Thursday, March 22, 2012

Summary of my Embouchure Dystonia Rehabilitation

First, if you think you have this disorder, seek out the help of a professional neurologist. However, there are few who can properly diagnosis it. One of the most well-known neurologists in the U.S. is Dr. Frucht who has not only diagnosed several musician's with dystonia, but has published a significant amount of research on the disorder. He is also one of the founders of Musician's with Dystonia which is an affiliate of the Dystonia Medial Research Foundation. His link is on my sidebar to the right under medical referrals.

Please do not contact me asking if you have dystonia, as I am not a certified neurologists. I had to put this note here because I get a lot of people asking me to diagnose them after reading this blog post.

I've spoken with several professionals and musicians who have been debilitated, either by an injury to their face, or who have embouchure dystonia. I believe it is important to understand what works and doesn't work for others, and to look at everything objectively.

As I've rehabilitated over the years, I tried so many suggestions and advice at first because I didn't know what worked for me yet. I've had to deal with constant messages about who I should go to, what I should do, correct, or fix. All of which is mostly given out of good intention...however can be very unintentionally disrespectful, sometimes very misinformed, and can be frustrating having to deal with when I've recovered significantly. I also go to great depths to share my process and feel like no one takes the time to read it before writing to me.

Recovering from Embouchure Dystonia is a very individualized process. I can only take and leave what works and doesn't for me. It has been an evolving process to say the least, and I'm beginning to realize that trying to summarize it does not do it justice and difficult to explain thoroughly from all angles.

Also I want to mention that embouchure dystonia it is often mistaken for overuse injury or overuse syndrome. If you do not know much about the disorder, and especially if you don't have it, please realize that statements based on assumptions are not helpful and can be misleading to others. Also if you haven't read my blog very much, please don't assume things without first getting to know my process through reading several posts. I've invested several years into this blog to not only share my journey, but have links to several research, case studies, information, and studies on the disorder that can help you understand it further.

This is the simplest way I can try to explain my current process, and I'm sure I'll come back and make edits and add more as I begin to understand how to word it more properly.

Right now my rehabilitation is based on 3 main things, and is more of a holistic approach; meaning one that addresses many different layers such as retraining sensory/muscle function, body mapping, mental awareness, emotional coping/healthy self-esteem, and modifications.

Again, I am only sharing what has helped me. Embouchure Dystonia recovery is a very individualized process, so what works for me might not work for you. However, it is important for me to share what I have learned and benefited from, as there are no publicly documented recovery efforts by any musician's with embouchure dystonia in existence. Hoping this will provide a rare insight into what the neurological disorder can be like.

[1] Understanding what Dystonia is from a medical standpoint as much as I possibly can. Reading research, talking to people (medical and non-medical who deal with the disorder and the different types of dystonia), searching out various viewpoints. First and foremost, always thinking objectively while also balancing an open mind. Don't believe everything anyone tells you, but also don't avoid considering others thoughts/advice without first thinking it all through and seeing it from multiple angles. When someone says something that doesn't make sense or isn't thoroughly explained, ask more questions that pertain to how they got A+B = C and ask for them to explain and give examples or share a video if can of what they are talking about.

Also study as many articles, research, and related facial injuries or information. I have many links on this site under "links of interest" and along my sidebar on the right. I also feel it is vitally important to study not only embouchure form and function, but more importantly to study anatomy of the face; not just the muscles or the "obicularis oris" but all the muscles of the face and how they function together (Gray's Anatomy Book helps), as well all the nerves (facial and trigeminal nerves of the face), what feeds into what, what each muscles function does in the face, and also nerve-related injuries and alternative medicines and options outside of mainstream traditional medical care.

Even though there is not one culprit known to trigger dystonia, nor one method of recover that works for everyone, doesn't mean we know nothing about it.

What we do know is that it is a neurological disorder. Reprogramming sensory through retraining is what my rehabilitation routine is based on, and addressing many other areas; emotionally, mentally, physically. I believe many factors contributed to the onset of my dystonia, therefore it takes a great deal of work to not only overcome it, but approach my horn in a different way than before.

I should mention here that if you are having any pain alongside your dystonia symptoms, it's best to resolve the pain first and quit playing until fully recovered. It will only make things worse if you keep playing in pain. Sometimes rehabilitating and trying to play after being diagnosed with dystonia can cause a secondary injury from too much effort put into recovery. It is important to remember it is a process and takes significant time and patience and slow work. Nothing should be forced.

[2] Focusing on sensory-movement: reprogramming sensory by retraining muscle movement. This consists of three areas: (a) Relocation - basically playing in a different location than I normally do and building a foundation of playing based off that location. (b) embouchure tension awareness - learning how my dysfunctional embouchure functions; knowing when and where the tension and involuntary contractions/lateral pulls occur when I play, and making slight adjustments, and finding opposing movements and exercises that help release or lessen contractions in the embouchure. (c) practicing formation/muscle group motions or movements and regaining strength through specific exercises outside of playing. This is only focused on in my buzzing exercises, and not when playing the horn  - I'm not trying to force a stabilized embouchure and avoid focusing on what it should look like. I explained this better in my "beginning rehabilitation" blog posts and videos. When you become debilitated your embouchure does lose strength too because you can't play as much and you don't want to cause a secondary injury or create more tension.

Reprogramming embouchure functionality involves: rebuilding muscle strength, muscle memory, and sensory...they all go hand-in-hand. (d) stretches - moving your muscles in different ways and different stretches than you're use to doing.

[3] Building a personal routine: Which consists of (a) performance psychology - incorporating a positive mentality and rebuilding self-esteem...this helps a lot with the depression that comes with being affected by dystonia or an injury (b) retraining exercises - I use a large amount of buzzing exercises and range specific exercises. Again, I will outline my exercise routine more clearly on here soon. Also I have started posting videos of my it will all eventually be on here.

I want to add a note of caution here: Rehabilitation is a layered process, so my routine (or parts of my routine that I show) as a whole is an example of what I've slowly come to focus on as my embouchure function develops/recovers. It is an ongoing for example; in the beginning I just focused on trying to produce a buzz into my mouthpiece, and slowly over time I was able to adapt and do more on my for months I worked on this; just buzzing. As I worked on buzzing and saw improvement, I was able to add on more exercises. Then a couple months later I started to focus on moving from buzzing to playing on my horn, and focused on producing a sound and eventually was able to move around and start to get to know my dysfunctional embouchure. So it is a very rigorous process because it is literally one baby step at a time...and it comes down to just relearning everything, small things that use to not be difficult before buzzing into a mouthpiece. I just wanted to re-emphasize that my routine is not so much a set routine, but a cumulative ...or I should say an example of what I've slowly built upon as I've recovered....what I was able to do step-by-step as my symptoms were relieving. My rehabilitation is learning how to reprogram/retrain my embouchure function or motor-skills after it's been completely deprogrammed...I don't know if I'm making an sense, but that's the best way I can describe it.

Annnnd....[4] I forgot! Some adjustments: I forgot to mention how important ice pack/heat packing is for me, and taking "women's 1-a-day vitamins". Also playing on my leg helped a ton in the beginning, and even now sometimes I don't feel comfortable enough to play off the leg. Breathing exercises and stretching exercises ...I always do them first and foremost before I start my routine! And most importantly, I play on a mouthpiece that feels good; is comfortable, and the first mouthpiece I started on actually. I played on it for a good 5-6 years since I started horn 12 years ago before switching...and now that I've gone back to it, I feel it helps out with the muscle memory some-how, and it has enough supportive back-pressure.

I have come a long ways, as my dystonia symptoms use to be prevalent in every register, and even when I buzzed. You can see this in some of my early videos under "Practice Journals" or "(Videos) Rehabilitation Practice Journal" on the side bar to the left.

Tuesday, March 20, 2012

Wilktone Embouchure Blog

I wanted to share this great review on the Wilktone Blog over Dr. Peter Iltis's video lecture on Embouchure Dystonia; Dr. Iltis is a professor of Kinesiology, and a horn player with Embouchure Dystonia (I also have one of his own articles over FTSED on the side of my page). You will probably recognize the video from youtube if you've ever searched "embouchure dystonia" on youtube. You can watch the video at the link below, and read Dave's comments on the video. He makes a lot of great points!

Embouchure Dystonia: Mind Over Matter?

I will also put a link below to Wilktone - one of my favorite sites I may add. You can find a ton of great blogs over embouchure function, and videos too. I highly recommend his site.

Dr. David Wilken's Website & Blog: Wilktone

From his About Section: While a graduate student Dr. Wilken developed an interest in how brass embouchure's function after lesson's with trombonist Doug Elliot. His dissertation topic explored the physical characteristics that can make different players’ embouchures function correctly in very different ways.  He continues to study brass embouchures in detail and is devoted to making this under-recognized topic more accessible to teachers and brass musicians.

More Progress...

Surprisingly my lip isn't irritated after practice today. Weird? I tried to play higher than normal. Safe to say spasms are feeling like they're almost to the point of being completely gone and have been for a while. Even the feeling of them being beneath the surface is getting less noticeable! 

Hooray!!!! I never thought they would go away in my mid-to-low register. Hope I don't jinx myself by saying this.
But now I just need to stabilize the notes (lots of air leaking going on, and I really don't feel like I have 100% grip on the core), and work on landing on them via larger interval jumps.

There's still a ton of work to do, but with the involuntary muscle contractions being almost completely gone (still some embouchure collapsing going on when working on flexibility). When there are spasms that occur, they are at least controllable because they are right beneath the surface - still frustrating to sense them though. It's gotten a lot easier to focus on specific things in my playing.

Hopefully everything keeps getting better. So far progress has been less sporadic; meaning I feel it's not one huge step back for every 2 steps forward. Just have to patience and faith.

Monday, March 19, 2012

(Video) Step 2: Buzzing, Stretching, Breathing, and Strengthening Portion of Routine

There is a list on the right side of this page called "Quick Links: Important blog posts," that highlight some important blogs I wrote over my rehabilitation. Here is a link to a blog I wrote over embouchure stretches and messaging lip tissue ---> Link.

I want to add a note of caution here: Rehabilitation is a layered process, so my routine (or parts of my routine that I show) as a whole is an example of what I've slowly come to focus on as my embouchure function develops/recovers. It is an ongoing process.

Monday, March 12, 2012

Older Practice Journals

This is my actual practice journal...I bought a bookmark that says: " Never. Never. Never Quit." - Winston Churchill
 Warning! There are some very gruesome photos of lip tissue below in some of the posts. Just wanted to let you know. It's very nerve-wracking to show them, but I felt they were important to show. :-S

Some of my crazy practice journal notes. I've been trying to collect them and add them all into one blog, but it will take forever. So here are the most recent (some are already on my blogsite but as individual posts, you can find them under the label "practice journal")...not very organized, and mostly just chicken scratch on a paper or either a book of rambling trying to remind me of what I was focusing on during the practice session. Anywhoo, here we go!!!

Some past journals....

March 13th, 2012

Lower lip on left side of embouchure seems to be the cushion of strength. I rely on strength of left side corner...if I focus on putting more balance towards the left corner, it makes it easier to pivot in registers somehow. It occurs every now and then, but it's better than what was happening before..I couldn't find a spot to rely on for support before. Higher register tends to want to go more towards the middle of lips, with a more equal pressure from side-to-side.

My dystonia limits my abilities in the following areas still...and each varies in limitations: Poof/air attacks are still more easier to do than tongue attacks. After poof attacking for a while, then I can tongue with less problems, unless I attempt a loud attack. Slurring of course is easier than tonguing, but I don't have to rely on it as much to help me transition from note-to-note like before. I still can't do any type of dynamic changes...piano and mezzo-forte are about as much as I can do for now. Playing on my leg for support is still necessary. Flexibility is awful and can't seem to transition between different ranges smoothly. I'm seeing a lot of differences in how my embouchure functions on a certain group of's changing....but for now I'm going to have to spend some time feeling it out and observing it further in practice. Spasms haven't been a problem lately surprisingly, but if I do sense them beneath the surface or if they occur on a particular note, they go away after about 15-20 minutes of ironing them out with my exercises. Still beneath the surface but it's comforting to know I can reduce them in this short amount of time compared to the past where it was more like 2-4 hours spaced out during the day of routines before I felt more comfortable.

For some embouchure dystonia patients, they may have similar limitations, or the opposite. For example; tonguing fast may be easier than slurring or using air attacks, for some playing louder/higher is easier than playing soft or in the pedal register.

March 19th, 2012

Spasms are subtle more often unless I try to play louder in the middle register without proper time ironing/smoothing out tremors and first making adjustments. Still can feel spasms beneath the surface on certain notes, but lately my face and embouchure feels relaxed and has vitality...don't know how else to describe the feeling. Trouble areas currently are low F to middle C (8 notes/chromatically). There are lots of air leaks in this group of notes/cluster, and the notes feel so shallow, like I'm just skimming the surface....but when I try to push more air down onto the note to try and find the core of the note, the spams start. I can't seem to adjust or grab the center of the notes. Still can't play up to an high "f". Comfortable only with playing up to a "d" on the staff. Some days it's trouble with low F to middle E on the staff line, it kind of varies.

March 22nd, 2012

A bit of a relapse today. Spasms start to occur around my low A today, but only when I play the 5 note major scale starting on low's coming back down and landing on the A that is difficult...or stopping on the low A. The spasm isn't super bad, it's wobbly, but enough to frustrate me. At first my chin wanted to embouchure wanted to collapse again...maybe so that my lower lip quits shaking. As soon as I tried to straighten out or flatten my chin, spasms started. So I tried to analyze how I played on the notes above and below the A. In my range above the low A, my chin is most comfortable being flat (but sometimes it varies oddly - some days it's flat, others it wants to bunch when more tension), but below in my low range my bottom lower lip wants to stick out the left side of my mouthpiece and requires a little more pressure on the left corner or left side of embouchure. As soon as I tried this it worked and I was comfortable.

I guess I have to remind my embouchure or muscle memory that this is what works...since it doesn't naturally grasp this way of doing things. So as soon as I repeated my 5 note major scale/pattern while emphasizing more focus on the left corner and lower left lip worked and was comfortable. I would practice this over and over again trying to get use to the feeling. I will have to try this again in future practice sessions and see if it keeps working. It might seem like a slight adjustment, but for people with embouchure dystonia, the slightest adjustment, even one that helps or works can take so long to find....also the muscles adapt over time too as they regain control which throws in another wrench in the whole rehabilitation.

March 24th, 2012

I'm practicing at the University. Spasms have been gone for a while today - they aren't bothering me or noticeable, but doesn't mean I'm not working on my trouble area - my middle to low register...I'm focusing on it, but now my focus has shifted more to gripping the core of the note since spasms aren't an issue (well at this dynamic level/relaxed state of playing...hopefully! crosses fingers) My lower lip in my pedal-to-middle register wants to roll out and protrude out of the side of the cup on the left side. When I try to bring the protruding part of the lip back in it quivers. BUT, I also noticed that my lower lip wants to roll back over my teeth as I play above in my treble staff range (i.e. "f" on the staff and above). So I tried seeing if I was strong enough to start in my pedal range with lower lip adjusting and go up. Then did the same starting on middle "c" and going down and I could do it effectively for a while! But I can tell it wants to resort to the former the more I keep practicing it. So I am trying to space out this exercise in order to pace myself. My higher register my chin likes to bunch but it doesn't feel out of my control...I feel like I can flex it and flatten it out..but it definitely saps my endurance.

March 31st, 2012

Difficult to play low G to middle B tonged while going upwards. Difficult to play middle F down to middle C tongued. A bit shaky in terms of feeling in control of larger motions... but improves the more time I spend going through my exercise routines.

April 4th, 2012

Looking back at the past couple months, I noticed spasms reduced in following order: middle F, middle C, now working on middle A and G...the spasms are subtle to almost gone (but I don't want to jinx myself by saying that), but I can still sense them right beneath the surface on my A and G and in certain passages I play. Noticed when playing upwards 5-note major scales starting on low F, the sides of my cheeks go in between teeth on side of face. But this doesn't occur if rarely when going downwards, just upwards...and my corners want to frown. Probably because it's harder for me to play anything going in an upwards motion, harder to control or move. That too is a weird realizations because before I had dystonia, when I could play naturally, playing downward was much more difficult technique-wise...but now here I am struggling with anything I have to play ascending.

April 21st, 2012

Played a bit on right side of face to see if pain would come back. Not bad today. The throbbing didn't kick in, and few underlying spasms occurred. I moved back to left side of embouchure where I remain working on rebuilding my embouchure function. I only practiced from 12:40-1:15pm or so. Then went to lunch, and when I parked my car, I looked in my car mirror at the underside of my upper lip. There was a cluster of small blood vessels on underside of upper lip that were bright red like they were irritated, and they were farther up nearest to my gums. I took pics on my phone the best I could. I may have done a bad thing by trying to play on the right side of my embouchure....and even worse is as it got later in the day the throbbing did kick in, and ice-packing and aleve only helped a little bit. It's obvious now that the right side has no protection or strength to handle playing what I can on the left side setting....can't apply even medium pressure...hoping this doesn't mean I can easily re-injure myself, or that my right side I will have to keep an eye on for the remainder of my life as I play my horn. Just worries me. I was really upset about it today. Definitely not attempting that again!!!!!! :-(

May 14th, 2012

Still working on my low A and G. The spasms are not noticeable today, at least not enough to bother me again...they seem more controlled if that makes sense, but now when I hit my low A and especially low G, my corners want to frown, and lower lip now wants to completely protrude into my mouthpiece. Feels comfortable, but awkward, and very limiting in terms of mobility....but no spasms. Yep, it's the collapsed embouchure returning again.

The break point or pivot is now on my middle B or C. From middle C and up my lower lip is curled back, corners are straight, and feels comfortable/functional. I can move around easily, little to no spasms, and feels natural.

I also tried to seek out areas where my spasms do occur or feel beneath the surface if possible. I didn't run into them until I started observing my mouthpiece setting. If I set my mouthpiece first, then breath through my corners without taking away contact from my upper or lower lip, everything is great!!!! But if I attempt trying to reset my mouthpiece every time I breath - meaning taking it off my face or either just taking the upper rim away from face while lower rim still in doesn't work. I start to spasm...can't start a note without spasming. This is a weird observation.

Thinking about the past, before I had dystonia, I could move my mouthpiece anywhere on my embouchure and it would be fine. In the past I could do the Farkas exercise where you play a note, take the horn off your face, breath, then apply mouthpiece on next note, etc. ....but now...nope. Can't do it at all. Now I feel like I want to do a similar but opposite exercise that I know of, where you set the mouthpiece, play a note, then keep the mouthpiece on face and nose breath, then play again. This seems like it would be doable for me and better. Now I know I have to be more aware to not reset my mouthpiece....but then again, in the last few months I didn't have a mouthpiece "setting" that existed...I didn't have a comfy spot that worked. It was all a mess and I had to move my mouthpiece all around my embouchure and make slight adjustments here and there in order to find one tiny minuscule adjustment that helped reduce the spasms. I still need to make adjustments, but not so much larger ones involving a complete resetting of the mouthpiece...which is different than pivot adjustments though. I'm not making any sense am I?

May 16th, 2012

Making an effort to breath through the corners of my mouth while my mouthpiece is already set is making a huge difference!!!! Also today I came upon another interesting observation. A couple months ago I was struggling with transitioning from my low range to treble staff range playing ascending. My corners kept frowning, and my lower lip keeps wanting to protrude completely into my mouthpiece, and the sides of my cheeks keep going in between my teeth like I'm chewing on gum (I know this is a bad sign! Just like puffing out your cheeks to try and play the horn, ahhh), and when I tried to change/get away from this collapsed looking embouchure, the only other positioning that worked was playing with my mouthpiece tilted at a high upward angle...looked like dizzie's trumpet bell haha! felt neutralized....with no spasms...but I know this is not the most healthiest or natural nor comfortable way of playing either. I felt like it wasn't helping me. But how can I change it but also face the spasms that do occur when I try to change it?

So I've been doing some work on transitions, and of course it takes a thousand maneuvers to finally realize one little thing that helps at the right place and right time. I realized a combination of trying to flatten out my chin while playing at a more downward angle of my mouthpiece, while keeping focus on the left corner of my embouchure for support...this did it! It is a bit difficult because I can feel the spasms beneath the surface, but I know it is doable and will be in time the more I practice this way. I tried playing 2 octave scales starting in my pedal register (ex. Pedal C up to the C in the staff and back down) to see if I could transition without a huge change in my embouchure, and it worked!!!! I also felt like my cheek muscles were getting a work out. I know this is the best way to work on transitions because it feels more natural, it also is similar to the way I use to play when I could play before I had dystonia.....I use to play at a downward angle. But when I got dystonia, it became an extremely downward angle in the beginning during my first attempt at rehabilitation. This is only a slight downward angle, which works well since my jaw drops and chin pulls back and flattens out when I play my pedal or low notes.....again it's frustrating trying to do this, I swear my muscles are fighting a war against me...but recently they've been losing to me. Yes! It definitely will take time to retrain my muscles to do this.......retraining should be called "manually retraining each and every individual movement"...nothing describes it better than that! :-)