Musicians' Health Collective

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

Filtering by Tag: neck

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

Image from HealthSurgical.com 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

Rethinking Headstand

image from Leslie Kaminoff's Yoga Anatomy.

image from Leslie Kaminoff's Yoga Anatomy.

The two yoga asana that are often touted as "the mother and father of yoga poses" are shoulderstand and the headstand, neither of which I teach.  You may remember my thoughts on shoulderstand risks for musicians, and  I thought it was time to tackle (and retackle) headstand and its risks (for musicians and normal folks too).  I used to practice headstand and it *always* flummoxed me.  I asked teachers about my alignment constantly, and yet I usually left class with a dull headache.  I stopped practicing it unless absolutely necessary (like when a teacher comes over to you and asks what's wrong with you and why you aren't doing a particular pose in class), and even then, have often put up a fight.  (PS. Any teacher, whether it be crossfit, yoga, Pilates, whatever, that doesn't respect your actual mechanical limits or your desire to perform a complex movement on any given day is probably not the right teacher for you).

Here are some of the health claims that headstand supposedly provides:

  • Builds strength in the shoulders, neck and core
  • Slows and reverses signs of aging
  • Stimulates the pituitary and pineal glands
  • Improves digestion
  • Calms the mind and relieves stress and mild depression
  • Relieves some symptoms of asthma, menopause, infertility, insomnia and sinusitis
  • Reverses the effects of gravity on the lungs, diaphragm and skin
BKS Iyengar in supported headstand.  Iyengar's teachings touted shoulderstand and headstand as the most important asanas, yet, they are precarious, and perhaps should not be held for as long a duration as has been taught in the last 50 or so years.

BKS Iyengar in supported headstand.  Iyengar's teachings touted shoulderstand and headstand as the most important asanas, yet, they are precarious, and perhaps should not be held for as long a duration as has been taught in the last 50 or so years.

-Courtesy of MyYogaOnline.com

And now a few (of many) risks: 

-Cervical vertebrae damage from an inability to support weight in shoulders

-Additional soft tissue/nerve damage (muscles, ligaments, etc.) to upper extremity

-Dangerous for those with high blood pressure who can experience ruptured blood vessels in the eyes and upper body

-Anti-inflammatory drugs  can add to risk

Courtesy of Performance Sports Care

Many of the supposed benefits may be true, but there's not much evidence based research out there.  I do have colleagues who believe to have injured themselves from this posture, and certain styles of yoga encourage students to hold this posture for 5-10 minutes daily.  More and more research based and anecdotal evidence is coming to light in regards to the hazards of headstand (and shoulderstand).

Here's a few reasons why I've never taught it in a group class:

1) First of all, it always gave me headaches.  Yup- It actually caused pain afterwards which usually subsided.  Why?  Because I found out two years ago that I have a pituitary tumor (non-cancerous), which means maybe I shouldn't put weight on my head like that.  No amount of "benefit" is worth that for me, even though it should balance the very system that I have a tumor on.  Did headstand cause my tumor?  Most unlikely.  Did headstand cause my headaches and occasional neck pain?  Most likely.  In a group movement class, you have NO idea what students are working with, and students may not themselves know what their limitations are.  I certainly didn't know I had a tumor, and other students may not know they have "forward head position," neck challenges, or that they lack the strength to support themselves.

Forearm balance- strength and range  needed before even thinking of headstand!

Forearm balance- strength and range needed before even thinking of headstand!

2) Headstand requires a huge amount of shoulder strength in external rotation, protraction, and upward rotation of the scapula to name a few.  A student would need to have impeccable alignment in forearm planks and dolphin, coupled with an ability to have stable shoulders in forearm balance before adding in a headstand.  In addition, some classes and styles of yoga have students hold this pose for 5-10 minutes in class.  We don't know what the long term damage can be to the neck and spine from holding a pose like this daily for that duration, so use your judgment!  

Lacking the range to attempt headstand or forearm stand.

Lacking the range to attempt headstand or forearm stand.

A starting range for attempting such postures- forearms can be parallel to the floor, shoulders protracted and supporting.

A starting range for attempting such postures- forearms can be parallel to the floor, shoulders protracted and supporting.

3) Not everyone has the range ability to get their arms over their head with elbows bent unloaded.  Take a look at these pictures below: see how the forearms aren't parallel to the ground in the first image?  If she then attempts a head stand or forearm stand, her body won't be able to get upright without some serious adjustments, possible with the neck taking too much load (poor delicate, highly mobile cervical vertebrae), her spine extending, or her shoulders getting shredded.  Before even considering head stand, a student should have the pure range of getting their forearms parallel to the ground in standing without compromising the spinal integrity.

This is a headstand adapter which takes the head and neck out of the equation.  I'd say that you still need shoulder strength, but it's a nice alternative for inversion junkies.

This is a headstand adapter which takes the head and neck out of the equation.  I'd say that you still need shoulder strength, but it's a nice alternative for inversion junkies.

4) Folks sometimes interpret headstand as time to jump on their head, literally.  Whereas you can kick into handstands relatively safely, headstand kicking up is a terrifying prospect.  Also, I hate being in a class where someone falls over backwards out of headstand-not only does it sound awful, it is painful.  (And never go upside down near a door, window, or an open flame, folks!).   In many ways, the foundations of handstands and forearm stands are much safer, both in terms of falling, and in terms of building long term strength for other poses and movements.  If you are determined to practice headstand, add in the piking piece to gain strength in the lower body, rather than hopping up!

5) We've built up a false history for headstand; most yoga asanas are not thousands of years old-most poses were "created" and codified in the last hundred years.  Attaching serious health and historical value to one or two poses (more than anything else) is  ridiculous and unfair to practitioners for whom this is not suitable and will never be suitable.  You can have a full beneficial yoga practice WITHOUT headstand, shoulderstand, or even downward dog!  This doesn't mean that you (or anyone) can't practice that pose anymore, but be aware of the inherent risks involved and notice when it is not well instructed in a group class setting (in which the teacher doesn't know every student's body, injuries, or abilities). 

If you're a teacher and you have the range and strength to perform the pose, you have to ask, "do all of my students understand what is needed here, do they have the pure range of motion, do they have the strength in their shoulders and serratus anterior, and can I instruct this in a way that everyone feels safe and supported?"  

This poor neck has taken a beating from constant neck flexion!  Keep your neck happy instead with gentler inversions!  Pic from  performancesport care.com

This poor neck has taken a beating from constant neck flexion!  Keep your neck happy instead with gentler inversions!  Pic from performancesport care.com

6) Lastly, many people have kyphotic standing and sitting posture, with necks a little forward and spine rounded.  If that already exists, why are you going to add 150-200 pounds of weight to it?  Even if the student is not misaligned in standing, headstand goes full throttle rather than gradually adding weight in the head and shoulders.  A hundred years ago or more, people (especially in India!) moved differently- they might have carried loads on their heads, they might have had better posture, they might have moved more, walked more, etc.  Nowadays, things are different-without head carrying, there's no pre-training of neck strengthening to even see if you can support any weight, let alone your whole body weight.  If you're a musician who plays an asymmetrical instrument, you're more at risk for one side of your neck to be tighter/stronger/weaker than the other side.  Combined with typical musician shoulder range and strength issues, poses that stress the neck should probably be avoided for many (many!) other more beneficial movements.

Last thing- if someone of something tells you that a movement you love is perhaps unsafe or not beneficial, rather than getting defensive, look at the big picture.  Why is this unsafe for you?  What restrictions do you have?  Do you lack strength or stability?  If you lack the range of motion in the shoulders or strength to support yourself in headstand, these are separate things that can be cultivated over time without doing the pose itself.  If your neck vertebrae are fragile from previous injury, then it may not be worth it to take a risk.  You only get one spine and one set of vertebrae (and discs!).  Rather than seeing the pose as the end goal, look at the movements and ranges required to execute the pose and then ask yourself: why am I so attached to this pose, and does it matter if I achieve it?  Doesn't any version or regression of the pose count as the pose?  Does it make you a better person, yogi, or teacher to do the "full pose?" ...Just my thoughts on that.

Copy of If you want to practice an advanced inversion like a yoga handstand, headstand, shoulder stand, or forearm stand, you have to ask yourself_ do I have the Range of Motion to perform this movement unloaded? Are.jpg

Shoulderstand, or Just Because A Teacher Suggests A Pose Doesn't Mean You Should Do It

This is an anatomical cutaway of shoulderstand with the the hands and forearms on the ground.  (Note the breast tissue is defying gravity and not descending towards the earth.)  I can't remember where I found this, so I'm sorry!

This is an anatomical cutaway of shoulderstand with the the hands and forearms on the ground.  (Note the breast tissue is defying gravity and not descending towards the earth.)  I can't remember where I found this, so I'm sorry!

If you're not a yoga or pilates person, this particular blog post may be of little interest to you.  My apologies.  For everyone else, let me continue.  I rarely teach full shoulderstand in a yoga class (or full jackknife in pilates), especially not to musicians.  I've mentioned this before, but I realize that I should give some thoughtful explanation to some of my yoga musician friends who may be wondering what I'm thinking.

First of all, yoga is not inherently beneficial, meaning that not all yoga poses are equal, and not all yoga postures will be suitable for everyone.  There is sometimes a view that yoga cannot harm people, which is frankly a lie.  People get injured in yoga classes, teachers get injured in yoga classes, and like any movement based activity, certain movements are riskier than others.  With that in mind, let's look at musicians as a general population and some of their tissue issues.

-We often have neck pain and neck injuries from Repetitive Strain and decades of instrumental study.

- We often have limited ROM in our shoulders, weak shoulders, or shoulder pain.

Iyengar was one of the most famous teachers of the 20th century who touted this pose as the most beneficial, as well as headstand.  He is also built like gumby, and his lifestyle and body is not similar to most of my musician and yoga realm colleagues.  He also does not have female breast tissue, otherwise he might have reconsidered the suffocating detriment of this pose.

Iyengar was one of the most famous teachers of the 20th century who touted this pose as the most beneficial, as well as headstand.  He is also built like gumby, and his lifestyle and body is not similar to most of my musician and yoga realm colleagues.  He also does not have female breast tissue, otherwise he might have reconsidered the suffocating detriment of this pose.

-We have often accepted a certain amount of pain from musical study as normal, which means we might not be able to detect destructive pain signals in weight bearing situations.

-We have spectacular proprioception of hands, jaw, fingers, embochure muscles, etc, but don't necessarily have large muscular/joint proprioception.

- We often have tucked pelvises and forward head position from sitting in a slouched chair for 6-8 hours a day.

I'm sure you get the idea, so let's go back to shoulderstand.  I bring this posture up because it is often touted as the most beneficial posture ever, and its risks are typically ignored, or at least an afterthought.  Here are some of the yoga articles promoting it's benefits: 10 reasons to do a shoulderstand every day, Shoulderstand: a Love Story, or another article on how to modify shoulderstand as to not overstretch the ligaments of your neck.  Ok folks, let's take another look at the benefits of shoulderstand.  Here are some highlights from yoga journal and the above mentioned blogs:

This is an awkward internet drawing of neck flexion.

This is an awkward internet drawing of neck flexion.

-It circulates lymph, it's an inversion which has inherent benefits, it's excellent for thryoid disorders, it soothes the nervous system (unless you're suffocating on your own breast tissue), it's good for fat loss (I'll believe that when there's a study), and will apparently relieve symptoms of asthma.  

Sorry for the cynicism, but I have always strongly disliked this posture because (suprise!) it doesn't feel great for my neck, I always feel like I'm suffocating in my own breast tissue, and I think there are better postures for musicians (and most yoga students) who already put stress on their neck ligaments and cervical spines.  But I digress.   There are two main actions needed for shoulderstand: full shoulder extension and full cervical (neck) flexion.  

Here's the test I learned from the folks at Yoga Tune Up® which has alleviated my guilt from disliking this pose.

1.  Interlace your hands behind your back.  Lift your arms.  

2.  Do your arms end up being parallel to the floor when you lift up?

3.  If you can get your arms parallel to the floor in full extension, do you distort your torso and neck?

4.  Can you then also flex your neck fully to your chest with shoulders in extension?

5.  If not, then why try and and invert when you'll be smooshing all your weight into your neck?  Can you see why you need to be able to lift your arms to parallel?  You're essential trying to make a 180 degree line between your flexed neck and your arms in order to support yourself.  

"Viparita Karani" or legs up the wall for you non-sanskritters.  Leotard optional.

"Viparita Karani" or legs up the wall for you non-sanskritters.  Leotard optional.

If you can't get your shoulders in extension  parallel to the floor, why are you going to turn it upside and try to force your arms to the floor when you can't do it upright?  It's an impossible task!  Then, add some weight and you'll just end up crunching your neck.  Sounds painful, right?  Simply put, most people (especially musicians) don't have the shoulder capacity to do this pose safely, and their lack of range puts a huge strain on the neck, which is already a tricky place and source of pain for many of us.  Added in that many people can't do the full range of neck flexion, (i.e. chin to chest) needed here, which is why there can be problems.  Why try to put yourself into a posture that's not built for your body or most bodies?  Do something that makes sense for your body and your range of motion, as well as your long term health.  Or even better, start practicing movements that will prepare your body for that posture (if you really want to do it).  Some people can (and do) have the range of motion and strength to do this pose safely.  Others don't and have injured themselves.  There are lots of supposed benefits to this posture, but not at the expense of your neck, folks!  Try something a little more friendly, like viparita karani, which is a gentle inversion (getting you that lymph exchange and blood flow benefit).

And here's a warning about what can go wrong in shoulderstand: 

“What happens if your student forces her neck too far into flexion in Shoulderstand? If she is lucky, she will only strain a muscle. A more serious consequence, which is harder to detect until the damage is done, is that she might stretch her ligamentum nuchae beyond its elastic limits. She may do this gradually over many practice sessions until the ligament loses its ability to restore her normal cervical curve after flexion. Her neck would then lose its curve and become flat, not just after practicing Shoulderstand, but all day, every day. A flat neck transfers too much weight onto the fronts of the vertebrae. This can stimulate the weight-bearing surfaces to grow extra bone to compensate, potentially creating painful bone spurs. A still more serious potential consequence of applying excessive force to the neck in Shoulderstand is a cervical disk injury. As the pose squeezes the front of the disks down, one or more of them can bulge or rupture to the rear, pressing on nearby spinal nerves. This can cause numbness, tingling, pain and/or weakness in the arms and hands. Finally, a student with osteoporosis could even suffer a neck fracture from the overzealous practice of Shoulderstand.” -Roger Cole

If you want to practice an advanced inversion like a yoga handstand, headstand, shoulder stand, or forearm stand, you have to ask yourself_ do I have the Range of Motion to perform this movement unloaded? Are my tiss.jpg

If you DO want to practice shoulderstand, here are some things to think about:  do you have the necessary range of motion to perform it? How often do you practice the pose, and for how long?  If you need to improve certain ranges of motion to perform the pose, are you working on those in your daily life (like improving shoulder extension)?  Since I've started teaching pilates in the last few years, I've really enjoyed the different regressions and different approaches to a similar movement in the pilates repertoire, jackknife, which asks for less extreme ROM in the shoulders and spine, as well as a much shorter hold.

Ouch! Believe me yet? Want to read more?: I like this article from Smarter Bodies and the ongoing work from Matthew Remski re: yoga injuries and asana.  

 

 

 

 

Violinists and Violists: Your Chin Rest is Actually a Jaw Rest

I know, it's called a chin rest.  And the Kun thing is more of a collarbone rest, which is another misnomer for another day.  Today in my lesson with Alexander Technique teacher/bodymapper/violinist Jennifer Johnson, we talked about how the chin rest which should really be called a jaw rest.  When we hear chin rest, whether as an adult or child, we invariably think our chin goes on the rest, and we often turn our head extremely out to the left and press down with our head to "keep the violin up."

Using the chin rest as a point of contact with the "Chin" rather than allowing the back of the jawbone to make contact.

Using the chin rest as a point of contact with the "Chin" rather than allowing the back of the jawbone to make contact.

     When you look at Benedict Bones in the first image, you'll see that the portion of the body contacting the chin rest is the chin when the head turns out extremely to the left.  Few people have the violin or viola set up so that the head is in neutral and not turned out to the left, but notice how much you turn the head to the left.  Some students were told to look at their hands when first learning the instrument, but you can look without turning your head.  Others combine the head turn to the left with elevation of the scapula, which can lead to long term tension and discomfort.  Look at your setup or your student's: How much muscular work is happening in the back of the neck and the left side?  What's happening in your jaw?  Do you clench the jaw to hold the instrument up? Do you roll the head to the left or push the head down?

Image from Vital Gaitway, courtesy of Christine Altman

Image from Vital Gaitway, courtesy of Christine Altman

       I tend to agree with the image above, which shows the head in a pretty neutral position, bobbling from the AO joint rather than extremely turning the head to the left.  See the difference when the head is more neutral (image below)?  The jaw bone is in contact with the rest, rather than the chin.  Now you might say, "Oh, I'm going to drop it!"  First of all, the instrument is contacting many parts of your body besides your mandible.  Your hand is holding it, it's resting on the collarbone, it might contact your left neck, and your bow friction is helping matters too!  (Thanks to Jennifer Johnson's awesome book for listing those 5 places of contact).  We definitely don't want to push down or down and forward on the chin rest to hold the violin, so play around with positioning this week and start to notice where you contact your chin rest!

Notice that the back/side of your jawbone actually contacts the chin rest.  The chin is a layperson term which can also lead people to crazy head positions.

Notice that the back/side of your jawbone actually contacts the chin rest.  The chin is a layperson term which can also lead people to crazy head positions.

Still in Pain? Ditch the Heels and the Purse

Every once in a while, a musician friend will come to me in a panic because they have sudden shoulder, arm, neck, or back pain that's never been a problem before.  I usually ask them two (maybe three) questions: what sort of shoes do you wear, how big is your purse/case, and how do you sleep? If you're a regular reader of the blog, or if you know me personally, you know I don't like wearing high heels (or standing or walking in them) for long periods of time.  I frankly feel gypped- our society has told us that women look sexy, tall, powerful, etc., in heels, despite the fact that the shoes are killing our feet, knees, hips, back, and neck.  Any mainstream magazine will have articles for "comfortable heels" or "treatment after heels," but it wasn't until this year that I learned that elevated heel shoes are seriously contributing to your pain.  However, the combination of a heavy purse and heels is the real kicker.  Last week, I mentioned how carrying your instrument case can be a source of pain and misalignment, especially if you have a repetitive pattern of carrying that is never changed.  But let's take a quick look at purses and how they're really causing some pain.

For most people, it's not the style of purse that's the problem, it's how much it weighs and how you carry it.

For most people, it's not the style of purse that's the problem, it's how much it weighs and how you carry it.

There are a few different types of purses out there:

1.  The Over the Shoulder Holder

2. The handbag, which you must carry in hand or over the elbow.

3. The Big @$$ Tote, or the BAT

4. The Cross Body Bag (or a messenger bag)

Now quick, if you have a scale, go weigh your full purse, man bag, messenger bag, etc.  I'll wait.  Every once in a while, I weigh my purse, especially if I'm at an airport and they have one of those luggage scales, and it's disturbing how much we carry.  I've had bags weigh 10-20 lbs, and in school, my backpacks and messenger bags weighed 20-30 lbs.  Yikes!  Couple that with high heels, and no wonder people have back pain!

How high heels force a compensation pattern in the body- letter C is the control, and A,B, and D, are a few of the different ways your tissues might adapt.

How high heels force a compensation pattern in the body- letter C is the control, and A,B, and D, are a few of the different ways your tissues might adapt.

*Just in case you're wondering about my beef with high heels, take a moment to read these.*

Heels force the foot, knee, pelvis, spine, and neck out of alignment, and causing them to tuck their pelvis and jut the chest forward or round the spine, pushing the head forward.  Think of that as your starting position, and then add an 8 lb weigh on one shoulder when your body is already vulnerable.  Ouch!  If the head is in a forward position from heels (see images A, B, and D), and a one shouldered purse is added (and a case), the risk for injury is much greater, especially if you've already had neck, shoulder, or nerve pain in your life.

With our four types of bags, each poses a risk.  The over the shoulder bag tends to favor one shoulder all of the time.  Few people switch sides, which can pose a long term risk to those tissues, who remain on tension and in contraction which widens the asymmetry between the sides.  The handbag can be a great option if you carry it in your hands and don't rest it on your elbow constantly.  When heavy handbags dangle off the elbow, we put extra risk on the radial side of the forearm, specifically the delicate tendons and nerves.  The BAT is especially suspect because most of us (myself included) will fill that bag to the brim with things that we may not actually need.  If you need to carry lots of stuff, consider a messenger bag, a backpack, or carrying your tote in your hand to reduce the stress on your shoulders.  Lastly, the crossbody bag is a great option if you switch the sides with some frequency and keep the weigh in check. 

In the last year or two, I've moved away from carrying everything in my life on my shoulder (and ditched most of my heels...still have my cowboy boots, which have a half inch-1 inch heel), and my pain has diminished exponentially.  If this is something you've never thought of, stop walking in heels (and I don't just mean stilettos- I mean everything.  Take a ruler to your closet, folks!) and switch out your bag for something lighter.  Even if you don't have a scale in your house, look to see what you're carrying, and whether you need it.  If I'm honest, I don't need half of the things I used to carry, and I'm not in pain for it.



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