“An apple a day keeps the doctor away”: Is it time for a different perspective on playing-related injuries?

images-5 I’ve been reflecting recently on current practices in promoting musicians’ health, particularly after revisiting the article Musculoskeletal pain and injury in professional orchestral musicians in Australia, the results of a national survey of Australian symphony orchestras led by Bronwen Ackermann, Tim Driscoll, and Diana Kenny (2012).

There are undeniably huge problems in our field. This article indicates that 50% of the professional musicians questioned were currently suffering pain and / or injury, reflective of many studies in the literature. In the majority of cases, pain had been present for more than three months (Ackermann, Driscoll, & Kenny, 2012, p. 183). 84.4% of the musicians surveyed had experienced pain at some stage in their career severe enough to interfere with their normal performing commitments Ackermann et al. (2012, p. 182). 50% of these musicians had not completely recovered from their prior injury (Ackermann et al., 2012, p. 183).These findings confirm that many wonderful performers play exquisitely despite pain. One cannot assume that reaching an elite level of technical skill and impeccable musicianship equates with a healthy technique to be modelled and imitated.

There have been pleasing developments in the attention and awareness given to musicians’ health within Brisbane tertiary music institutions in recent years. These initiatives are laudable, but necessary. By April, 5 of the 11 first-year piano students at the Queensland Conservatorium (QCGU) had injuries and were having a break from playing. In a session led by a physiotherapist in Project Week in May this year, 50 of the 55 students admitted to pain at the instrument.

Much of the information presented to students at QCGU and similar institutions focuses primarily on general health and wellbeing. Of course it is important to take care with one’s diet, get sufficient sleep, exercise, and maintain a healthy mind and outlook. Yet this alone does not prevent playing-related musculoskeletal disorders (PRMDs). Rest does not prevent the problem reoccurring, nor does eating large amounts of green vegetables or physical activity. Neither do stretching or strengthening exercises. A massage or session with a chiropractor may temporarily alleviate the problems but does not address the root of the problem. Many musicians I know have a complex “management program” of rotating treatments and visits to specialists to help them survive their playing commitments, which is considered a normal and unavoidable part of a performing career.

Allowing breaks during practice sessions, or avoiding “over-practicing” is a common prescription. Yet having breaks does not prevent the musician using unhealthy movements during practice sessions, which is the problem. It goes without saying that if there is pain, tension and technical limitation present, increasing the practice time magnifies the risk of injury. But practicing less, or ensuring a ten minute break after 50 minutes of playing would not have helped the amateur pianists I have encountered who were injured by playing 40 minutes a day. Nor does this theory account for the supposedly “lazy” young students who don’t practice as much as their teacher would like, but when probed confess that the reason behind their “laziness” is that the passage doesn’t feel good. Who wants to practice if it hurts?

Conversely, I know pianists who were severely injured, but after having retrained in the Taubman Approach can, and do, play up to 10 or 11 hours a day without any problems. I’m one of them. The length of our practice sessions should be determined by our ability to focus on the task at hand, rather than an arbitrary set time. If your mind is wandering after 15 minutes, stop practising. Get up and walk around until you can concentrate again. Changing old habits can be mentally exhausting. Particularly during retraining, it is more effective to practice in small amounts, executing the movement perfectly each time, than risking inconsistent results.

Small hands are commonly blamed as a cause of injury, rather than acknowledging stretching as the problem, of which both small and large-handed musicians can be guilty. I have worked with many men who have been injured despite their large hands.  Sometimes pianists with small hands are smarter in redistributing notes, more astute with clever fingering and pragmatic about leaving out occasional dots. Sometimes those with large hands pay the price of obeying stretchy fingering, and trying to physically connect everything with their fingers. Some blame the instrument, and suggest using a 7/8 size instrument instead, but a smaller size keyboard would only lead to temptations of playing intervals and chords that are impossible on a full size keyboard. As pianists, we have to be realistic about the fact that we cannot sustain the sound in the same way as a string or woodwind instrument. Yet we have the tools of shaping, tone production, pedal, and timing to create the illusion of legato. 

Another common misconception is that playing loud, thick textures such as Brahms is potentially injurious. Some pedagogues teach that loud sonorities cannot be achieved without the shoulder becoming involved, the wrists feeling like concrete, and are impossible if you have a slight build. Anyone who has heard Edna Golandsky’s huge sound would disagree.  For one Singapore pianist who had been told all her life that she was too small to ever produce a big sound, just hearing Edna’s powerful tone on YouTube prompted her to travel to the Golandsky Institute in the USA to learn more. Rather than assuming that smaller pianists can and should only play Mozart, lest risking injury by playing Rachmaninov, the student needs to be taught the skills behind making a free, huge, and comfortable sound, with control over the tone colour.

Unfortunately, my students at QCGU have been taught in various classes that tension is to be expected, and are even prescribed exercises with the advance warning that they will cause pain. Behind this is the popular justification that tension is fine as long as one relaxes afterwards. Yet pouring heavy relaxation into the technique does not remove the source of tension. It is surprising to many people to learn that relaxation creates many problems, including reduction of speed (Ortmann, 1929/1962, pp. xxi, 125, ). Otto Ortmann proved in the late 1920s that the most efficient and coordinate movement is the midrange, wherein the most comfort, speed and facility lie, in addition to “accuracy of kinaesthetic judgement” (1929/1962, pp. 99, 118). As Taubman noted, the ideal is freedom of movement, there should be no tension to relax from in the first place (correspondence with Taubman’s students, 2009).

In the Taubman world, low-level symptoms such as fatigue and tension are warning signs to be immediately addressed. Students are encouraged and trained to become extremely sensitive to how their body feels, and to bring their “shopping list” of questions and complaints to each lesson. If pain is identified, this is a red light moment, and musical interpretation immediately becomes secondary to eradicating the discomfort. Some musicians are unaware that fatigue, tension and technical limitations form a continuum towards injury, and that they may be closer to pain and / or injury than they realise. Perhaps we each have our own level of resilience. Perhaps some people have a higher pain tolerance, or can do more things “wrong” without incurring injury. Regardless, we do not know where our individual threshold is until we have reached it, and once the line from “symptoms” to “injury” has been crossed, the path to recovery is more difficult. Once the pain has become chronic, it can be more complex to find the way back to healthy movement.

Importantly, reported pain levels have not significantly changed since the last national survey of the major Australian symphony orchestras twenty five years ago (Ackermann et al., 2012, p. 184). Further, even though the survey offered anonymity, musicians were still worried about potential implications to their careers if they identified to symptoms, (Ackermann et al., 2012, p. 184). Despite the growth of the performing arts medicine sector, despite more awareness and understanding of playing-related injuries, statistics have not changed, and musicians are still reluctant to admit to problems. To my mind, there is insufficient acceptance that playing-related injuries are just that, physical issues caused by how we play our instruments and often other aspects of daily life, such as typing and mouse use. Dorothy Taubman strongly believed in returning to the “scene of the crime” (correspondence with Taubman’s students, 2009). If playing octaves were the problem, at some point the pianist has to learn how to play octaves comfortably to fully resolve the issue.

I believe that the number of musicians affected by playing-related injuries will not decrease until performer / pedagogues have a clear understanding of healthy movement at the instrument, and the tenets in traditional pedagogy that create tension, technical limitations, pain and injury. As performers and educators, there is information available now. Is it not our duty to be open to learning, to be as informed as we can, in order to best help the next generation of performer / pedagogues?

Dr. Therese Milanovic  

Reference List: Ackermann, B., Driscoll, T., & Kenny, D. (2012). Musculoskeletal pain and injury in professional orchestral musicians in Australia. Medical Problems of Performing Artists, 27(4). Ortmann, O. (1929/1962). The physiological mechanics of piano technique: An experimental study of the nature of muscular action as used in piano playing and of the effects thereof upon the piano key and the piano tone (Rev. ed.). New York: Dutton.  


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