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Empowering musicians: teaching, transforming, living: arts-medicine mailbox: Dr. Dawson answers your questions.

Learning you have a medical problem, especially one that may affect musical practice and performance, can be a scary thing. Musicians and health professionals often seem to live in separate worlds, divided by different terminology/jargon within a common language. Most performers have basic knowledge of how human bodies are built or how they function, and health professionals generally are un- or under-informed about the particulars of musicians' lives or how much bodily perfection they demand in their art.

These great chasms separating the two groups gradually are becoming smaller and shallower, as both sides become better informed about the other's field and the special terminology associated with it. Nonetheless, musicians still may have many questions to be answered, usually based on concern, lack of knowledge and (often) pain that affects their playing. As a medical practitioner and writer, as well as a bassoonist (65 years) and music teacher (19 years), I've been asked many of these questions over the years. Here are some common queries and helpful answers; readers should discuss their specific questions with their own health professionals.

1. What happens when a musician meets a physician for the first time?

It can be a bit scary for both and certainly may be stressful for the patient, who often is hurting and usually doesn't know why. An aware and understanding physician will take a thorough history of the problem, considering factors both medical and musical. Especially important are details relating to practice/playing duration, frequency and intensity--especially if it seems the disorder is playing-related. Symptoms should be probed relating to location, nature, prior occurrence and treatment (if any) and whether or not they affect non-musical activities. A general health history is important, too.

Physical examination is next, concentrating on the symptomatic area. Ideally the musician should bring and play her/ his instrument at the visit to demonstrate what is occurring, although most medical offices don't have a musical keyboard handy. In most cases, testing joint movements, muscle strength and coordination, and basic nerve function are important elements of the exam. Other body systems likely will be evaluated also, depending on the nature of the complaints.

The third step is formulating a provisional diagnosis and planning a treatment program. Treatment usually will involve some activity modification, and occasionally oral medication may be prescribed. Most painful problems are musculoskeletal, and changes in playing time, intensity and repertoire usually are recommended. Depending on the disorder, there may be some opportunity to continue playing in a limited manner during treatment, so musical skills may not be too severely compromised; the patient should inquire into this possibility and should discuss it with the physician.

During the appointment, full communication between physician and musician is paramount to the success of the visit; each person needs to explain and describe completely and clearly, in understandable language. Do not be afraid to ask questions, demonstrate any painful actions, explain your personal techniques or describe your playing schedules.

2. Why do my hands hurt so much when I play?

Beginning in late winter, a college freshman music performance major experienced "horrible" bilateral hand and arm pain. It began insidiously, worsened progressively and was aggravated especially by playing piano. She had tried heat, ice and oral anti-inflammatory medications with no appreciable benefit. Upon questioning, she admitted to playing significantly more In the past few months, working on more difficult repertoire and preparing for both juries and a spring recital. Her pain was generalized to both forearms and hands, especially the small muscles in the palm. Everyday activities were also difficult; even grasping a toothbrush or textbook hurt!

Physical examination confirmed local tenderness in the fleshy parts of the forearm and hand muscles, which became worse when she contracted the involved muscles or when the physician stretched them passively. Even demonstrating repetitive octaves with both hands was especially painful. A presumptive diagnosis of playing-related muscle strain was made--a not-too-difficult task for a health professional with some knowledge of piano technique and pedagogy, as well as the playing requirements of a performance major. Her muscles had been asked to repetitively contract and relax beyond their physical capabilities and had not been given a chance to restore themselves after each episode of overuse. Continuing to stress them resulted in a pattern of chronic strain with accompanying pain.

Despite the pressures of approaching performances, this student's muscles needed a rest from the excessive stress they were experiencing, so they could recover properly and ultimately permit comfortable playing. Decreasing her practice frequency and duration, modifying some techniques to lessen physical force on the keys, and varying the repertoire during practice sessions were suggested as the basics of treatment. Consultation with her teacher was recommended regarding how best to implement these suggestions. In addition, modifying non-musical activities also would be needed, so they too would be pain-free. A follow-up visit was arranged to evaluate the success of this program; if the initial treatment was not completely effective, further muscle rest and restriction of playing would be needed.

3. When can my student return to playing after a broken wrist?

A private teacher asked me this question after learning that one of her 13-year-old pupils had broken his right wrist 10 days prior to his lesson and was in a cast from palm to elbow. He was comfortable and able to use the fingers to some degree. I confirmed that the other hand was normal, so, depending on the instrument he plays, he should be able to use that hand musically. This presents no problem for keyboard players, but other Instrumentalists may have to be creative in finding alternative playing methods. For example, the French hornist can depress the valves, while string players can do left-hand pizzicato and fingering exercises.

I believe that if a body part can move, it must be moved from the beginning of treatment; if it is immobilized or restricted, this is being done for a specific medical purpose. If this young man's cast allows the forearm and wrist to rotate into a proper playing position, the right fingers can help make music also. For example, trumpeters may be able to depress the valves, and some woodwind musicians may be able to reach and move the keys. I always cautioned my patients that, if any motions caused or aggravated pain around the fracture, they should not be performed.

Wind players will still be able to use their embouchures and keep their lip, tongue and facial muscles in shape by working with mouthpieces and reeds. Brass mouthpiece buzzing, crowing on double reeds, and blowing on a single reed or flute mouthpiece maintain important skills that will not have to be rehabilitated later. Obviously, mental practice should continue without restriction.

If the child gets a new cast or splint during the healing stage, it may permit more motion, and playing techniques can be modified if necessary. In each case, the goal for all concerned parties is to permit some playing, if possible, while proper healing is taking place.

4. My family doctor said my painful wrist is caused by De Quervain's tendinitis; what is it, and will it end my career?

Tendinitis of any kind is an inflammation of the tendon and the adjacent tissues through which it glides, transferring muscle contraction force into movement of nearby joints. When specific tendons on the thumb side of the wrist are affected, the condition is named after De Quervain, the French physician who first described it. Wide, repetitive motions of the thumb with flexion of the wrist seem to be the principal cause. Although not specifically related to making music, it can occur at times after playing powerful octaves on the piano or doing thumb-under work to an excessive degree. Wrist pain on flexion and thumb motions is the most common symptom, and often a rubbing feeling can be noted by the patient or physician who places examining fingers over the moving tendons. De Quervain's is usually treated by decreasing or modifying the offending motions, sometimes with the use of a thumb splint, and by taking oral anti-inflammatory medication. Occasionally a local injection of cortisone or other steroid is used as well. Most patients respond to this conservative treatment, but in severe cases, a small surgical procedure is employed to enlarge the tunnels through which the tendons glide, reducing irritation and inflammation. If the disorder is diagnosed correctly and treated in a timely and proper manner, most instrumentalists can return to their music gradually, increasing thumb use as comfort permits. However, it may take a number of weeks or even months to regain full capabilities, and musicians, like other patients, are cautioned not to attempt a too-rapid return to activities.

I cannot emphasize strongly enough the need for communication and understanding between musician and health professionals when dealing with medical disorders. Full disclosure of facts, willingness to ask questions if unsure about something, and a desire to learn more about our bodies can lead to longer and more healthy playing.

William J. Dawson, MD, a retired orthopaedist and active symphonic bassoonist/teacher, is past-president of the Performing Arts Medicine Association, a worldwide lecturer and clinician, and the author of Fit as a Fiddle: The Musician's Guide to Playing Healthy.
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Title Annotation:Professional Resources
Author:Dawson, William J.
Publication:American Music Teacher
Geographic Code:1USA
Date:Oct 1, 2016
Previous Article:This & that.
Next Article:Basic Elements of Music: A Primer for Musicians, Music Teachers, and Students.

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