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Musician, Heal Thyself
Charness’ musical practice grew by word of mouth, and he started seeing musicians once a week at Brigham. On weekends he took his three children to the New England Conservatory for practice; after enough parents stopped to ask him for advice about their kids’ musical injuries, the conservatory gave him his own examining room.
McClain is one of several thousand musicians Charness has seen in the last quarter century—and with each, he has made it a point to withhold his diagnosis until after watching his patient play.
“Very subtle problems that occur in musicians are often missed unless you watch people play their instrument,” he says. “If a person has an entrapment of the ulnar nerve, very often the diagnosis is normal. But five minutes after they play, their exam is no longer normal. They now have weakness in muscles supplied by the ulnar nerve. It lasts 10 minutes, and it goes away.”
There are other common missteps. “Often a violinist uses the shoulder to hold the instrument because the setup isn’t adequate,” he explains. “They are not only gripping it with their neck and shoulder but also with their hand and you can see it as they try to shift where they sort of squeeze their thumb and they let go and they squeeze again. So their hands are working too hard. But the problem isn’t their hand, it’s their shoulder. There are lots of subtleties to this that a doctor who is not a musician might not appreciate.
Bringing doctors up to speed on the delicacy of musician injuries has been the goal of the Performing Arts Medicine Association, founded in the mid-1980s by physician Alice G. Brandfonbrener. A former student health physician at Northwestern University, today she runs a clinic for performing artists at the Rehabilitation Institute of Chicago.
Brandfonbrener, who has played classical piano, says PAMA established early on that “to really analyze what was going on with a musician patient you had to understand the musical aspects as well as the medical.” But along with educating doctors, she says, a key goal was to “demystify medicine to musicians.”
Such mystification, says Brown, the Peabody lecturer, can come out of confusing medical terms. For example, he cites “repetitive stress.” It’s really an umbrella term, he says, that can include both tendonitis and carpal tunnel syndrome. “They are two very separate problems but both are referred to as repetitive stress. Yet each requires a different type of treatment.”
While musicians are usually aware of the pinched nerve condition of carpal tunnel, most are unaware of thoracic outlet syndrome. In this, the most common pinched nerve condition, nerves that come out of the spine get trapped between bones and muscles as they go through the chest. A common cause, Brown says, is poor posture or an incorrect grip on an instrument.
While every instrument can cause injury, keyboard players tend to develop the most problems, says Brown. They tend to practice more than other instrumentalists, he notes, because they usually have more solo repertoire.
Peabody’s Dean Morris, herself an acclaimed pianist, says she has managed to avoid injury through her playing career, but was forced to stop playing and go into therapy after suffering tendonitis while working out with weights.
“You really have to know your limits, to be in tune with your body so you know when you’re pushing it too far. You can think about it at the keyboard, but may not while doing everyday activities. You use your hands to do just about everything, and you don’t appreciate it until you jeopardize your arm.”
The manner in which musicians approach practice is key to preventing injury, say the experts (See sidebar, p. 17). When a musician pushes a tired muscle to do more, notes Bastepe-Gray, the brain’s efficiency at building memory of that activity lessens.
“Basically what we do in practice is functional conditioning,” Bastepe-Gray explains. “You are conditioning your body and building procedural memory in your cerebellum. The average attention span of an adult is 15 minutes. Intense focus is about seven seconds. After that your brain takes a little break. Not long. And it comes back. After 15 minutes it needs a longer break. After 20 minutes your brain will probably zone out for 10 minutes or so. At that time what you’re doing is basically mindless repetition.”
Not only will muscle memory diminish, says physical therapist Shulman, repetitive motions that are standard to a musician over many years could end up becoming confused in the brain.
“In some people,” he says, “the brain may read things inaccurately and combine things. So instead of moving each finger individually, the brain can’t make out the difference between the third, fourth, and fifth fingers. You start getting cramping of these fingers and they move as one. The brain is plastic. It changes. It gets altered over time by overuse.”
Fixing it, says Shulman, is a matter of retraining the brain through specific exercises. “You do exercises with the pinky alone, the ring finger alone and so forth. You’re retraining the brain to see each finger as an individual finger again.”
That kind of practical advice has begun to resonate with musicians, teachers, and conservatories.
“Twenty to 30 years ago,” says Brown, “a lot of people in the music world didn’t think medical folk had any business telling them or their students how to play their instruments. There’s a little bit of that still, but there’s a lot more awareness than there used to be.”
Thus, at Peabody, part of McClain’s job as the residence life and student activities coordinator is to encourage students to get out of the practice room and join yoga classes or attend a movie night.
“It’s important to have a well-balanced life here,” says McClain. “More students are taking advantage of relaxation techniques to be more in tune with their bodies so they don’t sustain injuries. Practicing seven to eight hours at a time is just not healthy.”
Those who doubt that advice can simply examine the two long scars on her left arm. Though McClain’s ulnar nerve surgery was successful, she sustained a second injury in high school, this time to the radial nerve in the same left arm, and this, too, was corrected by surgery. She went on to attend and graduate from the Eastman School of Music and play in a variety of symphony orchestras in upstate New York. But things were not the same.
“I realized during my junior year at Eastman that I no longer had the drive to go from audition to audition until I found a job,” she says. “I attributed a lot of that to the injuries. But they also made me realize I could do more than just play the bass. I realized I was good at other things than just music. When this job at Peabody became available, it was the best of two worlds. I love being surrounded by musicians.”
McClain still practices her double bass. While she doesn’t rule out joining a chamber or symphony group in the future, for now, she says, “I just play for me. It’s a wonderful outlet. Music makes me feel as though I’m a part of something bigger. It produces a beautiful balance.”
