Musicians' Health Collective

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

Filtering by Tag: injury prevention

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.     


When Poor Posture Doesn't Cause Pain

A former colleague sent me this article about back pain myths, which initially frustrated me, and then provoked a series of internal responses.  Here are some of the author's main points:

1.  Bad posture doesn't inherently cause back pain.

2.  Herniated discs and other structural abnormalities don't always cause back pain.

3.  Strengthening the "core" doesn't prevent future back pain.

4. "It is an article of faith among many mainstream experts that poor posture, lack of core strength, and/or structural abnormalities such as bulging discs are major causes of pain, especially back pain."

There's a lot going on back here, and there are many layers of myofascial tissue that can be strong, weak, flexible, inflexible, and pain provoking. 

There's a lot going on back here, and there are many layers of myofascial tissue that can be strong, weak, flexible, inflexible, and pain provoking. 

So what's going on here?  First of all, pain is a complex and individualized neurological and emotional process.  Things that cause pain to one person won't to another in similar circumstances.  The author is also bringing up a large point- causation doesn't imply correlation, meaning that just because someone does have poor posture doesn't mean he will automatically be in pain.  However, this isn't an excuse to slump in your chair and stop caring about movement quality!  Here's why:

1.  Poor posture may not cause back pain on its own, but it may cause lots of other issues in your body:  Muscle tension patterns, weakened bones, lack of mobility in the spine and neck, etc, all of which can lead to pain and dysfunction.  In addition, a "slumped (kyphotic) spine" affects your capacity to breathe because your respiratory diaphgrahm will be compressed and unable to contract and relax fully.  (Did you hear that, wind players and singers?)  When we move the body out of alignment in standing, walking, etc., we change the wear patterns on our joints, as well as affect the long term bone density.  For example, having a head forward position will increase the bone built on the back of the neck and spine, thanks to Wolff's law, while also wearing out the discs in your neck.  Wearing shoes with a small toe box with force your big toe to turn towards the little toes and possibly set the framework for a bunion, or bone built at the MTP joint.  And if that wasn't enough, whole body misalignment is connected with a host of other issues- pelvic floor, internal organ compression, lack of range in joints...the list goes on.  

2.  Let's all just try to avoid having herniated discs, shall we?  A herniated disc refers to the cartilaginous cushion between your vertebrae, which has ruptured, allowing some of the cushion to spill out.  A bulging disc is where that cushiony cartilage has expanded beyond its normal boundaries.  Both issues have the risk of being painful, but bulging discs are often less so.  Our discs lose their elasticity as we age, but trauma, genetics, mobility, and movement patterns  play a role in their health. 

3.  The core is more than just the abdominal muscles, but in fact refers to all the musculature around your viscera and spine.  Strengthening the muscles of your back body as well as your obliques can help one's posture (!)  and one's bodily awareness.  Also, if you do any sort of movement or exercise practice, your core muscles (rectus, obliques, transverse, spinal stabilizers, back muscles, and more!) need to support you, which can also affect pain.  If you want to do a plank in yoga, pilates, or in a gym setting, you have to be aware of your whole body, including your core and spine muscles.    As musicians, many of us engage in an asymmetrical activity, which means that one side of the body is taxed much more than the other, which also may mean that one set of abdominals, obliques, transverse, multifidi are stronger than the other from years of asymmetrical habits. 

While I can't promise that the texting posture will hurt you, I don't think it's great for your body long-term.

While I can't promise that the texting posture will hurt you, I don't think it's great for your body long-term.

4.  Just because you do something that may not be healthy does not mean you will suffer from it.  The opposite is true.  We all know folks with crazy instrumental technical setups and strange tension patterns that never suffer from overuse injury.  We also know people who smoke and don't suffer the same consequences as other people.  However, in my mind, if you can change the way you move, eat, and act, and the changes are better for your long term health, then they're worth pursuing.  It's not worth gambling on your health because there isn't a 100% chance you'll suffer from pain due to poor posture or high heels or jaw tension while playing.  Also, every human body is wildly different, and something that causes back pain in person A may never create discomfort in person B.  (Also, just on back pain, there are a TON of possible causes.  From psoas and piriformis issues to genetics to discs to hips to hamstrings...everything is connected fascially which means that there are many possible causations!.)

Why Bother Stretching?

A few months ago, I opened a big ol' can of worms with the discussion of how stretching doesn't actually lengthen muscles.  Now, it's time to address that subject again, with the help of Stretch Armstrong, which some of you may remember from your youth. 

If you're a child of the 70's or 80's, you may remember this toy, clad in a speedo or a tee-shirt, depending on the decade that you lived in. 

If you're a child of the 70's or 80's, you may remember this toy, clad in a speedo or a tee-shirt, depending on the decade that you lived in. 

In case you missed our previous chat, take a moment to catch up on the last post in case things are a bit confusing.  Basically, in many movement disciplines, teachers and professionals perpetuate the idea that we must stretch muscles to lengthen them.  Period.  I went to a few yoga classes this weekend, both of which said this.  "We just lengthened your hamstrings a bit so you should feel open."  Being the slight know it all that I am, it's time to correct that notion and learn a little more about the science of stretch.

This pose, a pigeon variation, is often a "dream goal" pose for yoga folks.  Does this degree of spinal flexibility necessarily serve us all?  Perhaps not.

This pose, a pigeon variation, is often a "dream goal" pose for yoga folks.  Does this degree of spinal flexibility necessarily serve us all?  Perhaps not.

Back to Stretch Armstrong-there's an idea in yoga and in other movement disciplines that the infinite stretchability is the goal, AKA.  stretchier=better=magical poses and feats.  Yet, like Stretch Armstrong, when we stretch things, our body (hopefully!) goes back to the initial tissue length...depending on how intensely we stretched our tissues.

-Our connective tissues have about 4% healthy stretching range, meaning that your tissues can "stretch" about 4% healthily.  Collagen starts to break down at 8% of your stretching range, which means that you are in a damaging range, risky for muscle tears, etc.  (Thanks Jules Mitchell for the stats!) This means that YOU ARE NOT STRETCH ARMSTRONG, ladies and gentleman, nor should you strive for such a feat.  There is a healthy end range of stretch for all of us, and it doesn't need to be pushed beyond reason.  (Also, 4% is not very much, in case you were wondering, which is why I stick to the logic that muscles are not being lengthened much with stretching.)

- Our flexibility is heavily governed by our tolerance, which means that our nervous system prevents us from going into ranges that we don't frequently use (like the splits!), because it's unfamiliar and potentially risky.  Over the course of a yoga class, for example, your tolerance will change because your nervous system is allowing range, the muscle isn't actually lengthening.  (Remember how you might be flexible in a hot yoga class and then the next day, it's like it never happened?  Your hamstrings are the same as ever?  That's because of a phenomena called Creep and Recovery (which is how the body recovers from stretching back to its normal resting position).  Stretch Armstrong does not have this capacity, nor does he have a nervous system (unless he's some hybrid of Chucky and that's just eerie).

I took this picture at a zoo last year- I loved the one sedentary zebra juxtaposed with the crazy rolling zebra.  We tend to be a teensy bit sedentary which affects our range of motion and flexibility-lets move more, folks!

I took this picture at a zoo last year- I loved the one sedentary zebra juxtaposed with the crazy rolling zebra.  We tend to be a teensy bit sedentary which affects our range of motion and flexibility-lets move more, folks!

What is flexiblity?  Basically, flexibility is having a normal range of motion in your whole body.  Therefore, if you DO NOT have normal range of motion, stretching can help work that range and then it's time to strengthen.  Remember that stretching for stretching's sake will not help much, but a combination of stretching and strengthening will help create sustainable change.  Moving frequently in more ranges of motion will help most (read more here!).  Time out: I've done yoga for 7-8 years and stretched my hamstrings for a long time, with little change.  What helped is actually getting a standing desk, wearing flat shoes, and walking more.   Fascinating- I needed to gain strength in more ranges.  Lunges, standing yoga poses, walking, squats- these are all strengthening poses and movements. 

  Whatever range you're trying to change (hamstrings, shoulders,etc.) also requires strength at that range- you don't want to stretch without supported strength.  So while Stretch Armstrong's stretchability implies that muscles are infinitely lengthen-able, in fact, your goal should be to expand your range first and then strengthen.  Don't just keep stretching and "lengthening" tissues!  Read more about your "short hamstrings" here with Jules Mitchell's awesome post.

I opened up a chat with some of my fellow teachers last month inquiring about why we stretch, and I love what my colleagues had to say (Thanks Alex E. and Alexa P.!)  Here's what one of my teachers, the brilliant and fabulous Sarah Court said, "Losing healthy range of motion sets you up for injury.  Stretching is not about trying to change the length of anything, rather you are trying to optimize overall mobility and not lose movement options from lack of use." 

The conclusion?  Stretch (a little bit) to regain mobility and move better, then strengthen and move more.  Stretching the same thing every day?  Maybe not so much, unless you're Stretch Armstrong in the hands of a seven year old. 

Summer Festival (and general life) Survival Guide

Last month, I wrote up a brief informational sheet about self-care and overuse injuries for a summer festival.  While most of you regular readers will be familiar with these concepts, I thought I'd give you the option to read the highlights of the article, and also have the pdf download.  (huzzah!)  

PDF to Download! 


Did you know?

-Musicians often live with a certain amount of expected pain.  Not to paint a depressing picture for you, but a 1998 Survey of Symphony and Opera musicians by ICSOM (International Conference of Symphony and Opera Musicians) revealed that 76% of musicians during the course of their career had at least one medical condition compromising performance.  As musicians, we tend to underestimate the sheer mechanical repetition needed in order to perform in our jobs-many traditional symphonic works are thousands of measures long, requiring hundreds of notes per minute.  (Remember this post on statistics?)

-Overuse is a blanket term for muscle, tendon, ligament, bone, and joint issues which are induced through repetitive motion beyond typical limits.  Tendonitis is most common, which is an inflammation of the connective tissue that connects muscle to bone.


-Move more! Exercising can't undo 6-8 hours of sitting, so add more movement to your day.  Walk more often, take the stairs, carry things- don't take the easy route unless you need to. Your body molds itself like silly putty to the shapes that you put it in-choose wisely (and move diversely)!

- Do simple mobility and stretching every day.  Stretching may not seem like the coolest thing to do at breaks or between rehearsals, but movement can make a big difference in maintaining healthy tissues.  In addition, try to warm up before serious practicing or rehearsals to increase blood flow.  Also keep in mind that when you can't control the amount of rehearsals you have in a given day, self-care should be a priority, not an add-on!

-Use your ischial tuberosities (your sitting bones!).  This Katy Bowman video is my personal favorite for explaining how to sit better, as opposed to sitting on your sacrum.  Poor alignment in sitting (especially if you rehearse more than 6 hours a day) can lead to many other musculoskeletal issues, including back pain and neck pain.

-Get a massage or try self-massage.   If you have residual knots, adhesions, or tight spots in your upper back, consider a serious deep tissue massage, myofascial release, or rolfing session.  Restriction in the trapezius and upper back can affect your whole upper body (shoulders, neck, forearms, etc.).  A good session can restore normal range of motion and increase blood flow as well as remove adhesions in the soft tissue.  Rolling on balls (YTU®, lacrosse, pinky) can also be incredibly helpful as well!

-Sleep more than 6 hours a night. Sleep is when your body takes on cellular repair, renewal, detoxing (!!), and provides rest for your vital internal organs.  When you don't sleep enough, you’re hungrier, more vulnerable to illness, less focused, increasing your odds for injury and disease, and preventing your cells from repairing adequately, which is important when you're playing often.  Sleep often gets sacrificed in the summer for revelry, which is great, until your forearm muscles feel like you've been doing crossfit "musician-style," and your body runs on a combination of all-day caffeine and nocturnal alcohol.

-Drink lots of water. Your body is 60% water, which is essential for cellular operation.  If you're in hot, humid weather, you need to drink more, and if you're moving and exercising in the heat, even more.  Keep in mind that soda, caffeine, and alcohol can contribute to dehydration, and that water helps in the cellular regeneration process.

dB Danger Zone chart!

dB Danger Zone chart!

-Protect your ears in ensembles.  Sounds above 140 decibels cause immediate damage to your auditory sensory receptors, and normal conversational levels are 60-70 dB.  Flutes and piccolo are between 111 to 145 dB, trumpets can reach up to 140dB, and a full orchestra can be between 120-150 dB.  We all know that hearing loss can be permanent, so wear earplugs if you're in the line of fire and ask for a sound shield.  I love the Etymotics brand, but even cheap foam ones can prevent damage.  Your hearing is not only the basis of your musical career, but a primary mode of our verbal communication

    Overall, pay attention to your body, your tissues, and your pain signals.  Pain is your body's way of telling you that something is not working in your movement patterns, habits, or duration of activity.  Shooting pains, numbness, and tingling are warnings of bigger potential issues, and you should stop playing immediately and see a medical professional if these are occurring.  No festival rehearsal schedule is worth long-term tissue damage, nor is a competition, a recital, or any other concert engagement.

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