NARRATIVE REVIEW: Focal hand dystonia is a disabling movement disorder, often task specific, that leads to impaired hand use. In addition to a genetic predisposition, environmental risk factors including repetitive use and musculoskeletal constraints are contributory. Although the underlying cause is unknown, recent studies have identified several key mechanisms that may play a part in its genesis. Failure of inhibition, abnormal sensorimotor integration, and maladaptive plasticity seem to be important. Understanding the underlying physiology may lead to the design of novel therapies.