Prevention Revisisted

I've been going back and editing some of my past blog posts. Here's the most recent one I've been working on, "Is Focal Embouchure Dystonia Prevention Possible?"

New Website! - Focal Embouchure Dystonia

I finally designed a website to link to my blog thanks to a friend recently advising me to do so. I still have a lot more work to do on it, but maybe this will help me reach my advocacy goals and spread more awareness, and provide guidance. Thank you to those who take the time to check it out!

I'm also in the process of updating my blog and rewriting important blog posts, editing, and adding new sections. Thank you for your patience as I go through the process of cleaning house on my blog.

- Katie

https://www.focalembouchuredystonia.com/

October: Monthly Shared Articles

First article is titled: "What DOES it take to be a Professional Orchestra Musician?" 
This blog post also points out something that is a significantly huge part of preparing for focal dystonia rehabilitation! Changing your mindset from a performance technique mindset to an exploratory mindset full of love, creativity, and adaptability. 

Everything taught to you haas to go out the window. Foget it all (i.e. all knowledge and practice of technique, embouchure formation, setup, proper breathing...). Literally have to deprogram everything so you can start over and start physical rehabilitation from a healthy mental place. Not easy because musicians instruments and reputation are woven tightly into their identity.

What a great article! If you're like others who lean more towards this side, do whatever it takes to regain even a little ownership of your own voice/sound and expression in music. This is why guitar has always been my secondary instrument. It allowed me to feel creative and free of many limitations at times, or when demands got tough. 

Second article is titled: "Focal Dystonia of the Hand and What the Brain has to Do with It"

A glimpse at part of the article:

 "We get similar effects in blind people who read Braille with several fingers at once: they develop a single representation of all these fingers on the somatosensory cortex, but are not able to determine which part of the information received in the brain comes from which finger. Psychologist Thomas Elbert further points out a parallel of this in all of us: our toes are generally stimulated only simultaneously as we walk, and most of us have trouble telling which of the middle toes has been touched upon application of a light pressure stimulus. Indeed, our toes are not individually represented on the somatosensory cortex as our fingers are."

"Dr Merzenich of the University of California San Francisco calls focal dystonia of the hand a “learning-based catastrophe” and a “failure of the brain’s learning processes”. Consequently, he focuses on developing techniques that will help to “re-normalize the learning system”, in helping to newly distinguish the areas on the somatosensory cortex that have become blurred. Although this approach is very new, Merzenich claims some good results in training children with linguistic impairments, such as dyslexia, which show similar blurring of representations in the brain."

PAMA Referral Listing

I am now listed on the PAMA website as a referral. I registered encase anyone needed someone to talk to about FTSED and having trouble finding information on the subject. Again, I'm only doing this for the purpose of leading others to information, research, and/or help with FTSED if they are diagnosed with it and are unsure of where to go/what to do.

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. :-)

Month of March Research Articles

Apologies for not imputing much into my blog this year! My first year teaching has been one of the most challenging, yet rewarding blessing in my life. I'm finally doing what I love, but do feel a bit sad over not having enough time to tend to my blog. This blog means so much to me! I'm writing to you from the desk in the photo...I finally have a place to work at home. Until summer rolls around, I'll be posting mainly resources/research articles.

Here are two research articles I've read recently. I'm been searching a great deal to find information over tests focused around the somatosensory part of the brain in musicians with dystonia. Last month I posted an article that explains what acetylcholine is and how it supports the CNS/PNS systems (and the somatosensory cortical neurons).

The first article below is pretty self explanatory; how we should focus on somatosensory, as it may be another key component in research on musician's dystonia, and what these researchers have found. The second one involves some EMG electrode work in stimulating muscles of musicians who have dystonia and how this has helped restore sensorimotor organization.

That is all for now! I will post more if and when I can. Thank you to those who have reached out...I promise to be in touch as soon as possible.

Focal Dystonia in Musicians: Linking Motor Symptoms to Somatosensory Dysfunction

Regaining Motor Control in Musician's Dystonia by Restoring Sensorimotor Organization

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. 

Berklee College of Music: A New Understanding of Overuse Injuries by Dr. William F. Brady, D.C.

I just had to share this amazing find! It is an article titled: A New Understanding of Overuse Injuries by Dr. William F. Brady, D.C. Please read the article linked, because it provides a new way of looking at overuse injuries or repetitive strain. I highly recommend it.

I find this highly fascinating because my acupuncturist and myofascial therapist told me a similar thing when I went in for treatment. She said that part of my problem was built up connective tissue in the back of my jaw. She felt around my face and the inside of my mouth (I know, weird) and said I had an overwhelming amount of it.

So I basically went under several months of myofascial release therapy where she released the connective tissue from the inside of my mouth by using pressure. The connective tissue started in the middle of my cheek and went back deep into my jaw and even as far back as the corner of my lower jaw. Equally important is we worked a lot on releasing tissue and tension around my whole upper body, and predominantly around my neck.

Many other forms of therapy such as rolfing and feldenkrais use similar methods of helping the body release tension. It was very very very painful releasing the tissue. But! It was definitely needed and it actually changed the way my face looked and felt (my right side of my lip and face looks more equal to my left now without the upper lip pulling back and upwards on that side, which gave me a weird appearance). I wish I had known about it before, even as a non-injured musician in the past! A professional European horn player told me that he also received this, even if he isn't injured because it's important to take care of the body. Warming-up is always not enough.

We have to treat our bodies like athletes, even if it's use of smaller muscles. A lot more goes into playing than we give credit because we are not aware, and tension can build up over the years....and not necessarily because we're doing anything wrong, but because it is natural. Some people can take a beating for years and years and not feel anything, whereas others are more prone to overuse because of their physical makeup, or even genetics in the case of onset of dystonia.

We just have to take extra measures that are not traditional to keep check on tension....which is hard to do since most often injuries sneak up on us and slowly degenerate our ability over time before we are even aware of it.

Also a lot more muscles come into play than we know. Most brass musicians consider their embouchure as only the use of the muscles around the lips, and never understand the actual anatomy or function of the muscles in the face (where the muscles connect to, what each on initiates) and that the neck and upper back muscles make a great impact on your playing too, since they tie into the facial muscles and nerves around the jaw.

Additional notes: Thank you to Scott King, DC for getting in touch with me! If any injured musicians are in the Denver/Colorado area and looking for soft tissue diagnosis and treatment, Scott is available and has trained with Dr. Brady who wrote the article I shared above. I offered to share his contact information below:

Scott King, DC
Novo Soft Tissue & Spine

720 S Colorado Blvd Ste 610S

Denver, Co 80246

(303) 990-0159

List of Performance Arts Clinics

I've been so busy with school that I haven't had a chance to write a blog post for the month of October AT ALL. So I'll try to post 2 blogs this month. Right now this current post is a draft. I want to make a list of performing arts clinics around the U.S.

As you can see, I just started this, so let me know if you want to add any and I'll upload the link, or post in the comments. On a different note, just want to say I have 4-5 weeks of fall classes left and then I get a break, which I'll be posting quite a bit within my time off. See you soon! I miss writing on my blog, so hope to get back to it soon!!!! - Katie Berglof

University of Michigan

Allina Health - Minneapolis MN

Performing Arts Rehabilitation Institute of Chicago

Bringham Performing Arts Clinic - Boston MA

Virginia Mason Clinic - Seattle WA

Cleveland Performing Arts Clinic

List of Performing Arts US clinics

New York Presbyterian Clinic

Musicians Clinic - Texas

Performing Arts Physical Therapy - Boston MA

UNT Performing Arts Medicine Clinic

Al Hirschfeld Health Clinic - New York

100th Post! Facial Myofascial Release, Acupuncture, Embouchure Dystonia, and Nerve Damage Work on my Face

I think it was 4 weeks ago I had gone on a 2 and a half week stretch without acupuncture. I began to feel the soreness in my face start to creep back in and I had no idea what was going on. Things seemed to be getting better until then.

I was becoming worried. Also even though I'm only allowed to practice 15 minutes a week, I noticed my face was pretty weak due to the intensity of the sessions, so I backed away a bit and have been avoiding my horn as much as possible. However, when I did play, it seemed a lot worse...and I just didn't want to push myself. I realize it's going to take a lot more time.

When I went to my acupuncture appointment I realized my original acupuncturist must have went on maternity leave since there was someone else standing in. We went over my symptoms and paperwork. Surprisingly she specialized in (barnes?) myofascial release and acupuncture. She had some facial damage after a car accident a long time ago, so she knows what it's like being in pain.

There is a huge difference between myofascial release and just a facial massage. I don't know a whole lot about it yet, but will post more links after do some reading. She told me that repetitive movement (such as what I do with my jaw and facial muscles when I play horn) causes the body to build up connective tissue to reinforce the protection of the muscles from being overworked. This tissue becomes too strong and can cause a lot of problems such as nerve entrapment, TMJ symptoms, spasms/involuntary contractions, pain, and can cut off or lessen blood-flow to certain areas of the limb/body part.

She could tell immediately that the right side of my face had a lot of tissue built up and was tense....not soft tissue like it should be. She could see the left side of my face was the side that was weak and not moving properly. The right side also was so tight that the skin was pulling my lower lip....which is what I always see most noticeably when I play horn. Also when I open and close my jaw, the right side has so much tightness that it closes first more than the left side, and the left side is able to go down further when I lower my jaw.

Her aim in the first session was to release some tissue in my face and then do acupuncture to increase the blood flow to the trigger points or areas needed. This required her to push against the tissue on the inside of my mouth. It was very painful!!!!! But! Afterwards the reward was an enormous amount of relief of tension form my face. She was surprised to see an immediate softening of the tissue in one area, and even I could feel how soft my right side had started to feel compared to how it felt before. Even when looking in the mirror, I could see that my physical features were more aligned.

Even more pleasing, was how much less tense my jaw was when I slept at night. I feel like my right side joint had been able to close properly or seemed to sit properly...if that makes any sense. I had always felt like my jaw had been becoming more and more misaligned and thought maybe it was a wisdom tooth coming in or something, but the dentists said I had none coming in.

She's also working on opening up my C1 ...which I think is the cranial nerve?
I am really surprised as to what acupuncture is teaching me. When I first came in, I never expected for things to get so intense, as I only had a slight bit of throbbing in my cheeks...but thought it was because I had been playing a lot in rehabilitation. I never thought much about it. But the sore muscles became more constant and eventually became chronic soreness.......but it always remained in just the center of my cheeks. But once I received acupuncture, it's like all my nerves flaired up, sending signals. I felt certain areas all over my face start to feel sore, and I realize that these types of signals area always signs pointing to the fact that there's something wrong or that there's something more going on besides just the embouchure dystonia symptoms, or just the soreness in my cheeks.

However, the more I received acupuncture, the more relief I've been getting. But the myofascial release I believe is exactly what is getting to the source of my dystonia and pain relief. Acupuncture has helped with the nerves and blood flow in my face, and it's definitely done a lot to help, but myofascial has made such a huge difference in the structure of my face and feeling of my face from the inside-out, that I can't help but notice how significant it is to my recovery....and I've only had two myofascial sessions so far.

Anywhoo! I feel like it was a blessing or miracle that I met her!!!! I'm so glad she knows what I'm going through since being through something similar but different, and her passion about helping those with facial trauma means a lot! I got that feeling like I had fallen into the hands of the right person at the right time. Divine timing!

The soreness in my face was most noticeable near my ear and back of my jaw when I first started acupuncture in November. However after one session of myofascial release, it has now moved to primarily the front of my face and behind my ears, and the back of my head. I also am not allowed to play my horn at all. Which I think is really good. I can do this! She said that if the muscles are always in contracting-mode, they will remain contracted. We must teach the face to have the natural reflex of relaxing again. The body has "contraction" built into it now, and it takes a lot of repetitive work to reverse this and teach the body to relax instead of contract. That is the aim. So playing my horn would just reinforce contractions in my face, so I need to wait until I'm 100% recovered before trying anything again. And even then, I will have to of course relearn how to play my horn avoiding as much tension as possible.

I think myofascial release would be great for even non-injured/disordered musicians. Like sports medicine, but for musicians; it's good to have a licensed professional release some of that tension from the body from time to time.

I am really grateful to God for bringing these people into my life. My acupuncturists have changed my life and I have so much hope and faith with the relief they've given me in this short amount of time. I will do whatever it takes and be patient with however long it takes to make sure my face is relieved 100% of tension! :)

Is Focal Task-Specific Embouchure Dystonia Prevention Possible?

Focal task-Specific Embouchure Dystonia is no walk in the park, and there is not much hope to be given in this area of discussion. Currently there is no known prevention. The very blunt answer would be no, it is not preventable.

The best thing you can do is try to understand the signs and symptoms thoroughly, and know the difference between dystonia and other performance-related injuries in the hopes of getting an accurate diagnosis when things get really bad; especially the difference between focal embouchure dystonia and overuse injury which are often mistaken as the same thing, but they are completely different.

The reason why overuse and embouchure dystonia are often mistaken as one another is because the symptoms during onset are very similar. The key difference is that embouchure dystonia does not elicit pain (yet it does come with a lot of tension/resistance when trying to play).

COMMON INJURIES & SETBACKS

With overuse injuries a player will usually go through a period of time where they are playing more, have added responsibilities, and they start to see a degradation in their higher register and usually start to exert abnormal pressure to try to hold it together and end up with swelling, pain, tingles, sometimes this leads to other injuries like muscle tears or nerve entrapment. The upper lip or obicularis oris in general starts to feel rubbery, stiff, sometimes there are slight tremors or twitches, and eventually if very bad, no ability to produce a sound occurs. Overuse can sometimes be a result of improper technique or bad habits, but not all the time. It can be as simple as ignoring signals of pain, or not taking them seriously enough and taking improper care. Unfortunately musicians are not taught enough about medical care or preventative care from strain injuries such as how to properly ice/heat pack, stretch, myofascial release, use of guards etc. Usually taking a month or two off from playing, ice packing/heat packing and rest improves things and playing resumes to normal. If it is a result of bad technique/habits, then focusing on those areas will show improvement.

If a secondary injury occurs like a muscle tear or Satchmo's Syndrome, a player will usual feel a striking/jabbing pain in the upper lip that feels somewhat like it's been pierced with a needle. Usually there is a bump/small lump in the upper lip you can only feel when rubbing the inside of the lip with your fingers. It will hurt when playing with the mouthpiece on that area and/or after playing for a short time in the upper register.

Never entrapment will feel similar, but mainly tingles in the upper lip, jaw, or other area of the face, and no noticeable bump or jabbing pain. I don't think this is common. There are some brass players that develop nerve entrapment in the upper lip due to a perturbing incisor tooth digging into the lip and there will be swelling that runs from the bottom of the lip up to the nose on the inside, tingling, sometimes a dullness to the pain. The tooth can be filed down or corrected with braces.

Both nerve entrapment and muscle tear early signs are tingles. If you feel any tingling at all, you need to take time to rest and properly take care of things. Even if you feel the tingles go away a couple hours after playing...it is not good enough to just assume things are getting better, especially if it occurs every time you play and/or on a consistent basis. You need to figure out what you are doing or what is causing the body to signal that something is wrong.

Bell's Palsy is when one side of the face is paralyzed/lacks mobility and the other side doesn't. This is very noticeable right away visually and physically. A player will find it difficult to eat, talk, there will be a noticeable droopiness to the paralyzed side of the face and lack of ability to move anything on that side, especially near the eye. Noticeable drooling, decreased taste, no ability to close or open the eyelid, pain and numbness behind the ear (where the facial nerves branches out from), and sometimes an increased sensitivity to sound; everything seems louder. The paralyzed side will feel extremely weak and sometimes there are twitches that occur.

TMJ - pain in the jaw joint, soreness around the back of the jaw, difficulty chewing or eating due to the pain, popping in the jaw, all of this on one side or both sides of the jaw. Sometimes lock-jaw...meaning difficulty opening or closing the jaw. Pain when trying to open the jaw wider. Sometimes headaches, and sometimes a feeling of unevenness in the jaw closure (teeth don't feel aligned), accidentally biting the tongue or cheeks. In low brass playing sometimes lock jaw. It is common to see TMJ in woodwind players such as clarinetist, sax, etc.

There are several other ailments a musician can encounter that I have not listed here such as tooth infections residing in the jaw, gland infections/mouth stones, other forms of severe nerve compression, other related dystonias like oromandibular dystonia, etc. It helps to educate yourself on the various ailments and trauma that can happen to the upper body and face, and know your anatomy and nerves, etc.

Focal embouchure dystonia onset is hard to recognize and diagnose because the signs and symptoms are very similar to other setbacks. During onset of embouchure dystonia a player will usually be going through a period of time with increased performance responsibilities or working a lot on repetitive practice preparing for something or in an environment where a lot of emphasis is focused on technique. There might be an embouchure change focus too. There are a multitude of things that are known to possibly harbor breeding grounds for dystonia. However, it is without a doubt a multi-faceted neurological disorder that occurs out of the blue and very sneaky to catch.

Like with any other injury/setback, they might be experiencing a lot of stress or taking on a lot of work, but with embouchure dystonia, despite stressors, usually the player is at the height of their playing career or feel their playing is the best it's ever been; things usually feel natural and easy and at peak performance ability. Usually they are late starters, extremely fast learners, high achievers, and not all, but most are are in leadership positions. Though it is not uncommon to see why professionals usually develop the disorder, amateur enthusiast do too and usually hold common characteristics.

During onset there is no pain. Yet a player will notice small things that occur that phantom technical/mechanical issues. For example, there might be a slight air leak in the lower register, or a slight tremble on notes in the lower register that come and go, or troubles with certain interval jumps that usually aren't an issue. There is a feeling of loss of endurance sometimes (not painful, but like can play something one time through, but the second time feeling a lot of resistance while playing and like there's a lot of overshooting notes, missing notes, or not being able to land on notes when doing certain interval jumps).

The common symptoms (yet not everyone develops every single one of these symptoms, so just because you don't have all these symptoms, doesn't mean you should just disregard it...it's usually a combination of any of the following) of embouchure dystonia can be: range-specific (having troubles playing in one register), dynamic specific (having troubles executing decrescendos but not crescendos or vice versa, troubles playing quiet, but not loud or vice versa), articulation-specific (can articulate scales going upwards but not downwards, or vice versa, or no ability to tongue at all, or can articulate at a fast tempo, but not at a slow tempo or vice versa), tempo-specific (can play things fast, but not slow or vice versa). Other signs are lock-jaw in low brass/woodwinds with no pain, aperture clamping (the aperture closing shut randomly while playing or spasming shut), if symptoms are most noticeable in the tongue (inability to articulate passages) or very intense it can carry over to other tasks like drinking out of a water bottle and sometimes speech (tripping on words). Most all, but not everyone, notice a lack of symmetry to the face - not so definite as bell's palsy, but one side of the face will seem less responsive than the other side. Air leaks are common as I stated before too.

Usually the player will increase their practice time or focus on correcting these specific issues with technique, or the opposite, trying to rest, but to find it only made things worse. The symptoms are gradual and they seem to layer on top of one another over time.

For example, I noticed a small air leak in my low register, then later on I noticed I had troubles decrescendoing while doing long tones, my muscles would give way. Then I couldn't do large interval jumps, I had to slur them. Then I had troubles tonguing things in descending passages later on, and when I looked in the mirror, my embouchure would look stable for 5-10 minutes, and the second time I tried to run through a passage, my embouchure started moving a lot all over (looked like I was chewing a wad of bubble gum in my mouth while playing). I started to notice loss of smaller interval control, and after focusing on my lower register studies, it made things worse, and after taking time off, I had uncontrollable and intense spasms and tremors.

Some players will go so far as to continue playing on an unstable embouchure due to performance responsibilities and/or obligations, and this increases a secondary injury factor. Some will develop overuse symptoms on top of their embouchure dystonia symptoms because they are forcing their embouchure to stabilize via pressure or just by continuing in general and result in swelling, etc. and at worse a muscle tear, and possibly TMJ/jaw strain or pain. Even if there is a secondary injury, usually after resolving it, the embouchure dystonia remains. The key difference is that overuse injury/syndrome and other injuries is that they can be prevented and/or cured with rest, medical care, and significant time off. Dystonia will only worsen over time with or without rest, and correcting things will not help either.

You can see why onset is so hard to catch and especially how it can be mistaken as other setbacks during the early stages. Even though we don't know the etiology of embouchure dystonia, we know that it manifests as a neurological disorder. Not only is it neurological, it seems selective, and with that said, it is most likely inevitable. There might be no stopping it even if recognized. Hand dystonia is much easier to catch and has some cases of prevention during onset, whereas embouchure dystonia, not so much.

Even if it was, the embouchure is extremely difficult to navigate while having dystonia and there are few rehabilitation strategies if none that have been documented, tested, or that can be applied in the hopes of prevention.

That is why I document my rehabilitation, because no one else has ever attempted to publicly in history.

EMBOUCHURE DYSTONIA PREVENTION

It is not realistic nor correct to tell musicians, "Avoid placing yourself in situations where you are playing more than normal, avoid bad technique or bad habits sneaking in, don't use too much tension, and avoid using too much pressure, try to take care of anxiety or nerves, etc. " BECAUSE EMBOUCHURE DYSTONIA IS NOT A RESULT OF BAD HABITS, BAD TECHNIQUE, PRESSURE, BUILT UP TENSION, LACK OF AIR SUPPORT, PERFORMANCE MENTALITY, or whatever else you want to try to re-label it as!!!!! (Sorry, I got a little angry there...but this re-labeling trend is part of the problem and a bigger issue to address in writing later).

By telling musician's to avoid common situations that we are all usually placed in at one point or another, is like telling a musician, "You might as well not try at all. Your safest option is to not play music at all, because you might injure yourself or develop a rare neurological disorder called dystonia."

If you notice a change in your playing and it seems to be of concern, your best bet is to keep a journal (written and/or video) observing your playing and document any changes over time. If you feel like it might be dystonia, focusing on standard technique or repetitive tasks in your playing will degrade you further. Avoid it if can, but even avoidance won't help necessarily. If you can take time away from playing, do so not to rest, but to carefully observe your symptoms and note changes.

If you feel it is embouchure dystonia, then stop playing immediately, remove yourself from your current environment if can, seek out a neurologist who has diagnosed and/or researches embouchure dystonia....though most will not diagnose you during early onset because it is too early to tell, they might (not guaranteed) provide you with some temporary medicine to try tetrabenazine/artane, risperidone, etc. that might provide temporary relief...however, these are used to suppress symptoms, not cure them, and there is no promise it will regress the symptoms. It is important to get tested in order to rule out any other possible ailments in the blood work and brain scans.

Other things you can do is try increasing your dopamine levels through dopamine supplements or anything that might affect serotonin too. You can also try tremor supplements that are not drugs, but nutritional supplements that can be found online. Look for supplements for essential tremors or tremors in general. I do find these have helped me, but again it's not the same for everyone. There's all kinds of alternative holistic therapies and supplements you can try.You can look at my left hand side-bar and it covers several alternative-medicines and therapies.

If you have dystonia, a sensory trick might work. Does touching areas of the face when spasms occur cause the spasms to stop? does placing something between the teeth cause things to stop? (like a cotton ball, mouth guard, etc.).

I also would suggest that if you think it is embouchure dystonia...and even if it is not....you should start implementing stretches in the upper back, neck, jaw, tongue, and face every day. This should already be a part of any routine, but not often taught to students. It helps take away tension from fighting the symptoms.

Sadly there is no preventative measures. Everything that I have suggested here can only aim to possible temporary relief, and/or reduce of symptoms maybe at best.

Like I stated before, educating yourself on signs and symptoms is best and seeking out help when it is time. After you have been diagnosed by a reputable neurologist, seek out a rehabilitation practitioner who aids in the recovery process.