An overview of rehabilitation approaches for focal hand dystonia in musicians: A scoping review.

OBJECTIVE: To provide a comprehensive overview of rehabilitation treatment strategies for focal hand dystonia (FHD) in musicians, examining their evolution and effectiveness. DATA SOURCES: A systematic search of five databases, PubMed, PEDro, Cochrane Library, Trip, and Google Scholar, to identify relevant articles on FHD rehabilitation. The last search was performed on 20 December 2023. METHODS: Inclusion criteria were applied to 190 initially identified articles, resulting in 17 articles for review. Exclusions were made for duplicates, irrelevant titles, abstracts, and non-rehabilitation interventions. RESULTS: Ten different rehabilitation approaches were identified over 20 years. While no definitive intervention protocol exists, a multimodal approach is commonly recommended. CONCLUSIONS: This scoping review underscores the diversity of rehabilitation strategies for FHD. It suggests the potential of multimodal approaches, emphasizing the need for further large-scale clinical efficacy studies.

Assessment of the effects of Kinesiotaping on musical motor performance in musicians suffering from focal hand dystonia: a pilot study.

OBJECTIVE: The aim of this study was to explore the immediate and short-term effects of a Correction Kinesiotaping intervention on fine motor control in musicians with focal hand dystonia. DESIGN: A single-blinded, single-arm repeated measures, pilot study. SETTING: Medical outpatient clinic. SUBJECTS: Seven musicians diagnosed with focal hand dystonia. INTERVENTIONS: Musicians performed musical exercises under the following conditions: without Kinesiotape (baseline), during a Correction Kinesiotaping intervention and immediately after tape removal (block 1) and during a Sham Kinesiotaping intervention and immediately after tape removal (block 2). Blocks were randomly presented across participants. A tailored Correction Kinesiotaping intervention on affected fingers was provided based on the dystonic pattern that each patient manifested while playing. MAIN MEASURES: Motor performance was video-documented and independent experts blindly assessed the general performance and fingers' posture on visual analogue scales. Also, musicians' self-reports of the musical abilities were evaluated. Finally, electromyographic activity and coactivation index of wrist antagonist muscles were analyzed. RESULTS: No significant differences in effects between Correction Kinesiotaping and Sham Kinesiotaping were reported by the experts, either for general performance (P > 0.05) or for fingers' posture (P > 0.05); any subtle benefits observed during Correction Kinesiotaping were lost after the tape was removed. Musicians estimated that Correction Kinesiotaping was ineffective in improving their musical abilities. Also, no significant changes with respect to the coactivation index (P > 0.05) were found among the conditions. CONCLUSION: Correction Kinesiotaping intervention may not be useful to reduce dystonic patterns, nor to improve playing ability, in musicians with focal hand dystonia.

Effect of botulinum toxin A & task-specific training on upper limb function in post-stroke focal dystonia.

OBJECTIVE: To determine the effect of botulinum toxin A and task-specific training on upper limb function in post-stroke focal dystonia patients. METHODS: A randomised control trial was conducted at hospitals in Rawalpindi and Islamabad, Pakistan, from October 2015 to September 2016. The subjects were recruited using non-probability purposive sampling and were divided equally into control and experimental groups by sealed envelope method. The experimental group received botulinum toxin A followed by task-specific training, while the control group received only task-specific training for 8 weeks. Data was collected at baseline, after 4 weeks and 8 weeks by using upper extremity items of Motor Assessment Scale and Fugl-Meyer Assessment scale of upper limb. RESULTS: There were 43 subjects divided into two equal groups of 23(50%) each. In the experimental group, mean age of patients was 43.57±10.94 years while in the control group it was 48.75±10.75 years (p=0.135). There were 15(71.4%) male and 6(28.6%) female patients in the experimental group and 9(45%) were male and 11(55%) were female in the control group. Both groups showed significant improvements on the Motor Assessment Scale and Fugl-Meyer Assessment scale (p<0.01), but no significant differences were observed between the groups at baseline, after 4 and 8 weeks of intervention (p>0.05). CONCLUSIONS: Eight weeks of task-specific training improved upper limb function in post-stroke focal dystonia patients.

Neuromuscular Re-Education Programs for Musicians with Focal Hand Dystonia: A Systematic Review.

OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of neuromuscular re-education programs on reducing abnormal movements during instrument play in musicians with focal hand dystonia (FHD). METHODS: A systematic literature search of published articles was performed. Databases searched included MEDLINE, CINAHL, PsycINFO, OTseeker, and the Cochrane Library. Additional articles were identified from reference lists. Studies meeting inclusion criteria were independently assessed by the two coauthors for eligibility and quality of methods. Study data were summarized in a critical appraisal chart. RESULTS: Nine studies met the inclusion criteria for review, including 1 non-randomized two-group study, 6 single-group repeated measures studies, and 2 single-subject studies. The studied neuromuscular re-education programs included constraint-induced therapy plus motor control retraining, sensory motor retuning, learning- based sensorimotor training, and slow-down exercise. CONCLUSIONS: The results of this review indicate there is moderate evidence to support the effectiveness of neuromuscular re-education programs on reducing abnormal movements during instrument play in musicians with FHD. However, additional research should evaluate the effectiveness of neuromuscular re-education programs using reliable and valid outcome measures, as well as study methods which provide higher levels of evidence.

A simple orthosis solves a problem in a patient with a dystonic finger after stroke.

These authors use a custom-fabricated orthotic device to improve hand motion and function for a client with hand dystonia after stroke. Clinical observation and reasoning resulted in an effective solution to control the dystonia that was acceptable to the client. - Kristin Valdes, OTD, OT, CHT, Practice Forum Editor.

Differences in active range of motion measurements in the upper extremity of patients with writer's cramp compared with healthy controls.

STUDY DESIGN: Exploratory case-control study. INTRODUCTION: Writer's cramp (WC) is a type of focal hand dystonia. The central nervous system plays a role in its pathophysiology, but abnormalities in the affected musculoskeletal components may also be relevant. PURPOSE OF THE STUDY: We compared the active range of motion (ROM) in patients with WC and healthy volunteers (HVs) and correlated the findings with disease duration and severity. METHODS: Affected limb joints were measured with goniometers. Patients were assessed at least 3 months after their last botulinum toxin (botulinum neurotoxin) injection, and strength was clinically normal. t tests were used to compare the ROMs of WC with matched HVs. The Spearman correlation coefficient assessed the relationship of active ROMs to the disease duration and handwriting subscore of the Dystonia Disability Scale. RESULTS: ROMs of D1 metacarpophalangeal (MCP) joint extension as well as D2 and D5 MCP flexion were significantly smaller in WC, and distal interphalangeal joint extension in D3 and D5 was significantly greater compared with HVs. There were negative correlations between D2 MCP flexion and disease duration and with Dystonia Disability Scale. DISCUSSION: Abnormalities in ROMs in WC were found. Severity and disease duration correlated with reduced D2 MCP flexion. This may be related to intrinsic biomechanical abnormalities, co-contraction of muscles, or a combination of subclinical weakness and atrophy from repeated botulinum neurotoxin injections. CONCLUSIONS: Hand biomechanical properties should not be ignored in the pathophysiology of WC. LEVEL OF EVIDENCE: 2c.

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.

Focal hand dystonia: individualized intervention with repeated application of repetitive transcranial magnetic stimulation.

OBJECTIVES: To examine for individual factors that may predict response to inhibitory repetitive transcranial magnetic stimulation (rTMS) in focal hand dystonia (FHD); to present the method for determining optimal stimulation to increase inhibition in a given patient; and to examine individual responses to prolonged intervention. DESIGN: Single-subject design to determine optimal parameters to increase inhibition for a given subject and to use the selected parameters once per week for 6 weeks, with 1-week follow-up, to determine response. SETTING: Clinical research laboratory. PARTICIPANTS: A volunteer sample of subjects with FHD (N = 2). One participant had transcranial magnetic stimulation responses indicating impaired inhibition, and the other had responses within normative limits. INTERVENTIONS: There were 1200 pulses of 1-Hz rTMS delivered using 4 different stimulation sites/intensity combinations: primary motor cortex at 90% or 110% of resting motor threshold (RMT) and dorsal premotor cortex (PMd) at 90% or 110% of RMT. The parameters producing the greatest within-session increase in cortical silent period (CSP) duration were then used as the intervention. MAIN OUTCOME MEASURES: Response variables included handwriting pressure and velocity, subjective symptom rating, CSP, and short latency intracortical inhibition and facilitation. RESULTS: The individual with baseline transcranial magnetic stimulation responses indicating impaired inhibition responded favorably to the repeated intervention, with reduced handwriting force, an increase in the CSP, and subjective report of moderate symptom improvement at 1-week follow-up. The individual with normative baseline responses failed to respond to the intervention. In both subjects, 90% of RMT to the PMd produced the greatest lengthening of the CSP and was used as the intervention. CONCLUSIONS: An individualized understanding of neurophysiological measures can be an indicator of responsiveness to inhibitory rTMS in focal dystonia, with further work needed to determine likely responders versus nonresponders.

Functional recovery from chronic writer's cramp by brain-computer interface rehabilitation: a case report.

BACKGROUND: Dystonia is often currently treated with botulinum toxin injections to spastic muscles, or deep brain stimulation to the basal ganglia. In addition to these pharmacological or neurosurgical measures, a new noninvasive treatment concept, functional modulation using a brain-computer interface, was tested for feasibility. We recorded electroencephalograms (EEGs) over the bilateral sensorimotor cortex from a patient suffering from chronic writer's cramp. The patient was asked to suppress an exaggerated beta frequency component in the EEG during hand extension. RESULTS: The patient completed biweekly one-hour training for 5 months without any adverse effects. Significant decrease of the beta frequency component during handwriting was confirmed, and was associated with clear functional improvement. CONCLUSION: The current pilot study suggests that a brain-computer Interface can give explicit feedback of ongoing cortical excitability to patients with dystonia and allow them to suppress exaggerated neural activity, resulting in functional recovery.

Current uses of botulinum toxin A as an adjunct to hand therapy interventions of hand conditions.

STUDY DESIGN: Literature review. DISCUSSION: Botulinum toxin A, a neurotoxin causing temporary muscle paralysis at the neuromuscular junction, has been used to treat multiple acquired conditions of the hand and upper extremity. Initially approved for use in treating blepharospasm and strabismus in the 1980s, indications have expanded to include spasticity associated with cerebrovascular accidents, vasospastic disorders, focal dystonias, and pain conditions. This article reviews the current literature discussing the efficacy of botulinum toxin A in management of disorders of the hand and upper extremity relevant to hand therapists. LEVEL OF EVIDENCE: NA.

Effect of a musicians' exercise intervention on performance-related musculoskeletal disorders.

PURPOSE: To evaluate the effect of a purpose-designed exercise program on performance-related musculoskeletal disorders (PRMDs) and associated risk factors in a sample of professional orchestral musicians. METHODS: A 10-week exercise program was made available to full-time musicians employed by the eight premier symphony orchestras of Australia. Questionnaires were administered before, immediately after (T1), and 6 months after interventions (T2) containing questions relating to change in frequency and severity of PRMDs, ratings of perceived exertion (RPE) during rehearsal, private practice, and performance, as well as nine performance-related factors. Participants were also asked to rate whether these performance-related factors affected their overall playing capacity during different playing situations. A comparative control group of musicians had no intervention and completed a modified questionnaire at the same time points. RESULTS: Exercise participants (n=30) reported a reduction in frequency (p<0.05) and severity (p<0.05) of PRMDs at T1 but not at T2 compared to controls (n=23). The exercise group reported a significant improvement in RPE during private practice at T1 (p<0.01) and T2 (p<0.01), but not during rehearsal and performance. At T1, the intervention was rated to be moderately to highly effective for three performance-related factors: strengthening muscles that support playing, learning techniques that support playing, and posture. Further, participants reported an intervention effect on overall playing capacity during rehearsal at T1 and T2. CONCLUSIONS: A tailored exercise program for musicians was effective at managing PRMDs, especially in reducing the frequency and severity of PRMDs. Physical therapy exercises should be considered in modifying performance-related factors that have been reported to be predictors of PRMDs.

Writer's cramp: increased dorsal premotor activity during intended writing.

Simple writer's cramp (WC) is a task-specific form of dystonia, characterized by abnormal movements and postures of the hand during writing. It is extremely task-specific, since dystonic symptoms can occur when a patient uses a pencil for writing, but not when it is used for sharpening. Maladaptive plasticity, loss of inhibition, and abnormal sensory processing are important pathophysiological elements of WC. However, it remains unclear how those elements can account for its task-specificity. We used fMRI to isolate cerebral alterations associated with the task-specificity of simple WC. Subjects (13 simple WC patients, 20 matched controls) imagined grasping a pencil to either write with it or sharpen it. On each trial, we manipulated the pencil's position and the number of imagined movements, while monitoring variations in motor output with electromyography. We show that simple WC is characterized by abnormally increased activity in the dorsal premotor cortex (PMd) when imagined actions are specifically related to writing. This cerebral effect was independent from the known deficits in dystonia in generating focal motor output and in processing somatosensory feedback. This abnormal activity of the PMd suggests that the task-specific element of simple WC is primarily due to alterations at the planning level, in the computations that transform a desired action outcome into the motor commands leading to that action. These findings open the way for testing the therapeutic value of interventions that take into account the computational substrate of task-specificity in simple WC, e.g. modulations of PMd activity during the planning phase of writing.

Utility of multi-channel surface electromyography in assessment of focal hand dystonia.

INTRODUCTION: Surface electromyography (SEMG) allows objective assessment and guides selection of appropriate treatment in focal hand dystonia (FHD). METHODS: Sixteen-channel SEMG obtained during different phases of a writing task was used to study timing, activation patterns, and spread of muscle contractions in FHD compared with normal controls. Customized software was developed to acquire and analyze EMG signals. RESULTS: SEMG of FHD subjects (20) showed "early onset" during motor imagery, rapid proximal muscle recruitment, agonist-antagonist co-contraction involving proximal muscle groups, "delayed offset" after stopping writing, higher rectified mean amplitudes, and mirror activity in contralateral limb compared with controls (16). Muscle activation latencies were heterogenous in FHD. CONCLUSIONS: Anticipation, delayed relaxation, and mirror EMG activation were noted in FHD. A clear pattern of muscle activation cannot be ascertained. Multi-channel SEMG can aid in objective assessment of temporal-spatial distribution of activity and can refine targeted therapies like chemodenervation and biofeedback.

Inhibition of the dorsal premotor cortex does not repair surround inhibition in writer's cramp patients.

Writer's cramp is a task-specific form of focal dystonia, characterized by abnormal movements and postures of the hand and arm during writing. Two consistent abnormalities in its pathophysiology are a loss of surround inhibition and overactivity of the dorsal premotor cortex (PMd). This study aimed to assess a possible link between these two phenomena by investigating whether PMd inhibition leads to an improvement of surround inhibition, in parallel with previously demonstrated writing improvement. Fifteen writer's cramp patients and ten controls performed a simple motor hand task during which surround inhibition was measured using transcranial magnetic stimulation. Motor cortical excitability was measured of the active and surround muscles at three phases of the task. Surround inhibition and writing performance were assessed before and after PMd inhibitory continuous theta burst stimulation. In contrast to healthy controls, patients did not show inhibition of the abductor digiti minimi muscle during movement initiation of the first dorsal interosseus muscle, confirming the loss of surround inhibition. PMd inhibition led to an improvement of writing speed in writer's cramp patients. However, in both groups, no changes in surround inhibition were observed. The results confirm a role for the PMd in the pathophysiology of writer's cramp. We show that PMd inhibition does not lead to restoration of the surround inhibition defect in writer's cramp, despite the improvement in writing. This questions the involvement of the PMd in the loss of surround inhibition, and perhaps also the direct link between surround inhibition and dystonia.

A combination of constraint-induced therapy and motor control retraining in the treatment of focal hand dystonia in musicians: a long-term follow-up study.

UNLABELLED: Focal hand dystonia (FHD) in musicians is a painless, task-specific motor disorder characterized by involuntary loss of control of individual finger movements. The aim of this study was to investigate the long-term effects of a combined behavioral therapy intervention aimed at normalizing finger movement patterns. METHODS: Eight musicians with FHD had taken part in the 1-year study involving intensive constraint-induced therapy and motor control retraining at slow speed as the interventions. Four of these subjects volunteered to take part in this 4-year follow-up. A quasi-experimental, repeated measures design was used, with 9 testing sessions over 4 years. Video recordings of the subjects playing two pieces were used for data analysis. The Frequency of Abnormal Movements scale (FAM) was the main outcome measure. It was hypothesized that there would be significant differences in FAM scores achieved over the 4-year period. RESULTS: The results from the ANOVA revealed a significant decrease, by approximately 80%, in the number of abnormal movements for both pieces over the 4-year period (F=7.85, df=8, p<0.001). Tukey's post-hoc test revealed that significant improvements occurred after 6 months of therapy (p-values between p<0.001 and p=0.044). Although the results were not significant between month 12 and follow-up at year 4, the trend revealed that the progress achieved during the first year of intensive retraining was maintained at year 4. CONCLUSIONS: A 1-year period of intensive task-specific retraining may be a successful strategy with long-term, lasting effects for the treatment of musician's FHD. Results suggest that retraining strategies may need to be carried out for at least 6 months before statistically significant changes are noted.

Error-enhancing robot therapy to induce motor control improvement in childhood onset primary dystonia.

BACKGROUND: Robot-generated deviating forces during multijoint reaching movements have been applied to investigate motor control and to tune neuromotor adaptation. Can the application of force to limbs improve motor learning? In this framework, the response to altered dynamic environments of children affected by primary dystonia has never been studied. METHODS: As preliminary pilot study, eleven children with primary dystonia and eleven age-matched healthy control subjects were asked to perform upper limb movements, triangle-reaching (three directions) and circle-writing, using a haptic robot interacting with ad-hoc developed task-specific visual interfaces. Three dynamic conditions were provided, null additive external force (A), constant disturbing force (B) and deactivation of the additive external force again (C). The path length for each trial was computed, from the recorded position data and interaction events. RESULTS: The results show that the disturbing force affects significantly the movement outcomes in healthy but not in dystonic subjects, already compromised in the reference condition: the external alteration uncalibrates the healthy sensorimotor system, while the dystonic one is already strongly uncalibrated. The lack of systematic compensation for perturbation effects during B condition is reflected into the absence of after-effects in C condition, which would be the evidence that CNS generates a prediction of the perturbing forces using an internal model of the environment.The most promising finding is that in dystonic population the altered dynamic exposure seems to induce a subsequent improvement, i.e. a beneficial after-effect in terms of optimal path control, compared with the correspondent reference movement outcome. CONCLUSIONS: The short-time error-enhancing training in dystonia could represent an effective approach for motor performance improvement, since the exposure to controlled dynamic alterations induces a refining of the existing but strongly imprecise motor scheme and sensorimotor patterns.

Rehabilitation of a cellist whose vibrato was affected by focal dystonia.

Focal dystonia can result in a variety of technical problems in the performing musician, most often affecting control of finger movement, and embouchure. Less common is the effect of focal dystonia on the vibrato of string players. The professional cellist in our study presented with difficulty controlling her vibrato, which fluctuated both in speed and amplitude, causing an inconsistency of sound. This study investigated whether instrumental retraining could alleviate her condition. We report the novel finding that instrumental retraining can significantly improve the symptoms of a dystonic vibrato in a cellist.

Somatosensory cortical remodelling after rehabilitation and clinical benefit of in writer's cramp.

In order to explore the pathophysiological basis of a new rehabilitation therapy in writer's cramp (WC), healthy controls, untreated WC patients and WC patients who recovered a legible handwriting after rehabilitation were explored using magnetoencephalography, and the somatosensory evoked fields of fingers I, II, III and V in the sensory cortex were studied. In the cortex controlling the dystonic limb, the size of the hand representation in the trained patients was similar to that of healthy controls, and significantly different from that of untrained patients. Trained patients exhibited 'super-normal' reorganisation of the finger maps. In the cortex controlling the non-dystonic limb, there was little difference between trained and untrained patients, and the hand representation was enlarged and disorganised. The authors hypothesise that prolonged tailored rehabilitation in WC may induce long-term plasticity phenomena, lateralised to the cortex controlling the dystonic hand.

Long-term treatment effects of sensory motor retuning in a pianist with focal dystonia.

Here we present the case of a pianist suffering from unilateral focal hand dystonia for 10 yrs which affected his piano playing as well as other activities of daily life. The treatment applied was sensory motor retuning (SMR), a behavioral treatment for focal hand dystonia. Improvement was clearly achieved from the beginning of therapy. After 10 mos of treatment, performance levels were comparable to those before illness onset. The patient returned to high-level piano playing, and after 8 yrs of follow-up, performance remains normal.

Rehabilitation of focal hand dystonia in musicians: a systematic review of the studies. / Rehabilitación de la distonía focal de mano en músicos: una revisión sistemática de los estudios.

INTRODUCTION: Focal hand dystonia in musicians is a task-specific movement disorder characterized by an involuntary loss of control and coordination of finger movements during instrumental playing. MATERIALS AND METHODS: Literature searches with the keywords 'dystonia' AND 'musician' AND 'finger' OR 'treatment' OR 'therapy' OR 'rehabilitation' were conducted in PubMed, EMBASE, Cochrane Library and Web of Science to perform the systematic review about the several strategies used to treat dystonia in musicians. The search was performed independently by two authors (R.C. and M.V.) from 6 April 2020 till 6 June 2020. The research identified a total of 423 articles. Seventy-seven selected articles were analysed by the reviewers. Thirty-six publications met the inclusion criteria and were included in the systematic review. RESULTS: The systematic review was performed to identify the main used treatments for dystonia in musicians. We defined the several techniques to better guide the physician to delineate a rehabilitation protocol adopting the better strategies described in the current literature. CONCLUSION: This systematic review tried to provide to the reader a complete overview of the literature of all possible different treatments for dystonia in musicians. A correct protocol could permit to improve the motor performance and the quality of life of musicians.

TITLE: Rehabilitación de la distonía focal de mano en músicos: una revisión sistemática de los estudios.Introducción. La distonía focal de la mano en los músicos es un trastorno del movimiento relacionado con una tarea específica, que se caracteriza por una pérdida involuntaria del control y la coordinación de los movimientos de los dedos al tocar un instrumento. Materiales y métodos. Se llevaron a cabo búsquedas bibliográficas con las palabras clave 'dystonia' (distonía) Y 'musician' (músico) Y 'finger' (dedo) O 'treatment' (tratamiento) O 'therapy' (terapia) O 'rehabilitation' (rehabilitación) en PubMed, EMBASE, Cochrane Library y Web of Science para realizar la revisión sistemática sobre las diversas estrategias usadas para tratar la distonía en los músicos. La búsqueda se realizó de forma independiente por dos autores (R.C. y M.V.) entre el 6 de abril de 2020 y el 6 de junio del mismo año. La investigación identificó un total de 423 artículos. Los encargados de la revisión analizaron 77 artículos que fueron previamente seleccionados. Treinta y seis publicaciones cumplieron con los criterios de inclusión y se incluyeron en la revisión sistemática. Resultados. La revisión sistemática se realizó para identificar los principales tratamientos utilizados para la distonía en músicos. Se definieron las diversas técnicas existentes para orientar mejor a los médicos a la hora de diseñar un protocolo de rehabilitación que adopte las mejores estrategias descritas en la bibliografía actual. Conclusión. Esta revisión sistemática intenta proporcionar al lector una mirada completa sobre todos los posibles tratamientos diferentes para la distonía en los músicos. Un protocolo correcto podría permitir mejorar el rendimiento motor y la calidad de vida de los músicos.