The development and use of an anatomy-based retraining program (MusAARP) to assess and treat focal hand dystonia in musicians–A pilot study


      • The development and use of a musically applied anatomy retraining program (MusAARP) to assess and treat focal hand dystonia in musicians – a pilot study.
      • Development of an off-instrument progressive retraining protocol for musicians (MusAARP).
      • Effective objectively and subjectively in pilot testing in improving symptoms on and off the instrument associated with focal hand dystonia.
      • Individual actions progressing into functional synergies can potentially be applied to focal hand dystonia in any population, but requires further research.



      Movement dysfunctions are commonly reported in musicians, and in extreme cases may result in a persisting loss of motor control. This condition, whereby motor control of the hand during previously highly trained movements on the instrument is lost, is termed focal hand dystonia. It is widely considered to be a consequence of prolonged repetitive daily practice, often in combination with exposure to a range of other risk factors. Current literature recommends retraining as a promising treatment intervention, although only scant scientific evidence exists on which components should be included in a retraining program, and how these may be best administered.


      A progressive muscle activation and movement exercise program was devised by one of the authors applying a series of anatomy-based off-instrument movement tasks. This series of fine motor control exercises, was used to both assess and retrain focal hand dystonia in a population of musicians. The standardized approach aimed to provide a systematic method of retraining musically relevant muscular synergies that could later be applied to the instrument, while still allowing individual modifications. Retraining sessions were mostly run online as a consequence of the coronavirus pandemic, although some early sessions were also able to be undertaken face to face. Both qualitative and quantitative measures were used in this case series to evaluate program efficacy, due to the typical heterogeneity of the focal hand dystonia participants. This included: blinded external neurological evaluation of video footage using the Tubiana grading system, written subjective feedback, exercise progressions, and performance outcomes.


      Pilot testing of 4 patients indicated the utility of the program over approximately a 12- month time period. All subjects improved, 2 of whom have returned to pre-dystonia performance levels. These patients reported the importance of patience and persistence with daily exercise sessions in their recovery.


      Using off-instrument playing-relevant exercises to enhance fine motor control and muscle activation can be effective in retraining focal hand dystonia, regardless of additional treatments or level of performance. They should be regularly practiced and progressed in order for effects to be best progressed to instrumental applications. Further research may elucidate whether there are optimal outcomes with single or particular combinations of treatment approaches.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Therapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Steinmetz A.
        • Scheffer I.
        • Esmer E.
        • Delank K.S.
        • Peroz I.
        Frequency, severity and predictors of playing-related musculoskeletal pain in professional orchestral musicians in Germany.
        Clin Rheumatol. 2015; 34: 965-973
        • Kenny D.
        • Ackermann B.
        Performance-related musculoskeletal pain, depression and music performance anxiety in professional orchestral musicians: a population study.
        Psychol Music. 2015; 43: 43-60
        • Altenmüller E.
        • Ioannou C.I.
        • Lee A.
        Apollo's curse: neurological causes of motor impairments in musicians.
        Progress in brain research. Elsevier, 2015: 89-106 (Vol. 217)
        • Lee A.
        • Eich C.
        • Ioannou C.I.
        • Altenmüller E.
        Life satisfaction of musicians with focal dystonia.
        Occup Med. 2015; 65: 380-385
        • Pirio Richardson S.
        • Altenmüller E.
        • Alter K.
        • et al.
        Research priorities in limb and task-specific dystonias.
        Front Neurol. 2017; 8: 170
        • Butler K.
        • Sadnicka A.
        • Freeman J.
        • et al.
        Sensory–motor rehabilitation therapy for task-specific focal hand dystonia: a feasibility study.
        Hand Therapy. 2018; 23: 53-63
        • Ackermann B.J.
        • Adams R.
        Finger movement discrimination in focal hand dystonia: case study of a cellist.
        Med Probl Perform Artists. 2005; 20: 77-81
        • Rosset-Llobet J.
        • Candia V.
        • Fàbregas S.
        • Ray W.
        • Pascual-Leone A
        Secondary motor disturbances in 101 patients with musician’s dystonia.
        J Neurol Neurosurg Psychiatry. 2007; 78: 949-953
        • Safavynia S.
        • Torres-Oviedo G.
        • Ting L.
        Muscle synergies: implications for clinical evaluation and rehabilitation of movement.
        Topics Spinal Cord Injury Rehab. 2011; 17: 16-24
        • Tubiana R.
        Prolonged neuromuscular rehabilitation for musician’s focal dystonia.
        Med Probl Perform Artists. 2003; 18: 166-169
        • Prudente C.N.
        • Zetterberg L.
        • Bring A.
        • Bradnam L.
        • Kimberley T.J.
        Systematic review of rehabilitation in focal dystonias: classification and recommendations.
        Mov Disord Clin Pract. 2018; 5: 237-245
        • Enke A.M.
        • Poskey G.A.
        Neuromuscular re-education programs for musicians with focal hand dystonia: a systematic review.
        Med Probl Perform Artists. 2018; 33: 137-145
        • Sadnicka A.
        • Rosset-Llobet J.
        A motor control model of task-specific dystonia and its rehabilitation.
        Progr Brain Res. 2019; 249: 269-283
      1. Altenmüller E, Trappe W, Jabusch HC. Expertise-Related Differences in CyclicMotion Patterns in Drummers: A Kinematic Analysis. Front Psychol. 2020 Nov 10;11:538958. doi: 10.3389/fpsyg.2020.538958. PMID: 33304291; PMCID: PMC7693443.

        • Scott V.C.
        • Alia K.
        • Scaccia J.
        • et al.
        Formative evaluation and complex health improvement initiatives: a learning system to improve theory, implementation, support, and evaluation.
        Am J Eval. 2020; 41: 89-106
        • Sciascia A.
        • Cromwell R.
        Kinetic chain rehabilitation: a theoretical framework.
        Rehab Res Pract. 2012; 2012
        • Röijezon U.
        • Faleij R.
        • Karvelis P.
        • Georgoulas G.
        • Nikolakopoulos G.
        A new clinical test for sensorimotor function of the hand–development and preliminary validation.
        BMC Musculoskelet Disorders. 2017; 18: 407
        • Sadnicka A.
        • Kornysheva K.
        • Rothwell J.C.
        • Edwards M.J.
        A unifying motor control framework for task-specific dystonia.
        Nat Rev Neurol. 2018; 14: 116
        • Tubiana R
        Musician's focal dystonia.
        Tubiana R, Amadio PC ed. Medical Problems of the Instrumentalist Musician. Martin Dunitz, London2000: 340

      JHT Read for Credit

      Quiz: # 764

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to There is only one best answer for each question.
      • # 1.
        The subject population was _______ musicians
        • a.
        • b.
        • c.
        • d.
      • # 2.
        The exercise program is centered on
        • a.
          off-instrument movement tasks
        • b.
          progressive practice sessions starting with a minimal period of playing
        • c.
          PREs for the intrinsic muscles
        • d.
      • # 3.
        A favorable outcome would see improved
        • a.
          self esteem
        • b.
          grip strength
        • c.
        • d.
          fine motor control
      • # 4.
        The Tubiana rating scale
        • a.
          incorporates 3 elements of the DASH
        • b.
          was developed in conjunction with the Cleveland Clinic
        • c.
          uses a 0-5 scoring system
        • d.
          has an ICC of .98
      • # 5.
        75% of the subjects returned to pre-dystonia playing levels
        • a.
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.