Myofascial Release and Focal Embouchure Dystonia

Answering a question asked during a live-stream about how to do the myofascial release stretches/tissue work:

Part 1

Part 2

Part 3

Colin Williams: On Muscle Tear Recovery

A wonderful post by trombonist Colin Williams who teaches at the Manhatten School of Music. He shares his experience overcoming a major embouchure injury - muscle tear. Please read the comment section full of questions, informative answers, including links. What I love most is the respect shown for Lucinda Lewis and the late Laurie Frink; both trailblazers in helping others in the area of recovery and injury knowledge. My heroes. Not to mention Dr. McGrail and Dr. Vander Kolk who have helped several musicians via muscle tear surgery when out of all options. ❤

 

April: Important Embouchure Dystonia Research Articles, Information, and Videos

MRI Horn and Brass Repository Project (MBRP)
Dr. Peter Iltis is currently directing this research project in collaboration with the Max Planck Institute for Biophysical Chemistry (Gottingen, Germany) and the Institute for Music Physiology and Musician's Medicine (Hannover, Germany). The goal of the project is to research and find ways to restore function in musician's with Embouchure Dystonia, and also find ways to prevent FTSED in general. If you are interested in more information, please click on the link and scroll to the bottom of the page for Dr. Iltis information. Also if you would like to donate to this important research, there is a link on his webpage as well. Currently the International Horn Society executive committee encourages fellow musicians and horn players to support this research if can!

Here is a video of Dr. Iltis speaking in a new video posted on facebook about the research project. And here are further informative videos over his current research below:

American Academy of Neurology Podcast: Sensorimotor Overactivity as a Pathophysiological Trait of Embouchure Dystonia
An interview with Dr. Bernhard Haslinger about his paper published on sensorimotor overactivity in embouchure dystonia.

Activity and Topographic changes in the Somatosensory System in Embouchure Dystonia
I believe I've posted this before! But here is a more condensed overview of this research publication by Tobias Mantel MD, Christian Dresel MD, Eckart Altenmuller MD, Claus Zimmer MD, Jonas Noe MD, Bernhard Haslinger MD ( <-- Who was speaking in the previous podcast link above).

Allegro: Foundation is Created to Assist Musicians with Dystonia
This is an article from the year 2000 when Glen Estrin and Dr. Frucht founded the Musician's With Dystonia Foundation. It has Dr. Frucht's contact information, and talks about how they assist musicians with information on how to get health care coverage, and where to go when they need a diagnosis. "Dr. Steven Frucht of the Columbia Presbyterian Medical Center Movement Disorders Clinic may be reached at (212) 305-5277...for further information regarding Musicians with Dystonia Foundation, send e-mails to musiciandystonia@aol.com."

Clinical and Epidemiological Correlates of Task-Specific Dystonia in a Large Cohort of Brazilian Musicians
This is a general study on focal task-specific dystonia in musicians around Brazil. The study was conducted by Rita C. Moura, Patrcia Maria de Carvalho Aguiar, Graziela Bortz, and Henrique Ballalai Ferraz. 49 individuals were diagnosed with FD (mean age 26.4 years; 92% male). The instruments most associated with FD were acoustic guitar (36.7%) and brass instruments (30.6%). They concluded that Brazilian FD music players were mainly male, classical music professionals, around 30 years of age, with arms, hands, or oromandibular muscles affected. They end their study by stating that Musicians Focal Dystonia should receive more attention from musicians, teachers, and health professionals.

Worlds First Focal Hand Dystonia Patient in Japan Treated with Focused Ultra-Sound (FUS) Enabling Musician to Play Again
I was quite interested in this and contacted Nadia Scantlebury at SunnyBrook about a current focused ultra-sound study that was going on in Canada. Unfortunately they are only letting Canadian citizens participate. However, she did mention that there is a focused ultra-sound research study or trial going on at University of Virginia. Here is a list of all their current trials going on with focused ultra-sound! If interested, you can contact them directly.

From Embouchure Problems to Embouchure Dystonia? A Survey of Self-reported Embouchure Disorders in 585 Professional Orchestra Brass Players
This research was conducted by Anke Steinmetz, Andreas Stang, Malte Kornhuber, Marc Rollinghoff, Karl-Stefan Delank, and Eckart Altenmuller. "The final publication is available at link.springer.com.

Music and Medicine: A Research Model
These are slide presentations by professor Karendra Devroop of the School of Music and Conservatory at North-West University that cover a variety of music performance-related injuries, disorders, research, knowledge, and statistics. I highly recommend reading it, as it covers a wide variety of very important information we can all benefit from as musicians. Raise awareness!

Review: Music, Motor Control, and the Brain. By Eckart Altenmuller, Mario Wiesendanger, and Jurg Kesselring. 
You have to have a Jstor account in order to read this! Easy to sign up, and easy to access this article, as it is a free read. I highly recommend a Jstor account anyways!...so many articles and quality information.

Carmine Caruso Method Adapted and Taught by Julie Landsman
Last, but definitely not least!!! These are some of my favorite videos to watch. I actually started using the freebuzzing/mouthpiece buzzing exercise video in rehabilitation, as it helps me a ton!!!

The Recovery

Freebuzzing and Mouthpiece Buzzing

The Six Notes

The Harmonic Series

Carmine Caruso Method: Introduction with Julie Landsman

Note Tasting

Noodles

Spider

Intervals

Dynamic Studies

Low Register

Snakes

Video: Collapsed and Puckered Embouchure with Dystonia

Haven't recorded a video in a really long time! Well, after a long duration of time of having very few symptoms, I of course get a day full of intense relapse symptoms. So I thought I'd record my relapse and also show what the symptoms look like on both a puckered, and on a collapsed embouchure.

So many people think that in order to overcome embouchure dystonia it requires a "fixing" of the embouchure setup by either puckering more, or loosening the embouchure more...and although less tension is key, it isn't the answer to overcoming embouchure dystonia. No matter what way I form my embouchure, I still deal with the symptoms, and I always have to adapt to them and try to iron out the contractions to an extent. But the symptoms are never 100% non-existent.

*I want to clarify that it is my left side that has the most visual symptoms (i.e. air leaks, uncontrollable rolled out lower lip on the side, and corner moving all over the place), and my right side that looks stable, yet it feels stiff and flacid at the same time, and my upper lip is raised up so much on that side. 

I tried to actually plan out my recording this time. The first thing I did was play a low excerpt with a collapsed embouchure/no tongue (i.e. air-attacks) zoomed in and then zoomed out. The second thing I did was play the same low excerpt with an extremely puckered embouchure (as puckered as my muscles would allow me) with tonguing, zoomed in and then zoomed out. Then I did the same with the higher register excerpt. 

Jonathan Vieker: McGrail Lip Exercises Post-surgery for Ruptured Obicularis Oris (Embouchure)

Wanted to share another great post by Jonathan. The exercises are very similar to the stretches I do. You can find his awesome blog and post here.

Further Experience with Rupture of the Orbicularis Oris in Trumpet Players

I came across this set of articles written by a surgeon who has experience mending torn muscles in trumpet players. There are some pictures of the surgery, just FYI.

1. Jaime Planas, Barcelona Spain: Plastic and Reconstructive Surgery on Embouchures

2. Another Ruptured Orbicularis Oris Case

Ice Packing VS Heat Packing

Article Post: When to Use Hot and Cold Therapy

Every now and then I come across musicians who either swear by ice packing or heat packing (or both, like I do!)......or the opposite...they absolutely refuse to do it when injured, mainly due to misusing one or the other because they were not trained on how to properly ice pack and heat pack, or they heard from a professional musician who misused it...yes, even professionals make mistakes (because not a lot of musicians are trained in how to physically take care of injuries). Therefore, I wanted to share this medical post from the University of Rochester Medical Center over the benefits of ice packing and heat packing and when to use either. 

I feel it is vital to ice pack and heat pack if you have a new or old injury to your embouchure. This post shows not only how to ice pack and heat pack, but when to use it, how long, and what exactly happens to your tissue. I hope this helps many musicians who are newly injured or who have a old injury but still experiencing pain, to heal a bit! Or at least prevent further damage. :-)

Who to Contact for Help Rehabilitating from Upper Lip Injury or Muscle Tear

I came across-----> THIS <----great blog a while ago and forgot to post it on here. I also posted it under my resources on the side bar to the right.

The author of the blog writes:

"I’m Jonathan Vieker, a trumpet player who’s been living with a severe lip injury since May 7, 2010. I created The Lip Rip Blues to help brass players understand lip injuries. The morning after I got hurt, as I made a cup of coffee and sat down at the computer to figure out what was wrong with the muscle in my lip, I discovered quickly that there just wasn’t enough information available about embouchure injuries.

This site is my attempt to do something about that."

A HUGE THANK YOU TO JONATHAN for his website/blog! :-)

More Alternative Medicine/Therapies (Part 2): Body Movement Awareness Methods (Somatics), Modifications, and Musical Exercises for Focal Embouchure Dystonia

PART 2: Body Movement Awareness Methods (Somatics).

In my last post I spoke a little about being mindfully aware during physical rehabilitation. This is a huge part of recovery for me; making adjustments and modifications to help improve or redirect my tension into a less tense state of contraction based on both mindful awareness, and understanding of anatomy/functional muscle movement.

There are quite a few body methods out there that you may have heard of. Why these methods are important is because most of them focus on reprogramming a more efficient body map. Your body map is the brains general perception and understanding of ones body/movement/function based on the sensory input it's been receiving. This carries over to how we use our bodies with our instruments.

Body Movement Methods are technically referred to as somatics. Somatics refers to practices in the field of movement studies which emphasize internal physical perception. The term is used in movement therapy to signify an approach based on the soma or "the body as perceived from within."

I'm listing them here as a resource because knowing a little about them or even taking the time to take a course in one of these methods may be helpful to you, as they can help with the rehabilitation process...it doesn't mean that one method or any of the methods are the answer to overcoming dystonia, but can be used in aiding the physical rehabilitation process to an extent.  

I've noticed universities recently incorporating classes on some of these methods which is awesome to see!

Types of Body Movement Methods or Somatics

• Alexander Technique - Most musicians know of this method, and it is not uncommon these days to see it being taught as a course or summer course within music programs at universities or institutes. Alexander practitioners are certified and teach the course between 10-40 sessions. Alexander's approach focuses on mindful action. The instructor uses guided modelling with light hand contact for detecting and guiding the student past chronic pain and effort. It should be noted that A.T. is also used to help with stage-freight and anxiety too. Suggestions for improvements are student-specific/individual-specific, and the instructors analyze the student's responses, as well as using mirrors, video feedback, or classmate observations. The practitioner is well-trained in guiding free-movement.

• Feldenkrais - Feldenkrais was highly influenced by Judo. He taught that increasing a person's kinesthetic and proprioceptive self-awareness of functional movement could lead to increased function, reduced pain, and greater ease and pleasure of movement. The Feldenkrais Method is therefore a movement pedagogy, similar to the Alexander Technique in being educational and not a form of manipulative therapy. The method is experiential, providing tools for self-observation through movement enquiry. The practitioner directs attention to habitual movement patterns using gentle, slow, repeated movements. Slow repetition is believed to be necessary to impart a new habit and allow it to being to feel normal. These movements may be passive (performed by the practitioner on the recipient's body) or active (performed by the recipient). Feldenkrais is used to improve movement patterns rather than to treat specific injuries or illnesses. This holistic focus means that the primary intention is not to treat injuries. However, it can be used as a type of integrative medicine because correcting habitual movement patterns can help heal injury, pain, and physical dysfunction.

• Mitzvah Technique - is focused on dealing iwth body mechanics in a state of motion. It is a development of the Alexander Technique, the Feldenkrais Method and health-oriented work on musculoskeletal problems and stress diseases. Each of these techniques are based on correcting common postural faults by addressing  the neuromuscular system through postural re-education. Yet the Mitzvah Technique encompasses both a unique philosophy and a set of procedures. This includes the discipline, exercises, the work that Mitzvah Technique practitioners do with their hands. The Mechanism consists of a sequence of natural body movements that magnify the ripping motion in the body. There are four components to the Mechanism; (1) The interplay of physical forces acting between the pelvis and spine, (2) the rippling spinal motion, (3) the dynamic relationship involving the pelvis, spine and head in a synchronized motion, and (4) the freedom of the head to balance on its spinal support. All of these together promote the operation of the Mitzvah Mechanism. It is designed to improve posture and release tension and stress through exercises and therapeutic table work. It claims to realign, re-balance, and exercise the entire body during sitting, standing and waling. It's aim is to replace long-term work by practitioners, to have people learn how to use the technique itself. Musicians, actors, and singers have been extensive users.
  
  *These next two listed are not so much a body movement method (except Rolfing is kind of), but more of a alternative physical therapy that integrates somatic education into it's foundation.

• *Oral Myofascial Release (MFR) - This is what I currently have experience with. Myofascial release deals with built up/rigid connective tissue or fascia in the jaw-joint and muscles surrounding the face. My acupuncturist was a specialist in John F. Barnes technique of MFR, which is a much gentler approach to releasing the tissue tension than the traditional way. Typically they will wear a glove and push their fingers against pressure points inside of your mouth (in the cheek or back of jaw) and they hold it for 2-6 minutes until the tissue releases; this is highly painful but extremely relieving afterwards.When I think of the jaw-joint, I compare it to the wrist-joint. A lot of woodwind players or typist get carpel tunnel, which is connective tissue built up in the wrist. The same thing can happen to our jaw-joint...it too can build connective tissue and cause our jaw to be unaligned, in pain, cause TMJ, or build more tension.

• *Rolfing - It is very similar to myofascial release to an extent. It is a holistic system of soft tissue manipulation and movement education that organizes the whole body in gravity. It is essentially identical to structural integration. The difference between myofascial release is the cumulative process over ten session. Although myofascial release techniques derived form the work of Ida Rolf, it does not have the same strategic planning as rolfing. The various parts of the human body relate synergistically to each other, therefore rolfing integrates the whole body or various parts of the body, rather than focusing on one central area.

• Andover Educators - This is actually not a method, but a service. I wanted to list this here as a resource. Bodymap.org is the home of Andover Educators, a non-profit organization of music educators committed to saving, securing, and enhancing musical careers by providing accurate information about the body in movement. 

Some Alternative Medicine/Therapies (Part 1: Non-traditional Medicine or Treatment) for Facial Pain, Trauma, and Dystonia

PART 1: NON-TRADITIONAL MEDICINE OR TREATMENTS

Happy post-day-of-Halloween! Here are a couple of things that may possibly support the recovery process for various facial ailments such as TMJ, Nerve Damage, Muscle Tears, Bell's Palsy, and Focal Embouchure Dystonia.

Again! These do not cure, nor is there any guarantee that this will help you. There is research on some of the methods applied to specific issues, for example - Bell's Palsy and Acupuncture, which can be found online.

However, embouchure dystonia doesn't leave you with many options, and when there is no known cure, one cannot help but do what is natural and test/observe various treatments through trial and error in the hopes of finding a small glimmer of hope.

It is important to realize that there are few musicians with dystonia that go out on a limb and share their personal process and do trial and error publicly. It is important to share the process, even if it cannot be applied to all. It is my hopes to bring more awareness of this disorder and provide a rare look at what this disorder can be like by sharing my own experiences. Although my experience is subjective, I am someone who thinks objectively, therefore I posted the statement above.

•  Acupuncture, provides blood flow/circulation to specific areas and activates the nerves. I received acupuncture for once a week, for a year. It wasn't until about my 15th session I started to feel and notice drastic improvement in reduced tension overall in my face. It cost about $65.00 a session, and my acupuncturist had a passion for helping people with facial trauma.
  
  She had previously helped many people overcome Bell's Palsy, Nerve Damage from car accidents or injuries, etc. She also was certified in John F. Barnes Myofascial Therapy, so that was also included in my sessions.
  
  Just a note of caution though: I did find that the acupuncture made my nerves in my face very overly sensitive and it took about 2 years to fully wear off. At times it limited me from playing because my muscles were so loose (like jelly) and my muscles/nerves could only handle so much playing. I had to be very careful when working on my playing. I also would not suggest playing at all if you are receiving re-ocurring acupuncture treatments because the acupuncture is actually quite exhausting on the face because it is bringing in so much blood flow to a centralized area. Most acupuncturists will tell you to drink lots of water and to rest a lot after receiving treatment.
  
  I also would say that if you are going to try acupuncture, to consider doing as a last resort. Although I felt it helped me in the long-run, it was scary how overly sensitive my muscles and nerves became. The best example I can give is if you received a muscle relaxer. It feels great and there's not tension whatsoever left, but you're also left with no endurance, strength, and the muscles and nerves are much more sensitive to playing and get twice as sore. So please be careful. Maybe don't do a years worth of acupuncture and only do it 2 times a month or not every month.

• *Oral Myofascial Release (MFR), which released built up/rigid connective tissue or fascia in the jaw-joint and muscles surrounding the face. My acupuncturist was a specialist in John F. Barnes technique of MFR, which is a much gentler approach to releasing the tissue tension than the traditional way. Typically they will wear a glove and push their fingers against pressure points inside of your mouth (in the cheek or back of jaw) and they hold it for 2-6 minutes until the tissue releases; this is highly painful but extremely relieving afterwards.When I think of the jaw-joint, I compare it to the wrist-joint. A lot of woodwind players or typist get carpel tunnel, which is connective tissue built up in the wrist. The same thing can happen to our jaw-joint...it too can build connective tissue and cause our jaw to be unaligned, in pain, cause TMJ, or build more tension.
  
• *Rolfing - I haven't received rolfing, but wanted to list it here. It is very similar to myofascial release to an extent. It is a holistic system of soft tissue manipulation and movement education that organizes the whole body in gravity. It is essentially identical to structural integration. The difference between myofascial release is the cumulative process over ten session. Althogh myofascial release techniques derived form the work of Ida Rolf, it does not have the same strategic planning as rolfing. The various parts of the human body relate synergistically to each other, therefore rolfing integrates the whole body or various parts of the body, rather than focusing on one central area.
  
  *I've listed Myofascial Release and Rolfing also on my blog post over Body Movement Methods too. Since it crosses over into that area as well.

• TENS unit, which sends electric pulses that interfere with the signal of pain being sent to the brain, it stimulates the nerves and endorphins, and helps control pain. This allows the muscles to relax instead of being in a state of contraction all the time (which dystonia causes our muscles to be in a state of chronic contraction...therefore the TENS helps me a lot). I use to receive a light does of TENS unit or electromagnetic therapy in acupuncture, but it wasn't until I started seeing a neuromuscular dentist that I used a heavier dose of TENS unit therapy which helped me tremendously. Now I  even have my own TENS unit at home after borrowing a friends for a while...decided I needed to invest in one for long-term relief.
  
  I feel like the TENS unit is more effective than acupuncture in relieving tension. Acupuncture was too over the top. Whereas TENS unit I can control the strength of output, and it doesn't overly-relax my face to the point of weakness. It helps relieve the right amount of tension. It takes time to get use to knowing how to use it and works best.

• Po Sum On Oil, which can help with many ailments, including neuralgia. It provides deep muscle pain relief, headache relief, etc. It consists of Peppermint Oil 45%, Dragon's blood 1%, Cinnamon oil 1.5%, Camellia oil 100%, and Methanol 15%. It only cost about 6 bucks or more for a little bottle which will last forever. 

• Ice packing/Heat packing. Alternating the two is highly important! Sometimes I will drink hot tea instead of heat packing, and then apply ice pack between drinks. I'll hold the tea in my mouth so that it warms up all my muscles.

• Facial Muscle Stretches. i.e. Making certain facial expressions or movements to help relieve tension. I have various names for them too like duck lips/goldfish lips, the scrunchy face, the clown-frown, the angry brow, marshmellow cheeks, the horror screamer, the side-grin, etc. 

• TMJ Jaw Stretches. i.e. Specific jaw stretches that help the mandibular joint. (I'll try to find a link to post on here of some stretches I use)....also buying a mouthguard may help relieve jaw pressure, even if you don't have TMJ.
  
• Tongue Stretches

• Neck and upper back stretches, which help relieve tension and keep the muscles flexible in the neck and upper back. (I posted a link somewhere in one of my posts on the stretches I use, I'll try to find it and repost it here)....this is important because the neck and shoulder muscles DO pull on the jaw muscles. They are all connected and work together. Think big picture! :-)

• Taking off as much external pressure on your upper body as you can. Ex. Not wearing backpacks, heavy instrument cases, non-supportive or constricting bras that may dig too far into the shoulder, baby slings, avoiding lifting heavy things that require the shoulders or upper back. If you have pain at all on a certain side of your face, avoid sleeping on that side. If you have clenching problems with your jaw, avoid putting any pressure on the bottom of the chin/jaw when sleeping and practice holding the tip of your tongue in between your upper and lower teeth...this takes the pressure off the jaw immediately. Even if keeping your hair down and not pulled back it into a bun helps lessen muscle constriction on the face/head, then do it. 

• Taking daily vitamins - keep your body provided with enough nutrients. I take women's one-a-day, and also GinkoSmart, and sometimes Fish Oil. There's also men's-one-a-day. It just depends on what your body needs or what you think will help boost your nutrients. It can even be in the form of a shake.
  I also write a blog on natural supplements.

I'm hoping to come back and add more to this post, because there's quit a bit more detailed information I'd like to share about each area. But for now, if you google any of the things I listed, you should find a wealth of information.