Performing Arts Medicine

Performers and Medicine:  There is a new field in medicine: Performing Arts Medicine. Many people are not aware of this new field of medical diagnosis and treatment. Most of the existing information is not available to the general public, including performers.

Think of it as the same kind of repetitive-motion problems experienced by office workers who sit in one position, operating the same keyboard, day after day. It might also be likened to sports medicine because musicians, like athletes, train strenuously and are subject to the anxieties of competition and public performance.

Studies have primarily focused on orchestral performers; and it has been noted that as many as half, perhaps more, of all orchestral performers have had at least one ailment related to the physical activity o~ playing an instrument. If this is true, how much more prevalent piano-playing injury must be. The piano is commonly studied; it is the primary instrument of musical composition; and most churches, dance studios, and vocal instruction require piano accompaniment, even in the age of portable stereo equipment.

So it isn't surprising that a common medical complaint among pianists is tendonitis. There are others, both physical and psychological, but as with other professions that put the bulk of the work on (and therefore can overwork) the forearm and hand, the prevalent piano playing injury involves tendons in the forearm.

Literature on the subject began to appear after American pianist Gary Graffinan was forced to retire from concert performance at the end of the 1970s. This was the first instance of a performer announcing to the public that piano playing had caused or aggravated a grave physical problem.

One has to wonder why, after centuries of keyboarding from harpsichord through fortepiano and modem piano, this was the first "big" performing arts medicine case in terms of professional study and public exposure. But, because performing is very competitive, performers often smile and suffer. In other words, "The show must go on."

The best example of show-going-on philosophy is the case of the great Ignace Paderewski, which began during the winter of 1891-1892 while Paderewski toured the USA. Steinway & Sons sponsored the tour on the condition that only on Steinways be used on stage. Paderewski stood to profit handsomely, but the concert schedule was quite demanding. Over about four months, there were 107 concerts and 86 dinner parties.

The pace fatigued the concert pianist, and he found the Steinways very hard to play. Although the sound was wondrous, Steinways required great energy and physical strength. Eventually the artist persuaded the Steinway managers to make sure that a technician visited before each concert to soften the action. All was well until one fateful evening in January at a concert in New York.

Paderewski had no time to try out the piano; he went straight from the train to a filled hall. He was not aware that the instrument had been in the factory for servicing earlier that day. A Steinway regulator, unaware of Paderewski's specifications, found that the action drastically differed from the factory specs. He restored it to its factory-fresh state, leading to an excruciating situation.
 

When Paderewski began to play, immediately he could feel something co~g apart in his arm; the pain he felt signaled he was in serious trouble. He completed the concert and immediately sought a doctor, who had terrible news. Paderewski had tom one tendon, as well as strained some others; he had also seriously injured his finger.

The doctor recommended complete rest and seriously doubted that the pianist's career could continue. But Paderewski was stubborn. He could not endure the public humiliation of canceling the rest of the tour; and did not wish to give up his fees.

He managed, miraculously, to continue to the tour's finish. His finger was in awful shape by then, but with massages and rest, he recovered. In Paderewski's time, there was little research or literature, let alone treatment theory or testing, upon which physicians might rely.

Not until 1983 did a medical team keep records of physical difficulties reported by musicians. The team described their experience with 100 performers who consulted physicians for various hand afflictions. Forty-two had either tendonitis or tenosynovitis, the two most common occupational problems of the musician to this day.

Although other conditions arise, these two prevail. The terms Tendonitis and Tenosynovitis have been somewhat misunderstood as they refer, respectively, to an actual inflammation in the tendons and in the tendon sheaths. The same applies to epicondylitis or inflammation of the tendon attachment at the elbow, what is commonly called ''tennis elbow" or "golfer's elbow".

While it's commonly reported by musicians, tuners must occasionally suffer this ailment from repeatedly turning the tuning wrench. It is common for the suffering person who consults the doctor to complain of pain and swelling in the affected body part, but upon examination, no swelling can be detected.

Furthermore, anti-inflammatory drugs have been tried, but they do not seem to be very helpful. More study of the problem will prove helpful, however. Previously conducted repetitive-motion disorder studies involving office workers will likely serve as a baseline, since tendonitis and tenosynovitis are also the most common work-related difficulties reported by typewriter and computer keyboard users. Interestingly, female musicians report problems more commonly than men do.

However, many studies exist showing that females are more likely to consult a physician for any medical reason; when males catch up to females in their willingness to speak up, the 16-year-old girls were the most frequent to report musical performance injuries. One challenge facing both the patients and the physicians:

The absence of visible physical signs means that it is difficult to know with any certainty what lies underneath the surface. Muscle biopsy can be helpful, but this is rarely done. Often, doctors simply shake their heads and say that there is nothing wrong--nothing physical, that is. Absence of physical-ailment diagnosis means that the symptoms must be imaginary. Musicians are known for sensitive nervous systems-psychosomatic problems could be expected.

On the other hand, there have been instances of medical concerns about hand and forearm usage ailments going too far. Medical experts have been known to induce, if not panic, at least undue apprehension on the subject. Between 1983 and 1985, RSI (Repetition Strain Injury) became epidemic in Australia among keyboard operators such as typists and others working with screen-based equipment. "Kangaroo paw" was the nickname for the condition, and alarm spread so far that even children were taught about the "dangers of keyboards" in schools.

As usual, there were two sides to the argument. Some doctors even refused to believe that the symptoms were genuine, since in most cases they could prove nothing wrong with the patients. They argued that the occupational hazards of the keyboard were completely imaginary and that RSI was simply psychological--once again, psychosomatic was the label for the condition.

Most of the time, the truth lies not at one edge or the other, but somewhere in the middle of the argument between physical and psychological reasons for pain. We now know that the condition, which is termed "carpal tunnel syndrome," is a legitimate medical condition--but not the dangerous problem that every typist, computer user, or musician must necessarily suffer.

Preventing the suffering and expense (due to medical costs and loss of income), and containing it once it begins, is not a simple task or a simple formula, because it seems obvious that there is no one singular cause of he problem. More and more, though, experts agree that physical and mental stress must receive the lion's share of the blame. Doctors can be found who assert that one can "misuse" or "overuse" the hand and forearm; however, a growing consensus points to the wrong kind of tension, be it mental or physical, as the major culprit.

As everyone knows, physical and mental tensions are radically different; and even "physical stress" can be traced to a multitude of sources. One system, one muscle, one tendon, if stressed, overworked, or injured, has an effect on others. One nerve, if pressed, can cause trouble in some fairly distant location of the body.

Often, it is difficult to decide whether physical or psychological stress is the main factor. A heavy concert schedule, for example, could cause both physical and mental stress. So, there is no simplistic advice, such as "keep your hands in this position," or "do this warm-up" that will eradicate forearm and hand difficulty. There are steps that should be taken, though, if a pianist wishes to protect a career. New PAM (performing arts medicine) experts have emerged from the general medical field, and they have plenty of advice for musicians.

One of the first agencies to form a team in the field was the London College of Music, spurred by Mrs. Carola Grindea and her 1978 book, Tensions in the Performance of Music. It is a vast understatement to call this book forward-looking; and if one simply considers the title, the key to repetitive motion can be discovered. Reducing tensions, in whatever form they arise, and through any of a number of techniques, offers the prevention and probably the cure in nearly all performance arts medicine.

However, Mrs. Grindea's work was just the beginning, the instigating force behind research that continues. Choosing the correct preventive or curative measures may require a lengthy process of elimination. There is no one correct way to execute a particular movement, including playing an instrument. Any of a number of methods may improve a player's technique at the keyboard and thus prevent or eradicate the pain-producing tensions.

Beginning with basic posture and extending to frame of mind, all contributing factors should be considered. Ultimately, whatever produces the maximum relaxation for the performer will result in the safest, most problem-free performance-and, it can be argued, the most enjoyable performance as well. A discussion of various performance tension remedies might take volumes. It should suffice to say that piano players face many challenges, and may have to take measures to address those challenges through treatment, by changing the piano, or by purchasing a new instrument.

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