Kelly L. Sullivan, MSPH Christopher L. Ward, LMT Robert A. Hauser, MD, FAAN Parkinson’s Disease and Movement Disorders Center Department of Neurology National Parkinson’s Foundation Center of Excellence University of South Florida Tampa, Florida, USA Department of Molecular Therapeutics James A. Haley Veterans Administration Hospital University of South Florida Tampa, Florida, USA *tzesiewi@health.usf.edu REFERENCES 1. Wolanczyk T, Grabowska-Grzyb A. Transient dystonias in three patients treated with tiagabine. Epilepsia 2001;42:944-6. 2. Kralic JE, Criswell HE, Osterman JL, et al. Genetic essential tremor in gamma-aminobutyric acidA receptor alpha1 subunit knockout mice. J Clin Invest 2005;115:774-779. 3. Ondo W, Hunter C, Vuong KD, Schwartz K, Jankovic J. Gabap- entin for essential tremor: a multiple-dose, double-blind, placebo- controlled trial. Mov Disord 2000;15:678-682. 4. Zesiewicz TA, Ward CL, Hauser RA, Pease Campbell JA, Sullivan KL. 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Embouchure Dystonia and Tremor in a Professional Windpipe “Nadaswaram” Player Professional musicians playing instruments develop dystonia of perioral and jaw muscles called as “Embouchure Dystonia.” 1 Involuntary “task-specific” tremor resembles primary writing tremor and are called as dystonia. 1 Task specific dystonia occurs in 8% of musicians and hinders their performance. 2 We describe perioral tremor resembling embouchure dystonia in a professional musician while playing “Nadaswaram,” an Indian windpipe instrument and debate the relationship between dys- tonia, essential tremor and task specific tremor. A 72-year-old professional Nadaswaram player started play- ing at 15 years of age and presented with hand tremors while playing Nadaswaram for 3-years. A year later, he developed postural tremor of hand and head. Examination showed mild bilateral postural hand tremor and no rest tremor. The music was distorted on blowing into the mouthpiece due to upper limb and lip tremor. He supported the Nadaswaram on the floor while blowing into the mouthpiece as he developed moderately severe head, upper limb, and lip tremor. The postural tremor was grade 3 on spirography and handwriting test and one for items 3 and 4 of daily living questionnaire. Response to alcohol could not be assessed, as he is a teetotaler. His mother had bilateral upper limb tremor since age of 50-years with no task specificity. Our patient improved by 60% on 2 mg of clonaz- epam and played Nadaswaram without breaks. Electromyographic recordings (EMG) activity of the lip and right forearm were recorded in the patient and compared with an age and experience-matched Nadaswaram musician (Con- trol). Surface EMG activity from six channels (lips and fore- arm) was recorded at rest and while playing Nadaswaram. Control: EMG bursts were absent at rest and while playing the instrument in the forearm muscles (Fig. 1a,b: lower two traces). While playing music, intermittent 5 Hz frequency rhythmic EMG bursts were recorded from the lips (upper four traces of Fig. 1a,b) that varied with musical notes and synchronously and symmetrically. At rest there was no tremor. A 5–5.5 Hz rhythmic EMG activity synchronously occurring in the forearm muscles were recorded with the instrument near his mouth and while playing (lower two traces of Fig. 1c,d). While playing Na- daswaram, the lip EMG bursts were irregular, lacked rhyth- micity with more prominent lower lip activity distorting the musical notes (upper four traces of Fig. 1c,d). In between the EMG bursts the baseline activity was prominent suggesting dystonia. In Figure 1c, baselines of the second and fourth traces dip for 150 ms due to lower lip dystonia. Occasion- ally, the lip and forearm EMG bursts were synchronous. It is possible that the altered motor program causes task specific dystonia and is further modified by his essential tremor eventually causing a dystonic lip tremor. Our patient had task specific lip tremor appearing on playing the musical instrument. The lip tremor did not appear when mouthpiece was placed in his mouth but appeared on blowing as in task specific embouchure tremor and primary writing tremor. It is this task specificity that made us consider this task specific tremor as dystonia. Initially, the task specific limb tremor occurred while playing the Nadaswaram; only later did the head and pos- tural limb tremor appear even without playing Nadaswaram satisfying the Tremor Research Investigation Group’s defi- nition of “definite” essential tremor. 3 Our patient’s mother had postural limb tremor suggesting that this familial essen- tial tremor presented as task specific tremor. In a large series of embouchure dystonia and primary writing tremor, limb tremor and family history of tremor were absent, hence they were called task specific dystonia rather than tremor. 1 Focal task specific dystonia is not associated with prominent pos- tural tremor. 4 Further, hereditary essential tremor can begin as a focal action tremor but is never task specific at onset. 5 Our patient is of interest as he started with embouchure tremor and, later, developed postural tremor typical of es- sential tremor. Electrophysiologically, the 5–5.5 Hz hand This article includes supplementary video clips, available online at http://www.interscience.wiley.com/jpages/0885-3185/suppmat Published online 21 August 2007 in Wiley InterScience (www. interscience.wiley.com). DOI: 10.1002/mds.21709 LETTERS TO THE EDITORS 2133 Movement Disorders, Vol. 22, No. 14, 2007