Objective: To present a unique case of embouchure tremor when only playing a Shakuhachi, a Japanese musical flute.

Background: Embouchure dystonia (ED) is a rare focal task-specific dystonia affecting the muscles that control the flow of air into the mouthpiece of a brass or woodwind instruments (1).  ED has been documented in both brass instrumentalists (trumpet, French horn, trombone, tuba) and woodwind players (piccolo, flute, oboe, clarinet, saxophone, bassoon), but has not been previously reported in musicians playing Asian instruments.

Method: A 70-year-old right-handed man developed a spontaneous lower lip and jaw tremor only while playing a Shakuhachi, a handmade Japanese vertical bamboo flute. The shakuhachi has five finger holes, and lacks keys, pads, reed, nor mouthpiece. Despite its structural simplicity, it produces a remarkably rich and hauntingly beautiful sound (2).

He started playing the Shakuhachi 3-4 years ago, practicing for half an hour each day, with a weekly 2-hour lesson, prior to developing the tremor. Initially, his chin and lower jaw would occasionally quiver while playing, but the tremor became persistent over time, destabilizing the instrument sitting on his chin and creating an unintended vibrato. Eventually, he quit playing. His speech, chewing, swallowing, and tongue movement are normal. Occasionally, he experienced tightness in his jaw muscles.

Results: Examination revealed a mild to moderate rhythmic tremor (6-7 Hz) in the lower lip and chin while playing, with concurrent contraction of the masseter muscles.  The tremor worsened when producing lower-pitched sounds, which required greater oral muscle tension. He was able to whistle with inhalation but not exhalation, and the rest of his neurological examination was normal without a significant intention tremor.  Treatment with propanolol did not improve the tremor and caused significant bradycardia.  He declined treatment with additional medications and botulinum toxin injections.

Conclusion: Despite differences in instrument design and technique, this patient likely developed embouchure dystonia/tremor while playing the Shakuhachi. This is the first reported case of embouchure dystonia associated with a non-Western instrument highlighting the need for further research on task-specific movement disorders across diverse musical traditions.

References: 1. Frucht, S.J. Embouchure dystonia: a video guide to diagnosis and evaluation. J Clin Mov Disord 3, 10 (2016). https://doi.org/10.1186/s40734-016-0035-x
2. Ziemer, T. Sound Radiation Characteristics of a Shakuhachi with different Playing Technique. International Symposium on Musical Acoustics, 2014, Le Mans, France. https://musiconn.qucosa.de/api/qucosa%3A70635/attachment/ATT-0/?L=1

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MDS Abstracts - https://www.mdsabstracts.org/abstract/task-specific-embouchure-tremor-in-a-shakuhachi-player/