When practice is a pain

Whatever the instrument, physios figure out a way to help musicians in need. Janet Wright investigates

Sex and drugs aren’t the only health risks for rock stars. Neck pain, numbness and overuse injuries are a lot more common than the mishaps hitting the headlines  and they affect musicians of all kinds. Like anyone whose work involves repetitive movements, musicians are at risk of performance-related disorders. Bass player Tom Kenrick, a graduate of the Academy of Contemporary Music, was suffering from classic neck and shoulder pain when he first went to see physiotherapist Joanna Stokes, who provides assessment clinics for the British Association for Performing Arts Medicine. ‘Jo was great,’ he enthuses. ‘I’d been practising for hours without taking a break, holding my arm in the wrong position. Jo did ultrasound on my muscles and taught me stretches and strengthening exercises.’  All went well until he added the double bass to his range: the notes are the same, but the size difference requires a different technique. ‘I naively thought I could transfer straight over, but I should have eased myself into it,’ says Tom Kenrick, who has now written a book of advice for bass players. Overuse of his forearm muscles and tendons led to pain and inflammation around his elbow, diagnosed as ‘golfer’s elbow’. Further physiotherapy relieved this too. A classical orchestra may look more civilised, but viola players and violinists often suffer neck and shoulder pain, exacerbated by playing with head on one side  some end up lopsided even when they’re at rest. And the highly competitive environment piles on the pressure. One of the main causes of injury among musicians is simply spending far too many hours a day in practice. Add in a refusal to do ‘time-wasting’ warm-ups or cool downs, a disdain for taking breaks and a dose of anxiety for extra muscle tightness.

Piano, drum, marimba

‘I recently saw a young pianist whose friends had said it was painful to watch her playing, as she had her nose on the keys,’ says Joanna Stokes. ‘She was practising for eight hours a day, trying to prepare for several auditions. It was sad to hear her say that, but good she recognised it was why she was in so much pain. I told her she wouldn’t be able to continue playing the piano if she carried on like that.’ A drummer’s work is at least symmetrical, though it can just mean both elbows and wrists are equally overused. Physiotherapist Patrice Berque worked with a drummer with Dupuytren contracture, a thickening of tissues in the palm that can cause a finger to curl  ‘Stretch exercises helped, and I got him to change the way he was holding the sticks.’ One of Joanna Stokes’s patients played a marimba: a massive xylophone-like instrument played with two mallets in each hand. ‘Having to supinate and pronate as well as hitting the keys, the stresses involved are extraordinary,’ she says.

Classical versus rock

The problems can vary from one kind of music to another. Classical guitarists hold their instruments in a different position from rock guitarists, and pluck the strings instead of strumming, causing different stresses on their fingers and arms. Folk singers playing the guitar may get back pain from perching unevenly on a stool. Physiotherapists in various parts of the UK may also see injuries stemming from different traditional forms of music. ‘I’ve seen quite a few bagpipers with dystonia,’ says Patrice Berque, who is based in Glasgow. He puts this down to their playing so many ornamental ‘grace notes’. ‘These are very, very fast notes which mean a lot of simultaneous movements, and the pipers develop faulty movement,’ he explains.

From musician to physio

He’s also had patients who play the small Celtic harp, popular in Scotland and Ireland. ‘You can buy a stand for it and sit on a normal chair to play,’ he says. ‘But some people like to be traditional and sit on a very low stool with the harp on the floor, and they get back pain.’ Physiotherapists can help prevent further injuries with advice about posture, taking breaks and exercising, and while certain conditions are painless, that can be a disadvantage as performers may not feel forced to seek treatment until an advanced stage. One condition, known as focal hand dystonia, has ended several professional careers. This involves the gradual loss of control of one or more fingers, which is particularly noticeable when the fingers need to move at high speed. Patrice Berque has been treating and researching this, with some excellent results so far (see panel: Physiotherapy made the difference). And he’s all the more motivated by his own poignant experience. Patrice Berque started out as a professional horn player with orchestras in France and Germany, but gradually developed problems in the muscles around his lips and mouth. That turned out to be focal dystonia, but in an area that’s much harder to treat than in the hands. ‘You can immobilise a finger and retrain another finger. But for lips there’s no way the muscles all work together. I didn’t manage to solve my problem, and in 1991 I had to stop playing,’ he says. His career as a musician over, he went on to retrain as a physiotherapist. ‘At that time there wasn’t much backup. I never got an answer to what my problem was. Maybe that’s partly why I went into treating musicians.’ Work such as Patrice Berque’s is gradually unlocking the mysteries of this kind of disabling condition. Focal dystonia, for example, is a neurological condition changes can be seen in the cortex. But do these cause the hand problems, or does the cortical map change as a result of the changed movement of the fingers? ‘Which came first, the chicken or the egg?’ says Patrice Berque. ‘It could be dystonia starts in the brain, but it probably happens the other way round. There does seem to be a genetic predisposition. People who get it in one hand may develop it on the other side too.’ Focal dystonia is harder to treat than problems caused by incorrect posture or technique. But, says Patrice Berque, whether it’s a professional player returning to work or a man in his 40s who wanted to play the guitar for fun, there’s all the more satisfaction when they persevere and succeed. fl

Physiotherapy made the difference

Ewan Robertson, a flute-player with the BBC Scottish Symphony Orchestra, started to notice problems with his left hand in 2000. ‘I was losing control of the fifth finger very slightly, but not to the extent it was bothering me at work,’ he says. ‘It gradually started curling in towards my palm, especially when I was playing fast passages.’ Over the next few years, his condition slowly deteriorated. ‘The fifth finger was beginning to come down with the fourth finger when I didn’t want it to. Then I started to be aware of my fourth finger, not actually curling but feeling it wanted to pull away from the key on the flute. ‘I kept thinking it was just me getting older, or perhaps I was doing something wrong. But by April 2007, it was so severe that I couldn’t do my job any more.’ He went to a British Association for Performing Arts Medicine doctor who, after watching him play his flute, advised him to contact specialist physio Patrice Berque. ‘It was an enormous relief when I saw Patrice’s website because it had photographs of musicians with dystonia, and I recognised it at once,’ says Ewan.

Detailed protocol

His relief was tempered with concern his career might be over at the age of 47  by the time he saw Patrice he was missing notes and coming in late. But he launched into the prescribed protocol, starting with a week of long daily sessions and continuing with a detailed protocol of strictly timed exercises at home. Patrice treats focal hand dystonia with a combination of two techniques. Sensory motor retuning uses splints to immobilise fingers, and slow-down exercise therapy reinforces normal patterns of movement. For Ewan, to stop his fourth and fifth fingers curling together, one finger was strapped and the other was retrained. ‘The aim,’ says Patrice, ‘is to stimulate only one finger in order to allow that finger to work independently. It’s not a muscle problem, so you’re not retraining the muscle, you’re retraining the brain.’ Ewan took six months off playing. Each evening, with one or other of his fingers splinted, he would spend two hours working through the exercises. To ensure he could get back to work in good time, he added a series of botox injections, but he credits physiotherapy for most of the improvement. ‘It was extremely tiring, but I was determined to do everything I could to return to playing,’ he says. ‘The results were fantastic. Before that it was horrendous; it was physiotherapy that made the great difference. The difference between April 2007 and today is wonderful.' After six months, Ewan was able to return to the orchestra. His fourth finger has recovered well, almost completely, and the fifth finger still curls a bit but much less than before. Commenting on his work, Patrice says: 'It's very satisfying, especially with patients like Ewan, whose job was in the balance.’

Can you help?

Music-loving physiotherapists are keeping bands and orchestras on the road, by treating performers when they’re injured and showing them how to play without pain. Now they’re looking for others to join them. The British Association for Performing Arts Medicine is a charity providing musicians and other performing artists with free assessments and referrals for performance-related health problems. It runs clinics in cities around the UK. Practitioners, who must be registered and insured, provide their services either free of charge or for a reduced rate. Why? Those who take part say it’s fun, rewarding, always interesting, with plenty of support from colleagues in relevant disciplines. ‘There’s a wonderful back-up team at BAPAM who book in the patients and type my letters,’ says Joanna Stokes, who works one day a week at the charity’s premises in London. She also values ‘the ability to refer onward to a multidisciplinary team including specialist consultants if needed, and the two highly informative study days organised by BAPAM each year.’ The only downside she’s found has been the difficulty of seeing patients regularly when she only does one day a week, and seeing someone only once and not knowing whether she has helped. But this is outweighed by the rewards: ‘Showing a patient how to ease their symptoms on their own, and the glint in their eye when they can see it works. And when a patient comes back to tell me how much they have been helped.’ And of course there’s always the chance of free tickets to the best shows in town. 

Further information

BAPAM tel 020 7404 5888, email enquiries@bapam.org.uk or visit www.bapam.org.uk  
Janet Wright

Number of subscribers: 0

Log in to comment and read comments that have been added