Focal Dystonia and Retraining the Hand

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guit-box
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Re: Focal Dystonia and Retraining the Hand

Post by guit-box » Mon May 22, 2017 5:17 pm

renlute wrote:
Sat May 20, 2017 10:11 am
While I do not purport to be an authority on focal dystonia myself, I am currently collecting and editing a series of articles by and about Patrick O'Brien, the late New York City guitar and lute teacher who cured himself of severe tendinitis in the early 1970s and spent much of his subsequent 40-year teaching career coaching guitarists and other musicians who had acquired FD, tendinitis, carpal tunnel syndrome and similar disorders. Several articles will constitute testimonies about successful FD therapies of his -- in the patients' own words. Pat believed the afflictions were usually acquired by faulty technique. He told me (in 2012) that he had observed distal flexion -- overuse of the tip joints of the right hand -- to be the cause of FD upwards of 80-90% of the time. He spoke from a perspective of observing hundreds of his student patients during four decades, and referred to the legendary pianist Glenn Gould, who inadvertently ended his career with FD by sitting lower and lower on the bench and thus engaging the DIP joints excessively. Pat's success rate was not perfect, but was apparently better than the low estimates I read about in neurological journals.
One of our testimonies is from a guitarist whose very complex case improved very substantially under Pat's guidance, but recovered still more years later with David Leisner. Leisner's therapeutic technique is remarkably distinct from Pat's, but once explained (though I admittedly understand it only vaguely), it seems to make sense. The mere fact that Leisner had become disabled but has recovered to the point that he plays as astonishingly well as he does now, indicates that he must have an understanding of the issues that has to be respected, even if it does not work for everyone. The method itself is not always the cause of failure in an individual case, whether it be O'Brien's or Leisner's, since there are other factors involved that are still being researched.
The series of articles I refer to will be published in the Journal of the Lute Society of America starting within the next couple months. The clinical studies won't be in the first memorial issue for Patrick, but in it, Pat lays out his most fundamental understanding of the anatomy of the hand and the reasons why distal flexion and a couple other fairly common technical mistakes can cause harm.
Douglas Alton Smith, Consulting Editor, JLSA
I had lessons with both of them in the mid-1990s and tried both of their ideas for months before abandoning them both. I'm still on the fence about distal flexion, certainly many players do rest strokes by letting the DIP collapse, but other don't do that, and it's less common in free strokes. I can play my guitar left handed and my distal joints will not collapse at all (probably because I trained them not to for pull offs) and I can perform excellent rest and free strokes with that hand with no collapsing. So, I'm suspicious of his teaching on this subject. Leisner is another case, I don't believe anyone can play the guitar by swinging the whole arm at the strings, that method is bogus and I've heard from no one who has learned to play again using Leisner's method. I would love to hear some names of O'brien's or Leisner's students who recovered from focal dystonia after following their advice. -- maybe they exist, but I'm not aware of anyone.
An eyewitness will often only see what he already believes to be true.

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Re: Focal Dystonia and Retraining the Hand

Post by Dofpic » Mon May 22, 2017 9:54 pm

guit-box did you switch to playing left handed?

I took lessons from Pat in the late 70's just regular lessons and he was a terrific teacher and my playing really improved in a short time. i recently spoke with someone who while not a concert player said that Leisner method helped him as a finishing exercise for keeping his hand relaxed. Mark Ashford a fine english player told me he worked with Leisner that helped him but he started with Leisner then went to Kathryn Butler a hand therapist from London who was the most helpful. Another person I just spoke with thinks an all of the above approach is the way to go as no one has a magic pill but used in conjunction can work . He is going to fund a study at Johns Hopkins on this...
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Re: Focal Dystonia and Retraining the Hand

Post by renlute » Tue May 23, 2017 5:43 am

Three of the half-dozen patient reports about Pat O'Brien's therapy are former focal dystonia victims who recovered completely or virtually so. One tells me that he was mostly recovered after working with Pat and then Leisner put him over the top. The names and their detailed stories will be published within a couple months I hope; I 'm still chasing tardy submissions from a couple volunteers.
I you understand why Pat thought distal flexion was a risk, then you can't deny that it makes perfect sense. The underlying problem, Pat explains, is the structure of the flexor digitorum profundus, the muscle that flexes the tip joints but also causes simultaneous cocontraction of the extensors for the same joints. It's continuous cocontraction of opposing muscles that confuses the brain, Pat thought.
Leisner's technique is less easy to understand, since the use of the full arm to pluck a string appears at first to make no sense. But this is only the first step. He works down to the smaller joints eventually. As it was explained to me by the successful patient, it sounded logical though very different from Pat's direct retraining and focus on the small joints.
I should add that if you don't believe in a technique nor conscientiously follow the directions, then it is likely not to work. This axiom applies to many other endeavors of course. I'm collaborating on a study of this issue right now, the elements that may contribute to failure of a therapy.

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Re: Focal Dystonia and Retraining the Hand

Post by renlute » Tue May 23, 2017 5:47 am

I should add that New York pianist Dorothy Taubman seems to have discovered the problematical distal flexion independently of Patrick and about the same time. Neurologist Frank Wilson mentions both of them in his explication of the issue in his book The Hand, page 357.

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Re: Focal Dystonia and Retraining the Hand

Post by guit-box » Tue May 23, 2017 7:54 pm

renlute wrote:
Tue May 23, 2017 5:47 am
I should add that New York pianist Dorothy Taubman seems to have discovered the problematical distal flexion independently of Patrick and about the same time. Neurologist Frank Wilson mentions both of them in his explication of the issue in his book The Hand, page 357.
I watched many hours of Taubman videos on focal dystonia. It was 20 years ago, so I don't recall them very well. I remember a lot of it was about using the rotation of the forearm back and forth to produce notes on the piano, which for me didn't seem to translate to guitar well. I don't recall what she said about the distal joint.

I suspect the issues may be somewhat distal joint related, but I more suspect an over-use of MCP flexion and not enough PIP flexion. I've been told that virtuoso piano players use lots of PIP flexion. There is a limit to how much MCP flexion is helpful and then you're just using too much force and that excessive tension may, over time, contribute to the problem. All that unnecessary tension over time probably shuts down the hand for some people.
An eyewitness will often only see what he already believes to be true.

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Re: Focal Dystonia and Retraining the Hand

Post by Blondie » Wed May 24, 2017 8:36 am

renlute wrote:
Tue May 23, 2017 5:43 am
I you understand why Pat thought distal flexion was a risk, then you can't deny that it makes perfect sense. The underlying problem, Pat explains, is the structure of the flexor digitorum profundus, the muscle that flexes the tip joints but also causes simultaneous cocontraction of the extensors for the same joints.
renlute wrote:
Tue May 23, 2017 5:47 am
I should add that New York pianist Dorothy Taubman seems to have discovered the problematical distal flexion independently of Patrick and about the same time. Neurologist Frank Wilson mentions both of them in his explication of the issue in his book The Hand, page 357.
And in the classical guitar literature, Christopher Berg addressed this issue of co-contraction at length in his book published in the 90's, 'Mastering Guitar Technique: Process and Essence'.

Berg's book remains, as far as I am aware, the most detailed exposition of cg technique derived from an anatomical understanding of hand function. His work is fully referenced, and he devotes several pages to the tip/distal joint, explaining the multiple problems caused by deliberate continuous flexion of this joint. Whether or not this can lead to FD (and Berg makes no mention of FD) remains to be proven, although the risks of injury are very clear and it is extraordinary that there are several respected pedagogical works out there (often recommended on this forum) that instruct students to make a conscious effort to keep the distal joints firm.

None of my teachers advised me to keep my tips firm, but in my quest for volume and speed its something I unconsciously did, and I ended up with FD.

I'd b interested to hear more about these 'other' technical problems Pat observed - the ones you mention earlier.

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Re: Focal Dystonia and Retraining the Hand

Post by Blondie » Wed May 24, 2017 8:53 am

Dofpic wrote:
Mon May 22, 2017 9:54 pm
. Mark Ashford a fine english player told me he worked with Leisner that helped him but he started with Leisner then went to Kathryn Butler a hand therapist from London who was the most helpful.
Kathryn is a flautist and has no knowledge of guitar technique which I found very limiting. When I saw her she was basically trying a variety of approaches outlined in the research literature - eg sensory re-education (Nancy Byl), CIMT (Candia et al), etc. I became very good at identifying dominoes/Scrabble letters by touch but it did nothing for my FD. The splint she made helped a little whilst it was on, but without any kind of methodological approach it too got me nowhere. The most useful thing she gave me was the paper by Sakai on slow down therapy (Mark has it as a download on his website) which I did find useful,and it helped me claw my way back to playing at reasonably advanced level. Unfortunately I crashed again a couple of years later.

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Re: Focal Dystonia and Retraining the Hand

Post by guit-box » Wed May 24, 2017 7:56 pm

When I saw O'brien, he insisted that I had to play with collapsing tip joints all the time and that was the only way to recover from focal dystonia. He was very confident and convincing about it. But when he demonstrated his tremolo on my guitar with relaxed tips it was terrible. He had no control and the sound was weak. Does that mean what he was teaching me was bogus since he couldn't do it himself? Maybe yes, maybe no, but it didn't give me confidence that it would work. He also whispered to me that Parkening had come to see him for focal dystonia. Was that true or was he just name-dropping to puff himself up, I don't know that either, but when I hear people do that kind of thing I'm suspicious. He was a nice enough guy, a bit eccentric, but he charged me a fair price for a lesson -- which I can't say for Leisner who seems to just be in it for the money.

The most important thing that is working for my re-learning to play after focal dystonia is to stop pushing through the string with MCP. I was using way too much MPC force and not enough PIP follow-through. Check out the slow motion video thread I posted in the first comment and you'll see that players teach one thing, but they often do something completely different. Too much MCP with no PIP release will make your hand feel heavy and like it's getting stuck on the strings. The sound will be loud, but the tone is harsh and that extra tension added up to shutting down my hand. Watch someone like Manus Noble play with very little MCP force and lots of PIP follow through. Experiment with loose, collapsing, firm tips and don't get locked into one way with the tip joints. Tip joint firmness is a variability.

Youtube
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Re: Focal Dystonia and Retraining the Hand

Post by guit-box » Thu May 25, 2017 1:18 am

For me, what has helped my FD the most is 1. temporarily staying away from rest strokes because it was too programmed in my brain to push down and through the string with MCP alone, and 2. To focus on pulling the finger up and away from the soundboard more for free strokes (perpendicular to the soundboard). This automatically repositions the finger for the next stroke because PIP is flexing while MCP is extending.

Since I started treating my rest strokes more like free strokes and using the PIP to pluck towards the resting string instead of trying to use the MCP to release the string in a downward (towards the back) movement, my rest strokes are better and lighter feeling. Kevin Gallagher makes a good observation about this here, and I believe he reported having FD at one point but I'm not certain about that:

Youtube


When many players hear #2 they think of a thin sound, but if done correctly, using the nail as a ramp instead of getting under the nail, the tone can be very warm and loud. Check out this video of Raphael Elizondo teaching to play this way with staccato arpeggios. Forcing the unused fingers to stay planted on the strings was a challenge for me because it forces the MCP to extend instead of follow-through, but I believe, for someone like myself who has been trained to play in this large-knuckle-centric method, it helps to break me of that technique and keeps the finger trajectory more correct.

Youtube
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Re: Focal Dystonia and Retraining the Hand

Post by Dofpic » Sat Jun 17, 2017 6:57 pm

I just started working with Serap Gray wife of Julian Gray on trying to overcome this awful FD. She is a terrific guitarist who studied with Julian and Manuel Barreuco but is also a doctor as well as occupational therapist. An amazing person. She also works in conjunction with Johns Hopkins. I came to her not being able to play anything anymore after going to numerous places in Europe and the US.

It has been three weeks and after 6 hours of in person lessons she has me playing IM alternation as I have not done in years. I have a very long way to go but she seems to understand all aspects of this including physical, psychological, neurological how to practice etc. I have been optimistic before but the results have me quite hopeful.
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Re: Focal Dystonia and Retraining the Hand

Post by bacsidoan » Sat Jun 17, 2017 7:16 pm

Dofpic wrote:
Sat Jun 17, 2017 6:57 pm
I just started working with Serap Gray wife of Julian Gray on trying to overcome this awful FD. She is a terrific guitarist who studied with Julian and Manuel Barreuco but is also a doctor as well as occupational therapist. An amazing person. She also works in conjunction with Johns Hopkins. I came to her not being able to play anything anymore after going to numerous places in Europe and the US.

It has been three weeks and after 6 hours of in person lessons she has me playing IM alternation as I have not done in years. I have a very long way to go but she seems to understand all aspects of this including physical, psychological, neurological how to practice etc. I have been optimistic before but the results have me quite hopeful.
Back at it again :) You have my deepest admiration for your tenacity. I wish you nothing but the very best!

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Re: Focal Dystonia and Retraining the Hand

Post by guit-box » Tue Jun 20, 2017 6:02 pm

Dofpic wrote:
Sat Jun 17, 2017 6:57 pm
I just started working with Serap Gray wife of Julian Gray on trying to overcome this awful FD. She is a terrific guitarist who studied with Julian and Manuel Barreuco but is also a doctor as well as occupational therapist. An amazing person. She also works in conjunction with Johns Hopkins. I came to her not being able to play anything anymore after going to numerous places in Europe and the US.

It has been three weeks and after 6 hours of in person lessons she has me playing IM alternation as I have not done in years. I have a very long way to go but she seems to understand all aspects of this including physical, psychological, neurological how to practice etc. I have been optimistic before but the results have me quite hopeful.
Tell us about the details.
An eyewitness will often only see what he already believes to be true.

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Re: Focal Dystonia and Retraining the Hand

Post by Dofpic » Sun Jun 25, 2017 1:47 pm

I head back to Baltimore later this week for 3 2 hour lessons over 3 days. I continue to make solid progress with her guidance. This is a very complicated ailment that is not just about how to stroke the strings, hand position etc but a lot about how to practice, learn, unlearning as well psychological etc.

In fact she says people who obsess about how the fingers work etc often get the ailment more than those who do not think about it.

She started me as If I had never played guitar but of course I have to stay on basics longer to undo the bad habits not only in muscle memory but mental association etc. She slightly changed my hand position which I am not there yet and started with what I could do without Dystonia which is Block chords. she says it takes 3 weeks to learn a new skill and another 3 weeks to perfect it. She has me practice 3 times a day for only 10 minutes at a time. This is important in not to over practice bad habits but small practices of correct movement that feels easy.

She keeps repeating that I have to trust the "chemical learning process" that is after you stop practicing the learning process continues while you rest.

She said the key to a fluid and efficient technique is the ability to "micro release tension in between the strokes" Easier said than done but she had me doing this on IM alternation that felt effortless. Just 4 notes at a time but of course this is a start. This is still very hit or miss with me mostly miss but each day I get some of the micro release movement done but it takes a while to get there but I now know right away when it is wrong.

There has been no discussion like... "this is how the hand works, or play from this joint, or relax the fingertips etc" She just demonstrates and has me try and repeat it. If it is too difficult she breaks it down further into smaller pieces then builds it back up. Terrific teacher and I am quite encouraged so far. Of course I have been there before but this time it seems much more direct in the approach. Also watching her right hand in person is extremely helpful as it looks perfect in motion with no excess movement and very efficient.
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Re: Focal Dystonia and Retraining the Hand

Post by guit-box » Sun Jun 25, 2017 6:56 pm

Dofpic wrote:
Sun Jun 25, 2017 1:47 pm
I head back to Baltimore later this week for 3 2 hour lessons over 3 days. I continue to make solid progress with her guidance. This is a very complicated ailment that is not just about how to stroke the strings, hand position etc but a lot about how to practice, learn, unlearning as well psychological etc.

In fact she says people who obsess about how the fingers work etc often get the ailment more than those who do not think about it.

She started me as If I had never played guitar but of course I have to stay on basics longer to undo the bad habits not only in muscle memory but mental association etc. She slightly changed my hand position which I am not there yet and started with what I could do without Dystonia which is Block chords. she says it takes 3 weeks to learn a new skill and another 3 weeks to perfect it. She has me practice 3 times a day for only 10 minutes at a time. This is important in not to over practice bad habits but small practices of correct movement that feels easy.

She keeps repeating that I have to trust the "chemical learning process" that is after you stop practicing the learning process continues while you rest.

She said the key to a fluid and efficient technique is the ability to "micro release tension in between the strokes" Easier said than done but she had me doing this on IM alternation that felt effortless. Just 4 notes at a time but of course this is a start. This is still very hit or miss with me mostly miss but each day I get some of the micro release movement done but it takes a while to get there but I now know right away when it is wrong.

There has been no discussion like... "this is how the hand works, or play from this joint, or relax the fingertips etc" She just demonstrates and has me try and repeat it. If it is too difficult she breaks it down further into smaller pieces then builds it back up. Terrific teacher and I am quite encouraged so far. Of course I have been there before but this time it seems much more direct in the approach. Also watching her right hand in person is extremely helpful as it looks perfect in motion with no excess movement and very efficient.
Good luck, maybe you can video the process and post something here? I have a healthy skepticism for anyone giving lessons (and charging $) who claims to cure focal dystonia, but maybe she's not doing that here and just advising you on guitar playing and technique. It's too soon to know if this method will solve your problem, the proof will be if you can play pieces again down the road. For me, the joint movement was critical since I had been attempting to move my fingers in a way that fingers do not want to move. Focusing on flexing exclusively from the MCP and not allowing joints to move in opposing directions. -- Shearer's Principal of Uniform Direction of Joint Movement. I've since learned these things are bogus, and I can now play again at an intermediate level with no dystonia. It has lasted for over a year.
An eyewitness will often only see what he already believes to be true.

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Re: Focal Dystonia and Retraining the Hand

Post by Michael.N. » Thu Jun 29, 2017 11:49 am

Just a question in respect of FD. If you suffer from FD on one instrument (let's say guitar) what happens when you try to play another type of musical instrument? Does the condition automatically spill over?
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