Repeated stage exposure reduces music performance anxiety.

Background: High heart rate (HR) and restlessness are two important features of music performance anxiety (MPA). In a case report of a cellist suffering from this condition, we showed that HR and restlessness decreased after repeated live performances of the same musical excerpt, thereby positively modulating objective performance criteria and subjective components. Here, we largely replicate these results in a group of 18 string players reporting MPA. Methods: Objective measurement devices included a miniaturized electrocardiogram monitor and three 3-axis accelerometer loggers. Subjective measures included the Multidimensional Mental Health Questionnaire (MDBF) and a customized visual analogue scale (VAS) questionnaire for MPA. Non-artistic performance errors were assessed by music experts using a composite score for technical playing errors (i.e., intonation errors, omission of notes, and bowing noise). Data were collected from each study participant during three brief public solo performances of the same musical excerpt, with each performance occurring before a new audience on the same day. Results: From the 1st to the 3rd performance, HR, VAS, and playing error scores decreased significantly. MDBF (RU scale) showed a significant increase in calmness from the 1st to the 3rd performance on stage. HR and RU, VAS, and RU, as well as bow acceleration and overall duration of playing correlated significantly across participants and performances. Discussion and conclusion: We conclude that repeated stage exposure significantly reduces HR as well as restlessness and playing errors linked to MPA. Public performances are still successful when HR is significantly higher than during rest periods. These results underscore the importance of stage training to become accustomed to realistic public self-exposure. Musicians - especially students - should consider this component of stage training as an integral part of their practice routine. Therefore, stage training can reduce MPA, promote better live performances and prevent stress-related mental disorders and physical injuries. These result from excessive self-exercise strategies common in musicians experiencing MPA. HR monitoring should be an integral part of evaluating the effectiveness of interventions for better MPA management and efficient performance training.

Pleasure-related analgesia activates opioid-insensitive circuits.

Recent findings suggest that pain and pleasure share common neurochemical circuits, and studies in animals and humans show that opioid-mediated descending pathways can inhibit or facilitate pain. We explored the role of endogenous opioid neurotransmission in pleasure-related analgesia. µ-Opioidergic activity was blocked with 0.2 mg/kg naloxone to assess its effects on hedonic responses to pleasant emotional pictures (International Affective Picture System) and its modulating effects on heat pain tolerance. Naloxone did not alter subjective and autonomous reactions to pleasure induction or overall mood of participants. In addition, pleasure-related increases in pain tolerance persisted after reversal of endogenous µ-opioidergic neurotransmission. Subjective pain intensity and unpleasantness ratings increased after naloxone administration. These findings suggest that, in addition to opioid-sensitive circuits, mainly opioid-insensitive pain-modulating circuits are activated during pleasure-related analgesia.

Increment of fatigue, depression, and stage fright during the first year of high-level education in music students.

BACKGROUND: Public opinion associates music performance with pleasure, relaxation, and entertainment. Nevertheless, several studies have shown that professional musicians and music students are often affected by work-related burdens. These are closely related to stress and anxiety. OBJECTIVE: Scrutinizing specific health strains and work attitudes of music students during their freshman year of high-level education. METHODS: One hundred five students in three Swiss music universities were part of a longitudinal study using standardized assessment questionnaires. Before and after their first study year, some custom-made questionnaires designed to fit the particular work environment of musicians were used together with the already validated inquiry instruments. RESULTS: Fatigue, depression, and stage fright increased significantly. CONCLUSIONS: Our results indicate more study is needed and attempts should be made to minimize the stress level, improve the students' ability to cope with stress, and otherwise reduce their risk for injury. This appears particularly important considering the long-term negative effects of stressors on individuals' health as revealed by modern research.

Monitoring stage fright outside the laboratory: an example in a professional musician using wearable sensors.

We implemented and tested a wearable sensor system to measure patterns of stress responses in a professional musician under public performance conditions. Using this sensor system, we monitored the cellist's heart activity, the motion of multiple body parts, and their gradual changes during three repeated performances of a skill-demanding piece in front of a professional audience. From the cellist and her teachers, we collected stage fright self-reports and performance ratings that were related to our sensor data analysis results. Concomitant to changes in body motion and heart rate, the cellist perceived a reduction in stage fright. Performance quality was objectively improved, as technical playing errors decreased throughout repeated renditions. In particular, from performance 1 to 3, the wearable sensors measured a significant increase in the cellist's bowing motion dynamics of approximately 6% and a decrease in heart rate. Bowing motion showed a marginal correlation to the observed heart rate patterns during playing. The wearable system did not interfere with the cellist's performance, thereby allowing investigation of stress responses during natural public performances.

Placebo-mediated, Naloxone-sensitive suggestibility of short-term memory performance.

Physiological studies of placebo-mediated suggestion have been recently performed beyond their traditional clinical context of pain and analgesia. Various neurotransmitter systems and immunological modulators have been used in successful placebo suggestions, including Dopamine, Cholecystokinin and, most extensively, opioids. We adhered to an established conceptual framework of placebo research and used the µ-opioid-antagonist Naloxone to test the applicability of this framework within a cognitive domain (e.g. memory) in healthy volunteers. Healthy men (n=62, age 29, SD=9) were required to perform a task-battery, including standardized and custom-designed memory tasks, to test short-term recall and delayed recognition. Tasks were performed twice, before and after intravenous injection of either NaCl (0.9%) or Naloxone (both 0.15 mg/kg), in a double-blind setting. While one group was given neutral information (S-), the other was told that it might receive a drug with suspected memory-boosting properties (S+). Objective and subjective indexes of memory performance and salivary cortisol (as a stress marker) were recorded during both runs and differences between groups were assessed. Short-term memory recall, but not delayed recognition, was objectively increased after placebo-mediated suggestion in the NaCl-group. Naloxone specifically blocked the suggestion effect without interfering with memory performance. These results were not affected when changes in salivary cortisol levels were considered. No reaction time changes, recorded to uncover unspecific attentional impairment, were seen. Placebo-mediated suggestion produced a training-independent, objective and Naloxone-sensitive increase in memory performance. These results indicate an opioid-mediated placebo effect within a circumscribed cognitive domain in healthy volunteers.

REM sleep behavior disorder is not linked to postural instability and gait dysfunction in Parkinson.

To evaluate a potential association of REM-sleep behavior disorder (RBD) with gait and postural impairment in Parkinson's disease (PD). Gait difficulties and postural impairment are frequent in PD and are a major cause of disability. Animal studies indicate a key role of the pedunculopontine nucleus (PPN) in gait, postural control, and REM sleep, and also in the pathophysiology of RBD. In humans, such an association has not been investigated. Twenty-six patients with mild-to-moderate PD (13 with polysomnography confirmed and 13 with excluded RBD), and 20 age-matched healthy controls were prospectively investigated. Gait assessment on a treadmill, and static and dynamic posturography were performed. PD patients with RBD do not differ from those without RBD in gait and postural control. Greater severity of PD or prevalence of gait and postural disturbances in the presence of RBD were not found. RBD was not associated with any particular motor phenotype. We found no association of RBD with gait disturbances and postural impairment. Human gait and postural control and RBD appear to depend upon different neuronal circuits.

Heat pain threshold and tolerance show no left-right perceptual differences at complementary sites of the human forearm.

Pain threshold and pain tolerance of heat noxious stimuli were assessed to determine whether they are equivalent when measured at three equidistant sites of both volar forearms. Heat pain threshold and tolerance were measured in 18 healthy volunteers using a standard stimulation device consisting of a thermode. Pain threshold and pain tolerance did not differ within and across forearm sites. Experimenters addressing heat pain threshold and tolerance in healthy volunteers may freely choose and change stimulation sites on both volar forearms, without the risk of confounding site effects on dependent variables. This data completes previous reports on side effects by analyzing the effect of site on the forearm for both heat pain threshold and tolerance. The absence of side and site effects may contribute to setting a more secure basis for assessments of laterality effects of painful stimulation.

Secondary motor disturbances in 101 patients with musician's dystonia.

OBJECTIVE: Musician's focal dystonia is usually considered to be task specific but secondary motor disturbances have been reported also. We carried out a detailed evaluation of the incidence of these secondary motor problems in 101 patients. METHOD: Symptoms were assessed using clinical histories, neurological examinations and observation of instrumental manoeuvres. RESULTS: 53.5% of patients reported secondary motor disturbances in activities other than playing their main instrument, with the onset delayed in some cases by up to 12 years from the awareness of dystonic symptoms. 46.5% suffered from simple, 19.8% from complex and 33.7% from progressive cramps. Plucked string players (guitarists) mainly suffered from simple cramps while keyboardists more frequently displayed the progressive form. In all patients, symptoms were focal, and the type of cramp was unrelated to the severity of the perceived symptoms. Those patients playing a second instrument similar to their main instrument showed symptoms which worsened to a higher degree than those playing either only one instrument or whose second instrument was different. CONCLUSIONS: Longer follow-up assessments may reveal secondary motor symptoms that are not visible over shorter examination periods. Therefore, a thorough evaluation of everyday life motor activities should be considered in any clinical and treatment protocol. We speculate that the avoidance of movements that are similar to the main affected task may be of help in limiting symptoms. Consequently, focal dystonia may be considered more movement than task specific.

A portable and low-cost fMRI compatible pneumatic system for the investigation of the somatosensensory system in clinical and research environments.

There still is a need for devices that allow reproducible stimulation of skin areas of the human body. We constructed a stimulation system and tested it by using brief pneumatic stimulation to the right thumb of nine healthy volunteers. BOLD-signals in response to tactile stimulation with frequencies of 1, 3 and 5 Hz were measured using a 3T MRI scanner. The stimulation device consists of synthetic membranes connected to plastic tubes capable of carrying compressed air, and an electronic component, which controls the on- and off-switching of an electromagnetic valve. The valve near the MR-scanner did not lower the image quality. Primary somatosensory activation contralateral to the stimulation site was reliably detected in response to a stimulus magnitude of 3.5 bar in all volunteers. 1 Hz stimulation resulted in higher maximal percentage BOLD-signal changes. Our device is an easy-to-construct, low-cost and portable tool suitable for research and clinical environments. It permits passive non-painful stimulation relevant for clinical assessments and is also compatible with magnetoencephalography (MEG) and electroencephalography (EEG). In basic and clinical research, this device therefore contributes to meaningful comparisons between results obtained with different techniques.

Changing the brain through therapy for musicians' hand dystonia.

Focal hand dystonia is a disorder in which sensory and motor anomalies emerge that appear to be grounded in maladaptive routes of cortical plasticity. Remodeling cortical networks through sensory-motor retuning (SMR), we achieved long-term reduction in the symptoms of focal hand dystonia. Magnetoencephalography confirmed that SMR modified the representational cortex of the fingers, whereby the representation of the affected hand was reorganized so that it resembled more the organization of the non-affected side. Furthermore, we observed differences in abnormal tactile acuity between patients with musician's cramp and those with writer's cramp: Using two-point finger discrimination, dystonic musicians showed perceptual asymmetry between hands, while writer's cramp patients did not. To further evaluate the occurrence of collateral disturbances in focal dystonia, we assessed the clinical histories of 101 affected musicians. An important finding from this study was that dystonic musicians who play a similar first and second instrument reported a continuous worsening of their symptoms. In addition, collateral disturbances appeared with a shorter delay when more than one instrument was played. Taken together, these studies suggest that (1) neurological dysfunction can be reversed by context-specific training protocols, (2) specific symptomatic and etiological differences among various forms of focal hand dystonia might result from different behavioral experiences and their central representation, and (3) the spread of symptoms might be prevented by avoiding training that implies movement patterns similar to the main affected task, and by reducing the amount of task-associated movement behavior.

Fast or slow? Compressions (or not) in number-to-line mappings.

We investigated, in a university student population, spontaneous (non-speeded) fast and slow number-to-line mapping responses using non-symbolic (dots) and symbolic (words) stimuli. Seeking for less conventionalized responses, we used anchors 0-130, rather than the standard 0-100. Slow responses to both types of stimuli only produced linear mappings with no evidence of non-linear compression. In contrast, fast responses revealed distinct patterns of non-linear compression for dots and words. A predicted logarithmic compression was observed in fast responses to dots in the 0-130 range, but not in the reduced 0-100 range, indicating compression in proximity of the upper anchor 130, not the standard 100. Moreover, fast responses to words revealed an unexpected significant negative compression in the reduced 0-100 range, but not in the 0-130 range, indicating compression in proximity to the lower anchor 0. Results show that fast responses help revealing the fundamentally distinct nature of symbolic and non-symbolic quantity representation. Whole number words, being intrinsically mediated by cultural phenomena such as language and education, emphasize the invariance of magnitude between them­essential for linear mappings, and therefore, unlike non-symbolic (psychophysical) stimuli, yield spatial mappings that don't seem to be influenced by the Weber-Fechner law of psychophysics. However, high levels of education (when combined with an absence of standard upper anchors) may lead fast responses to overestimate magnitude invariance on the lower end of word numerals.

Temporal Processing in Bistable Perception of the Necker Cube.

Perception of ambiguous figures is unstable and alternates repeatedly between possible interpretations. Some approaches to explaining this phenomenon have, so far, assumed low-level bottom-up mechanisms like adaptation and mutual inhibition of underlying neural assemblies. In contrast, less precise top-down approaches assume high-level attentional control mechanisms generalised across sensory modalities. In the current work we focused on specific aspects of the top-down approach. In a first study we used dwell times (periods of transiently stable percepts) and the parameters of dwell time distribution functions to compare the dynamics of perceptual alternations between visual (Necker cube) and auditory ambiguity (verbal transformation effect). In a second study we compared the endogenous alternation dynamics of the Necker cube with parameters from two attention tasks with different regimes of temporal dynamics. The first attention task (d2) is characterised by endogenous self-paced dynamics, similar to the dynamics underlying perceptual alternations of ambiguous figures, and we found clear correlations between dwell time parameters (Necker cube) and processing speed (d2 task). The temporal dynamics of the second (go/no-go) attention task, in contrast, are exogenously governed by the stimulus protocol, and we found no statistically significant correlation with the Necker cube data. Our results indicate that both perceptual instability and higher-level attentional tasks are linked to endogenous brain dynamics on a global coordinating level beyond sensory modalities.

A new tool for real-time pain assessment in experimental and clinical environments.

Pain measurement largely depends on the ability to rate personal subjective pain. Nevertheless, pain scales can be difficult to use during medical procedures. We hypothesized that pain can be expressed intuitively and in real-time by squeezing a pressure sensitive device. We developed such a device called "Painmouse(®)" and tested it on healthy volunteers and patients in two separate studies: Sixteen male participants rated different painful heat stimuli via Painmouse(®) and a Visual Analog Scale (VAS). Retest was done one week later. Participants clearly distinguished four distinct pain levels using both methods. Values from the first and second sessions were comparable. Thereafter, we tested the Painmouse(®) by asking twelve female and male leg- ulcer patients to continuously squeeze it during the whole length of their wound-dressing change. Patients rated each step of dressing change on an 11-point numeric rating scale. Painmouse(®) ratings were highest for the wound cleaning and debridement step. Application of the new dressing was not evaluated as very painful. On the other hand, numeric scale ratings did not differentiate between dressing change steps. We conclude that the Painmouse(®) enables pain assessment even under difficult clinical circumstances, such as during a medical treatment in elderly patients.

Organizational psychosocial factors and deployment-related exposure concerns in Afghanistan/Iraq War veterans.

OBJECTIVE: Environmental exposure concerns are associated with adverse health outcomes in soldiers deployed to South West Asia. There is little data on factors associated with the reporting of exposure concerns. We explored the relationship between deployment-related preparedness/support and exposure concerns. METHODS: Retrospective chart review of 489 Afghanistan/Iraq veterans evaluated at a Veterans Affairs tertiary center for postdeployment health. RESULTS: Virtually all subjects were concerned about environmental exposure(s). There were no significant demographic differences in exposure concerns, preparedness/support variables, or both. Preparedness/support correlated inversely with exposure concerns. Mental health function mediated the relationship between preparedness/support and exposure concerns. CONCLUSIONS: Deployment-related preparedness/support is associated with exposure concerns and mental health functioning. Definitive studies will provide data and insight on how the military may better prepare/support soldiers to optimize their resilience and reduce deployment-related exposure concerns.

Prefrontal cortex modulates placebo analgesia.

Expectations and beliefs modulate the experience of pain, which is particularly evident in placebo analgesia. The dorsolateral prefrontal cortex (DLPFC) has been associated with pain regulation and with the generation, maintenance and manipulation of cognitive representations, consistent with its role in expectation. In a heat-pain paradigm, we employed non-invasive low-frequency repetitive transcranial magnetic stimulation (rTMS) to transiently disrupt left and right DLPFC function or used the TMS device itself as a placebo, before applying an expectation-induced placebo analgesia. The results demonstrated that placebo significantly increased pain threshold and pain tolerance. While rTMS did not affect pain experience, it completely blocked placebo analgesia. These findings suggest that expectation-induced placebo analgesia is mediated by symmetric prefrontal cortex function.

Brain activation in response to bladder filling and simultaneous stimulation of the dorsal clitoral nerve--an fMRI study in healthy women.

AIMS: Using functional magnetic resonance imaging (fMRI) we investigated the cortical and subcortical representations during bladder filling and the effect of simultaneous stimulation of the dorsal clitoral nerve on these cortical and subcortical structures. METHODS: After approval of the local ethics committee, 8 healthy females were included. Prior to scanning, subjects were catheterized and the bladder was filled until first desire to void occurred. In a block design protocol we performed repetitive manual bladder filling (FILLING) and emptying of additional 80 ml saline, alternating with rest conditions (REST) of constant bladder volume. The protocol was repeated with simultaneous stimulation of the dorsal clitoral nerve during the filling periods (COMBINED). Activation maps were calculated by means for 3 different contrasts: 1) FILLING>REST, 2) COMBINED>REST and 3) FILLING>COMBINED. RESULTS: A group analysis of contrast 1) showed activation of the right prefrontal and orbitofrontal cortices, the insula bilaterally, the left precuneus, the parietal operculum bilaterally, the cerebellum bilaterally (q(FDR)< or =0.001), the right anterior cingulate gyrus (q(FDR)< or =0.005) and the right anterior mid pons (q(FDR)< or =0.05). Contrast 2) showed activation in the right frontal area, the left insula, the parietal operculum bilaterally and the left cerebellum (q(FDR)< or =0.001). Deactivations were found in the middle frontal gyrus bilaterally and the post- and paracentral gyri bilaterally. Contrast 3) revealed stronger activation during FILLING in the bilateral frontal and prefrontal areas, the right anterior cingulated gyrus, and the right putamen (q(FDR)< or =0.05). Only the right insula showed stronger activation during the COMBINED condition. CONCLUSION: Simultaneous dorsal clitoral nerve stimulation during bladder filling reduced the activation of certain cortical areas suggesting a neuromodulatory effect of this stimulation on supraspinal centres involved in lower urinary tract control.

Changes in self-perceived role identity modulate pain perception.

Pain is an experience including physiological and psychological factors. We assume that emotions may be elicited and increased through self-perceived role identity and that change of role identity alters quality and intensity of pain perception. We used role-play strategies to assess whether pain can be better tolerated whenever, in an unavoidable and unpleasant context, role identity confers pain a meaningful and thus suitable character. We induced antithetic roles in 21 actors who received heat stimuli on their arms before and after role-play conditions. Pain tolerance, skin conductance and voice signals were measured. Pain tolerance increased for heroes/heroines and decreased for faint-hearts. Men showed higher pain tolerance. Heroes/heroines evaluated heat stimuli as more intense. Faint-hearts found pain stimuli more affectively loaded at lower temperatures. Women showed higher pain ratings. Hence, self-perception influences pain perception. Role-play strategies may be of value for new pain management strategies.

Effective behavioral treatment of focal hand dystonia in musicians alters somatosensory cortical organization.

New perspectives in neurorehabilitation suggest that behavioral treatments of movement disorders may modify the functional organization of central somatosensory neural networks. On the basis of the assumption that use-dependent reorganization in these networks contributes to the fundamental abnormalities seen in focal dystonia, we treated 10 affected musicians and measured the concomitant somatosensory changes by using whole-head magnetoencephalography. We found that effective treatment, using the method of sensory motor retuning, leads to alterations in the functional organization of the somatosensory cortex. Specifically, before treatment, somatosensory relationships of the individual fingers differ between the affected and unaffected hands, whereas after treatment, finger representations contralateral to the dystonic side become more similar to the less-affected side. Further, somatosensory finger representations are ordered more according to homuncular principles after treatment. In addition, the observed physiologic changes correlated with behavioral data. These results confirm that plastic changes in parallel with emergent neurological dysfunction may be reversed by context-specific, intensive training-based remediation.

Sensory motor retuning: a behavioral treatment for focal hand dystonia of pianists and guitarists.

OBJECTIVE: To evaluate the long-term effectiveness of sensory motor retuning (SMR), a new treatment for focal hand dystonia in musicians. DESIGN: Prospective case series with an (adventitious) comparison group with 3- to 25-month follow-up in piano and guitar and 0- to 4-month follow-up in flute and oboe players. SETTING: General community in Germany. PARTICIPANTS: Eleven professional musicians. INTERVENTION: Immobilization by splints of 1 or more digits other than the focal dystonic finger. This finger carried out repetitive exercises in coordination with 1 or more of the other digits for 1(1/2) to 2(1/2) hours a day for 8 consecutive days under therapist supervision. The subjects then were instructed to continue practice for 1 hour daily for 1 year. MAIN OUTCOME MEASURES: Spectral analysis of the output of a dexterity-displacement device that continuously recorded digital displacement during finger movements and a dystonia evaluation scale on which patients rated how well they had just performed dystonic movement sequences and repertoire passages. RESULTS: The 3 wind players (adventitious placebo controls) did not improve substantially. However, each pianist and guitarist showed marked and significant improvement in spontaneous repertoire performance without the splint. The first subject is now 25 months posttreatment. CONCLUSIONS: Results suggest that SMR is of value for the treatment of focal hand dystonia in pianists and guitarists.