner of the mouth so that
the lower most band passes into the upper lip, and the upper most band passes into the lower
lip. At the back, it merges with the outer muscle layer of the pharynx so that the muscular
wall of the throat is continuous all the way to the lips. This ensures that the airways can
resists the high pressures generated in the playing of many wind instruments, namely the
trombone.
The function of the mentalis is to push the lower lip up against the upper lip. The upper lip
does not push downward, as there is no musculature that acts in this manner. The buccinator
is a sheet of muscle that forms the inner wall of the cheek and extends forward to the opening
of the mouth, where it contributes to the embouchure. It is located deep into the temporalis
and masseter muscles that attaches to one end to the bone above the upper teeth, and at the
other end of the outer surface of the lower jaw below the teeth roots.
Focal Task-Specific Embouchure Dystonia, otherwise known as FTSED, is a neurological
movement disorder that affects the facial muscles, which are utilized in the production of
brass instrument sound. The condition causes abnormal involuntary movements which occur
during playing, inhibiting the performance ability of the musician to a great extent. The exact
cause of FTSED is still unknown. Since FTSED is classified as a neurological disorder, the
most likely theory is that the brain develops a dysfunctional response which is the result of
distorted or damaged sensory-motor integration. This is also known as maladaptive
neuroplasticity.
94
34
A proper diagnosis of FTSED is usually obtained from either a neurologist who has
knowledge of the disorder or a medical professional that is accustomed to treating various
ailments that often plague musicians. The diagnosis of FTSED is determined from a
combination of a physical examination, neurological examination, and observations that are
made while playing. Treatments of FTSED include botulinum toxin injections, otherwise
known as BOTOX, oral medication trihexyphenidyl (Artane ) and muscle-training therapies
such as the Alexander Technique and Feldenkrais method. Although these forms of treatment
provide short term relief to the musician suffering from FTSED, there is no known cure for
the ailment. A combination of non-medical therapies has proven effective in treating Focal
Task-Specific Embouchure Dystonia, an approach which has produced successful results for
musicians such as trombonist David Vining.95
Not enough information on Embouchure Dystonia is known simply because not enough
research has been dedicated to the study of this particular illness, and how a possible cure can
be derived from these studies. In order for FTSED to be treated and prevented, thorough
clinical studies should be undertaken to test theories based on treatment and prevention of the
disorder. This will require the improvement of accuracy regarding the diagnosis of FTSED,
development and testing of effective treatment programs, and facilitating the necessary
rehabilitation programs which will increase awareness among performers and teachers
involved in brass pedagogy.
According to research, the most effective form of treatment for FTSED is embouchure retraining programs. However, there is little information available on these treatment programs,
apart from the individual success stories of musicians such as trombonist David Vining.
Several studies have reported that FTSED is a disorder that affects the musician intellectually,
physically and emotionally.96 It is therefore recommended that the treatment of FTSED be
95
96
Berglof, K. 2012. Living With Embouchure Dystonia: list of practitioners. Available:
http://embouchuredystonia.blogspot.com/2012/08/list-of-practictioners.html [23 October
2013].
35
approached holistically by integrating therapy aimed at targeting all these areas with a
pedagogically-based re-training of the embouchure.97
There are two methods which have proven to be of great assistance to brass musicians
suffering from Focal Task-Specific Embouchure Dystonia. They are the Alexander Technique
and the Feldenkrais method. The Alexander Technique can be briefly described as a practical
method for improving ease of movement, balance, support, flexibility and coordination. Its
aim is to heighten kinesthetic sensitivity and improve specific actions or use of a particular
body part through improving us of the whole body.98 The Feldenkrais method is aimed at
improving self-image, learning and movement through a practical and philosophical
approach. Its main goals are targeted towards mental, physical and overall human
improvement.99 Both methods of therapy encourage awareness of body relaxation, proper
airflow and physical well-being; factors that are important and conducive to the rehabilitation
of Focal Task-Specific Embouchure Dystonia.
Embouchure Overuse Syndrome arises when a musician ignores pain and fatigue while
practicing. It is also caused by practicing with a greater intensity than one is normally
accustomed to, especially when the repertoire is of a higher technical virtuosity than the
musician is used to. Rest is the first solution for treatment, which can be accompanied by
mental practice of repertoire as well as reading in order maximize the use of period of
recovery. Placing an ice cold pack on the lips helps to reduce swelling and bruising that is
caused by Embouchure Overuse Syndrome. It causes the blood vessels to contract, which
reduces inflammation. Once swelling and bruising has subsided, a warm compress is placed
on the lips to invigorate the muscle fibres by sending a fresh flow of blood to them.
97
Kagarice, J. 2004. A Pedagogical Approach to the Issue of Focal Task-Specific Dystonia of
the Embouchure. Available: http;//www.ita-web.org/files/committees.cfm; [23 October 2013].
98
99
36
The best methods of preventing injury to the embouchure during playing are proper rest in
between practice sessions, and systematic planning of practice time. A proper warm-up is
essential in building your lip muscles up towards strenuous materials and practice sessions,
and it is advised not to ignore any pain or fatigue during playing.100 A review of correct
trombone playing technique by a professional musician or qualified teacher can assist in
preventing injury during playing.
The main objective of this thesis is to increase awareness and knowledge of embouchure
disorders and injuries among the brass and medical community. It is important to increase
knowledge in the severity of these disorders and how they can be treated and possibly
prevented. This can assist in establishing clinical research which could lead to the
development of successful rehabilitation programs and forms of treatment that are essential in
reducing the negative effects of embouchure ailments such as Focal Task-Specific
Embouchure Dystonia and Embouchure Overuse Syndrome on brass musicians, more
specifically trombone players. The topic of playing-related injuries should form an important
part of brass pedagogy. An effective way of incorporating awareness of playing-related
injuries in the music community is to include the study of embouchure maladies in the
syllabus of music education programs. These important steps in raising awareness could
result in the prevention, treatment and possible eradication of playing-related injuries.
100
Injuries in Instrumentalists. 1st ed. San Antonio: International Conference of Symphony and
Opera Musicians.
37
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Table of Contents

Chapter 1: Description of facial musculature utilized in creating the embouchure

Chapter 2: Focal-Task Specific Embouchure Dystonia

Chapter 3: Embouchure Overuse Syndrome

1 Bache, S. & Edenborough, F. December 27 2008. A Symphony of Maladies

Chapter 1: Description of facial

Levator anguli oris

Depressor anguli oris

Levator labii superioris

Depressor labii inferioris

Chapter 2: Focal Task-Specific

volitional movements.19 In his observation of the disorder, Oppenheim placed emphasis on

unclear articulation, poor tone quality in an isolated register

accompanied by muscle tremor.

muscular contraction called a lateral pull which is easy to identify.46

Diagnosis of Focal Task-Specific Embouchure Dystonia

Treatment of Focal Task-Specific Embouchure Dystonia

Chapter 3: Embouchure Overuse

Symptoms of Embouchure Overuse Syndrome

Treatment for Embouchure Overuse Syndrome

Prevention of Embouchure Overuse Syndrome

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