ISSUE #2

In this issue, you can choose any of these articles:

  • How to modify your own flute by John Lunn
  • On Finding Solutions anonymous
  • Uses of Psychiatry in Performing Arts Medicine by John Braverman Levine M.D.
  • Return to HANDS ON! menu

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    HOW TO MODIFY YOUR OWN FLUTE
    by John Lunn

    If you are considering having your flute modified to better fit your hands, there are many "homemade remedies" that you can try to find out if they will help. It gives you an opportunity to test the water without having to spend a lot of money. In the long run, however, it is wise to replace them with permanent extensions.

    If you want a cushion where the left hand index finger supports the flute, stick a round corn pad (from a drug store) on that spot. You can also use a Bopep (available at music stores). This is a plastic clip on crutch for the left hand that makes the flute feel like it is as large around as a wooden flute. It can help relieve tension in the index finger and relax the position of the hand by reducing the angle. You can put the corn pad on the Bopep, too. There is also a Bopep available for the right hand that helps support the thumb behind the flute.

    To find the best finger positions, plug open holes with corks or plastic plugs (also at music stores). Once the holes are plugged you don't need to touch the center of the key so you can place your fingers wherever they comfortably reach. For the left hand, experiment by playing on the outside edges of the G and A keys. This will give you a chance to straighten out your wrist a bit while maintaining a bit of a curve in your fingers.

    To make extensions, find or make plastic discs about 1/2 inch in diameter to glue* onto the top edges of the keys. You can cut disks from plastic bread bag ties. With this you can reposition your hand to a more comfortable, natural position. For the G#, buy a false fingernail and glue it onto the top of the lever.

    For the index finger of your left hand, glue an 1/8th to 1/4 inch slice of round cork to the top of the C# finger button. This helps reduce, possibly even eliminates any kink in this finger that causes pinching. This can be used in conjunction with a bopep.

    On the right hand, most difficulties stem from the reach to the footjoint. Even if you feel discomfort in the other 3 fingers, it can be caused by the stretch between them added to the reach to the low rollers. After plugging the holes, bring your 1st and 3rd fingers together so that they are almost touching the trill levers. (Keep in mind that years of practice have trained you to automatically feel for the center of the cup so you must consciously remind yourself that you are trying to keep the fingers in a new position.) If that stretch isn't causing problems, but you find that you must rotate your wrist to reach the rollers, at least plug the D cup so that you don't lose that note.

    Unfortunately, there is nothing temporary that can be done to bring the footjoint keys closer. This must be designed and reconfigured by a skilled craftsman. My angled footjoint cluster is a proven success for this.

    After you have worked with the plastic shims, fingernails and plugs you will discover some things help and others don't. Be careful to keep tabs on your progress. If the extensions relieve pain in one area but you start feeling discomfort somewhere else, remove them. Transferring a problem is no solution. Don't overdo. Most things that you try must be tempered with a dose of common sense.

    Custom designed flutes are becoming more and more acceptable. If done properly, it can be aesthetically and functionally preferable. Offset G and closed hole flutes are no longer seen as just "student models". There are a variety of special headjoints and key configurations that can be designed on any new flute. When you start looking for a new instrument consider comfort and reach as much as you would acoustic design because a lifetime of playing requires hands that work as well as an embouchure.

    *Contact cement works best because it's easy to use and, if you don't like where you put an extension, you can remove it easily enough and then you can remove the remaining cement with alcohol.

    ~ John Lunn is a flutemaker who specializes in finding solutions to hand problems for flutists.~

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    ON FINDING SOLUTIONS
    anonymous author 1
    I have been a flute player for 24 years and held a major U.S. orchestra chair for 18. I have very small hands and two years into my job, my left thumb suddenly wouldn't slide on the flute from B to Bb, and would cramp up into a bent position when I moved it, especially off the B key. I consulted other flutists including Geoffrey Gilbert and Tom Nyfenger who all assumed it was tension related and gave me hand positioning advice. One recommendation was to get a crutch made for the flute which did help a bit.

    Since there was no pain involved, I didn't panic. However, the problem didn't disappear. I continued to research over the next 5 years trying different crutches, developing better muscles, practicing the Alexander Technique and even shock treatment. Still my thumb wanted to cramp during any rapid motions.

    In 1987, I started working with Dorothy Taubman techniques which involves learning to use muscles in new ways which prevent injuries. The first step was to stop injuring my hand any further. To accomplish this I developed a method of "throwing" my thumb from one key to the other, which is a pianists technique for striking the keys. Rather than stretching or lifting my thumb, I move it from low down near the wrist and, while keeping my wrist straight I 'throw' it off the B or Bb key.

    By the time I consulted a hand specialist in 1991, I had gathered enough information to target my condition as a focal dystonia, which accounted for the lack of pain. The hand specialist confirmed my diagnosis. I heard about the possibility of having the left hand keys modified to fit my small hand so I had extensions put on the G and G# keys to allow my wrist to better straighten out. This helped me develop the thumb throwing technique further.
    Lately, I have been playing an old Louis Lot flute and found no need for extensions because my thumb throwing technique works so well.
    After being advised by so many different professionals, I learned that I needed to evaluate all the information and make my own decisions. Each professional tends to make a diagnosis which relates to his or her area of expertise. Although I learned many useful things from them, individually they did not solve my problem. Reading about different performance-related injuries helped me recognize my own condition. The Dorothy Taubman techniques enabled me to find alternate solutions through retraining. Adapting my flute helped it fit my individual hand size. There wasn't one formula readily available for focal dystonia in the lefthand thumb of flutists. As flutists, we must take an active part in our treatment and recovery. No one else knows what difficulties we encounter and how much it means to us to keep playing. We must become our own best advocate, judge, teacher and healer!
    *
    This article was submitted to HANDS ON! with the stipulation that the author remain anonymous. It is a good indication of the problems that still face flutists. There is still fear and doubt that employers and peers won't accept anyone who must overcome problems just to keep their job. Until everyone can start talking about it openly, stories like this one will continue to go untold, flutists won't know where to get help, and many won't be as lucky in finding a solution that works. ~editor
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    USES OF PSYCHIATRY IN PERFORMING ARTS MEDICINE
    by John Braverman Levine, M.D.

    Heather Mandry, in A Return from the Brink (HANDS ON! 2:2) recommends psychological support for injured musicians. But psychiatrists, psychologists, and social workers experienced in coordinating medical care, particularly in hospital settings, are resources for more than psychotherapy. Consultation-liaison psychiatry, a branch of general psychiatry and a sub specialty in its own right, deals both with patients' emotional responses to physical illnessand with the direct effects of medical illness on mood and thought.
    Traditionally, psychiatrists have utilized psychotherapy and, more recently, psychopharmacology as medical interventions. 

    Psychopharmacology is the use of prescribed medications, called psychotropic drugs, for the treatment of psychiatric complaints such as anxiety, depression and instability of mood. Because many of these symptoms can occur as part of everyday life, and because taking psychiatric drugs can have unanticipated medical, psychological, and social consequences, careful history taking, assessment, diagnosis, and monitoring are required.
    Consultation-liaison psychiatrists are also concerned with the psychological side effects of nonpsychiatric drugs. Patients taking the anti-ulcer medication cimetidine, for example, can become confused.
    Conversely, psychiatrists attend to the medical side effects of psychotropic medications. For example, patients taking antidepressants, particularly tricyclics, (an older class of antidepressants still commonly prescribed because of their availability in low cost, generic form) may develop dry mouth or have difficulty focusing their eyes at close distances. Patients taking lithium, a mood stabilizer used in manic-depressive disorder, can develop tremor.
    Psychiatrists also deal with the unintended side effects of the patient/doctor relationship. Medicine lacks the precision of pure mathematics. When patients' initial complaints are subjective, medical findings subtle, and diagnosis not readily apparent, emotional friction can develop between patient and doctor. Consultation-liaison psychiatrists can help sort out the occasional lapses in communication, empathy, and continuity of care which inevitably occur.
    Finally, specialists, including consultation-liaison psychiatrists, can help with problems of referral. A long-standing cause of restricted access to medical care for musicians in this country has been lack of insurance coverage. In the new age of "managed care", even individuals who are insured may have difficulty getting referrals to specialists in performing arts medicine, in part because it is a relatively new field-- some primary care physicians may not have heard of the specialty.
    Yet even when they have, and when referral to specialists is appropriate, obtaining a referral may not be easy. Under "managed care" primary care physicians are supposed to act as "gatekeepers", screening out unnecessary referrals and limiting access to expensive specialty care. In addition, managed care systems create incentives to motivate their primary care doctors not to refer their patients to specialists. Thus there can arise a conflict between the clinical needs of the patient for specialty care and the bureaucratic requirement that the physician not refer. Informed patients, when denied needed specialty care, can advocate for themselves by obtaining an independent consultation and educating their gatekeeper physicians about appropriateness of referral and the medical consequences of denial of treatment.
    Consultation-liaison psychiatry is part of the training of all general psychiatrists. Psychiatrists specializing in consultation-liaison can be found in departments of psychiatry and ambulatory (outpatient) medicine, particularly in teaching hospitals affiliated with medical schools. Clinical psychologists and social workers who have worked as part of hospital-based teams are also knowledgeable resources.
    A musician seeking an initial evaluation of a performing arts medical problem could begin by calling the department of neurology and of orthopedic surgery at a teaching hospital, preferably in a city where both a major symphony orchestra and a medical school are located, and requesting referral to someone who evaluates neurological and musculoskeletal problems in musicians. Having a referring physician make the call could simplify the process. In addition, there are now 40 to 50 performing arts clinics in the United States.
    The specialty of performing arts medicine is a work in progress. Not all the procedures for referral and treatment have yet been worked out, but musicians and clinicians can help advance the quality of care and the knowledge base of this specialty by educating each other.

    John Levine is a psychiatrist in private practice in Cambridge, Massachusetts and a Clinical Instructor in Psychiatry at Harvard Medical School.

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    HANDS ON! is a public service provided by John Lunn Flutes
    The opinions expressed are not necessarily those of the editors.
    If you have questions, comments, articles, ideas or letters to the editor, we'd love to hear them.
    If you are in pain or experiencing phyical difficulties while playing, contact your healthcare provider.