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F r e e m u s i c d o w n l o a d s f o r C e r t i f i e d m e m b e r s : w w w. a b m p . c o m / g o / c e r t i f i e d c e n t r a l 97 CLINICAL APPS richest and largest sensory organ is not the eyes, ears, skin, or vestibular system, but is in fact our muscles with their related fascia. Our central nervous system receives its greatest amount of sensory nerves from our myofascial tissues." 3 With this in mind, it seems possible to reorganize some of the dysfunctional neurological programming by influencing neurological input to the brain through soft-tissue treatment of the myofascial tissues. Consequently, numerous myofascial massage applications could be helpful in conjunction with other treatments Dustin might employ. While medial epicondylitis and carpal tunnel syndrome may not have been the primary pathologies in this condition, the dysfunctional muscular coordination of focal dystonia could easily lead to these complications in the local tissues. Thus, it is still helpful to focus significant attention on reducing cumulative tightness in the wrist and finger flexor muscles, as they are responsible for every repetitive keystroke on the piano. Because problems in the wrist and finger flexor muscles can easily lead to median nerve entrapment in the proximal forearm, as well as in the carpal tunnel, Dustin will benefit from deep, specific stripping applications to the muscles along the pathway of the median nerve. Addressing the muscles along the nerve's pathway can help reduce the likelihood of overuse in those tissues. There is no single traditional medical treatment method that has proven to be highly successful in treating focal dystonia. Commonly used strategies include acupuncture, psychotherapy, relaxation therapy, and other body therapy approaches. 4 Botox injections are frequently used to address the local muscle spasms, but this has numerous adverse effects on the delicate and precise muscular coordination that is needed for the musician to continue playing. An interesting treatment strategy that is increasingly used is the wearing of latex gloves by the musician while playing. Because the gloves slightly alter the pattern of sensation associated with touching the piano keys, this can create new neurological pathways and potentially override the dysfunctional neurological patterns that have developed. 5 This case points out the critical importance of taking a thorough history and paying close attention to the pattern of signs and symptoms being presented. Dustin came in with an existing diagnosis from a general practice physician, but the results of the clinician's initial assessment did not seem to match that diagnosis. At a point where unusual signs and symptoms are present, it is always a good idea to consider a referral for a second opinion, or reevaluate the condition. Dustin greatly benefited from the massage treatment because there was a physiological rationale for how the treatment could be incorporated with his existing treatment approaches. Massage, in Dustin's case, was used both as a preventive treatment for other conditions and experientially to influence neurological input to the brain by treating the myofascial tissues, perhaps ultimately reducing the focal dystonia symptoms. Notes 1. H. S. Lee et al., "Musicians' Medicine: Musculoskeletal Problems in String Players," Clinics in Orthopedic Surgery 5, no. 3 (2013):155–60. 2. Robert Schleip, "Fascial Plasticity—A New Neurobiological Explanation: Part 1," Journal of Bodywork and Movement Therapies 7, no. 1 (2003): 11–19; Robert Schleip, "Fascial Plasticity—A New Neurobiological Explanation: Part 2," Journal of Bodywork and Movement Therapies 7, no. 2 (2003): 104–16. 3. Robert Schleip, "Fascial Plasticity—A New Neurobiological Explanation: Part 1." 4. Floris T. van Vugt et al., "Musician's Dystonia in Pianists: Long-Term Evaluation of Retraining and Other Therapies," Parkinsonism & Related Disorders 20, no. 1 (2014): 8–12. 5. J. Paulig et al., "Sensory Trick Phenomenon Improves Motor Control in Pianists with Dystonia: Prognostic Value of Glove-Effect," Frontiers in Psychology 5 (2014): 1,012. Whitney Lowe is the author of Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2009). He teaches advanced clinical massage in seminars, online courses, books, and DVDs. You can find more ideas in Lowe's free enewsletter—and his books, course offerings, and DVDs—at www.omeri.com. This case points out the critical importance of taking a thorough history and paying close attention to the pattern of signs and symptoms being presented.