Medication
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The first-line treatments offered by medical professionals include botulinum toxin injections (Botox) or anticholinergic medications. Firstly, it is important that the neurologist or physician involved in the diagnosis of musicians' focal dystonia has experience with the condition (this is not always the case), and secondly, the musician should be aware of how these medications work, what benefits they bring, and what side-effects, or undesirable effects they might bring.
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Botulinum Toxin Injections
Botulinum toxin injections work by acting at the neuromuscular junction in carefully selected muscles to cause temporary paralysis, inhibiting the release of the neurotransmitter acetylcholine from presynaptic motor neurons (cells located in the brain or spinal cord that send signals or information down to your muscles to contract or relax). Many studies have shown the potential benefits of botulinum toxin injections for musicians. Some report a remission of symptoms, allowing them to regain control of their movements and return to normal playing. Others, state that there was no noticeable benefit of having the injections and in some cases, the associated temporary paralysis or weakness of the injected muscle caused a deterioration in their symptoms.
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Botox injections should be administered only when guided by ultrasound and ideally, following an electromyographic (nerve conduction) examination. It is crucial that the right part of the affected muscle/s is/are targeted, and any contamination of surrounding muscle tissue be minimized. This will maximize the chance of a successful outcome and minimize the chances of unwanted side effects.
It is also imperative that the medical professional administering the injection/s has experience working with musicians. If you decide to go ahead with injections, be confident that your medical professional has sufficient experience in treating musicians' focal dystonia.
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What is important to understand is that botulinum toxin injections are palliative in nature, they are not a cure. Their effect is temporary (3-6 months) and repeated visits to the doctor's surgery for injections are usually necessary.
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Anticholinergic Medications
Anticholinergic medications offer a non-invasive alternative to botulinum toxin injections. They help to relax the muscles and reduce spasms, acting by blocking and inhibiting the neurotransmitter acetylcholine (ACh) at both the central and peripheral nervous system synapses. Medications include trihexyphenidyl, benztropine, ethopropazine, procyclidine, and biperiden.
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In contrast to botulinum toxin injections, anticholinergic medications work both centrally and peripherally upon the nervous system. They do not cause the temporary paralysis experienced with injections, but they can cause undesirable side effects for some. The effectiveness of these medications is often limited although for some they may have positive outcomes.
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It is important to note that these medications may have side effects, such as dry mouth, dizziness, and constipation. They may also interact with other medications that an individual is taking. It is important to discuss the potential risks and benefits of anticholinergic medications with a doctor before starting treatment.
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Benzodiazepines
Benzodiazepines are sometimes prescribed to treat certain types of dystonia, including focal dystonia in musicians. They work by enhancing the activity of the neurotransmitter GABA, which helps to relax the muscles and reduce spasms. Some common benzodiazepines used to treat dystonia include diazepam and lorazepam.
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Unfortunately, benzodiazepines have side effects, such as drowsiness, dizziness, and impaired coordination. They may also be habit-forming and cause dependence, particularly if they are taken for long periods of time.
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Anti-Parkinsonism Agents
​Antiparkinsonian medications such as levodopa and carbidopa, are commonly used to treat Parkinson's disease but can also be used to treat dystonia. They work by increasing the availability of the neurotransmitter dopamine in the brain, which can help to improve muscle function.
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Dopamine acts on receptors located in various areas of the brain, including the basal ganglia and the cerebral cortex. The basal ganglia are a group of brain structures that play a key role in the regulation of movement. The cerebral cortex is the outer layer of the brain and is responsible for higher brain functions, such as decision-making, learning, and memory.
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Low dopamine levels can affect the function of these brain areas, leading to problems with movement, tremors, stiffness, and difficulty initiating movement. Low dopamine levels in the cerebral cortex can also cause problems with cognitive functions, such as decision-making and problem-solving.
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It is important to stress that Parkinsonism may occur for a variety of reasons, including focal dystonia. It is important to talk with a neurologist if you are concerned about dopamine levels, but this a not a common presentation in musicians' focal dystonia.
There are also a number of possible side effects associated with anti-parkinsonian medications including nausea and vomiting, constipation, drowsiness, dizziness, dry mouth, and blurred vision. In some cases, the benefits of treatment may outweigh the potential risks.
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