davidvining.com

Trombonist, Author, Composer, Educator, Entrepreneur

My Dystonia Narrative

original1-front-notes-of-hope-scaledThe following story is extracted from Notes of Hope, a compilation of stories by musicians who have dealt with debilitating injuries that made making music painful, difficult, or impossible. Their stories have been collected and shared in Notes of Hope as a testament to what is possible through resourcefulness, creativity, and perseverance. Here is my narrative:

Prelude

I grew up in Cocoa, Florida, a small town inland from the more famous coastal community of Cocoa Beach. My older brother played the baritone in the high school band and was always trotting off to somewhere fun, like Disney World. I wanted desperately to join in, and that is the primary reason I began playing an instrument—for the social activities. Such are the whimsies of junior high school students!

I don’t know why I chose the trombone, but I remember being immediately good at it. I must have all the right natural attributes to be a good trombonist: coordination between the arm and tongue, good natural tone quality, and the right sort of musical intuition. It didn’t take me long to rise to the top of the trombone section in the high school band and receive top ratings on my performances. Invitations to honor bands and ensembles soon followed, and it seemed I had found my musical calling.

Exposition

Throughout college as a trombone performance major, I never had to work terribly hard to accomplish musical goals. I had a teacher, John Drew, who allowed me to explore repertoire at my own pace, and I was grateful for the autonomy. I performed in virtually every ensemble Florida State had to offer, and enjoyed myself immensely. Upon graduation in 1985, I was hired by the Chestnut Brass Company, a Philadelphia-based brass quintet specializing in performances on historical brass instruments, as well as commissioning new works and performing standard brass quintet literature. At my audition, I was asked to play the Quintet by Malcolm Arnold, a standard brass quintet piece. The members of the group probably did not consider this to be sight reading because this piece is so popular among brass players; however, I had never seen it before! My musical intuition must not have steered me wrong, because I spent the next five years touring and recording with the group.

This sort of thing seemed to happen frequently in the early stages of my career. I always seemed to come out ahead simply because I had good instincts and things came naturally for me, like sight reading for the Chestnut Brass job. I would learn later that musicians who get dystonia are often very natural players who don’t typically have to overcome great technical shortcomings in their formative years.

The Chestnut Brass is a touring ensemble, so it was a terrific way to see the country while making music. One of our concerts was with the Lima Symphony in Ohio. The executive director (who was also our contact person) was Leslie Friese and, to make a long story short, Leslie’s last name is now Vining and we have two children, Sarah and Ben.

After Leslie and I married, I grew tired of touring with the Chestnut Brass and decided to go back to school to pursue a master’s degree. Bowling Green State University is just north of Lima, and I managed to complete the M.M. degree in one year. I was subsequently hired as the sabbatical replacement for Paul Hunt, the trombone professor at BGSU. This year of teaching experience enhanced my resume so I could enter academia full-time the following year, with an appointment as professor of trombone at the University of Kansas. My professional playing experience, combined with my teaching experience, has allowed me to climb the ranks of academia without a doctoral degree, something virtually unheard of these days.

Six years later, literally days after I was granted tenure at KU, I got a phone call from the trombone search committee at the Cincinnati College-Conservatory of Music. The committee was having trouble finding someone to fill their trombone position and wanted me to apply. I was offered the job and, not long after we moved to Cincinnati, I began to recognize the first signs of trouble with my embouchure.

Development

In the summer of 1999, I began my duties at CCM by serving on the faculty of the Mendez Brass Institute hosted by CCM. I recall house hunting amidst the conference duties of playing chamber music, delivering masterclasses, and joining the Summit Brass on a few selections. I also recall not playing well and feeling terrible about starting a new job on the wrong foot. I was assigned to play in a low brass ensemble with some of the most famous brass players in the world. The selection was a soft chorale, and I couldn’t make any entrances clean and on time. Little did I know these were the first symptoms of focal dystonia.

After the conference, we moved our young family across the country and CCM started up in earnest. My dystonic symptoms were worsening—I could not center pitches in the middle and low registers, my already late attacks were getting later, and I could not reliably play a smooth phrase. I looked everywhere for a solution, starting with various brass pedagogues. Many of them said I did not have anything serious and I just needed to work through things as usual. This advice is typical and, incidentally, not at all helpful. I finally ended up asking my family doctor, who sent me to a neurologist, who finally offered the diagnosis of dystonia. This particular neurologist was not a musician and, somewhat playfully, asked, “Why don’t you just play the saxophone?”

I consulted with two other neurologists, both of whom specialize in neurological problems of musicians: Dr. Steven Frucht at Columbia Presbyterian Hospital in New York City, and Dr. Richard Lederman at the Cleveland Clinic. They both confirmed the diagnosis and told me there was no reliable medical treatment. Dr. Lederman offered to inject my embouchure with BOTOX® to deaden the offending muscles, but my wife talked me out of this procedure because it was too risky. It was about three years from the first signs of trouble in 1999 to an official diagnosis in May of 2002.

Nobody knows conclusively what causes embouchure dystonia, though many have suggested that an equipment change, a sharp trauma to the embouchure, or playing too much, too high, or too loud could cause it. While none of these variables explain my situation, I can, in hindsight, identify several things which I think contributed to the onset of my dystonia, including:

  • Before I got dystonia, I defined trombone playing as an athletic activity and exerted a corresponding athletic, isometric effort to play. This created a sort of global tension throughout my body, which created the right conditions for the dystonia to develop. Decades of the athletic approach resulted in a sort of “kinesthetic dulling” that made it impossible to recognize dangerous isometric tension.
  • I was under some misunderstandings about breathing which reduced my air flow and created an imbalance in my embouchure, requiring the muscles to work harder than necessary. There was a cumulative detrimental effect of this imbalance over time, which resulted in a “critical mass” of misuse manifesting itself as dystonia.
  • I believe stress contributed to my development of dystonia. In the years leading up to the diagnosis, not only did I start a new high profile job, but I also recorded a solo CD, applied for tenure at the University of Kansas, and we had our second child. In fact, if we had stayed at KU, I think I probably would have still gotten dystonia, but it would have taken longer to develop. By the same token, if I had stayed at KU, I would have had job security with tenure and may not have had the same strong incentive to recover.
  • I believe there may be a genetic “x” factor (which I believe I possess) predisposing some people to the development of dystonia. Additionally, my obsessive “type A” personality contributed to the problem. Of course, one could make the argument that all musicians are obsessive, but I suspect I took this trait to a higher, abnormal level.

Recapitulation

My version of dystonia was called focal task-specific embouchure dystonia—focal, meaning it only affected the area around my embouchure, and task-specific, meaning it only affected my trombone playing. When we move a part of our body, the movement is represented in the brain by neural pathways. The pathways consist of chains of individual neurons which cooperate with one another to deliver the movement messages out to various parts of the body. Someone with dystonia has neural pathways which are corrupt in some way. Apparently, in my case, the neural pathways delivered the message that my embouchure muscles were required to work extremely hard to play the trombone. Every time I would take a breath and try to blow out into the trombone, the muscles of my face which formed my embouchure would seize up in a tight clenching fashion, making it impossible to produce a smooth, reliable sound. The term coined by some neurologists for this type of dystonia is “lip-lock”, and that’s exactly what it felt like.

Aside from the physical malfunction, I experienced a profound sense of loss. There is an important and unique expressive component to music-making which gives us our musical personality—for example, it’s the instinctual addition of a slight crescendo here and a subtle push through a note change there. These are attributes which define us as musicians and are only expressed by performing. When I could no longer perform, I felt like I lost an important part of my personality, and a deep depression covered me like a cloud.

Like most musicians, I was accustomed to receiving specific instructions from a mentor to refine my playing. This is the traditional way musicians learn, and it works well until a problem arises for which the mentor has no solution, like dystonia. Injured musicians often search for a template or standard protocol to follow in order to recover, but rarely is there such a template. Dystonia is not understood by the majority of musicians, and those who are stricken are left virtually without guidance of any sort. Even worse, sometimes dystonia victims get bad advice from mentors and teachers. For example, shortly after my diagnosis, one of the brass teachers I consulted suggested I view old concert videos from when I was healthy in order to recapture my former, successful way of playing. This seemed logical to me, so I studied old videos of my performances, carefully mimicking what I saw. This made the dystonia worse because I was reinforcing the old, aberrant neural pathways, essentially strengthening bad movement habits. The neural pathway is like a groove constructed out of beach sand: the deeper the groove, the more durable the old movement pattern. If you have embouchure dystonia, once you begin to play a note on trombone, you have entered the beach sand groove and it’s impossible to climb out, because when you try, the sand gives way. The harder one tries to create a note, the worse the spasm becomes. This explains why trying to recapture how I used to play by watching old videos did not work—those were the old aberrant neural pathways. Of course, the advice I got about watching old videos was not intended to cause harm and I do not blame the person who delivered it. It’s actually indicative of a larger issue: everybody wants to help but nobody really knows how.

Perhaps understandably, my physical malfunction and depression, accompanied by the lack of a treatment protocol, caused me to panic. I had a mortgage to pay and a wife and two children to support, and this diagnosis was a clear threat to our future. In my desperation, I considered changing careers, but my wife was the voice of reason. She encouraged me to see a psychiatrist who helped me understand the confusing array of issues which accompanied the diagnosis. With the help of the psychiatrist, I was able to work through my depression and clear my head so I could decide what to do about the dystonia.

Shortly after starting the sessions with the psychiatrist, I happened upon an article in the International Musician (the trade magazine of the musicians’ union) called How to Resolve Dystonias: A Movement Perspective” by Barbara Conable. This was the first time I encountered anyone who claimed they could provide an effective therapy for dystonia, and I quickly arranged a visit to Barbara in Portland. While there, I received my first Alexander Technique lesson from Barbara and was introduced to Body Mapping. This was, for me, the beginning of my recovery. The Alexander Technique and Body Mapping lessons set me down the path to a new sense of balance and tension-free movement. One does not reverse years of misuse in a couple of hours, though. Barbara referred me to one of her protégés named David Nesmith, a hornist in Columbus, Ohio, with whom I took a series of Alexander Technique and Body Mapping lessons. These lessons were experimental in nature, not always involving playing the trombone. Sometimes we would simply lie on the floor as David guided me through a series of thoughts in constructive rest. This was the period when I finally managed to get away from the concept that I would find a template for recovery, and started experimenting with non-medical movement therapies such as the Alexander Technique. Once I finished the lessons with David, I found a Feldenkrais practitioner in Cincinnati named Donna Lilley. She guided me through the subtle yet powerful Feldenkrais lessons, which continued the improvement I experienced with the Alexander Technique lessons.

The movement therapies helped me cultivate a sense of global awareness and brought my body to a neutral state of balance. Before the lessons, I was tied up in knots and didn’t even know it. I most certainly felt better as a result of these sessions and my playing improved somewhat, but I was not cured. Something was still missing, so I kept looking for answers even as I underwent the movement therapies. I learned that Jan Kagarice, a trombone-playing acquaintance, was successfully helping players with dystonia. In the summer of 2003, I spent a week working with Jan with very encouraging results. Her system involves lots of generous blowing through the instrument in addition to redefining how to play. Jan and I worked together for five or six hours each day over the course of five days. Once again, I was improving, but something was still missing; somehow, I felt like my recovery had not gained traction and was not durable enough to last.

Working with Barbara, David, Donna, and Jan were integral parts of my recovery, and I’m certain I would not have been successful without them. It was as though I had many pieces of a puzzle in front of me and I knew they would come together and coalesce in some way, but I did not know how. Ultimately, the missing link was how I fused all the therapies and information I had received into an amalgam of my own devising. I had assembled all the ingredients of the cocktail—now it was up to me to stir it until it blended.

This is where my recovery takes on an experimental aspect that may be somewhat controversial among musicians, doctors, and scientists. I knew from my research and working with Jan that I needed to create new neural pathways to circumvent the old, corrupt ones. Neuroplasticity suggests there may be ways of doing this, although more traditional research suggests the aberrant pathways are inaccessible and permanent.

When I first learned to play trombone, I used a famous book called The Art of Brass Playing by Philip Farkas, which contains photos of the embouchures of members of the Chicago Symphony brass section. I learned about brass playing, in part, by reading this book and looking at the embouchure photos. The photos, however, are obviously two-dimensional—they lack movement. My version of dystonia included the lack of movement as one of its symptoms, so the photos represented the old way of playing. I had to redefine embouchure in order to create a new neural pathway; the new definition would serve as a sort of “mission statement” for my retraining efforts. Here is my new definition: an embouchure is a three-dimensional entity in motion created when air moves past the lips. This new definition of embouchure represents the new way to play. It’s different from the old way because it includes air flow as part of the embouchure. This is a meaningful distinction to a brass player. According to my new definition, if there is no movement, there is no embouchure. You can take a video of an embouchure, but you can’t capture a two-dimensional image of an embouchure.

Another important idea for my retraining came from The Mind and the Brain by Jeffrey Schwartz, which stated that people require at least ten thousand repetitions of a therapeutic exercise to restore normal use. Now I had a mission statement definition of a new way to play, and I had evidence that I could circumvent the old pathway, given enough repetitions. Now I needed a vehicle for logging repetitions and some way to measure the success of the repetitions.

Imagine using a meter to measure the muscular activity of an embouchure on a scale of zero to ten. No activity would be a zero and a spasm would be a ten. Just to assign an abstract value, a healthy embouchure might require muscular effort of about a three. In my dystonic state, every time I would form an embouchure, my meter would go all the way over to ten even though I didn’t want it to. That’s the groove in the beach sand; it seems to suck you in against your will. Using this gauge would serve as a way to measure the success of my repetitions.

Now it was time to put all this information together as part of the cocktail of therapies and stir. I chose a musical phrase I knew would be particularly treacherous for me to play smoothly to serve as my test phrase. I figured if a spasm was ten on my muscular activity scale, I should begin by countering with repetitions that have no muscular activity, or zero on my scale. If I amassed enough repetitions, thinking in the new way, perhaps I could establish a new habitual movement pattern that did not lead to spasms. I had to ensure that I was thinking about the new way of playing, so I made index cards with cues like “count on the air” and “an embouchure includes air flow.”

At first, each repetition was like playing “air trombone.” I would blow a generous amount of air through the instrument while thinking the new thoughts and moving the slide and tongue just as though I was playing. Admittedly, there was no tone—just air moving through the trombone—but there was also no spasm. I wanted to amass an overwhelming number of spasm-free repetitions in order to create the new pathway in my brain, so I counted repetitions. My cue cards served to help me tally repetitions; each time through the phrase I would turn over a card and look at the next card.

I knew I had to get to at least ten thousand repetitions in order to establish a new movement pattern, but what I didn’t know was whether or not this would result in reestablishment of muscular control. When I was retraining, I would do between fifty and 250 repetitions a day and nothing else—no warm up, no long tones, etc. To effectively create the new pathway, there can never be a repetition using the old pathway.

One day when I was blowing through my reps (I was on repetition number three thousand or so), I was surprised when sound spontaneously came out. This was quite astonishing, because my muscular activity measure was still at zero and I thought I would have to bring it up to about three to initiate sound. This was my “aha” moment. It was then that I realized I did not have to engage my muscles at all. I had to cultivate a strong aural concept of what I wanted to sound like, and trust the movement of air instead of the “formation” of an embouchure. This was the moment I knew I would be OK, because I had systematically created a new, healthy movement pattern which allowed me to create the tone without a spasm. From this point forward, it was a matter of completing my ten thousand repetitions (which I did) in order to reinforce the new pathway.

I believe the cocktail of therapies which preceded this moment laid the groundwork for success. Every step along the way was crucial but, in the end, it was their symbiosis that made the difference.

Coda

I don’t think my methods will work for everybody, but perhaps my story will inspire those in trouble to be creative about devising their own recovery strategies. If you have been rendered musically mute by dystonia or some other injury, by all means seek help, but don’t wait for someone to present you with a magic bullet. Rarely is there a therapy template for recovery. Question traditional pedagogy and look at your recovery process as a unique cocktail of therapies. It’s up to you to pull them together in various ways until you find a way that works for you.

As I mentioned above, one of the factors that contributed to my development of dystonia was my confusion about the mechanics of breathing. The confusion was caused in part by falsehoods that are embedded in traditional brass teaching. These distortions manifest themselves in catch phrases such as “breathe low” or “breathe like you are filling up a glass of water.” It is beyond the scope of this essay to debunk these myths, but suffice it to say that all teachers have an obligation to deliver accurate information. If a catch phrase can be misunderstood or misinterpreted, it should be abandoned, regardless of its seemingly universal acceptance.

I have experienced countless benefits from retraining. The most stunning to me has been a recalibration of my sense of self-worth. No longer do I depend upon trombone playing to define who I am. It’s certainly important, but it’s no longer the obsession it was prior to the dystonia. Another unexpected benefit of my experience is Mountain Peak Music, the publishing company I started to share some of the concepts and strategies I learned through my retraining. The items offered promote health and wellness and innovative teaching strategies to all musicians, injured or healthy.

I am pleased to report that I have resumed a normal performing schedule playing recitals, chamber music, and in orchestras. I look forward to many more performances and many more Mountain Peak Music publications.

Many people have asked me about my recovery from focal embouchure dystonia. This page features a narrative of my story, some theories about how it happened and links to resources for those who may need help. In addition, I offer skype lessons for those who would like to meet with me to get some personalized attention.

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