Medical treatment of Michael Houstoun - Dr Dale Speedy.
Michael first presented to me for assessment and treatment in early 2001. This involved a full history of his problems (see Michael’s own account of this) and physical examination. The examination focussed on a full neurological exam, especially looking for any signs of neurological disease or nerve entrapments, and a detailed musculoskeletal examination of the upper limb and neck. In particular, myofascial trigger points were looked for and documented.
Initial examination revealed an obvious extensor lag of the right middle finger. The only demonstrable weakness on testing the intrinsic muscles of the right hand and forearm was slight weakness of finger abduction (spreading of the fingers). Isolated tendon function was normal. Neurological examination of the upper limbs revealed the dystonic movements of the middle and ring fingers (as described by Michael) but was otherwise normal. There were multiple trigger points in the forearm muscles that extend the fingers.
Investigations included nerve conduction studies and electromyography of the upper limb to exclude nerve entrapments (these tests were normal), and an MRI scan of the hand (normal).
A “roundtable” of health professionals was convened to assess and treat Michael, including Simon Loudon physiotherapist, Glenn Williams osteopath, Dr Jonathan Kuttner musculoskeletal medicine physician, myself (sports physician) and further on in the treatment Rae de Lisle pianist and senior lecturer in piano performance at Auckland University.
A diagnosis of focal dystonia was made on the basis of the history, examination, and normal tests.
The understanding of focal dystonia in the medical literature was sketchy at best, and with a poor prognosis described. The best way to conceive of focal dystonia is to think of the areas in the brain that control adjacent fingers becoming “over-developed” to the point that they overlap and the signals get “smudged” between fingers. This results in the unwanted movements and postures of focal dystonia.
The aims of Michael’s treatment were two-fold: First, to correct any intrinsic biomechanical issues that may be contributing to the focal dystonia, and second, explore ways of creating new “neurological pathways” for playing the piano.
Biomechanical correction involved extensive myofascial work (releasing “trigger points” in tight muscles) of the upper limbs and shoulder girdles (physiotherapy and osteopathy from Simon Loudon and Glenn Williams), and acupuncture treatments together with postural correction work at the piano. Attention to general health and fitness included institution of a cardiovascular exercise programme (swimming and cycling).
The most exciting challenge lay in exploring new ways of playing that might use different neurological pathways, (rather than the old ones which had become “smudged”). This involved regular “roundtable” meetings of the above described team with Michael at the piano, and exercised our minds and creativity to think laterally. Treatments and approaches used included:
- Altering the height of the piano stool (sometimes quite drastically)
- Altering the position of the music on the music stand
- Altering posture at the piano – sometimes in quite extreme ways eg adopting a Glenn Gould type of posture, if only to demonstrate that using new ways of playing could bypass many of the dystonic movements
- Altering sensory input:
- Playing with rubber gloves
- Covering the ivories of the Steinway with Elastoplast tape
- Rubbing the finger tips on a rough surface to “sensitise” them before playing
- Playing with white noise through headphones
- Using mirrors
- Sensory retraining away from the piano to “redefine” the sensori-motor areas of the brain for each finger eg learning Braille, blind fingering of dominoes and other objects
- Motor retraining using splints (a technique called “constraint induced therapy” where the finger that compensates for the dystonic finger is splinted prior to short periods of practice), and even a short period of cast immobilisation
Considerable improvement in the focal dystonia was noted over several years with the above rehabilitation measures. However, his symptoms were still present enough to stop him from returning to performing. Subsequent pianism retraining by Rae de Lisle involving modifying technique to create a new way of playing (ie using new neurological pathways and patterns) completed Michael’s rehabilitiation, and has enabled him to return to the concert platform.
Dr Dale Speedy, MBChB, MD, FACSP is a specialist sports physician practising in South Auckland New Zealand. He has a full time sports medicine practice and is consulted by athletes (including musicians and performing artists who are also athletes in their own disciplines). He has worked extensively with sporting teams and was the Chief Medical Officer for the New Zealand Olympic Team to Athens in 2004. He has a part time research fellowship position at the University of Auckland and his research interests include focal dystonia in pianists and exercise associated hyponatraemia.