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ISSUE # 6
Music performers are an important part of music history. Without them, music would be an unspoken language. The day-to-day lives of many performers have been documented extensively, but little mention is made about injuries that affected them due to their careers (aside from Robert Schumann, whose injury raises a great deal of speculation). Although the term ‘Performing Arts Medicine' did not emerge until 1982, performers have been suffering from performance-related injuries for centuries. This emergence was due to a change in the perception of performance-related injuries by musicians and consequently, medicine's ability to deal with these injuries. However, both musicians and their doctors continue to struggle with many aspects of the injuries. Not only did such problems stump doctors of the nineteenth-century, but even with the advancement of medicine in the twentieth century, relatively little is understood about what causes the injuries, how the musician's psychological situation factors in, and even how to treat certain types of these injuries.
Performance injuries, often-called ‘overuse' injuries include a wide variety of ailments. There are numerous articles detailing these injuries (listed in my bibliographical references), so I will cover the injuries as briefly as possible, limiting the scope to musculoskeletal and neuromuscular injuries. The most common type of performance-related malady is given a number of terms: tendinitis or tenosynovitis, rheumatism, repetitive-strain injury (RSI), or overuse syndrome. All of these terms vaguely describe the ailment itself. For example, a musician diagnosed with tendinitis has often been shown to have no evidence of inflammation associated with such a pathology. This class of injury is associated with localized and acute aches and pains. Another type of injury is neural impingement or nerve-entrapment. Carpal-tunnel syndrome exists in this class, along with ulnar nerve neuropathy and thoracic-outlet syndrome. With these injuries, the musician experiences pain and numbness. The final class of injuries, focal dystonias, is the most puzzling and most difficult to treat. This injury involves either painful and/or painless loss of muscular control. It is often chronic in nature, and there are no studies proving it is linked to repetitive motion. Other names for the injury are musician's cramp or piper's palsy.
So who is actually affected by these injuries? Most musicians know of someone who has experienced aches and pains while playing, but most of these problems aren't enough to scare potential musicians from ever picking up an instrument. There have been several studies performed which all result with similar statistics. In Ralph Manchester's study, from 5-10% of music performance students were affected. Women were affected almost twice as often as men were. The average age of injured musicians ranged from 17 to 39 years. The greatest increase in injuries occurred in February and September (months where new quarters/semesters begin). As far as instrumental distribution, keyboard and string players are affected equally (although the larger the string instrument, the greater the risk for injury). Wind players follow next with the greatest risk attributed to the flute. Brass players and percussionists have relatively low incidence of injury.
It would be relatively easy to dismiss this topic completely on those statistics. If these injuries affected only those who were aspiring to musicianship, then the loss of future musicians would hold little value to the musical world (after all, there are plenty more musicians begging to take their places). It is when one begins attaching names of reputation and importance to the statistics that the historical importance of performance-related injuries comes alive. Many professional musicians have been affected by such injuries including Gary Graffman, Leon Fleisher, Ernestine Whitman, Jeanne Baxtresser, Glenn Gould, Robert Schumann, and even his wife, Clara Schumann (to name just a few). When such talent is damaged and pulled from the musical world, it is a cause for alarm to some (an opportunity for those aspiring to replace them).
Knowing that performing has the potential to harm their career goals should make musicians wary and careful. However, in the performing field, there is little existence of any fear of occupation loss. Why? The problem stems from far more than the performer's denial that they are somehow protected from injury. For the most part, it lies in the unawareness and lack of understanding of the problems, what causes them, and what can help overcome them. Prior to the latter end of this century, performing-related injuries were a ‘closet'-disorder. Performers rarely admitted nor discussed an injury with another performer. This doesn't mean that such injuries didn't exist prior to 1980. There is a great deal of evidence that they did. However, they were often grouped into general classifications of ‘worker's afflictions' or ‘occupational disorders.' In 1713, Bernardino Ramazzini published Disease of Workers. This book deals with a variety of occupations and disorders, but ‘overuse' injury is included as he states "No sort of exercise is so healthful or harmless that it does not cause serious disorders, that is, when overdone."
Historical evidence of performance-related injuries increased for the nineteenth-century. Instrumental changes greatly affected performers. Pianos were created that had heavier action and a stronger frame. Woodwind instruments emerged that were made from heavier woods and taunted a great deal of keywork. In addition to this, the compositions of the time became more difficult and demanding. In spite of all of these changes, however, the physical approach to the instruments did not change. An example is the piano's ‘finger-only" technique used with 18th century pianos. Teachers continued to teach their students this technique well into the 19th century.
In 1967, Kochevitsky wrote:
"Composers wrote piano pieces which called for greater physical endurance
as well as technical brilliance from the performer. Owing to the taste
of the general public and to the conditions of performance in large halls,
pianists strove to enrich and increase their tonal capacities. So a set
of rather complicated technical problems arose for the pianist, for instance,
overcoming the resistance of keys due to their greater depth and heavier
action.
Consequently, with changes in the pianoforte itself, some expansion
took place in the performing technique. It is surprising that these changes
did not influence piano pedagogy, which still taught the principle of isolated
finger technique and prohibited use of the upper parts of the arm."
All of the performance-related injuries sustained by musicians in current times were experienced by musicians of the 19th century. Fry states many examples of 19th century writings concerning overuse and focal dystonias (cramp). An excellent and well-used example of a performance-related injury prior to 1900 exists with Robert Schumann. Actually, there is a great deal of speculation as to whether or not his injury was even performance-related. Authors writing on this issue prior to 1981 preferred to speculate the cause of his injury as caused by anything other than piano playing. This shouldn't be completely shocking, because they referenced the available documentation of doctor's records and Schumann's own letters to arrive at their conclusions. Traditional belief was that Schumann's injury was due to a mechanical finger-stretching device. However, in 1971, Eric Sams disputed this belief, by using documentation from Clara Schumann that told of Schumann's injury existing in the index finger (it had been previously documented that the machine had affected the third and fourth fingers) and that any such machine did not cause it. Sams goes on further in the same article to use doctor's records and records of Schumann's psychological problems to indicate that the proper cause would have been poisoning caused by mercury-treatments for syphilis. In 1980, Peter Ostwald explored another theory concerning the cause of Schumann's injury. His theory agreed with Sams in that the mechanical device did not cause the injury. However, Ostwald indicates that chemical tests of Schumann's hair did not show any traces of mercury. He furthers his argument by using examples from Schumann's letters and points out the changing nature of the injury and the instability of the composer's personality.
Ostwald concludes the following:
Those with some experience in the psychopathology of nineteenth-century
figures will, however, form a reasonable assumption about this matter;
and the fact that he was so constantly preoccupied with his hand, and that
the symptom he subsequently developed was a stiffened finger, strengthens
this assumption. If masturbation was what this "hypochondriachal" musician
was worried about, then one might postulate a displacement onto his hand
of sensations relating to another part of the body. Certainly Schumann
would not be the only young man of his time who dealt with emotional conflicts
by developing psychosomatic symptoms as well as mental anguish."
While Sams and Ostwald were attempting to reach an informed conclusion using what seemed like reliable evidence, they both reach what seems to be far-fetched conclusions to the nature of Schumann's injury. But, according to the records of many of the doctors Schumann saw, his injury was changeable, did not affect his piano playing and was all in his imagination. It isn't so outlandish to conclude that Schumann's problems were psychologically based, assuming his doctors knew exactly what he was afflicted with and even understood the impact the potential loss of a performing career could have on him. Schumann saw many doctors, and received just as many (if not more) treatments for his condition. He tried drinking (his own remedy), herbal compresses, soaking his arm in brandy, electric-therapy, small amounts of medication and even inserting and soaking his arm in the carcasses of freshly-slaughtered animals. It seems that the greatest problem Schumann had was finding a doctor who could understand his injury and his needs as a performer.
In her doctoral thesis, Jinie Kim states:
"From the (above) disparate accounts and speculations about Schumann's
hand problem, we can see that determining the precise cause of a musician's
physical problem was just as difficult in the past as it is today. Although
Schumann wrote about his trouble with his hand, it appears that he himself
was unable to explain its cause. It is indeed unlikely that modern physicians
and scholars could explain Schumann's hand problem satisfactorily from
the historical evidence. Even with a clinical examination of a patient
and laboratory investigation, it is often difficult to make an accurate
diagnosis of a performance-related disorder!"
The 20th century did not progress much further than the 19th century's
conceptions of ‘occupational' maladies until 1982. In this year, the term
‘Music Medicine' was created, thanks to a lengthy and accurate article
written by dance critic Jennifer Dunning, called "When a Pianist's Fingers
Fail to Obey" which appeared in the Sunday New York Times (June 1981).
This article, written about Gary Graffman and Leon Fleisher, was preceded
by many years of suffering from performance injuries. In an introductory
article of a new journal, Medical Problems of Performing Artists, Gary
describes the circus he went through prior to 1981.
After trying to deny and hide his injury and canceling many engagements,
he finally agreed to see a doctor:
"I opened my mouth and said, "Aaaaah." My blood pressure was checked,
my urine analyzed, my inner ears probed, my chest thumped, and, finally,
my brain scanned. ("Brain's fine!" the technician cheerfully informed me,
"Nothing there!") But my hand? "It's neurological," I was told, and electrical
needles invaded nerves and muscles for signs of blockages, tangles, injuries,
disease. No abnormalities? Sorry, can't help you. On to the next doctor."
Each doctor that Gary saw gave him a different diagnosis according to their specialty, whether it was cancer or Parkinson's disease. He tried to explain to each doctor what he thought was happening, and that what had happened was caused by his piano playing, but nobody would believe him. In the spring of 1980, he finally found a group of doctors at the Massachusetts General Hospital who listened to what he had to say, treated him "like a rational adult," and strove to seek a cure for his affliction.
Leon Fleisher had a more difficult injury. This injury cost him his marriage and kept him from playing for 15 years. After being diagnosed with torsion dystonia, he swore he'd never see another doctor. But, after hearing of Gary's successful reports, Leon agreed to see the doctors at the hospital. He was diagnosed with carpal-tunnel syndrome and surgery was performed. News about Gary and Leon traveled fast, and the famous article was written. Phone calls from injured musicians came pouring in from around the country starting at 8 a.m. Monday morning. The disorder was out of the closet.
Since the publication of the New York Times article, much has progressed in the Music Medicine field: ‘The Biology of Music Making,' a conference concerning Music Medicine was held in Denver, Colorado in 1984; Medical Problems of Performing Artists was first published in 1986; the International Journal of Arts Medicine began publication in 1991; and there are annual meetings in Aspen, Colorado of the Performing Arts Medical Association (PAMA).
Even with all of the publicity that Music Medicine has received, ‘medicine'
itself is, in many ways, just as puzzled by performance-related injuries
as it was 100 years ago. There is immense speculation and disagreement
over causes and treatments. The reality is that even musicians are not
much further advanced in their perceptions of injuries than Schumann was
himself.
Musicians see themselves as infallible. They play through the pain,
believing they will be better for it. Even when the problem persists and
makes performing difficult, they still fail to admit problems, because
they fear losing their status or future career. They are faced with sometimes-insurmountable
frustration and depression similar to what Schumann experienced. They feel
that they have caused the injury themselves and feel a strong lingering
of their musical identity. Just like Gary Graffman and Leon Fleisher, injured
musicians still face doctors who do not understand the depth of a performing
artist's needs.
Ernestine Whitman, a flutist suffering from focal dystonia, relates
her experience:
"One of the orthopedic specialists I consulted told me that of course
I should have expected problems since I was doing something weird and foolish
with my body: I was "like the Chinese women who bind their feet and the
African women who wear rings in their noses." A counselor I went to thought
my problems would be solved if I would just make a practice chart, ranking
my expectations and my actual "performance" and gradually reducing my expectations
to align with what I could do."
Unfortunately, medicine seems just as confused as musicians do about what causes performance-related injuries. It seems that a majority of doctors are very good at diagnosing what their specialty warrants. Many doctors believe that musicians are prone to the injuries when their overall health and physical well being is compromised. Many other professionals blame injuries on incorrect postures and positioning. One theory states that "some musicians suffer the end results of lifelong contact with a chosen instrument that carries some health risks because of weight, surface chemistry or functional demands." Similar to Ostwald's approach to Schumann, Julie Nagel, a psychologist, believes that injuries are the result of psychosomatic transferals of angry feelings into the part of the body that are associated with performance.
However, Alan Lockwood believes that:
"In spite of the many emotional factors associated with musicianship
and the sensitive nature of the personality of many musicians, somatic
complaints of purely psychic origin are very unusual."
While musicians remain shy of doctors, they are equally shy of the treatments prescribed. It is unheard of in today's times to insert one's arm into the carcass of a freshly dead animal, but there are many equally invasive and undesirable tests and treatments such as electrical testing of nerves, medications which could alter performance, injections of corticosteroids or botulinum toxins, and worst of all surgery that threatens to end a career if unsuccessful. The most common, and least invasive, treatment for acute ‘overuse'-type injuries is rest. However, even rest appears threatening to the musician who has rehearsals and concerts to plan for. Even when the musician agrees to ‘rest' (discontinue playing the instrument or significantly decreasing practice time), it is difficult to continue the program, because when they begin to feel better, they rush back to their instrument and sometimes play for hours, causing the injury to return. There are other less invasive treatments, which teach the mind to focus on the posture and positioning of the body. These treatments, Alexander Technique and the Feldenkraise Method, work well for performers whose problems are due to muscular and structural imbalance. The least advised treatment for injuries is surgery, except in cases of carpal-tunnel syndrome or ulnar nerve neuropathy where surgery has proved highly successful.
Alice Brandfonbrener, president of PAMA and editor of Medical Problems
of Performing Artists, stated the following about the risk of performing
surgery on musicians with injuries:
"Many, if not most, of these patients will have already consulted a
large variety of both medical and, oftentimes, alternative practitioners
and have been subjected to a variety of diagnostic procedures, some very
sophisticated, costly, and frequently inconclusive… Not surprisingly, and
especially with the passage of time, because of the ongoing disability
and the inevitably progressive uncertainty about their occupational future,
many musician patients become significantly anxious and depressed. They
also become frustrated, confused, demanding, and angry…. In the course
of their ongoing problems, these musicians have had lots of time to think
as well as to get confused... Therefore, irreversible treatments, such
as surgery, present special hazards.
It is obvious, then, that both musicians and doctors could use more insight into the field of performance-related injuries. Continual new studies are being attempted and new research performed. However, few musicians are willing to put their valuable time aside to become guinea pigs, participating in range-of-motion studies or medication trials, so doctors are looking to perform less invasive and more accurate studies. Brandfonbrener believes that doctors in performing arts clinics should take advantage of the increasing number of patients they see to reach accurate conclusions of specific types of injures. She says, "it is critical that we of PAMA not bask in past successes. It is time to move on and to make some significant contributions to the science of performing arts medicine."
So what can the musical field do to protect future Gary Graffmans and
Robert Schumanns from injury? Performing artists learn what they know from
their teachers. Frank Wilson states:
After five or six years of listening to music teachers discuss their
work, I have come to the conclusion the best teachers just stay out of
the way when students are determined to become musicians, hoping at least
to instill in them a sensitivity to historical traditions in music aesthetics.
When it comes to any objective pedagogic issues, however ---- how an instrument
can be held, the number of hours a certain routine should be practiced,
and so on ---- successful instruction is mostly inspiration, intuition,
and luck, usually propelled by old-fashioned love."
The perception of injuries prevalent in performing artists plays an important role in the prevention of injuries in future generations. While less should not be expected of performing musicians, more understanding should be provided for their efforts and problems. Some university music programs are beginning to include and require classes on performing-related injuries and issues. As perceptions change, injuries should be treatable and fine musical talent will be preserved.
*****
Bibliography
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Cole, Reginald A., Leonardo G. Cohen, and Mark Hallett. "Treatment of musician's cramp with botulinum toxin." Medical Problems of Performing Artists 6, no. 4 (Dec. 1991): 137-143.
Dawson, William J. "The role of surgery in treating upper extremity problems in musicians." Medical Problems of Performing Artists 7, no. 2 (June 1992): 59-62.
Enright, E. "Research to aid musicians in need of injury rehab." Downbeat 62, no.12 (Dec. 1995): 82.
Fry, Hunter J.H. "The effect of overuse on the musician's technique: a comparative and historical review." International Journal of Arts Medicine 1, no. 1 (Fall 1991): 46-55.
Graffman, Gary. "Doctor, can you lend an ear?" Medical Problems of Performing Artists 1, no. 1 (Mar. 1986): 3-6.
Grindea, Carola, ed. Tensions in the Performance of Music: a Symposium. With a foreword by Yehudi Menuhin and preface by Allen Percival. London: Kahn & Averill, 1995.
Harste, Ann M. "'Tuning' musicians." Physician and Sportsmedicine 18 (Dec. 1990): 16.
Kella, John J. "Medicine in the service of music: health and injury on the podium." Journal of the Conductor's Guild 12, no.1/2 (Winter/Spring 1991): 2-15.
Kim, Jinie. "Physical Problems Prevalent Among Pianists." Ph.D. diss., University of Washington, 1997.
Lederman, Richard J. "Entrapment neuropathies in instrumental musicians." Medical Problems of Performing Artists 8, no. 2 (June 1993): 35-40.
____________."Focal dystonia in instrumentalists: clinical features." Medical Problems of Performing Artists 6, no. 4 (Dec. 1991): 132-136.
____________. "The challenge of occupational cramp." Medical Problems of Performing Artists 6, no. 4 (Dec. 1991): 109.
____________. "Occupational cramp in instrumental musicians." Medical Problems of Performing Artists 3, no. 2 (June 1988): 45-51.
Lederman, Richard J. and Calabrese, Leonard H. "Overuse syndromes in instrumentalists." Medical Problems of Performing Artists 1, no. 1 (Mar. 1986): 7-11.
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Lockwood, Alan H. "Medical problems in secondary school-aged musicians." Medical Problems of Performing Artists 3, no. 4 (Dec. 1988): 129-132.
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Manchester, Ralph. "The incidence of hand problems in music students." Medical Problems of Performing Artists 3, no. 1 (Mar. 1988): 15-18.
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Locating a specialist you will be comfortable with is not difficult, but will take some time and effort on your part. Most likely you are being referred to a specialist by your family physician who will recommend one or several physicians to contact. You may also ask for suggestions from nurses you know, family, friends, co-workers, or you may decide to start searching for help on your own. Here are some things to look for, questions to ask, and resources that will help.
Once you have compiled a list of possible specialists to see, you will want to check:
office location and hours (if you need to be seen several times or over
a long period of time it may be more convenient to locate a specialist
in your town or within an easy traveling distance)
insurance (is your insurance accepted or payment arrangements available)
hospitals or outpatient centers (which facilities is the specialist
affiliated with)
You can also readily find out:
Board certification (see resource list below)
Medical school attended (see resource list below)
suspended or revoked license or fines (State Board of Medicine)
lost malpractice suits (county courthouse),
general information (county medical association)
When you have narrowed your list down to a few, then you will want to set up a for a consultation/interview. Things to consider:
the office
is the staff friendly, efficient, professional
how long is the usual wait for an appointment? in the waiting room?
are same day appointments available for urgent problems
does the physician keep on time with appointments
are payments over time accepted or is your insurance accepted
how are calls after closing time handled
where do you go for emergency care
what are the fees for office visit fees; costs of tests and treatments
the doctor
forthright, respectful, concerned about your care
communicates so you understand without being condescending
takes the time to answer your questions without rushing
allows you to express concerns
gives real information, not just reassurances
knowledgeable about your condition
knows the latest treatment options
explains medical tests and procedures
discusses potential side effects or complications
behaves in authoritarian way? easygoing way?
comfortable with the idea of your getting a second opinion; or is threatened,
defensive
willing to talk on the phone for advice, prescription refills, and
referral authorization or always require an office visit
emphasizes preventive care
open to your active involvement in decision making
open to use of alternative treatments if this is important to you?
supportive of your efforts for self-help and wellness care
If surgery or a procedure is recommended by the specialist:
how many times a year does he/she do this procedure
his/her success rate
specialized training received
affiliated with what hospitals
*****
Resources
Books:
The Best Doctors in America. 1996-1997. Aiken, S.C.: Woodward / White. 1996.
D & B Healthcare Reference Book: America's Leading Healthcare Providers & Suppliers. Bethlehem, Pa.: Dun & Bradstreet. 1998/99.
Detwiler's Directory of Health and Medical Resources. New York: Hatherleigh Press. 1997
Directory of Physicians in the United States. Chicago, Ill.: American Medical Association. 1999.
Encyclopedia of Medical Organizations and Agencies. Detroit: Gale Research. 1994
Medical and Health Information Directory. Detroit: Gale Research. 1994.
National Health Directory. Gaithersburg, Md.: Aspen Publications. 1998.
Official American Board of Medical Specialist (ABMS) Directory of Board Certified Medical Specialists. Evanston, Ill.: American Board of Medical Specialists, Research and Education Foundation.
Physician Marketplace Statistics: Profile for Detailed Specialties. Chicago, Ill.: American Medical Association. 1997.
Questionable Doctors Disciplined by States or the Federal Government. Washington, D.C.: Public Citizen's Health Research Group. 1998.
Referral Directory / American Holistic Medical Association. Raleigh, N.C.: American Holistic Medical Association. 1996
Yearbook - American College of Surgeons. Chicago, Ill.: American College of Surgeons.
Also, the U.S. News and World Report magazine publishes an annual issue
of Best Hospitals in the United States.
Internet:
The American Medical Association's Physician Select
(http://www.ama-assn.org/aps/amahg.htm)
The American Board of Medical Specialties
(http://www.certifieddoctor.org)
Also, you may want to call the American Association for Accreditation of Ambulatory Surgery Facilities (1-888-545-5222) to find out accreditation of outpatient facilities that might be recommended.
The big recital's coming up and you've locked yourself up in the practice
room for 4 hours at a time,then realize you can't move your fingers or
your neck. Ouch. While rehearsing, take some time do do the
following to relieve tension, headaches, and nerves!
Deep Breathing
Before ever starting, give yourself time to calm and relax yourself
by just breathing slowly and deeply. Doesn't hurt your breath support,
either! Do the following:
Inhale very slowly through
your nose, taking in every bit of air you can. Exhale, hissing through
your teeth and counting to see how many seconds you can go before you totally
run out of air. Only do this a couple of times, though, so you don't
get dizzy! This is a slow process that calms your brain down and
also helps develop your lung capacity for playing.
Once you're actually into playing, make sure you allow yourself breaks.
Rehearsing is not a marathon. I'm sure you've found out that sometimes,
long, tedious, tense rehearsals actually have a detrimental effect.
Practice for about a half hour, then take a water break. During that
time, stretch out all your muscles this way:
Lean in towards a wall, bracing yourself
with your palms. Rise up and down on your toes so that you're flexing
your hamstrings. Do finger "push-ups" against the wall so that you're working
those muscles in different ways. Pump your arms up and down in the air
as if you're lifting barbells, then bend your elbows and push them back.
That will work your back muscles in different directions to relieve tension.
Do neck rolls frequently. I've developed problems
in my neck because of marathon sessions, and didn't do this. Roll
your neck around in one direction, then the other. Then, tilt your
head to one side, bracing it with the hand that's on that side and gently
push, trying to resist your hand with your head, then repeat on the other
side. Or, tug on each ear gently, allowing your head to move in
the direction of the tug. Repeat on the other side.
Another relaxation technique that works is to actually supertense your muscles, then let go. Sitting in a chair, start tensing all your muscles, starting with your toes, working up to the calves, thighs, buttocks, stomach, etc., all the way up to your eyes. Tense every muscle you can find to tense, then suddenly release and go limp like a Raggedy Ann. Repeat at least once. It's amazing how relaxed you feel after you force your body to do just the opposite.
After a couple of hours, your brain my be feeling mushy, and it's time for a "Calgon" moment. Actually, you don't need a real bubble bath, but you need to take a brain vacation. This is called "visualization". Again, sitting in a chair, allow yourself to go limp (hey, posture can go on vacation for a couple of minutes). Close your eyes and allow yourself to breath slowly and deeply. Visualize the most relaxing place you can think of. For me, it's a beautiful meadow on a bright sunny day.(However, in this case, it should NOT be the recital hall or the classroom!). Keep breathing slowly and keep visualizing. This takes care of those episodes where, no matter how much you practice a lick, it keeps getting worse and worse. Sometimes, you need to get away from it totally, even if it's just in your mind.
The main thing is.....allow yourself breaks. You get no benefits from long rehearsals if the information is not penetrating your brain and your muscles refuse to cooperate in protest to the overuse you're putting them through.
ADVISORY BOARD
Jeanne Baxtresser, Mary Louise Poor, Richard N. Norris M.D.
Janet Weiss, John Braverman Levine M.D.
