Saturday, December 22, 2018

Rehabilitation Methods for Embouchure Dystonia VS Standard Performance Technique Methods - Including Jacobs Method

It would seem common sense that when one is facing embouchure dystonia or even another type of injury, that the rehabilitation process would require both a different approach and mindset focused on the body, rather than focusing on standard techniques to facilitate recovery efforts. Yet, we unfortunately see so many turning to standard techniques to alleviate their symptoms. Even worse, we see teachers and professors trying to help their students the same way.

It is is not anyone's fault that the symptoms of embouchure dystonia are mistaken for bad technique or faulty mechanics (which it is most certainly not the case) because the symptoms are similar to most setbacks in the early stages.

It would help to understand what having embouchure dystonia is like if more musician with the disorder were open about explaining further details and consistently reminding the public that it is a neurological disorder; or to put it in layman's terms - similar to a sensory disorder. Nonetheless, any setback should be approached with less focus on technique.

As Albert Einstein says, "We cannot solve our problem with the same thinking we used when they were created." 

That is definitely not meant to imply that embouchure dystonia is due to negative reinforced thinking, a mental or emotional block, paralysis by over thinking and perfectionism,  or some type of psychogenic issue; which is unfortunately the most common misconception thrown around.

The quote is simply meant to imply that our focus now must be shifted to what the body is telling us and what we can learn from it. In this way our mindset and approach changes to recovery-mode.

In order to become better attuned with our body and what it is asking of us, we must take on what some consider mindfulness, or what I call body awareness. It is an awareness of not what signals or lack-there-of (sensory feedback from our body) are being sent to us as we adapt. It also involves studying our body functions as a whole which can be understood through learning about body somatics, body mapping, and anatomy. To take it a step further, it helps to learn about other physical traumas and diseases to the face, teeth, glands, nerves, muscles, tissue, and upper body.

In brass playing we are limited to being taught about one muscle called the obicularis oris, and sometimes the buccinator and masseter muscles if lucky. Even then, there is little known about what all is actually involved in the use of an embouchure when it comes to form and function. The embouchure is a complex wiring and intricate system involving many small and large muscle groups of the upper body, face, tongue, nerves, jaw joint, skeletal/teeth structure, and lungs. There are many who avoid going into further detail or even bringing the subject of embouchure form and function into lessons.

The teachers that do bring up embouchure form and function tend be very strict about how an embouchure should look and move, and this is usually tied heavily to Farkas studies. Most often their students are the ones subjected to embouchure changes (sometimes drastic changes when unnecessary), which is seen as one of the many possible gateways into developing embouchure dystonia.

With embouchure dystonia, it helped me to deprogram the entire embouchure. Although if feels like the the signals from the brain are causing overwhelming and unpredictable muscles hyperactivity, it paradoxically allowed me to begin understanding how my body functions as a whole through accepting, observing, and exploring the dysfunctional movements that where happening.

I learned how my dysfunctional embouchure functioned in order to start deprogramming "playing mode" and disassociating the "embouchure setting", and then rebuilt from the ground up.

Throughout rehabilitation, it is important that the mindset shift to one focused on curiosity, exploration, with the determination to embrace the hard work, while continually loving and accepting the sound coming out of our horn despite the lack of control and stability.

In order to really understand the disorder as a whole, we must dig deep to find knowledge to support our understanding of embouchure dystonia, as there are few publically accessible and promoted  resources; scientific research, case studies, information on non-traditional and traditional treatments, knowledge on causes and cures of similar maladies or trauma to the face and upper body, and body somatics in one place.

We also must be open yet objective to everyone's views on what has helped or not helped them find progress or recovery, and most importantly we must be in a good place psychologically in order to not rush rehabilitation and risk creating a secondary injury as a result.

Do not underestimate how important a healthy environment can be as well; i.e. not performing in a high demanding group or continually doing performances in the beginning stages that would take away time from investing in recovery efforts and continually putting stress on an unstable embouchure. However, not everyone can step away due to performance demands, commitments, and even harder when it is what provides ones primary income and sustains their career and reputation.

Almost every musician you speak to who has dystonia will bring up the fact that musician's dystonia is a very individualized experience and requires a personalized recovery plan or at least one that adapts to their needs as they improve. The reason they say this is because the truth is that only they know their body better than anyone else ever will. Only they can navigate through the complex and messed up signals being sent to their embouchure, can tell from day-to-day what symptoms have surfaced and which ones are a more subdued over time. Most importantly, they decide what works and doesn't work best for their own recovery.

The most noticeable symptom with having embouchure dystonia is the lack of feedback you receive from touch/sensory. The best example that I can give is that there is no sense of where your mouthpiece should set on your lips (referred to as the "sweet spot" sometimes), no feeling of grasp on the surface of notes, and an overall foreignness in the face while playing...however, this is not to be confused with tingly or needle/prickly sensations...more like a dull lack of sensation, a lack of familiarity, and no ability to taste the notes. The reason I avoid tingly feelings, is because that is usually associated with a different type of injury such as nerve damage, nerve entrapment, muscle tears, or other more severe health issues.

I constantly compare embouchure dystonia to a sensory disorder. Both dystonia and sensory disorders involve a traffic jam of signals from the brain, and both are neurological-based, yet completely different disorders.

I have a weird description of what dystonia feels like. I liken it to a leg that has fallen asleep (without being aware of it). When you try to stand up and walk, you are suddenly surprised at not knowing what part of the foot to apply pressure to, and therefore your knees begin to buckle under because you have no sensation to guide your movement of the entire leg, and you need to slow down and think about what you are doing in order to keep your balance. All you can think about is how much lack of control you have and 90% chance you'll fall flat onto the floor, so you start panicking. In the meantime, there is someone hitting your knee with a reflex hammer every time you decide to move, which makes it even more frustrating and confusing!

Like I stated above, it is hard to grasp just the surface of a note, let alone hold one out. There is definite sense of foreignness and for some they can't even distinguish the feeling of vibration, vitality, or flexibility in the embouchure.

This is why no set detailed rehabilitation method applies to all, nor can cure all. That is not to say recovery is impossible, as there are a few of us who have, and progress is definitely possible if you put in the time and effort.

How is the focal dystonia individualized you might ask? Does it really vary that much? Yes, in the smallest most delicate subtle movements. It also depends on specific symptoms, and what multiple factors may be contributing to that individuals onset of dystonia. It also depends on what effects them the most, and what helps too.

One person might find that using a sensory trick by touching an area of their face while playing reduces or eliminates a tremor on one specific note, or it could reduced in a specific range, or it could only be when they are playing loud or only when playing soft. A 2nd person might find that no sensory trick or geste works, and after trying a medication (that didn't work for the previous person) works for them and they can actually return to playing at a decent level. A 3rd person might have cervical dystonia or oral mandibular dystonia and it led to them having embouchure dystonia symptoms (coming about as a secondary disorder is very rare though). A 4th person might find that their dystonia symptoms reduce significantly after taking a nutrient supplement.

When it comes to embouchure dystonia there are common symptoms that occur; tremors, twitches, air leaks, muscle pulls/jerks, jaw closure/jaw lock/aperture clamping. But when individuals describe their symptoms in detail, about when/where/how they occur, it can vary greatly. Not everyone has all of the symptoms, and not everyone has the same severity of embouchure dystonia symptoms, and not everyone has the same reaction to different treatments.

This is why it is so hard to diagnose. There is also the issue of misdiagnosis. If someone who claims to have embouchure dystonia and is easily recovered within a month, a few weeks, or even a year by focusing on only technique building or solely emotional therapy, it is most likely a misdiagnosis. Also another sign of misdiagnosis is if the musician's core issue is pain. Embouchure Dystonia is not overuse syndrome and does not elicit pain. Unfortunately a majority of musicians who have embouchure dystonia do not make it to a complete recovery, and even fewer return to playing professionally. Most that do report full recoveries spend years or a lifetime rebuilding their neuropathways and tend to have tried or used a multitude of treatments to overcome it.

With all of that said, I want to discuss the importance of why standard performance technique methods should not be used on musicians with embouchure dystonia. I should say that, it isn't that we cannot use certain techniques, but it is the manner of which it is applied.

When you have embouchure dystonia, you can not continually practice working on articulation, range, *air control, dynamics, efficiency/accuracy, endurance, speed, scales, repertoire, etc. Anything that requires repetitive practice/tasks will only further develop the dystonia. Intense playing or anything that requires endurance or advanced skills will only lead to over-exertion. Working on refining our motor skills will only create more tension and we risk creating an injury on top of already having a disorder.

When you have embouchure dystonia, the focus cannot be on anything resembling the Arnold Jacobs Method. "Singing the music in your head as you play....singing through the phrases...singing the pitch...wind and song."

Although I understand the intention of singing transcending technique (like a sensory trick) and how this might help people with embouchure dystonia not focus on the symptoms. However it does not help to completely ignore the dystonia symptoms, as this makes things worse. Also not to mention the fact that the symptoms can't just be "played through", as musicians with embouchure dystonia lack complete control of their playing and don't even have the ability to sometimes hold onto a note for 0.47 of a second.

Visualizations tend to help musician's sometimes. However, I am talking about manipulatives such as mirror boxes for hand dystonia sufferers, or visualizing blowing on hot tea in order to trick the brain into thinking it is doing something else.

That is not to say this method can't work in the later stages near the end of recovery, because I really do value the Jacobs Method and think it should be used more often in pedagogy practices for non-injured and non-dystonic musicians. But for a majority of the process it should be avoided.

Also a huge thing to mention here that Jacob's method is often used to re-establish correct habits via a focus on purely musicality. Embouchure dystonia is neurological. Meaning it has nothing to do with correcting bad habits, our musicality, level of technical mastery on the instrument, our way of thinking - positive or negative, nor is it about overthinking or perfectionism, or have to do with a lack of correct focus on a more musical-based mindset.

It literally has to do with the brain signal(s). Imagine a CD that has a tiny scratch on it, yet this tiny scratch happens to be in a spot that causes the whole CD to skip over several songs. It is like a domino effect or the domino theory; when one signal gets even slightly messed up, the rest comes tumbling down.

My neurologist brought up a theory that makes the most sense to me, even though no one knows what causes dystonia. He said that the human brain might be attempting hyper-efficiency in order to make things easier by streamlining the refined motor skills, but instead this backfires and turns into a maladaptive trait.

As musicians we refine our motor skills over years of repetitive practice, and the brain starts to refine the signal being sent out and our playing becomes more efficient. A scan of the brain's body map of a healthy musician's hand while playing guitar or piano will show the brain recognizing each finger as an individual limb, whereas a scan of the brains body map of a musician with hand dystonia has shown the brain clumping some of the fingers together into a big blob/blur.

Musician's with hand dystonia have a lot more research on their disorder, devices to help with retraining, and sensory tricks. What does help though as a sensory trick with embouchure dystonia in some cases is touching the area of the face where the tremor is happening while playing, and even sometimes mentally imagining they are touching the area where the tremor is happening reduces it (usually a sign of a more generalized dystonia though if that happens). Some find that ice-packing the face somehow allows them to temporarily regain playing abilities....but again, this is dangerous to work with and should be done carefully as it can easily cause other injuries or mask an already existing injury if you are not sure what setback you have. However, musicians with severe embouchure dystonia, sensory tricks do not always work, and the embouchure is more complex and less understood than a hand.

It's as one of my friends said, "The muscles in the face are meant to eat, chew, and talk, not to blow into a tiny mouthpiece and accurately hit a high C over and over again. It is the strangest body part we could use to create music. It an abnormal use of those muscles."

This brings me to my next point. With embouchure dystonia, the focus cannot be on standard embouchure formation function and correction. I won't write much on this because you could write a book on embouchure form and function. But for those who do not know about it, or haven't read Farkas's studies on the art of brass playing and horn playing, there are some commonalities found among healthy and/or professional embouchures. To put it in a very short description - there are two extremes of the embouchure; a full pucker (corners brought all the way inwards and lips moved outward), and a full smile (where the corners stretch outwards towards the cheeks and the lips become spread thin/flat).
An ideal healthy embouchure should be somewhere in between the two extremes. The corner muscles of our lips hold the bulk of the strength and allow the aperture to be flexible in adjusting size (the small opening between the lips). When the corners are working properly, the chin should remain flat and not bunched. The chin can be flattened by bringing the jaw down (and in lower playing - down and forward). If the chin is bunched it causes a lot of problems later on, and especially dangerous as it puts more pressure onto the upper lip which is spread thin, whereas the lower lip needs to provide the stability. The flatness of the chin allows for more flexibility and fluidity when crossing between registers, and it allows us to adjust the lower lip. With the embouchure set up this way we can also hit the center of the pitch more accurately...or as some say the lower part of the note. This ties into air.

With embouchure dystonia even putting the horn up to the face or going into "playing mode" or "embouchure setting" will cause the dystonia to kick in and go haywire. Like I stated above that we must disassociate this link and deprogram our entire body from recognizing we are playing the horn. I go over this in great detail in the video further down and show examples.

*When you have embouchure dystonia, the focus cannot be on standard breathing techniques or exercises (with some exceptions). Again, for those who do not know about standard breathing techniques or exercises, most often in our university studies we are taught about how to properly intake air and exhale it with fluidity while aligning with the metronome.

You hear a lot about hot air, breathing from the lower abdomen and not raising the shoulders, opening the throat, imagining things like inhaling a basketball, sometimes using words like "ho" or "toh", practicing breathing exercises with the metronome and increasing your lung capacity.
Learning about the anatomy of the diaphragm, learning about the difference between mouth/corner breathing and nose breathing, recognizing the sound of proper breathing, and sometimes use breathing devices to train and measure progress

We also learn about how to exhale well supported air and focus it into a solid stream or like a jet-stream or thread of air directed into the mouthpiece, reaching out past the bell and filling every corner of the room, focusing on filling the entire room up with your sound.
We learn about how to use our air to bend the note (note bending/air bending pitches) down (also why the chin being flat and brought downwards is important) digging into the bottom of a pitch against the resistance in order to find the center of the note where it rings and you can hear the overtones. ...again...could write an entire book on this subject.

We also are taught how to use the tongue to initiate clean articulation at the beginning of a phrase on the front of our notes. This ties into tonguing...another area I will save for later. But tonguing must be left out when recovering from embouchure dystonia, at least in the beginning stage and middle stages until the embouchure becomes more functional.

What people don't realize, is that even with strong air support, we are still exerting muscle control and using proper air isn't just all about air, or just all about muscle control and requires both, and there is a delicate balance between the two. I will talk more about that further below.


However, when it comes to embouchure dystonia rehabilitation, it is important to not focus on any of the standard techniques listed above. It must all be cleansed away out of your thoughts, as if you were brainwashed and need to undergo an exorcism of some sort. Do not follow or listen to the following Farkas diagram (I did the courtesy of crossing everything out for you and added a not-allowed sign...a bit over the top perhaps...but you get the point). My primary point is that standard technique can only be applied to functional embouchures. Put that stuff away and out of your mind for years to can only be reintroduced way further down the road when you are almost fully recovered.

Whenever a musician who does not have dystonia tries to use conventional standard methods to address your embouchure dystonia symptoms, ignore everything they say, as it will only make things worse. Embouchure dystonia is so far beyond dysfunctional that there isn't a word that exists for it. If dystonia had an ounce of functionality, then normal standard conventional methods/techniques would fix everything easily.

With embouchure dystonia, we must focus on completely letting the embouchure be loose and letting the air initiates the sound before all else; before the tongue, before the embouchure sets, before articulation, before we even try to control it. It is about the air passing through the aperture in its most basic and relaxed natural way, before everything else goes into action.

Most importantly, we do this in order to deprogram the embouchure. Think of it as uninstalling software. Letting air swell up in our cheeks, in our corners, even frowning our corners if have to. We must practice using different muscle groups than what we are use to, and especially ones that release tension and oppose the normal setting we are use to. The goal being to completely deprogram, then slowly start reprogramming. It is a difficult thing to navigate and requires a lot of body awareness and most of journaling/documenting your observations.

I also want to mention that in standard air technique, there is a delicate balance that must be recognized and kept aware of (this actually applies to both musicians who have dystonia and those who don't). That balance is: 1. Is the air guiding the direction of your embouchure? Is it guiding the function of the embouchure muscles and directing them? OR 2. Is the embouchure/aperture guiding the direction of the air? Is it controlling or overly supporting the sound?

Ideally we want a balance of both. But, the air should be the predominant guide always. However, it is not always easy to tell because we are not usually hyper aware during playing or have time to think about it while in action. Usually when you are a normal (non-dystonia) you just play and trust the feeling of ease and comfortability, and sometimes we get too caught up in the feeling that "It feels natural"  that we forget this delicate balance and how easily the tendency to start controlling the air/sound with solely the embouchure starts to sneak in and cause problems.This is where we can sometimes get in trouble if we don't actively try to keep track of what is going on with our body/face during intense playing periods of time.

I'm not saying that this is what causes embouchure dystonia at all...please don't misinterpret what I'm saying. What I am saying is that the focus on letting the air guide the embouchure is one of the several methods/tools we use to re-establish a production of sound out of the instrument, to deprogram, and then reform a connection. But even so, the method requires tweaking, which I talk a lot about it in this video I did over Beginning Rehabilitation Strategies below:

With FTSED our embouchure is easily thrown off by even the action of bringing the right (or left...whichever is predominantly used in playing) hand up to the face (sometimes not even with the mouthpiece). It is because our muscle memory/programming has developed a embouchure setting over years of practice and growth. Eventually when you go to play, the embouchure naturally sets (also called "embouchure setting"). I call this "Playing Mode". It is because we have this embouchure setting that is programmed to react instantaneously and the signal from the brain goes into "set for playing mode." But when the signal is damaged, such as in embouchure dystonia, how can you deprogram the reaction?

For me, the key was to take away everything; the horn, the mouthpiece, even the action of bringing your dominant arm(s), hands, and body into playing posture.

Sometimes focal embouchure dystonia is so bad it carries over to some of these basic actions. The answer is to bring it all back to simply practicing passing air through the lips gently and practicing using opposite movements in our embouchure than what we are use to using. This is most important in the first month(s) and year of rehabilitating. Some practitioners will have you focus on blowing on a windmill, feather, blowing through a straw, while relaxed. Just re-focusing on letting the air pass through the lips without going into "playing mode."

For some who start rehabilitating, this is the key focus in overcoming their embouchure dystonia, whereas others will require more focus on other areas of recovery once they've re-established a sound. That is why I believe some call it "air dystonia" or say that focusing on their air was key in recovery. It continually plays a role throughout rehabilitation; constantly letting the air guide your playing, however, there are other areas that require equal attention depending on your individual symptoms, and I don't want to give the impression that it is ONLY about this act of blowing gentle air support. Recovery is like peeling layers of onion and you've got 99 million problems, and air isn't just one.

Another huge fact that is overlooked is that when an embouchure sets, most of us bring our chin forward a little bit to align with the mouthpiece if we are downstream players (especially when dropping into the very low register on horn) and opens the aperture up more, thus, the sternocleidomastoid muscle along the sides of our neck flex in order to help support the jaw muscles and movement (even if minimal movement). Go ahead and try free-buzzing high and low while keeping one hand or a couple of fingers on the sides of your neck and you will feel them subtly flex. You can try this while playing too and feel it. Try touching both sides of your neck, and touching different areas of your upper body, face, and neck to locate muscles that activate when playing.
Keep a journal of it and what you become aware of....ex. if one area is more tense than another.

I can't say this for sure, as this is only a speculation. Sometimes I think the sternocleidomastoid muscle is overactive or tension more noticeable in certain people due to their individual anatomy or because the nerve connected to the muscle is easily disturbed. I believe this muscle along with the masseter causes over tension in the neck area when playing and sometimes leads to lock jaw, TMJ, or even just a basic restricting of the air flow because the neck tenses up. I know for me, I have to work on a relieving tension in my neck a lot in order to loosen up my jaw and then facial muscles.

However, that is not to say that muscle tension isn't necessary (every muscle in playing requires one to flex, and another to oppose it, as that is how the body works in balance - antagonist and agonist muscle groups), as it is naturally flexed, but that it often tends to be overly tensed when you have embouchure dystonia and I in particular have to take extra steps to massage and relax my upper body muscles.

I cannot stress the importance of focusing on relieving muscle tension (created by the dystonia/ muscles fighting/ signals clashing) through a variety of means, and the re-direction of letting the air stream pass through the mouth gently with no muscle control. When sound is reestablished, then focusing on practicing opposite muscle movements becomes an equally important area. I cover this in the second video below.

This post has gotten quite long and I could write much more, but will stop here. If you have any questions, comments, or topic suggestions, please let me know and I will respond! Hope that this provided some insight into the neurological disorder Focal Task-specific Embouchure Dystonia.