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Playing (Less) Hurt: An Injury Prevention Guide for Musicians
Playing (Less) Hurt: An Injury Prevention Guide for Musicians
Playing (Less) Hurt: An Injury Prevention Guide for Musicians
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Playing (Less) Hurt: An Injury Prevention Guide for Musicians

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Making music at any level is a powerful gift. While musicians have endless resources for learning the basics of their instruments and the theory of music, few books have explored the other subtleties and complexities that musicians face in their quest to play with ease and skill. The demands of solitary practice, hectic rehearsal schedules, challenging repertoire, performance pressures, awkward postures, and other physical strains have left a trail of injured, hearing-impaired, and frustrated musicians who have had few resources to guide them. Playing Less Hurt addresses this need with specific tools to avoid and alleviate injury. Impressively researched, the book is invaluable not only to musicians, but also to the coaches and medical professionals who work with them. Everyone from dentists to orthopedists, audiologists to neurologists, massage therapists and trainers will benefit from Janet Horvath's coherent account of the physiology and psyche of a practicing musician. Writing with knowledge, sympathetic insight, humor, and aplomb, Horvath has created an essential resource for all musicians who want to play better and feel better.
LanguageEnglish
Release dateApr 1, 2010
ISBN9781476855745
Playing (Less) Hurt: An Injury Prevention Guide for Musicians

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    Playing (Less) Hurt - Janet Horvath

    edition.

    PART ONE

    Overview of

    How Injuries Can Arise

    Music was my refuge. I could

    crawl into the space between the notes and

    curl my back to loneliness.

    —MAYA ANGELOU

    Chapter 1

    My Story

    No pain, no gain

    I WAS BORN INTO A MUSICAL FAMILY. My father was a cellist. At the time of his retirement he had performed with the Toronto Symphony for 38 years. My mother enjoyed a successful dual career as singer and piano teacher. For all my early years, music permeated our home, and there was absolutely no question that I would become a musician. My mother always envisioned me in a gorgeous long gown striding onstage with my cello! My lessons began at the age of nine, and despite the fact that no teacher was ever good enough for my father, I learned something. You see, he is Hungarian and comes from a rigorous tradition of schooling. He thought playing duets was a waste of time when I should have been practicing etudes.

    To my father’s great pleasure, I was accepted at age 22 by the great cellist and pedagogue Janos Starker at Indiana University. Although I had heard stories about Starker’s intensely competitive class, I made up my mind. I was going to be the best Starker student who ever lived.

    One of my favorite Starker stories concerns a talented young cellist who lacked the backbone necessary to lock himself in a practice room and make the stellar progress demanded of Starker students. One day in quiet frustration Starker said to him, I wish I could chop off your hands and give them to someone more deserving! Being a Starker student was an honor, to be sure, but it had challenges and pressures.

    Indiana University School of Music is a large, competitive place, and we Starker students were really in the limelight, right alongside the students of the legendary violinist Josef Gingold. We were talked about, emulated and the envy of the whole school. On top of those pressures, I had been a very sheltered young lady, and this was my first time away from home. I had to live in a dorm that I hated. I was very lonely, so, I practiced. Every day I would plant myself in a tiny cubicle of a practice room and I wouldn’t get up for fear someone else would take my room. Easily, three or four hours would pass. Eventually my left arm began to hurt.

    I had embraced the prevailing mentality, borrowed from the aerobics boom, that physical discomfort was an outcome of time well spent: No pain, no gain. So I continued to play with a sore arm with the rationalization that I could play through the pain and that the discomfort would just miraculously go away as I got into better shape as a cellist. But the pain didn’t go away. It got worse.

    My first impulse was denial. My thoughts were, Nah, it doesn’t hurt that much, it just couldn’t be hurting. I was wrong. There came a point when I could no longer ignore the pain and loss of function and dexterity. My pain became so acute that I couldn’t use a knife and fork, or turn a doorknob, wash my hair or hold a telephone. I had let it go too long. I had developed a major case of what we now call overuse, or repetitive strain injury (RSI). At the time (1974) this came under the general heading of tendinitis or, as it was affectionately known at my school, Bloomingtonitis.

    I went to about a dozen doctors and tearfully explained my problem. Their shrugging—unhelpful—responses ranged from disbelieving to insulting. Some asked, how can it hurt to play a musical instrument? It can’t possibly be as physically taxing as, say, football or ditch digging. After all, music is so ethereal, and performing onstage is so glamorous. They pay you for that? It’s all in your head was one diagnosis. It must be psychological; everyone knows musicians are sensitive creatures. Perhaps you should consider a change of career, said another doctor. This one did not go over well with me. Do something else? Inconceivable!

    I do not fault those physicians so much now as I did then. I know now that many musicians’ injuries affect primarily soft tissue and, as a result, are harder to detect on standard medical tests. I learned the hard way why consulting a physician experienced with repetitive strain injuries is essential for a proper diagnosis.

    I went through a phase of utter desolation and panic. I thought I would never play again. My life was essentially over, I felt. At the time, Starker was on a solo concert tour. It seemed I had nowhere to turn for support, and I certainly had no concept of how to face the challenge.

    Immobilized by pain, fear and despair, I didn’t touch my instrument for three months. I feared reinjury and I was terrified to tell Starker. I had let him down! When Starker returned to town, I worked up the courage to let him know my predicament, and to his credit, he did a brilliant acting job and hid his horror quite well. Together we set out to put my technique back together from scratch.

    Fortunately, I had the right teacher; Starker is a master of ease and perfection. With his guidance, we sought first to eliminate any tension, and to focus on ease of playing. I accepted my limitations and learned to recognize the danger signals. We took an analytical approach: Each motion was scrutinized from a whole-body use perspective. The three-month rest period had allowed my muscles to recover. It took six months to implement our strategy. The result: After nine months I was totally cured and ready to learn how to become an advocate for injury prevention.

    I honed my skills early on in Bloomington. During my student years I circulated a petition protesting the fact that we were required to rehearse and perform the opera Parsifal by Wagner, a five-and-a-half-hour work. It seemed debilitating and unfair, especially due to the fact that the school chose to use two vocal casts (doubling rehearsal time), but only one orchestra!

    Since those student years, I have encountered countless musicians in various stages of denial or shame concerning their very real pain. Admitting to a problem ultimately means reckoning with it, making changes to playing technique or habits and oftentimes taking a hiatus from playing altogether.

    We’re all afraid of real or imagined stigmas associated with injury. Rationally or irrationally, we may wonder, does our pain signal that we have failed in some way? Will we be branded as bad musicians, flawed people?

    Prestigious schools and festivals frequently perpetuate a culture of overuse. These intensely pressured environments are virtual breeding grounds for injury.

    At Starker’s famous Saturday morning master classes, we would often perform pieces we’d worked on for only a week or two. Every string player in the school attended, or so it seemed, to hang on Starker’s every word. He had the amazing ability to play any cello well and to play anything and everything of the cello repertoire while sitting for three plus hours in his chilly, windowless studio. In his master classes, we were expected to follow suit. We sat there, albeit nervously, taking in every note and every word spoken. With no warm-up, we were expected to play with supreme confidence, before a large audience of fellow students and Starker himself. We would giggle nervously as we told this joke among ourselves:

    Three cellists die and ascend to the pearly gates, where they are greeted by St. Peter. Cellist number one requests entry into Heaven. With whom did you study? St. Peter asks. Leonard Rose, he says. Sorry, says St. Peter. Please go to hell. Cellist number two asks to enter. St. Peter again asks, With whom did you study? Second cellist answers, Rostropovich. Sorry, says St. Peter. Please go to hell. Cellist number three nervously asks to enter the gates to Heaven. St. Peter asks impatiently, With whom did you study? Janos Starker, he says. Come in, welcome! says St. Peter, now smiling. You’ve already been through hell!

    Summer festivals and summer music camps can be particularly dangerous to your health. Often, we are big fish in our towns, only to be thrust into a stimulating, exciting and intense environment for a period of weeks, where we are suddenly only a teeny weeny fish. The inspiration of being amongst our peers and outstanding performers is offset by the frantic pace of performances and rehearsals and the pressures of new competition and different standards. When under these circumstances we also try to implement a new technique, we have a prescription for trouble!

    When, in 1980, I was hired as Associate Principal Cello of the Minnesota Orchestra, I began encountering colleagues in pain. Six musicians were sidelined by injuries at one point. I was appalled. Surely we can come out of the closet and find solutions to our problems, I thought. I began extensive research into pain issues and as I did so, musical colleagues, physicians, orchestra managers, therapists, college teachers and even insurance carriers came out of the proverbial woodwork, making a beeline in my direction.

    Due to overwhelming interest in the subject I approached the University of Minnesota in 1984. They agreed to sponsor a national conference called Playing Hurt™, which took place in 1987. Twenty-three states were represented by the several hundred attendees. Doctors addressed musicians, pedagogues addressed doctors, and musicians shared their stories with musicians. It was cathartic, and a huge relief for everyone to finally talk about this to a receptive audience and to explore solutions. The field of performing arts medicine was given a shot in the arm.

    Today, performing arts medicine is an established medical field. Clinics have sprung up all over the country. More and more music schools have advocated for injury prevention programs and there is awareness in the orchestral world as never before. In the chapters ahead we will delve closely into the hows and whys of injury. Remember that this is a new and growing area of understanding and healing. The lessons we are learning are only as good as the teacher and advocate that you become for yourself and for others.

    Chapter 2

    You Are Not Alone

    The prevalence of injuries among instrumental musicians

    THE ARRIVAL OF THE COMPUTER has brought with it a wide awareness of the hazards of repetitive stress injury. The explosion of computer use created an ominous shadow, a problem so serious that it has been dubbed ‘the occupational disease of the nineties: repetitive strain injury,’ wrote Emil Pascarelli, M.D., former Medical Director of the Miller Institute for Performing Artists, and health journalist Deborah Quitter, in their 1994 book, Repetitive Strain Injury, A Computer User’s Guide. A decade after the introduction of the personal computer, RSI has mushroomed into one of the fastest-growing and most worrisome problems facing American business.

    Today, RSI is a serious health problem that the American workplace has struggled to address, with some success. But we have a long way to go. According to the U.S. Department of Labor Monthly Labor Review of March 30th, 2004, repetitive motion results in the longest absences from work. Furthermore, the Bureau of Statistics indicates that in 2005 and 2006 musculoskeletal disorders accounted for 30 percent of the injuries and illnesses that caused absences from work. Nineteen distinguished scientists contributed to a recent Department of Labor report indicating that such injuries cost the U.S. economy $9 billion each year. The Occupational Safety and Health Administration (OSHA) has estimated the cost at more than double that amount.

    There is some good news. A 2006 report from the U.S. Department of Labor entitled Nonfatal Occupational Injuries and Illnesses Requiring Days Away From Work, indicates that the rate of occupational injuries requiring days off from work are decreasing. The overall cases of carpal tunnel syndrome decreased 21 percent from the previous year. The parts of the body most affected by injuries are the shoulder and back, which account for 34% of cases; these have decreased by 6 percent from 2005, and injuries due to repetitive motion decreased by 13 percent. This is most certainly due to the increased awareness of ergonomics in the last decade.

    But is this true for musicians? Musicians have lived with this occupational hazard since the arrival of, say, the violin, and it’s only gotten worse over time. In 1986 the International Conference of Symphony and Opera Musicians (ICSOM) distributed a national survey to determine the number of orchestral musicians who have had problems. Thanks to the work of the ICSOM delegates and the commitment of the musicians, 2,212 multi-page questionnaires were received, representing 47 of 48 ICSOM orchestras. The results were staggering.

    Orchestral musicians have what is probably one of the highest rates of occupational injury. Seventy-six percent of respondents had experienced a serious injury during their careers that required time off from performing. Here is a quote from the study of Fishbein and Middlestadt Medical Problems Among ICSOM Musicians: Overview of a National Survey, published in the Medical Problems of Performing Artists, March 1988, and because no equally comprehensive studies have been undertaken since then, it is still regarded as the standard:

    The results show that the prevalence of medical problems among ICSOM musicians is very high. In fact, 82 percent of ICSOM musicians reported experiencing a medical problem, and 76 percent listed at least one problem as severe in terms of its effects on performance. . . . 14 percent of the musicians reported one severe problem, 14 percent indicated two, 12 percent listed three, and fully 36 percent reported four severe problems. . . . Musicians between 35 and 45 were most likely to report at least one problem (86 percent) while those under 35 and over 45 were less likely to list a problem (80 percent). Severe problems were more common in people under 35 (77 percent) than over 45 (71 percent). . . . Medical problems were most prevalent among string players, as 84 percent of them reported at least one medical problem and 78 percent indicated at least one severe problem. Among players from the woodwind, brass, and other instrument groups 79 percent of each group indicated at least one medical problem, and 75 percent at least one severe problem.

    The highest rate of injury was found to be in musicians between the ages of 35 and 45. Musicians over the age of 45 were injured somewhat less often. This may be a reflection of the fact that during our twenties and thirties we encounter many life stresses as well as those of our musical work. We’re getting our first jobs, and trying to learn an immense amount of repertoire. Many of us are moving, trying to establish ourselves, and rearing young children. It’s a time in our lives when sleep deprivation is common, as are poor physical conditioning and insufficient warm-up time before practicing, rehearsing and performing. Freelance musicians may go weeks without a day off.

    The true extent of our problems may be surprising. Dr. Kris Chesky of the Texas Center for Music and Medicine reported in a 2007 Wall Street journal article that 86 percent of piano majors who participated in a study at the University of North Texas reported having pain associated with their playing. He goes on to say in the article that at a recent Northwestern University conference, 100 percent of their entering music majors reported having some physical difficulty. I know only too well how many of my orchestral colleagues are suffering.

    Emotional Tension Translates into Physical Tension

    The nature of our profession is to strive to excel, to compete, to win auditions. We may be unaware that as a by-product, our lives are under constant scrutiny permeated with criticism, often negative, initially from our parents and teachers and later from colleagues, conductors, newspaper reviewers and audiences. We expect the highest of standards. We place demands and sometimes unrealistic expectations on ourselves and in so doing, get caught in the guilt and blame game. If something goes wrong, We didn’t practice enough! If we hurt, We must be doing something wrong.

    But we are human after all, and we will on occasion miss notes, have memory slips or overplay. The repetition and awkward postures are only part of the equation.

    Injury risk increases with emotional tension, and current research indicates that the history of criticism is correlated to a higher risk of injury. The role of stress in setting the stage for injury cannot be overstated.

    There is a mind-body connection, says Alice Brandfonbrener, M.D., a leading expert in performance injury and treatment. Depression not only makes people more injury-prone, but also it increases with pain and if not recognized, tends to prolong illnesses, injuries and musculoskeletal pain syndromes.

    Of course, there are other contributing factors that have an impact on a musician’s well-being. External events like slipping and falling on ice, automobile accidents or other traumas to our fragile anatomies may lead to further injury when during our recovery time we also play an instrument. Failure to allow such injuries to heal fully before we return to a rigorous playing schedule can bring on disaster.

    In other words, many factors can conspire to bring on injury, and every case is unique. The statistics show that no musician or artist is immune from injury risk. The following chapters examine in detail the factors that may lead to an injury, as well as those that may increase your chances of escaping unharmed. Today I am happy to report that prevention, education, and awareness are burgeoning, and new and better approaches are being developed.

    Chapter 3

    Why It May Hurt to Play

    A definition of overuse

    OUR GOAL IN PROFESSIONAL LIFE is to make music. We strive each day to increase our abilities at our instruments so that we can re-create great music with ease and expressiveness. But it’s vital to keep in mind that our violins, cellos, flutes and trombones are only half the musical product. They can do nothing until they interact with our physical, emotional and very human beings.

    It is now widely known that it can hurt to play. Playing too much, too intensely, over the weeks, months and years of a career can do cumulative damage. Perhaps right now you can launch into any concerto or difficult orchestral work even without warming-up, no problem, and pretty much nail everything. Due to a wear and tear in your muscles that occurs over time, however, you may become less able to do these things and you may be at a higher risk for injury.

    Overuse is a loose term applied to several conditions in which body tissues have been stressed beyond their biological limits. These disorders of the musculoskeletal system can affect bones, joints and such soft tissues as ligaments, tendons and muscles.

    Repetitive action, especially when combined with poor posture, excessive force and stress, brings about overuse injuries. OSHA reports that workers required to apply force while performing highly repetitive tasks are at a 31 percent greater risk than those not subject to this kind of work. Every occupation has its risks, but this statistic, of course, does not take into consideration the intense and competitive nature of our wonderful profession. We’re all trying to play bigger and louder and faster. That adds up! Just as elite athletes can sustain an injury we, too, can be injured, even if we’re doing everything right.

    What activities or postures put us at risk? In her book The Athletic Musician (coauthored by Christine Harrison), orthopedic physiotherapist Barbara Paull says:

    Drawing from copious amounts of data accumulated by health and safety associations investigating soft tissue injuries in industry, musicians can identify similar risk factors. Workers who use their hand and arm muscles very forcefully with many repeated, fast-paced movements, suffer from rapid muscle fatigue. They frequently need rest periods that must exceed the actual time worked if they are to avoid accumulative muscle or tendon trauma. The likelihood of injury is increased if their work necessitates adopting awkward neck postures, such as bending or twisting. Working with one or both arms held away from the body, without any support for the weight of the arms is similarly identified as a hazardous posture.

    Repeatedly lifting the arms out to the side, repeatedly twisting the forearms and frequently working with the wrists flexed forward (palm bending toward the forearm) or deviated outward (hands bending toward the fifth finger) are all activities and positions that have been identified as responsible for accumulative wear and tear injuries that stop the workers from being able to do their jobs. Working in cold conditions, where workers actually feel cold while they work, increases their susceptibility to injury.

    Obviously, some work does include some of these hazardous components, so industrial health and safety experts have recommended a two-hour limit for each of these continuous activities followed by either adequate rest or a complete change of activities.

    How does all this apply to what we do? Here are a few examples of the repetition we subject ourselves to on a daily basis:

    "Why is Handel’s Messiah such a taxing work? I wondered during one particularly tiring performance. I chose a two-minute movement of the three-hour piece to analyze, the aria Why Do the Nations." Each bar contains eight eighth-notes at a moderate tempo. In the course of the 96-bar movement, my right arm moves back and forth 740 times. Try brushing your teeth with 740 strokes.

    Ravel’s Bolero brings the house down every time it’s played. The snare drum player always receives an ovation, well deserved. In the fourteen-minute work, the snare drum player repeats a 24-note pattern nonstop from beginning to end. The piece is 430 measures. That’s 5,144 arm strokes. What a teat! Add to that the control necessary to start almost inaudibly at pianissimo and ever-so-gradually increase in volume over fourteen minutes to the piece’s rousing fortissimo conclusion. It requires intense concentration and physical control to play unwaveringly steady in rhythm from start to finish. Adams’s Harmonielehre contains an awesome amount of repetition. The first 94 bars of Part III have approximately 976 repeated eighth notes for the flute and piccolo and for the piano, harp and clarinet as well. (They at least have a few measures of rest.) This during a mere fraction of the work! Is there any wonder some players develop carpal tunnel syndrome?

    The carpal tunnel is a narrow tunnel at the wrist. Nine tendons and their membranes, as well as the median nerve, have to pass through this tunnel. (See medical illustration #5A on page 67.) To feel this, place your right fingertips onto the inside of your arm at the wrist, the base of the hand. Now wiggle your fingers. You should be able to feel these tendons sliding.

    Let me offer you a comparison. A highly proficient typist can type 60 words a minute. Typing 60 words a minute (with tendons sliding thousands of times per hour) translates roughly to five letters per second, fifteen letters per three seconds. Frank Wilson, admired neurologist and author of Tone Deaf and All Thumbs and The Hand, in a 1994 lecture at an American Symphony Orchestra League conference, calculated that musicians are able to execute 38 notes in three seconds. That’s more than twice as much!

    Recently, we performed Stravinsky’s Rite of Spring. The Danse de la Terre movement starting at rehearsal number 75 contains 360 notes. We performed this section in 36 seconds! The last movement of Mahler’s Symphony No. 5 contains 800 measures, the majority of which contain eight notes. That totals 6,400 left-hand finger movements.

    Recently, after playing a passage over and over of an obscure work of Sibelius entitled Oceanides I counted the bow strokes: 27 per bar. I knew it was tiring, but this was ridiculous. In 22 measures played in 1 1/2 minutes, there were 589 bow strokes! I approached our Maestro and said "Osmo, from here to here we have to perform 589 bow strokes! He appeared taken aback for a moment and then replied Thank you for counting!"

    I think I make my point. What the human body can do is incredible! On a daily basis we demand these feats of athleticism, precision, coordination and beauty from our bodies, and yet we are dismayed and astonished when they let us down. What does all this repetition mean, anatomically speaking?

    Overuse: A Vicious Cycle of Sprains and Strains

    Overuse is the term applied when any tissue, bone, joints or soft tissue such as muscle, ligaments or tendons are stressed beyond their anatomical or physiological limit. Emil Pascarelli, in his book Repetitive Strain Injury: A Computer User’s Guide says it concisely:

    Repetitive strain injury is an umbrella term for several cumulative trauma disorders caused by overuse of the hand and arm. The tendons, tendon sheaths, muscles, ligaments, joints and nerves of the hand, arm, neck and shoulder can all be damaged by repetitive movements.

    Sprains and strains are one category of overuse injuries. These occur when minute tears and inflammation occur in tissues and are brought about by overexertion or sudden excessive force.

    A strain refers to the muscle-tendon unit. Tendons attach muscle to bone. They are rope-like bands of fibers that cannot stretch or contract. They transfer movement from muscles to bone. A strain occurs when a tendon is injured. Scar tissue may easily form, which can result in a shortening of the muscle or in chronic muscle tension. Tendinitis is a condition in which the tendon becomes inflamed. It is caused by physical stress on the tendon and may start suddenly.

    A sprain refers to the ligament. Ligaments are tough rope-like fibers. They attach bone to bone, forming and stabilizing joints, limiting their movement. A sprain occurs when a ligament is torn due to repetitive tasks or is overstretched for any reason. Tears in ligaments, or sprains, can lead to permanent joint instability.

    In musicians, overuse is usually the result of multiple factors, which can include excessive force, repetition, high intensity, awkward postures and poor technique. It’s a vicious cycle. Muscles that are overused have exhausted their endurance capacity. Muscles that are fatigued become less efficient and less responsive; thus a demanding activity requires more force. This results in more fatigue and tension. Round and round you go, with increasing pain and diminishing returns. To put it in a nutshell:

    The structures of the upper extremity are particularly vulnerable to soft tissue injury, writes Vern Putz-Anderson in the 1988 manual Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper Limbs. A main reason is that almost all work requires the constant and active use of the arms and hands which are typically unprotected and open to injury. Changes in either the intensity or duration of human activity are often sufficient to provoke symptoms and over-exertion of the musculoskeletal system.

    The classic Catch-22 for professional or otherwise serious musicians is that both strains and sprains require many weeks of recovery. Players who will not or cannot allow sufficient healing are headed for disaster. This is when overuse injuries can become chronic. The scenario is all too common.

    Loose vs. Tight

    Musicians come to the profession in all shapes and sizes. While tight individuals may become injured due to shortened muscles, loose individuals are vulnerable as well. Joint laxity, or hypermobility (otherwise known as double-jointedness), is a condition that may be found in joints throughout the body of an

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