by Greg Brown
Your shoulders are aching after sitting in the pit for three and a half hours; your neck is killing you, and you still have an hour to go for this club gig; you can barely pick up your bow because your elbow hurts so much; you have to learn that Chopin etude, but that burning feeling in your wrist is back again. You may have . . . begin suspense-movie dissonant music . . . a CTD! To find out what that is and how to treat it, read on.
Let me introduce myself. I have a M.M. from Boston University, played for 20 years in the USAF Band Washington DC and our own USAF Academy Band, and play bassoon regularly around town. My wife Nancy and I own Crystal Creek Music, and we do weddings and concerts on hammered dulcimer and oboe. A few years ago I added a new career direction to my life, and am just about to complete my associate’s degree to become a physical therapist assistant (PTA).
As part of that training, I gave a presentation on musician’s injuries to the outstanding staff at Spectrum Rehabilitation and Wellness Centers, where I interned. To prepare for that presentation, I conducted an anonymous survey with members of the Colorado Springs Philharmonic (CSPO). Following are the results, and some recommendations for “playing healthy” that I have learned as I’ve trained with some of the finest physical therapists in the region.
37 surveys were returned of the 72 handed out (51%). Of those 37, 29 described some kind of music-related injury, either caused or aggravated by playing music. While it is impossible to know the medical condition of the 35 who did not return a survey, what can be known is that at least 40% of CSPO players have sustained some kind of music-related injury. Of these respondents, the majority were female (by a small amount), and the largest percentage were string players, 51% of respondents. While other factors may be in play, (i.e. males and non-string players are less likely, for whatever reason, to answer a health survey), the statistics have a wide enough spread to suggest that female string players are probably the most at-risk group of sustaining a music-related injury.
Research has shown that musician’s injuries are almost always cumulative trauma disorders (CTDs). These are an accumulation of microtears in muscle, tendons and other soft tissue, that cause inflammation and are not given time to heal before the next period of trauma begins. Carpel tunnel syndrome is the most well-known CTD. I only surveyed musicians of the CSPO, but it can be assumed that other musicians who perform long periods of practice and performance (pianists, musicians on club gigs, etc.) are also at risk for CTDs.
Injuries to shoulder and arm were most prevalent to all injured musicians, with wrist/hand and neck/face equally represented in second place. Practitioners who were instrumental in the healing process were listed in this order (although the statistical differences between them are small): physical therapists, doctors (M.D.s and D.O.s) and massage therapists (tied), chiropractors, and alternative practitioners.
Instrument families have different injury tendencies. String players tend to be injured more in the neck and arms, with [surprising to me] the bow arm having more problems than the left arm. Woodwind players’ injuries tended to be in the neck, shoulder, and arm, with the right arm having more problems than the left, since it is the supporting arm for the instrument in most cases. Brass players’ injuries didn’t fall into any patterns or categories. The one percussion response listed an injury from carrying equipment rather than playing it.
One question asked which therapies brought healing. Responses, from most to least were: 1) Physical therapist-prescribed exercise and modalities (ultrasound, electrical stimulation), including self-applied heat/ice; 2) exercise; 3) massage; rest (tie); 4) stretching; 5) change posture/position/technique; chiropractic adjustment (tie); 6) anti-inflammatory drugs; book/advice from other musicians (tie); 7) surgery; still hurting (tie); 8) orthotic, body or instrument support.
When questioned about extent of healing, respondents replied: Completely healed, including knows how to keep it from recurring – 50%; chronic condition that can only be controlled – 30%; healing still in process – 13%; no healing – 7%. When asked what they do to keep the injury from recurring, responses from most to least were: 1) exercise, including fitness, wgt. training, yoga, tai chi; 2) stretching; 3) awareness/adjustment of posture/position/technique; 4) rest, limit playing time and/or type of music played; 5) massage; use orthotic/body or instrument support (tie); 6) anti-inflammatory drugs; 7) ice/heat; 8) chiropractic adjustments; 9) still hurting.
Having a vantage point from both the world of professional musician and physical therapy, allow me to share some perspectives that I have learned. (continued on next page)
Hurting? If you are hurting, go see a physical therapist! They are as expert and trained in our musculoskeletal system, as we are on our instruments. If tissues are damaged, they first need to heal, then be strengthened correctly, and then trained in efficient biomechanical movement. PTs have the knowledge of the human body to help you heal as quickly as possible and get back to playing sooner. Bring your instrument. One of the most important things you can do for your therapist is to play your instrument for them – bring it to the clinic. They can then see your posture and body mechanics, point out things that you had no idea you were doing, and work with you on more efficient use of your body. Play a difficult passage for them, because we usually introduce more tension into our bodies as the music gets harder.Feel the burn?. When strengthening a muscle you should work to fatigue, but NOT feel pain. You should feel the fatigue (it might feel slightly “burny” or painful) in the main part of the muscle (the muscle belly), not in the joints. When stretching, you should feel it pulling and stretching, but not painful. The old “feel the burn” was bad advice. You have to hold a stretch for at least 30 seconds for the muscle’s neurological contraction reflex (how your body protects it from being overstretched and torn) to relax and “let go.”
Ice or heat? When you have a new injury, like a sprain or “pulled muscle,” use ice on it to reduce inflammation and swelling. The re-freezable ice packs you can get in drug stores work great – leave it on for about 20 minutes at a time, for 2-3 days. Use heat for chronically sore and stiff areas, like a stiff neck, to increase blood flow to the area.
Play through the pain? No! It almost never works, and the opposite, complete rest from playing the instrument, is many times unnecessary (but follow your physician’s and PT’s advice). Dr. Richard Norris, M.D., founder of the Performing Arts Medicine Association (and an oboist), uses the term “relative rest” to describe the time off from the instrument that must be taken when an injury becomes acute. It is a mindset of heightened body awareness in which the musician becomes aware of exactly what motions, actions, time periods, etc., cause pain, and avoids these.
Warm up. Always warm up your body as an athlete would before a practice or event. Your muscles need a good warm up in order to function at their best. Begin with gentle stretches and playing passages of music slowly or begin with warm up exercises such as scales or arpeggios. Try not to practice or perform when you are physically or mentally tired. Almost all CTDs are caused when fatigued tissue receive inadequate recovery and are forced to perform in spite of fatigue.
You’re an athlete. Approach a concert as a performance athlete. Determine the physical requirements of the repertoire. Then begin structuring your practice time to meet those requirements. For instance, if the music takes 20 minutes to play from beginning to end, don’t wait until the week before the performance to start playing the piece straight through from beginning to end without breaks. Approach it as a marathon runner who systematically increases the number of miles he can run over a period of months in order to be fully prepared for the 26 miles the day of the race. Likewise, dramatically increasing the number of practice hours the week or two before the performance can cause increased fatigue and strain which can lead to injury.If your hands and arms are not injured, the best self-help source I know of is: Healthy Hands, a DVD by Martin Gray. Stretches and exercises demonstrated by Gray to “relieve pain and stiffness, develop dexterity, prevent problems, and increase strength.” The single best resource I discovered, easy to follow stretches and exercises. Excellent! ISBN: 09753581-0-3. About $20, and available from Amazon.com or: http://sacredsites.com/shop/
If you are dealing with a CTD injury, try: The Repetitive Strain Injury Recovery Book by Deborah Quilter, Deborah Quitter, Robert E. Markison. Publisher: Walker & Company, February 1998. ISBN-13: 9780802775146. Robert E. Markison is an associate clinical professor of surgery at the UC San Francisco School of Medicine, and hand surgeon with the San Francisco Hand Specialists. He’s also a jazz pianist who has managed the symptoms of carpal tunnel syndrome and works with musicians specifically to recover from and manage repetitive stress injuries. Available at Amazon.com.I hope this article has helped you think about how you can “play healthy,” and become more aware of better using your body in the intensely physical activity of making music. Please feel free to email me with comments or questions. Let’s make pain-free music!