Playing The Piano: Playing With Fire? Introduction

Contents | Playing The Piano: Playing With Fire?

• Acknowledgements
• Introduction
• Chapter 1: Casualties of the Keyboard
• Chapter 2: Treating the Body
• Chapter 3: Treating the Mind
• Conclusion
• Notes
• Bibliography

Introduction | Playing The Piano: Playing With Fire?

Performing Arts Medicine is a new name. It is so new that a lot of people do not know what it stands for. Recently, I wrote to a fairly well known author, who is considered something of an expert on a certain type of healing (1). After complimenting her on a book she had written, I asked for an interview. I have had to speak to several people; therapists, doctors, teachers, in the process of my investigations, since books on the subject are hard to come by. There are a number of articles of course, but most of these are very technical and are only to be found in various medical journals.

The author in question, whom I had assumed could give me a lot of valuable information, promptly answered me in a very kind letter. After reading it however, it became evident that she knew nothing about the issue. She had completely misunderstood me and thought that Performing Arts Medicine refered to healing by the use of the performing arts. This is understandable, since after all there are things such as music therapy, art therapy and therapeutic dances. However, the name Performing Arts Medicine refers to the study and treatment of various medical problems which can afflict those involved in the performing arts, and which are related to their occupation. In a sense it is similar to sports medicine, since performing artists are a kind of athletes. They have to endure intense training of their bodies, usually several hours a day, year after year. An incredible coordination is necessary. And, for the more competitive among them, great stamina and nerves of steel.

The present dissertation (1991) will focus on pianists. The simple reason is that I am a pianist myself, and have something of a personal experience of these problems. Other pianists have, also. According to all the surveys which have been carried out in the past eight years, many pianists suffer from various health problems related to their instrument. It is obvious that physical conditions, painful or otherwise can happen to anyone, but the risk is higher among those who use their bodies as intensively as pianists and other instrumentalists do.

More studies have been done on the prevalence of these problems among members of symphony orchestras than among pianists. One such study, for instance, was conducted five years ago by the British Association of Performing Arts Medicine. It revealed that 50 to 60% of orchestral players had at one time or another had an acute physical problem connected with their playing (2). There is no question that a similar situation exists among pianists. Pianists seem to be everywhere, and the piano is definitely the most commonly-played instrument. There is a lot of accompanying, chamber music, concertos and solo recitals; pianists often live busy lives.

Of all the different problems which can arise in connection with piano playing, the present thesis will mainly focus on physical disorders. These include painful conditions such as what is now called "work-related upper limb disorder", also often refered to as tendonitis or tenosynovitis. Additionally, a "new" mysterious disability will be explored, a painless syndrome, which usually goes by the name of Focal Dystonia. Then there are various psychological problems connected to the above, and as these are very important I shall discuss them as well.

In the past ten years or so (prior to 1991), there has been growing concern about these problems. Musicians are becoming aware that playing an instrument can be hazardous under certain conditions, and the medical fraternity has begun to develop an interest in the whole matter. A journal now exists called  "Medical Problems of Performing Artists", published quarterly in the USA. Most of its contributors are doctors, and it is definitely the main body of literature on the subject.

The first issue came out in March 1986. In it was an article by the once-famous American pianist Gary Graffman, entitled "Doctor, Can You Lend an Ear?". It described a serious hand problem which afflicted him and the lack of understanding which was exhibited by all the doctors he visited. The condition forced him to retire from the concert platform at the end of the 1970s, causing a great stir in the USA. The reason was that he was the first pianist to publicly admit a grave physical problem associated with playing. Naturally, the fuss alerted the medical community. However, pianists have existed for two centuries. Why is it that it took such a long time for these problems to become an object of scientific study and popular interest? The answer is that it was inevitable — sooner or later. Physical problems associated with musical performance have probably been around since time immemorial. But musicians have been reluctant to come into the open with them. Mr. Graffman explains why in the following words:

"… instrumentalists' hand problems — somewhat like social diseases — were unmentionable. Understandably so: If a performer is still performing, or hopes to get back on the road soon, he'd be crazy to advertise his disablilities. Nobody wants a wounded pianist. There is an oversupply of healthy ones. Admitting difficulties is like jumping, bleeding, into piranha-filled waters." (3)

The above is well illustrated by the case of the great Polish pianist,  Ignace Paderewski, during the winter of 1891–1892 while he was playing throughout the USA. The entire tour was sponsored by Steinway & Sons on the condition that he play only on Steinways. In return, he would make a vast amount of money. The concert schedule was intense, not to mention all the social obligations. In 117 days he gave 107 concerts and went to 86 dinner parties. At such a pace, Paderewski was feeling increasingly fatigued, and to add to the difficulty he found the Steinways very hard to play on. The sound was beautiful, but producing a big tone seemed to require great physical strength. His hands were beginning to ache, so he persuaded the Steinway managers to soften the action. After that, everything went well until one fatal evening in January. The concert was to be in New York, and Paderewski had had no time to try out the piano. Instead he went straight from the train to the crowded concert hall. As usual, he mounted the stage and walked to the gleaming Steinway. The piano showed its white and black teeth in a smile, but Paderewski did not know that it had been in the factory for servicing earlier that day. A regulator who knew nothing of the arrangement which had been made, had gone lovingly over the piano and found that something was obviously wrong with the action. He restored it and the Steinway was back to its evil self. Paderewski began to play, but had no sooner been through the opening chords when something seemed to break in his arm. An enormous pain followed and he knew that he was in trouble. Somehow, he managed to go through the recital, and after the applause went straight to the nearest doctor.

The doctor was not happy. He told Paderewski that he had torn a tendon, strained others and injured his finger very seriously. Only a complete rest could make him recover, and even then it was doubtful if he would ever be able to play again. But Paderewski refused to listen. Having an injury was humiliating. And if he cancelled the rest of the tour he would forfeit the contract. No contract, no money. So in spite of everything, Paderewski went on playing. The simple fact that he managed to continue is something of a miracle. At the end of the season, his finger was worse than ever, but with rest and with the help of a masseur he did finally get back to normal.

Others have not been so lucky. The case of  Schumann's hand injury is well known, for instance. Fewer people know about  Scriabin. Yet it was a serious hand injury which forced him to stop playing and to devote his life to composing. He was devastated, since his aspirations were towards a glorious career as a concert pianist. He injured his hand while he was still a student at the Moscow conservatory, and from then on he composed ceaselessly. His first work after the problem developed was a sonata. It is very expressive of the feelings experienced when a pianist loses his ability. Aptly, it ends with a marche funèbre. Since I will be writing about the psychological aspects of Performing Arts Medicine it is of interest to let Scriabin himself describe how he felt:

"Gravest event of my life…Trouble with my hand. Obstacle to my supreme goals — GLORY, FAME. Insurmountable, according to doctors. This was the first real defeat in my life… Doubted, however, that I would NEVER recover, but still my darkest hour… Cried out against fate, against God. Composed First Sonata with its "Funeral March". (4)

If Scriabin had been living in our time, he might have recovered. There are a number of Performing Arts Clinics in the USA, and the  British Association of Performing Arts Medicine (BAPAM) is planning to set up 15 such centres throughout the UK. At present, there are three clinics in operation in London. One is the so-called Musicians' Clinic which is run by Dr. R. M. Pearson. Another is a child of BAPAM and is sanctioned by the National Health Service. It is run by the registrars of the rheumatology department at the Royal Free Hospital and its consultants are on the hospital's staff. Finally there is a clinic at the London College of Music, which is unique in the sense that it offers a collaborative team of a doctor, a physiotherapist, an Alexander teacher, a Feldenkrais practitioner, a psychiatrist, a counsellor and highly-skilled musicians. This multi-disciplinary clinic was formed by Mrs. Carola Grindea, and without doubt she has been more influential in this area than any other person.

In 1978 she published a book entitled "Tensions in the Performance of Music". Stress, or tension, is a fundamental issue, since physical tension and stage-fright are a great hindrance in music making and can lead to injuries. Later in the thesis I will try to show why. At the time nothing of any importance seemed to have been written on the subject. The book was therefore intended to make people more aware of the problem and to stimulate research in the field.

Some studies had already been undertaken, however. In 1977, Dr. Ian James, the chairman of BAPAM, had published the results of experiments on betablockers and their practical use for musical performers. His team proved that these drugs, which lower the blood-pressure, were effective in combating such effects of stress as trembling of the hands, etc. Similar studies had been conducted in the USA at about the same time (5). Mrs. Grindea maintained, however, that beta-blockers were unnecessary; control over stage-fright could be achieved by using more conventional methods, such as the Alexander Technique, and others.

The Alexander Technique is very popular. It is concerned with relaxation and the improvement of posture while engaged in various tasks. It has existed since the turn of the century, and has been found very useful in Performing Arts Medicine. For a long time it was the only method of relaxation which had been specially designed to help performing artists. Today, stress management has become an industry and in the UK the technique has been taught in the principal music colleges since the mid-1970's (6). Before then, however, very few knew about it, let alone practised it.

Mrs Grindea's book received a lot of interest, both in the USA and in the UK. Its publication led to a seminar which was organised by Dr. James, Dr. Paul Lehrer, a well known American psychologist and, of course, Mrs. Grindea herself. The topic was Tension In Performance and it was held at the Guildhall School of Music and Drama. The event was quite a sensation and aroused a lot of attention. It led to the founding of the  International Society for the Study of Tension in Performance, or ISSTIP, at the end of 1980. ISSTIP has been a leading force in Performing Arts Medicine ever since, and its first conference in 1981 was attended by parties from all over the world (7).

Journalists became interested. A lengthy article appeared in the Sunday New York Times, headlined " When a Pianist's Fingers Fail to Obey". To my knowledge it was the very first "in depth" coverage to appear in the media. It described Gary Graffman's condition in detail, and Leon Fleisher, another famous American pianist, received his due as well. Mr. Fleisher had lost the use of his right hand in a manner quite similar to Mr. Graffman. Was physical tension the cause of their problems? The article mentioned the medical team at Massachusetts General Hospital which had been highly involved in their treatment (8). Soon after, doctors and scientists began to make systematic studies of these problems, and the hospital in Massachusetts became inundated with indisposed musicians who had finally found the courage to come out of the closet.

Centres and organisations devoted to this new type of medicine began to appear, such as the International Arts Medicine Association or IAMA, which publishes a bulletin from time to time. There has also been no end to the articles written on the subject. In May 1991 "The Strad", which is one of the leading magazines for string players, included a long and excellent exposé of the subject. (9)

There are many controversies in the field. A lot of debate has been going on as to whether these various problems and injuries are caused by a wrong way of playing, or whether they are simply caused by overuse of the body. Later, I will try to examine the issue in depth. Many doctors think that there is only one way of playing an instrument, and are not aware of the subtleties of different techniques. In addition, few of them understand the psychology of being a professional musician. Mrs. Grindea believes that there is not enough cooperation between musicians and doctors, which is the reason why she founded the clinic at the London College of Music. Dr. Georg Gomez, a retired but interested General Practitioner comments:
"A lot of GPs tend to rubbish the symptoms presented to them by musicians. Many are not aware of the current thinking on work-related upper limb disorders, let alone those specific to musicians — after all, how many of their patients are musicians?" (10).

Therefore, diagnoses tend to be simplistic and based on a lack of understanding. Today however, the medical community is increasingly recognising the need to examine the conditions under which an instrument is played. A close relationship has to be kept with the musical fraternity and, in addition, scientists are making more and more investigations into the mechanics of playing, what is natural for the body and what is not.

Most of these findings have been published in  "Medical Problems of Performing Artists". Its editor, Alice G. Brandfonbrener, M. D., has also organised annual seminars at the famous Aspen festival where doctors and musicians meet and exchange ideas. There will be more such meetings in the future. A huge congress with some 80 courses and workshops will be held in Rotterdam in September 1991. It is called "Medart International" and the event will focus on the following issues:

1. "The relationship of ARTS AND MEDICINE: phenomenology, philosophy, aesthetics, neurosciences, biology, bioengineering, etc.
2. MEDICINE FOR ARTISTS: Specialized medical and allied health care for performing and visual artists, aiming to diagnose, treat and prevent their occupation-related or job-threatening disorders,
3. ARTS AS MEDICINE: numerous applications of the Arts as treatment, namely music therapy, dance therapy and other creative arts therapies." (11)

I have tried to tell the story of Performing Arts Medicine in the last few pages. It is not much to tell. As Dr. Ian James told me bluntly in an interview: "Performing Arts Medicine has no past; only a future." With such an event as Medart International coming up, much is certainly going to happen. And let us hope that, as this new medicine expands, the musicians of the world will find it safer to practise their art, and to enjoy it without problems and without worries.

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