First, a disclaimer—what this article is not intended to be: This article is not a substitute for medical care or medical judgment. If you even suspect that you may have an injury, disease, or condition that could impact your career as a musician or your quality of life, I strongly urge you to seek out competent medical advice. I do hope, however, that this article will assist you in finding a specialist who understands the medical needs and peculiarities of musicians and that it will help inform you as to what that means. If your medical concerns are more about prevention, I hope this article might point you toward helpful information. But be forewarned that neither ICSOM nor I endorse any of the practitioners, methods, or advice mentioned here or advocated by any of the sources herein.
That out of the way, we can start by noting that there is much more help available to musicians looking for such information than ever before. The first entry I found in Senza Sordino archives on the topic was from August 1975. It was a reprint of a letter in the New England Journal of Medicine that cautioned doctors to be aware of cardiac stresses on performing musicians. The subspecialty of performing arts medicine was in its infancy back then. In fact, another letter from the New England Journal of Medicine reprinted in the April 1976 issue of Senza Sordino was from a doctor with an interest in the developing field, for which he suggested the name “musical medicine.” (The more widely used term “music medicine” eventually morphed into the more encompassing “performing arts medicine” in part to differentiate it from the field of music therapy, which uses music to heal.) He encouraged similarly inclined doctors to form networks so that traveling musicians might find appropriate care when on the road. The July 1982 issue of Senza Sordino offered a cover story about the then-new use of beta blockers by musicians.
The first Symposium on the Medical Problems of Musicians was held in Aspen, Colorado, in 1983. The second Symposium was held the next year and was reported on in the February 1984 issue of Senza Sordino, which had a lengthy cover story on the state of music medicine. Further coverage of music medicine can be found in the April 1985, December 1985, and February 1986 issues of Senza Sordino.
ICSOM’s focus on the study of professional orchestra musicians’ medical problems led to a medical questionnaire that was distributed to ICSOM musicians in May 1986. Martin Fishbein, Ph.D. and Susan E. Middlestadt, Ph.D. were chosen to analyze the data. Funding came from ICSOM, the AFM, the Major Orchestra Managers Conference, and the University of Illinois Research Board. The entire August 1987 issue of Senza Sordino was devoted to the resultant landmark medical study, which was published as “Medical Problems Among ICSOM Musicians: Overview of a National Survey.”
That study revealed much of interest. Fully 76% of ICSOM musicians reported at least one problem that had a severe effect on their performance. More than 25% reported using beta blockers. Perhaps the most important part of the study, though, was the conclusion that there was an urgent need for techniques to treat and prevent occupation-related medical problems and that information on these problems should be disseminated to musicians and their physicians, teachers, and other concerned professionals.
In the intervening years, there has been much progress in meeting that need and disseminating such information. The first issue of Medical Problems of Performing Artists was published in March 1986, with Dr. Alice G. Brandfonbrener as its first editor (sciandmed.com/mppa). (That first issue, by the way, included an article by our own former Senza Sordino editor, Tom Hall.) Dr. Brandfonbrener, who among her many other credits was director of health services at the Aspen Music Festival, must be lauded as one of the pioneers in the field who helped establish performing arts medicine (including singers and dancers along with instrumentalists) as a recognized specialty. Later, in 1986, she became the founding president of the Performing Arts Medicine Association. In 1991, with Dr. Robert Thayer Sataloff and Dr. Richard J. Lederman, she co-authored Textbook of Performing Arts Medicine, the first medical textbook for the field. The second edition of their book, now titled Performing Arts Medicine, was published in 1998. Dr. Brandfonbrener also authored an article in the April 1987 issue of Senza Sordino.
Even beyond the issues of Senza Sordino already mentioned, performing arts medicine has received regular coverage in these pages. (You may find it interesting to peruse issues that contained those articles. They are all available and cataloged on our website.) In 1993, ICSOM published its first book, The Musician’s Survival Manual: A Guide to Preventing and Treating Injuries in Instrumentalists, written by Richard Norris M.D. and edited by former Senza Sordino editor Deborah Torch. Performing arts medicine has also been a frequent issue at ICSOM Conferences.
One musician who entered the field early on was Minnesota Orchestra cellist Janet Horvath, who got involved after having her own problems with tendonitis. She established the Playing (less) HurtTM Injury Prevention conference and lecture series, the first of which was held in 1984. Janet has been preeminent in focusing attention on the medical problems of performing musicians. She published the first edition of her book, Playing (less) Hurt: An Injury Prevention Guide for Musicians, in June 2002. It is one of the most comprehensive resources available, having chapters dealing with (among other topics) overuse, risk factors and stressors, danger signals, explanations of numerous injuries and conditions, preventative and restorative approaches, stretches, work hardening, hearing, instrument modifications, and what to do when you’re hurt. A newly revised 2009 edition of the book has just been released. It contains a 26-page resource list of carefully researched listings of doctors and therapists, videos, tapes, books and CDs, websites and organizations, products, props, splints, and adaptive equipment including ergonomic instruments, chairs, and equipment. Copies may be ordered through playinglesshurt.com, where you can also find the Dr. Norris book (as well as a DVD he produced), helpful links, and “stretch cards” that include all 90 stretches featured in her book. Janet has been kind enough to allow us to reprint an excerpt from her book, which you will find on page 12.
Lucinda Lewis, principal horn of the New Jersey Symphony, is another musician who has contributed to the field. What started in 1993 as a desire to publish a small, informational pamphlet on embouchure injuries has turned into a massive, open-ended research project, two books, and a website. After documenting the histories of 4,603 players (worldwide) with embouchure-related playing problems, Lucinda says unequivocally that embouchure overuse is the leading cause of the protracted and painful performance injuries sustained by wind players.
According to Lucinda, “Overuse has the potential of inflicting significant detriment to a player’s embouchure that can linger for years, something few players realize until they become a victim. Unlike any other performance injury, embouchure overuse syndrome does not respond to rest, and there is no medical treatment for it or speedy way of reversing its disabling effects. Every musician has to learn to navigate a busy performance schedule and weeks of heavy orchestral repertoire, but it is especially critical for wind players to be mindful of symptoms such as facial fatigue and lip swelling. These are the early warning signs of embouchure overuse. As much as possible, these symptoms should be met with caution and a reduction in playing time and playing intensity. The good news is that even the most painful and disabled of embouchures can be restored to full and normal function.” Lucinda’s website holds a wealth of information, some of it geared toward brass players. Her two books, Broken Embouchures and Embouchure Rehabilitation are also available for purchase there.
Another source of information, Polyphonic.org, (Eastman School of Music’s Orchestra Musician Forum website), is a fairly new entry to the scene. It was launched in April 2006 and already has many articles about musicians’ health and links to health-related websites. In addition to contributions from Dr. Alice Brandfonbrener, Janet Horvath, and Lucinda Lewis, there are also articles by Milwaukee Symphony violinist Samantha George, Alexander Technique teacher Barbara Conable, Pittsburgh Symphony violist Penny Anderson Brill, and flutist Amy Likar. One of the nice things about Polyphonic.org is that it is constantly being added to. Also, being a forum, it allows for discussion of issues through the posting of comments. The health-related articles can be found under the “Orchestra Life” article category.
If one is going to explore treatment alternatives, a good place to start is Dr. Brandfonbrener’s cautionary and informative article on Polyphonic.org. Although she acknowledges that reading never hurts anyone, she also points out many things to consider when one is faced with medical problems that impact one’s performance. These warnings might be especially important when considering advice from the many sources available on the Internet, including from physicians, physical and occupational therapists, chiropractors, holistic medicine practitioners, spiritual counselors, fitness trainers, musicians, and lay people. All one need do is use a search engine to find such sources, but determining whether the advice will help or hurt might be more problematic. One site of interest, though, is that of shape, a Canadian not-for-profit organization whose mandate includes providing health and safety information for the performing arts and film industries. Their website, at shape.bc.ca, includes many downloadable pamphlets and studies related to our industry.
In addition to the books already mentioned, there are a good number of interesting titles available through normal channels. A partial list includes: The Athletic Musician: A Guide to Playing Without Pain by Harrison Cristine; What Every Musician Needs to Know About the Body: The Practical Application of Body Mapping & the Alexander Technique to Making Music by Barbara Conable and Benjamin Conable; Indirect Procedures: A Musician’s Guide to the Alexander Technique, by Pedro de Alcantara; The Musician’s Body: A Maintenance Manual for Peak Performance, by Jaurme Rosset i Llobet and George Odam; and The Percussionists’ Guide to Injury Treatment and Prevention by Darin Workman.
It almost goes without saying that none of these books, or any other, will fit the bill for everyone. We all have different bodies and different frailties. We play different instruments, and they place different demands on our different bodies. Further, our approaches to our instruments, and to music itself, make one person’s goldmine another’s junkyard. Even so, there is one additional out-of-print title that, although it relates only tangentially to the topic at hand and has little application to musicians as a whole, I feel compelled to mention here (because of its subtitle): The Orchestra Conductor’s Secret to Health & Long Life: Conducting and Other Easy Things to Do to Feel Better, Keep Fit, Lose Weight, Increase Energy, and Live Longer, by Dale L. Anderson.
Over the years, we have seen the quantity and quality of medical services available to musicians improve steadily. While there were only a handful of medical clinics dedicated to treating performing artists back in the eighties, now they can be found in many major cities across the nation and worldwide. You can find physicians and other medical practitioners specializing in music medicine through resources already listed, including the referral service of the Performing Arts Medicine Association at artsmed.org/referrals.html. Another encouraging sign is the number of hospitals that now host centers for performing artists. In fact, the Methodist Hospital in Houston, Texas, operates the Methodist Center for Performing Arts Medicine (CPAM) and touts itself as the official health care provider for the Houston Ballet, the Houston Grand Opera, and the Houston Symphony. It even issues a CPAM Artist Card to members of the professional performing arts community to help the hospital meet performers’ special needs.
For musicians suffering hand or finger problems, I should mention that during the time period we’ve discussed, hand therapy has become an established specialty for physical and occupational therapists. The American Society of Hand Therapists was founded in 1977. Out of that grew a certification process for hand therapists, and Certified Hand Therapists (CHTS) have been certified by the Hand Therapy Certification Commission since 1991. Hand therapy goes beyond the treatment of hands, though, as the practice includes the upper quarter of the human body. In addition to additional training, some CHTs have very specialized equipment that won’t be found at other therapists’ offices. Of course, not all CHTs are equally knowledgeable about musicians’ injuries, but if you don’t find one who has substantial experience with musicians’ problems, perhaps you can find a therapist with at least a sensitivity to your needs and a willingness to help. My personal experience suggests that this, in and of itself, may be worth quite a bit.
While playing Wozzeck, I suffered a severe pain in the little finger of my left hand. I assumed I had somehow strained it and that, like the other minor injuries we all sustain, it would go away in due course. But it didn’t—although, months later, it was decidedly better. I saw a highly regarded hand surgeon who was very sympathetic and who would have liked to help; but I was unable to tell him precisely where the pain was, and his examination of each of my finger joints revealed nothing. He did take an X-ray and thus relieved my fear that something terrible was responsible. He told me that I should return if it got worse and I could tell him where the pain was. Until then, there was nothing he could do.
Months later, with the problem still affecting my playing, I went to my primary care physician to discuss it. He has always been very understanding of my needs as a musician, as he is a violinist himself. He immediately referred me to another hand surgeon. (We both understood that I didn’t want surgery, but it seems that hand surgeons are supposed to know the most about hands.) That was a total disaster.
The second surgeon, without caring to listen to much of anything, told me that I had simply worn out my finger and that there was nothing that was ever going to make it better. He suspected arthritis—even after I told him that two other doctors had assured me otherwise—and he kept to his opinion even after he looked at an X-ray he ordered and could find no evidence of arthritis. When he told me that he would not recommend surgery, I explained, again, that I wasn’t interested in surgery and asked him whether some sort of therapy might help. He flatly said no and told me there was nothing that could help. It was all I could do to shake the hand he offered me as I hurried past him on my way out.
I returned to my primary care physician, and we agreed that I would try occupational therapy. I was given a list of occupational therapists from which to choose. Not knowing any of them, I started phoning to find out if any had worked with musicians’ hands before. That’s when I learned about CHTS. I found one who spoke on the phone with me at great length. That in itself was the most encouragement I had found in a long time, as not only had she worked with musicians’ hands before, but she understood and was sensitive to how even a slight pain at the wrong time can be disastrous to a musician. She definitely was willing to work with me in a positive way!
The therapy sessions were also encouraging, at least at first. They would start with a wax bath to warm up my hand, then continue with massage followed by strengthening and flexibility exercises that used a variety of equipment and techniques. After some initial improvement, I was disappointed that we failed to make more progress after what both my therapist and I agreed had been sufficient time. At my last scheduled appointment, my therapist, too, was disappointed as she looked at my finger. Then she noted that I had left my wedding ring on this time, whereas I had normally taken it off during the wax bath. She had always told me that she suspected some sort of nerve involvement, and this time she theorized that the ring might be compressing a nerve in my adjacent little finger. She thought that might be causing the problem.
It was certainly worth a try, and I left the ring off to see what would happen. Much to my wife Jean’s chagrin, the wedding ring was the culprit, and I called my hand therapist’s office a couple of days later to report the almost immediate success. I was particularly glad that, after Jean’s disgruntlement at the prospect of my going ringless, she eventually showed a sense of humor over the situation. At least she laughed when I told her about the comment made by the other therapist in the room when we were discussing the wedding ring: “Divorce. It’s the only cure!”