Guest post of Andreas Eggertsberger,
first posted on January 8, 2018 here.
I think this essay is also most relevant for beginner lessons because already in the first lesson the cause for eventual injuries can be founded. Read about the experiences of Andreas Eggertsberger supplemented with invaluable video documentations and conclusions:
Andreas Eggertsberger: My Experiences with Focal Dystonia
Join us on Facebook: Pianists who defeated focal dystonia
Injuries often occur in the music world. Although still a taboo theme, a lot of musicians are suffering from it. While pain is something which is commonly known amongst musicians, there is another injury out there which is approaching something much subtler. It is called focal dystonia. Prominent sufferers in the piano world are pianists like Leon Fleisher, Gary Graffman, Keith Emerson, Michele Beroff, Michael Houstoun or Hung Kuan Cheng. The principal oboist from Chicago Symphony, Alex Klein, has a long story of losing, regaining and losing his job again because of dystonia.[i] Most likely it seems that Robert Schumann was also prone to this devastating condition.[ii]
What is focal dystonia?
Dystonia belongs to the family of movement disorders. It is a neurological condition with a very broad range of manifestations. The basic underlying problem involves over-activity of the main muscles needed for a movement, extra activation of other muscles that are not needed for the movement, and simultaneous activation of muscles that work against each other.[iii] The term focal describes where just an isolated area is affected. For pianists, it usually means that one hand (in most cases, the right hand) is disturbed, although in some cases both hands are troubled by it.
Weird Movements
In the Summer of 2012, I was participating in a Summer festival in Italy. A violinist colleague and friend pointed at my left hand as I was playing the fugue from Beethoven’s Hammerklavier Sonata (Sonata in B flat major, Op. 106). She told me that she has never seen a pianist whose hands were moving so differently. She was telling me that she could hear a different colour and that there is always an issue of accuracy when she listens. Some notes got swallowed. She directed my attention to my index finger and we came to the conclusion that if it stretches that much, then I could not bring it down on the key on time. Besides that, my middle finger was curling. The ring and pinkie finger were also stretching a lot. All of this seemed to be unnatural and was causing problems. At the end, we came to the conclusion that this was a real issue for me.
Here is a recording of my playing of the fugue which made my friend so uncomfortable:
The next day I started to compare my finger movements with other pianists. I found a recording with Wilhlem Kempff and consciously compared his hands to mine:
I saw that his hands moved in the same direction. I started looking at pianist’s hands everywhere! A video of Michelangeli playing the 4th movement of the 2ndChopin Sonata (Sonata in B flat minor, Op. 35) confirmed that hands in normal cases were mirroring each other and not going on different paths:
I started also looking at the hands of the other participants at the festival. And I could not find any pianist whose hands were heading in different directions. Everyone’s hands were moving synchronic. Mine were different. This was separating me from the rest.
I told my observations to the piano professor in the festival and expressed my concern that there might be something wrong. The reply was that I should not worry about it and just enjoy the sound. The same week I played for another teacher at the same festival and she too told me that I should not be concerned. Some great musicians make some weird movements. She gave the example of a famous violinist who held his bow quite awkwardly.
At this point I was quite skeptical towards this advice, but I was also clueless about what was really going on.
The Diagnosis
Back in Austria I had to play a recital at the festival in Gmunden. I played the whole concert with a feeling of losing control. In the intermission, I told a friend that I think that something is wrong but that I have no idea what it was. The next day he visited me in my home and I played for him. He too came to the conclusion that I have to change and this was indeed a problem.
I investigated the problem further and implemented a simple exercise comparing the right and left hand:
As I found out, I was unable to play the little exercise clearly with my left hand. I sent the video to a piano professor. He replied to me that it is normal that left and right are not equal. But was it normal that the left hand was failing basic patterns? If this was normal then Chopin would never have written a piece like the Etude Op.10 No. 12 because no one could execute it clearly if such weakness in my left hand was the normal case.
I came to the conclusion that I had to look further. One evening I was thinking about the pianist Leon Fleisher. Why could he not use his right hand for around the half of his life? As I googled his name I found out that he has focal dystonia in his right hand. And that this was a neurological condition. As I watched one of his videos, I was able to draw a parallel to my own problems:
As one can clearly see, his ring and pinkie finger were constantly curling.
I then started to read about focal dystonia. And the more I read about it the more it was clear that this was my real problem. It was a neurological issue which was often treated with botox injections and was practically unhealable. But also, that musicians could manage the condition well and came back into playing, as Michael Houstoun had done, who recently recorded Beethoven’s 32 Sonatas to great critical acclaim.[iv]
I told a piano professor in Austria about my findings and that I want to consult a neurologist. He was quite amused about it and asked me what a neurologist has to do with piano playing and scales.
Nevertheless, I went to see a neurologist who made a careful investigation. At the end, he confirmed my assumption. To really make sure that this was dystonia and no other issue I had to have a brain scan. If this was normal we can exclude all other sorts of neurological issues and focal dystonia would be confirmed.
As we assumed, my MRI was completely normal. After this process, I had a completely sure diagnosis. It was recommended that I get in touch with Dr. Altenmüller[v] who is a great scholar on this issue.
I sent Dr. Altenmüller a video and he saw the problem too and recommended to start a retraining with Laurent Boullet[vi] in Berlin.
Unfortunately, I had to leave Europe and go back to USA where I was a third year DMA candidate at the University of Michigan in Ann Arbor (USA), about to play all my doctoral recitals.
Complete Breakdown
Back in Ann Arbor I told my teacher that I was officially diagnosed with focal dystonia. “Focal what?” was his reply. I told him that it was a movement disorder where people had lost their control over their hands. At the end of our conversation he told me that there are people with real serious hand problems and that this was nothing to worry about it. I should just play through it.
This plan did not work out well and after a few weeks I was in real trouble. I started having problems playing scales:
When playing with my ring and pinkie finger, the middle finger would involuntarily move to the ring finger:
The same would happen also when playing slower:
I could not feel the space between the keys anymore. As I tried out to play the last page of the first Brahms concerto (Concerto No. 1 in D minor, Op. 15), I only played wrong notes. It was impossible to play it at all:
After these recordings, I went home and I realized that I had problems opening my hand at all. I couldn’t even tie my shoes. I could not open my hand enough to hold a glass with my left hand. Focal dystonia was now causing problems in my every-day life.
Road to recovery
I had to take a break for the next few weeks. I could barely open my hand. After some time, the cramping got less and less. So, I could start to practice again. But after this experience I knew I had to begin solving it. The normal lesson was of no help and I wrote to Laurent Boullet who was offering retraining in Berlin. We made an appointment on Skype the next days. After playing for him via Skype I began to understand what was going on. My index and middle finger were compensating for the instability of my ring finger. As soon as I started to stabilize the edge of my hand the curling and stretching of my middle and index finger became less.
I also had to change the position of my wrist. Ideally the wrist should be positioned slightly under the metacarpophalangeal joint, also known as the large knuckle. When playing I consciously rested the ring finger as much as I could on the keyboard. I made sure if kept contact as much as I could with the surface of the keyboard.
A good example of the ideas which I applied to retrain is the C–minor Sonata (Sonata in C minor, Hob. 20) by Haydn. The triplets F-Ab-Bb were unrhythmical as the second finger was hyper extending. I was playing them with the fingering 3-2-1. As I silently held down an additional key with the fourth finger the hyper extension decreased. My aim was to accomplish this without depressing the additional key. I used a combination of rotation and lateral movement towards the thumb to make the execution of the triplets effortless. I practiced this passage diligently, sometimes up to four hours a day. After 9 months, I realized that I had achieved the precision I was seeking in this passage.
I did something very similar with the passage in Beethoven’s Sonata in D minor (‘Tempest’) Op.31 No. 2. I kept the ring finger depressed while I was playing with the others. I also added some rotation on E and C#.
I made exercises to consciously use my fingers just as weight transferers. Weight cuffs (0.5kg) were worn around the wrist to help highlight the sensation in the MCP joints for providing support for the hand.
I also played with the middle and ring finger only while I stayed relaxed with the other fingers.
In scale passages, learning how to cross the fingers over the thumb while maintaining stability and flexibility in the thumb:
Over time things have changed. In 2012, I played Mozart’s Sonata KV331:
As one can see: the index finger was hyper extending already in the theme. In 2016 this had significantly changed:
It comes out clearly when comparing the third movement in both recordings. Listening to the two recordings, it is clear that the sound in the later recording has more projection and that it is more fluid. The tone has got a much more cantabile quality and the sound was generally fuller.
The way into Dystonia
As I was diagnosed with dystonia I was thinking that it was probably going on for much longer than I was aware of. Some issues in my biography started making much more sense.
As a child, I was an incredibly fast learner. After six months of learning piano I played already Wilder Reiter from Schumann’s Album from the Young Op. 68:
It was recommended that I enter the local conservatory in Linz. There I proceeded very fast again. I soon played Mozart’s Sonata in C major KV545 and Beethoven’s Sonata in C minor (‘Pathétique’) Op.13. I was practicing a lot. I was experiencing troubles with the scales in the left hand in the recapitulation of Mozart’s Sonata KV545. I solved the problem with a lot of practice. After practicing them around four hours long (voluntarily!) I could play them perfectly. Youth success continued. I won the national youth competition and a prize in Ettlingen in the international competition for young pianists. I was the youngest recipient of the Yamaha scholarship. I gave my first full recital at aged 12 and played my first Mozart concerto with the Bruckner Orchestra, aged 13. I became the youngest graduate in the history of the conservatory at the age of 15 (a record not broken till today!).
A recording of me playing Mussorgsky’s Pictures at an Exhibition is revealing some differences between the two hands.
The wrist is high and the bridge is practically not there. Even in the picture “Il vecchio castello” one can see a hand with unnatural movements – a cramped hand (from minute 7.00 onwards, for example):
In summer holidays, I often practiced up to 10 hours every day. The amount of repertoire was growing fast. Soon the index finger started to hyper extend which became one of the typical movements of my dystonia (Minute 1:10):
After graduation in Linz I went on to study in Salzburg. I was experiencing a strange feeling of playing against a wall. The teaching took place quite irregularly and I had to follow my teacher to masterclasses to have a chance to play for him. Time space between lessons was sometimes several months. When I go through the scores I now see passages in the left hand were often circled. But hardly anywhere in the right hand. The first time I gave up working on a piece happened because it was exhausting to use the left hand in the Etude Op.10 No. 12 by Chopin. In Schumann’s Kreisleriana Op. 16, my teacher asked me why I was not able to play the left hand solo passage regularly. It was recommended I practice it and play it slowly.
A quite interesting habit was the inclusion of warm up exercises. One of them was playing chromatically from C to E and back. Then from C# to F etc. While this exercise was not difficult for my right hand, my left hand often needed repetitions to play it accurately.
Later I moved to Vienna. My playing was obviously deteriorating. At the time of my master’s recital, my teacher was telling me that I should be happy when I pass at all. I was practicing English Suite No. 3 BWV 808 by J S Bach and I saw some interesting movements from fingers in my left hand. I thought of them as quite funny, even though the left hand just did what it has to do. And if there would be a problem with it, it would have been a theme in a lesson. I still had no idea that something like focal dystonia even existed. I did not connect my finger movements to any problems which occurred during this time. I had difficulty playing the first solo, a sixteenth note scale run in both hands, in the third movement ofBeethoven’s Piano Concerto No. 5 Op. 73, and also when playing the octaves at the end of the exposition of the Grieg’s Piano Concerto in A minor Op. 16.
After graduation in Vienna I felt untalented and gave up playing. I studied political science in Salzburg and did not touch the piano for the next four years.
Coming back to play and finally being diagnosed
After four years of not playing at all I was curious to see what was possible. So, I started to play again. And I did nothing less than the Goldberg Variations BWV 998 by J S Bach. I learnt them again very quickly and played them in a recital. At first, piano playing felt easier. But soon I practiced left hand runs much more often again. One Sunday I practiced the 26th variation nearly the whole day, especially the left-hand passages. At the end of the session the passages nearly worked. The whole work was good enough to impress audiences and teachers. I was invited to perform at a piano conference in Serbia and had a great success with it.
I was then invited to study at the YST (Yong Siew Toh) conservatory in Singapore. In one lesson, the teacher there said that he has never seen anyone’s finger moving like this.
In 2008, I was invited to participate in an international piano competition and made it to the semifinal. After the competition, a judge came to me and told me that he expected me to get to the final. But he said that my coordination of the right and hand in the first movement of the Beethoven Sonata in C minor Op.111 was unclear. My left hand was playing in an unsteady manner and was sometimes lacking clear articulation. He seemed to be quite confused about it because it did not fit in to the impression I gave in the first round. I personally came to the conclusion that I probably was lacking in competition experience since this was my first competition for 12 years.
After that I auditioned for DMA in Ann Arbor and was taken into the programme. I was encouraged to play with more energy and to take more risks. I should play with more passion. Many of these elements I simply did with a strong will and much force. The diagnosis of dystonia came finally in 2012.
Conclusions
Focal Dystonia is still quite new to teachers and students. The condition as such was only recognized in the mid 1980s. My personal view is that we still have not much awareness of it. Therefore “It is critical that musicians and teachers keep focal dystonia on the radar. Fortunately, the vast majority will not get focal dystonia, but people should know the signs so they can avoid the common pattern of misreading early symptoms, practicing harder, and thus cementing faulty brain connections.” [vii]
The symptoms I was developing were not perceived as dangerous for a long time. It was a time frame of around 18 years till the right diagnosis came. The seriousness of the problem was often denied or underestimated. Even as I was diagnosed with it, it was not perceived as a problem by my teacher. Managing to come clean about it took over 5 years. Comparing this fugue will show just how much has changed:
I want to offer some thoughts about how I originally got dystonia and how I think we can minimize the risk for future students:
- The prevention of focal dystonia starts already at the beginning. It is crucial to learn to move efficiently. “Unless the body maintains movement patterns that are biomechanically sound, the musician is at risk of injury.”[viii]
- In situations when we focus on the music only and on learning very fast, we might mistakenly open the door to focal dystonia. As I was starting my lessons I was going for the music and did everything which was necessary to achieve what I wanted. “When preparing for an important performance a musician will often practice without physical awareness because of focus on the music itself. Then it is easy for physical distortions to occur in order to produce a desired musical result and for these to become ingrained as a way of playing that is less than biomechanically ideal.”[ix]
- In my own experiences, I was encouraged to achieve a lot in the shortest amount of time. Teachers and audiences were surprised how fast I was growing. My first teacher’s idea was: the earlier, the harder, the better. As I was studying the Mozart Sonata KV545 the excessive practice of the scales and the permanent repetition led to success. In the long-term this might have taught me incorrectly. “…, incessant repetition of certain problematic passages, especially when the way of playing causes tension, can put musicians at risk. Highly motivated practisers tend not to vary the material in their practice sessions, meaning that there is too much repetition of the same physical movement.”[x]
- Another point for me is that taking breaks is important. My habit of working through long sessions without breaks and repeating the same over and over was a factor which might have contributed to focal dystonia. Consciously relaxing and evaluating what was achieved will be of great help.
- I think another factor is the aim of perfection. Studio recordings nowadays are cut together and show often an unrealistic picture of artists. I think listening to older and uncut recordings can lead to more realistic aims for one’s own performances.
- Taking time to learn the fundamentals. The piano might be a quite injury provoking instrument as it is possible to produce a sound with simply depressing a key. Therefore, there is a big temptation to simply move on to the next, more difficult piece, pushing ahead.
- Developing both hands equally. Not every Sonata for example is challenging the right and left hand equally. Therefore, it is crucial to play etudes and other pieces which are aiming to develop both hands.
- Having a flexible hand position. The wrist should be constantly adjusted in order to avoid fixed hand positions.
- It is important for the developing artist to get regular mentoring. Having an irregular teaching schedule with lots of space between lessons makes it possible for bad practice habits settle in or to fall back into them.
- It is crucial that teachers and their students are aware of the lurking danger ofdystonia and take issues of coordination seriously. Over time, tiny little problems can become big. There should be an atmosphere where the student can admit problems with a passage. Sometimes teachers might consider watching their students just from the right or left side and compare the finger movements of the two hands. If one hand is moving in a different direction than the other, chances are high that there is a problem developing.
- Students can record themselves with smartphones from the side and watch how their hands are moving. Especially virtuosic pieces with scale runs. The reason is that while playing, our eyes will be often ahead and barely get a full picture at all:
12. Rethinking our heritage: In teaching we rely on traditions. But old schools did not think about biomechanics at all. So called finger independence exercises might cause a lot of trouble because they cannot be done without tensions in the forearm.
13. Tailoring the teaching to the needs of a student. One day Richter came to Neuhaus and played the Liszt B minor sonata, S.178. There was not much to teach as Neuhaus wrote. They discussed the interpretation of some passages and the lesson was done. After that another student came in playing the same piece. Neuhaus wrote that he had to work on every bar with her.[xi] This is a great example how a teacher can adjust to the needs of a student. In my experiences, a lot of teachers just give everyone the same approach.
14. It is not about playing without tension but with the right amount of tension. We have to be aware that we release the built-up tension as often as possible.
I am convinced that we can at least minimize the risk of dystonia. It is crucial that it is recognized early as such and pedagogical intervention takes place. Although genetics play a role in the development of dystonia I am convinced that in a lot of cases focal dystonia is the result of an unfavorable use of the body. It might be of more importance how we achieve results and not just that we achieve them.
Over time I got in contact with quite a lot of dystonic musicians. I was astounded to learn just how many people knew someone who was suffering from it. Some of the pianists had won great prizes at competitions like the Cliburn, Busoni or Hilton Head. Very often it was a highly talented individual who went somehow down the wrong road. I was surprised how often I was confronted with it since having been diagnosed.
Focal Dystonia is a highly complex issue. Retraining is a complicated affair and veryindividual. In every case one has to find the fitting exercises. There is no way to apply the same exercises for every case. Recovering from it is possible but very time-consuming.
I hope that this essay will at least raise the awareness of this kind of problem. During my journey, I have encountered a lot of teachers who have never heard of it. I am hoping to improve this, and speak out, informing as many pianists as possible, so they may be able to avoid such issues.
You can explore Andreas’ YouTube Channel, here.
[ii] Altenmüller, Eckhart. Robert Schumann’s focal Dystonia https://www.karger.com/Article/Pdf/85633
[iii] https://www.datasci.com/solutions/neuroscience/movement-disorders
[iv] http://www.michaelhoustoun.co.nz/
[v] https://www.immm.hmtm-hannover.de/en/institute/people/eckart-altenmueller/
[vi] https://www.pianophysiology.com/
[vii] White, Joanna. “Musician’s Focal Dystonia: Strategies, Resources, and Hope.” Flutist Quarterly, p.33, (Winter 2017).
[viii] Wilson in de Lisle, Rae: “Focal Dystonia: An Understanding for the Piano Teacher.” 12th Australian Piano Pedagogy Conference, p.1, 2015.
[ix] Tubiana in de Lisle, Rae: “Focal Dystonia: An Understanding for the Piano Teacher.” 12th Australian Piano Pedagogy Conference, p.5, 2015.
[x] de Lisle, Rae: “Focal Dystonia: An Understanding for the Piano Teacher.” 12th Australian Piano Pedagogy Conference, p.13, 2015.
[xi] Neuhaus, Heinrich. Die Kunst des Klavierspiels, p.149 (1967)