PIANIST'S INJURIES:

MOVEMENT RETRAINING IS THE KEY TO RECOVERY

By Thomas Mark
Copyright 2001 Thomas Mark

Repetitive stress injuries bring misery to many pianists. They are very common, and the pain they cause can be dreadful. The list of famous pianists with injuries is much longer than most people think---it includes Gary Graffman, Leon Fleisher, Wanda Landowska, Artur Schnabel, Alexander Scriabin, Ignaz Friedman, Sergei Rachmaninoff, Clara Schumann, Glenn Gould, Michel Beroff, Richard Goode and many others. In most cases the injury did not end the career, but it forced cancellations of concerts or tours, or restriction of repertoire. This is a tragic situation, since injuries are preventable and curable. Unfortunately, the literature I have seen on pianist's injuries does not clearly explain how injuries are caused, and some of the most commonly recommended "cures" are band-aids: they are good in themselves and helpful up to a point, but they do not remove the cause of the injury. In this paper I shall briefly describe the causes of pianists' injuries and then indicate what has to happen to permit an injured pianist to recover. I believe that every pianist and teacher should have this information, since injuries can lead to permanent damage if left untreated.

Injuries are caused by stressful movement. Our hands and arms can move in many ways, but some ways of moving put extra stress on the tendons and other soft tissues. If a person moves in a stressful way, and does this repeatedly over a long period of time, the vulnerable structures may be injured. In this paper, I shall use the terms "efficient movement" or "stress-free movement" to refer to ways of moving that can be used even in highly repetitive tasks without causing injury. Which ways of moving are "efficient" or "stress-free" in this sense is a matter of anatomical fact, not of conscious awareness. Conscious awareness tells us whether a particular movement hurts right now, but it does not tell us whether that same movement repeated millions of times over a period of years would lead to injury.

Four Causes of Injury

• Co-contraction. Our arms and hands are moved by muscles. Muscles exert force only when they contract, so each muscle can exert force in only one direction. To move a body part in two directions requires two muscles or two sets of muscles, one to move it one way and one to move it the other way. When one muscle contracts, the opposing muscle must release and lengthen to permit movement. If this does not happen--that is, if the opposing muscle remains tense—then both muscles are contracting simultaneously, which is called co-contraction. Co-contraction inhibits movement and can cause injury.
• Awkward positions. A muscle attaches to the bone it moves by means of a tendon, and the tendon passes over a joint (or several joints). The relative position of the bones will influence the efficiency of the tendon in transmitting the muscular force to the part moved, especially in cases like the fingers where the tendon passes over several joints. Awkward or extreme positions of the wrist and hand stress these tendons, making movement more difficult and also weaker. The mid-range position of the wrist, with the wrist in a straight line with the arm, gives the greatest mechanical advantage to the fingers. Deviating from this position sideways or up and down results in a loss of grip strength; in extreme positions grip strength is reduced by 25% or more. Awkward positions make movement stressful and can cause injury.
• Static muscular activity. Typically, when a muscle exerts force to move a body part, the muscle contracts and decreases in length as the part moves. When the part moves the other way, the muscle releases and lengthens. Thus, the muscle alternately gets shorter and longer. This kind of activity is called dynamic. But if the muscle exerts force without changing in length, the activity is called static. This is the type of activity used in isometric exercise. Static muscular activity is more stressful than dynamic activity. Dynamic activity permits circulation of the blood, whereas static muscular activity inhibits blood circulation, causing the muscle to become fatigued and making it prone to injury.
• Excessive force. Obviously, stress to the muscles, tendons and other vulnerable structures varies according to the amount of force used: more force is more stressful than less force. But this does not make clear how damaging excessive force can be. According to some studies, doubling the force multiplies stress on the tendons not by two but by five. Pushing down keys on the piano does not require much force; the standard touch weight for a well-regulated piano is only fifty grams, about the weight of ten nickels. But it is easy to fall into the habit of using more force than needed, and because of the extremely high levels of repetition involved in piano playing, excessive force is potentially injurious.

In short: Pianists' stress injuries are caused by

1. co-contraction
2. awkward positions
3. static muscular activity
4. excessive force.

These factors, alone or in combination, are the source of virtually all the pain and discomfort experienced by pianists.

Although stressful movements are the cause of injury, there are other factors that contribute to the body's resistance to injury and its ability to recover. A person's general health is one factor, physical fitness is another. Rest is also important. A person who gets adequate rest will be more resistant. Another factor is age. The body's ability to resist injury becomes less as we get older. This is why some pianists play for years without problems, and then, in their thirties or forties, they develop an injury. They are not playing differently, but their body's ability to withstand the strain is less.

How Injury Develops

Power to move our fingers, hands and arms comes from muscles, which are attached by tendons to the parts they move. Some tendons are quite long. For example, since the muscles that move the fingers are mostly in the back of the forearm, the tendons to the fingers extend through the wrist and hand. Tendons are like long fibrous cords. They are made of collagen, they are not very elastic and they are very strong. They slide back and forth as we move our arms and fingers; some by as much as 2 ½ inches. To facilitate the back and forth movement, tendons may be enclosed in sheaths for part or all of their length. These are the synovial sheaths, which secrete a fluid (synovial fluid) that acts as a lubricant. Circulation of blood in the tendons is limited, which means that if a tendon becomes injured, recovery is slow.

For pianists and others who engage in repetitive motion, the tendons are the weak link in the system, the structures especially prone to stress injury. Most stress injuries of the hand, wrist, arm and shoulders involve the tendons. To be sure, muscles can also be injured, but they recover more quickly. The four causes of injury listed above are dangerous because they increase stress on the tendons.

Tendons become injured because of repeated tensing or from rubbing on nearby ligaments and bones. Subjected to constant stress, tendons may fray or tear apart, or become thickened and bumpy. The injured area may calcify. The tendon sheath is also vulnerable; it may produce excess fluid, causing swelling. The tendon may become "locked" in the sheath and move jerkily; the sheath may become inflamed and press on the tendon. Inflammation and swelling in the restricted space of the carpal tunnel can put pressure on the median nerve, leading to the tingling and numbness of the thumb and second finger which often indicate carpal tunnel syndrome. All this starts to sound like a catalogue of medieval tortures, and for pianists who have been injured it might as well be just that. Symptoms include aching, tenderness, tingling, soreness--in short, pain. The pain can be so severe as to prevent not only piano playing, but everyday actions as well. One pianist (now fully recovered and playing beautifully) says that when suffering from acute tendinitis the mere lifting of a paperback book was excruciating.

Cure of Injury

Dreadful as all this is, the good news is that we can be cured. Our bodies have an amazing capacity to repair themselves, and injuries will heal, provided that they have not been allowed to progress to the point of permanent damage. Even the tendons, despite their limited blood supply, will recover in time. In the acute phase of an injury, treatment may involve rest, anti-inflammatories to reduce inflammation and swelling, and massage, which can stimulate circulation (producing some of the benefits of exercise without actually having to work the injured structure). What these "treatments" really do is to provide conditions in which the body's own healing powers can do their job.

All this is marvelous, but far too often the cure is only temporary because the person returns to the same activity as before and performs it in the same stressful way, causing re-injury. A permanent cure requires identifying and removing the cause of the injury. Now, we know that piano playing need not be injurious, since many people, including some fabulous virtuosos, do it without ever injuring themselves. Therefore, the fact of someone being injured does not prove that piano playing is dangerous in itself. What it does prove is that there was something in the technique that was stressful, something that with constant repetition over years of playing, resulted in injury. The person must learn to play the piano using non-stressful movements to perform the tasks that were formerly performed with stressful movements. In short, a permanent cure for pianist's injuries requires movement retraining.

To summarize: we can avoid injury by maintaining good physical health and fitness, getting sufficient rest, and--by far the most important--eliminating stressful movements, those involving awkward positions, co-contraction, static muscular effort and excessive force. We can cure injury the same way.

Why many pianists do not recover

To say that to cure an injury we must remove its cause sounds too obvious to require emphasis, but in fact movement retraining, which is the way to accomplish this, very often does not happen. There are several reasons why injured pianists often do not get the retraining that would cure their injuries.

Very often, people don't understand the need for retraining or believe in the possibility of moving differently to play the piano. After all, they play the piano the way they always have done, the way they were taught to play. Consequently, when first injured they rarely look for someone to analyze their technique, identify the technical problem and find a solution. Instead they resort to transparently poor strategies like denial, wishful thinking, or "toughing it out." They say "I'll rest over the weekend and it will be better on Monday," or "I guess I just overdid it, I'll take it easy for a while." Sometimes the first symptoms are even welcomed, and people say "I must really be making progress in my practicing, I can feel it in my arms" (the "no pain no gain" fallacy). Or else, misled by discussions in the literature, they say "I just tried to do too much without proper warm-up; I'll be careful always to warm up from now on," or "I guess I need to exercise and develop strength in my fingers." As the injury persists and they become desperate, they go to doctors, physical therapists, chiropractors, accupuncturists, nutritionists, massage therapists--the list is endless. All of these professionals can help, especially in treating the acute condition, but only to a limited extent. They are not trained to do what is really necessary, namely teach the person how to play the piano without danger of re-injury.

This brings us to a point that it is vital for pianists to recognize: pianists' injuries are rarely medical problems, they are movement problems. An injury would count as a medical problem if it were caused by illness or trauma. Occasionally this is the case; carpal tunnel syndrome, for example, can be caused by diabetes, and arm pain can be caused by a fracture or sprain. These conditions are appropriately treated by medical science. But (according to some authorities) such cases account for only about 5 percent of pianists' injuries. It follows that roughly 95 percent of pianists' injuries are not medical problems; they do not come from illness or trauma but from the way the person habitually uses his body. This explains why health care professionals are rarely of much help to pianists who seek a permanent cure. The fact is that the injured pianist does not need a doctor, he needs a teacher, and the solution to the near-epidemic of pianists' injuries will come not from therapy but from education.

Becoming injured can be emotionally devastating for a pianist. If a person?s thoughts, aspirations, and, perhaps, very livelihood center around the piano, then to be unable to play one?s best, unable to play without pain, perhaps unable to play at all, is a dreadful experience. Injured pianists often become deeply depressed and discouraged. The injury can become a stigma and the injured pianist feels isolated, rejected, inadequate, and humiliated. Depression and a sense of hopelessness can themselves be obstacles to recovery. An injured pianist desperately needs emotional support and understanding from friends, relatives, colleagues, and teachers.

Unfortunately, many colleagues and teachers, though well-intentioned and sympathetic, can offer only limited help. Typically, they offer moral support, which is essential, but few have a clear understanding of the causes of injures or the conditions for recovery; few have the information they need to prevent injury in their students or show an injured pianists how to recover. What I described a few paragraphs back as ?transparently poor strategies? are the ones most often invoked by teachers and pianists at all levels. This is understandable; after all, the required information is not part of most music curricula, pedagogy classes, or conservatory programs. On the assumption, natural enough but usually mistaken, that the problem is a medical problem, not a movement problem, teachers and colleagues may send the injured pianist for medical treatment or therapy. Such treatment rarely produces a complete, permanent cure, so teachers and colleagues feel helpless, frustrated and anguished along with the injured pianist. The general problem will be solved only when sound information is part of every pianist?s training.

Piano periodicals and books on technique are not generally very helpful to the injured pianist. Few discussions of pianists' injuries emphasize movement retraining and the strategies they do recommend are not especially effective, either for avoiding or for curing injury. These include "building endurance," "developing strength," taking frequent breaks, warming up, "pacing ourselves," and the like. In themselves, I have no quarrel with any of these suggestions; all are good things to do, and they may contribute to our ability to resist injury. But they are not the full answer; someone can do all of them and still be injured. For example: suppose my way of playing octaves involves forcefully flexing my wrist. There are anatomical reasons why repeated forceful flexion of the wrist is dangerous; it is, in fact, one of the common causes of carpal tunnel syndrome. Therefore, if that is how I play octaves I am risking injury. Even if I take breaks, warm up before practicing, and so on, it will still be true that with every octave I play I will be stressing the tendons in my wrist. If I use stressful movements to play octaves, then telling me to avoid injury by warming up before practicing the Sixth Hungarian Rhapsody is like telling a smoker to take some deep breaths before lighting up in order to avoid lung cancer. Warming up and deep breathing are great, but they don't remove the cause of the problem. Just as lung cancer is caused by smoking, not by failure to do lung exercises, so pianists injuries are caused by stressful movement, not by failure to warm up, take breaks, and so on.

How does it come about that a good pianist may play in a way that stresses the body? I think there are two principal reasons. First, most people's technique is not deliberately chosen. That is: the person does not analyze the movements needed to play a passage and practice those movements. Instead, the person just finds a way, by hook or crook and trial and error, to get to the right notes. With constant repetition the movements become habits. Sometimes, movements acquired this way will be efficient. But there is no guarantee. Our bodies can become used to inefficient movements as well as efficient ones, and when we are used to them, the inefficient ones feel "natural." I have heard pianists with techniques full of potentially injurious movements describe their technique as "natural" and "relaxed."

The second way in which people come to move stressfully is that they are taught stressful movements. No teacher would knowingly teach harmful movements. But too few teachers understand the principles of efficient movement, and some ways of moving that are dangerous to our health are firmly established in traditional pedagogy. I shall give only one example: playing with "curved fingers."

The expression "curved fingers" is vague, so let us be more precise. When we hold our hands in a relaxed position hanging at our sides, the fingers assume a gently curved position. I shall call this the "natural curve" and it is indeed the appropriate position for the fingers in playing the piano. But some methods would have us bend the two end joints of the fingers, resulting in a more pronounced curve than the "natural" one. I shall call this curled fingers, and it is potentially injurious. The reason curled fingers are dangerous is that the two end joints of the fingers are moved by the flexor muscles on the lower side of the forearm. Holding the fingers curled requires maintaining the contraction of the flexor muscles. Lifting of the fingers, on the other hand, is accomplished by contracting the extensor muscles on the top of the forearm. Therefore, if I lift my fingers while maintaining the "curl" of the two end joints, I am using flexor muscles and extensor muscles simultaneously; in other words, I am co-contracting. Co-contraction is one cause of injury; there are pianists who have suffered injury from playing with curled fingers (see Beth Tomassetti's story in Oregon Musician, Fall, 1995).

That playing with curled fingers is stressful is not just an opinion for people to accept or reject as they choose. It is a fact of anatomy. There is no way, anatomically, to lift our curled fingers without co- contracting. No amount of practice, no exercises aimed at "finger independence" or "strengthening the fingers," no amount of telling ourselves to "relax"--none of these will change the way our bodies are made. The anatomical fact is that if we play in this position we are risking injury. Yet playing with curled fingers is not only tolerated, it is advocated by some piano methods. There are beginning methods that tell students to use a pencil to line up the tips of the fingers into a straight line--a recipe for producing co-contraction. If the student plays that way and practices diligently, no one should be surprised if injury is the result. (Let me point out again that although "curled" fingers are dangerous, the "natural curve" is correct; the "natural curve" is not what I am arguing against. Also, I am well aware that not everyone who plays with curled fingers winds up injured. Some people are lucky, their bodies are more resistant, or whatever. But that does not alter the facts presented here; after all, some people smoke for sixty years without developing lung cancer, but smoking is still the cause of lung cancer.)

The movements that can cause injury do not necessarily feel bad or painful. Indeed, they are not dangerous in non-repetitive tasks. They are dangerous for pianists because piano playing is extremely repetitive. One handbook on stress injury considers "highly repetitive" any tasks requiring 1500 or so repetitions per hour. That may sound like a lot of repetition but it is nothing compared to piano playing. The hourly rate of repetition for sixteenth notes at a metronome setting of 120 is 28,800, a number that might give a health inspector apoplexy. In fact we can play sixteenth notes at 120, but we can't use just any motions to do it; some motions safely permit that level of repetition, and others do not.

Learning a less stressful way to move at the piano means abandoning old physical habits and replacing them with new ones. This is possible to do, though it takes time and application. But there is a deeper problem as well: the old ways may be embedded not just in our bodies but in our minds. Suppose I have been injured by my way of playing octaves. But suppose further that I was taught to play octaves by a teacher whom I deeply admire. Learning a new way to play octaves may cause me to modify my opinion of my former teacher. It may force me to re-think many aspects of my own teaching and playing, and I may be obliged to conclude that things I formerly believed sincerely were not actually the best. In short, movement retraining forces me to examine myself and my relationship with the piano, and I must be prepared to question and change my attitudes and beliefs. Even if the results make the effort worthwhile, the process is not easy.

Additional Obstacles to Understanding

The sports analogy. In our sports-oriented society, comparisons with sports are everywhere and they can be very harmful. Playing the piano is not actually very much like an endurance sport, and building a technique is not a matter of building muscles. The amount of physical strength required to play the piano is very little, and endurance is not an issue if one is moving efficiently. The weight of the forearm alone is ample to push down the keys. Making this weight available as needed is a complex skill; we need to move rapidly and efficiently. But it is not a matter of strength.

The sports analogy infects our ways of dealing with injury; we may say "no pain, no gain" when our arms are sore, and continue practicing in the same way. If our hands feel weak--a frequent symptom of injury— we think the answer is to do strengthening exercises. In fact this may only make the problem worse. If a structure is injured, working it harder will not promote healing. Some (very few) comparisons with sports may be useful, but for the most part the sports analogy is misleading and harmful.

Arguments from authority. I have in mind the invoking of a famous pianist or teacher as a justification for some element of piano playing. "Horowitz did it this way" or "Vengerova taught such and such." One reason to be suspicious is that we often have no way of knowing whether the claims are true--especially with historical figures. More important, though, is that the authority of a famous pianist or teacher does not make a movement efficient. What makes it efficient or inefficient are facts of anatomy. Some famous pianists have moved very efficiently, others have had techniques that included inefficient ways of moving (as is shown by the famous pianists with injuries). We need to have the knowledge to recognize stressful movement, and if someone tries to justify a stressful movement by saying "so and so did it that way," we need to reply that if so and so really moved that way they were risking injury, and if they taught that way of moving they were putting their students at risk of injury.

Conclusion

Movement retraining is an exacting process; a complete retraining involves building an entire technique from the ground up, with strict attention to every motion. To describe this in detail would require a book, and even the most carefully written instructions could be misleading. Movement retraining requires individual instruction. Nevertheless, it would be nice to conclude with some practical suggestions, so I shall offer three very important principles. These are aimed more at prevention than cure, but if teachers inculcated these habits in their students, we would see fewer injuries.

The first principle is to sit at the correct height and insist to students (or their parents) that the bench at home be at the correct height. Some piano methods do say things like "the forearm should be level when the student sits erect without hunching the shoulders," which is correct; much the same advice is found in any ergonomics text. If a person is not at the correct height, the body is likely to compensate somewhere. A person sitting too low may hunch the shoulders or lift the elbows, a person sitting too high may drop the wrist or pull the shoulders down. All of these compensations involve static muscular activity that limits freedom and can in time lead to injury.

Since the correct bench height is the one that puts the forearm level, it is not the same for everyone, and it may not be the same even for people of the same stature. The correct bench height is determined by the relation between the length of the upper arm and the length of the torso, and this proportion varies from one person to another. A handy way to find the correct height is to let the tip of the elbow be even with the top of the white keys. To many pianists, the correct height will feel high at first, since most benches are too low for most people. Even adjustable benches do not go high enough for many people.

The second principle is to avoid dropping the wrist. The wrist should be roughly straight with the forearm, neither arching way up nor falling appreciably below the level of the main knuckles. The reason is that any other position puts stress on the tendons as they pass through the carpal tunnel. Forcefully flexing the wrist (as in "wrist octaves") is an important cause of carpal tunnel syndrome. The mid-range position of the wrist is the one in which the fingers move most easily and have the greatest strength, with least stress on the tendons.

The third principle is to avoid ulnar and radial deviation (what many pianists call "twisting"). That is, the hand should not be turned to either side, but should be straight with the forearm sideways as well as up and down. Again, the reason is anatomical: sideways bending of the wrist inhibits free motions of the fingers and puts extra stress on the tendons that pass from the arm to the hand. Common situations in which people twist are in bringing the thumb to the keyboard, or in playing black keys with the thumb. Twisting is one of the most common causes of injuries in pianists.

The three principles are not equally easily adopted. The first, correcting the bench height, is easy. A person soon gets used to the new height, and most people find that their playing improves immediately when the bench height is corrected. The other two principles are harder to assimilate, since they may involve changing long-established habits. If I habitually drop my wrist in playing chords, or twist when passing the thumb in a scale, I will need to learn a new way to accomplish those tasks.

Throughout this article I have advocated movement retraining as the way to avoid or cure injury. But there is another point that is equally compelling: we play better if we move efficiently. Many pianists have retrained after injury because it was the only way they could play at all, and found that they could play better than before. Others have retrained without being injured and found the same thing: they can play better, with greater ease, play more difficult pieces, and overcome problems that formerly seemed hopeless. In short: an efficient technique is not only the way to cure or avoid injury, it is the best way to further our artistic goals.

Note: I am a pianist, not a health care professional. I am grateful to William Pereira, MD, MPH, of the Interdisciplinary Ergonomics Research Program at Lawrence Livermore National Laboratory, for discussion and clarification of many issues relating to repetitive stress injuries.

An abridged version of this paper was published in The Oregon Musician, Spring 1999, pp. 11-13.

Thomas Mark holds AB, MA, and PhD degrees from Columbia University. He studied piano in New York with David Bar-Illan and Jeannette Haien. From 1994 to 1999 he attended the Taubman Institute of Piano, where he served for three years as a practice assistant. He studies the Taubman technique with Robert Durso of the Taubman Institute. He studies Alexander Technique and body mapping with Barbara Conable, founder of Andover Educators, a network of teachers dedicated to putting music education on a sound somatic foundation. He is a certified Andover Educator, an adjunct faculty member of Marylhurst University and a member of the committee on musicians' wellness of the Oregon Music Teachers Association. From 1992 to 2001 he organized and performed in the Newport Coffee Concerts, a chamber music series. In collaboration with Barbara Conable he is currently preparing a book, "What Every Pianist Needs to Know about the Body," which will be published by Andover Press. He has taught the course "What Every Pianist Needs to Know about the Body" at various locations in Oregon, North Carolina and New Mexico, and at the "Piano Wellness Seminar" at Gardner-Webb University in 2000 and 2001. Tom teaches piano and Body Mapping in Portland, OR. Thomas Mark maintains a website www.pianomap.com with information for injured pianists and anyone interested in free movement at the piano. Readers with comments or questions concerning this paper are encouraged to contact him by email: tom@pianomap.com

Copyright 2001 by Thomas Mark

Medical Issues for Performers

This page, along with other pages in the `Classical Music Resources' series, was previously maintained by Sandy Nicholson. As he can no longer do so he has passed them on to be included on the Musicians & Injuries web site. I will not be adding more material to this page as I am posting similar stories on the M&I page. -PMx 10/96

These articles provide some different perspectives on the medical treatment of various ailments affecting performers.

• Repetitive Stress Injury
• Over-use Syndrome (tendonitis, carpal tunnel syndrome etc.)
• Some thoughts on tendonitis
• On Carpal Tunnel Syndrome

Further articles on RSI are available (though geared to typists rather than musicians). There is also an electronic newsletter for RSI sufferers which can be subscribed to by sending email to dadadata@world.std.com with the subject line `RSI Subscription'. Back issues are available.

Repetitive Stress Injury

The following notes were put together by Allyn Weaks <allyn@u.washington.edu> in response to a question in the Usenet newsgroup rec.music.classical.performing. 

Synonyms [for over-use syndrome] more likely to be found in the medical abstracts include cumulative stress disorder, repetitive motion disorder, repetitive stress injury. These all include a wide range of more specific things like various tendon disorders of particular tendons, or entrapment of nerves, or joint problems: de Quervain's is a thumb tendon, carpal tunnel is the tendons and median nerve that controls roughly the thumb and first two fingers, tennis elbow, trigger finger, bursitis, etc. Quite often, if you have any one of these, you'll have several others as well.

There is no simple easy definition, since the symptoms and affected bits of the body vary greatly from person to person, and task to task. Some of the worst things you can do to yourself include not only lots of finger motion, but grasping and squeezing, leaning on a desk edge with your wrists, palms, or elbows, holding a phone with your shoulder, carrying a shoulder bag, bad posture. The initial symptoms often involve the tendons. If it's ignored, scar tissue starts to form around the tendon sheath, causing even more friction and inflamation. If the tendonitis is in the wrong place, such as in the carpal tunnel, a nerve can get squeezed. As it gets squished, it loses its blood supply, and cells start to die, eventually causing permanent disability.

None of this necessarily has anything specific to do with musicians, but many wusicians have a lot of the predisposing factors - lots of finger motion with the hand in awkward positions, stress while doing it, tendency to practice or play for long periods without a break, tendency towards poor upper body posture. And other things you do add to the load: computer use (mice and other pointing devices are often worse than typing), hand tools (especially screwdrivers), gardening, washing dishes by hand, rowing, holding a book.

Some keys to avoiding it: 1) listen to your mom - don't slouch; 2) take frequent breaks; 3) be aware of other activities that put you at risk - e.g., if you spend a lot longer than normal typing one day, spend less time practising that day and do some sight singing instead; 4) use an exercise/muscle stretching routine so that one set of muscles doesn't become inflexible and cramp up, which can compress tendon channels. (This is the problem with slouching - it leads to tendonitis in the shoulder and/or neck, which can then trap one or more nerves.)

A few early symptoms to watch out for: 1) a deep down tickly feeling in the base of your thumbs, especially when you wake up or push a shopping cart over a rough surface (vibration sensitivity in general); 2) numbness or pins and needles in the hands or arm especially at night; 3) twinges in the hand, wrist or arm when you do things such as reach for something or push open a door; 4) reduced touch sensitivity and/or pain in your finger tips; 5) even just noticing too much that your hands or arms exist - thinking about things that you used to take for granted and not notice.

If you notice any symptoms, run, don't walk to a doctor who knows what's going on. If a doctor doesn't ask a lot of questions about shoulders and elbows and neck, and seems stuck on a simple `carpal tunnel, therefore wrist splints at night, ibuprofen, then cortisone injections, then surgery' track, find someone else. De Quervain's tendonitis is much more common than carpal tunnel syndrome - if a doctor doesn't check for it straight off, he doesn't know enough. They should also test for diabetes and thyroid function, which are predisposing factors, and arthritis, which can have some similar symptoms. Insist on going to physical/occupational therapy as soon as possible. Don't allow a non-specialist to give you cortisone injections, and only then if physical therapy has failed, or if nerve conduction tests show impairment. Surgery is absolutely the last resort - it has a high long-term risk of complications.

Early treatment is essential. The longer you ignore it, the more it will affect the rest of your life. Some of the conditions can become permanently painful and disabling. Even early on, it can take months to recover, and you can never go back to business as usual (soft tissue injuries never heal completely; there will probably be at least some reduction of endurance, and in any case, you need to change whatever caused it in the first place). Ten per cent of the population at large is expected to get RSI, more like 25% and more if you are in a high risk group. Women are more at risk than men, and middle age people more so than young people, but young men shouldn't be complacent about it... Prevention is possible, but these days, with so many things demanding hand use, training in or at least awareness of good technique and ergonomics is a good idea. It doesn't come naturally.

There is finally an excellent book out, Repetitive Stress Injury by Pascarelli (may be slightly misspelled). It's aimed at computer users, but his computer users are a side line at a clinic for performing artists in Chicago(?). If I had had this book last fall, I could be playing Dufay trios this summer, instead of just starting physical therapy.

Over-use Syndrome (tendonitis, carpal tunnel syndrome etc.)

The following article was written by Andy Brandt <andybrandt@delphi.com> for inclusion in the frequently asked questions file for the Usenet newsgroup rec.music.classical.performing. Mr Brandt disclaims any liability for the accuracy of material contained in this article.

There have been several articles in the newsgroup from people asking about dealing with pain during or after playing their instruments. Here's a brief description of some types of over-use syndrome and a few suggestions on what to do if you have pain.

If you have pain while playing your instrument (or after playing), it might be related to what doctors now call `over-use syndrome.' This is caused by strain on muscles, ligaments and tendons causing swelling, which induces pain. One common type of `over-use syndrome' is tendonitis, caused by a swelling of the blood-vessel sheath surrounding tendons. For performers, this often occurs in your fingers, your hand, or your arm, or your shoulder. Tendonitis is common among musicians, typists, professional phone bank workers and assembly-line workers; the common denominator is work (or play) involving very repetitive motion in the fingers, hands or arms.

Another, more specific, injury is carpal-tunnel syndrome (CTS). The carpal tunnel is a wrist `tunnel' formed on three sides by bone and the 4th side by a strong ligament (the Transverse Carpal Ligament, to be technical). There are nine tendons and the median nerve which travel through this tunnel. Each tendon is surrounded by a lubricating lining, called the synovium. CTS is caused by the compression of these tendons in the carpal tunnel, either by swelling of the synovium, injury to the bone or ligament, or by fluid retention. CTS should be treated by a doctor. There are several types of treatment for CTS, including surgery, but surgery is the last resort and should never be done on a musician without a second or third opinion.

If you think you have tendonitis, there are several things you can do on your own to try to relieve it:

1. If possible, stop practising for a day or two. Also try to avoid doing a lot of typing or other repetitive hand activity. If the pain persists after a couple of days, see a doctor.
2. Before practising, warm up your hands, wrists, arms with warm water or a heating pad on a low setting. Keep the affected area from getting cold while playing (say, from sitting under an air-conditioning duct).
3. While practising, stop frequently, put the instrument down (unless, obviously, you're a keyboard player) and relax. A slow warm-up session with several short rest
4. You can use an anti-inflammatory medication (such as Ibuprofen, also sold under such names as Nuprin, Advil, and others). A doctor can prescribe stronger medication. You may want to take Ibuprofen after eating to reduce stomach upset. Aspirin is slightly less effective than Ibuprofen, but works. Tylenol (acetaminophen) is not an anti-inflammatory drug.
5. Right after playing, apply a cold pack or ice to the affected area. An ice cube massage right after playing can do wonders for tendonitis in the hand or fingers or arms. I have a large cold pack I keep in the freezer which I used to use for my shoulder. You can apply lots of cold for short periods of time, but don't go overboard and get frostbite.
6. Sometimes a hand brace can help by immobilising the hand, wrist, arm while not playing the instrument.
7. If you type a lot, say while writing messages for rec.music.classical.performing, use a wrist rest for your keyboard. They even make mouse wrist rests if you do a lot of mousing at the computer. Avoid computer games that call for a lot of typing or clicking.
8. Again, though, if the pain continues, seek a doctor's care. Cortisone shots, prescription anti-inflammatory drugs, physical therapy and even surgery can be required. There are special medical clinics for performing musicians.
9. Tell your teacher. Perhaps there is a way to change your technique to relieve stress on a particular muscle or tendon. A doctor who is familiar with instrumental technique can analyse what is causing the problem and suggest solutions. Some doctors specialise in keyboard instruments, wind instruments, string instruments, etc.
10. Try to stay in good general physical condition. Normal exercise can do a lot to prevent over-use. Many musicians, in school or later, often neglect their general physical (and mental) well-being. This information, based on personal research and experience, is not professional medical advice. If you want professional advice, seek a good physician.

Some thoughts on tendonitis

The following advice comes from Cassie Conley <cc37@cornell.edu> who has had tendonitis (or a similar problem) for seven years. These simple remedies were suggested by her physical therapist.

• Lift small (1-2 pound) weights and stretch your arms and hands to warm up before playing. Move the weights slowly the whole range of motion of your arms (back and forth at shoulder level, then over your head) with only a few repetitions of each motion. The chinese `harmony balls' which have recently become popular in the US are also good to excercise with, in moderation. Also stretch your arms with palms together, fingers pointing up, then down. I'm sure that there are many other stretches.
• Use alternating warm and cold water baths any time you feel pain or tension in your injury (e.g., after practising). Repeat this 3-5 times: 1 minute in an ice-water bath or rubbing the area with ice, then 3 minutes in a warm (not any hotter than comfortable) water bath, moving/massaging the muscles gently.
• Something which worked for me but may not work for everyone is to take Gamma Linoleic Acid supplements (Borage oil is best, but also black currant oil or evening primrose oil). GLA is a fatty acid which is incorporated into cell membranes; it helps reduce swelling and lubricate tendons. Take 1 pill/day for the first several weeks, then cut back to 2-3 pills/week, and it takes about a month to see any improvement. This stuff is rather expensive and may be hard to find outside of a health food store or herbal shop, but, as I said, it really seemed to work.

A combination of these things and taking lots of breaks to rest has me back playing (violin) after having my arm in a brace for 2 years. Now if only I can persuade myself to practise... I hope this helps!

On Carpal Tunnel Syndrome

Lawrence E. Mallette <mallette@bcm.tmc.edu> is a physician and musician and gives the following advice on CTS.

[first line missing] travel through this tunnel. These are the tendons that flex the fingers (toward the palm). The transverse carpal ligament is very strong and has little pliability, so the tunnel can not expand much. Each tendon is surrounded by a lubricating sheath, called the synovium. CTS develops when there is increased pressure in the tunnel that compresses the tendons and nerve. The increased pressure can arise from swelling due to inflammation of the synovial tendon linings caused by an inflammatory disease or simply by overuse, from injury to the bone or ligament, or from fluid buildup in the tissues due to systemic illness (low thyroid or excess growth hormone, for example). Once the synovium becomes inflamed and the pressure increases, the process becomes self perpetuating, as the increased pressure will allow formerly normal and non-injurious levels of use to incite continued inflammation. Pain developing in the wrist is an indication of swelling or inflammation there. The only proper response is a period of several days of enforced rest to allow the swelling and any inflammation to subside completely, followed by a gradual return to a somewhat lower level (or at least a different pattern) of activity, with more frequent intervals of rest. Otherwise, continued insults and the resulting prolonged inflammation may produce scarring that further reduces the room within the tunnel, and the CTS may develop. Proper hand/wrist positioning during activity, avoidance of pressure on the wrists during finger motion, and gentle application of exercises that help stretch the ligament may all help prevent CTS. Pain in the wrist that does not subside with rest or that returns rapidly with resumption of activity after a few days of rest may indicate an evolving CTS, and medical advice should be sought. CTS should be treated by a doctor.

Musicians Injuries Page
The Classical music department of the WWW Virtual Library

Medical Clinics for Performers (in the US and Canada)

This page, along with other pages in the `Classical Music Resources' series, was previously maintained by Sandy Nicholson. As he can no longer do so he has passed them on to be included on the Musicians & Injuries web site. Please note that there are more resources for finding clinics and providers on the FindADoc web page. - PMx 10/96

The following lists of occupational health and arts medicine clinics were supplied by Andy Brandt <andybrandt@delphi.com>. Both lists were obtained by Andy from a bulletin board system based in New York and may be up to two years out of date at present.

Occupational Health Clinics

This list was updated with help from the Association of Occupational and Environmental Clinics (AOEC).

 
Alabama
UAB Occ Medicine Services
930 20th St South
Birmingham, AL 35205
(205) 934-7303

Arizona
HELIAM Occupational
4600 South Park, Ste 5
Tucson, AZ 85714
(602) 889-9574
HELIAM Occupational
2545 East Adams
Tucson, AZ 85716
(602) 881-0050
Environmental, Preventative & Occupational Health Clinic
Schl of Med/Univ of AZ
1450 N Cherry Avenue, Annex #2
Tucson, AZ 85719
(602) 626-7900

California
Irvine Occup Health Center
Univ of California at Irvine
19722 MacArthur Blvd.
Irvine, CA 92715
(714) 856-8640
Occup Hlth Ctr/Barlow Hospital
6331 Greenleaf Ave, Ste B
Whittier, CA 90601-3553
(213) 907-4570
Occup & Env Medicine Clinic
University of California/Davis
4301 X Street
Sacramento, CA 95817
(916) 734-27155
Occupational Health Clinic
San Fran Gen'l Hospital, Bldg 9
1001 Potrero Avenue, Room 109
San Francisco, CA 94110
(415) 206-5391
Occup & Env Medicine Clinic
Univ of California/San Francisco
400 Parnassus, A-585, Box 0322
San Franscisco, CA 94143
(415) 476-1841

Colorado
Occup & Env Medical Division
National Jewish Center
1400 Jackson Street
Denver, CO 80206
(303) 398-1520

Connecticut
Yale Univ New Haven Occup Med Prog
333 Cedar St, Bx 3333
New Haven, CT 06510
(203) 785-4197
Univ of CT Occup Med Program
263 Farmington Avenue
Farmington, CT 06030
(203) 679-2366
Lawrence & Memorial Occup Hlth Ctr
404 Thames St, Ste 2B
Groton, CT 06340
(203) 445-4551

District of Columbia
Div of Occup & Env Medicine
George Washington University
2300 K Street, NW, Ste 201
Washington, DC 20037
(202) 994-1734

Georgia
Emory Univ/Schl Public Hlth
Div Occup & Env Health
1599 Clifton Road, NE
Atlanta, GA 30329
(404) 727-3697

Hawaii
Occupational Medicine
Straub Main Clinic & Hospital
888 South King Street
Honolulu, HI 96813
(808) 522-4321

Illinois
Bridgeview Internal Med Clinic 7217 West 84th Street
Bridgeview, IL 60455
(708) 599-8200
JOBMED
St. Mary's Hosp - 2233 W Div
Chicago, IL 60622
(312) 770-3275
Div Occup Med - 720 S Wolcott
Chicago, IL 60612
(312) 633-5310
Managed Care Occup Hlth Prog
2720 W 15 St, Kling Bldg, rm 534
Chicago, IL 60608
(312) 650-6480
Univ IL Occup Med Prog
840 Southwood
Chicago, IL 60612
(312) 996-2592

Iowa
Pulmonary & Occup Medicine, C33-GH
University of Iowa
Hospitals & Clinics
Iowa City, IA 52242
(319) 356-8269

Kentucky
Occup Health Clinic, Dept of Prev Med
& Env Health
Room MS129X - Univ of KY
Lexington, KY 40536
(606) 233-5166

Louisiana
Ochsner Clinic/Dept Occup Med
3rd floor, Brent House
1514 Jefferson Highway
New Orleans, LA 70121
(504) 838-3955

Maryland
Johns Hopkins Ctr for Occup & Env Health
Bayview Med Center
5501 Hopkins Bayview Circle
Baltimore, MD 21224
(301) 550-2322
Occup Hlth Project, MD Univ Schl of Med
405 W Redwood St
Baltimore, MD 21201
(301) 328-7464

Massachusetts
Occup Hlth Clinic/Ambulatory Care Center
Mass Genl Hosp
15 Parkman Street
Boston, MA 02114
(617) 726-2721
Occup Health Clinic
Mass Respiratory Hospital
2001 Washington Street
Braintree, MA 02184
(617) 848-2600 x 445
Occup & Env Hlth Ctr Cambridge Hospital
1493 Cambridge Street
Cambridge, MA 02139
(617) 498-1580
Occup Hlth Services - Regional Health Center,
500 Salem Street
Wilmington, MA 01887
(508) 657-3910
Occup Hlth Prog\Dept of Family & Com Med
Univ of Mass Med Ctr, 55 Lake Ave North
Worcester, MA 01655
(508) 856-3957

Michigan
Occup Hlth Ctr - Receiving Care, Receiving Hospital,
4201 St. Antoin, Room 3G 26
Detroit, MI 48201
(313) 745-3349
Occup & Env Health Clinic
MI Univ - Dept of Medicine
B338 Clinical Center
East Lansing, MI 48824-1317
(517) 353-1846
Div of Occup & Env Medicine
505 South Woodward
Royal Oak, MI 48067
(313) 543-4410
Occup Health Prog, Schl Public Health, MI Univ
1420 Wash Hts Ann Arbor, MI 48109-2029
(313) 764-2594
Center for Occup & Env Med
159 West 9 Mile Road
Southfield, MI 4875
(313) 559-6663

Minnesota
Occup Med - Park Nicollet Medical Ctr
5000 W 39th Street
St. Louis Park, MN 55416
(612) 927-3170
Occup Hlth Serv/St. Paul Ramsey Medical Ctr
640 Jackson Street
St Paul, MN 55101
(612) 221-3313

New Jersey
Env & Occ Hlth Clinic/UMDNJ
Robert W. Johnson Med School
681 Frelinghuysen Road
New Brunswick, NJ 08901
(908) 932-0123
EnviroCare/135 Raritan Ctr Pkwy
Edison, NJ 08837
(908) 225-5454

New Mexico
Emp Occup Hlth Services/Family Practice Center
Room 232
Univ NM 2400 Tucker, NE
Albuquerque, NM 87131
(505) 277-7810

New York
Occupational Health Clinic
Mount Sinai Hospital
1 Gustave L. Levy Place
New York, NY 10029
(212) 241-9743; 9740
HHC Bellevue - Occupational & Environmental
Health Clinic
1 Ave and 27 St, Room CD349
New York, NY 10016
Union Occupational Health Ctr
450 Grider Street
Buffalo, NY 14215
(716) 894-9366
Eastern NY Occup Hlth Program
1201 Troy-Schnectady Road
Latham, NY 12110
(518) 783-1518
Finger Lakes Regional Occup Hlth Program
Univ of Rochester
601 Elmwood Ave, Box 644
Rochester, NY 14642
(716) 275-7171
Occup Medicine, HFC, Level 3
SUNY School of Medicine
Stony Brook, NY 11794-8036
(516) 444-2167
Central NY Occup Hlth Clinical Center
550 Harrison Ctr, Ste 300
Syracuse, NY 13202
(315) 464-6422
Family Practice Residency Prog
Utica Satellite Center,
St. Elizabeth Hospital
Foery Drive
Utica, NY 13501
(315) 798-1149

North Carolina
Duke Occup Health Service
Duke Medical Center, Box 2914
Durham, NC 27710
(919) 286-3232

Ohio
Cleveland Clinic Foundation
Section Occ Health Med, 1 Clinic Center
9500 Euclid Avenue
Cleveland, OH 44195
(216) 444-5707, (800) 223-2273
Greater Cinci Occup Health Ctr
10475 Reading Rd, Ste 405
Cincinnati, OH 45241
(513) 769-0561
Ctr for Occup Hlth, Holmes Hospital
Eden and Bethesda Ave
1st Fl, Tate Wing ML458
Cincinnati, OH 45267-0458
(513) 558-1234
Occupational Health Center,
Univ Hospitals of Cleveland
Douglas J. Morp Health Center
2074 Abingdon Road
Cleveland, OH 44106
(216) 844-1619
Occup & Env Health Clinic
Dept of Family Practice
MetroHealth Medical Center
2500 Metro-Health Dr
Cleveland, OH 44109
(216) 398-5494

Oklahoma
Univ Occup Health Services
1600 North Phillips
Oaklahoma City, OK 73104
(405) 271-3100

Oregon
Legacy Occup Medical Clinic
1650 NW Front, Ste 180
Portland, OR 97209
(503) 226-6744

Pennsylvania
Dept of Community and Prev Med
Div Occup & Env Health
Medical College of Pennsylvania
3300 Henry Avenue
Philadelphia, PA 19129
(215) 842-6540
Occup & Env Medicine Clinic
149 Lothrop Hall, 190 Lothrop St.
Pittsburgh, PA 15261
(412) 648-3240
Occ & Env Med Program
Univ of Pittsburgh, GSPH Room A-729
130 DeSoto Street
Pittsburgh, PA 15261
(412) 624-9985

Rhode Island
Memorial Hosp of Rhode Island Occupational
Health Service
Brown University Prog in Occup Medicine
Divison of General Internal Medicine
111 Brewster Street
Pawtuckett, RI 02860
(401) 729-2000

Utah
Occup Med Clinic - Rocky Mountain Ctr for
Occup & Env Health
Bldg 512, Utah University
Salt Lake City, UT 84112
(801) 581-4800
WorkMed - Occup Health Clinic
1685 West 2200 South
Salt Lake City, UT 84119
(801) 972-8850

Virginia
University Internal Medicine Foundation Medical Clinic
Environmental Medical College of VA
Box 520, MCV Station
Richmond, VA 23298
(804) 786-9059

Washington
Occup Med Clinic
Harborview Medical Center
Univ of WA
325 9th Avenue, ZA-66
Seattle, WA 98104
(206) 223-3005

West Virginia
Div of Occup & Env Health
Dept of Family and Community Health
Marshall Univ Med Schl
Huntington, WV 25755
(304) 696-7041

Wisconsin
OMCA, 16351 West Lincoln Ave
New Berlin, WI 53151
(414) 786-4422
Medical Group/West Allis
9131 West Greenfield Ave
West Allis, WI 53214
(414) 774-8500

Canadian Occupational
Health Clinics

Alberta
Alberta Workers Health Center
111-10451 170 Street
Edmonton, Alberta T5P 4T2
(403) 486-9009

Manitoba
Manitoba Federation of Labour
Occup Hlth Ctr, 102-275 Bway
Winnipeg, Manitoba R3C 4M6
(204) 949-0811

Ontario
McMaster Univ - Occup Health Program
1200 Main St West, Room 3H50
Hamilton, Ontario L8N 3Z5
(416) 525-9140, ext 2333
Sandy Hill Health Centre
24 Selkirk
Venier, Ontario K1L 6N2
(613) 741-7752
Evans Occup Hlth Clinic
364 Evans Avenue
Toronto, Ontario M8Z 1K5
(416) 252-5885
Lakeshore Area Multi-Services
Project Occup Health
185 5th Street St
Toronto, Ontario M8V 2Z5
(416) 252-6471
Occup & Environ Health Clinic
St. Michael's Hospital
61 Queen St East, 8th Fl
Toronto, Ontario M5C 2T2
(416) 867-7470

Quebec
Direction de la Sante Publique
1075 Chemin Ste-Soy
Quebec, G1S 2M1
(418) 643-6084

Arts Medicine Services

These clinics and individuals (*) provide arts medicine services. This list was compiled with help of the International Arts-Medicine Association and Susan Harman.

Performing Artists Hlth Program
San Fran Med Ctr, Univ of CA
400 Parnassus Ave, 5th Floor
San Francisco, CA 94143
(415) 476-7465

Performing Arts Medicine Program
Glendale Adventist Medical Center
1509 Wilson Terrace
Glendale, CA 91206
(818) 409-8076

Stuart Schneck *
University of Colorado
Health Sciences Center
Neurology Dept/Box B 183
4200 E 9 Avenue
Denver, CO 80262
(303) 270-7566

National Arts Medicine Center
National Rehabilitation Hospital
102 Irving Street N.W.
Washington, D.C. 20010
(202) 877-1000

Alice Brandfonbrenner *
Med Prog for Performing Artists
The Rehab Inst of Chicago
345 E Superior St, Rm 1129
Chicago, IL 60611
(312) 908-ARTS

Division of Performing Arts Medicine,
Evanbrook Orthopaedic and Sports Medicine Assoc., Ltd.
1144 Wilmette Avenue
Wilmette, IL 60091
(708) 853-9400

Performing Arts Med Program
Indiana Univ School of Medicine
541 Clinical Drive
Indianapolis, IN 46202
(317) 274-4225

Performing Arts Medicine Program
Bennett Institute for Sports Medicine & Rehabilitaion
Children's Hospital
3835 Greenspring Avenue
Baltimore, MD 21211-1398
(317) 669-2015

Program for Performing Artists
Sinai Rehabilitation Center
Belvedere at Greenspring
Baltimore, MD 21215-5271
(301) 578-5918

Musical Medicine Clinic
Mass General Hospital
1 Hawthorne Place
Suite 103
Boston, MA 02114
(617) 726-8657

Performing Arts Clinic
Brigham and Women's Hospital
45 Francis Street
Boston, MA 02115
(617) 732-5771

Boston Arts Medical Center
Youville Hospital
1575 Cambridge St
Cambridge, MA 02138
(617) 876-4344, ext 784

James Blessman *
Wayne State Univ, Arts Health Interlock,
Univ Hlth Ctr
4201 St. Antoin, Suite 4J
Detroit, MI 48201
(313) 543-4410

Arts Medicine/Med Rehab
355 Briarwood Circle Drive
Ann Arbor, MI 48108
(313) 998-7899

Kenny Rehab Clinic/Sister Kenny Institute
800 East 28th Street
Minneapolis, MN 55407
(612) 863-4481

Simon Horenstein *
3655 Vista Avenue
St Louis, MO 63110
(314) 776-8100

Performing Arts Program
Jewish Hospital
216 S Kingshighway
3rd floor KB
St Louis, MO 63110
(314) 454-STAR, (7827)

Arts Medicine Program
Duke Univ Cultural Services Med Center,
Durham, NC 27710
(919) 684-2027

David Goode *
Bowman Gray School of Medicine
Medical Centre Boulevard
Winston-Salem, NC 27157-1087
(919) 748-4142

Pieter Kark *
Neurological Consultants of Central New York
P.O.Box 505
5730 Commons Park
Dewitt, NY 13214
(315) 449-0011

Kathryn & Gilbert Miller
Health Care Institute for
Performing Artists
425 West 59th Street, Suite 6A
New York, NY 10019
(212) 523-6200

Harkness Ctr for Dance Injuries
Hosp Joint Diseases, 301 E 17 St
New York, NY 10003
(212) 598-6022

Center for Osteopathic Medicine
41 East 42th Street
New York, NY 10017
(212) 685-8113

Inst of Rehab Med
NY Univ School of Med
400 E 34 St
New York, NY 10016
(212) 263-6105

Vasoma Challenor *
Blythedale Children's Hospital
Department of Rehab Medicine
Valhalla, NY 10595
(914) 592-7555

Center for Orthopedic Care
2123 Auburn Ave, Suite 235
Cincinnati, OH 45219
(513) 651-0094

Cleveland Clinic Fdtn
Performing Artists Med Ctr
9500 Euclid Avenue
Cleveland, OH 44195
(216) 444-3903

Arts Medicine Center
Thomas Jefferson Univ Hosp
11th and Walnut Sts
Philadelphia, PA 19107
(215) 955-8300

PA Pain Rehab Center
Ballinick #12
Rtes 313 and 611 Bypass
Doylestown, PA 18901
(215) 348-5104

Medical Center for Performing Artists
Suburban General Hospital
2705 Dekalb Pike Suite 105
Norristown, PA 19401
(215) 279-1060

The Vitality Center/St. Francis Hospital
1 St. Francis Drive
Greenville, SC 29601
(803) 255-1843

Stephen Mitchell *
Austin Regional Clinic
1301 West 38th St, Suite 401
Austin, TX 78705
(512) 458-4276

Sports Arts Ctr\TIRR
Institute for Rehab & Research
1333 Moursand Avenue
Houston, TX 77030-3405
(713) 799-5000, (800) 44REHAB

Clinic for Performing Artists
Physical Medicine & Rehab Section
Virginia Mason Medical Center
1100 Ninth Avenue, PO Box 900
Seattle, WA 98111
(206) 223-6744

Center for Human Performance & Health Promotion
Sir William Osler Health Inst
565 Sanitorium Rd
Hamilton, Ontario L9C-7N4
(416) 574-5444

Coping With Performance Anxiety

This page, along with other pages in the `Classical Music Resources' series, was previously maintained by Sandy Nicholson. As he can no longer do so he has passed them on to be included on the Musicians & Injuries web site. I will not be adding more material to this page as I am posting similar stories on the M&I page. - PMx 10/96

• Performance anxiety - why do we perform?
• Miscellaneous suggestions
• The Archer and the Prize - a final thought

Performance anxiety - why do we perform?

The following comments on performance anxiety and our motivation for performing come from Les Taylor <Les_Taylor@com.gulfaero>.

I am a baritone soloist and have performed serious music, in public, for some thirty years. The first time was for my entire high school class at graduation where I did the Coronation scene from Boris Goudonov.

For the first fifteen years, it was not always a pleasant experience. I got nauseous and shook like a leaf before, during and after nearly every performance. At one point, during a Messiah performance in the middle of `But Who May Abide', I asked myself why I was doing this. Even though scared half to death, my heart in my throat, blood pounding in my ears, I continued, almost compulsively, to seize every opportunity to perform that I could. I was determined to overcome the problem.

It was always worst when I tried to achieve perfection. This was usually in front of other students at weekly recitals in graduate school, when I just knew that they were taking exquisite note of my every mistake.

I pondered over the solution for years and the realization slowly dawned that the degree of nervousness was directly related to why I was doing what I was doing.

If I tried to achieve perfection, I was scared to death and a poor performance followed. If, on the other hand, I concentrated on the message or feeling that the composer intended the music to convey, I was someimes transported into realms of ecstasy. Inevitably, the audience was quite pleased as well.

If I tried to impose my (not inconsiderable) ego on the audience, the performance always suffered.

If I tried to share what I loved in the music with the audience, without getting my ego involved, trying to be faithful to the `soul' of the music, all was well.

The idea of using drugs, a special diet or sessions on a psychiatrists couch does not address the real problem. One either performs for ones self glorification or as a service to others. A drink before a performance, at least for a singer, is the worst thing to do since it clouds the attention and dessicates the vocal apparatus. Drugs and diets and the like may well have a beneficial effect on ones overall nervous condition but really have very little to do with performance anxiety.

I truly hope that this information does someone some good and serves to reaffirm why we performers do what we do.

Miscellaneous suggestions

Many of the following suggestions are culled from articles in the Usenet newsgroup rec.music.classical.performing; for the most part they originally appeared in the frequently asked questions file for that newsgroup. Further contributions/comments are welcome.

If you do not suffer particularly from performance anxiety, count yourself privileged. Anxiety in moderation can be a good thing, helping you to focus all your energy on the task in hand. Clearly, though, if you feel especially uncomfortable when playing or singing (or conducting...) in front of an audience, your performance will suffer.

There are countless ways of coping with the stress of performing, some of which work better for some people than for others. Some have suggested pre-performance exercises of various sorts, from deep breathing to meditation to screaming (quietly if necessary!). Also suggested were longer-term techniques such as the Alexander Method.

Many people suggested (temporary) dietary changes as a means of calming nerves prior to a performance. Indeed, one of the most popular remedies would appear to be the humble banana. Eat a couple of these before you perform and you'll have no problems (or so we are told) - apparently they contain some sort of natural beta-blocker.

Now for the serious stuff. A number of performers have advocated the use of various drugs as surefire ways of reducing/avoiding anxiety. While it is certainly true that drugs can be effective, it is equally true that their misuse can be highly dangerous. Never use anxiety-reducing drugs unless medically directed.

Beta blockers, such as propranolol (Inderal in the US), block the body's response (reaction) to adrenaline. Propranolol is well recognized as effective in reducing performance anxiety. It is one of the safest drugs ever developed, having been in use for treatment of high blood pressure, angina pectoris, and hyperthyroidism for more than 20 years. Unfortunately, beta blockers have at least one potentially fatal side effect: they will worsen the severity of asthma attacks and may precipitate an attack in an otherwise well controlled asthmatic. Persons with heart failure or mild degrees of heart block should usually not take beta blockers, as they can worsen these problems. Propranolol is supplied both in straight tablet form (taken every 6 to 8 hours) and in a long acting (LA) formulation, so be sure to find out from the prescribing physician how soon before a performance to take the medication.

Corticosteroids, such as Prednisone, work by reducing inflammation through suppression of immune responses. A number of side-effects have been attributed to use of such drugs, including thinning of the skin and redistribution of fatty tissue. Short term use of these drugs (a few days to a couple of weeks) will not usually have such adverse effects, though, given the suppression of immune response, corticosteroids should never be taken when suffering from a bacterial or viral illness.

A book on the subject of performance anxiety which comes highly recommended is `Stage Fright; its causes and cures, with special reference to violin playing' by Kato Havas.

The Archer and the Prize

- a final thought from Ken Fox

An archer competing for a clay vessel shoots effortlessly, his skill and concentration unimpeded. If the prize is changed to a brass ornament, his hands begin to shake. If it is changed to gold, he squints as if he were going blind. His abilities do not deteriorate, but his belief in them does, as he allows the supposed value of an external reward to cloud his vision.

Contributors

: [1] Greg Baker <glbaker@silver.ucs.indiana.edu>; [2] Daniel Downey <ddowney@carson.u.washington.edu>; [3] Jonathan Helton <jah@casbah.acns.nwu.edu>; [4] Nancy Leinonen Howells <howells@athena.mit.edu>; [5] Seth S. Katz <katzs@mcclb0.med.nyu.edu>; [6] John Lewis <court@morgan.ucs.mun.ca>; [7] Lawrence E. Mallette <mallette@bcm.tmc.edu>; [8] Ken Fox <jrenard@leonardo.net>

Musicians and Injuries

[Books][Tapes/DVDs] [Links & On-Line Articles]

Maybe it's a nagging ache in your thumbs, every time you practice at the piano. Perhaps there have been long rehearsals for that crucial recital, and now you notice stabbing pains in your forearms. Or you find yourself struggling with hands that have become increasingly clumsy, or numb. It may be that you are even waking up at night with pain in your arms, or your back, or your neck. Well, it's just a part of being a serious musician, right? And after all, you can't stop practicing - there's too much at stake, and music is your very life!

Instrumental musicians are a special risk group for repetitive motion injuries. Sizable percentages of them develop physical problems related to playing their instruments; and if they are also computer users, their risks are compounded and complicated. My own computer-induced tendinitis was very much aggravated by my guitar and violin playing and did not begin to improve until I stopped all playing for several months.

Instrumental injuries often include the same conditions experienced from computer overuse : Carpal Tunnel Syndrome , Tendinitis, Bursitis , Tenosynovitis / DeQuervain's Syndrome , Tendinosis , Thoracic Outlet Syndrome, Myofascial Pain Syndrome, Cubital Tunnel Syndrome, and Trigger Finger/Thumb are particularly common among keyboardists, fretboardists, flute, and string players. But the particular demands of different instruments produce other problems as well, including hearing loss or TemporoMandibular Joints Disorder . (Additional TMJ leaflets: 1, 2, 3, 4, or this new site from the TMJ Association ). Incorrect posture, non-ergonomic technique, excessive force, overuse, stress, and insufficient rest contribute to chronic injuries that can cause great pain, disability, and the end of careers.

But while these problems are unfortunately common, it's NOT an unavoidable part of being a musician. If we're willing to listen to what's being learned in the field of arts medicine, we may be able to escape the bullet of occupational injury and recover our ability to play.

What Can You Do?

• INFORM YOURSELF. Take time to read the resources listed below. Causes and prevention are a complex topic, as J�as Sen's excellent thesis makes clear.
  
• EVALUATE YOUR TECHNIQUE. Again, the materials listed have much more information, but in general musicians often need to reduce force, find postures that keep joints in the middle of their range of motion, use larger muscle groups when possible, and reduce body usage that involves fixed, tensed positions.
• ALWAYS WARM UP. Athletes do not abruptly start vigorous physical activity without warming up and stretching because they know it is an invitation to injury. Musicians are putting athletic demands on fine motor musculature and should similarly be religious about warming up before practice or performance.
• TAKE LOTS OF BREAKS TO STRETCH and RELAX. This means both momentary breaks every few minutes and longer breaks every hour or so. This may be the single most important thing to remember. Constant tension and repetitive motion does not allow the body to flush away metabolic waste products and this is traumatic to tissues over time. Even in the middle of playing a piece you may have a moment to relax a hand or arm to restore circulation. The marathon rehearsals that musicians pride themselves on have great potential to hurt us. Emerging research on athletes reveals that overtraining actually decreases performance. Try two or more shorter rehearsals in a day rather than one long, intense session, and limit total time on your instrument.
• PACE YOURSELF. It is very common for musicians to notice injury when we are...
  • preparing for recitals or concerts
  • attending music camps
  • heavily involved in multiple musical groups

  ...not surprising, because all of these can radically increase our playing time and exceed the limits of our body. (Yes, even for young people, who feel invincible. I have seen more than one gifted high school string player in my city seriously injured in this way.) Learning to pace ourselves and learning to say "No" to some playing is critical.

• GET MEDICAL HELP. Therapists and doctors know that musicians are notoriously hard to persuade to reduce or stop their playing to allow injuries to heal, and some instructors (or even parents) may tell students to ignore pain, or accuse them of trying to avoid practice. But "No Pain, No Gain" is a disasterous policy for a musician. If it hurts, back off. THIS IS SERIOUS STUFF: is it worse to have to not play for a few months . . . or to risk a permanent injury, disability, pain, and never playing again? Also, I hear of musicians with pain who are afraid to see a doctor because they may find out they have a difficult injury. It's better to know the truth and do something about it. Don't put off seeking treatment if you are in pain. Use the FindADoc Web page to locate knowledgeable medical care.
  
• EVALUATE OTHER ACTIVITIES. Your problems may be caused or aggravated by other things you do frequently. Computer use is a notorious example, but sports, carrying children, hobbies, and excess effort/tension in other daily things may have enormous impact too.
• PAY ATTENTION TO YOUR BODY. Pain is your body yelling that it's in big trouble, but learning what is comfortable or awkward for your body before you're in pain may prevent injury. "Physical re-education" through The Feldenkrais Method, T'ai Chi, yoga , The Alexander Technique , stretching, or dance classes all may be helpful.
• CHECK OUT YOUR INSTRUMENT. Are you using an instrument that is too large or awkward for you? Is it set up optimally for you? Tiny differences in playing action or tension can make a HUGE difference. Could you use lighter strings or reeds? Is there a strap or stand that could make playing less stressful? If it's big and heavy (like a string bass), can you get a cart to help transport it? And remember: if it is a new instrument, especially a larger one, you need to take time to adjust to it before you plunge into intense use of it.
• BE CAREFUL WITH STRENGTHENING METHODS. Building up muscle strength with special devices (GripMaster, putty) or musical exercises (Hanon) is very controversial. If you are already injured and in pain, such things may make it worse. And overdoing musical exercises while using bad technique, poor posture, or too much force may only speed you along to trouble. On the other hand, if you are not yet injured, or are undergoing rehabilitative therapy, properly conditioning muscles may help prevent injury or re-injury. Be patient in building strength, and talk to a qualified doctor or physical therapist.

I'll be putting more information here as I am able, but for now I highly recommend looking at some of the resources listed below. If you have pointers to similar literature, especially ergonomically oriented instrumental methods, or just have a tip or two of your own on safer techniques and injury prevention/recovery, drop a line so it can be added here. Please note that authorities in this area of study have differences of opinion about points of technique, treatment, or prevention: read as much as you can for the balanced view. Please note that several of the "reviews" below are written by persons other than myself: these have quotation marks and attributions to distinguish them. -Paul Marxhausen

Books . . .

Books contain far more useful information than can be easily presented on-line. I strongly encourage you to read some of the following titles. The publishing information and Web links to the publisher or distributor are included where they are known. In addition, in association with Amazon.com Books

you can purchase many of these titles on-line by clicking the

Order from Amazon ...

link after each listing, which will take you directly to that particular catalogue item. If you buy from Amazon, they will handle all billing, shipping, etc. and inquiries should be directed to them.

• MUSICIANS' INJURIES: A Guide to their Understanding and Prevention.
  . by Nicola Culf

  ISBN 1-898594-62-7 1998 Parapress Ltd, Guilford

  Nicola Culf has done musicians everywhere a service by packing into one slim volume (100 pages) a succinct and comprehensive account of the risk for injuries among musicians, and the means by which such injuries can be avoided. This contribution is notable in that it covers the whole range of music making; touches on every aspect of the problem, including practice habits, pain management, technique issues, recovery; and presents a wealth of fundamental, critical information quickly, efficiently, and readably.

  I would hope that the economy and accessiblity of Culf's writing make this a title widely read in our music schools as a matter of routine, and not simply a title that instrumentalists who are already injured and alarmed seek out after the fact.
  This book can be ordered online at www.parapress.co.uk or mail-order from : Parapress Ltd, The Basement, 9 Frant Road, Tunbridge Wells, Kent TN2 5SD (UK), Tel:(01892) 512118

• THE MUSICIAN'S SURVIVAL MANUAL:
  web A Guide to Preventing and Treating Injuries in Instrumentalists.
  Richard Norris, M.D.
  International Conference of Symphony and Opera Musicians, 1993. ISBN 0-918812-74-7
  MMBMUSIC,INC. Tel: 314 531-9635; 800 543-3771 (USA/Canada) ST262 $16.95 Web Site here.

  "The book is aimed at an audience of performers. It has chapters on recognition and prevention of injuries, thoracic outlet syndrome, some of the nerve entrapment syndromes, tendinitis, also "therapeutic exercise for musicians" and "returning to play after injury", among others. Very readable." (quote from Ann Chukurian) It had important insights for me as a musician, and much also applies to computer users. Musicians who are computer users need to read it. Here's the Table of Contents

  Appendix B (a list of performing arts clinics) from this book is included on my FindADoc list.
  Order MUSICIAN'S SURVIVAL from Amazon . . .

• "My current all-purpose recommendation for physical issues is Julie Lyonn Lieberman, YOU ARE YOUR INSTRUMENT, which covers all the mental/physical side of music, with lots of suggestions, physical exercises, and references to everything from chiropractic to yoga - she has done a lot of work with doctors on the physical side of musical performance. worth the money." (quote: Dave Sanderson)
  Huiksi Music, PO Box 495, NY NY 10024-3202 ISBN 1-879730-20-0
  [Note: I've read this book, and I agree with Dave. The book has great breadth and accuracy, funky but superb illustrations, and references for the additional reading musicians will want to do. - PMx]
  Order YOU ARE YOUR INSTRUMENT from Amazon . . .
• THE ART OF PRACTICING: A Guide to Making Music from the Heart
  Madeline Bruser
  Bell Tower, 1997 ISBN # 0609801775
  If a musician could only read a single book to learn about how to PREVENT injury, this would be the one. Madeline Bruser has assembled, from a host of resources (many listed on this page) terrific practical advice that does far more than help you find a healthy approach to using your instrument: The Art of Practicing also examines how to bring the highest level of artistry and communication to your playing. It includes question/answer sections throughout and instrument-specific advice. I really can't say enough about this book: if all teachers and students would take its guidance to heart, we would not have the levels of injury among musicians we now see, and music making would be both more human and humane. Excerpts and information is on her website.
  Order THE ART OF PRACTICING from Amazon . . .
• TEXTBOOK OF PERFORMING ARTS MEDICINE
  Sataloff, Brandfonbrener, Lederman, eds. New York: Raven Press, 1990.

  "The textbook is more for health care people. It has information on how to diagnose and treat many problems performers have, including tendon/muscle problems, also things like hearing loss, vocal nodes, and problems specific to dancers. I found it very useful when I was first starting to research my problems ("tendinitis" in forearms), especially when I needed to tell the doctor what to do. ...(has) extensive bibliographies. If your library doesn't have it, you could request that they be borrowed for you via interlibrary loan." (quote from Ann Chukurian)

  Note: this book is connected with the quarterly journal MEDICAL PROBLEMS OF PERFORMING ARTISTS, which can be found in some University libraries.
  Order TEXTBOOK OF PERFORMING ARTS from Amazon . . .

• PLAY IT SAFE: A Health Resource Manual for Musicians and Health Professionals
  by Christine Zaza, ARCT, BMus, MSc, PhD
  available from the Canadian Network for Health in the Arts
  The author sez:
  "Play it Safe" provides reseach-based information on musicians' health problems:
  • information on symptoms, risk factors, treatments, and prevention of playing-related health problems (including musculoskeletal disorders, hearing loss, performance anxiety, and other health problems).
  • an International Directory of health professionals who specialize in treating musicians' injuries
  • listing of health resources (books, videos, Internet sites, organizations etc.)

  The book sells for $19.95 US + $3.50 shipping and handling - order forms can be printed from the CNHA web site.

• THE MUSICIAN AS ATHELETE: Alternative Approaches to Healthy Performance
  by Dorothy Bishop
  Web Site here . . . Susan writes: "...written in 1991 by Dorothy Bishop, a Calgary, Alberta based cellist, teacher and herbalist and published by Kava Publications, 111-32nd Ave. N.W. Calgary, Alberta, Canada, T2M 2P7. She describes in great detail the physiological problems that can develop for musicians and approaches treatment primarily from a nutritional/herbal perspective, although she evaluates all manner of conventional and experimental treatments." Buy from Web Site
• ON PIANO PLAYING
  Motion, Sound, and Expression
  Gyorgy Sandor
  Schirmer Books, NY 1981 ISBN 0-02-872280-9

  This remarkable book is perhaps the most outstanding written resource available to pianists pursuing efficient, effective, pain-free technique on their instrument. In a little over 200 pages, Sandor provides an exceptionally thorough and readable analysis of piano technique with ample diagrams, photographs, and musical samples. At every turn he displays a detailed understanding of human physiology and the means to use it to produce musical effect without excess strain and effort. Very impressive, very accessible, it's a "must-read".
  Order ON PIANO PLAYING from Amazon . . .

• ' . . .A new book authored by classical pianist Stephanie Brown has tips for avoiding repetitive stress injuries, applicable to both computer and musical keyboards. "The Hand Book" uses clear and simple language to describe righ and wrong positions in keying, with easy-to-remember names for no-nos, such as the "spider" and "cobra" positions. Brown recommends allowing wrists to "float" above the keyboard, and hands and forearms should follow a natural line ("relax into the rainbow"), rather than being held too close to the body or arched out like chicken wings. The book is available from Ergonome (800) 222-6996. (St. Petersburg Times 7/3/95 A8)' Also can be ordered from 212-222-9600. $19.95

  More reviews of the book and info about the upcoming "Keymoves" software based on the book can be read here.

• PIANO POWER:A Breakthrough Approach To Improving Your Technique by Richard Prokop
  Web site here.
  I have not read this book but from the description and reviews from both musical and medical professionals it sounds like it is a useful resource. (Though at least one reviewer at Amazon dissents.) Read it and send me a review . . .
  Order PIANO POWER from Amazon . . .
• TENSIONS IN THE PERFORMANCE OF MUSIC : a symposium edited by Carola Grindea ; foreword by Yehudi Menuhin ; preface by Allen Percival London : Kahn and Averill, 1978. An excellent collection of articles on physical and mental tension in music with implications for injury. Includes: String Playing - Kato Havas; The Conductor - Vilem Tausky; The Composer - Alfred Nieman; Voice Production - Walther Gruner; Actors & Opera Singers - Leigh Howard; The Alexander Technique - Nelly Ben-Or; Piano Playing - Carola Grindea; Clarinet Playing - Gervase de Peyer; A Psychologist's Perspective - Paul Lehrer
  Order TENSIONS from Amazon . . .
• LEARNING THE CLASSIC GUITAR, Part I Aaron Shearer Mel Bay Publications, Inc. #4 Industrial Drive, Pacific, MO 63069-0066 Toll Free 1-800-325-9518 FAX (314)257-5062

  This prestigious teacher had his own concert career ended by tendinitis. In this book he gives invaluable advice on learning how to play without injury through proper positioning, technique, and practice habits. Even experienced guitarists should consult this. Includes sections on: Conditioning and Coordination Exercises, Procedure for Stretching Exercises , Economy of Movement, and an entire chapter dealing with Repetitive Strain Injury. Here's a quote about the Four Principals of Efficient Muscle Function.
  Order LEARNING THE CLASSIC GUITAR from Amazon . . .

• CLASSIC GUITAR TECHNIQUE: Process and Essence Christopher Berg Mel Bay Publications, Inc. #4 Industrial Drive, Pacific, MO 63069-0066 Toll Free 1-800-325-9518 FAX (314)257-5062

  The author sez: "It is the only guitar technique book, to date, that discusses the relationship between the requirements of a musically sensitive technique and the physiological capablilities of the body. I also integrate some of the concepts developed by Feldenkrais and F.M. Alexander."
  Order CLASSIC GUITAR TECHNIQUE from Amazon . . .

• THE PHYSIOLOGY OF GUITAR PLAYING by Ricardo Iznaola
  International Centre for Research in Music Education

  Ricardo Iznaola's "The Physiology of Guitar Playing" is markedly different than many of the titles emerging on the topic of healthy, effective musicianship. As a text, it is not structured towards the popular audience but is purposefully aimed at providing detailed, focussed information to guitar teachers. The text includes a short course in human anatomy with a focus on the musculoskeletal and nervous systems, with particular comments on those components that are key elements in guitar playing. Another departure is that the author, having explained many aspects of bodily function, does not proceed to develop a detailed and exhaustive prescription for technique. The examples he gives instead point out how rigid formulas and dogma in regard to technique do not adequately take into account the constantly changing positions in playing guitar, or the variations in human anatomy between players. Instead of producing yet another "guitar method", Iznaola supplies the guitar teacher with resources, valuable background information, and challenges.

• THE WHOLE GUITARIST by Peter Inglis
  I haven't read this but the Web site and comments by the author on-line demonstrate an approach to the guitar rooted in the Alexander Technique and an awareness of the body.
• THE ATHLETIC MUSICIAN : A Guide To Playing Without Pain Barbara Paull and Christine Harrison

  A review on Amazon.com says the following: "Every musician who wants to avoid a playing injury or is recovering from such an injury should own this book. This is not a read-once book but a book to use and refer to until one has it memorized. It gives easy-to-follow instructions for safe warming up, exercises and stretches to do at home and even some for doing on stage, ways to avoid injury and means to stay healthy when one has recovered. The psycological and social aspects which confront injured musicians are sensitively dealt with in "The Athletic Musician". The title already tells us that this is a relevant approach to treating the subject of musician's health. Read it, it could save your career!" Alan sez: "YEAH, I DID READ THE BOOK. IT'S NOT BAD. THE BOOK WAS WRITTEN BY A PHYSIOTHERAPIST (...) AND A VIOLINIST. THEY OFFER SOME GREAT ADVICE ON THE ERGONOMICS OF PLAYING YOUR INSTRUMENT. THEY ALSO DISCUSS HOW MUSCLES INTERACT WITH EACH OTHER....AND HOW ONE CAN BECOME MORE DEVELOPED THAN IT'S COUNTERPART...CAUSING PAIN. VERY INTERESTING STUFF!"

  The authors also run the The Stouffville Musicians' Injuries Clinic , provide treatment, consultations, and workshops.
  Order ATHLETIC MUSICIAN from Amazon . . .

• PLAYING (less ) HURT:An Injury Prevention Guide for Musicians. Janet Horvath I haven't read this book myself, but as you can see from the website, it comes highly recommended by some Big Names in the realm of healthy musical technique. Sounds good! If you read it send me a review.
• NEW DIRECTIONS IN CELLO PLAYING: How to Make Cello Playing Easier and Play Without Pain Victor Sazer Ofnote Publishers, P.O. Box 66760, Los Angeles, CA 90066; telephone 310.391.9787; fax 310.391.1251.
  Web Site here.

  The author explains: "Directions in Cello Playing introduces natural, tension-free ways of playing the cello. It presents anatomically-improved ways of sitting and holding the cello, a new approach to left arm and hand techniques and fundamentals of bowing. It also addresses musicians' pain problems, including causes of pain, types of injuries and pain prevention."
  Order NEW DIRECTIONS from Amazon . . .

• ESSENTIAL BASS TECHNIQUE Peter Murray

  Web Site here.

  "The book is a 52-page in-depth exploration of the essential elements of bass guitar technique . . . focuses on how to practically train your hands to play with efficiency--which will in turn benefit your chops, tone, endurance and flexibility." (This book is exceptionally well researched and packs a lot into 52 pages. It really is "essential." - PMx) 08/02/2002 - The author sez the 2nd edition is now out. - PMx

• "...I believe very strongly in the principles set out by Tobias Matthay early this century and published by Oxford University press.They are not easy to read for most Americans but his FIRST PRINCIPLES and THE VISIBLE AND INVISIBLE IN THE ACT OF TOUCH might have an answer for you. The way you use your body determines what happens to you, the piano, and the music. If you have physical problems, you're doing something wrong. Fundamentally you're either working against your body's natural way of working, or the piano's natural way of working." (Lisa Thein)

  It appears that there is an American Matthay Association with a Web page, check it out for contacts with persons involved in training based on Matthay's work.

  TITLE The visible and invisible in pianoforte technique, being a digest of the author's technical teachings up to date, by Tobias Matthay.
  AUTHOR Matthay, Tobias, 1858-1945.
  PUBLISHER London, New York, Oxford University Press [1960]
  Note: Matthay's books appear to be available through the on-line Advanced Book Exchange.

• PIANO TEACHER'S COMPANION.
  Guy Maier.
  NY: Belwin Mills Music, [c1963].
  Steve writes: " I have read much about Matthay, yet we had at one time here a teacher whom, I believe, made the many of the prinicples that Matthay was trying to get across in his volumes, simple and understandable for simple folk to understand.. and with humor. His name was Guy Maier. You might find this compilation of his writings, actual questions he answered while writing for the old Etude Magazine, interesting: "The Piano Teacher's Companion" published by Belwin Mills.

  Maier was concerned with many of the problems I have read in this web site. Check him out if you haven't already. Kind of surprising that he hasn't been mentioned by any of the folks who are concerned with injuries."

• MY THOUGHTS ON PIANO TECHNIQUE
  THOUGHTS ON THE SUZUKI PIANO SCHOOL
  Haruko Kataoka
  I've heard that this Suzuki instructor has much to offer on healthy, tension-free piano playing.
  Order #1 from Amazon . . .
  Order #2 from Amazon . . .
• ABBY WHITESIDE ON PIANO PLAYING
  Indispensables of Piano Playing - Mastering the Chopin Etudes and Other Essays
  Abby Whiteside
  '...the overall co-ordination of the body . . . is a subject covered in great detail in the suberb "...On Piano Playing" ... by the late American piano teacher Abby Whiteside, whose concept of an "emotional rhythm" - a sense of physical continuity, freedom and expert timing, resulting primarily from an emotional connection with the music, and producing both musical continuity and beauty and virtuosity - has implications not only for piano playing, but for the playing of other instruments and for other art-forms.'
  (Comments by Stephen Marquiss)
  Order ABBY WHITESIDE from Amazon . . .
• "I strongly recommend the teachings of Kato Havas when it comes to violin/viola playing. She has helped many play again when they thought they couldn't. There is an organization (KHANA) the Kato Havas Association for the New Approach and she has several books and a video: " (Recommendation by Tim McCarrick)
  A NEW APPROACH TO VIOLIN PLAYING; Kato Havas (Bosworth Pub)
  STAGE FRIGHT; Kato Havas (Bosworth Pub)
  12 LESSONS ; Kato Havas (Bosworth Pub)
  Bosworth & Co. Ltd
  14/18 Heddon St. Regent St.
  London W1R 8DP

  The Editorials of Kato Havas - Kato Havas -
  Castle Enterprises, 3478 B Pleasantbrook Village Ln, Atlanta GA 30340-5661 USA. US$10.00 + $2.00 shipping in the USA; US$3.95 international shipping. Info from: stos@mindspring.com
  Freedom to Play : A String Class Teaching Method
  Published by Alexander Broude September 1981 ISBN: 9992292784
  You might also note that "Freedom to Play" is a teacher's guide for string class instruction...no student books exist.

  I'm told that Havas' books are available from Timberwood Industries, Inc., Box 82, South Salem NY 10590 USA (914)533-2020.
  For information on KHANA, contact International Membership Chairman, Robert Stoskopf, 3478 B Pleasantbrook Village Ln, Atlanta GA 30340-5661 USA. E-mail: stos@mindspring.com
  Order FREEDOM TO PLAY from Amazon . . .

• New Approach violin tutor books for beginners by Gloria Bakhshayesh based on the teaching of Kat�Havas A structured course of lessons suitable for individual, class or group teaching.
  DANCING BOWS
  Open string patterns and tunes in duet form. PUPIL’S BOOK: 14 lessons; 32 pages; 9 bowing patterns;21 pupil/teacher duets;22 photographs PRICE 3.70 plus p&p: UK 1.50, Europe 2.30, Other countries: Air 3, Surface 1.50 TEACHER’S BOOK: Manual on the use of Pupil’s Book,including teacher’s parts for folk song duets. 60 pages;49 photographs PRICE 5.50 plus p&p: UK 1.70, Europe 2.70, Other countries: Air 4, Surface 2.50 p&p for both books: UK 2.50 Europe 4. Other countries Air 6. Surface 3

  RINGING STRINGS
  Introduces left hand fingering BOOK 1: 12 lessons; 62 pages; 25 exercises with finger patterns; 12 bowing patterns; 44 pupil/teacher duets; 11 photographs. Supplement of 7 Concert Pieces with piano accompaniment. BOOK 2: 12 lessons; 54 pages; 27 exercises with further finger patterns in 1st position, including the 4th finger; 11 further bowing patterns; 47 pupil/teacherduets. Supplement of 12 Concert Pieces with piano accompaniment. TEACHER’S BOOK : A manual on the use of both books. 54 pages; 13 photographs. PRICE Each book 5.50 plus p&p UK 2 Europe 3 Other countries Air 5 Surface 2.50 p&p for all THREE or all FIVE books: UK 5 Europe 6.50 Other countries: Air 12 Surface 5

  The books incorporate Kod�y principles of rhythm, ear training and inner hearing. The development of listening, performing and composing skills is an intrinsic part of the lessons.
  Available from G.Bakhshayesh, 3 Beacon View, Marple, Stockport. SK6 6PX. England. Payment in sterling please. US Agent: Timberwood Industries Inc., c/o Box 82, South Salem, NY 10590. USA

  Gloria Bakhshayesh is a peripatetic string and singing teacher who studied with Kat�Havas for many years and has become her Personal Representative in England. Working with the New Approach, she is specialising in the prevention of tension and anxiety in children learning the violin and in-service training courses for school instrumental teachers and college students. She is Administrator and Treasurer of the European branch of KHANA.

• THE COMPLEAT VIOLINIST
  VIOLIN, SIX LESSONS WITH YEHUDI MENUHIN
  Yehudi Menuhin
  "Yehudi Mehnuhin published a book in the early seventies called Six Lessons of Violin....He discusses posture and warmup techniques as means of avoiding tension and playing fatigue. ...the pictures are wonderfully informative, and it's easy to know that he teaches from real knowledge." (Quote:wcm1@cornell.edu) "Look in your local library for his The Compleat Violinist. I'm not sure when it was published (this could be the same book) but the first few chapters have excellent stretching/warmup excercises. " (Quote:Ian & Laurel MacCulloch )
  Order from Amazon . . .
• THE TEACHING OF ACTION IN STRING PLAYING
  BASIC PRINCIPLES OF STRING PLAYING
  Paul Rolland
  Paul Rolland led some extraordinary research with the University of Illinois String Research Project. This included the production of a whole series of films under the TEACHING OF ACTION title, and a book (with Marla Mutschler) as a guide to it. The films and book, first made in the early 1970s, draw from a variety of contemporary string pedagogues and are greatly concerned with healthy, effective use of the body in playing strings. Your nearest university library may hold these films as video cassettes. The TEACHING OF ACTION book (Boosey & Hawkes, c1986) is intended to accompany the films and could have been better edited for stand-alone reading, but is full of good discussion and illustrations. I have not seen the BASIC PRINCIPLES book (Presser, 1979) but judging from Rolland's other work would assume it is a useful resource as well.
• THE VIOLIN BOOK Eden Vaning-Rosen
  The publisher says: " While The Violin/Viola/Cello Book Series do not present themselves as a cure for any injuries, these books teach techniques on a completely step-by-step basis (not step 7, 28, 107; but rather, step 0, 1, 2, 3, etc.) fully illustrated, and the books anticipate poor techniques creeping in, and handle them individually before they become bad habits. We have experienced zero students developing painful injury using these books, and that includes people in their 60's. The books are not available in the stores generally and can only be obtained from The Violin Book Website .
• PREVENTION AND CORRECTION OF CHRONIC INJURY FOR HARPISTS Laurie Riley
  Box 249 Vashon WA 98070 Price $7 plus shipping $1. E-mail: harp@seanet.com

  The author says: "Who said harping could be pain free? If your teacher didn't, you need this book! Playing a musical instrument can and should be comfortable. Discomfort can lead to permanent injury. Why take the chance? Find out how easy it is to avoid and/or correct problems now! "

• UNDERSTANDING DRUM TECHNIQUES
  Dave Hughlett
  The International Foundation for Performing Arts Medicine says, "This book is a great asset for those who teach percussion. Especially useful are the large, clear illustrations, including anatomical pictures."
  To order: send $15.00 (bank check or US currency) to:
  IFPAM
  55 West Lindsley Road
  North Caldwell, NJ 07006
  A portion of the cost of this book is donated to IFPAM. Non-US orders $20.00
• KEEP YOUR VOICE HEALTHY: A Guide to the Intelligent Use and Care of the Speaking and Singing Voice
  Friedrich S. Brodnitz
  2nd Edition Paperback October 1987 ISBN: 089079331X
  A thorough and readable manual by an otolaryngologist - every serious singer should read this title.
  Order from Amazon . . .
• CHANGE YOUR VOICE, CHANGE YOUR LIFE: A Quick, Simple Plan for Finding and Using Your Natural, Dynamic Voice
  STOP COMMITTING VOICE SUICIDE
  Morton Cooper
  1986 ISBN: 0064637123
  1996 ISBN: 0879804378
  Both of these books explain Dr. Cooper's simple keys to avoiding common voice usage problems. The central concepts and information could actually fit in a small pamphlet and his writing suffers from repetition, filler, and name-dropping, but the core information is important and simple - I recommend finding these in a library if you can.
  Order CHANGE YOUR VOICE from Amazon . . .
  Order STOP COMMITTING from Amazon . . .
• Shoulders, Upper Back, & Neck: Free Yourself from PAIN!
  Rosemarie Atencio
  HWD Publishing, PO Box 220 XA, Veneta, OR 97487. (503)935-1608 FAX (503)935-0705 $17.95 + $2.50 s/h

  Good all around practical information on preventing and alleviating upper body musculoskeletal pain.
  Order from Amazon . . .

  Also good is her book Carpal Tunnel Syndrome: How to Relieve & Prevent Wrist "Burnout!"
  $13.95 + $2.50 s/h; the VHS tape (20 mins) is $2l.95 + $2.50 s/h or you can buy book+tape & get a free 8 1/2 x 11 laminated poster for $39.15 including s/h.
  An excerpt from Carpal Tunnel can be read here.
  Order from Amazon . . .

• Recommended by many on the 'Net is . . .
  Conquering Carpal Tunnel Syndrome and Other Repetitive Strain Injuries: A Self-Care Program
  Sharon Butler
  Advanced Press, Paoli PA USA, 1995.
  1 800 909-9795 (U.S.) or +1 610 889-9795 (Int'l) (US$18.95 + 2.50 shipping) Discounts for groups & multiple copies.
  This book emphasizes an extensive collection of stretches intended to rehabilitate tight and injured tissues. Good multiple indices help you find the stretches for your pains and/or your occupation. More info and ordering here.
  Order from Amazon . . .
• REBELLION OF THE BODY
  Understanding musician's focal dystonia
  Dr. Joaquin Farias
  " This book gathers together some thoughts which emerged during the process of reeducating musicians suffering from a movement disorder known as focal dystonia."
  More info and ordering here.
• THE EGOSCUE METHOD OF HEALTH THROUGH MOTION
  by Pete Egoscue, Roger Gittines
  Harperperennial Library 1993 ISBN 0060924306

  PAIN FREE : A Revolutionary Method for Stopping Chronic Pain
  by Pete Egoscue, Roger Gittines

  In "The Egoscue Method", Pete Egoscue has a very accessible manual for identifying dysfunctional habits of posture and motion that are the source of much musculoskeletal pain and disability. His book also lays out a series of exercises to correct these problems. Very readable, do-able, recommended by RSI recoverees. Egoscue's clinic also has a Web Site.

  PAIN FREE in some ways simply revists the same material in THE EGOSCUE METHOD, and includes many of the same "E-cises" recommended in the earlier book. However, it organizes itself by body section, working from the feet up to the head, and thus it's easier to get to the material that applies to your particular pain. All these areas are functionally related, as Egoscue continually points out, and the same corrective postures and "E-cises" may apply to different pains. Like many authors presenting a personal approach to wellness, Egoscue is very optimistic about his ability to remedy a great many problems; but on the other hand, his methods are very reasonable and rational and he explains physical problems and his proposed remedies in careful detail, so I haven't got any quarrel with him. There's nothing "off-the-wall" here.

• THE ANATOMY BOOK FOR MUSICIANS
  by Susan L. Weiss, CMT.
  "I recently published a book entitled "The Anatomy Book for Musicians". It contains diagrams of the muscles of the head, neck, and upper body, and lists:
  • - Each muscle
  • - Its action
  • - Which instruments use it
  • - How an overuse might occur (other than performance-related)
  • - Symptoms of overuse
  • - Solutions

  It is a wonderful resource for performers to communicate more fully with physicians, and for the teacher to help avoid posture problems. It can help a teacher to figure out what a student is doing that is creating problems." The book is softcover, spiral bound, and sells for $18.00 + 7.75% tax (IL residents) + $4.00 s/h. The address to order from is:
  Muscle Dynamics
  P.O.Box 431
  Glenview, IL 60025
  (888) 729-3770

  Payment is accepted in the form of checks (made out to Muscle Dynamics), Mastercard or VISA.

• Sean P. Gallagher, PT writes: "The new issue of Orthopaedic Physical Therapy Clinics of North America (June 1997, Published by W.B. Saunders * a division of Harcourt Brace & Company) is titled "Physical Therapy for the Performing Artist, Part II - Music and Dance". I was the guest editor and contributors include:
  Linda H. Hamilton, PhD - A psychological Approach to the Rehabilitation of Injured Performers.
  Nicholas F. Quarrier, PT - The Biomechanical Examination of a Muscian with a Performance-Related Injury.
  Richard Norris, MD and Jan Dommerholt, PT - Applied Ergonomics: Adaptive Equipment and Instrument Modification for Muscians and Physical Therapy Management of the Instrumental Musician
  Blair F French, PT and Gina Giammanco, PT - Developing a Work Hardening Program for the Performing Artist.
  There is one other article in this issue that deals only with dance. This clinics on Performing Artists . . . became two issues because there was to much information to put in just one. The first issue was mainly on dance but there is also articles that deal with musicians . . . That issue was published in December of 1996 and was titled Physical Therapy for the Performing Artist, Part I - Dance I am not sure Amazon will carry these since it is published for subscription. If not people can contact me and I would be able to order it for them through our ArtsCare Catalogue. I'm at spgpt@aol.com so if you have any questions please e-mail me."
• INDIRECT PROCEDURES: A Musician's Guide to the Alexander Technique.
  Pedro de Alcantara
  Oxford [England] : Clarendon Press ; New York : Oxford University Press, 1997. ISBN: 0198165692
  This book is excellent in two ways: first, it does the best job I've yet seen at explaining the Alexander Technique, a body-awareness method used by many musicians. It cleared up a number of misconceptions I had about A.T., and anyone interested in the Technique should see it, musician or not. On top of the Alexander material, the author has many intriguing discussions of musical applications, rehearsal techniques, and mental attitudes that bear careful consideration even if one is not involved in Alexander training.

  New: Pedro de Alcantara has his own website at www.pedrodealcantara.com, with book excerpts, original articles and essays, news of seminars and workshops, and links to pages of interest to musicians, fellow Alexander teachers, and laypeople.

  Order INDIRECT PROCEDURES from Amazon . . .

• CURIOSITY RECAPTURED : Exploring Ways We Think and Move
  Jerry Sontag, Editor
  MORNUM TIME PRESS,October 1996 ISBN: 0964435217

  The editor sez: 'The 15 essays in Curiosity Recaptured provide a compelling introduction to the Alexander Technique. Whether you are interested in the performing arts, problem-solving, the field of health, or simply a more satisfying way to live, this book can open the door to a new world. ' Includes articles by Edward Avak, Anne Bluethenthal, Deborah Caplan, Walter Carrington Barry W. Collins Galen Cranz, Robertson Davies, Mary Holland , Barbara Kent, Ilana Machover.

  Order CURIOSITY RECAPTURED from Amazon . . .

• More good books on RSI in general here . . .

Tapes and DVDs

• THERAPEUTIC EXERCISE FOR MUSICIANS - VIDEO
  "This one hour instruction video is designed to guide musicians in the right direction Based on the course "Physical Education for Musicians," which Dr Norris taught at the New England Conservatory, it offers a balance of warm up and breathing exercises, strengthening, strething, nonimpact aerobics and instrument-specific exercises drawn and blended from Dr Norris' extensive background in Yoga, Tai Chi and dance, and from his medical training in Rehabilitation Medicine and Orthopedics. "
  Duration: 60 minutes.
  MMBMUSIC,INC. Tel: 314 531-9635; 800 543-3771 (USA/Canada) VHS Video ST248 $35.00
• Dr. Norris told me that the difficulty some persons have finding good care for computer or musical RSIs prompted him to create a VHS tape titled "NONSURGICAL TREATMENT OPTIONS FOR UPPER EXTREMITY OVERUSE INJURIES", targeted at folks whose physician may not be too hip to this stuff, available directly from him for $65. (Excerpts from this are being reprinted in the RSI Network newsletter: click here to read the article.)

  Dr. Richard Norris, Director
  National Arts Medicine Center & Center for Repetitive Motion Disorders
  National Rehabilitation Hospital
  3 Bethesda Metro Ctr. Suite 950
  Bethesda, MD 20814
  (301) 654-9160

• Choreography of the hands [videorecording] : the work of Dorothy Taubman
  / produced and directed by Ernest Urvater.
  PUBLISHER Amherst, Ma. : JTJ Films, Inc., 1986.
  (60 min.) VHS format. Dorothy Taubman and various performers and Master Class students present her techniques for playing musical instruments which help to prevent injuries and reduce pain.

  Note: So far I haven't found any method books by Dorothy Taubman but have been told that you can reach the Taubman Institute for instructor references at 518-239-4756. In addition there is now a Web Site for the institute.

• The Taubman Techniques: An In-depth Analysis of a Technique for Virtuosity and the Prevention of Injuries among Musicians

  "There is now a set of five videotapes published by the Taubman Institute which give a detailed account of many of the most important aspects of her teaching. The tapes are based on lecture/demonstrations given by Taubman's associate Edna Golandsky at the Institute's summer school at Amherst MA. Further details available from Enid Stettner, tel (518) 239-4756 or 1-800-826-3720. The focus is almost entirely on the piano. They are expensive, but worth it IMO for their wealth of information and detail. (I've bought them myself!) Reviews have appeared in Clavier Vol 36 No 5 May/June 1997 (Jane Magrath) and in Piano and Keyboard No. 186 May/June 1997 (Wilma Machover). " (submitted by:Henry Micklem)

• The You Are Your Instrument Video is a companion piece to the book. While enhancing the material from the book, it has been designed to function as a separate resource. Julie Lyonn Lieberan explains many new approaches to music-making; leads you in a number of powerfully useful mental and physical techniques; uses live musicians to illustrate important concepts that are key to fluid, pain-free music-making; interacts with a professional physical fitness model to demonstrate all of the muscle balance techniques outlined in her book.
  • You ARE YOUR INSTRUMENT FOR INSTRUMENTALISTS:
    This exciting two-hour video addresses such issues as six-fold memory, channeling nervousness into increased playing ability, the four planes of movement, the usefulness of gravity, the role of proper breathing in relaxation, and how to use the muscles and joints in harmony with anatomy. Also included are individual segments in which Julie presents detailed information on the specific challenges of the bowed, fretted, wind and keyboard/percussion instrument families. Through interaction with experience musicians in each of these fields, Julie will demonstrate many new mental and physical approaches to practice and performance.
  • You ARE YOUR INSTRUMENT FOR VOCALISTS:
    On this unique two-hour video, Julie explores such important issues for vocalists as singing from whole brain/whole body, breath support and control, vocal stamina, the causes of vocal dysfunction and injury, and the effect of diet and environment on the body's ability to produce sound well. She is joined by three experts in the field: Maitland Peters, professor of voice at Manhattan School of Music, Jeannie Deva, the author of The Contemporary Vocalist, and Katie Agresta, teacher to such artists as Phoebe Snow, Cyndi Lauper and Bon Jovi.

  To Order: Call 1-800-338-2737 or write to Homespun Tapes, PO. Box 694, Woodstock, N.Y 12498 Price: $49.95. Visa or Mastercard accepted. (Add 7% sales tax if delivery is in New York State) Postage and Handling: U.S. and Cananda $4.00, Europe and South America: $12.00, Africa, Asia and Australia: $20.00

• FREEING THE CAGED BIRD
  Developing Well-Coordinated, Injury-Preventive Piano Technique
  with Barbara Lister-Sink 160 minutes

  Wingsound Productions
  PO Box 10912
  Winston-Salem, NC 27108 for . Phone = 336 945 2304
  $39.95 + 4.95 P&H

  Web Site here . . .
  "This is a video about acquiring a tension free piano technique in order to avoid injury . . . It is fairly extensive and features many people who had injury and fixed their problems by retraining. The end of the tape details techniques for learning advanced material without injury. Very practical and competent in its approach to both music and human physiology." (Recommendation by Dick Norton)

  The author of this tape was good enough to give me a copy and it is superb. It is very thorough (2.5 hours) and well produced. More than Ms. Lister-Sink's clear and insightful verbal presentation, it provides ample on-camera demonstrations by the presenter and several students at various levels of experience, enhanced at times with slow-motion playbacks. It is especially aimed at piano instructors, and does not claim to be a replacement for skilled teachers. Even so, every pianist may gain valuable insights into healthy technique by watching it, and the price is very reasonable for the value received, in my opinion. - Paul Mx

• THE KATO HAVAS TEACHING VIDEO
  
  a practical, hour-long, teaching video, on the causes and cures of physical injuries in violin and viola playing (can be applied to 'cello and bass also). It has detailed exercises on the release of tension and the prevention of anxiety in performance.
  Available from Lakeland Home Music
  Watermillock, Cumbria CA11 0LR ENGLAND
  or
  Timberwood Industries, Inc.
  Box 82
  South Salem NY 10590 USA (914)533-2020.
• ". . . last week I saw an excellent video: " Keyboard Comfort" produced by USC instructional TV.
  The instructions were given by Greg Dempster, pianist and typist. He discussed one's approach to the keyboard and gave tips which he said pianists began to use in the 40s, such as "Rest Down" (resting/relaxing your hand when the key is down).
  Those interested might want to ask their friendly librarian to try to find this video!" (Joan Garvin)
• CC writes: " I have a great videotape called Healthy Hands: Wrists and Forearms , made by a guy named Martin Gray who is a juggler, massage therapist and really cool guy. The video has an hour of stretching, strengthening and care information just for the hands. I recommend it for listing on your site- which is such a great resource! I will recommend it to all my students. Check out
• THE TEACHING OF ACTION IN STRING PLAYING
  Paul Rolland
  University of Illinois String Research Project produced series of films. See book of same name above.
• Repetitive Strain Injury? Rx: Yoga!
  by Gail Dubinsky, M.D.
  

  Pamela writes: "A reminder that there are special yoga tapes available that are targeted specifically to RSI patients. Information can be found at www.rxyoga.com. The author of Rx:Yoga! is Dr. Gail Dubinsky, who treats soft-tissue orthopedic injuries, and is also a long-time yoga practitioner. I reviewed the tape for MC Journal (see here ), and found it to be extremely appropriate -- I suffer from carpal tunnel and tendonitis, and found the yoga poses to be very doable and helpful."

• CARPAL TUNNEL SYNDROME: CAUSES AND TREATMENTS
  TRIGGER FINGER: SURGICAL AND CONSERVATIVE TREATMENT APPROACHES
  Eileen Apfel
  Order through Web Site.

  CARPAL TUNNEL SYNDROME: CAUSES AND TREATMENTS
  This educational video describes the causes, surgical, and conservative treatment approaches for Carpal Tunnel Syndrome. It specifically teaches important basic concepts, such as anatomy, and effects of hand positioning and hand use on nerve compression. Home programs such as range of motion exercises, scar massage, cold application, splint use and care, and ergonomic modifications are demonstrated. Individual tape price is $59.00.

  TRIGGER FINGER: SURGICAL AND CONSERVATIVE TREATMENT APPROACHES
  A Hand Surgeon and two Certified Hand Therapists describe the causes and various treatment approaches for Stenosing Tenosynovitis of the digital flexor tendon (Trigger Finger). Viewers will learn about the pathophysiology of Trigger Finger, and are specific therapeutic techniques such as splint use, cold application, and differential tendon gliding exercises are demonstrated. Individual tape price is $59.00.

  Eileen Apfel says: "I am a Registered Occupational Therapist and Certified Hand Therapist with 24 years of experience treating Upper Extremity Disorders. I also have a strong music background, with a subspecialty in treatment of the injured musician. I work on a physician referral basis only ( by written physician prescription). I am located in Coastal North San Diego County. I prefer to be contacted by email at apfelroberts@worldnet.att.net."

• Yuri Ziskin offers a personalized videotape instruction based upon video recordings of individual students who want to learn non-injurious technique. He can be e-mailed at yuriz@pcweb.net and has an interesting website at www.pianoinjurycure.net .
• PLAYING WITHOUT PRACTICE
  Dr.Joaquín Farias
  The publisher says: "A simple, revolutionary method which lets you reduce the practice time required to play a musical instrument. The system is ideal for the prevention and treatment of professional injury to musicians. The full sequence takes only 20 minutes and can also be used to warm up before playing. Since the first two weeks of practice you will develop the control you have over your muscles, thus improving the efficiency of your movements. The perfect tool for all instrumentalists. DVD includes: Muscular control exercises / Tone up exercises / Relaxation session
• WOMAN TO WOMAN GUITAR is "a comprehensive course of study which can take you from being a guitar player with basic skills to an accomplished guitarist." Charlotte Adams puts a strong emphasis on healthy playing and has excellent articles on her website.

Links & On-Line Articles

• Jonas Sen's superb Playing the Piano,Playing...With Fire?A Study of the Occupational Hazards of Piano Playing - important reading for non-pianist musicians, too. A downloadable text-only version is now available by FTP from musicmed.txt.
• A similar excellennt document is Valerie Kampmeier's dissertation, The Impact of RSI on Creativity in Musicians .
• Dr. Richard Norris NONSURGICAL TREATMENT OPTIONS FOR UPPER EXTREMITY OVERUSE INJURIES
• Website for the International Foundation for Performing Arts Medicine . (E-mail address: IFPAM@bigfoot.com). Includes message boards to leave questions.
• New . . . Web page of the The Performing Arts Medicine Association .
• OCCUPATIONAL DISEASES OF PERFORMING ARTISTS BIBLIOGRAPHY
• More resources listed at the Center for Safety in the Arts , in particular be sure to read:
  • MUSCULOSKELETAL PROBLEMS IN MUSICIANS
    
• Performing Arts Medicine at Ithaca College - this school is taking a lead in this field and their Web site has good resources.
• An important group concentrating on performing arts injuries is the Performing Arts Special Interest Group of the Orthopaedic Section of the American Physical Therapy Association. This site includes affiliated clinics that deal with performing arts injuries.
• New . . . . Arts Medicine, a new European site.
• French site, La Musique Et La Medecine (Bio-Amadeus), includes UNE NOUVELLE APPROCHE DE L'ENSEIGNEMENT DU VIOLON ( A NEW APPROACH TO TEACHING THE VIOLIN), a thesis very relevant to string instrument injuries.
• About Seats and Sitting for Cellists and Other Musicians by Victor Sazer is an excellent explanation of how sitting can give you back pain.
• HANDS ON! ONLINE, the performance health newsletter for flutists. Great stuff!
• Additional flute notes in the article Relieve Those Aches and Pains! in the web-zine Suite 101.
• CANADIAN NETWORK for HEALTH in the ARTS -The CNHA allows performing artists and health professionals to keep informed of research and health services for artists.
• SHAPE (Safety & Health in Arts Production and Entertainment) is the not-for-profit association dedicated to the promotion of workplace health and safety in the motion picture and performing arts industries in British Columbia, Canada. They provide health & safety information, education, and training for the performing arts and film industries. They have publications, posters, videos and access to professionals at the Workers' Compensation Board (WCB). In particular, download their publication PREVENTING MUSCULOSKELETAL INJURY (MSI) FOR MUSICIANS AND DANCERS
• Dr. Joaquin Farias has posted the this site that discusses his treatment of musicians' injuries.
• Hearing Problems are common among musicians, classical and rock alike. A good resource list is the Tinnitus Frequently Answered Questions Web site. Detailed information on protection, earplugs can be found from Aearo Company's technical support page, and definitely see HEARNET , the Web site for H.E.A.R. (TM) ( Hearing Education and Awareness for Rockers.)

  Also, read this thread on How Loud is Too Loud? , and Doug Yeo's article on Noise levels on stage/hearing .

• More insights on musicians' hearing loss is found on Ken Laberteaux's "When It Hurts To Play: A Look Into Injuries Common Among Musicians"
• Phil & Vivian Williams write on TENDINITIS PROBLEMS OF MUSICIANS - IDENTIFICATION, PREVENTION, TREATMENT
• Andover Educators , "a network of teachers saving, securing and enhancing musical careers with accurate information about the body in movement", training aimed at preventing musicians' injuries. Includes an interesting and growing on-line book, At Last! Music Education on a Secure Somatic Foundation . Check it out, some interesting stuff here.
• Six Golden Rules for Conquering Performance Anxiety by David Leisner.
• Vox Cura , a Canadian voice care clinic, has useful information about taking care of your voice.
• The Texas Center for Music & Medicine includes an interdisciplinary team of musicians, music educators, clinicians, and research scientists. The Center represents educational, medical and musical resources, brought together to study, treat, and prevent various medical problems associated with learning and performing music. Clinical resources are available for both students and non-students. Clinical care is provided through the Center for Performing Arts Medicine at the UNT Health Science Center in Fort Worth, the UNT Counseling and Testing Center, and the UNT Speech and Hearing Center. CALLING ALL ORGANISTS! All ages - all levels - whether you play concerts on trackers or polkas on fun machines. Please participate in the anonymous, international SURVEY OF MUSCULOSKELETAL PAIN OF ORGANISTS, a dissertation project. Your input is important!
• The Classical music department of the WWW Virtual Library has excellent sections on Medical Issues for Performers , Coping With Performance Anxiety , and Medical Clinics for Performers (in the US and Canada) .
• JAMES R. OESTREICH wrote this article discussing the impact of musicians' woes for the New York Times.
• Musicians are also afflicted with Focal Dystonia, a baffling and controversial loss and distortion of muscular control. Read this first-hand account of this condition. The National Institute of Neurological Disorders and Stroke has a the NIH Dystonias Information Page and a Dystonias Fact Sheet. Also see the Dystonia Dialogue page from the Dystonia Medical Research Foundation, which includes a bulletin board for discussions of the disorder. I am told this board has more traffic than the alt.support.dystonia USENET newsgroup. Also: Read Constraint-induced movement therapy for focal hand dystonia in musicians in The Lancet . An excellent new dystonia resource and advocacy groupis Care4Dystonia, Inc.

  Some case studies and other information is on Andreas Kurth's Focal Dystonia in Musicians web page.

  Some possible insights on musician's dystonias are discussed in How To Resolve Dystonias: A Movement Perspective by Barbara Conable.

• Dr. Tim Jameson, D.C. contributes articles on:
  • advice on alternative medical care;
    
  • trigger finger;
    
  • Carpal Tunnel.

  Also see his new Musician's Health Web site for many more articles, suggestions, and stretches.
  

• Another health clinic has some interesting articles, see the Performing Artists Health Center.
• A forum for on-line discussions of musicians' injuries has been set up by PrivateLessons.com. Join in!
• Andover Educators site promotes their What Every Musician Needs to Know about the Body course, also includes some on-line articles well worth reading.
• Related information on computer injuries is on the RSI Page . . .
  
• A list of performing arts clinics is included on the FindADoc list.
• Many musicians report that The Feldenkrais Method and The Alexander Technique are helpful in learning non-injurious use of the body. A Feldenkrais practitioner has some good info on his Somatic Options page. Another Feldenkrais practitioner assisting musicians in particular is Aliza Stewart.

  Also there are many good reports on the effectiveness of Hellerwork , Trager Approach, Rolfing , and The Pilates Method in treatment of RSI. You may want to read Three Musicians Talk about the Alexander Technique. Music-oriented Alexander info is found at Alexander Technique for Musicians .

• If Feldenkrais interests you, there is also a SANTA FE 2000 FELDENKRAIS TRAINING PROGRAM coming up soon.
• John Link writes on The Feldenkrais Method for Singers (and Instrumentalists) Parts I and II . More resources and info from John are here.
• GUITAR-SPECIFIC LINKS:
  • Sitting & Proper Positioning with the Guitar By Nitin Arora - read this on his Humane Guitarist website.
  • Mark Long maintains and contributes to the excellent Classical Guitar FAQ including an article on Avoiding RSI.
  • The Paul Anders Sogaard Website has good information from a professional guitarist who is also a qualified Music Medicine Therapist and a Practitioner for The British Association for Performing Arts Medicine.
  • Sue Shockey documents an amateur's attempt to develop a ergonomic guitar. (Click on Sue's picture and then the "Guitar Design" button.)
  • William R. Cumpiano has developed his own wedge shaped ergonomic guitar.
  • A most excellent site, Dan Smith's The Guitarist's Guide to Hand Care with info on exercises, callouses, nails, warm-ups, etc. Go there, read that!
• Paul Adams relates his experience with traumatic injury to his hand.
• Health and Safety for Guitarists and Other Musicians, a good resource site with an emphasis on guitar.
• Charlotte Adams has excellent articles and resources on her website. Well worth spending time with, whether or not you get the videotape.
• PIANO-SPECIFIC LINKS:
  • Jonas Sen's superb

  Playing the Piano,Playing...With Fire?A Study of the Occupational Hazards of Piano Playing - important reading for non-pianist musicians, too. A downloadable text-only version is now available by FTP from musicmed.txt .

  • Thomas Mark's PIANIST'S INJURIES: Movement Retraining Is The Key To Recovery. In addition, he now has set up a web site at www.pianomap.com .
  • Portland State University has created the Coordinate Movement Program for Pianists , a program of study to "allow a limited number of applicants to pursue a degree option while recovering from pain, injury and physical limitations."
  • Niks Piano Technique and Hand Guide page provide information on another low-tension piano technique, as well as a special practice tool used to help learn the technique.
  • Stephen Marquiss shares his experiences and thoughts on healthy, effective, pain-free piano playing on his Web site.
  • Dr. Teresa Dybvig's The Balanced Pianist presents a variety of short, intensive programs for small groups of pianists, high school age and above, amateur and professional. In The Balanced Pianist programs, pianists improve their practice, performance, and teaching skills while growing to enjoy all these activities more. The goal of programs is removing tension in practice and performance through good musicianship, healthy movement and positive mental attitude, removing tension in teaching through use of learning styles, and general wellbeing. The web site has information about Taubman technique, Dunn & Dunn Learning Styles, about what constitutes a healthy approach to practice, performance, and teaching, and the curriculum of programs.
  • David C. Stanwood has developed technology to modify piano keyboard touch, thereby reducing the chances of injury. (See article on Key Weights listed below.)
  • Yuri Ziskin conducts an interesting discussion of what brings about injury on piano at pianoinjurycure.net . Unique content and conversational presentation.
  • Sheila Paige facilitates regular Piano Wellness workshops and seminars.
  • Irini Emanoilidis has many good resources and reviews relative to healthy piano playing, including the article "Preventive Techniques and Exercises for Pianists with Performance-Related Hand Injuries".
• Robert Burnson discusses his experience with piano-related injury and his success in using both John Sarno's approach to pain relief, and Dorothy Taubman's philosophy (explained in good detail) of effective and safe piano technique.
• WIND INSTRUMENT SPECIFIC LINKS:
  • Article on a sax student's injury . . .
  • DOUGLAS YEO , Bass Trombonist with the Boston Symphony Orchestra has a Web site with, among other things, articles on Hand tension while playing and Noise levels on stage/hearing .
  • Brad Howland, another brass player, also has a Web site discussing how to Play Without Pain .
  • Excellent discussion of flute ergonomics is found at Flutelab/De Fluitstudio
  • David Sawyer has built a nicely illustrated Hand care for musicians page, aimed at shakuhachi players but applicable to other instrumentalists as well.
• STUFF:
  Some ergonomic accessories for various instruments are appearing on the market. Here's some on the web. I don't endorse all of these, just passing them along. Such items may be very useful indeed, but don't go looking for a gadget to "fix" all your problems. If you are already injured, for CERTAIN don't be thinking you can get an accessory or new instrument and then go right back to full-speed, full-time playing with no other changes and with no visit to the doctor. It doesn't work like that!
  • The new Y-strap ergonomic guitar strap is on the market.
  • Here's another ergo strap company, supporting several instruments with their designs.
  • Similarly, sax players may want to check out The Smart Strap
  • Arm'n Track guitar support, includes articles on playing position.
  • The Neck-Up guitar support.
  • Gracie Stands, makers of no-strap stands that hold your guitar in playing position. I use one of these myself - PMx.
  • Quodlibet Inc. sells ergo supports for Clarinet, Basset Horn, Oboe, English Horn, Oboe d'Amore, Bass Oboe, and now saxophone.
  • The Guitar Chair , optimized for classic guitar performance.
  • "BassBrace is a guitar belt - a revolutionary new way to support an electric bass or guitar that will shift the weight of the instrument off the shoulder and place it comfortably on the hips. At the same time, it provides for more optimal instrument positioning to relieve wrist strain." [Paul adds: I got one of these and use it with my solidbody electric guitar to give my hurting shoulders a break. I *do* endorse these.]
• Ton Kooiman designed and markets a number of woodwind thumb rests on his Woodwind Ergonomics website.

  Nitin Aurora is compiling a list of guitar supports on his website.

  OTHER ERGONOMIC PRODUCTS: A whole lot of other ergonomic products, services, devices, etc. (mainly computer-oriented) are found on this Web page.

Discussions

(Note: Most of the following articles are taken from discussions on USENET newsgroups and as such represent only the opinions of individuals. Also note that as of 1 January 1997 I will strip identifying names from the threads reproduced here to protect privacy.)

Guitar Discussions

• Guitar Article 1
• Guitar Article 2
• Guitar Article 3
• Taylor guitars: are thin necks good or bad?
• Leo Kottke's injury
• Guitar positions
• Fingertip Pain
• Hand Fatigue
• Don't Blame the Guitar . . .
• LH pinky "locks up" . . .
• Don't Say "But I Can't Quit Playing . . ."
• Focal Dystonia
• Dr. Tim's Advice
• "Correct" Thumb Use and Barre Chords a Problem?
• RH positioning, holding guitar, stands.
• Electrical Shock Hazards from grounding problems.
• Finger picking hand and arm placement
• Gracie Guitar Stands
• Elbow pain, good classical advice.
• Classical positioning discussion
• Impact of Nail Length on Guitarists Injuries
• Cut Fingers, Traumatic Injuries to Hand
• Left Thumb Parallel or Perpendicular to Neck?
• Guitar Changes in Response to Tendinitis
• Right Arm Soreness
• Defining Tension in Guitar playing
• Doctor's Comments on Guitar; Standing Posture
• Finger Pain & Callouses
• Right Arm Protectors
• Tilting Guitar Face
• Segovia's "Deviant" Position
• Numb Finger
• Pinkie Wars!
• Back Pain, Seating Options
• Fingertip Irritation
• Help, Left Wrist Pain
• Hand Strength
• Lowering Left Shoulder
• Flat Picking Technique
• Shearer's Injury, etc.
• Using Hand Strengthening Equipment?
• Use Lighter Strings!!!
• 3 Letters Guitarists Fear the Most!
• Wrist Pain After Long Recording Session
• Playing Pain Also Psychological
• Damping Strings?
• The evil of barre chords
• Left Hand Pain
• Building Endurance on Acoustic
• Tension in Right Shoulder
• Paul's recovery

Piano / Keyboard Discussions

• Piano Posture
• Piano Article 2
• Sore Wrists?
• Discussion of Weighted Electronic Keyboards
• Changes to Piano Key Weights
• Dorothy Taubman
• Comments by Kay Hooper
• Leon Fleischer's Injury
• Plug for the Feldenkrais Method
• Too Much Practice?
• A Therapist's Advice
• One Pianist's Recovery
• Piano Ouch
• Another Piano Story
• Injured At Young Age, What Helped . . .
• Muscles/Fingers (was Re: Hanon)
• Roland RD-600 Keyboard; Bench Height (was Re: Hanon)
• Cold Fingers/Hands
• Recovery; Small Hands?
• Back Problems, Solution
• Cramping in Hands
• Cracked Fingertips
• Boy, my Arm Hurts!
• Finger Muscles
• Tight Shoulders
• Tense Fingers and Wrists
• Piano Suggestions from a Therapist
• Why Does My Arm Ache?
• Backache!
• Harpsichord Thoughts

Percussion, Strings, Voice

• Dutch drum articles
• Handbells
• Timpani
• Drum Corps Injuries
• Breaking Drum Heads
• General Drum Comments
• Earplugs for Drummers
• Drum Problems, Tips
• Weak LH 4th Finger (violin)
• High Action = Trouble (violin)
• Sitting, Back Pain w/ Violin
• Violin, left arm buzz/numbness
• Common Violin Playing Faults
• TMJ From Classical Singing
• Singing Causing Hand Pain?

Winds

• Use Oboe Strap
• Equipment Setup Matters! (bassoon, but applies to ALL instruments.)
• Recorder, rehearsal techniquest

Other . . .

• Conductors get hurt too . . .
• Advice for harp . . .

Featured Site on

Click for the E.E. Shop Page, or the Electrical Engineering Home Page.

Univ. of Nebraska-Lincoln / Music Injuries Web Page / Paul Marxhausen