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case report a musician s dystonia michele vecchio giulia malaguarnera maria giordano michele malaguarnera giovanni li volti,fabio galvano filippo drago francesco basile mariano malaguarnera lancet 2012 379 2116 centre of physical medicine and rehabilitation vittorio emanuele hospital catania italy m vecchio md international phd program in neuropharmacology university of catania medical school catania italy g malaguarnera phd prof f drago md department of internal medicine and geriatrics hospital cannizzaro catania italy m giordano md prof ma malaguarnera md department of biological chemistry medical chemistry and molecular biology mi malaguarnera phd prof g li volti phd prof f galvano phd and department of general surgery university of catania catania italy prof f basile md correspondence to prof mariano malaguarnera department of internal medicine and geriatrics cannizzaro hospital via messina n 829-95100 catania italy malaguar@unict.it in february 2010 a 50-year-old man was referred to our physiotherapy clinic with an extension movement of his right index finger and simultaneous contraction of the corresponding flexor muscles he was a guitar player and had seen various medical specialists rheumatologist orthopaedic surgeon neurologist psychiatrist and alternative healers on presentation he had an uncontrolled movement of the right index finger that interfered with the highly skilled coordination required for playing the guitar the extension movement of his right index finger was prevented by a simultaneous co-contraction of the flexor muscles and the strong contraction bent the finger into the palm the other fingers and wrist had normal movement mirror dystonia of the affected finger was seen while he played with the opposite unaffected finger the loss of control had been gradual but within 4 months he could not play at all complete blood count serum concentrations of electrolytes glucose calcium magnesium creatine phosphokinase and caeruloplasmin esr antinuclear antibody screen and syphilis screen were normal as were kidney liver and thyroid function examination of the index finger showed no anatomical limitations triggering tendons or ligament or joint damage our patient had ct and mri of the brain and transcranial magnetic stimulation to exclude a central nervous disease no evidence of nerve compression or muscloskeletal conditions were found and all joints were normal and pain free we suspected a focal dystonia and used electromyography to study the contractions of the involved muscles electromyography of the right hand showed overflow into muscles not normally involved in the a 0·81 0·72 0·63 0·54 0·45 0·36 0·27 0·18 0·09 0 emg mv 2nd right finger flexor rect provoking activity on the basis of these findings and the clinical presentation we diagnosed a focal dystonia we gave our patient levocarnitine 3 g daily for 3 months to decrease cramps1 and botulinum toxin injected into the superficial 20 iu and deep flexor 20 iu muscles of the right index finger under electromyographic and ultrasonographic guidance figure a the contractions diminished 5 days later and he was able to play the guitar again figure b the beneficial effect of botulinum toxin lasted for about 8 months treatment was repeated and at last follow-up in november 2011 he was symptom free oppenheim2 described dystonias 100 years ago as a heterogeneous group of hyperkinetic movement disorders characterised by involuntary sustained muscle contractions that lead to abnormal repetitive movements other characteristic features included sensory tics gestes antagonists abnormal postures with or without tremor depression anxiety mirror movements and overflow dystonia mirror dystonia occurs on the affected side of the body when a specific task is done by the opposite unaffected body part.3 other task-specific dystonias include those in people performing fine motor skills such as professional craftsmen and sportsmen whose work involves frequent repetitive and precise movements of particular muscle groups exposure to certain drugs environmental factors and wilson s disease can cause dystonia.3 the diagnosis is mainly based on clinical examination most patients need a combination of levodopa anticholinergic drugs benzodiazepines and chemodenervation with botulinum toxin botulinum toxin is beneficial mainly through its primary mechanism of action blocking the release of acetylcholine into the neuromuscular junction causing local temporary chemodenervation and muscle paralysis botulinum toxin can also be helpful in controlling the most disabling symptoms of segmental or generalised dystonia.4,5 the benefits of physiotherapy in treating focal dystonia are still unconfirmed medical practitioners should be aware of the potential immediate benefits of using botulinum toxin in the treatment of focal dystonia contributors all authors looked after the patient and wrote the report written consent to publication was obtained references 1 malaguarnera m carnitine derivatives clinical usefulness curr opin gastroenterol 2012 28 166­76 2 oppenheim h Über eine eigenartige krampfkrankeit des kindlichen und jugendlichen alters dysbasia lordotica progressiva dystonia musculorum deformans neurologia centrablatt 1911 30 1090­107 3 phukan j albanese a gasser t warner t primary dystonia and dystonia-plus syndromes clinical characteristics diagnosis and pathogenesis lancet neurol 2011 10 1074­85 4 jankovic j treatment of dystonia lancet neurol 2006 5 864­72 5 jankovic j treatment of hyperkinetic movement disorders lancet neurol 2009 8 844­56 b 0·81 0·72 0·63 0·54 0·45 0·36 0·27 0·18 0·09 0 emg mv 0 20 time s 40 figure electromyography of the 2nd right finger flexor showing a dystonic pattern before treatment and b decrease of dystonic pattern after treatment 2116 www.thelancet.com vol 379 june 2 2012

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