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Stop me if you’ve heard this one. Violinist goes into a doctor’s office. Raises his violin and plays several notes, wincing in pain. Immediately stops playing. Says, “Doc, you gotta’ help me. It hurts when I do that.”

Also of interest

The Big Question for Leon Fleisher, Johns Hopkins Magazine, Fall 2009

Therapist for musicians in pain, The Baltimore Sun, August 29, 2009

Medicine for Musicians, The New York Times, January 28, 2010

Doctor shrugs, says, “Don’t do that.”

Sha-BOOM!

If you’re a physician you probably don’t think that’s very funny. If you’re a violinist or a pianist or a flutist or a guitarist or anyone who plays a musical instrument for a living—anyone who has played through debilitating pain because doctors couldn’t find anything wrong with your elbow or shoulder or fingers or neck—that joke may be so funny you forgot to laugh. Or perhaps you’re a musician reluctant to admit that constant pain is slowly shrinking your repertoire and sapping your confidence. Maybe you’re thinking if you were more talented this wouldn’t be happening. That if you tell anyone about it, your place will be taken by some rising star waiting eagerly in the wings. So you suck it up and play hurt.

Welcome to the musician’s unenviable perch between a rock and a hard place. It’s a sore spot that musicians and conservatory students have occupied for years without much official acknowledgment or medical understanding—and in too many instances without knowing there’s a good chance the musician sitting on either side is suffering in silence with the very same pain and career anxiety.

Consider that a recent survey of 330 incoming freshman students at a Midwestern school of music showed 79 percent with a history of “playing-related pain.”

“In a population of…young people presumably in otherwise good health and with a ‘clean slate,’” noted the study published in the journal Medical Problems of Performing Artists (MPPA), “the majority had already encountered music-induced pain as high school students or younger.”

At the Peabody Institute, faculty and administrators have been painfully aware of performer injury for decades. “Peabody has a very heightened awareness,” says Mellasenah Y. Morris, dean of the Conservatory and deputy director of the Institute, “particularly because of Leon Fleisher.”

The brilliant career of the renowned pianist was interrupted for almost 40 years by a neurological condition known as focal dystonia. Unable to use his right hand, he developed a lefthanded repertoire. He also became a well-known conductor and teacher, and in recent years, with the help of his daughter, Leah, a physical therapist, has returned to two-handed playing.

“We have had others who have had injury problems,” says Morris, whose own daughter ended up in traction after 12 steady hours of violin practice. “It’s just so prevalent.”

To help address the issue, Peabody in 2005 added a special course to the curriculum, which is aimed at teaching the basics of injury prevention. Anatomy and Injury Prevention for Musicians is taught by Baltimore physician Scott Brown. A physiatrist, Brown specializes in treating musculo-skeletal and neurological conditions such as those that occur in musicians. His Peabody course covers basic concepts including warm-up and cool-down stretches, the need for enough sleep, and the caution to stop playing when in pain. He also emphasizes attention to posture and avoiding “extremes of motion,” such as keeping the wrist bent or extended too much.

“Almost all musical instruments are biomechanically unwieldy to begin with,” says Brown. “They almost all require positions you wouldn’t use for any other reason but to hold that instrument.”

It’s not unusual, he says, to see students coming to class wearing braces and splints. “They are very receptive, they ask a lot of good questions, and have told me that what we talk about rings true.” Brown, himself an amateur pianist, is just finishing a second edition of his biography of James P. Johnson—the 1920s musician who invented the Charleston and “stride” piano playing. Brown believes that without an interest in music, doctors can be blind to the critical nuances of performing arts medicine.

“One of the most frustrating things for a musician is to be told to stop playing if they have a problem,” he says. “That recommendation doesn’t fit. It’s rare where absolutely stopping all playing is required. So it’s important how you counsel the musician in the proper way to keep playing while being able to heal and rehab from injury.”

That doesn’t mean just gritting your teeth and playing through the pain, however, which can only exacerbate the injury. Ten years ago, for example, when she was a junior guitar student at Peabody, Serap Bastepe-Gray (BM ’96, MM ’99, Guitar) developed painful tendonitis in her right arm. She’d been practicing up to eight hours a day for her junior recital and at first ignored the pain and kept playing.

“It got worse,” she recalls. “I had a big recital in three months. I had to do this; I was goal oriented. When a musician gets injured there are a lot of things at play: not being able to do what has kept you company for years, eight hours a day; the fear of not passing your recital and not graduating. So I played through it for four days. Then I had to stop because it was so painful.”

A native of Turkey, Bastepe-Gray had played several instruments as a child before earning a medical degree at Hacettepe University in Ankara. She came to the United States in the 1990s for a medical fellowship, but fell in love again with the guitar and enrolled at Peabody.

When her injury became too painful to ignore, she visited a variety of doctors who conducted tests on her nerves and told her everything was fine. This included a 19-hour drive to a specialist who said simply, “Take it easy.”

“It was hard to convince people I actually injured myself playing the guitar,” she says. “So for 19 hours on the drive back I thought to myself, what does ‘take it easy’ mean?”

After doing her own medical research, Bastepe-Gray devised a new practice regimen. She set a kitchen timer to ring after 20 minutes of practice and then took a 10-minute break before starting again. She also decided that if she couldn’t get a passage right after five tries she would consult her teacher. “That cut down on banging my head on the wall,” she says, “and hoping that it would break before my head did.”

“ Injuries are heartbreaking,” says guitarist Bastepe-Gray “I know what I went through psychologically. And I have seen many talented musicians give up their art.”

After eight weeks, her pain had subsided, and she was able to perform at her recital. “Injuries are heartbreaking,” says Bastepe-Gray. “I know what I went through psychologically. And I have seen many talented musicians give up their art.”

Maria Lambros was nearly one of them.

A violist and Peabody chamber music instructor and faculty member who has performed in string quartets around the world, she has actually rehabilitated two serious music-related injuries in her career. The first, a painful case of tendonitis, struck just after she graduated from the Eastman School of Music. After meeting with several doctors and alternative medicine practitioners, she discovered that her left hand technique was slightly off. She spent an entire year rehabilitating the injury and changing her left hand technique.

Until then she had never considered the possibility of injury. “It was the whole invincible thing,” says Lambros. “I thought it couldn’t happen to me.”

It made her second, more recent injury to her right shoulder even more stressful. For now she was married—to Michael Kannen, Peabody’s chamber music director—with a teenage son and a demanding teaching and performance schedule. This time Lambros suffered a torn labrum, bone spurs, bursitis, and what’s known as a frozen shoulder—all most likely from overuse of her muscles.

“I tried to play through it for quite a few months,” she says, “but the pain eventually prevented me. I couldn’t drive or push a shopping cart. I had to have surgery. It was a hard time of life to go through that.”

David Shulman, a physical therapist in Baltimore, helped Lambros rehabilitate her shoulder so she could play again—a process that required 18 months. Shulman, a one-time professional clarinetist, has lectured at Peabody and treated musicians for 30 years.

“When playing an instrument,” he says, “you’re always in danger of injury because you’re constantly overworking your muscles. People don’t understand that. They will come to me with an injury and say, ‘I’ve been playing 15 years and never had a problem.’ I tell them, ‘Well, now it’s 15 years of overuse. Your body tolerated it to this point. Now it won’t.’”

Musicians play through pain, Shulman believes, because they don’t understand the potential danger of long-term repetitive play without care of the specific muscles.

“They’re also in a bad position,” he says. “A student can’t stop lessons. You certainly can’t stop in the middle of a performance because your forearm feels tingly or your pinkie doesn’t work. Your career is on the line, so you push your limits.”

Even as a preteen, Kyley McClain understood that. Today the residence life and student activities coordinator at Peabody, McClain sports a pair of long scars on her left elbow that tell a painful story many musicians can relate to.

A native of Princeton, N.J., McClain played piano and violin as a child before gravitating to the double bass. At 12, she experienced a tingling and numbness in the fourth and fifth fingers of her left hand—akin to a constant pain from hitting the funny bone.

“I went to numerous doctors,” she says. “No one could figure out what was wrong. Some thought it was carpal tunnel syndrome. One said it was tendonitis, just rest it you’ll be fine. One doctor said, ‘If you could never play your instrument again what would you do?’ which, to me, was like the end of the world. I’d decided playing the bass was my lifelong dream.”

Tests on the nerves in her arm were always inconclusive, but after a year of frustration she heard of a Harvard doctor specializing in neuropathy in musicians. McClain recalls visiting the doctor in his home near Boston. Because she hadn’t brought her double bass, the doctor asked if she could play his piano. After she played, he tested her muscles.

Between the time she started playing and finished, she says, “my muscle strength had decreased so much that the doctor said you need surgery right away.” Startled, she remembers one calming moment. “The doctor was also a concert pianist and he lifted up both his elbows and showed me he’d had the same exact surgery.”

That doctor was the Johns Hopkins–trained Michael Charness, currently an associate dean at Harvard Medical School, an assistant dean at Boston University School of Medicine, and chief of staff of the VA Boston Healthcare System. One of the most knowledgeable doctors in the relatively young field of performing arts medicine, Charness came to his expertise literally by accident.

While pursuing his medical degree at the Hopkins School of Medicine, he spent his spare time playing classical piano. Often he prowled the halls at Peabody looking for a room with a second piano and a duet partner. When he moved to the University of California, San Francisco, as a neurology resident, he continued to practice the piano up to three hours a day.

“I noticed my hands starting to get a little bit less responsive,” he says. “It got worse as I played more and more.” He asked his neurology colleagues for help, but none could see anything wrong.

“We did nerve conduction studies,” he says, “but mine were always normal. People cocked their head a little bit when I said I was having trouble. They couldn’t tell what I could tell so easily. I was aware of a detriment enormous to my playing. It was like that for two to three years.”

Eventually a neurosurgeon who played violin in Charness’ chamber music trio offered an opinion. He had a trapped ulnar nerve—something not immediately apparent to all of the nonmusician neurologists Charness had seen. The violinist-neurosurgeon operated and fixed the nerve. A grateful Charness was able to return to playing, he says, “at the level I had before.”

Injured musicians started asking Charness for advice. He was just launching a laboratory research career and wasn’t seeing patients. So he began seeing a few of them in the back of his research lab. Before long, orchestra members from around the country were paying visits. Eventually he and other doctors at UCSF established a health program for performing artists—the first such clinic on the West Coast. When Charness moved to Harvard in 1989 he established a performing arts clinic, headquartered today at Brigham and Women’s Hospital in Boston.

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.”

“It’s important to have a wellbalanced life here,” says Kyley McClain. “More students are taking advantage of relaxation techniques to be more in tune with their bodies so they don’t sustain injuries.”

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.”