Musicians' Health Collective

Musicians' Health Collective: Supporting the health of musicians (and normal people)

Going Beyond "You're Doing it Wrong" : Finding the Root of Injury

Injury Categories.jpg

When we talk about musician injuries or injuries in general, we tend to think overuse: playing too much or fundamental misalignment, which is sometimes (but not always!) the case.  It can also be easy to blame oneself for such an injury, or to receive blame from teachers that your setup isn't good, that you didn't take breaks, or my personal favorite “you’re doing it wrong because if you did it right, it wouldn’t hurt.”  

This is not always the case!  In Elizabeth Andrews' book, "Muscle Management for Musicians," she outlines three different categories, which I've found helpful to look at and evaluate, both for students, teachers, and professionals.

Yes, this is real. It's a contrabass flute.

Yes, this is real. It's a contrabass flute.

1.  Musician Versus Instrument: This can mean the size and shape of your particular instrument (one viola vs. another) or having to play a lot of contrabassoon/bass flute/subcontrabass sax/etc. in relation to your normal workload.  This can also be as simple as pointing out that not everyone can reach the keys on a flute (without contorting one's hand) or that a full size string bass is not for most people.  There are an infinite number of ways to alter one's setup to potentially help support the body, and those changes definitely fall into this category.

2. Musician Versus Environment: This is a category orchestral players are certainly aware of- chairs, stand height, conditions of the room/space/concert hall, temperature, etc.  This can also include clothing restrictions (violinists in tuxedos, high heels for performance, or simple elevating one foot to play bass or guitar) or even carrying one's instrument (s) upstairs, around the city, etc. Wielding a contrabassoon is not the easiest! For string players, this could also include the way one has to rotate one's chair or torso to share a stand, or the cramped sitting positions of the orchestral pit. This category also includes the acoustical aspects of the space- perhaps creating conditions that are excessively loud, resonant, or putting players too close together.

3. Musician Versus Self: In my mind this includes the other things we do that stress our arms, body, voice, spine, etc., which includes computer use, cell phone use, driving, standing (!), sleeping, etc.

I love Elizabeth's categories, and although I've altered the descriptions a bit to be more relevant, I think they're great points.  I would however, add a fourth category.

4. Musician Versus Music: Sometimes, even against your best intentions, the repertoire that you're studying, playing in ensemble, or preparing for an audition is too much for your body.  I've previously talked about how Paganini may have been hypermobile- for some folks, the extensions and left hand demands of the caprices are too intense and not practical.  This is true for a lot of contemporary repertoire in general- as our levels of mastery and virtuosity have skyrocketed, so have the demands of our pieces, often bringing near impossible pieces into the forefront of music.  (For example, some violists find the extensions in the Schnittke concerto to be too extreme.)  That doesn't mean that those pieces don't deserve study, they just may not be the right piece for you, or for you right now, or for you with your current instrument.  Another example might be an orchestra or opera company planning to do a Ring Cycle performance, which is a huge undertaking for any instrumentalist.  The rehearsal schedule alone might be very taxing, let alone the music itself, especially if you have never played them before and are learning the repertoire for the first time.  Even if you're doing your best to take care of yourself, the repertoire, concert schedule, rehearsal schedule, or audition list might be too much for you, either now or in general. 

I've always been afraid of taking an opera orchestral job because of the challenges (physically and mentally) of playing cycles of Wagner operas. Loud volumes, orchestral pits, and an infinite amount of string notes scare me!

I've always been afraid of taking an opera orchestral job because of the challenges (physically and mentally) of playing cycles of Wagner operas. Loud volumes, orchestral pits, and an infinite amount of string notes scare me!

If you've been injured, reflect on what it was that may have caused or exacerbated the injury- which categories were applicable?  Having an awareness of these categories can certainly prevent future injuries, especially if you know what previously caused an injury.

Disempowerment in Injury Treatment and Recovery

I just thought this article  needed a picture.

I just thought this article

needed a picture.

      So I’ve previous discussed Injury Shaming in the music field, as specifically related to employment, education, festivals, etc.  However, I did want to discuss some of the other issues related to injury treatment and recovery, as pertaining to musicians.  First, let's look at some of the problems with seeing medical professionals about a musical issue.

1.  The classic answer to overuse injuries, which sometimes prevents musicians from seeking medical attention for more serious issues, is "stop playing and take some anti-inflammatory drugs."  Let’s be clear, rest is important. But if the solution is to tell people to completely stop their career without looking at the whole picture of what’s creating an injury, we’re setting up for a problem. While there are some fabulous medical professionals out there willing to look deeper, many musicians don't seek help as quickly as they might otherwise because they receive a less-than-helpful answer for a long term solution.  If music is your profession and how you make money, then having a medical professional dismiss your concerns is incredibly insulting.  

Also, about those anti-inflammatory drugs- inflammation is your body's way of bring more blood to an area that has been damaged, irritated, infected, etc.  It can be a way of protecting against further damage, (unless we're talking chronic inflammation, which changes the type of cells present at the site), and is accompanied by pain, swelling, redness, and heat.  When we constantly and repetitively take NSAIDs (non steroidal anti-inflammatory drugs), we are disrupting our body's process for dealing with tissue damage.  

"Overuse of the muscles causes cells to break down, releasing waste products, which produces pain and inflammation.  Cleanup crews in the form of white blood cells, known as macrophages, carry away the cellular debris.  If you take anti-inflammatory drugs, the natural inflammation process is disrupted and instead of being cleansed away in the bloodstream, the trash settles into scar tissue."  (Emil Pascarelli, Repetitive Strain Injury for Computer Users, New York: Wiley, 1994) 

Interesting.  Another stat I heard in an interview with Jonathan FitzGordon stated that while Americans make up only 4.5% of the world's population, we use 80% of the world's (!) pain-killers.  Yikes!  Maybe it's time to reconsider a few things?

2.  While healthcare reform is a great thing for us musicians, especially freelancers, it's been a long time coming, and many of us have had to pay for some expensive stuff along the way.  Because of my pre-existing condition, I was denied healthcare and paid out of pocket, which was awful.  Even now, many insurance policies have a high deductible which may discourage patients from seeking the treatment they need because of the high up front cost.   (If a deductible is $1500, that means that you will pay all costs up to that deductible, which can be a lot of money!  MRI's are very expensive...)  In addition, that can prevent musicians from getting the PT, regular check ups, and care they need long-term.

3.  Many homeopathic and alternative treatments are not covered by insurance- acupuncture, chiropracter, rolfing, etc.  For a musician in a professional orchestra with a good salary, that might be ok, but for a freelancer or someone with a lower salary, paying $140 for one session is prohibitive.  I had a rolfing session (structural integration) which was amazing, and really changed how I felt in my muscles and soft tissues, but it was really expensive and I can't justify going again for a long time.  I would love to see more professionals offer their services at a discounted or sliding rate for people who could benefit from their services but can't afford it.  I know there are quite a few great community acupuncture clinics in the US-what about sliding scale rates for other modalities?  Yoga, pilates, and gyms can be outrageously (!) expensive, and I know that also turns people off too.  In my fantasy land, orchestras, schools, and arts organizations would make health a priority for their employees/students by supporting these resources, rather than expecting students to pay out of pocket.

4.  Many musician injuries are chronic.  A musician might stop playing for a bit, and feel ok, and then 6 months later, the pain comes back.  We need to both look at our own actions and how we're contributing to our own pain, but we also need medical professionals who are interested in creating long term change, not just a treatment of symptoms.  It's a combination of taking responsibility for one's own health, combined with assistance from homeopathic and allopathic folks interested in changing the problem, not the symptoms.

5.  Lastly, it's really hard to be injured, in pain, or with undiagnosed symptoms of illness. A few years ago, I was consistently unwell.  I had headaches, digestion issues, low energy, etc., many of which were difficult to treat or identify.  After a period of a few months, I was eventually diagnosed with a non-cancerous pituitary brain tumor, which explained a lot of my issues.  Yet, during that time of non-diagnosis, I felt terrible.  Generally, we like to take steps in maintaining our health, to be in control if possible.  If we move enough and eat vegetables and sleep well, we expect to feel ok.  When those things don't happen, it can be devastating, regardless of the injury or issue.  RSI's don't go away quickly, and there's rarely a quick fix solution.  The process of healing and diagnosis can be very stressful in and of itself, especially if the body doesn't heal itself quickly.  That combines with the stress of school or a job and a lack of compassion in both the medical and job/education setting can be damaging long term.     


Help! I have a reversed cervical curve!

I received a message from a former colleague this week about a reversed cervical curve, and although I can't directly work with her (she lives in another country), there's a lot to be learned about the curves of the spine and when they begin to move from "normal."  As I've written about earlier, your spine is a series of different curves in the sagittal plane rather than a "column."  Each person's curvature is different depending on their movement habits, career, genetic predisposition, trauma (bike accident, sports injuries, etc.) and other factors.  

Image from  The spine on the left is a "normal" spine, whereas the three on the right show different spinal abnormalities that may occur.

Image from The spine on the left is a "normal" spine, whereas the three on the right show different spinal abnormalities that may occur.

Now back to the neck, or the cervical vertebrae (there are 7 of those).  There should be a natural lordosis to the cervical spine which allows weight transfer between the vertebrae and maintains a healthy amount of movement in the neck.  However, a reversed curve or a straight neck will lack that lordosis and either have a curve in the opposite direction or lack a curve altogether.

This digitally rendered image from  Katz Chiropractic  demonstrates three different neck curve variations- "normal," straight, and reverse.

This digitally rendered image from Katz Chiropractic demonstrates three different neck curve variations- "normal," straight, and reverse.

Many people will seek out treatment for such neck issues as a result of pain, whether in the form of the migraines, thoracic outlet syndrome, nerve compression, or disc herniation.  The irregular curvature will change the weight distribution into the discs, potentially negatively affecting the whole series of cervical joints, and overtaxing the ligaments, tendons, and connective tissues of the neck and upper back.  However, with such a diagnosis, it's hard to know whether the neck curve has always been there and is only showing symptoms now, or whether it's the cause of a host of issues.  Many people have herniated discs in their spine and no pain, but an MRI reveals structural issues they didn't know existed.  The neck curve may be a symptom of a bigger issue (a larger, whole spine issue), a trauma, accident, or something else, and may not actually be the cause of the issues.  

The question is, "how do I treat this?" which is a much harder question to answer!  As always, it's important to check with your medical professionals, get an x-ray and MRI to ascertain if there are spinal irregularities or disc herniations. I have not personally had this particular diagnosis, but as a movement teacher, I would seek out practitioners that will look at all of the spine for other issues that could be triggering the neck issues.  That can mean chiropractors, Physical therapists, manual therapists, and other bodyworkers.  However, there is a huge range of approaches to these disciplines, and it can be difficult to find one that works for you- some chiropractors take approaches that may not work for you, others will have a gentler approach, and some PT's will give you cookie cutter exercises and others will give hands on, individual attention.  Finding a good practitioner is certainly a challenge!  As a patient, you want to address the skeletal issues, the soft tissue issues, and look to the causation of the pain or abnormality.  Some treatments focus on treating the symptoms of neck pain, but if it's recurring, it would be good to figure out if it's a result of your movement habits, your instrument setup, your sleeping habits, etc.  In terms of organizing your instrument setup, a Body Mapping® instructor, Alexander Technique® teacher, or Feldenkrais® instructor can also help look at your setup for issues and see how you can move better on a day to day basis.  As always, if you feel that your medical practitioner, movement instructor, or bodyworker is not supporting you in your process, or is dismissive of your pain, or dismissive of music as your career (and your need for a healthy body!), search for another person- you deserve to be taken seriously and to have someone invested in your recovery and improvement. 

if you feel that your medical practitioner, movement instructor, or bodyworker is not supporting you in your process, or is dismissive of your pain, or dismissive of music as your career (and your need for a healthy .jpg

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