1. Introduction

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Dystonia is a condition in which increased muscle tone causes abnormal posture and movements [1]. Musician’s dystonia often affects the portions of the upper limbs used in playing instruments, especially the fingers, and makes it difficult to play the instrument in question. Although the pathophysiology of dystonia remains unknown, it is believed to lie in repeated abnormal motion subroutines centered in the basal ganglia. In other words, with acquired movements that are frequently repeated, there is often tension in the specific muscle groups that are used so often, and a tendency for the associated joints become fixed at specific angles [1]. Playing a musical instrument is an acquired movement, and one in which repetitive, frequent exercise is common due to the need for practice to maintain one’s ability. These movements are done almost unconsciously once established, are often performed under tension, and hence present a risk of developing dystonia [2]. In Japan, a previous survey of 480 music students found that 29% of the students knew of musician’s dystonia, and 1.25% reported having dystonia while performing music [3].

Musician’s dystonia is often misdiagnosed as tenosynovitis, and so many musicians are not treated appropriately [1]. To improve the ability to differentially diagnose dystonia in musicians, as well as to determine a better idea of the actual level of need for treatment, a questionnaire-based survey was conducted. The survey aimed to identify aspects of musician’s dystonia in the population related to (1) symptoms, (2) coping methods and treatment, (3) the type of musical instruments and the duration for which they had been played, and (4) personal characteristics of the musicians that may represent potential risk factors (e.g., being overly driven to practice due to insecurity).

2. Materials And Methods

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The subjects of this survey were musicians, both professional and amateur. We mailed the questionnaires and consent forms to each conservatory, music faculty, and music department together with a document explaining the nature of the research, asking that students and faculty members respond and submit them to us in return envelopes. We sent a total of 1,300 questionnaires to 41 conservatories, music faculties, and music departments in all cities throughout Japan; the number of surveys sent was based on the number of students/musicians at each school. In addition, we included some outpatients from Kawasaki Municipal Tama Hospital. We decided to consider responding to the questionnaire as a formal consent.

The questionnaire itself comprised 28 questions grouped into four main components in Japanese: (1) Symptoms (questions 1-10), (2) Coping Methods and Treatment (questions 11-17), (3) Musical Instruments and Length of Engagement (questions 19-22), and (4) Personal characteristics (questions 23-28). Symptoms included level of pain, movement difficulty, etc.

Coping methods included both informal (“taking a break”) and formal (“acupuncture”) methods. This section also inquired as to the subject’s knowledge of dystonia. Length of engagement included the amount of experience (e.g., how many years) playing the instrument(s) the subject identified within the survey, as well as frequency of playing and practicing during that time. Personal characteristics included both self-and external-reported personality traits as well as basic demographic information. The questions were primarily formatted as having multiple choices provided, though several allowed for more open-ended answers (or at least an “other” category for the subject to use).

Data accumulation was entrusted to an external contractor rather than the creators of the questionnaire in order to eliminate bias.

This study was approved and validated by the appropriate committee (No. XXXX).

3. Results And Discussion

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We received responses from 66 of the 1,300 recipients (5%). The questions, respondents’ answers, and the number of respondents answering with a given choice are provided for each of the four main categories (see Methods above) in Tables 1-4, respectively. Briefly, we found that the respondents complained of 67% of the symptoms being in the right hand; the main symptom was pain. Many respondents could also not maintain good embouchure. The majority of respondents did not utilize formal treatment, but instead took “breaks” from playing/practicing. A small number did undergo more formal medical treatment, including among others acupuncture, surgical intervention, and nerve block injections. Thus, the majority of respondents did not have a definitive diagnosis of dystonia. A small number knew what dystonia was, but many did not. Of the instruments cited, the piano was most commonly played. Length of engagement was cited by respondents as averaging 15 years of experience including at least 1 h/day of work. Embouchure was a problem primarily in those respondents playing wind instruments. Of the 66 respondents, 27 described themselves as “professional” or “semi-professional” musicians, and 37 as “student” or “amateur” musicians. Given that more of the questionnaires were sent to students, the rate of response of the student and amateur musicians was distinctly lower than that of the professionals. Finally, the three most-cited character traits of the responding musicians were “serious”, “patient”, and “kind”. Female affected more than male (music department in Japan, female students are predominantly).

This study found that in the group of survey respondents, the musicians complained primarily of right-hand symptoms that had not been diagnosed as dystonia or any other disorder, and that these musicians, whether amateur or professional, coped with the pain mostly through taking time off from playing rather than seeking medical help.

This study was strong in its thoroughness and recognition of the need to educate musicians on dystonia. In general, the incidence of task-specific dystonia is 1 in 3,400 people in the world [1]. However, in overseas reports, the incidence of musician’s dystonia amongst professional musicians is 1 in 100, making it a very common disease [2]. However, the incidence of musician’s dystonia in Japan has been previously studied inadequately, and our respondents did indeed have very little knowledge of the disorder, especially in relation to their profession or avocation (music). This study attempted to gather information on a range of potential risk factors for musician’s dystonia, as well as potential factors that might indicate in follow-up who will be more likely to develop dystonia, and how it will be expressed if it does develop. Stress induces dystonia, so the personal characteristics are also important[4].

This study was limited by a very low response rate, possibly due to the fact that the questionnaires were sent to department heads and conservatory leaders rather than being sent directly to individual potential respondents. Some packages returned to us. It is possible that the purpose of the questionnaire was not fully communicated to the individuals in charge, and thus it was not passed on to many students or teachers. The lower response rate by amateurs and students supports this possibility. Finally, this study was performed in a survey format; there was no comparative (control) group, and no way to control for selection bias resulting from the relative few who responded to the survey, so formal statistical comparisons could not be performed.

Our response rate was lower than other studies. For example, Tamagawa et al. conducted a survey on occupational dystonia with a questionnaire sent to 294 full-time occupational health physicians working for large companies nationwide, and obtained responses from 145 individuals (49.3%)[5]. This is much higher than our 5% response rate. However, there are no other studies addressing dystonia in Japanese musicians, so little comparison can be made between this study and others [6].

There are cases where dystonia, being a neurological movement disorder, may be hidden due to lack of exercise as well as poor physical condition at the time when it becomes difficult for sufferers to play their musical instruments. Symptoms often occurred in the right hand. In the case of musical instruments that involve movements of the rotator cuff, such as the piano, this may be because the right hand plays delicate melodies. In the case of musical instruments that involve plucking strings, such as the guitar, this may because the right hand generally plays the strings to produce sound [1].

Conservatories, music faculties, and music departments in Japan are mainly focused on study of classical European music. Vocational schools, which focus on genres such as jazz and rock, and overseas schools (such as the Berklee College of Music) were not included in this survey, so this study may undercount cases of musician’s dystonia; alternatively, the types of dystonia and locations in the body may be more diverse than in this study.

4. Conclusion

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Education is important, because dystonia can be hidden, and can become severe enough to force premature retirement by musicians. In the future, we hope that those affected by pain when playing will seek medical attention and the appropriate diagnoses and treatments.

At present, there are musicians in Japan who have difficulty playing their instruments and, rather than seek medical attention, are instead “quietly suffering”. Without diagnoses, these musicians cannot be provided with the proper treatment. We conclude that the lack of knowledge of dystonia and its consequences is hindering musicians in Japan, and believe education on this occupational dystonia would improve the health and quality of life of these musicians.

5. Acknowledgements

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This study was funded by a Health and Labour Sciences Research Grant (“Research on the pathophysiology and epidemiology of dystonia”, Research on Measures for Intractable Diseases, Fiscal Year 2012) from the Japanese Ministry of Health, Labour and Welfare.