Musicians, how about that nagging pain in your shoulder, your back, your hand, or maybe just your pinky? Is it "all in your mind?" And if not, are you skeptical, like most musicians, that anything can be done for you through conventional medical channels?
Then perhaps it's time to consider the possibilities of a new, growing specialty that pays attention to the very specific needs of musicians with stress injuries. Clinics have sprung up in Chicago, Denver, San Francisco, Cleveland, Washington and New York, and soon there may be one here in Utah.At Utah Valley Hospital's Rehabilitation Center, Dr. Stuart King hopes to treat such injuries, and as a physiatrist and an amateur violinist, he has useful qualifications for the job.
"I'd like to establish and build up a clinic for treating musicians as a part of our comprehensive out-patient rehabilitation facility," he said. He's supported in his aims by Rosalie Rebollo Pratt of Brigham Young University, whose work in music/medicine has attracted national and international recognition.
Since this is a new specialty, King frankly admits he wants to gain experience, to be open-minded, willing to learn and sensitive. "Each person is a fresh challenge," he said.
Note that King is a physiatrist, not a psychiatrist or physical therapist, though physiatry does involve a certain amount of each, along with its many other aspects.
"It's the smallest medical speciality," said the affable King, seated in his office. "We specialize in physical medicine and rehabilitation for in- and out-patients - victims of stroke, arthritis, brain damage, amputations - with the traditional team approach.
"Stress injuries to musicians comprise only a small part of my practice, but the principles of diagnosis and treatment are similar.
"One of our techniques is electro-diagnostic studies of tissues surrounding a pain or disability site. We analyze reactions - how quickly the nerve picks up a stimulation, and how long it takes the impulse to travel along the nerve. A quick pickup and slow travel or vice versa indicate different kinds of ailments, such a carpal tunnel, or muscular dystrophy, or simple injuries and stress ailments. The physiatrist specializes in prescribing drugs and sports medicine therapy."
For a time King dreamed of a career in music; indeed, he holds degrees in violin performance and music education from Arizona State University. But he was feeling "a certain disillusionment" with music as a career when he traveled to Gunsbach in Alsace-Lorraine - near the birthplace of Albert Schweitzer, the great musician and medical missionary - for a workshop on unaccompanied violin music of Bach.
"It was there that I began to ponder the possibility of a life in medicine, with music as a hobby," said King. "Now I love music again, because it's not my bread and butter. I have a balance."
After medical school at the University of Arizona, he interned at LDS Hospital in Salt Lake City and did his residency in Rochester, N.Y. There he became interested in the possibilities of treating stress injuries in musicians, through assisting Dr. John Baum, a rheumatologist who worked with musicians from the Eastman School of Music.
Back injury and pain constitute the second largest reason why people miss work, after the common cold, said King. "Some people with back injury never return to the work place, and there may be no reason for their pain that you can put your finger on."
He finds a considerable analogy between back injury and stress injuries of musicians. "The spine is like the mast of a sailboat," he said, "with ropes (muscles) steadying it fore and aft. If there is injury or pain, it's because sound principles of balance and usage have been violated in some respect. This also applies to more localized areas of the body.
"As of now, many people are not recovering. They keep reinjuring themselves, and some have a psychological overlay; their injury may be healed, but they have developed chronic pain syndrome. You can treat the back (or other area) and prove that it's intact, but even so, some patients need training to rid them of psychological crippling."
King noted that such chronic, long-term problems of pain and disability among musicians can eventually terminate careers. Musicians are inclined to seek help through non-traditional health-care providers, and often their plight is worsened. They don't have the right insurance coverage, and they don't know where to go.
"Many musicians are never without pain, ranging from mild nervous stress to really sharp discomfort," said King. "Indeed, pain is often expected. It's not uncommon for people to play in pain all their lives. For example, violist William Primrose, who settled in Provo before he died, said that he had played 60 years, never without pain.
"Some can override it better than others, but after many years of pain and, more specifically, the maladjustment that causes it, a musician may reach the disaster level," said King. "The disabilities of Gary Graffman and Leon Fleischer, whose right hands have become disabled, are only extreme examples of what can happen.
"The less attached to his instrument a musician is, the more likely he is to have trouble. Therefore, those who blow their instruments are less injury prone (barring lip numbness) than pianists and string instrumentalists - except the low ones, where they bend around their instruments. Hence those who play the upper viols and piano are most at risk."
How do these syndromes develop?
King places the most blame on abrupt changes that can take place in practice routines, usually around junior-high age, when a young person commits himself to his art and feels driven to be the best - as a pianist, violinist, singer, dancer or whatever, come what may. (A similar dedication to sports yields the same sorts of injuries.)
"Up until then the youngster has practiced short hours, he's been relaxed. Then he sublimates natural adolescent desires and activities to getting very good, suddenly starting to practice four or five hours a day in high school or college. He may go to a master teacher, who requires alterations in his technique. Some teachers are rigid in their approach to technique, and not right for every pupil," said King.
Or if the student carries some little maladjustment in his original technique into long hours of practice, he has laid himself open to stress injuries, said King. And some people are predisposed to injury by their inherited physical formation, their genes or nerves. Also, there are physical injuries unrelated to performance that are not allowed to heal properly before the musician resumes full-scale practice.
If a young person were to bring a perfect technique, good physical equipment and relaxed attitude to his practicing, could his body be expected to withstand a 7- or 8-hour onslaught every day? Isn't this too much for anyone to endure?
Not necessarily so, said King, if the pupil made his approach to long hours gradually, adding a few minutes a week until he reaches his desired level, allowing the muscles and tendons to strengthen slowly.
King noted that those who develop typical overuse complaints - carpal tunnel syndrome; tendonitis; tennis elbow; a myriad of nerve, muscle, tendon, ligament and joint ailments; and stress fractures of the small bones of hand and foot - must be approached case by case, since no one approach works for every person. But to cure any injury there should be a three-pronged attack, involving medical, physical and functional methods.
King acknowledged that musicians in general are hard to work with. For years, medical doctors have been throwing up their hands about this; and the longer a problem persists, the harder it is to cure.
"An instrumentalist will tell you, `I'll do anything you want, but don't ask me to quit playing, and don't tell my boss,' " he said. "They will go to all ends to conceal career-threatening conditions, and they are totally unwilling to make changes in their techniques, even though therapists may identify areas of strain and tension.
"For example, a violinist may have been told to hold his left arm still as he fingers his strings. That may become interpreted as `rigid,' and the rigidity not noticed by his teacher. A violinist needs a little play in his body," said King, standing to demonstrate the slight swaying from the feet up, seen in most good violin soloists. "A frozen joint is prone to injury."
The Utah musicians King has seen so far have been about half self-referred, the rest referred by teachers, and he welcomes teacher concern. He finds that clients who come on their own do better than if they are forced to come. The ideal solution for many problems would be cooperation between instrumentalist, teacher and physician to pinpoint what actions and positions predispose to injury, and work to tailor a plan that enhances both treatment and training.
A teacher who goes through such a procedure with one pupil might learn many valuable things about spotting incipient trouble spots and working to overcome them in others. And King is totally converted to the preventive approach, examining all technical movements to analyze how students develop trouble. He suggests that eventually taped seminars might be made available for teachers and students to consider.
"An injured person may be most concerned with regaining the use of his faculty, hence pain relief may be only incidental to restoring and enhancing function," he added. "We can learn to deal with pain, but not always to get rid of every bit of it."
King showed a quarterly magazine, Medical Problems of Performing Artists, founded in 1986, with articles by injured musicians and those who work with them.
In an interview with this magazine, Arnold Steinhardt, a very tall violinist who has had to adapt to his instrument, offered some intriguing insight:
"The important thing . . . is to instill the sense of running their own lives and not panicking, of being very mature about (injury). . . . Whatever is happening took a long time to happen . . . and it will probably take a long time to disappear, if it disappears entirely at all. So it is a little bit like taking a film and playing it backward in slow motion. You slam your fingers down on the finger board in the wrong position and too hard for many years, and now we want you to unwind yourself slowly, backward."