When music brings pain

Daria White has played the clarinet since age 9. Since starting college, her playing time has increased — and so has pain in her wrist, arm and shoulder.

For a while, she couldn't play more than 15 minutes at a time. She suspects the clarinet itself is to blame. It weighs 2 pounds, not much, you might think — until you hold it for sustained playing with only the thumb and mouth.

White has seen a number of doctors, including a neurologist, and had tests from MRIs to painful electromyographies, but doctors can't diagnose her pain. The advice so far: Lay off the clarinet.

"That sent me into orbit," White says, noting that the doctors don't understand that music is her college major and future career, not just something she fools around with.

Playing music can tax small muscles in much the way competitive sports strain the larger ones. Jennifer Gamboa, past president of the performing-arts special-interest group of the American Physical Therapy Association, calls musicians "upper-extremity athletes."

Musicians' injuries are as numerous as their instruments: fiddler's neck, tuba lips, violinist's jaw, horn player's palsy — even guitar nipples and harpist's cramp. And the flute is a "biomechanically impossible" instrument to play, says Scott Brown, chief of physical medicine and rehabilitation at Baltimore's Sinai Hospital.

Musicians tend toward the "no pain, no gain" philosophy. Reflecting on the hand injury that derailed his concert-piano career 20 years earlier, Leon Fleisher said in 1985, "There was something macho about practicing through the pain barrier. Even when my hand was exhausted, I kept going. Although I thought I was building up muscle, I was, in fact, unraveling it."

'Piranha-filled waters'

And musicians are loath to discuss or seek help for injuries. Concert pianist Gary Graffman, whose career was ended by a hand injury, wrote in 1986, "Nobody wants a wounded pianist. There is an oversupply of healthy ones. Admitting difficulties is like jumping, bleeding, into piranha-filled waters."

Music injuries can be difficult to diagnose and rarely show up on X-rays or MRIs, says Brown, who is past president of the Performing Arts Medical Association, a national group committed to improving performers' health care. Most tend to be lumped into the vague "overuse" category with carpal tunnel syndrome.

Pianist Fleisher spent 30 years playing only left-handed concerts after excessive practice caused the fourth and fifth fingers of his right hand to curl under. Psychiatry, lidocaine injections, traction, hypnosis, L-dopa, acupuncture, EST — he tried it all. Later, Graffman joined him in making the rounds, seeing more than 40 doctors.

In the early '80s, Fleisher and Graffman went public, bringing musicians' health-care needs into the open. Until then, many doctors believed such injuries were psychosomatic — a byproduct of the artistic temperament.

"The traditional medical community has not been very sympathetic," says Brown

Still, help is out there, and musicians say it's worth it to find it. When musicians make an appointment to see Jan Dommerholt, a physical therapist who played the clarinet and saxophone in the Netherlands' military band, he does one thing doctors rarely do: He asks them to bring their instruments. He checks their posture while they play and asks about their work environments.

"Do they play in the pit and can't see ... so they slump over the music? The physical environment of the orchestra pit is abysmal," he says.

Dommerholt had one client with myofascial pain syndrome in his knuckles; an orthopedist told him he'd never play guitar again. It turned out the man had large hands and his guitar neck was so thin that he had to use a pincher grip to play. He got a wider-necked guitar, and the problem went away.

Shadow practicing

Gamboa says traditional physical therapy doesn't always work for musicians. Trying to strengthen a pianist's hand muscles with weights or practice drills may make the pain worse.

She tries to improve musicians' posture and then build their strength to maintain it. She also works to limit their practice time and suggests shadow practicing, like playing piano on a tabletop.

Some musicians have found relief from alternative therapies. Fleisher returned to the stage with both hands in 1996, after discovering Rolfing — a form of deep tissue massage. Others swear by movement training such as Feldenkrais or Alexander techniques.

Three years ago, finger-style guitarist Nicholas Thompson was derailed by wrist pain after playing gigs every weekend and practicing hours a day. His doctors treated him for carpal tunnel syndrome. For 2-1/2 years, he endured acupuncture, steroid shots, wrist braces, massage, huge doses of ibuprofen. At work, he tried voice-activated software, a pen mouse, typing while standing up. Nothing helped.

Recently, a doctor referred him to an Alexander technique teacher who changed the way Thompson played. "It seems to have cured all my symptoms," he says.

"Sometimes I watch other people perform," he says today, "and I think, 'Oh, my God, you're going to get hurt.' "