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Guitarists’ hand injuries are most often due to
the
repetitive stress of playing for hours on end without taking adequate
breaks. Even though disabling pain may show up in the lower arm or
hand, most injuries result from a chain of events that starts in the
head. Creative mixtures of rest and playing are as essential to healthy
musicians as creative mixtures of silence and sound are to good music.
Maintaining a healthy lifestyle and attitude
toward
music can go a long way toward helping you avoid injuries and heal them
when they do occur. To get some advice on this area of perennial
concern to guitarists and other instrumentalists, I talked to
health-care practitioners who deal with musicians’ injuries as well as
professional guitarists who have successfully avoided or recovered from
debilitating injuries.
A HEALTHY
PLAYING ENVIRONMENT
Repetitive strain injury (RSI) is the most common
diagnosis that Lillie Rosenthal, M.D., makes in her practice as a
specialist in physical medicine and rehabilitation at the Miller Health
Care Institute for Performing Artists in New York City. Her patients
often arrive complaining of burning pain or aches anywhere in their
hands, arms, and neck. "It’s usually a multifactorial problem," she
says. "Musicians are playing for several hours without taking a break,
they often have poor posture with and without the instrument, and they
may be mentally stressed, which greatly affects the body. I often see
people who have been playing for many hours before a performance or a
recital and haven’t paid attention to the basics."
Rosenthal stresses the importance of warming up
with
stretches before touching the instrument and taking breaks every 20 to
30 minutes. Musicians should take breaks away from their instruments,
stretch, and move around. Rosenthal herself is a dancer, not a
guitarist, so she leaves the details of her recommendations to the
patient, but she emphasizes that establishing some sort of preventive
routine is essential to the long-term healing process. "You can give
the musician a pill and say, ‘Hope you feel better,’" she says, "but
the problem is likely to return unless the whole practice or playing
environment changes."
Assessing the practice and playing environment is
also a
crucial step for Robert Markison, M.D., a hand surgeon in San Francisco
who specializes in performing artists’ upper extremity problems. But
for Markison, a jazz musician who plays a variety of wind instruments,
the problems originate with the musician’s approach to making music. "I
need to know if they perceive music making as an unbelievably steep
learning curve, which they can only surmount by practicing four, six,
or eight hours a day," he says. "I try to perceive whether there might
be harmful behavior based on insecurity, or whether somebody is a
mature musician experiencing normal wear and tear."
Both physicians stress the importance of healthy
lifestyles, including rest, diet, exercise, fitness, good playing
posture, and proper instrument fit as crucial factors in restoring and
maintaining a healthy music-making physiology. But ultimately no amount
of exercises or procedures will overcome chronic, harmful playing and
practice patterns. "You are doomed if you play too many hours during
the day," Markison says.
KNOWING
WHEN
NOT TO PLAY
The difficulty comes with putting this advice into
practice. For instance, classical guitarist Scott Tennant’s practice
sessions with the Los Angeles Guitar Quartet are four hours long. And
his heavy practice days, when he is preparing for a big project or
imminent deadline, start when he gets up in the morning and don’t end
until he goes to bed at night. Transforming such a demanding schedule
into a healthy environment for playing and practice involves, he says,
"playing a certain way, and knowing when not to play."
The first rule is to stop playing until the pain
goes
away, not try to work through it. "I don’t sit back down until I feel
totally refreshed and recovered," Tennant says. "That might be the main
reason my aches and pains don’t turn into big problems." Even without
pain, his upper limit for a physically and mentally comfortable
practice session is a little over one hour, followed by a break of a
similar length. "If I have a problem I can’t solve in my practice, I
will take a break and I won’t go back to practice until my head is
clear," he says.
Nonetheless, such heavy practice days are far from
his
daily norm of two or three hours. On LAGQ rehearsal days or when other
activities interfere, his practice time might only consist of half an
hour on some particularly tough material. "A concentrated half hour is
better than nothing," he says. "I do that a lot. I also practice in my
head when I don’t have my guitar." He also goes for days at a time
without practicing at all. "I try to balance my really heavy periods of
playing with really short heavy periods of nonplaying," he says. "I
find it healthy for my head, too--not just for my body."
THE PATH
OF
LEAST RESISTANCE
Many musicians form healthy practice habits in the
process of recovering from injuries that occur at crucial points in
their careers. In 1987, self-taught fingerstyle guitarist Brian Gore
was about to present his repertoire professionally. But a heavy
schedule of practice, playing, and translating books from German into
English resulted in a painful case of tendinitis that lasted for about
three years. "It got to the point where it hurt when I woke up in the
morning," says Gore. "It progressed from carpal tunnel syndrome to
bursitis in my shoulders. And then I got diagnosed with thoracic outlet
syndrome. It got so bad that I couldn’t open the door."
Gore’s journey back to his present career as a
professional fingerstyle guitarist and founder of the touring
International Guitar Night began with a visit to a general
practitioner. The doctor recommended wrist surgery, which Gore chose
not to undergo. He ended up in massage therapy, yoga classes,
acupuncture, and psychotherapy instead--all focused on poor posture and
tense shoulder muscles. After three months, the problem went away and
Gore began performing again. The problem then returned and plagued him
for another six months. "But because I did the yoga, I could work with
it," says Gore.
Gore’s album The Path of Least Resistance
(Acoustic Music Resource) got its name partially from the less
aggressive playing style he adopted to reduce tension in every aspect
of his music. Realizing that a lot of the inspiration for his works on
steel-string guitar came from music that was originally played on less
physically demanding electric and nylon-string instruments, he lowered
his string gauges and worked to increase his hand strength. "I use a
mixture of medium- and light-gauge strings now," he says, "and that’s
very important, because if you just use light strings and you’re
working in anything that’s lower than a D, you’re going to have
problems with intonation."
To build strength without increasing tension and
the
risk of injury, Gore used classical and jazz guitar exercises to work
on his strength and technical issues rather than trying to work out
specific problems that arose in his own pieces. "If you bring your
stress into your music, you become prone to injury, and a lot of stress
in music comes from confusing the tasks with the project," he says. "If
you have technical challenges within a piece of music, you have to look
for ways outside that particular piece to solve those challenges."
The path of least resistance also extends to
Gore’s new
compositional approach in which, for example, he no longer uses five
strings for something that can be accomplished with three. He has also
adopted an elaborate routine for daily practice: yoga, followed by 20
minutes of left-hand strengthening exercises from Scott Tennant’s book Pumping
Nylon, followed by arpeggios and scales and more yoga before
he begins playing.
FIGHTING
DEPRESSION
Peace of mind can help avoid injury, but injury
can also
devastate a musician’s peace of mind, according to Richard Kendrick,
who teaches classical, jazz, and rock guitar at the Mission San Jose
School of Guitar in Fremont, California. Kendrick was injured five
years ago while working on his master’s degree in classical guitar
performance and playing music seven days a week. He was practicing five
hours a day, teaching, and playing gigs on classical, steel-string, or
electric guitar.
"It was summertime and I should have been taking
it
easy, going to the beach or relaxing, because I had already paid my
dues," he recalls. "I had already put in nine months of hard labor at
graduate school. But getting ready for my last year, I was going to
push it all the way through and be the ultimate classical player."
One day, Kendrick returned home after five hours
of
practice and a minirecital. He was absent-mindedly cracking his
knuckles by hyperextending his fingers backward when something went
wrong on his left index finger and Kendrick found himself lying on the
floor in excruciating pain. "I went into an immediate state of denial,"
he says. "Being one unit away from my master’s degree, I wasn’t going
to believe that I had done anything to myself by cracking my knuckle."
Kendrick was sidelined from playing with a severe muscle strain for
five and a half months.
He is fully recovered now, but Kendrick still
thinks
about the injury and the depression and anxiety that prolonged his
recuperation. He had initially tried to continue his five-hour-a-day
practice schedule without using the injured finger. When he did decide
to seek medical attention, he bounced from doctor to doctor, which led
to conflicting treatment regimens. "Bouncing from doctor to doctor was
not a good thing to do," he says. "But I was completely desperate, and
nobody seemed to understand the gravity of the situation. I couldn’t
play. I was one year from my master’s, and I was jacked up. I was in
horrible shape--depressed and still trying to give lessons on keyboard.
It was pathetic."
That depression is all too common, however.
"Depression
goes along with these injuries, even if they persist only for a very
short time," says Rosenthal. "Most musicians are afraid to admit that
something is wrong, because it’s a highly competitive situation. They
tend to ignore it and it gets worse. And that’s a really tough problem."
FOCAL
DYSTONIA
The toughest problem that Rosenthal has to deal
with is
focal dystonia, because medical science has no idea what causes it.
Several fingers on a musician’s hand just curl up and stop responding.
There’s no pain.
In 1984, classical guitarist and composer David
Leisner
was about to sign a recording contract when several fingers on his
right hand stopped working. He had won prizes in two major
international guitar competitions. "My career was definitely on the
upswing," he recalls. For five years Leisner went to experts in Western
as well as Eastern medicine with no results. His attempts at treatment
stopped after he underwent an eclectic Eastern therapy that had helped
numerous musicians with different problems but seemed to make his
condition worse.
A couple of years later, he started playing again
using
only the thumb and index finger of his right hand, and he resumed
concert performances in 1991. "I was doing wild things with my thumb
and index fingers that nobody could believe I was doing," he says. "But
I was doing it, and I was making a good sound and a good impression."
A conversation in 1992 about using large muscle
groups
started Leisner on the road to recovery. "I had this image of swinging
at the string with my arm from the elbow down," he says. "One big lever
from the elbow down to the tip of my finger." He attempted that motion
for about five minutes and found himself moving the ring finger that he
had not used in eight years. He eventually visualized a connection
between his fingers and a spot in the back of his shoulder, at the apex
where the arm meets the torso, and he continued to work with
visualization and exercises for three more years. It took about a year
for him to recover full use of his middle finger in concert and another
year for him to recover full use of his ring finger. Full recovery of
his hand came in 1996.
During the course of his odyssey, Leisner saw a
doctor
who advised him to take up swimming. Even though the swimming didn’t
help his focal dystonia, Leisner remains grateful for the advice. "I
feel a lot healthier," he says. "And I understand a lot of things I
didn’t understand before about how the body works and about relaxation
as opposed to working."
Whenever he gets the opportunity, Leisner
instructs
other musicians with focal dystonia in the method that helped him. "I
show them the basic idea. I show them exactly where the muscles are and
how to feel it in the string or on their instrument," he says. "And
then they have to take it from there and apply it." So far he has had
more success helping individual musicians than communicating his
methods to medical professionals. Part of the problem may be that his
healing technique contains just as much art as science. He likens it to
learning to play an instrument. "There are shelves of books written on
technique for any instrument, and so few of them have mastered a really
accurate way of describing technical things so that a person can just
read the description and go do it on the instrument," says Leisner.
"You’ve usually got to show it to somebody. And this, unfortunately, is
no exception."
PRESCRIPTIONS
So what can you do to avoid injuries like these?
Markison’s and Rosenthal’s prescriptions include a wide range of
elements—from adopting a healthy music-making attitude and lifestyle to
exploring various therapies and general hand-care advice.
According to Markison, musicians with the lowest
risk of
injury also tend to have a range of musical and nonmusical pursuits
that provide creative and fulfilling opportunities even when their
hands are not engaged with their instruments. "What you want to do is
measure out beautiful music over a long lifetime and not assume that if
you don’t get it in the next six months you’re done for," he says.
Teaching, composing, arranging, improvising, and maintaining some
involvement in other arts and social networks are all positive factors
that lessen the risk of injury.
Rosenthal recommends aerobic exercise, drinking a
lot of
fluids, maintaining body flexibility, and getting plenty of sleep. She
also stresses the harmful effects of smoking, drinking, and staying out
late, which can prove challenging for musicians who travel frequently
or who spend a lot of time in environments where smoking and drinking
are the social norm.
Breathing and relaxation are also key factors,
according
to Markison, and he recommends meditation and breathing exercises.
"String players are not good breathers," he says, "because breathing is
not embedded in the mechanics of music making unless you are a wind
player." Markison recommends Effortless Mastery by
Kenny Werner, (published by Jamey Abersold) as a guide for more relaxed
playing and breathing.
Markison also recommends improvisational source
material
in the Jamey Abersold jazz catalog for developing a more relaxed
approach to making music, and Reed Kotler’s Transkriber software as a
computerized aid to memorization of recorded music. Classical guitarist
and composer Richard Iznaola has also provided an easy-to-follow guide
for developing good practice habits in a concise 24-page booklet, On
Practicing: A Manual for Students of Guitar Performance (see
Resources).
Markison also stresses the importance of warming
up
before playing. He begins his examination of patients with a handshake.
"The greatest risk group has cool hands," he says. He adds that poor
circulation is bound to worsen when performance anxiety constricts the
blood flow even further. "You’re not fit to play music until your hands
are warm," Markison says. "You can increase microcirculation by
prehydrating with at least a pint of water." In some cases, he also
recommends boosting poor circulation by wearing fingerless gloves that
can be custom-made to extend from the forearm to the palm.
Pumping Nylon by Scott Tennant,
available in both book and video formats, contains comprehensive
exercises for building strength and a daily warmup routine. The book
also touches on aspects of breathing and performance anxiety, and the
video gives additional postural and hand-placement guidance primarily
for classical guitarists.
Other hand-care suggestions from Markison include
contrast baths--for tendinitis, he recommends soaking your arms and
hands in cool water for a minute and then in warm water for a minute
(not ice cold or red hot). Repeat the cycle a couple of times (for a
total of about four minutes). He also recommends massaging the hands
and arms from time to time with hand cream or lotion, proceeding from
the fingertips up toward the elbows. Gentle stretches are also
important--from the forearms into the palms, palm up and palm down,
stretching the wrist backward and then forward, and individually moving
the fingers to get the tendons gliding independently. Some physical and
mechanical stresses can be addressed with exercise programs, yoga,
massage, or acupuncture, and therapies like the Alexander Technique can
improve the body’s relationship to the instrument.
Sometimes a change of instrument or accessories
can have
an effect. Rosenthal asks her patients questions like: Have you changed
your instrument recently? Have you changed the strings? Did you change
anything on the fretboard? Has the style of your music changed? Have
you been traveling more than in the past?
So what’s the bottom line in avoiding or
recovering from
injury? Kendrick seemed to sum it up with the following words of advice
he received from a friend: "You don’t want to be a slave to your
instrument."
RESOURCES
BOOKS
Ricardo Iznaola, On Practicing:
A
Manual for Students of Guitar Performance,
Chanterelle, www.chanterelle.com
Scott Tennant, Pumping Nylon,
Alfred Publishing, (818) 891-5999, www.alfredpub.com
Kenny Werner, Effortless
Mastery,
Jamey Abersold Jazz, (800) 456-1388, www.jajazz.com
STRING
LETTER BOOKS
Keep you guitar in the best possible
playing
condition. Learn about basic guitar maintenance and home repairs in the
Acoustic
Guitar Owner's Manual.
WEB SITES
Alexander Technique, www.alexandertechnique.com
Dystonia Dialogue, www.dystonia-foundation.org
Reed Kotler Music, www.reedkotler.com
David Leisner’s experience with focal
dystonia,
www.davidleisner.com
The Miller Health Care Institute for
Performing
Artists, www.millerinstitute.org
Musicians and Injuries, www.engr.unl.edu/ee/eeshop/music.html
Excerpted from Acoustic
Guitar magazine, September 2000, No. 93.
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