Long-Term Muscular Atrophy and Weakness Following Cessation of Botulinum Toxin Type A Injections in the Flexor Digitorum Muscle of Musicians with Focal Hand Dystonia.

The present study assessed muscular atrophy and weakness of the flexor digitorum superficialis (FDS) and profundus (FDP) muscle as possible long-term side effects of botulinum toxin (BoNT) injections in hand dystonia patients after the termination of their treatment. For the assessment of both parameters, a group of 12 musicians diagnosed with focal hand dystonia was compared with a group of 12 healthy matched musicians. The minimum and maximum times since the last injection across patients were 0.5 to 3.5 years, respectively. The thickness and strength of the FDS and FDP were assessed via ultrasonography and a strength measurement device. Group differences were estimated through the calculation of the symmetry index between the dominant and non-dominant hand. The results revealed that compared to the control group, thickness and flexion strength of the injected FDS and FDP were decreased by 10.6% ± 5.3% (95% CI) and 12.5% ± 6.4% (95% CI), respectively, in the patient group. The amount of weakness and atrophy was predicted significantly by the total amount of BoNT injected throughout the entire treatment period. In contrast, the time after the last injection did not predict the amount of strength and muscle mass recovery after the cessation of the treatment. The current study revealed that even up to 3.5 years after the termination of BoNT injections, long-term side effects such as weakness and atrophy can still be observed. We suggest that the total BoNT dose should remain as small as possible to reduce long-lasting side effects to the minimum. Although side effects differ significantly among patients, a potential full recovery of atrophy and weakness after the cessation of BoNT treatment might be observed after periods longer than 3.5 years.

Development and Interrelation of Pain, Depression, and Anxiety in Music Students: Does Successful Treatment of Pain Have an Impact on Mental Health?

OBJECTIVE: Musculoskeletal pain is a common problem among professional musicians as well as music students. Studies have emphasized the effectiveness of music-specific physiotherapy for affected musicians. This study was designed to evaluate if physiotherapy treatment of pain-affected music students had an impact on pain perception as well as psychological well-being. To explore the possible development of musculoskeletal pain, depression, and anxiety, a second sample of pain-free music students, matched for age and gender, was examined twice at identical time intervals. METHODS: A convenience sample of 31 university music students with moderate to severe musculoskeletal pain and 31 pain-free music students, matched in age and gender, were included in the study. Both groups were examined physically and completed biographical, music-related, and psychological questionnaires. Perceived pain intensity was assessed with a visual-analogue scale (VAS), and depression and anxiety symptoms were assessed with the Beck Depression Inventory II (BDI-II) and the Hospital Anxiety and Depression Scale (HAD). Music students with pain received a series of 12 sessions of musician-specific physiotherapy, while controls waited for the same amount of time for retesting. RESULTS: On the 10-cm VAS, music students with pain reported an average improvement in pain intensity from a baseline of 6.25 (SD 1.95) to 2.7 (2.03) after the intervention, while the controls (music students without pain) did not change. Furthermore, music students with pain indicated higher depression and anxiety scores as compared to the control group before and after therapy. After intervention, music students with pain with higher BDI-II scores demonstrated clinical improvement concerning depression, but no significant improvement in mental health was found in the pain group taken as a whole. CONCLUSION: Physiotherapy was effective in reducing pain symptoms in music students affected by chronic musculoskeletal pain. However, physiotherapy did not improve mental health in pain-affected music students. Additional psychotherapeutic interventions may be needed to support music students with psychological comorbidities such as depression and anxiety.

Free Flaps in Sternal Osteomyelitis After Median Sternotomy: A Center's 12-Year Experience.

BACKGROUND: Adequate treatment of deep sternal wound infections (DSWIs) after open thoracic surgery still presents a major challenge. This study retrospectively analyzes the results of a single center's 12-year experience in treating DSWI, with special emphasis on free flap reconstruction. METHODS: In this single-center, retrospective study, all patients admitted with the diagnosis of DSWI after open thoracic surgery between 2009 and 2020 were included. A comparative analysis was performed between: (1) pedicled versus free flaps, (2) the center's two workhorse flaps-the pedicled latissimus dorsi (pLD) versus free anterolateral thigh (fALT) flaps, as well as (3) myocutaneous (MC) versus fasciocutaneous (FC) flaps. Primary endpoints were length of hospital stay (LOS) after reconstruction and in-hospital mortality. RESULTS: Of a total of 165 patients included, 152 underwent DSWI defect reconstruction with a total of 12 different reconstruction methods. Although the defect size was larger in patients who underwent free flap coverage, and the risk profile in the fALT and FC flap groups was higher, the LOS after reconstruction (in days) did not differ significantly between the groups (pedicled vs. free flaps: 23 vs. 28, p > 0.05; pLD vs. fALT: 24.5 vs. 26, p > 0.05; MC vs. FC flaps: 23 vs. 26, p > 0.05). Also, no significant differences were found in terms of in-hospital mortality when comparing the groups (pedicled vs. free flaps: 11.2 vs. 17.4%, p > 0.05; pLD vs. fALT: 11.5 vs. 12.5%, p > 0.05; MC vs. FC flaps: 12.9 vs. 12.5%, p > 0.05). CONCLUSION: With proper patient selection, free tissue transfer is a valuable alternative in the treatment of sternal dehiscence after a DSWI. Furthermore, our data demonstrate that MC flaps are not necessarily superior to FC flaps in the reconstruction of sternal osteomyelitis defects.

Utilizing Co-Creative Principles to Develop an E-Learning Platform for Interprofessional Training on Tinnitus: The Erasmus+ Project Tin-TRAC.

Tinnitus treatment, diagnosis and management across Europe varies significantly. The lack of national clinical guidelines for tinnitus management in most European countries and the absence of a common language across all disciplines involved is reflected in the diversification of healthcare practices. Interprofessional Training for Tinnitus Researchers and Clinicians (Tin-TRAC) is an Erasmus+ project that aims to develop common educational ground in the form of an e-Learning platform, co-created by patients, researchers and clinicians, which is able to unify tinnitus diagnosis and treatment strategies across Europe. A pan-European thematic educational platform integrating the best practices and latest research achievements with regard to tinnitus diagnosis and management has the potential to act as a facilitator of the reduction of interdisciplinary and interregional practice diversification. A detailed analysis of the educational needs of clinicians and researchers across disciplines will be followed by the co-creative development of the curriculum. Reusable learning objects will incorporate the training contents and will be integrated in an open e-Learning platform. Tin-TRAC envisions that its output will answer the need to create a common language across the clinicians and researchers of different disciplines that are involved in tinnitus management, and reduce patients' prolonged suffering, non-adherence and endless referral trajectories.

Novel Ultrasonographic Thickness and Strength Assessments of the Flexor Digitorum: A Reliability Analysis.

OBJECTIVES: Clinical conditions such as focal dystonia often require the assessment of atrophy and weakness of the finger muscles. However, due to a lack of well-established protocols, the current investigation focused on assessing the reliability of thickness and strength assessments of the flexor digitorum (FD) muscle, including both the superficialis and profundus components. As a secondary assessment, the reliability of the strength measurement of the extensor digitorum muscle was examined as well. METHODS: Different thickness measurements of the FD were taken via ultrasonography and averaged to estimate the mean thickness of the FD. Likewise, individual finger strength measurements taken by a custom-made finger pressure device were averaged to compute the mean strength of the flexor and extensor digitorum muscles. Test-retest reliability of the above measurements performed at two different time points (about 6 months apart) were examined on the right and left hands of 10 participants. RESULTS: Findings indicated excellent test-retest reliability (ICC > 0.92) for the mean thickness assessment of the FD and mean strength of the flexor and extensor digitorum for both dominant and non-dominant hands. The standard error of measurement was ≤4.3% for all three mean assessments, indicating high sensitivity. Likewise, the smallest detectable change was also sufficiently small for the mean thickness and mean strength of the flexor digitorum (≤5.1%) and moderately small (≤12%) for the strength of the extensor digitorum. CONCLUSIONS: Results indicated an excellent relative and absolute reliability, for both hands, for the mean thickness and strength assessments of the flexor digitorum muscle and for the mean strength of the extensor digitorum (measured for both hands). These measurements can be used for future investigations and can contribute to the establishment of more precise methods for assessing the muscles in the forearms which serve the hand.

Mapping of finger fascicles within the flexor digitorum superficialis and profundus muscles.

INTRODUCTION: In this study we aimed to systematically investigate and map localization of the individual finger fascicles within the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) muscles. METHODS: Using B-mode ultrasonographic assessments, the right forearms of ten healthy participants (five males and five females) were examined during active and passive finger movements. RESULTS: A topographical map indicating clear core areas of fascicle activation within the FDS and FDP muscles was created. Borders that could, to some degree, define individual differences were also indicated. DISCUSSION: Our findings offer a detailed image of fascicle distributions within the FDS and FDP muscles. Various challenges, such as managing individual muscular profiles or the existence of the palmaris longus muscle, are discussed and should always be taken into consideration. The current map can serve as a general orientation for future measurements or injection therapies.

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.

Psychodiagnostics: Classification of the Yips Phenomenon based on Musician's Dystonia.

PURPOSE: Similar to musician's focal dystonia, a task-specific phenomenon known as yips, has also been reported in professional athletes. Yips is usually described as focal dystonia, or choking under pressure, or as lying on a continuum between both. Based on the common occupational conditions across musicians and athletes, the present exploratory study aimed to investigate whether musicians diagnosed with focal dystonia and golfers affected with yips, can be similarly subclassified based on their psychological profiles. METHODS: Twenty healthy musicians, 20 musicians with focal dystonia, 20 healthy golfers, and 20 yips-affected golfers went through a test battery including three psycho-diagnostic standardized questionnaires (the Competitive Trait Anxiety Inventory, the Frost's Multidimensional Perfectionism Scale, and the Stress Coping Questionnaire), measuring trait cognitive and somatic anxiety, perfectionistic tendencies and different stress coping strategies. RESULTS: Findings based on a clustering procedure suggest that similar to musician's dystonia, yips-affected golfers can be classified into those with and those without specific elevated perfectionistic, stress and anxiety traits. The roles of these different psychological profiles as possible triggering factors of the yips are discussed and compared with those of musician's dystonia. CONCLUSIONS: The current study suggests that the yips phenomenon might cover a broader range of different subtypes of movement disturbances than those already suggested in the literature. Finally, a theoretical model, which explains the role of the different triggering factors in the discrimination of the different subtypes, is suggested. A better classification and understanding of the different subtypes of yips could lead to a more accurate diagnosis and to the design of more individualized treatment intervention.

Epidemiology, Treatment Efficacy, and Anxiety Aspects of Music Students Affected by Playing-Related Pain: A Retrospective Evaluation with Follow-up.

OBJECTIVES: Playing-related pain (PRP) is a common problem among music students. We retrospectively assessed epidemiological factors that contributed to the manifestation of PRP and evaluated the efficacy of treatment methods used by affected music students. The long-term course of PRP symptoms was also examined, along with current (today) levels of trait anxieties. METHODS: Demographic and epidemiological data of 186 music students who visited the musicians' outpatient clinic over a 5-year period were retrieved. Of these students, 122 had been diagnosed with PRP and were invited to participate (response rate 61.5%) in a follow-up online survey to: a) estimate the long-term course of their PRP symptoms, b) assess the efficacy of treatment methods they used, and c) assess their current trait anxiety (general and performance-related) using two standardized psychodiagnostic questionnaires. RESULTS: Two-thirds of music students who sought medical care were affected by PRP, with most being affected during their first year of studies, and with 69% having acute rather than chronic pain. The sudden increase in practice time was the main triggering factor for PRP (but not for non-PRP-related problems). Concerning the course of PRP, almost all students recovered or improved significantly. Students reported that "active" treatment methods (e.g., physical activities) were more effective than "passive" methods (e.g., oral medications). Psychodiagnostic questionnaires indicated that about 40% of PRP-affected students currently had increased levels of trait anxieties (music and non-music related), possibly warranting further medical assistance. CONCLUSIONS: PRP in music students occurs mainly at the beginning of their studies and has a good prognosis, although recovery may be lengthy. It is necessary to provide students with early information about PRP and about the multidimensional treatment framework that allows for individualized care of PRP in affected music students.

Objective Evaluation of Performance Stress in Musicians With Focal Hand Dystonia: A Case Series.

Five musicians suffering from focal dystonia participated in a pilot study that examined the feasibility of an experimental protocol designed to assess musicians' motor performance under stress. Electrocardiography, free cortisol levels, and subjective assessments were used to monitor alterations of the hypothalamic-pituitary-adrenal axis. As measures of motor outcome, temporal variability of finger movements and muscular cocontraction of the wrist flexor and extensor were assessed. Findings suggest that the specific experimental design could be successfully applied. Several methodological issues such as carryover effects, the use of free cortisol, the inclusion of a double baseline, and the classification of dystonic patients into stress responders and nonresponders are analyzed and discussed.

The impact of stress on motor performance in skilled musicians suffering from focal dystonia: Physiological and psychological characteristics.

Recent investigations have suggested that stress can modulate motor function. However, the impact of stress on motor performance of musicians suffering from focal dystonia (FDM) remains unknown. The current study assessed motor performance in 20 FDM patients and 16 healthy musicians (HM) before and under stress. Stress was manipulated using the Trier Social Stress Test (TSST). Motor performance was evaluated based on analysis of electromyographic (EMG) activity and temporal variability, while electrocardiography (ECG) and the level of free cortisol were used to test for objective alterations of the hypothalamic-pituitary-adrenal (HPA) axis. Finally, the psychological profiles of both groups were analyzed using three psycho-diagnostic standardized questionnaires. Results showed that patients' motor impairments did not change under acute stressful conditions. However, an increase in muscular co-contractions was observed, reflecting a physiological muscular response under stressful conditions. Psycho-diagnostic analysis revealed higher levels of psychological traits related to elevated anxiety, stress and perfectionism in 40% of the patients. Although the motor outcome between those patients and those with an opposing psychological profile did not differ, patients characterized by stressful and perfectionistic personalities had, on average, developed dystonia about ten years earlier than the rest of the patients. The current study suggests that acute stress conditions may not have any direct impact on fine motor control of FDM patients. However psychological traits associated with increased stress, anxiety and perfectionism may have a long-lasting effect on the motor function of affected musicians, by promoting the acceleration or even the triggering of dystonia.

Approaches to and Treatment Strategies for Playing-Related Pain Problems Among Czech Instrumental Music Students: An Epidemiological Study.

The current study examined the severity of playing-related pain (PRP) problems among music students at the Prague State Conservatoire, as well as the various treatment methods used by these students and how they approach and deal with these phenomena while studying. In total, 180 instrumental students participated and completed a paper questionnaire. Of these, 88.9% reported that they had experienced PRP at least once in their lives, with 12.6% experiencing pain every time they play. The onset of PRP seemed to coincide with the transition period on entry to the conservatoire and was associated with the increase in hours of practice. Specific body regions associated with playing each particular instrument were most frequently affected, with females being more susceptible than males to the development of PRP. An alarming 35% of the affected students tended not to seek help at all, whereas those who did tended to seek advice first from their instrument tutor and second from medical doctors. Most students who visited doctors reported that medical treatments only partially helped them to overcome PRP problems. The most frequent treatment methods used were resting, gel or creams, and physical exercises. Students believed that inappropriate posture played a key role in the development of their PRP problems. Finally, students indicated a willingness to be aware of and educated about PRP issues during their studies. Further exploration of PRP problems among student musicians is warranted. Better understanding of differing attitudes toward, use of, and efficiency of various treatment methods after the occurrence of PRPs will provide additional insight for prevention and treatment.

Electrical Brain Responses to an Auditory Illusion and the Impact of Musical Expertise.

The presentation of two sinusoidal tones, one to each ear, with a slight frequency mismatch yields an auditory illusion of a beating frequency equal to the frequency difference between the two tones; this is known as binaural beat (BB). The effect of brief BB stimulation on scalp EEG is not conclusively demonstrated. Further, no studies have examined the impact of musical training associated with BB stimulation, yet musicians' brains are often associated with enhanced auditory processing. In this study, we analysed EEG brain responses from two groups, musicians and non-musicians, when stimulated by short presentation (1 min) of binaural beats with beat frequency varying from 1 Hz to 48 Hz. We focused our analysis on alpha and gamma band EEG signals, and they were analysed in terms of spectral power, and functional connectivity as measured by two phase synchrony based measures, phase locking value and phase lag index. Finally, these measures were used to characterize the degree of centrality, segregation and integration of the functional brain network. We found that beat frequencies belonging to alpha band produced the most significant steady-state responses across groups. Further, processing of low frequency (delta, theta, alpha) binaural beats had significant impact on cortical network patterns in the alpha band oscillations. Altogether these results provide a neurophysiological account of cortical responses to BB stimulation at varying frequencies, and demonstrate a modulation of cortico-cortical connectivity in musicians' brains, and further suggest a kind of neuronal entrainment of a linear and nonlinear relationship to the beating frequencies.

Apollo's curse: neurological causes of motor impairments in musicians.

Performing music at a professional level is probably one of the most complex human accomplishments. Extremely fast and complex, temporo-spatially predefined movement patterns have to be learned, memorized, and retrieved with high reliability in order to meet the expectations of listeners. Performing music requires not only the integration of multimodal sensory and motor information, and its precise monitoring via auditory and kinesthetic feedback, but also emotional communicative skills, which provide a "speaking" rendition of a musical masterpiece. To acquire these specialized auditory-sensory-motor and emotional skills, musicians must undergo extensive training periods over many years, which start in early childhood and continue on through stages of increasing physical and strategic complexities. Performance anxiety, linked to high societal pressures such as the fear of failure and heightened self-demands, frequently accompanies these learning processes. Motor disturbances in musicians are common and include mild forms, such as temporary motor fatigue with short-term reduction of motor skills, painful overuse injuries following prolonged practice, anxiety-related motor failures during performances (choking under pressure), as well as more persistent losses of motor control, here termed "dynamic stereotypes" (DSs). Musician's dystonia (MD), which is characterized by the permanent loss of control of highly skilled movements when playing a musical instrument, is the gravest manifestation of dysfunctional motor programs, frequently linked to a genetic susceptibility to develop such motor disturbances. In this review chapter, we focus on different types of motor failures in musicians. We argue that motor failures in musicians develop along a continuum, starting with subtle transient degradations due to fatigue, overuse, or performance stress, which transform by and by into more permanent, still fluctuating motor degradations, the DSs, until a more irreversible condition, MD manifests. We will review the epidemiology and the principles of medical treatment of MD and discuss prevention strategies.

Psychological characteristics in musician׳s dystonia: a new diagnostic classification.

Numerous studies suggest that dysfunctional basal ganglia-thalamo-cortical circuits are involved in both movement disorders and psychiatric impairments. The current exploratory investigation explored possible psychological differences, firstly between 24 healthy musicians (HM) and 24 musicians diagnosed with focal dystonia (FDM) (Study I), and secondly among 35 FDM patients only (Study II). Results revealed that FDM patients are six times more likely to exhibit elevated anxiety, perfectionistic and stress characteristics than HM. These psychological conditions might contribute as aggravating risk factors to the development of FDM. However, half of the FDM patients did not demonstrate any signs of anxiety, perfectionism or stress. The findings point to the clear existence of two different psychological profiles among FDM patients. We suggest that this psychological distinction might reflect two different mal-adaptive processes mediated via different circuits of the cortico-basal ganglia-thalamicloops. The new classification of FDM patients will contribute to the reinforcement of the diagnostic repertoire, necessary for the selection of more specific treatment methods.