The cause of focal dystonia is as yet unknown. However, as it is task-specific, there are some common piano-related habits which seem to be associated with the condition and may have been contributory factors:

• A strong work ethic, often playing for long periods without a break.

• A perfectionist approach.

• An excessive focus on finger exercises, especially exercises involving lifting fingers forcefully while others are held down.

• Playing with very stiff fingers, with a high action, or overly curved fingers.

• Playing with a predominantly ‘finger technique’ with very little engagement of the rest of the arm.

• Feeling under a lot of pressure to play faster and achieve more than you could accomplish with ease.​

In my work with pianists with dystonia I have noticed that any technical imbalances generally pre-date the dystonia and are often also present to a lesser degree in the technique of the other hand.

It is important to get an accurate diagnosis and to ask to be referred if possible to a medical specialist who has experience in this condition (see BAPAM website). If you do have a diagnosis of dystonia, do not despair: much more is known about the condition nowadays and more practical help is available. The earlier the condition is addressed the better, but even longstanding cases can improve significantly with some retraining.

Focal dystonia is both a neurological and a physiological condition. A multi-disciplinary approach to treatment is generally considered the most successful. Focal dystonia specialists may recommend a programme which includes some or all of the following types of treatment:

• Sensory re-education

• Sensory motor retuning

• Mirror treatment

• Slow down exercise treatment

• Botulinum toxin or other medications (research all the pros and cons before embarking on Botox)

• Surgery (again consider all the pros and cons)

As musicians’ dystonia is so task-specific, and, in my opinion, so closely linked to technical habits, I believe that it is important to combine these types of exercises with specialised technical retraining at the piano. Exercises should be carefully tailored to the individual, depending on the nature of the problem at the piano

In this programme, I aim to integrate all the most relevant aspects of current research with my own specially devised exercises, based on my observations and experience of working with pianists with dystonia. These exercises have not been scientifically evaluated, but have shown to be of significant benefit to pianists with dystonia.

Inspirational practice

You may need to rethink your role as a pianist and your priorities to ensure that your practice methods do not exacerbate the symptoms.

• Aim for a good balance between work and relaxation.

• Rethink your practice methods and allow more regular breaks during practice.

• Above all avoid mechanical finger-work practice which is divorced from emotional engagement. Have a clear musical image of everything you play so that technique can flow in response to the emotional content of the phrase.

Technical retraining

With each pianist with dystonia I create an individualised programme depending on the specific nature of the problem. A programme typically consists of around eight to ten weekly or fortnightly sessions. In the first session I assess the most urgent technical problems and suggest exercises which are tailored to the pianist’s specific needs. New exercises are introduced in each subsequent session, so that the pianist remains motivated and inspired as the technique is gradually modified.

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The main purpose of the exercises is to teach the body (and brain) a new repertoire of ergonomic movements which reintegrate the fingers with the rest of the body. Each movement has a very direct effect on the sound, which offers immediate feedback via the improvement in quality of sound.and musical expression. Each new movement should be learnt at a speed and dynamic level at which the dystonic movement does not occur. Practised thoroughly, the new movements become habitual and so powerfully embedded into the subconscious that they replace the old dystonic movements.

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Piano exercises

I have found the following exercises the most relevant for pianists with dystonia. All are explained in more detail in The Complete Pianist.

‘The Roskell Parachute touch’ – this is particularly important for pianists with curling fingers, as the fingers are trained to open out, rather than bend. Focus on playing on the fingerpad, rather than on the fingertip in this exercise.

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‘The Parachute touch in chords’– the whole arm is integrated into each movement so that the load is shared. Fingers are supported by the arm in everything they do.

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‘Evenly curved fingers’ – many pianists with dystonia play with a distorted hand position. The hand needs to play in its natural position, with fingers evenly curved.

‘Releasing the non-playing finger’ and ‘Note endings’ are particularly helpful for pianists with fingers which lift involuntarily.

Scale technique – focussing on integrating the fingers with the arm, especially when passing over the thumb.

Re- aligning the hand – The hand is retrained to work around its natural alignment, with the third finger in a straight line with the forearm. A supple wrist allows the forearm to take each finger to its note, so that the playing finger is always in line with the forearm.

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Rotation – rotation movements re-integrate the fingers with the arm and are useful training for pianists with dystonia.

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General posture exercises – many pianists with focal dystonia have a tense overall posture, which can be improved over time with help from Alexander Technique, Feldenkrais or Yoga (See Yoga for Musicians DVD).

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Incorporating other techniques

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I incorporate elements of the Mirror treatment and Slow-down exercise treatment into each exercise. Each exercise is learnt initially with the non-dystonic hand, as it is important that this is working with a healthy technique from which the other hand can ‘learn’. It is then introduced to the dystonic hand in mirror image, at a slow tempo (initially a mirror box may be used). The tempo is only increased very gradually and never beyond the stage where the dystonic movement re-occurs.

Focal dystonia can be frustrating. Pianists who expect immediate results may be disappointed. New movements need time and enough repetitions to become etched into neural pathways. Make a longer-term plan to reassess your technique and learn a new approach to piano playing. Remember that you are trying to establish a new habit and this can only be done by focusing on the new movements and avoiding the old.

With patience and dedication, the new habits will not only alleviate the dystonia but also make your playing more expressive and natural.

It may be helpful to avoid pieces that feel challenging initially and focus on more simple, inspirational repertoire to avoid slipping back into old habits. Keep a balance between slow, concentrated technical work and playing from the heart. Once in a while, forget your dystonia and just enjoy your playing!