Musicians' Health Collective

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

Filtering by Tag: nervous system

Musicians and Muscle Imbalances

Common sense will tell you that musicians (and athletes, dancers, or anyone who focuses on one human activity the majority of the time) will experience muscle imbalances at some point in their life or career.  They might not label their pain or adaptation as a result of muscle imbalances, but it's often at the root of our issues.  Let's backtrack first though.

I sort of love this picture focusing on the more aesthetic side of muscle imbalances- most imbalances won't be this obvious! I mage from Pole PT.

I sort of love this picture focusing on the more aesthetic side of muscle imbalances- most imbalances won't be this obvious! Image from Pole PT.

Muscles move bones through a combination of contraction and relaxation in tandem with opposing muscle groups (i.e. the hamstring group and the quadriceps group or opposing groups).  Contraction is also called facilitation, and relaxation as inhibition.  In the gait cycle, the hamstrings will contract to extend the hip and flex the knee, whereas the quadriceps will contract to extend the knee and flex the hip.  They work in opposition at various points in walking. (*Just to be clear, there are many other myofascial units that play a role in gait. This is just a simplified example!) Normal muscle function is when the facilitation/inhibition cycle is balanced, with no one muscle or muscle group dominating above the others.

Imbalance is when a muscle or muscle group dominates within its role in movement.  This may be due to overtraining, meaning that the opposite muscle may be weak, with limited range of motion, or have difficulty firing.  If we apply this to walking with hamstrings and quadriceps, many people over-fire their quadriceps, meaning that they don't relax after their work is done.  This may then pull on the knee cap (patella), affect the resting length of the hamstrings, and also affect movement actions like walking, extending the hip, etc.  This uneven relationship may be because of overtraining (i.e., way too much quadricep strengthening, lack of hamstring mobility or strength) or a combination of other factors.

One of the common theories to address imbalances is upper/lower crossed syndrome. This  simplified chart  demonstrates muscles that are weak, which may be inhibited, and muscles that are tight and perhaps overly dominant or overly developed. I would also suggest that the words weak vs. tight are not the best to describe the syndromes, because some muscles are weak and "long resting length" and some are weak and "short resting length." There's more to it than just weak=long and strong=short. This is still a muscle theory, which means that there are mixed feelings about whether these relationships are accurate!

One of the common theories to address imbalances is upper/lower crossed syndrome. This simplified chart demonstrates muscles that are weak, which may be inhibited, and muscles that are tight and perhaps overly dominant or overly developed. I would also suggest that the words weak vs. tight are not the best to describe the syndromes, because some muscles are weak and "long resting length" and some are weak and "short resting length." There's more to it than just weak=long and strong=short. This is still a muscle theory, which means that there are mixed feelings about whether these relationships are accurate!

Although this is still a theoretical model, many musicians do have many of these symptoms, including forward head posture, and overly kyphotic/rounded upper spine, and weakness in the back body.

Although this is still a theoretical model, many musicians do have many of these symptoms, including forward head posture, and overly kyphotic/rounded upper spine, and weakness in the back body.

What makes this issue more interesting, at least to me, is that it's not just a muscle issue.  Our nervous system plays a huge role in the way we recruit muscles and retrain them.  For example, a trauma to the tissues (accident, injury, etc) can affect the muscles long after the injury has passed.  Speaking from personal experience, I injured my knee in a bike accident 8 years ago, but my non injured hip and leg do weird compensations, even though the other leg is perfectly capable of healthy movement now.  Physical and emotional trauma can also take on an emotional/fear response- a past injury or emotionally traumatic event may evoke a sense of fear, albeit unconscious, when addressing that muscle.  Musicians who have experienced tendonitis in one arm or hand may have this sense when beginning to rehab, practicing a challenging passage, or receiving massage/bodywork.  This can also apply to more complex traumatic events like assault, physical violence, car accidents, and other events, which may force the person to dissociate from their body or areas of the body.  All of this can be labeled as a neuromuscular imbalance, which is more complex than simple "muscle weakness/strength" models.  

Putting it all together, when someone comes in with a pain symptom, either related to music or other events, it's a lot more complicated than "you're practicing too much" or "your instrument setup needs to improve."  Imbalance can be a result of 

1) Exercise/overtraining: musicians often overtrain the flexor muscles of the hands and forearms with little attention to larger muscle groups or opposing actions

2) Daily movement and lifestyle choices: This can include sitting posture, shoe choices, standing posture, sedentarism, how one holds one's case, cell phone, or belongings, and so forth.

3) Injury

4) Neurological disorders

5) Illnesses: arthritis, diabetes, chronic fatigue, and many other illnesses affect muscle tension relationships, pain, and strength.

6) Pain: Pain will affect the nervous system's ability to know where it is in space (proprioception) and will affect movement.  There have been quite a few good blogs on pain and movement, so here is one from guest writer, PT Arlyn Thobaben, to get started.

7) Stress: Stress, along with pain, can affect muscle tensional relationships.  Often when we're stressed, we move and breathe in a less than optimal way, which may enhance tension in the upper back, neck, and so forth.

How can we address these issues?  Bodywork, especially with someone who can address muscle imbalances and nervous system imbalances can be a great starting point.  General exercise can make imbalances worse if not addressed- seeking a knowledgeable trainer in pilates, corrective exercise, weight training, or other movement modalities can help restore balance to overworked muscles.  As I mentioned in the last post, everything starts with awareness, so finding a teacher in subtle body practices like Alexander Technique, Body Mapping, Feldenkrais, or other practices can be very helpful in feeling the imbalances in your own body.  Lastly, giving your nervous system the chance to relax, whether through constructive rest, massage, or meditation is a great starting point for moving out of the fight and flight sympathetic nervous system response.

Focal Dystonia: A Violist's Perspective

Dystonia is a neurological movement disorder that can cause muscles to involuntarily contract, resulting in uncontrollable  movements. For musicians, focal dystonia or focal task-specific dystonia often affects muscles that are used for repetitive movements. Musicians can suffer from focal dystonia in the fingers or hand, embouchure dystonia, or even dystonia of the vocal chords.

I first noticed symptoms of focal dystonia in 2011. My ring and pinky fingers would involuntarily pull in towards my palm, and I would accidentally pluck the strings. I also noticed my ring finger wouldn't lift as quickly as I wanted it to on descending scales. For both issues, I thought that I just needed to practice harder, do more technical exercises, and relax my hand. When I had a quartet recital coming up and couldn't make my fingers work despite practicing as much as possible, I finally saw a doctor and went to physical therapy. After googling my symptoms, focal dystonia came up, but when I asked my first physical therapist about it, she said it couldn't possibly be that.  My PT sessions ran out, but nothing really improved. I continued to blame myself, my technique, and continued to practice harder. Finally, it all caught up to me. I was super tense and anxious because I couldn't play, and I was creating all kinds of extra tension trying to make my fingers work. My ring finger and pinky were curling in and my forearm was killing me after just a few minutes of playing because of the tension. I had to stop playing in the orchestra and figure out what was going on.

Over the course of 2 years, I saw 3 orthopedic surgeons with 3 different diagnoses, 3 physical therapists,  2 massage therapists, and a chiropractor, all with only minor temporary improvements. Finally, my last 2 physical therapist, who were amazing but still couldn't fix me, recommended I see a neurologist. I knew at that moment that it was focal dystonia. I waited weeks for my appointment at the Cleveland Clinic. After a thorough exam and seeing my symptoms while playing viola, the neurologist confirmed my suspicion of focal dystonia. I was waiting for him to tell me of this great new amazing way to treat it, but his outlook on my treatment was pretty grim. He said I could do Botox injections, but they really don't work unless you can find someone to help retrain the hand to use the correct muscles. I asked about playing right-handed and had actually already borrowed a student instrument to do this, but he said I could develop the same symptoms in my right hand. I asked about drugs, but he said there was nothing that would help this enough to play.

I decided that there must be someone doing research and looking for a cure, and I found them at the University of Michigan. Again, I had to wait about 6 weeks for an appointment. I saw a general neurologist who (again) diagnosed focal dystonia, but then referred me to a dystonia specialist. Another 6 or so weeks... In the mean time, I was trying Acupuncture, Alexander technique lessons, and had a body mapping lesson. When I finally got to the last appointment, all they had to offer was Botox. Really? No one will help me retrain? I had also heard that Botox could cause lasting side effects on my muscles, and that wasn't a risk I was willing to take.

I tried another acupuncturist and tried a chiropractor-neurologist. Nothing was helping enough to make a difference. I even gave up coffee, gluten and dairy. The jury is still out as to whether or not this is helping, so I (mostly) stick to it. Apparently, gluten is processed in the same part of the brain as dystonia. As for coffee and dairy, I don't understand exactly why, but two different specialists recommended it and I'm desperate!

As all of this was going on, I would try to play a little bit each day. Some days, I would only last for about 2 minutes because the symptoms were too bad or I would just break down because I really wanted to just play some Bach, not try to make my finger lift up or keep it from curling in. On good days, I could play for about 10 minutes.

Focal dystonia has affected many musicians, most notably pianist Leon Fleischer, who had focal dystonia symptoms in his right hand for many years.   He began to regain movement in his right hand more than thirty years later.   Other musicians with FD include violinist Peter Oundjian and pianist Glenn Gould.

Focal dystonia has affected many musicians, most notably pianist Leon Fleischer, who had focal dystonia symptoms in his right hand for many years.  He began to regain movement in his right hand more than thirty years later.  Other musicians with FD include violinist Peter Oundjian and pianist Glenn Gould.

Finally, I found a doctor in Canada, Dr. Joaquin Farias, who works with musicians who have dystonia. I have heard of many people starting to recover and who make full recoveries after meeting with him and following an individualized recovery plan. So, I made an appointment. This last January, I went to Toronto and met with him for 4 days in a row. He analyzed the movements of my hand and gave me exercises to help retrain the correct muscles to start working again. Within 2 days, I was able to play simple pieces. A lot of recovery is 2 steps forward, 1 step back, sometimes 3 steps back of 5 steps forward, but now I have hope.

I try really hard to accept whatever state my playing is in and look at any issues like a puzzle. It not only helps me make progress, but it helps me stay positive. I have learned that even on bad days, I am still making progress, even when it doesn't show. Recently, I had two weeks of bad days and then reluctantly went to practice. I found that my hand was working better than it had in at least a year. It still comes and goes, but I keep making new discoveries that help me to move forward.

I am still teaching private lessons, but my students and I have learned to have successful lessons without me having to demonstrate very much. My students listen to their pieces at home to enable them to guide themselves when learning new music, I use YouTube when necessary in the lessons, and I can use my right hand to play on the piano when needed. I have also been taking classes to become a certified Montessori teacher in a 3-6 year old classroom. I am learning tools through my classes and in the classroom that help my teaching in general, despite my lack of playing. It's been a learning process and very frustrating at times to teach without playing, but I'm grateful to still be able to work with kids who love music. I do think everything I'm learning to help my dystonia get better also helps me understand my students' challenges and be able to break things down better for them.

Aside from viola and violin, my focal dystonia only really interferes with typing. I have mostly typed things on my phone with my thumbs since last January. I have ninja-like skills :) I have become healthier by trying to take care of myself with enough sleep, healthy food, less caffeine, etc., and in trying to not be consumed by not being able to play. It helps to focus on other cool things I'm doing and the progress that I'm now making.

One thing I'm focusing on is raising money for dystonia research by running the Glass City Half Marathon on April 26th. If you'd like to check out my fundraising page or make a donation, click here! Any donation would be greatly appreciated!

While focal dystonia is not fun, it is not a death sentence. I do believe that someday, I will beback playing. I've gotta "Just keep swimming, just keep swimming" :)

What is Pain?

Guest Post from Arlyn Thobaben, PT, DPT

Pain can be difficult and confusing. I spent much of my musical career trying (and often failing) to understand and manage my recurrent struggles with a stiff neck, a tingly left arm, and a sore upper back. When these symptoms became too much for me to continue playing and teaching,I was referred to a physical therapist , for the first time. Not only did my physical therapist help me along and get me back to my violin, he inspired me to turn my curiosity and interest in human anatomy into a new career path. After much contemplation, I packed up my violin to purse a doctorate in physical therapy. I was on a mission to help other people understand and begin to manage their pain!

Now that I have become a physical therapist, my primary role is to collaborate with each patient in creating and implementing an individual plan for pain management. This can include hands-on treatment in the clinic, home exercises, movement strategies, and activity/behavior modification, but the first step often involves increasing understanding pain and its physiology.  If you have been struggling with pain as a musician, you are not alone! In this 3-part series, I aim to help musicians like you understand pain a bit better, shed some light on the role of physical therapy, and provide some battle tactics for those who have been struggling with nerve entrapment issues and / or chronic (long-term) pain.

First, what is pain? It is a multifaceted experience that we may describe as a sting, ache, burn, twinge, pinch, stab, throb, stiffness or other unpleasant term. It can be annoying, worrying, even debilitating. It can make a brief appearance, or hang out for a while. Pain is highly individual and personal, so much that there is no way for an outsider (for example, your doctor or therapist) to objectively measure your pain. In other words, you are the only person who can experience your pain. Pain is a normal body process, involving many body systems, that is experienced when the brain concludes that somewhere, somehow, you are being threatened. Pain is often a motivating force to change: your body position, your situation, your behavior. Pain is meant to keep you safe.

So why don’t we say “yay, thanks!” to our pain and embrace it for its important, life-preserving role? Acute pain caused by a sudden injury (a slip and fall on an outstretched right arm, for instance) can prevent a violinist from holding and manipulating her bow, thus forcing her to sit out of her orchestra job, perhaps even for the next several months. Chronic pain (which will bediscussed in greater detail in part 3) can affect a musician profoundly for months or years. No wonder why we can hate and fear our pain, wanting it to just go away! However, I believe that when we soften our stance by working with our pain, rather than fighting against it, that we can be happier and more productive. We just have to dig a little deeper to find out its message.

Here are some of the most common pain messages:

Call an ambulance / seek medical attention immediately. Maybe you were involved in a traumatic accident, or the pain is intense and sudden, unusual / disturbing, or accompanied by excessive bleeding, broken bones, or any other gruesome scene you could dream up. This time, the body is telling you to get help quickly.

Time to rest and recover. Following an acute injury, this type of pain usually requires time off for the bones, muscles, ligaments, and tendons involved. Although it can be difficult, this type of pain usually means the marathon runner should cease training, and the cellist should stop playing the cello. This time off can also be mandated by a surgeon, physician, therapist or other professional. The body’s healing functions can be more efficient with adequate rest, nutrition, sleep, and smoking cessation (if applicable)

Time to retrain the body / gradually return to function. This type of pain hasaffected most musicians at some time in their career. Overuse injuries such as tendinitis or nerve entrapments are often involved, and acute injuries often transition into this type of pain after several weeks once initial healing has taken place. Recovering from this type of pain requires patience, persistence and artistry.  It can be facilitated by someone like a physical therapist, Feldenkrais Alexander technique,  instructor, yoga teacher, your private instrument teacher, or other professional. The body is telling us that yes, we can return to our activities gradually, but we may need to examine and change our posture, technique, or rehearsal load.  It is telling us to plan and schedule our practice very systematically to allow the  body adequate recovery time. You do not want to play or practice through this type of pain.

• Time to retrain the brain.  When pain has continued for a long time (e.g. 3 months or longer), it may be necessary to retrain the brain through visualization, movement strategies, and carefully graded exposure to activities involved. You may have been searching for a definitive diagnosis for a long time, your pain may be becoming more widespread, or you may be noticing that you have been able to move and function less and less over time. This type of pain can be the most difficult to deal with, and requires a strategic approach (which we will discuss in part 3, stay tuned.)

How does your brain respond to pain?  And why does everyone's experience differ?  Watch this Ted-Ed video on pain thresholds and how pain causes different reactions in different people.

If you are a musician with pain, remember- you are in good company, and there are many resources available to facilitate your recovery! In the next post, we will discuss in more detail the physiology behind pain and nerve entrapment issues. Knowledge can be one of your best allies in managing your pain.


The Importance of De-stressing, De-caffeinating, and Resting

I've been in a movement challenge through the Liberated Body, and I've been thinking about the importance of resting in the course of the day.  In the west (and in classical music) we tend to just go-go-go, and every time we feel tired, overworked, and exhausted, we refuel with caffeine.  There's an expectation in music especially that we just have to keep practicing, keep auditioning, and keep stressing out all the time, and as you know from previous writings, that starts to affect the physiological function of your cells, internal organs, etc., courtesy of your sympathetic nervous system. 

How many musicians do you know that drink a teensy bit too much caffeine in an effort to just do more?

How many musicians do you know that drink a teensy bit too much caffeine in an effort to just do more?

Think about how most Americans work out/exercise:  they don't move much all day (we live in cars, sit at desks,etc.) and then do the MOST INSANE WORKOUT EVER for 45 minutes or an hour.  And then go sit again.  What kind of yoga do most studios offer?  HOT SWEATY (intense) flow and go.  What's the problem with this?  Our bodies need time to do the opposite-to decaffeinate, to stop moving so intensely (if that's our problem), to relax, and allow cellular renewal.  Now I don't necessarily mean that you need to quit your caffeine altogether- I just want you to notice how much coffee/tea/etc. you drink, and if that's your first reaction when you're fading in energy level. 

Simple drawing of Alexander Technique's Constructive Rest position. 

Simple drawing of Alexander Technique's Constructive Rest position. 

How do we help out this cellular renewal and parasympathetic response?  Simply put, constructive rest (which is similar to a yoga savasana).  Constructive rest is an opportunity to lie down (floor, bed, couch, yoga mat) with the knees bent, eyes closed, and arms relaxed.  Some folks prefer their hands on the belly or I prefer hands along side the torso.  Constructive Rest shows up as a concept in many different movement modalities- yoga, Alexander Technique, physical therapy, and massage therapy, to name a few. 

Why do this? 

-This triggers parasympathetic response, which can help with anxiety, stress, insomnia, etc.

- This gives the body the opportunity for a natural spinal curve, which may be difficult to maintain in sitting and standing

- Your psoas (AKA. your own personal filet mignon) has the opportunity to release.  That doesn't have to mean anything right now, but just trust me, it's a good thing.

- Your mind has the opportunity to slow down, and start noticing thoughts slow down.  Combining breath awareness with deregulating action gives you a conduit to thought awareness. 

Here's a beautiful quote from restorative yoga teacher Judith Lasater (from this interview) on the importance of restoring and lying down:

There is something spiritually profound about being still and watching your mind.Most of our unhappiness is not created by what happens to us but by what we tell ourselves about it. With Restorative you create a space to watch the rising and falling of thoughts. And then the most important thing we can do can happen- we can dis-identify with our thoughts, “I am having a thought of anger, a thought of sadness, but it’s not who I am.” We distract ourselves with entertainment. We pay people in our culture the most amount of money who can distract us the best. 20 minutes a day to notice the thoughts that never end. The chatter that never ceases. And slowly over time we have space between our thoughts and our reaction or the words we choose.
— Judith Hanson Lasater

Let me make this clear- this is not a nap, at least not intentionally.  This is active rest.  When should you do this?  Whenever you have time/space to do so, and you're energy is flagging.  Maybe you're preparing nonstop for a recital, competition, or audition-make sure you're restoring every day!  Maybe you have difficulties with stress and sleep-try this.  SO many things in the body are benefited by taking time out to rest and de-stress every day, and in adding this to my self-care repertoire, I have more energy and sleep better. 

Want a detailed video on exactly how to do this?  Brooke (from the liberated body) gives an awesome youtube video setup.



Nervous System 101

Most of us musicians understand "fight or flight," or at least we've felt it, but we often lack the understanding of what the rest of the nervous system is doing.  Our nervous system consists of the Central Nervous System (brain and spinal cord) and the Peripheral Nervous Stem (cranial and spinal nerves), which basically work in a feedback loop of information with the motor and sensory aspects. 

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Within the peripheral nervous system are the somatic, enteric, and autonomic systems.  Somatic can be conscious or unconscious, and results in movement of skeletal muscles as a response to sensory input.  Simply put, the somatic system moves your body.  The enteric system consists of the 100 million neurons of your GI system, and the various actions needed for homeostasis. 

The autonomic system is unconscious and regulates internal organs.  Within the autonomic system are two more divisions: the sympathetic and the parasympathetic systems (now we're in more familiar ground!).  The sympathetic system is what's responsible for our "fight or flight" response, which causes our breath to shorten, eyes to dilate, heart rate to increase, and a few other things.  Most of us know this well from performing and public speaking!  Our parasympathetic system is the compliment, in charge of day to day functions of organs, cellular repair, etc.   

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