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Musicians' injury - whose responsibility?

Karenna Caun

Introduction

Anyone who plays a musical instrument has the potential to suffer injury related to that activity. However, the tradition in training musicians and music teachers has not included much advice on this subject. This is understandable since the extent of the problem was not appreciated until relatively recently. Studies of orchestras have estimated that between 40 and 76% of players have suffered at least one medical problem that was severe enough to affect their performance (1 - 5). These include studies of adolescents, school orchestras and those in secondary and tertiary education.

Symptoms

Common symptoms reported include pain, particularly in the upper limbs, shoulders or back, loss of control, tingling and weakness. The figures above suggest that more players, and therefore pupils, are suffering than are complaining about such problems.

Pupils tend to try to please us, or feel that it is expected, and may not mention such symptoms. If a pupil does eventually complain, it is still likely to be to the teacher (6). A teacher is best placed to monitor the pupil for the start of many such problems, although a full-blown medical enquiry is also inappropriate (7), and a music teacher cannot be expected to be a doctor or a diagnostician. However, a ‘no pain no gain’ philosophy here is way off the mark. The teacher needs to strike a balance, being aware and asking about such possibilities while not becoming too intrusive, or worrying the pupil by too frequent enquiry.  Of course, if a pupil has any sever or persistent symptoms seek advice from a doctor.

Diagnosis

The British Association for Performing Arts Medicine (BAPAM)  provides a free medical consultation service for professionals and students in the performing arts.  It found that of affected players, about 52% have ‘musculo-skeletal problems which appeared to be due to technical faults’ (8). Essentially, this means that there is some problem related to the use of the body in relation to the instrument. So the ball is bounced back firmly into the music teacher’s court. The teacher may then feel ill-equipped to help.

Even the remaining 48% with the more concrete diagnoses such as tendonitis, carpal tunnel syndrome, tennis elbow, various neuropathies and over-use syndrome are thought to have, as a contributory element at least, causes related to the body/instrument interface.

The road back to health

Once a player has an injury, the road back to health is often a difficult and time-consuming one requiring physical and psychological readjustment.  Injury can significantly interfere with a musician’s playing and at worst it ends careers – some before they have started. On the more positive side, musicians who have recovered often gain much in the process and emerge as better musicians (9).

Prevention and treatment

The general approach used in preventing and treating the non-medical elements of musicians’ injury is to identify and help the player avoid and release inappropriate tensions, both physical and psychological. It is usual that when such release is achieved, the quality of the playing significantly improves and sought-after technical solutions are found as a side-effect. So for the music teacher to be able to do something similar would bring untold benefits to their pupils’ playing. Whilst this article does not really cover singers’ problems, the issues concerning injury and some of the principles of prevention apply to them as well.

Of course, if you feel that a pupil has any prolonged, severe or persistent symptoms seek advice from a doctor. BAPAM provides a free medical consultation service for anyone earning their living from or ‘serious’ students in the performing arts.

So what can we do to help our pupils avoid playing-related injury?

The myth surrounding the warm up

When a musician talks about warming up before playing or singing, they usually mean spending some time at their instrument with gentle scales or light playing, gradually increasing in technical difficulty. However, in order to prevent injury, warming up should deal with the whole body.

As we are aiming to increase the efficiency of muscles and mind, a good circulation is essential, and no amount of using the fingers or embouchure, for example, will help unless the heart is already pumping enough blood to the area. Using the larger muscles in the body is essential, aiming to get the player feeling generally warm. Subsequent instrumental warm-up can still be done and will probably be easier and more productive.

With very active pupils this physical activity may already be done, for instance in a preceding sports lesson, but we need this to become an understood and integrated part of the approach to playing, not just a haphazard extra. Even getting your pupils to walk briskly to their lessons could contribute significantly. As far as orchestras and choirs are concerned, I believe a formal physical warm up at the start of rehearsal would bring great benefits.

General exercise and lifestyle

Any form of regular, aerobic exercise (20 to 30 minutes, three times a week of an activity that gets you sweating slightly) will also help to develop a good circulation. I often recommend swimming as an exercise to help develop the larger muscle groups – around the shoulder, for example – which support the extremities.  Helpful to all, and essential for the serious musician, are the general lifestyle factors of a healthy balanced diet, adequate hydration, enough sleep and no smoking.

Releasing inappropriate tension and mobilising the shoulders

So many activities in our lifestyle encourage our shoulders to fall or be pulled forwards; think about writing, typing, playing computer games, driving and, of course, playing many instruments. We also tend to store emotional tension in our shoulders, accumulating stiff necks and pain as we go; and this applies to children as much as to adults. The extra load of music making can compound these tendencies.  Yet often, our awareness of this accumulation of tension only comes when it has been present for a long time and we start to experience aches and pains. So it is useful to pay particular attention to releasing these tensions and increasing mobility of the shoulder girdle.

I find that combining part of the physical warm up with releasing the large upper limb muscles works well. A few activities are described below, although practical demonstrations are often more useful (10). As with any exercises, if you have a medical condition or experience pain you will need to consult with a health professional first, but simply hearing a few creaks shouldn’t put you off!

Arm swings

1. Let the arm hang freely by your side. If you are very tense it can be tricky to let go so having someone lift your arm a little to see if it feels heavy can help you to establish how much you are holding on. If the arm feels light to the other person you are helping too much! It should fall with gravity when they let it go. (It is possible to do this yourself, using your other arm.)

2. Next you can swing the arm backwards and forwards gently, gradually increasing the swing and concentrating on the natural pendulum-like feeling. When it reaches the top you can let it travel over the top, swinging it in a full circle. If you swing your arm in a backward circle I recommend that you lead with the little finger (like a swimming backstroke).

Do this about ten times backwards then repeat stages 1 and 2 with the other arm.  It is probably worth doing some forwards as well, especially if that direction feels a bit more awkward or restricted.

3. With both arms hanging loosely - ‘like sleeves with nothing in them’ (11) - rotate the trunk from side to side, gradually letting your arms come up with the swing until they reach shoulder height. They must always feel free and not actively lifted.

Other common areas to accumulate inappropriate tension are the neck and the jaw, and exploring similar exercises to free these is also important (12, 13).

General posture and alignment

Everyone’s body has a posture and alignment that is the most efficient, when all the muscles can operate with minimal tiring and best recovery. Often this is not the most familiar nor, when new to us, the most comfortable.

Whole body alignment can best be demonstrated by dropping an imaginary line from the top of the head, through the centre of the ear, the tip of the shoulder, the top of the hip bone at the side, just behind the knee cap and in front of the ankle. These should ideally all be in a line (17). Whilst awareness of the ideal is important, trying to place the body in this position, can make us awkward thus creating more tension. In order to gain true alignment we can use, more successfully, special techniques such as the Alexander Technique, some forms of yoga, Feldenkrais, Pilates, and the Grindea Technique, described below.

We can also use imagery. David Lasserson demonstrated the next example at a BAPAM/ISSTIP conference ( British Association for Performing Arts Medicine ,  International Society for the Study of Tension in Performance ).  People find it fun to do and quite effective.

1. Walk about the room continuously as you think about the following:
2. How far is your head from the ceiling/sky? Don’t try and answer it, just think about it!
3. How far is your nose from the floor?
4. Imagine you have a string that leads you coming out from the sternum (breastbone).
5. Imagine you have beams of light that shine out from each shoulder.
6. Imagine a beam of light shining out from the sternum.

Sitting for prolonged periods can be a major cause of misalignment and back problems, so to get up and move around after about 20 minutes is useful. Sitting with the hips at 90 degrees (the angle of most chairs) causes loss of the natural curvature in the lumbar spine, creating excess pressure on the vertebrae (13, 14). A wedge-shaped seat (back higher than the front) can help this. Such seating is more readily available (even for piano stools) than most people realise.  If it is not available, orthopaedic foam wedges can be bought. Even a rolled-up towel placed at the back part of a chair’s seat can substitute.

The next step is to keep the best possible alignment when using the instrument. Always try to bring the instrument to the body, not the other way around. It is common to see twisted spines (for example in approaching the flute), swayed backs (for example playing any instrument held in standing), a tilted pelvis (for example at the guitar) to name but a few (19). Such habits usually set in early if not addressed and can be much harder to deal with at a later stage, which is when the damage is felt.

Alignment of the hand and forearm

If you let your arm hang loosely by the side and look in a mirror you are likely to see the best alignment of the forearm, wrist, hand and fingers. Whatever instrument you play, the closer to this alignment you are when playing (as long as you do not tense up to achieve it), the better placed you are for efficient, healthy movement. This applies as much to a bow hold as to positioning at the keyboard, to plucking strings of the guitar or stopping the holes on the recorder, playing the marimba or the clarinet.

There will need to be minor adaptations depending on the particular activity involved, but if you are far from this positioning then you need to think hard and make an informed assessment. You can, and will need to, move away from best alignment, but should return to it as soon as possible, by release of activity.

Remember, instruments are constructed differently, but our bodies are usually put together in the same way, albeit in different sizes! This difference in size can be important as well. If your hand is three times the size of your pupil’s, the pupil’s physical limitations will be different to yours. This has implications for issues such as fingering. Knowing more about how the body works will help you make appropriate decisions (19, 12).

Some common misalignments

• Continuous or over (hyper) flexion of the wrist.
• Continuous or over (hyper) extension of the wrist.
• Unnecessary or excess abduction or adduction and fixation of the arm at the shoulder.
• Radial deviation of the wrist (in the direction of the thumb).
• Ulnar deviation of the wrist (in the direction of the little finger).
• Deviation of the fingers (look out for the little finger) and thumb from neutral - keeping the fingers spread out.
• Over-flexion of the elbow, especially with rotation and supination – for example, turning in of a violinist’s left arm.
• Over-pressure with the side or ends of the digits - fingers or thumbs.

Avoid such positions when possible – that is, mostly! If this is impossible, try and stay in them for the shortest time possible using minimum pressure and minimum weight.  For all muscular actions, make sure you aren’t doing them when they aren’t required.

Joints also have an ideal range of movement after which they can become strained or impose strain on other joints. Joints work best in their mid-range.

Hypermobility

Hypermobility - when some joints are overly extendable or double-jointed – presents its own special problems.

Hypermobility is thought to be more common amongst musicians than in the rest of the population. It can have some advantages in increasing flexibility or reach but can create problems of joint pains, especially if the joint involved is weight bearing, or can inadvertently cause over-reaching and muscle imbalance. Such joints need to be watched carefully to see that they are not being over extended, and the musculature around them needs to be strengthened. You will need to consult a specialist if this seems to be a prominent feature.

Ergonomics

Sometimes the set up of the instrument needs to be adjusted – the height of a chin or shoulder rest can be crucial to the violinist – and needs review as the pupil grows. Occasionally, the shape of an instrument can be radically modified to fit the body better such as in the case of a flute with a swan-neck-shaped mouthpiece.

Practice schedules

Whilst it is often a music teacher’s concern that the pupil should practise enough, it is surprising how infrequently we are advised about over-practice!

The informed consensus is that an instrumentalist is less likely to suffer a playing-related injury practice is organised in 20-minute sessions interspersed with 10-minute breaks. Overall there should be no more that three to four hours of playing in any one day.

Whilst this may come as a surprise, there are many professional performers using this kind of schedule with success. I have certainly persuaded many talented students and professionals to stick to this kind of regime with benefit to both their health and their progress. For the beginner, it seems appropriate to shorten these playing times yet further.

Reasons behind the success of this type of regime include the fact that the fluid vital to protective tendon sheaths has to be replenished, as they are only indirectly in touch with their blood supply. Also that there needs to be a recovery time for contracting muscles to regain their energy stores and get rid of waste products. If a muscle gets tired, it becomes inefficient. This situation stresses the mechanics of the whole system and increases the work needed for the same muscle to do the same job again.

Stretches

Muscles contract to work and if properly released go back to their full length. If over-worked, they remain partially contracted, reducing efficiency. Hence stretches are thought to be of value. Their effect has not been fully studied, but many musicians feel they are of benefit.

Work in the sports world suggests that stretches are most likely to help prevent injury if done after the activity. So, in practice breaks and after playing I advise some stretching of the appropriate muscle groups. You will find good accounts of several stretches in various books (12, 13, 14).

All passive stretches need to be performed for at least 20 seconds to have an effect - taken to the edges of discomfort, but not pain.

It will, of course, be helpful to familiarise yourself with the location of the muscles that you use when playing your instrument. For instance, it is important to realise that there are no muscles at the wrist, and while there are a few in the hand, the major muscle bulk that operates those areas lies in the forearm.

Spotting and releasing inappropriate tension

We need muscular action, or tension, to play or sing but we need to avoid unnecessary tension. Achieving this balance is something that you can only learn gradually, preferably by observing yourself and with help from others experienced in the area. However, there are some things you can do to help your pupils.

• Stand back and look at the whole pupil.  For instance, when we are concentrating on fingers or hands we may miss the fact that there is a stiff shoulder with the arm clamped to the body restricting every movement of the hand or we may miss a hunched over or twisted back.
• Look out for fingers and hands being held in an active position when they don’t need to be. If you lift your fingers up and back from the knuckles, you will see tendons sticking out. This is a common sign, when persistent, of held tension and should be avoided.
• Make sure there is potential mobility at the wrist and shoulder - that these are not fixed.
• Get the pupil to feel complete relaxation between activity, for example, relaxing the hand between a series of chords, even if this means slowing parts of a piece right down for a while.
• Make sure the pupil doesn’t lock his or her their breathing. Exhalation is thought to be particularly helpful in relieving tension.

The mental approach

Perfectionism tends to be a trait amongst musicians, although some work suggests that it is less of a trait in the more successful musician (15). Combined with the great passion that music brings and all the issues surrounding performance anxiety, this adds another highly significant layer of contributory causes to musicians’ injury.

I am not addressing this in detail here, as it is such a large topic in itself. However, it is important to understand that achieving a healthy attitude to performing is essential to reducing physical tensions. A recent study suggests that for musicians, an emphasis on enjoyment was related to better performances (16); and musicians who have recovered from injury frequently talk about having to readjust their unifocal, over-intense perfectionist approach (9).

The Grindea Technique

The Grindea Technique (18) was developed as a pre-performance tool to help release tension and achieve mental focus. It was formulated by Carola Grindea, a pioneer in this field and Chairman of the International Society for the Study of Tension in Performance  (ISSTIP).  My view is that done regularly it may also help to correct longstanding postural misalignments and build general awareness of muscle tension and its release. The technique is described below.

1. Raise your shoulders right up to your ears.  Tense, then release, letting everything go. Repeat twice more.

Take care not to jut your chin out or back and keep it level.

2. Put your arms out straight in front of you with palms facing each other. Tense. Lift your arms above your head until they are beside your ears, parallel and with palms still facing. Then lower your arms to shoulder height with the palms down… still tense.  Imagine that you are trying to touch the walls either side of you.

Then release, letting everything go. Repeat once more.

Take care not to jut your chin out or back and keep it level. Try not to arch your back.

The following steps should be done with the eyes closed. It is important that you don’t try too hard, rather give your body the instruction mentally and then allow the effect to take place. Trust your body to sort itself out.

3. Let you neck be free.

4. Give your spine an order to lengthen and straighten in an upward direction. Give it time.

5. Imagine your head is like a balloon which floats off and hovers above your lengthened, floating spine.

6.Let your jaw lower and with open mouth exhale quite noisily three times, letting your tensions go out ‘through heavy hands’.

7. Let your knees and ankles feel like clouds – so they still support you but are not locked.

8. Open your eyes again!

Parts 3 to 7 are really the crucial part of the technique and can be done at almost any time and almost anywhere!

ISSTIP courses

An organisation that has been specialising in addressing the non-medical problems of musicians’ playing is the International Society for the Study of Tension in Performance  (ISSTIP). It was through one of their early courses that I became interested in and had some specific training in this field, on top of my general medical training and subsequent training from BAPAM.

I am in a privileged position, being both a doctor and a musician, and there is a handful of people like myself and a few dedicated musicians who over the years have developed a specialist expertise in this area. However, I believe it is time for music teachers as a profession to take up the challenge and take steps to reduce the alarming figures quoted at the start of this article. We should at least inform ourselves and do our best to make sure that our teaching contributes to healthy playing, as well as to musicianship.

As you gather from this article, there are some books on the subject, but there is also much that needs to be learned in a practical fashion. To this end, ISSTIP runs various courses and workshops and has now devised a series of lectures and workshops aimed at helping music teachers and other professional prevent musicians’ injury.

ISSTIP lectures and workshops 2005/2006

Lectures and workshops can be attended as individual days, pairs of days, or as part of a modular course towards a certificate in Integrative Music Practice. The following areas will be covered.

• The anatomy of playing, with practical exploration at the instrument.
• Focusing on freedom, alignment and ‘physiological’ movements, working towards release and developing awareness.
• Avoiding inappropriate tension, releasing accumulated tension, discovering how tension is linked to emotion.
• Working with the whole person.

Lecture and workshop venue

Royal Society of Musicians, Stratford Place, London W1

Dates

13/14 December 2005

16/17 January 2006

21/22 February 2006

18/19 April 2006

16/17 May 2006

11/12 July 2006

Further information about the ISSTIP workshops and lectures is available at www.isstip.org  and from:

• Emma Peake: peakeemma@hotmail.com
• Karenna Caun: kc@karenna.go-plus.net, 015242 21977 (answerphone)
• Andy Evans: AEatArtsandMedia@aol.com

If you are interested in an in-depth theoretical course, relating to all the performing arts, a new MA will soon be available at Thames Valley University.  Further information is available from Andy Evans: AEatArtsandMedia@aol.com

Karenna Caun is a medical doctor and Royal Northern College of Music trained singer. She teaches singing privately, in a school and at Lancaster University, and is a mentor for the Associated Board’s Certificate of Teaching (CT ABRSM) course. Karenna works with musicians to help them overcome playing-related injuries. She has completed a course in Music Medicine Therapy run by the International Society for the Study of Tension in Performance, of which she is now a committee member. She is also a medical practitioner for British Association for Performing Arts Medicine

Links

International Society for the Study of Tension in Performance (ISSTIP)

www.isstip.org

British Association for Performing Arts Medicine (BAPAM)

www.bapam.org.uk

Three case histories

Case 1

A 22-year-old violinist had a one-year history of headaches, pains in the shoulders, right forearm and right thumb, and pins and needles in her right arm whenever she played and for some hours afterwards. She had visited several doctors and a physiotherapist weekly during that time with no improvement at all. She was limited in her ability to type, write and open jars.

A diagnosis of hypermobility of the joint at the base of the thumb had been made. Her teacher had told her to free the bowing arm but she had been unable to do it. However, improvement came after only four sessions of addressing her body use in relation to playing, working from principles of physiological body movements. This was done by adjusting her shoulder rest to an appropriate height, developing and maintaining freedom of the shoulders, finding ways to release tension in and align the bowing forearm (which had been inwardly hyper-rotated) and using minimal finger pressure in the left hand. She felt that some of the most useful ongoing activities had been the warm ups - ‘so I don’t shock my body when I go to play’ - and swimming, which ‘opened up’ her shoulders. She also liked the use of regular reviews ‘to remind me what I need to do’. Her recovery was slightly slowed by anxiety over a lack of explanation as to what was wrong with her. While she did have a hypermobile joint, it was the excess pressure on it, inappropriate tensions and misalignments that had been causing the pains. This was explained at a visit to BAPAM and she felt a lot better!

Now, she feels that her ‘right thumb is sorted’, she occasionally gets a headache when her shoulders get tense, but she feels better able to deal with it. She feels that she is making better and easier progress on the violin and she is ‘able to concentrate on the more important things, like the music, and adjust technique without worrying’.

Case 2

A 22-year-old pianist described a long (four-year) history of severe hand, forearm and shoulder pains that appeared during playing and lasted for several days afterwards. The pains moved around and interfered with many aspects of her life. For instance she found it hard to open jars, brush her hair or lift anything of any weight. Similar symptoms occurred when using a computer.

She had visited two specialist doctors, two physiotherapists and two chiropractors with little benefit. She was diagnosed as having over-use syndrome. She gradually improved with adjustments to her body-use over nine months. There was close collaboration between her, myself and her teacher. We were able to optimise her seating at the keyboard, she practised deep muscular relaxation and numerous releasing techniques for her playing. There was some relief after some trigger point massage and she managed to use a voice-activated computer with special seating and desk. She reported, however, that what she found most useful was her own improved understanding of her condition, particularly of the role that stress played in aggravating her condition (being deeply religious, she found that prayer helped her with this). Other highly significant factors, she feels, were the adjustment to her practice/playing schedules, (20 minutes playing, 10 minutes break) and stretching after playing.

Much of the time she is now pain free and says that she only really gets an odd twinge if ‘I don’t treat myself well’ and feels that she can manage herself much better when that does occur.

Case 3

A 23-year-old guitarist gave a history of a few months of pain and loss of control of the right hand and forearm. He recovered after a couple of sessions where his alignment was analysed. He felt he could correct this once he had developed awareness of his own anxiety in relation to playing the guitar and once his many fears about injury were addressed.

References/bibliography

1.  Fishbein et al. (1988) ‘Medical problems among ICSOM (International Convention of Symphony and Orchestra Musicians) musicians: overview of a national survey’, Medical Problems of Performing Artists, 3/1: 1

2.  Brandfonbrener, A.G. reviews epidemiology at secondary and tertiary educational levels in: Amadio, P.C. & Tubiana, R eds. (2000) Medical Problems of the Instrumentalist Musician, London: Martin Dunitz, pp.172 – 174

3.  Fry, H.J.H. Ross, P. & Rutherford M. (1988) ‘Music related overuse in secondary schools’, Medical Problems of Performing Artists, 3/4: 133 - 34

4.  Fry, H.J.H. & Rowley G.L. (1989) ‘Music related upper limb pain in school’, Annals of the Rheumatic Diseases 1989, 48/12: 998-1002

5.  Manchester, R.A. (1997) ‘Musculoskeletal Problems of Adolescent Instrumentalists’, Medical Problems of Performing Artists, 12/3: 72

6.  Brown, A.N. (1997) ‘Musculoskeletal Misuse among Youth Symphony String Players’, Medical Problems of Performing Artists, 12/3: 15 - 8

7.  Williamon, A. ed. (2004) Musical Excellence: Strategies and techniques to Enhance Performance, Oxford University Press

8.  Brandfonbrener A.G. (2005) ‘Good and bad medicine: whose definition will it be?’ (Editorial), Medical Problems of Performing Artists, 20/1: 1 - 2

9.  BAPAM News, Summer 2004

10.  Royle, D. (2004) ‘Musicians’ experiences of a career-threatening, playing-related injury and their recovery and return to performing’, ISSTIP Journal, 12

11. Yoga for Musicians (DVD), Penelope Roskell with Catherine Nelson, peneloperoskell@yahoo.co.uk

12.  Lieberman, J.L. (1991)You Are Your Instrument, 4th ed., Huiksi Music

13.  Horvath, J. Playing (less) Hurt - An Injury Prevention Guide for Musicians, www.playinglesshurt.com

14.  Wilson, A. (1996) The Complete Guide to Good Posture at Work, 2nd ed., London: Vermilion

15.  Paull, B. & Harrison, C. (1997) The Athletic Musician: A Guide to Playing Without Pain, Scarecrow Press

16.  Evans, A. (2003) Secrets of Performing: Confidence, London: A&C Black

17.  Lacaille, N. Whipple, N. & Koestner, R. (2005) ‘Reevaluating the benefits of performance goals: the relation of goal type to optimal performance for musicians and athletes’, Medical Problems of Performing Artists, 20/1:11 - 16

18. Bunch, M. (1999) Creating Confidence, London: Kogan Page

19. Grindea, C. ed. (1995) Tensions in the Performance of Music : A Symposium, London: Kahn & Averill

20. Bruser, M. (1999) The Art of Practicing – A Guide to Making Music from the Heart, New York: Bell Tower