A multifactorial conceptual model of peripheral neuromusculoskeletal predisposing factors in task-specific focal hand dystonia in musicians: etiologic and therapeutic implications.

A model is presented showing how peripheral factors may cause a process of movement adaptation that leads to task-specific focal hand dystonia in musicians (FHDM). To acquire a playing technique, the hand must find effective and physiologically sustainable movements within a complex set of functional demands and anatomic, ergonomic, and physiological constraints. In doing so, individually discriminating constraints may become effective, such as limited anatomic independence of finger muscles/tendons, limited joint ranges of motion, or (subclinical) neuromusculoskeletal defects. These factors may, depending on the instrument-specific playing requirements, compromise or exclude functional playing movements. The controller (i.e., the brain) then needs to develop alternative motions to execute the task, which is called compensation. We hypothesize that, if this compensation process does not converge to physiologically sustainable muscle activation patterns that satisfy all constraints, compensation could increase indefinitely under the pressure of practice. Dystonic symptoms would become manifest when overcompensation occurs, resulting in motor patterns that fail in proper task execution. The model presented in this paper only concerns the compensatory processes preceding such overcompensations and does not aim to explain the nature of the dystonic motions themselves. While the model considers normal learning processes in the development of compensations, neurological predispositions could facilitate developing overcompensations or further abnormal motor programs. The model predicts that if peripheral factors are involved, FHDM symptoms would be preceded by long-term gradual changes in playing movements, which could be validated by prospective studies. Furthermore, the model implies that treatment success might be enhanced by addressing the conflict between peripheral factors and playing tasks before decompensating/retraining the affected movements.

Morphology of deltoid origin and end tendons--a generic model.

This study provides a model of the complex deltoid origin and end tendons, as a basis for further anatomical, biomechanical and clinical research. Although the deltoid is used in transpositions with upper limb paralysis, its detailed morphology and segmentation has not been object of much study. Morphologically, the deltoid faces two distinct challenges. It closely envelops a ball joint, and it reduces its width over a short distance from a very wide origin along clavicle, acromion and spina scapula, to an insertion as narrow as the humerus. These challenges necessitate specific morphological tendon adaptations. A qualitative model for these tendons is developed by the stepwise transformation of a unipennate muscle model into a functional deltoid muscle. Each step is the solution to one of the mentioned morphological challenges. The final model is of an end tendon consisting of a continuous succession of bipennate end tendon blades centrally interspaced by unipennate tendon parts. The origin tendon consists of lamellae that interdigitate with the end tendon blades, creating a natural segmentation. The model is illustrated by qualitative dissection results. In addition, in view of a proliferation of terms found in the literature to describe deltoid tendons, tendon concepts are reviewed and the systematic use of the unique and simple terminology of 'origin and end tendons' is proposed.

The minimum number of muscles to control a chain of joints with and without tenodeses, arthrodeses, or braces--application to the human finger.

While the underlying principles of controlling a single joint have been well described, the principles of simultaneously controlling multiple joints have not been comprehensively addressed in the literature of reconstructive hand surgery. This article analyzes (1) how many muscles are minimally required to fully control a chain of joints with in total N Degrees of Freedom (DoF), and (2) to what degree tenodeses, arthrodeses or braces can reduce the required number of muscles. It is demonstrated by mathematical analysis and illustrated by examples that the minimal number of muscles to control a chain of N DoF is N + 1. The number of muscles required for control can be reduced by mechanisms that reduce the number of DoF in the chain. (i) An arthrodesis is a permanent surgical fixation of a joint. An arthrodesis eliminates as many DoF in the chain as the arthrodized joints contributed. (ii) Tenodeses are coordinative tendon constructions. Each independent tenodesis eliminates one DoF from the chain. (iii) Braces are removable external supports. They eliminate as many DoF for muscle control as they immobilize. These principles are applied to illustrate the fundamental importance of tendinous structures in control in the human finger. Being able to determine the minimum number of muscles needed for multiarticular control gives additional knowledge in the design of functional reconstruction.

Left shoulder pain in a violinist, related to extensor tendon adhesions in a small scar on the back of the wrist.

A female professional orchestra violin player, age 54, with an 8-year history of severe left shoulder problems, presented with reproducible, acute, incapacitating left shoulder pain when playing the lowest violin string. This complaint was found caused by compensatory left arm positions for unnoticed finger extensor excursion limitations in a well-healed scar bed from two dorsal wrist ganglion operations 11 and 13 years before. Immediately after extensor tendon mobilization in the scar bed, the patient could assume a normal playing position, which was pain free, and could return to orchestral duties without further major shoulder complaints (follow-up of 10 years). The case study presents finger extensor excursion limitations at the wrist as an unusual extra-regional risk factor for a shoulder complaint and analyses the biomechanics linking these limitations to the complaint. The case illustrates the importance of long-term post-operative hand surgery rehabilitation in musicians.

Focal hand dystonia in musicians: a synopsis.

Focal hand dystonia in musicians (FHDM), also known as 'musicians' cramp', is a relatively rare, task-specific, pain-free disorder of control, causing unintentional, abnormal movements and/or positions in a part of the body directly involved in playing a musical instrument. Few physicians are familiar with the diagnosis, yet the exact cause of the disorder remains unknown and there is no generally effective therapy. In this synopsis, the authors present their experience with the diagnosis and treatment of FHDM and their aetiology hypothesis that musicians' cramp is caused by a loss of central motor control initiated by a failure of coping mechanisms, which (try to) compensate for the effects of peripheral local movement disturbing factors in the hand. Recent publications focus on the role of the central nervous system and on motor pattern relearning. We recommend further (prospective) research of the results of operative (peripheral) therapy, followed by (central) motor pattern relearning, and of neuropsychological contributions.

Reverse engineering finger extensor apparatus morphology from measured coupled interphalangeal joint angle trajectories - a generic 2D kinematic model.

The interphalangeal (IP) finger joints coordinate as a mechanism when the deep flexor is active. This mechanism is created by the complex finger extensor apparatus (EA) - a confluence of end tendons of one or two extensors, radial and ulnar interossei, and lumbrical - which inserts as a single structure into both the middle and distal phalanges. Although the IP-coupling principle was well demonstrated more than half a century ago, the detailed relationship between EA morphology and IP coupling remains not well described. Main reasons are that by dissection the EA's fiber network loses functional consistency, while fibers becoming taut or slack beyond measuring resolutions complicate measuring functional fiber motions. To circumvent these difficulties, we present a two dimensional kinematic multi tendon-string EA model of fiber slackness and tautness through IP motion, including the retinacular and oblique retinacular EA ligaments. The model parameters were the strings' lengths and attachment points. The model's functional redundancies were resolved by individually interactively fitting model IP trajectories to previously measured IP trajectories of 68 fingers. All model trajectories accurately fitted their target IP trajectories for proximal interphalangeal (PIP) joint ranges smaller than 25° to 45°; about half accurately fitted over the entire IP range with the remaining half having maximum approximation errors between 3° to 12°, while all models again converged to target trajectories for full IP flexion. These accuracies suggest the model reflects real functional EA principles, with potential applications in biomechanical modeling, surgical reconstruction, rehabilitation, and prosthetic EA replacements.

Kinematic evaluation of the finger's interphalangeal joints coupling mechanism--variability, flexion-extension differences, triggers, locking swanneck deformities, anthropometric correlations.

The human finger contains tendon/ligament mechanisms essential for proper control. One mechanism couples the movements of the interphalangeal joints when the (unloaded) finger is flexed with active deep flexor. This study's aim was to accurately determine in a large finger sample the kinematics and variability of the coupled interphalangeal joint motions, for potential clinical and finger model validation applications. The data could also be applied to humanoid robotic hands. Sixty-eight fingers were measured in seventeen hands in nine subjects. Fingers exhibited great joint mobility variability, with passive proximal interphalangeal hyperextension ranging from zero to almost fifty degrees. Increased measurement accuracy was obtained by using marker frames to amplify finger segment motions. Gravitational forces on the marker frames were not found to invalidate measurements. The recorded interphalangeal joint trajectories were highly consistent, demonstrating the underlying coupling mechanism. The increased accuracy and large sample size allowed for evaluation of detailed trajectory variability, systematic differences between flexion and extension trajectories, and three trigger types, distinct from flexor tendon triggers, involving initial flexion deficits in either proximal or distal interphalangeal joint. The experimental methods, data and analysis should advance insight into normal and pathological finger biomechanics (e.g., swanneck deformities), and could help improve clinical differential diagnostics of trigger finger causes. The marker frame measuring method may be useful to quantify interphalangeal joints trajectories in surgical/rehabilitative outcome studies. The data as a whole provide the most comprehensive collection of interphalangeal joint trajectories for clinical reference and model validation known to us to date.

Anatomic basis for individuated surface EMG and homogeneous electrostimulation with neuroprostheses of the extensor digitorum communis.

The extensor digitorum communis (ED) is generally regarded as a fairly undiversified muscle that gives extensor tendons to all fingers. Some fine wire electromyographic (EMG) investigations have been carried out to study individuation of the muscle parts to the different fingers. However, individuated surface EMG of the ED has not been investigated. This study analyses the anatomy of the ED muscle parts to the different fingers in detail and proposes optimal locations for surface or indwelling electrodes for individuated EMG and for electrostimulation with neuroprostheses. The dissections show that the ED arises from extensive origin tendons (OT), which originate at the lateral epicondyle and reach far in the forearm. The ED OT is V-shaped with shorter central tendon fibers but with a long radial and an even longer ulnar slip. The ED parts to the individual fingers consistently arise from distinct OT locations: the ED3 (medius) arises proximally, the ED2 (index) from the radial slip distal to ED3, the ED4 (ring finger) from the ulnar slip distal to ED3, and the ED5 (to ring/little finger) from the ulnar slip distal to ED4. This lengthwise widely spaced arrangement of ED parts compensates to some degree for the narrow ED width and suggests that ED parts should be individually assessable by indwelling and even by surface EMG electrodes, albeit in the latter case with variable mutual cross-talk. Conversely, the anatomic spacing of ED parts warrants that electromyographic stimulation with neuroprostheses by a single implanted electrode cannot likely homogeneously activate all ED parts.

Assessment of individual finger muscle activity in the extensor digitorum communis by surface EMG.

The extensor digitorum communis (ED) is a slender muscle group in the dorsal forearm from which tendons arise to the index (D2), medius (D3), ring (D4), and little (D5) fingers. Limited independence has been attributed to the parts that actuate the individual fingers. However, in a detailed anatomical analysis, it was found that the ED parts to the different fingers have constant and widely spaced anatomical locations that promote independent function. These observations and the superficial muscle belly locations prompted the hypothesis that these ED parts would be individually assessable by small anatomically placed surface EMG electrodes. In the present study, this hypothesis was evaluated by measuring electromyography (EMG) from the ED parts and surrounding muscles during individual finger tapping tasks with the forearm resting on a flat surface. It was found that individual ED activity can be well measured in ED2, ED3, ED4, and extensor digiti minimi (EDM). ED3 did not give nor did its electrodes receive significant crosstalk from other ED parts. ED4 electrodes recorded an EMG level of 30 +/- 19% (mean +/- SD) ED2 EMG in D2 tapping and ED2 electrodes a level of 53 +/- 22% ED4 EMG in D4 tapping, by hypothesis mostly crosstalk. EDM electrodes may record EMG at the level of ED4 EMG in D4 tapping. In D2 tapping, the mutual ED2 and extensor indicis redundancy reflected in large intersubject EMG differences with sometimes one or the other almost silent. The results may expand the possibilities of EMG analysis and finger muscle electrostimulation in ergonomic and clinical applications.