CITY UNIVERSITY
MUSIC DEPARTMENT

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PLAYING THE PIANO: PLAYING
WITH FIRE?
A STUDY OF THE OCCUPATIONAL HAZARDS
OF PIANO PLAYING

BY JÓNAS SEN

A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE DEGREE OF MA IN MUSIC

SEPTEMBER 1991

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ABSTRACT: The present dissertation is a study of injuries and other
occupational disorders related to piano playing. The symptoms of these
ailments will be described and the causes investigated. Pianists´ problems
often appear simple but, as I will try to show, they may have complex
ramifications and be of different origins. Various therapies; treatment of
the body and treatment of the mind will therefore be explored. Many case
histories will be presented; of these, the problems and recovery of three
pianists whom I interviewed personally will play the leading part and will
be discussed in some depth throughout the thesis.

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Contents:

Acknowledgements
Introduction
1. Casualties of the Keyboard
2. Treating the Body
3. Treating the Mind
Conclusion
Notes
Bibliography

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Acknowledgements

First of all I would like to thank my tutor, Dr. Malcolm Troup, for his
stimulating ideas which have had a great deal of influence on the present
work.

Secondly, I am very grateful to Mrs. Carola Grindea, the chairman of ISSTIP
and the director of the Performing Arts Clinic at the London College of
Music, for suggesting the idea for this dissertation and for offering help
and assistance whenever I needed.

Special thanks go to Dr. Ian James, the chairman of the British Association
of Performing Arts Medicine, for his kindness and valuable information.

Lastly, Halldór Haraldsson, ARAM and head of the Piano Department at the
Reykjavík Conservatory deserves my gratitude for his help and inspiration
throughout the year.

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INTRODUCTION

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 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, 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
1970´s, 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 funebre. 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 GP´s 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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CHAPTER 1
CASUALTIES OF THE KEYBOARD

Making music is an act which is as physical as it is mental. The brain is
responsible, and the brain is a machine of staggering complexity almost
beyond comprehension. It transmits a multitude of neurological signals to
the rest of the body and, with the right coordination, the movements of the
hands and the arms interact with the musical instrument and we hear the
wonderful sounds of a prelude, a fugue or a sonata. This coordination and
sensitivity is of such a degree, that a whole book, "Music and the Brain",
has been written on the neurological bases of music perception, talent and
performance (12). The musical profession is also very demanding and very
stressful. There are examinations, auditions, competitions and concerts.
Some or all of these challenges have to be met with an intense
concentration and courage. A special type of fitness and stamina is
required, and it is no wonder that the under such a strain the body can be
hurt in one way or another. The hands and arms of a musician are his most
precious possessions. After all, his whole career, his whole livelihood,
his whole life indeed, is finely balanced on a fragile finger, a nerve, a
tendon or a muscle. Therefore, an injury to this delicate apparatus is a
serious concern and deserves special attention.

Below are the case histories of three pianists. Throughout the thesis I
will be discussing their problems and the treatment which they were given.
None of them has had a unique disorder in any way; instead their complaints
are fairly typical of some of the problems which Performing Arts Medicine
aims to solve.

We are in a small village not far from London. It is Christmas;  it is dark
outside and the snow-flakes are falling. All is quiet, except for the
sounds of Christmas carols and merriment. Candles have been lit in almost
all windows, and Santa Claus´ presence fills the air.

One house is different, however. For a start, no candle adorns the window
and no songs can be heard from it. Instead, almost ceaseless bangings on a
piano. The neighbours are not too happy about this. Who wants to listen to
Stravinsky´s Petrouchka at a time like this? Finally, one brave person has
the guts to walk in direction of the noise and ring the door-bell. A pale
young man answers, but refuses to listen to the complaints. Instead, he
continues the blasphemous music. The neighbours shake their heads in anger
and amazement. "He was never like this! What has got into him?"

The reason is not hard to find. An important symphony orchestra has
announced that it needs a pianist. The audition is to be on January 2, and
every applicant is to play the first movement from Stravinsky´s Petrouchka.


Petrouchka is not exactly easy. The young pianist, whom I will call
Michael, has only ten days in which to prepare. So he decides on a
ferocious work schedule. Twelve hours a day the first three days; ease up a
bit the next four, and twelve hours again the final three.

On the first day, everything goes as planned. He wakes up stiff and with
some pain on the second day but decides to practise through it. On the
third day, however, he finds that he cannot play at all! His arms are
aching terribly, and the pain grows worse and worse. The days go by, but
there is no improvement. Michael realises that there will be no audition
for him; instead he has to see a doctor. The cause of his problems seems
fairly obvious but,  as I will show, he received more than one type of
treatment. How he was eventually cured is highly interesting.

Josephine is a pianist with a large repertoire. Until our story begins, she
had been giving some 15 concerts a year. Her age at present is 28. She
herself is not quite clear about how it all started. Somehow, at some stage
around a year ago, she began to lose the dexterity of her fingers. There
did not seem to be any reason; the fingers just seemed to be losing the
capacity and agility with which they had been endowed. Soon after she began
to notice this strange development, she started to feel pain in both her
arms. The pain grew steadily, until finally she sought help. As was the
case with Michael, she had to see a number of doctors and therapists.

I mentioned in the introduction that there are several controversies raging
in the field. Therefore, the suffering musician hears a hundred different
opinions. My third case was losing her patience when I last interviewed
her. She had actually lost count of all the specialists which she had
visited. She was getting low on the budget as well.

The strange case of Elisabeth, who at present is 43 years old, started some
ten years ago. She began to lose control over the third finger of her left
hand. When she wanted to press it down, it went into a spasm and came up
instead. The condition came on gradually, but happened only while she was
playing the piano. She could do everything else with her left hand with
perfect ease, and her GP was puzzled. He did not find anything wrong with
her, and dismissed her complaint as "it is all in your head". Elisabeth
believed him. She rarely appeared in public, anyway, so the condition did
not bother her much. "My technique is lousy, that´s all", she thought. She
had been giving piano lessons for a living and simply kept on doing her
business as time went on.

Then a year ago, she decided that she would like to start playing the piano
again. Not a recital or anything like that; playing for the simple fun of
it was all she wanted. She felt that her technique was seriously in the
need of being looked into. So she began with some scales, some finger
exercises and some Chopin études which she had learnt in her teens.
However, her third finger of the left hand refused to obey. And in
addition, her right hand began to develop similar symptoms. The fourth and
fifth fingers would curl whenever she had to play octaves. This meant a lot
of wrong notes, no matter how hard she tried. It did not make any
difference whether she played slowly or fast, the fourth or the fifth
finger simply would not be there when she needed them. Elisabeth saw her GP
again. And this time she refused to be sent away. She has not recovered
yet, but there have been some improvements. Therefore, let us follow her
trail and hope that she may find the solution to her ailment.

Pianists may suffer from many problems associated with their instrument.
These are usually classified into performance-related and
non-performancerelated disorders. There is a third group in addition which
is the subject of yet another controversy. Dr. Ian James, the chairman of
BAPAM,  describes it as

"a painless lack of control. The term occupational palsy has been used by
some but it is important to emphasise that the problem is painless" (13)

Performance-related disorders are also called overuse syndromes, misuse
syndromes or RSI which stands for "repetition strain injury". The latest
term is "work related upper limb disorder", which has the advantage of
implying neither overuse nor misuse. The controversy surrounding these
terms has been mentioned. Misuse implies incorrect use of the body or
faulty technique. The terms overuse and RSI, on the other hand, mean that
the muscles or tendons or whatever have been stressed beyond their limit
simply because of the time and intensity of the performance or practising
which caused the injury. In other words "intensity multiplied by time"
(14). The case of Michael would be an obvious overuse injury, for instance.
But then, a lot of pianists practise for hours and hours without any
problems whatsoever. Why do some suffer from these injuries, and not
others?

One of the greatest experts of Performing Arts Medicine in the UK is Dr. C.
B. Wynn Parry. I asked him whether a sudden twelve hours of practising
would be called an overuse or misuse of the body. "Misuse", he replied
without blinking. "Sudden twelve hours mean that you don´t know how to pace
yourself. But even then, if you were practising twelve hours using the
right technique, you wouldn´t have any problems." Let me however quote Dr.
Hunter Fry, who is a plastic surgeon in Australia. Dr. Fry is considered an
authority on the subject, and has written a number of articles. He favours
the term "overuse", but still acknowledges the importance of right
technique.
"1. Some people are more physically strong and can play for longer hours
even with a tense technique, without incurring injury. These people are
very fortunate, but it cannot be predicted who the genetically advantaged
people are.
2. The person´s technique is an important factor. Excessive incoordinated
muscular activity in the technique will interfere with good execution.
Joints that are overstabilized by excessive muscular tone will require more
force to move them, and the joint will be less responsive. All other things
being equal, the person with effortless coordinated technique will always
be further away from the threshold of overuse injury.
3. Intensity multiplied by time is an all-important factor. The author´s
studies indicate that most students practice themselves into injury through
use that is excessive for their own bodies. Even robust individuals can
contract overuse if the use is great enough." (15)


The findings of the first scientific study of such problems were published
in 1983. A medical team described their experience with 100 musicians who
had sought professional help due to various hand afflictions. Forty-two had
disorders of the musculo-tendinious unit which are usually called
tendonitis or tenosynovitis. These syndromes are therefore the most common
occupational problems of musicians (16). Subsequent surveys have confirmed
these findings. According to the study, most of the victims seemed to be
pianists. However, as I mentioned in the introduction, the piano is the
most popular instrument. Therefore it is only natural to expect pianists to
be the ones which are most frequently affected by misuse or overuse.
Typists also suffer quite often by these disorders. And female musicians
are more commonly affected than men. In a survey conducted by the
Performing Arts Medicine Society in Australia, 12- to 16-year-old girls
were the most vulnerable to injury (17).

The terms Tendonitis and Tenosynovitis have been somewhat misunderstood as
they refer strictly speaking to an actual inflammation in the tendons and
in the tendon sheaths respectively. The same applies to epicondylitis or
inflammation of the tendon attachment at the elbow, usually called "tennis
elbow" or "golfer's elbow". "Tennis elbow" is another frequent affliction
among musicians. It is common for the suffering person who consults the
doctor to complain of pain and swelling in the affected body part, but upon
examination, no swelling can be detected. Furthermore, anti-inflammatory
drugs have been tried, but they do not seem to be very helpful. Therefore,
"true" tendonitis, which is a specific condition and easily verifiable, is
actually quite rare among musicians. The same applies to tenosynovitis and
epicondylitis (18).

The frequent lack of objective clinical findings, despite the tearful
complaints of the patient, is the cause of still more arguments. Medical
textbooks tell one that pain means swelling, whether the eye can see it or
not. The inflammation presses the surrounding nerves and one feels pain.
However, the absence of visible physical signs means that it is difficult
to know with any certainty what lies underneath the surface. A way out
would be to take a muscle biopsy, but this is rarely done (19). As
mentioned before, some doctors simply shake their heads and say that there
is nothing wrong with the weeping musician. No clinical findings; the
symptoms must be imaginary. They believe that many of these cases are
nothing more than a "craft neurosis" (20).

Performance-related injury as a neurotic symptom or as simple hysteria
could be the subject of some discussion. It is not unlikely that some
degree of mass hysteria might arise with the advent of Performing Arts
Medicine, because it does make people aware that there are occupational
hazards associated with music performance. It is easy to imagine a
hypochondriac pianist. . .In Australia between 1983 and 1985, RSI, or
Repetition Strain Injury became epidemic among keyboard operators such as
typists and others working with screen-based equipment. The condition was
called "kangaroo paw". It went so far, that even children were taught about
the danger of the keyboard in schools. They were almost told that "if you
play the piano, you play with fire!" Some doctors refused to believe the
symptoms, however, since in most cases they saw nothing wrong with the
patients. They argued that the occupational hazards of the keyboard were
completely imaginary and that RSI was simply psychological.
"The occupational or craft neuroses have produced . . . (frequent)
epidemics. In each, the craft neurosis has been attributed to injury as a
result of work. Time has proved this to be otherwise, usually because the
work has continued while the alleged harmful effects have ceased with the
waning of the epidemic. Only a psychogenic basis for the occupational
neuroses could explain the time-course or the variations among epididemics
from time to time or region to region; they have been greater than is
possible for physical or mental illness and yet each epidemic has been
stereotyped in the one community." (21)

Localised pain and tenderness over the tendon and sometimes in the
surrounding area are the main symptoms of RSI or "work related upper limb
disorder". Often the injury to one tissue causes an increased strain upon
another, so multiple tissues are usually affected, either sequentially or
at the same time. As a rule the pain increases upon stretching or
contracting the involved muscle. As was the case with Michael, unusually
intense music making, as before a concert or an audition, precedes the
condition in most cases.  But both Dr Hunter Fry and Dr Wynn Parry
emphasise that the
technique, as well as the time and effort, is important. Upon observation,
the sufferer from a performance-related problem often has a poor posture
and/or other bad physical habits connected with playing. This misuse of the
body has usually lasted for years and has become an ingrained habit.

Bad posture can be described as a constant battling against the force of
gravity instead of utilizing or "flowing with" it. If the back is not
straight, an unnecessary amount of muscle tension is created simply to
maintain the balance of the body. This muscle tension is often a positive
hindrance against the movements and gestures making up a musical
performance. It results in a kind of a discoordination of the
interdependent voluntary and involuntary systems of the body. Explained
simply, the voluntary system has to do with voluntary movements, whereas
the involuntary system governs automatic functions, such as the heart beat,
digestion and most muscular reflexes which are necessary to maintain the
balance of the body. An armour of tense muscles is maintained by the
involuntary system, if a person is under stress. Agonistic and antagonistic
muscles may even be straining at the same time. One is voluntarily
performing, but the involuntary system is making it very difficult.

But what then is a correct or natural technique? There are several teachers
around teaching "the one and only right method of piano playing which will
save you from the horrors and miseries of all the other methods of piano
playing. . ." Such a teacher would maintain that all injuries happen
because of the folly and ignorance of some idiot professor of the past who
led the victim into his vast world of errors!  But is there only one way of
playing the piano? It would seem not, since the great pianists usually play
quite differently from each other. What is similar to most of them is the
ease and coordination in their performances. It follows then that there are
many correct techniques, but they always involve maximum relaxation.

Earlier, an overuse injury was defined by the formula of "intensity
multiplied by time". In view of the above, I can perhaps come up with a
formula for performance-related syndromes caused by misuse as "intensity
multiplied by time and poor use of space". Or even "intensity multiplied by
time, poor use of space and feeling low". This is because a bad posture and
a high degree of muscle tension is sometimes associated with anxiety and
depression. Stiff arms can be caused by emotional stress; playing the piano
in such a condition can be harmful to the body.

Overuse/misuse syndromes may in fact have deeper causes than seems at
first. The pioneering1983 survey mentioned above found that

"among the most frequent concomitant medical disorders were a history of
...alcoholism, manic depression (and) hypertension..." (22)
And Dr. Fry writing on the overuse syndromes and their victims in The
Lancet (September 27, 1986) notes:
"Fluctuating mental depression often appears different from a simple
reaction to the disorder and needs further investigation." (23)

The anxiety and depression need not necessarily be caused by professional
reasons at all. Richard, a concert pianist aged 30, had an intense concert
schedule when a close friend died suddenly. He had often in the past had
periods of frequent performances but never had any physical problems
before. At this time however he began to suffer from crippling pains in the
back which began to interfere with his playing. The pains became so severe
that he had to stop.  The physiotherapist that he subsequently consulted
told him that the pains, which were muscular, were tension-related and very
likely caused by a combination of grief and anxiety coupled with the
intense physical activity of performing. It was also discovered that
Josephine, who mysteriously stopped being able to play, had an emotional
problem which caused her physical symptoms. Her case will continue in
chapter three, where I will examine the issue.

It is interesting to note how dangerous the mental attitude can be. There
is often a disregard for the initial symptoms of an injury. In a survey
conducted by Alan H. Lockwood, almost 80 % of the musicians responded in
the affirmative when questioned whether pain was an acceptable factor in
the overcoming of technical difficulties (24). There is often an attempt to
play through the pain, a widespread tendency to avoid medical help and to
indulge in all kinds of self-diagnosis and self-treatment.

However, pain does go away sometimes. Let us not become hypochondriacs! The
muscles may simply be a little stiff and need some exercising. But often
the patients who come for the first time to a Performing Arts clinic have
had the symptoms which they complain about for years. Why? Well, eight
years is not a long time. And it has only been for about eight years that
the musical profession has received any serious medical and scientific
investigation. Therefore, in the past, musicians perhaps felt that the
doctors did not understand. As is so well illustrated with the case of Gary
Graffman whose problem caused him during a period of three months to visit
eighteen doctors and receive nearly as many diagnoses:
"Miraculously, (he)...was found to be suffering from the specialty disease
of each specialist (he)...visited. Finally, a famed  Parkinson´s authority
decided that (his syndrome)...exhibited the very earliest symptoms of this
debilitating affliction" (25)

However it was a wrong diagnosis. Gary Graffman was eventually found to be
suffering from "the painless lack of control" which I mentioned earlier, a
disease also called focal dystonia (see below).

We now come to those problems which can be called non-performance-related.
These are medical disorders which have nothing to do with music making.
Some of these include osteoarthritis, thoracic outlet syndromes and various
kinds of neural impingement or nerve entrapment such as the notorious
Carpal Tunnel Syndrome. Many other diseases such as diabetes, nervous
disorders, alcoholism, tumours (even death!) can also inhibit musical
performance. Naturally, there is no space here to explore these different
maladies. Some of them have to be mentioned, however, since a number of
patients come to the Performing Arts Clinics suffering from these
conditions.

The line between performance-related and non-performance-related syndromes
is sometimes a little blurred because there is often the "wear and tear"
associated with long-term playing on an instrument which can be one of the
contributing factors in bringing some of these diseases about.
Osteoarthritis, is

"...of complex multifactorial origin...(but) repeated petty traumata have
an important role to play in ...(its) genesis" (26)

In one study, the radiographs of the hands of 20 active pianists were
examined and were found to reveal changes of a degenerative nature. These
changes were probably in more or less direct relationship to the mechanism
of piano playing for they were more prominent in the right hand, with the
ring and little fingers the most seriously affected.

Nerve entrapment can be caused by muscle and tendon hypertrophy such as the
rare actual tendonitis resulting from misuse or overuse. However it can
also be caused by diabetes, kidney failure, alcoholism and even
malnutrition. The main symptoms are "paresthesias" which is a term employed
to describe
"spontaneous sensory phenomena such as numbness, tingling, prickling,
burning, coldness and even itching..." (27).

There can also be pain, cramps and loss of strength and dexterity. The pain
is usually aching and occurs when the arm is at rest, as well as when it is
being used. Sometimes changes occur in the appearance and temperature of
the skin. Nerve conduction study and other electrodiagnostic studies are
frequently necessary in diagnosis and in localizing the exact place of
entrapment or compression.

One of three main nerves are usually involved. These are either the Median
nerve, the Ulnar nerve or the Radial nerve. They originate from the
Brachial plexus, which is located in, and slightly above, the arm-pit.
These three nerves ennervate both muscles and skin which means that they
control both motor and sensory functions.

The Median nerve is the one most liable to compression. It rules or
controls some of the flexor muscles of the fore- arm as well as many
muscles in the hand, such as three of the four thumb muscles. It also
creates sensation in the thumb, the index, middle finger and half the ring
finger. The Ulnar nerve is the second most commonly involved in these
maladies. It controls the functions of the other flexor muscles of the
fore-arm, all intrinsic handmuscles not ennervated by the Median nerve and
governs the sensation in the little finger and the other half of the ring
finger. The Radial nerve controls the extensor muscles of the arm and is
the least frequently afflicted of the three.

The most common of all the neuropathies is the Carpal Tunnel Syndrome,
which refers to the entrapment of the median nerve in the wrist. The median
nerve passes through the Carpal Tunnel which is
"bounded by a concave arc of wrist bones below. . . , and a thick
transverse carpal ligament above, joined in this delineated space by nine
flexor tendons" (28).

As stated above, Carpal Tunnel Syndrome, as well as the other nerve
entrapment disorders, can have many causes and performance-related overuse
or misuse may be one of them. The main symptoms of this particular syndrome
are pain in the hand with paresthesias in the thumb, index, middle and ring
fingers. Sometimes however there is the experience of sensory loss. The
disease usually occurs in both hands with the dominant one being more
afflicted.

The most famous case of this syndrome in the field of Performing Arts
Medicine is probably the one affecting Leon Fleischer, whom I mentioned in
the introduction.  His problem was fairly complex, and the numerous medical
practitioners whom he visited were quite baffled by his condition. It was
in many ways similar to the one afflicting Gary Graffman, a focal dystonia
which will be discussed later. Whether the later onset of Carpal Tunnel
Syndrome developed as the result of the dystonia or independently is not
clear.  His right hand became painful yet numb, involuntarily claw-like and
eventually useless for all practical purposes. An operation was performed;
it cured the Carpal Tunnel Syndrome, but left the dystonia unchanged (29).

There is a number of other nerve entrapment syndromes, but these are less
common, and there is no space to mention them here. In any case they are
all purely medical conditions, which a Performing Arts Clinic would refer
to a neurologist, a hand surgeon, or some other specialist.

A lack of coordination is a group of medical problems which affects
performing musicians. In a survey of 1000 ailing musicians, 14 percent had
this affliction, and again the overwhelming majority were pianists (30).
The best known form of the disease is the so called "writer´s cramp"  which
refers to the inappropriate contraction of agonistic and antagonistic
muscles of the hand during writing, thereby making the action difficult or
even impossible. The cramp is usually "task specific", which means that the
hand can perform all other ordinary acts with ease.  Among musicians, the
parallel syndrome is sometimes called  "occupational cramp", but the more
common term is dystonia which means difficulty in (muscle) tone. Another
less common term is dyskinesia, meaning difficulty in movement.

Dystonia is usually divided into three categories, namely generalized,
segmental or focal. The generalized dystonia affects the motor control of
the whole body and the segmental one usually involves two or more adjoining
body-parts.  Focal dystonia, on the other hand, refers to the lack of
control over only one specific portion of the body, such as a particular
muscle.
"The presentation is characteristic: patients report incoordination while
playing, frequently accompanied by involuntary curling or extension of
fingers during passages of music that emphasize rapid, forceful finger
movements. Facial muscles may be involved, with a resulting loss of
embouchure or air seal. The problem...once established, evolves very
slowly, if at all, over a period of many years" (31).


The most common type of dystonia among pianists is that illustrated by the
case of Elisabeth. Both Gary Graffman and Leon Fleisher suffered from it,
also; a failure of the ring and little fingers to extend properly, such as
in the playing of octaves. These fingers have the tendency to droop, or
even to curl or flex involuntarilyinto the palm while playing.

The causes of dystonia have been the subject of much debate as to whether
it is purely a physical disease or a psychiatric condition.  Certainly, the
numerous synonyms for this malady, such as professional neurosis,
professional impotence, occupational spasms, occupational neurosis,
occupational palsies and craft palsies, reflect the many different views on
its nature and cause. In one study of 34 patients suffering from
occupational cramps, there was a "remarkably low incidence of psychiatric
disability" during the onset of the condition, thereby suggesting that
dystonia is indeed of organic origin (32). Ten percent of patients
suffering from writer´s cramp report previous hand injury, suggesting that
trauma may be a causal factor in dystonia (33). In some forms of dystonia,
a genetic basis has been established, and different kinds of dystonia have
been found in
several members of the same family (34).

However, in J. Walton´s  "Brain´s Diseases of the Nervous System", which is
in current use and is a much-respected textbook of neurology, writer´s
cramp and other similar disorders are classified as psychogenic diseases
(35). Generally, no physiological, biochemical or structural abnormalities
have been identified in association with dystonia, and this has led many to
favour the psychogenic hypothesis. Dr Ian James reports some success by
using anti-depressants in the attempt to cure this condition, suggesting
the above (36).  Perhaps there are a number of causes, psychological and/or
physical.

Fairly often, dystonia seems to be stress related. Dr Wynn-Parry, whom I
cited earlier, finds that its onset is often caused by great pressure from
more and more professional asignments. The patient is never at ease, never
relaxed, and eventually the control mechanism of the brain becomes
exhausted and seems simply to refuse to go on. The problem then begins with
motor control disturbances of the weak spot in the playing of the
instrument in question, such as the fourth and fifth fingers of pianists.

There has also been some speculation as to whether dystonia is caused by
some kind of technical faults. As I have tried to show, there is a
relationship between tension and bad technique. The chronic stress and
anxiety mentioned by Dr. Wynn Parry may result in tense and even awkward
movements of the hand and/or arm so that the musician is playing in an
increasingly forced manner.  Repeatedly, one may be liable to unwittingly
contract inappropriate muscles while performing a certain gesture, and this
tendency can develop into a habit. Since the movement is unnatural, fatigue
sets in, the desired task becomes more and more difficult and finally quite
impossible.

As should now be clear, Performing Arts Medicine is quite complex. The
problems are not always as simple as they seem; there is more to overuse
than meets the eye. There may be many different causes which are not
apparent on the surface. A successful musical profession is built out of
many elements, and various factors can go wrong. Various types of treatment
are therefore needed. The advantages of a multi-disciplinary clinic seem
obvious, since the doctor needs to be able to discuss his findings with,
and perhaps refer to,  professional musicians, psychologists and other
therapists. In the subsequent chapters, the more common methods
of treatment will be explored.

------------------------------------------------------

Chapter 2
Treating the Body

For the majority of musicians suffering from the problems which I have
attempted to describe, the chances of recovery are generally good. Surgery
is rarely indicated, except in the cases of nerve entrapment where it may
be the only effective treatment. Overuse or misuse disorders are those most
likely to respond successfully to therapy which includes rest as the basic
feature (or at least reduced playing time, in the case of less severe
problems).

Some doctors, however caution against resting. Very often, pain can be more
psychological than physical and the cure has nothing to do with rest. If
the technique or posture is faulty and this is corrected, the pain will go
away very soon. But if rest is  necessary, splinting is frequently needed
for the muscles and tendons to recover. Sometimes, this is coupled with the
use of ice, as in ice massage, to further aid the healing process.
Frequently, the local injection of certain anti-inflammatory agents may be
needed.

Since the vascularity of the tendons is low, recovery can take quite some
time, or up to eight months or even longer in the case of more serious
injuries. The involved muscles tend to atrophy if the patient has to
abstain from playing for such a long time.  A necessary part of the
treatment will therefore often include the rebuilding of the weak muscles,
sometimes accompanied by fairly intense and regular massage.

In the first chapter I mentioned the successful use of anti-depressants in
some cases of dystonia. A paper entitled "Medicine and the Performing Arts,
the Stage Fright Syndrome", Dr Ian James, presents a case history which
illustrates the successful treatment of dystonia by the use of a drug
called
Bromocriptine (37). It is a drug which is given to those who suffer from
Parkinson´s disease. However here is another controversy, for Dr Alan H.
Lockwood, writing in The New England Journal of Medicine states:
"Other forms of therapy have been used, including treatment with steroids,
diazepam, propranolol, bromocriptine,  tetrabenazine, and tricyclic
antidepressants, psychotherapy, biofeedback, muscle retraining, and
surgery, with uniformly disappointing results" (Italics mine) (38).

There have also been some experiments with the injection of Botullinum
toxin  into the affected muscle, with at least temporary benefits.

One of the imperatives in the treatment of these maladies is to look into
the possible causes in order to minimize the ever-present risk of
recurrence.
I keep mentioning bad habits of posture and hand use. Apart from
physiotherapy there are specific techniques that deal with these
conditions, especially the Alexander Technique, the Feldenkrais Method and
Yoga. Then there are persons who are sometimes called "piano therapists".
These are professional pianists with a special understanding of how poorly
coordinated body-use can contribute to injuries. Carola Grindea is one and
there are others as well.

The first thing Michael´s doctor instructed him to do was to take a lot of
pills. These included muscle relaxants, anti-inflammatory drugs and pain
killers. His arms felt so bad that he could not even do physiotherapy. The
pills produced no improvement, so Michael went to see one of the doctors
who runs a Performing Arts Clinic in London. There he was injected with
steroids, which are often used to combat inflammation. However, there was
still no improvement. By then four months had passed, and Michael was
becoming pretty desperate. What could he do? He was willing to try
anything.

Josephine went to the same doctor who made her wear tight straps around her
forearms. But this did not do any good either. So she went to another
authority in the field. This doctor told her it was all nonsense; her
problem only seemed physical, but in actual fact it was not. So he referred
her to a counsellor.

Elisabeth, on the other hand, was sent to a neurologist. He gave her a drug
called benzhexol which is supposed to
"produce modest improvements in tremor, rigidity. . . muscular stiffness
and leg cramps" (39).
However, these improvements were far too modest and Elisabeth decided to go
elsewhere. She saw the same doctor who had initially treated both Josephine
and Michael. He found some muscle wastage at the base of both her thumbs,
and recommended physiotherapy.

Physiotherapy can be quite effective with performance-related cases, at
least in the initial stages. It is also often attempted with the
coordination problems. Most physiotherapists examine the body of the
patient when he is playing the instrument in order to see which postural
errors or technical faults may be causing the pain or the lack of dexterity
which the patient complainsabout. In some clinics, the process is even
aided by the help of a video camera so that the musician can himself study
his mode of playing.

The spine is checked as well as how the arms, wrists and hands are used.
Very often, the neck is found to be stiff and the shoulders almost
constantly raised, which naturally throws off the balance of the arm. Also,
the back is frequently curved forwards and there is a general excess of
tension which by this stage has become chronic. Here, a specialist musician
may aid the physiotherapist in locating an error in technique which may be
causing the problem, since he has the understanding and experience of how
subtly unnatural movements of the arms, wrists and fingers can cause
difficulties.

Whatever the fault, the physiotherapy will start with a massage of the soft
tissues involved. This is extremely important because, as mentioned
earlier, there usually is a chronic tightness in the painful area and the
muscles have to be loosened up if there is to be any improvement.
Frequently, a kneading type of massage is used. Another form of massage, a
so-called trigger-point massage, can also be quite effective. The
trigger-points are the soft spots or areas in the muscle where the maximum
pain is located. If one can relax this painful spot the whole muscle will
be relieved of its tension. A healthy muscle should naturally be soft when
it is relaxed. Additionally, certain stretches are frequently very useful,
because the tension has usually led to the shortening of the muscles as
well.

At first, it is very important not to proceed too brusquely. Usually the
suffering musician is extremely anxious about the whole issue, and needs
constant reassurance. Elisabeth had a fit of anxiety and did not sleep for
a whole night after having had her first treatment. The reason was that,
during the session, the physiotherapist exclaimed despairingly: "You have
so many problems that I don´t know where to begin!" By this he meant, in
addition to the muscle wastage, tensions which seemed to afflict most of
her body. She also tended to curve her back while she played.

Elisabeth found the physiotherapist´s massage too harsh and went to another
who was far gentler. He started the healing with soft massage, then some
postural reeducation, and she was given a few simple exercises to practise.
These included various stretches for the arm, and some gentle selfmassage.
She was also instructed to do relaxation exercises.

Physiotherapists often use modalities like ultra-sound, laser and an
electronic equipment called the Interferential. I would like to touch
briefly upon some of these aids as they are frequently used in the
treatment of
"work-related upper limb disorders". It must be emphasized however that
these items do not work any miracles, but are rather supposed to stimulate
the body´s own natural healing processes.

Ultra-sound is used to break down excess scar tissue. Scar tissue is not
soft like ordinary skin or muscle and consequently does not stretch easily.
Therefore, this procedure may be needed, because when the body has had an
injury, the resultant scar, which is frequently far larger than is actually
necessary, can be quite uncomfortable and even immobilizing.

Interferential is an equipment which has four electrical pads attached to
it. A pair of these pads is placed on the opposite sides of the affected
limb, the electicity is then turned on and each pad emits a current of
different intensity. This is no shock treatment, so the currents are quite
low. However, they interfere with each other inside the arm or other
relevant body part-hence the name-and thereby create a field of sufficient
intensity to stimulate the tissues to reabsorb fluids created from
swellings. Here we come upon the inflammation controversy again; needless
to say, these swellings are in most cases invisible to the naked eye.

The lasers which are used in physiotherapy are soft lasers unlike those
which are employed in surgery. They create certain chemical changes or
reactions in the body which attract more white and red blood cells into the
area. The white blood cells clear away the debris from the injury and the
red blood cells bring in more oxygen to aid the healing.

I myself once injured my right little finger. This happened while I was
working on a very difficult piece of music which demanded, among other
things, loudly played chords with a very clearly heard melody at the top.
At the time I got the idea that my little finger, which plays the melody,
was not strong enough so I decided to strengthen it with some exercises
which I myself had invented. Then the disaster happened. I felt pain at the
tip of the finger each time I pressed it down. This worried me more and
more because, even though I took three weeks off practising, the finger did
not heal. Finally I went to a doctor who often employed some of those
processes which I have just mentioned. She used a laser on me which did the
trick and I had no more problems with my finger. But I had the wisdom to
dump my finger exercise, and have not done it since. . . (40).

The muscles which need to be strong are the muscles of the hand and of the
forearm, since both groups of muscles govern the movement of the fingers.
Previously, I mentioned that the muscles tend to weaken with the prolonged
rest which is often recommended as part of the treatment. A recent
invention to prevent this happening is called the Rosedale Web and is a
lattice of rubber bands inside a metal circle approximately one and a half
feet in diameter.  The fingers are placed inside the web and a great
variety of muscle strengthening exercises can be performed. To quote an
example:
"1. Place your fingers into the grid in a wide open grip and open and close
them, so that your fingers and thumbs touch...2. Insert your fingers into
the centre grid close together then expand your fingers outwards using your
free hand to assist the movement where necessary. When you have improved
enough you can also insert two or
more fingers into a single aperture and then expand." (41).

All of the above is often helpful in the treatment of performance-related
problems. Elisabeth, however, did not find her cure there. She did feel
better in a general sort of way, but her hand problem remained. So she
decided to try the Feldenkrais Method. This is a type of treatment which is
increasingly recommended for those who suffer from dystonia or coordination
problems. Dr. Ian James thinks highly of it, and has said on several
occasions that he knows of many cases which have been cured by the
Feldenkrais Method alone. Dr. Wynn Parry agrees and recommends it also.

The Feldenkrais Method is concerned with developing awareness of movement,
how one performs a certain gesture and how one can perform it in many
different ways. When someone has lost the coordination of a certain muscle,
or injured it by "unnatural" way of using it, the brain and the nervous
system often need to be reeducated so that the patient will relearn how to
do that which has become difficult or impossible.

However, changing a habit is usually far from easy, as anyone who has had
to change his technique has experienced. The Feldenkrais Method seems to
have found the conditions which can accelerate the learning and relearning
of various motor skills. Basically, this is done through feeling and
awareness. As they say in the Feldenkrais Method, a fool cannot feel. . .
It is very important to learn to differentiate through feeling between the
various parts of the body. Anat Baniel, who is an internationally renowned
teacher of the method, describes the process in the following words:
"...each skill (that) we aquire is based on prior skills and has a
developmental order to it. So for a musician to acquire movement skills, we
intentionally
create conditions for certain differentiations to happen. For instance,
someone starting to play a violin doesn´t know anything about it, including
how to hold it. Initially, he has to start with the very first
differentiations which allow him the first step, then the second and third
and so on. In the Feldenkrais Method, there is a very detailed
understanding of which movement ingredients need to come before other
movement ingredients can be introduced. So when we work with a musician,
beginner or professional, we see which elements are not available or
haven´t been differentiated and integrated into the desired skill. We help
the person learn those details that gradually integrate and create a more
evolved system." (42).

The method tries to use a very natural approach to learning. In many ways
it imitates the infant and how it gradually learns how to stand, walk and
so forth. The baby carries out an almost endless and seemingly irrelevant
variations of crawling, rolling, moving the head, etc. In this way it
explores new movements and slowly achieves a full coordination of the body.
In the Feldenkrais Method the learning process also contains many
variations of movement and action which at first may seem unrelated to
whatever the eventual goal of the treatment may be. The reason is that each
variation includes an element of differentiation that is important in one
way or another for the eventual regaining of the lost or reduced
coordination. Differentiation and integration are the basics of learning.

The Feldenkrais Method is concerned with self-improvement, both
psychologically and in physical posture and coordination. It recognizes the
wholeness of man and that all human activity consists of feeling, thought,
sensation and movement. By feeling is meant such  emotions as joy, anger,
self-respect and inferiority. Thought includes all intellectual functions
such as analysis, classification, imagination and so forth. Sensation
refers of course to the five senses as well as the kinesthetic sense of
space orientation and the passage of time. And finally, movement includes
all possible changes in the position and state of the body, whether it be
speaking, breathing, walking or circulating the blood.

According to Feldenkrais, any one of these factors interacts with, and
influences the others in the waking state at all times. The emotions
especially influence the state and action of the muscles. One is often only
dully aware of what feelings are inside until they express themselves in
some form of muscular activity such as laughter, clenched fists, changed
breathing etc. The process apparently is reversible. Consequently work
upon, and the correction of, physical movements is an effective way towards
emotional equilibrium and general self betterment.

Feldenkrais reasons:
"Movement occupies the nervous system more than anything else because we
cannot sense, feel, or think without a many-sided and elaborate series of
actions initiated by the brain to maintain the body against the pull of
gravity. . . We know more clearly and certainly about the organization of
the body against the pull of gravity than we do about the other components
(feeling, thought and sensation). . . A person´s physical build and his
ability to move are probably more important to his self-image than anything
else. . . the muscular pattern of the upright position, facial expression,
and voice reflect the condition of the nervous system." (43).

Therefore the condition of dystonia - difficulties in motor control - may
reflect some form of psychological malaise. I interviewed Roselyn Walters,
a practising Feldenkrais teacher, who takes referrals from doctors
specialising in Performing Arts Medicine. Mrs. Walters is of the opinion
that these problems occur more often than not to people who are liable to
depression and anxiety, usually caused by working under too much pressure
or by trying too hard to achieve or succeed in one area or another.

In the first chapter I mentioned the controversies surrounding the issue of
dystonia and that it may in some cases be caused by faulty, stress-related
habits at the instrument. Many piano teachers seem to share this attitude.
It is possible that a continuously anxious performer can play in this
forced manner for a long time without noticing any difficulty. Then
something happens which creates increased anxiety and/or depression. This
causes the weak link in the chain to break and suddenly one has no longer
the strength to keep on forcing that which in any case was never natural.
The victim then begins to notice the difficulty. But due to the sufferer´s
focussing upon it, and becoming conscious of something which had hitherto
been more or less unconscious, the problem only gets worse. It is then
necessary to become aware of tensions and discomforts which perhaps are due
to emotional problems, and learn to differentiate between those muscles
which should act and those muscles which should be relaxed.

I have previously referred to writer´s cramp as the best known form of
focal dystonia, consisting of the simultaneous contraction of agonistic and
antagonistic muscles during the act of writing. The conscious
differentiation between those muscles has become considerably distorted
and, in view of the above, it should be obvious how therapeutic the
Feldenkrais Method can be.

The work is usually done in groups, but lessons can also be given on a
one-to one basis. Each session usually lasts from 45 minutes to an hour.
Anat Baniel, whom I quoted above, teaches the Feldenkrais Method at the
Tanglewood Music Centre in the USA. Leon Fleischer, no stranger to the
subject of this thesis, is the artistic director of the centre and has a
high regard for the method. He said that before its inclusion in the
curriculum there was usually
"a small army of musicians who´d have overuse or practice-related injuries,
whereas last summer(1989) there was only one." (44).


The movements carried out during the lessons are exploratory rather than
goal oriented. The only goal is to experiment and explore many different
ways of doing things, whether it feels good or bad etc. As Anat Baniel
describes it:
"Each lesson is different from other lessons so the student does not fall
into automatic, habitual patterns of movement. The lessons are designed to
be interesting, fun, and absorbing for the student. They are created to
match the student´s level of ability so that the student is taken from his
or her existing level of skill to the next possible level." (45).

All movements are done very slowly and only a few times. More often than
not they are done when lying down. The reason for this is that when one is
in the upright position, a lot of the brain's work is concerned with the
direction of the muscles maintain balance. So when one is put flat on the
floor, the brain is more open to learning, because the nervous system does
not have to occupy itself with reactions to gravity. The nervous system
frequently does not recognize the most familiar movements, if these same
movements have been done previously in a more demanding position. So
habitual actions are suddenly strange and new. Therefore it is easier to
trick the brain, as it were, into learning new movements or changing old
ones when lying down. According to Roselyn Walters, when one is
reorganizing one´s technique, one should actually practise some of the new
movements in this way, then the nervous system will be quicker to pick up
the unfamiliar way of playing.

There have been cases when a pianist could not do certain movements on the
keyboard when sitting in front of it, but could execute those very same
passages when standing. This can be explained by what I said previously
about the developmental order of learning when playing an instrument. One´s
technique is based on a ladder of finer and finer differentiations. The
aspiring pianist starts with those which are necessary: to learn how to sit
in front of the piano, then  how to hold the arms and hands, then how to
move the fingers, etc., etc. The first habit learnt, i.e. that of sitting,
influences the second habit, the second habit affects the third and so on.
Therefore, when one stands or even lies in front of the instrument, one is
altering the very fundamentals, and is not bound by the chains of past
conditioning.

Elisabeth seems at last to be finding the solution to her long-standing
dystonia. When I last interviewed her, she had had twelve individual
lessons. At first, her teacher helped her to go through some basic
movements which  all students explore. Then they began to focus on her
hands. They discovered that Elisabeth was not differentiating enough
between the muscles of the thumb and those of the fourth and fifth fingers.
The thumb was not working properly, and she was "helping" it by
involuntarily contracting these other fingers. I mentioned that one of the
doctors found muscle wastage at the base of both her thumbs. This does not
sound strange in view of the above. She is now working on her thumbs and
trying to develop their strength and independence. She has found some
improvement already at the piano and is hopeful about the future.

None of my three cases has had any Alexander lessons. Yet it is a
time-tested method. In England there are 700 people registered as members
of the Society of Alexander Teachers (46). It is often recommended by
doctors, especially to those who suffer from performance-related disorders
which have originated in postural defects. Serious injuries cannot be
treated in this way, however, because the effects of the Alexander
Technique are quite slow. So the technique is more effective with those who
suffer from minor back aches, shoulder pains, stiff neck, etc., which are
fairly common among pianists.  Certainly, someone who has fully
incorporated the technique into daily life will experience a greater degree
of comfort and ease in all physical activities.

Basically, the technique is concerned with the body´s reactions to gravity.
The fundamental theory has been summed up in the following words:
"1. The reflex response of the organism to gravity is a fundamental
feedback mechanism which integrates other reflex systems.
2. Under civililized conditions this mechanism is commonly interfered with
by habitual, learned responses which disturb the tonic relation between
head, neck and trunk.
3. When this interference is perceived kinesthetically it can be inhibited.
By this means the antigravity response is facilitated and its integrative
effevt on the organism is restored." (47).

I have previously discussed the relationship between the voluntary and
involuntary nervous systems when discussing what characterizes bad posture.
There I described it as a constant battle against the forces of gravity
instead of utilizing or "flowing with" it. The tonic relation between the
head, neck and trunk, which is mentioned in the citation above, is termed
the Primary Control, and the state of it affects the quality of our
functioning as a whole. If the back is straight and the neck is free with
the head lightly balanced on the spine, the body is more harmonized and one
needs less effort in maintaining equilibrium. Thus the anti-gravity
response is minimized. Unfortunately, there is a strong tendency in most
people to curve the back, resulting in the head being tilted backwards.
Consequently various muscular tensions are created to maintain the balance
of the body. This downward pull of the body also results in a shortening of
the back of the neck, and this of course affects the neck muscles.

The freedom of the neck muscles seems to be extremely important for the
coordination of the body. This is for more than one reason. For one, they
contain far more muscle spindles than does the rest of the muscular system.
These spindles are receptors which send messages to the brain, telling it
how much the muscle is shortening or lengthening and how quickly. In
physiology these receptors are called proprioceptors, from Latin proprius,
meaning one´s own. Experiments have been carried out where anaesthetics
were injected into the neck muscles of animals, resulting in total numbness
in the area. As a result of simply having no feeling in the neck, and
thereby having no knowledge of the exact degree of the contraction of these
muscles, the animals lost much of their coordination. The following is
quoted from a description of an experiment with monkeys:
"...(they) staggered when they tried to walk, they had poor localization of
points in space so that they would miss when trying to pick up morsels of
food. They had difficulty in climbing tasks and missed grasping points..."
(48).
The same only happens with the surgical disconnection of the cerebellum,
the part of the brain which governs muscular coordination.

To further illustrate the importance of the neck muscles, I would like to
mention a colleague of mine, a pianist who developed a problem which was
characterized by a feeling of vertigo while performing on stage. He did not
have any Alexander lessons, but went to a physiotherapist instead. The
physiotherapist diagnosed the problem as an immense tension in the neck
which was actually restraining the normal flow of blood to the brain. By
regular sessions of massage and by consciously relaxing the neck muscles,
especially while playing the piano, his problem was eventually solved.

The Alexander Technique recognizes the importance of the neck and aims at
freeing it. This is done by moving the head slightly forwards and upwards;
in this way the above-mentioned shortening of the neck is avoided. The back
must be straight and, when bending it, the movement must come from the hip
joints without curving the spine. Arthur Rubinstein is often pointed at by
Alexander teachers as being the one pianist who never needed Alexander
lessons. Bill Benham, who is a teacher of the Alexander Technique at the
Performing Arts Clinic founded by Carola Grindea, told me in an interview
that he had once seen Rubinstein in a concert. His posture had impressed
him very much because he always played with his back straight. Once, he had
almost stood up from the chair to let the entire weight of his body fall,
as it were, upon the keys, playing very loudly, yet with perfect ease and
lack of effort.

Apart from acquiring better posture and improved body mechanics, students
of the technique have also reported increased calm and confidence, relief
from insomnia and a greater ability to concentrate (49). The technique is
not directly related to performance. Therefore, an Alexander teacher
helping a pianist need not be a pianist himself. The focus is on a better
general use of the body and a more coordinated function of the primary
control. This results in an improvement of all functions of daily life,
including playing the piano.

The basic steps of the Alexander Technique have been summed up in the
following words:
"1. Learning to stop one´s usual reactions-not through suppression, but
rather through a conscious refusal of allowing them to take place.
Alexander called this the "inhibition of habitual reaction";
"2. giving conscious mental directions to bring about the most balanced
state in the "primary control" of our total coordination...
"3. proceeding with any required activity while maintaining  this
consciously directed condition." (50).

The Alexander lesson has been compared to a "hands on" alternative or
spiritual healing session. The teacher uses a special touch with the hands
to harmonize the primary control in the student, thus "giving" the sensory
experience of a correct posture and movement instead of teaching it
verbally. Positive approach is considered very important; instead of
focussing on what has gone wrong, the student is made to concentrate on the
body as it should be, both with the help of the teacher´s hands and also
with the use of mental affirmations and suggestions such as "head forward
and up!". This is similar to when music teachers urge their pupils to first
study a passage and then practise it slowly. The importance lies in always
playing correctly and gradually increasing the tempo, instead of practising
fast and reinforcing one´s errors and wrong notes.

Lessons are usually private. A very important part of them involves the use
of a chair. The teacher uses his or her hands and words to help the student
get into, sit in, and arise from an ordinary chair without curving the
back, shortening the neck or losing  the balance of the head. Naturally,
changing such basic habits as how one rises from a chair is actually quite
difficult and takes a long time to integrate completely. The same applies
to the playing of an instrument; it is  even more difficult because playing
is a trained reflex. Therefore Alexander himself, the founder of the
method, insisted on seeing his pupils three times a week. In modern times,
this is often difficult and Bill Benham, whom I cited above, is of the
opinion that many people do not get what they should from the lessons
simply because they do not have enough of them. The Alexander Technique is
a way of life, and should ideally be taught from an early age. This has
been successfully attempted in certain schools, such as the Purcell School,
Wells Cathedral School and the Junior Department of the Royal College (51).
The technique will not make anyone play wonderfully, but it will help to
ensure that many of the misuses which lead to performance-related disorders
will not occur.

Another technique which is often recommended to those who suffer from
postural-related problems is Yoga. Yoga usually refers to a complex set of
physical exercises which are termed "asanas"-asana  being the Sanskrit word
for posture. Unlike the Alexander Technique, which can be called "active
continuous", Yoga could be called "active intermittent". In other words,
Yoga involves the adoption and maintenance of certain anti-gravity postures
during fairly brief sessions on a regular basis. The Alexander Technique on
the other hand requires the conscious use of the muscles in new ways
throughout the day.

Many of the Yoga exercises can be very helpful in correcting bad posture.
When practising  the asanas, great emphasis is usually placed on a straight
back and a balanced head position. One exercise in particular has been
recommended for the back by Dr Mossaraf Ali who is on the advisory board of
the Performing Arts Clinic at the London College of Music. This asana has
been termed "The Cobra" and is performed in the following manner: one lies
flat, facing forward  with the palms placed on the floor beneath the
shoulders. The head and the upper torso are then raised in an arc as high
up in the air as possible and this position maintained for some time. It is
absolutely essential to use the back muscles and not those of the arm when
performing this difficult stunt. As a result of regular practice the back
muscles are strengthened, and any forward curvature of the spine that one
might have grown accustomed to corrects itself automatically with time.

Another facet of Yoga is meditation. Meditation actually seems to be a term
covering an unimaginably wide variety of mental activities, but in all
cases some psychological benefits are promised to the practitioner. In
Yoga, meditation is always carried out in an upright sitting position with
the spine as straight as possible. Sometimes this is done in an asana
called the lotus position, which requires legs made of rubber instead of
muscles and bones. There is a mystical reason to the straight spine:
according to Yogic theory there is a secret channel inside the spine which
connects a certain esoteric power zone in the pelvis to the brain. The more
ambitious Yoga practitioner hopes to release the cosmic energy in the
pelvis and to direct it upwards along the channel to the head. This can
only happen if the energy is not obstructed on the way by any unnatural
curvature in the back. If all is right, then the lucky person is able to
see angels and behold the face of God in a light-show something akin to a
Pink Floyd concert. Be this as it may, Yoga can certainly be very helpful
and has in many cases been recommended by doctors when dealing with
postural-related problems.

Relaxation is an essential factor in Yoga. There usually is a relaxation
exercise at the end of each session of asanas. In addition to this, it is
very important when performing each exercise to relax as completely as
possible all those muscles which are not involved, which is somewhat
reminiscent of the differentiation which lies at the heart of the
Feldenkrais technique. Consequently, one develops an awareness of tension
in areas which should be relaxed when performing a certain task. A Yoga
practitioner can carry this awareness to the piano and benefit
considerably.

Michael did not try any of the methods described above. Instead, he went to
a faith healer. A number of various types of alternative medicine exist
today. Most of these approaches are based on the belief that the mind
influences the body to a greater extent than one would suspect. In fact,
the body is often seen as a mirror image of the psyche, and what goes wrong
"inside" is reflected in physical disorders "outside".

Some  doctors agree up to a point. Recently, a book entitled "The Healing
Brain" appeared on the subject by David Sobel, a physician, and Robert
Ornstein who is a professor of Neurobiology at Stanford University. They
maintain that western medicine has for too long separated body and mind,
and that the brain itself "minds the body" (52). The belief in the aid of a
supernatural force can also be very powerful and, in any case, believing or
not believing in whatever treatment one receives significantly affects the
outcome. "Faith moves mountains" is an old saying, and the following
account illustrates this truth quite beautifully:
"Religious fervour temporarily gripped Guatemala City recently when, after
a rainstorm, the face of Jesus Christ (or what he is believed to have
looked like) appeared on the wall of a church; prayers were offered and
miraculous cures were reported. More rain made the face clearer until it
was recognised to be that of Willie Nelson, a country and western singer
whose picture had been stuck to the wall and the painters who redecorated
the church wall had painted over it." (53).

Michael had only one session with the faith healer. She did not seem to do
anything; they only sat together in a room and closed their eyes.
Nonetheless, Michael suddenly felt cured. He went back home and played the
piano without any pain whatsoever. Subsequently he told his story to the
doctor who had unsuccessfully tried to treat him. But the doctor refused to
believe it. He maintained that the anti-inflammatory drugs which he had
given to him some time earlier had-a bit belatedly-effected the cure, not
the faith healer.

Another doctor thought differently. Michael was in fact cured before he
went to the faith healer, only he did not know it! The pain and the
inability to play the piano were so firmly engraved in Michael´s mind that
the symptoms existed long after the injury had healed.  Something
extraordinary was needed to dispel this negative image, and the faith
healer did that in an admirable way.

Just before Michael had his miraculous cure he had his piano technique
examined by a well known piano teacher. She pointed a few things out to
him. He was not using his arms very freely. But was this the result of the
injury, or was the injury result of his way of playing? Michael did not
remember exactly how he positioned his arms at the piano before his
problems started. He had never given it a thought; he just played. Some
"errors" in technique which piano therapists point out may actually be the
result  of the injury or the dystonia. The pianist may be trying to play
despite the disability and this may result in some very awkward movements.
The piano therapist notices the strangeness of it all and believes that
this weird use of the body is the cause of the problem. An attempt is
consequently made to correct the fault, but the fault is only one of the
symptoms, not the main problem.

But in the case of definite misuse injury and/or pain, it is important that
the sufferer´s technique be re-examined. If this is not done, the same or
similar problem may recur with resumed playing. However, as I stated
earlier, it is difficult to change one´s habits. Also, the unfortunate
"misuser" usually does not realize where the error lies and needs help in
spotting the culprit.

I would like to mention one person in London who deals with most types of
musicians. This is Mrs. Jean Gibson who has an excellent reputation. Both
Mrs Gibson and Carola Grindea take referrals from doctors. I have
interviewed Mrs Grindea and Mr Peter Feuchtwanger, an internationally famed
piano teacher, and they agree that gentleness, not force, which is harmful,
is essential in building up a healthy technique. Relaxation is imperative.
Excessive tension seems to be a plague among musicians. According to Mrs
Grindea, every case which she has examined at the Performing Arts Clinic is
guilty of either stooping shoulders, tense wrists, tense arms, tense neck
or similar error. I have quoted Dr Wynn Parry who says that one should be
able to play for endless hours without injury if it is done correctly and
without strain. This opinion is shared by both Mrs Grindea and Mr
Feuchtwanger. So the issue is how to play the piano without tension. The
ability to release the tension and maintain the relaxation of those muscles
which are not in use is the basis of a healthy way of playing the piano.

There is a special relaxation method which has many similarities to the
Alexander Technique. It has been found very useful, especially just before
a performance. It can also be quite effective when dealing with the
stresses and strains of daily living. It takes only a minute and can be
practised several times, daily. It is called the Grindea Technique because
it is the invention of Mrs. Grindea. Every patient who comes to the
Performing Arts Clinic is made to do this little exercise.

The exercise is performed in a standing position in the following manner:
First the musician is asked to "allow the spine to lengthen". In other
words, the back is gently straightened without any effort. This
automatically seems to liberate tensions at the back of the neck and be
conducive to a balanced head position. After this has been achieved, the
musician exhales loudly and slowly by uttering the syllable "Ha". This
relaxes the diaphragm area and there are certain physical changes which
become apparent. The shoulders, for instance, relax and the musician
generally feels very comfortable. After this complete exhalation, the body
also inhales differently. The inhalation is complete and full, and this is
very necessary when dealing with tension. The breathing must become regular
and deep, because in all states of stress it is shallow and irregular.

The relaxation is made complete by the third step which is "liberating the
whole body through the loosening of the ankles". One simply orders the
ankles to become very supple and flexible, and this final gesture releases
all the remaining tensions in the body. It becomes light and there is an
exhilarating sensation of floating.

This is a very easy exercise. The difficulty lies in carrying the
relaxation to the piano and maintaining this wonderful state during playing
and practising. Fortunately there is no need to tense up in order to
embrace and hold the piano as one does with a violin or a wind instrument.
The piano is much more detached from the body, therefore the only important
thing is that the body of the pianist be in a state of balance.

One should sit on the front half of the chair or stool in order to be able
to utilize the force of gravity. The gravity should be pulling the front
half of the body; in that way one is able to let the weight of it create
those effortless Rubinsteinian fortissimos which I mentioned earlier. On
the other hand, if one sits on the whole of the chair, the centre of
gravity is altered and one is much less able to let these fantastic bombs
drop on the keyboard. Mrs. Grindea believes in the sitting position
depicted in the ancient Egyptian paintings of the Pharoes and gods. The
chin is basically at right angles to the neck, and the back at right angles
to the keyboard and floor.

According to most piano teachers, one of the fundamental issues in piano
playing is how one uses the arm weight. The arm is very important in tone
production and in the creation of great sonorities and fortissimos. When
the shoulders are relaxed, there is automatically more arm weight resting
on the hands and fingers. And when the arms are relaxed, there is a
wonderful sensation of having no arms at all! At that moment, the arms are
in a state of balance and this is a prerequisite for a healthy technique.

The shoulders should not move forwards when the arms are raised and the
hands placed on the piano. This however is a common fault and inhibits the
agility of the arm. All movement of the elbow is thus considerably
inhibited, and movements such as passing over the thumb are rendered more
difficult. Of course, one should not pass over the thumb by raising the
elbow but rather by letting go of the thumb after it has depressed the
required note. With a correct hand position, that is, with the wrist
slightly outwards and the back of the hand as horizontal as possible, the
fourth or the third fingers are then in a comfortable position to continue
the passage, descending with the right and ascending with the left. I am
describing pure finger technique and yet, a very slight movement of the
elbow is absolutely necessary in this task. This is one reason why a
balanced shoulder and a relaxed, agile arm is of fundamental importance. It
facilitates the movements of the fingers.

A very common error according to Mr Feuchtwanger, is when the hand, instead
of being completely horizontal on the keyboard, is allowed to tilt towards
the little finger. This might seem more natural, however, since the anatomy
of the body makes for a vertical position of the hands when the arms are
completely relaxed.

I have come across a school of playing which is based on this fact. It is
the brainchild of a certain Monique Deschausées who teaches in Paris,
Canada and Spain. She maintains that the arm must be as relaxed as
possible, and the completely horizontal hand position mentioned above makes
for undue tension. However, if the hand is allowed the more natural
position, then the weight of the arm and upper torso rests obviously more
on the little finger than the others. Poor little finger! Being the weakest
of the five, this is hardly fair. But then Mrs Deschaussées has a
countermove.  This involves exercises designed to strengthen the fingers,
especially the little one. After some months of practice, the finger will
be bulging with strength and able to support the arm and torso, both
weighing I don´t know how many kilograms. Peter Feuchtwanger protests: "How
can you strengthen the fingers? There are no muscles in the fingers, only
tendons. Therefore the fingers cannot be strengthened."

A school of piano playing should be based on sound scientific knowledge. To
quote Raoul Tubiana, M.D., and Philippe Chamagne, P.T., writing in "Medical
Problems of Performing Artists":
"Instrumental musicians use their hands and arms continuously and, usually,
unconsciously. They adopt positions and develop trick movements to
facilitate their playing without considering the physiologic balance of the
muscles or joint biomechanics. . . Some positions are favorable because
they are physiologically normal. Others are unfavorable and put the
musicians at risk for the development of serious problems." (54).

Peter Feuchtwanger claims to be able to "mould" with certain exercises the
natural relaxed position of the arms. So when the arms hang loose, the
thumbs and not the palms face the sides of the body. This would make the
pianist look like an ape! However it would also guarantee the naturalness
of the horizontal hand position. The arms should in any case not be allowed
to touch the sides of the body when playing. Instead, the elbows should
turn a bit outwards which can be achieved without undue tension.

Michael´s new piano teacher told him that he had the tendency to play with
the arms almost glued to his body. This made his wrists turn inwards
instead of outwards when touching the keyboard. After his cure, the more
relaxed way of using the arms was a new and wonderful sensation to him. He
even claimed that he would never have injured himself if he had played
Petrouchka like that, twelve hours or not!

The suppleness of the wrists is imperative as well. Vovka Ashkenazy recalls
that one of the first thing he learnt from Sulamita Aronovsky at the Royal
Northern College of Music was always to "breathe" with the wrists (55). By
this I mean the constant up and down movement which effectively prevents
tension. Peter Donohoe, the famous British pianist, once consulted Carola
Grindea because he could play all the Chopin études except for one. This
was the Opus 10 no 2 in a-minor which is probably the most difficult and
tiring of them all. No matter how hard he practised, he did not seem to be
able to manage it. Mrs. Grindea gave him the above mentioned trick of
breathing with the wrist, which worked, and Mr Donohoe had no more problems
(56). The same goes for rapid octave passages; a mobile wrist prevents
tension and one is able to play both faster and without fatigue.

Another important factor is minimum movement. Small movements are logically
more effective than large movements. Also, the fingers should not be too
curved. Carola Grindea vehemently maintains that this is the cause of many
cases of dystonia manifested in the involuntary curling of one or more
fingers. Dr Wynn Parry agrees to the point that playing with relatively
flat fingers (not completely flat of course; only to the extent that one is
able to see one´s finger nails when playing) is physiologically more
natural.

Finally, a respect for one´s physical constitution is an obvious factor.
Somebody who is very tiny and with small, fragile hands should not bother
about playing Rachmaninoff´s 3rd piano concerto. He or she should stick to
Scarlatti. . .

The teacher should be something of a counsellor. The pupil must feel that
he is important. This can not happen if the teacher is egocentric,
suffering from a transcendental Messianic complex and delusions of
grandeur.
According to Mr. Feuchtwanger, many of the students of great performers,
like Schnabel or Horowitz, seem pretty much to have been psychologically
destroyed by their awe of the great professor. The teacher should be
patient and not put pressure on the pupil. He should rather let him or her
develop at a pace which is natural to the individual.

However, our culture glorifies youth and age-limited competitions seem to
be the only path to a career. Everybody wants to be famous and to possess
fortune and glory. Therefore, in this rat-race, to use a term frequently
employed by the great Indian philosopher Jiddu Krishnamurti, one is
sometimes bound to forget one´s individual limits. Even if one has the
talent, a demanding solo career takes a lot more than that. A thick skin,
stamina and a certain kind of one-track mind are only some of the qualities
of a concert pianist. Somebody who aims too high for his natural physical
and psychological endowments will have to pay the price, which can often be
an injury or even dystonia. Let me therefore end this chapter by
paraphrasing Beethoven´s famous dictum: "Pianist, know thyself!"

------------------------------------------------------

Chapter 3
Treating the Mind

In the present chapter I will endeavour to explore some of the
psychological illnesses which are either the cause or the result of the
physical problems described previously.

In the first chapter I mentioned that the medical history of those
musicians who sought professional help in Performing Arts clinics most
frequently included illnesses such as manic depression, stress and
alcoholism. These disorders were not always simply a reaction to a physical
injury, but seemed to have been lingering around for quite a while before
the physical trouble started. I will try to show how stress and depression
may be important causal factors, not only in the coordination problems as I
have previously suggested, but also in the performance-related injuries.
Naturally these same injuries often create additional psychological
problems, and therefore a vicious circle of, say depression/stress-injury-
increased depression/stress is formed.

In addition to psychiatrists, there are counsellors who specialise in
treating artists. Later in this chapter I will try to investigate the
methods of this therapy and mention the drugs which both doctors and
psychiatrists frequently use.

The best treatment is holistic. An injury or a focal dystonia can hardly be
treated solely on the couch. However, the counsellor or psychiatrist may be
a significant help in alleviating fear, stress or depression which can
block the performing musician in a variety of ways. As I have mentioned,
highly coordinated muscular activity coupled with stress is very bad for
the muscles and can be conducive to  injury. Therefore, it is necessary to
explore this issue of tension to some extent. Why is it so prevalent in the
music world?

There are many factors involved. Stage fright, concerts and competitions,
changing a teacher, how one is viewed by one´s colleagues, whether one
really wants to be a musician, the low salaries of the music profession and
how to get work after graduation. There are many others as well, and the
list seems endless.

For instance, all my colleagues whom I have questioned on the matter have
had the experience of coming to a new teacher who, during the very first
lesson, shouted angrily: "Mein Gott! Who taught you zhis terrrrible metode
of spieling zhe klavier? Ve vill haf to change everything!" Having to
change habits that have taken years to incorporate is a devastating blow
and can be a source of a great deal of misery. And often the poor student
has to labour through millions of exercises, only in order to change
everything once again as he or she leaves the professor and goes to a new
teacher in Paris, London or New York.

Another factor is the fierce competition in the musical profession, and
also in the music colleges before the commencement of a career. It is very
common to have all sorts of high expectations which, upon arrival in
whatever the college, are not met. One may have been the best pianist in
one´s hometown and cherished the dream that the same would prevail in the
rest of the world. Then suddenly one faces the fact that in the college of
one´s choice one is among equals. So one grits one´s teeth and practises
harder than ever before. After all, one set forth to college with the
determination to become bigger, better and brighter than all other
pianists, so everything is to be sacrificed for that one noble cause. The
trouble is that almost everyone else thinks the same. This is an example of
the rat race. One is not simply involved in a difficult training out of
pure love for music, and indeed that love may be totally forgotten in this
atmosphere of ambition and struggle. The entrance fee to this everlasting
competition is stress and tension. And for the underdogs, who slowly begin
to realize that they "won´t make it" as "big shots", there is depression as
well.

Actually, people often come to music colleges with completely unrealistic
ideas about how it is to be a full-time professional. Martin Lloyd-Elliot
is a counsellor at the Performing Arts Clinic at the London College of
Music. He is amazed how bad career counselling in the colleges seems to be.
People usually have no sound business plans as to how they are going to
earn a living after they leave their teachers. After all, very few people
get rich in the music profession. This has even led many to wonder why
people opt for music at all! One of these is the economist Charles Gray. He
has suggested that
"performing artists must be a pretty peculiar breed; their behaviour does
not seem to make much sense. Why would anyone seek employment in a
profession that pays notoriously low average salaries and entails equally
notorious unemployment and underemployment? Clearly, these people are
behaving in an irrational manner. Or are they?" (57).

This "irrational" choice of a career in music is quite hard for many people
to make, and has often involved serious inner conflicts. Interestingly,
there is evidence that the amount of stress that people suffer from when on
stage is actually affected in some ways by how the musician arrived at his
or her career decision, which in turn is influenced by certain early
inter-personal
relationships. There has been developed an "Identity Status Model" which
groups musicians into categories according to the way they made this
choice. Studies were carried out quite recently at the University of
Michigan School of Music which measured the different amount of "stage
fright, fear of success. . . (and) self-handicapping behaviour. . ."
between each group (58). The musicians were categorized in the following
manner:
"Identity Achieved
When applied to musicians, Identity Achieved individuals seek careers in
music performance but have also tried or thought seriously about other
options. . .Ultimately they have arrived at their choice, perhaps despite
parental objections and, most importantly, are relatively conflictfree.
Identity Foreclosed
Identity Foreclosed individuals, like Identity Achieved, maintain that a
career in music is their goal. However, these people, unlike the Achieved
musicians, never have considered carreer alternatives. Generally, they are
following a career path or life style predetermined by their parents, and
their self-esteem is greatly dependent upon authority figures (which
includes parents, teachers, and audiences).
Identity Moratorium
Identity Moratorium individuals are musicians currently in crisis about
their career plans in the performing arts. Currently undecided and weighing
alternatives, these individuals are considering their talent and potential,
parental objections, and social and economic problems that confront
performing artists.
Identity Diffused
The last category in this paradigm suggests that Identity Diffused
individuals may pursue music professionally because they enjoy music and
the attention performance brings; however, they also feel other professions
can offer satisfaction as well. . . (This reflects) a lack of commitment as
well as a lack of struggle. . ." (59).


Even though these categories are a kind of psychological portrait during a
particular period, the underlying dynamics of each stage are connected to
childhood and adolescent experiences, especially relationship with parents
and family. These are very strong influences in the shaping of career
plans, ego strength or the lack of it, and the degree of stress-related
symptoms. Therefore, there is a connection between high levels of stage
fright and high levels of family pathology. The anxiety generated from
unhealthy family relationship worms its way into the professional lives of
many unfortunate individuals.

The study revealed that Achieved subjects were statistically lower in
performance anxiety than were the Moratorium, Diffused and Foreclosed
subjects. This is not surprising, since the Moratorium individuals are
experiencing a crisis, and the Diffused ones are uncommitted to their
careers. The Achieved and the Foreclosed individuals appear very much alike
in their commitment to the musical profession, but there is a very
important difference. The Foreclosed musicians are motivated mainly by
parental expectations and have a very suppressed individuality. In other
words, their choice of a carreer was never their own and even though they
are listening to their own piano playing, they may not necessarily be
listening to their hearts. This lack of a strong ego makes them higher in
stage fright than the Achieved musicians, because anxiety over the loss of
parental approval and love is often projected to the audience. The Achieved
subjects have, on the other hand, had the courage to work through problems
with family, solved other troublesome issues that often arise in connection
with music, and have eventually found that music, and all that music
implies, is what their life is all about. They have arrived at knowing
exactly what they truly want and are therefore relatively free from inner
conflicts.

Unconsciously, the Moratorium and the Foreclosed subjects may actually want
to injure themselves in order to escape from an impossible situation,
which they have not had the courage to face honestly. The counsellor Andrew
Evans finds that a disproportionate number of the misuse syndromes occur to
people who come from families where the father has a successful career and
the mother is a housewife. The possible reason for this is that the mother
may have tried to use her child to fulfill her ownpersonal ambitions which
had hitherto been frustrated by her position at home.  She herself probably
wanted to become a musician and sees in her child  the potential
realization of her dream. Escaping from such a situation is not easy,
because    the mother subtly threatens the withdrawal of her love if one
expresses one´s personal desire to do something entirely different in life.
The injury then "happens" and usefully serves as a secondary benefit. It
creates a way of escape from "monstrous mama", and one is free to do what
one wants (60).

Now that I have looked at the element of stress in Performing Arts
Medicine, the other side of the coin needs exploration too. This is
depression. As with stress, depression is very common and there are many
causes of depression in the music world. There is depression resulting from
isolation and loneliness, which is not uncommon among pianists. It must not
be forgotten that pianists are rarely members of an orchestra. Therefore,
private teaching is the average pianist´s lot, and this is often a lonely,
not to mention dull, way of making money.

In addition to this, there are other causes. A special syndrome exists
which is called Post-Performance Depression. Then there may be a huge load
of depression caused by some personal problem which has nothing to do with
music at all.  There is also, as stated previously, quite a tangible
depression caused by the injury or cramp of a finger. And major depressive
episodes when that same finger refuses to heal. This is one of the reasons
why the holistic approach is the best. It is because few doctors merit the
name of Dr Jekyll and Mr Freud; they are unqualified to deal with these
psychological side effects, and have to refer their patients to a
psychiatrist or a
counsellor.

There is also depression which is simply organic. In other words, it is not
a reactive depression as are the instances mentioned above, but is caused
by certain chemical processes which are associated with cerebral
dysfunction. Manic depression fits this last category (61). As pointed out
earlier, manic depression seems to be one of the psychological causes of
injuries and motor coordination problems.

The presence during two weeks of five symptoms out of the nine listed below
meets the criteria for a major episode of reactive depression. These
symptoms are:
1. Depressed mood.
2. Loss of pleasure or interest in most daily activities.
3. Loss of sleep or, conversely, hypersomnia.
4. Recurrent thoughts of death, suicidal thoughts or even attempts at suicide.
5. Some form of "psychomotor agitation or retardation".
6. Lack of concentration and indecisiveness.
7. Fatigue.
8. Weight loss or gain which is not related to dieting.
9. Feelings of guilt and worthlessness (62).

The organic form of depression, however, is manifested in a special kind of
personality and the person with a manic-depressive temperament has been
described in the following terms:
". . . one could say that normal people become conditioned by receiving
enough love as small children to expect that others will give them
approval, and thus proceed through life with confidence. People who remain
in the depressive position have no such built-in confidence. They remain as
vulnerable to outside opinion as a baby is vulnerable to the withdrawal of
the breast. Indeed, for such people, the good opinion of others is as vital
to their well-being as milk is to the infant. Rejection and disapproval are
a matter of life and death; for unless supplies of approval are forthcoming
from the outside, they relapse into a state of depression in which
selfesteem sinks so low, and rage becomes so uncontrollable, that suicide
becomes a real possibility." (63).

People of such a disposition experience difficulties in finding a normal
outlet for their aggressive impulses. Since self-esteem is so much
dependent on other people there are frequent feelings of rejection. There
is a compulsive "good" behaviour, however, in order to receive as much
approval as possible. So all aggressiveness against those who frustrate
them is repressed and rage turns inwards (64). A self-destructive pattern
develops and there is a very definite tendency to physical self-abuse,
whether this is unconscious or not. The road is then clear to a Performing
Arts Clinic with an abused wrist, misused finger and an overused arm.

The manic phase can also easily lead to the same. An overconcern with
something is one of the main characteristic of this pathological state
(65). A kind of a "work orgy" of maybe a fifteen hours a day is typical in
order to bolster the low self-esteem, with fairly obvious consequences.

Other states of depression which come to the attention of a team working in
a Performing Arts Clinic is the phenomenon of Post-Performance Depression.
"Post-performance depression is characterized by sadness, crying bouts,
anxiety and panic attacks in some individuals, anhedonia or lack of
interest, lethargy, fatigue, excessive sleeping, truancy or failure to
attent class or coaching, failure to complete homework assignments,
suicidal ideation and, in some instances, serious suicidal attempt." (66).

Loss is probably the basic common factor in depression. There is a form of
loss that musicians sometimes experience after a series of concerts.
Teachers have noticed that some of their pupils in such periods often seem
to suffer from loss of spark and energy.  There is also a distinct decline
in posture, and a lingering depression (67).

Why do musicians suffer from post-performance depression? One reason may be
the sense of specialness which the performer enjoys. The attention which a
series of concerts bring is a tremendous boost for one´s ego. There is
large amount of tension as well and a "do-it-or-die" attitude towards the
coming concert. One person described such a period as "charged with a
cosmic tempo"! Some form of failure or mishap may cost one´s reputation, in
fact one´s whole life! Most pianists feel that you are only as good as your
last performance. . . If one survives and does well, one is a hero and is
adored. Resuming one´s normal life after such an excitement and hopefully,
success, is then often experienced as a feeling of sudden emptiness, and
life may seem to have lost its purpose. There is no longer that tremendous
intensity which has vitalized one´s dreary existence. Instead, one wanders
aimlessly through a dense and dark forest, "lost in space and lost in
meaning. . . "

Another possible reason may be that practising for a concert takes many
months, and in one´s college years, this preliminary preparation is
accomplished with the help of one´s teacher. After one becomes a fully
fledged performer, some form of help is usually sought in one´s colleagues
who then act as a substitute for the teacher. One constantly seeks both
positive advice and constructive criticism. However, at the same time one
may lose one´s autonomy and independence because one is relying more and
more on external feedback. After the end of a performance the feedback
suddenly disappears. The inevitable ending of this support is then often
experienced as a loss, and this loss may be another of the reasons for the
phenomenon of post-performance depression.

Another cause for depression is the isolation of the music student. After
all, one practises alone, and one´s instrumental lessons are usually
private. Many undergraduate and postgraduate students also live in foreign
cities or cities at least thousand miles from their families and homes. And
even though teenage piano students live with their families they still have
to be busily practising apart from their normal school curriculum.
Therefore they tend to be deprived of the normal social life which is so
important in adolescence. The teenager may even begin to resent the
instrument, because of the huge sacrifices he has to make in order to have
time for the music study.  Friends may also scorn the music student´s "lack
of time for fun", and teachers may worry that homework and class time will
suffer on account of the "bloody piano". All this tends to surround the
instrument with some really evil associations. Forinstance, it carries the
message that the music student is different from his fellows, which is a
very dangerous situation. Typically, thoughts such as "I am alone in the
world and nobody understands me" develop into an obsession, and suicide may
become an attractive option.

And there is more. Most musicians know the effort, stress and tension which
the Goddess of Music demands from Her followers. What, then, about the
depression which develops when the musician is forced for a period of time
to retire from playing? As I stated at the beginning of the last chapter,
many doctors rightly or wrongly include rest as the cornerstone of their
treatment.  Some of their patients are forbidden to touch their instrument
for many months, sometimes more than a year. And in the cases of dystonia
there are still gloomier prospects. Dystonia is very difficult to treat.
Therefore, doctors will usually tell the sufferer that they have no idea
how long it will take to recover. So it is common for the unfortunate
musician to have all sorts of doubts and worries about whether he really
will be able to play again, and if so, if he will be able to play as well
as before, etc., etc. This is a devastatingly difficult problem, because
injury and dystonia potentially destroy that aspect of the person´s
professional life which is concerned with performing. The self-esteem then
dwindles away and may even disappear altogether. It must not be forgotten
that, even though most pianists become teachers,  a substantial number of
these teachers are also performers to a greater or lesser extent. This may
simply consist of demonstrating to a pupil how to play a certain passage.


Apart from being an outlaw from the land of the keyboard, serious injury or
dystonia can also have a very negative effect on the musician´s private
life. Andrew Evans, whom I mentioned earlier, knows of many cases where
injuries demanding only six months´ withdrawal from playing ruined the
person´s  private life, resulting in a temporary separation or even
divorce. The reason is that the musician has suddenly lost his or her
expertise. That expertise may have bestowed an important aura of glamour
which caused the partner to be attracted to the musician in the first
place. And now, he or she appears only half the person he or she used to be
before. Many partners cannot cope with that and simply leave, thereby
completing the destruction of the musician´s life. . .

Psychotherapy is therefore a very important aspect of Performing Arts
Medicine, due to the close relationship of body and mind, or the body and
the feelings. Very often, a patient coming to a Performing Arts Clinic will
benefit immensely from consulting a psychotherapist or a counsellor, which
is the reason why these clinics should offer such services.

There are other cases, however, which do not respond as well to this kind
of treatment. As I mentioned above, depression is can be either reactive or
organic. The latter is difficult to treat with psychotherapeutic methods
alone, and indeed such pathologies respond poorly to any other treatment
than drugs (68). This is where the psychiatrist comes in. Manic depression
is constitutional in a sense; psychotherapy can do no more about that than,
say, changing the bone structure or the height of a certain individual.

According to Dr Ian James, anti-depressants alone are sometimes very
effective, no matter whether the symptom is a painful finger or a cramp.
This does not mean however that the patient is a manic depressive.
Depression, whatever the cause, can easily disturb the delicate balance
between mind and body, which is imperative in the study and learning
leading to a musical performance. There has to be a perfect flow between
the intellect, the emotions and the body.

The following illustrates this in very simplistic terms:
1. The intellect: I perceive this, this is what I want to do.
2. The emotions: It is the right thing, it is what I would like to do.
3. The body: The physical movements making up a correctly performed piece
of music (69).

The process is from the intellect to the body via the emotions. The flow
becomes affected if the emotions are seriously disturbed as happens in
severe depression. It makes one unable to learn correctly; one may
understand perfectly, but somehow the physical outcome is distorted.
Obviously, this is an important factor in the development of a misuse
syndrome or dystonia (70).

The case history below illustrates how depressive illness can cause
unconscious muscle tension to such an extent that pain may develop.

One pianist, a woman, had been suffering from severe pains in her arms for
several months, the reasons for these being unclear. As a result she had
been forced to stop playing the piano. It was immediately apparent to Dr
James that she was suffering from an enormous depression, and further
investigation revealed that it was caused by a personal problem completely
unrelated to anything to do with music. He therefore prescribed
antidepressants for her and the pains immediately started to disappear.
They eventually found out that the depression had been causing the woman to
tense her arms while she slept and this had been causing the pains. With
the pains gone, she was able to resume playing, and eventually recovered
with the help of a psychologist.

Drugs can control the effects of an unhappy situation, thereby enabling the
sufferer to view it more objectively. Most techniques of psychotherapy on
the other hand focus more on the roots of a problem, and attempt to solve
it with a verbal analysis alone.

The aim of psychotherapy or counselling is to make people better. Many
medically trained people have been known to scorn the whole idea however,
and some doctors in the past liked to say that in medicine people either
die or get better whereas in psychotherapy nobody dies and nobody gets
better!  This is no longer true though, and most doctors in the field seem
only too happy to refer people to a counsellor.

I have mentioned that Josephine received such advice. Since there seemed to
be no physical cause for her difficulties, her mind had to be searched out.
She had an appointment with a counsellor and, after the first session,
decided to work with him.

It became apparent that she had some psychological problems which were
definitely connected with her status as a pianist. Josephine had won a
small competition when she was twelve. Her parents and her teacher almost
exploded with pride and began to put a great deal of pressure on her. In
retrospect, she felt it was the end of her childhood. She had to practise
and practise, and her parents soon decided she was ready for another go. A
major competition was coming up and she was to participate in it. She did,
but failed miserably. Her parents showed a surprising understanding, but
her teacher scolded her. He became quite sarcastic for a long time
afterwards and she developed a huge sense of guilt. She got over it
eventually, but never won another competition. Yet there were some
successes and, just prior to her illness, a great career opportunity
presented itself. She was invited to give series of concerts in Germany.

Josephine thought she was eager to go, but her psychologist discovered
otherwise. Underneath the seeming self-assurance was a great amount of
fear. It had started after she failed in the competition and had to suffer
the nasty comments which her teacher occasionally launched at her.
Therefore she became extremely vulnerable towards criticism and afraid of
another failure. She suppressed her feelings, however, and did not realise
that her  attitude was causing problems. Instead, she had physical
symptoms.

As the counselling proceeded, she began to be more conscious of her inner
mind. Gradually, her physical problems started to disappear, and she was

able to play again. Before I tell about the relatively simple solution that
her therapist came up with, the act of counselling needs to be explained.

The British Association of Counsellors has defined it in the following words:
"When a person occupying the role of counsellor offers or agrees explicitly
to give time, attention and respect to another person in their role of
client. The task of counselling is to give the client an opportunity to
explore, discover and classify ways of living more resourcefully and toward
greater well being. The
boundaries of time, usually over several meetings, are an important
integral part of counselling and the attention of the counsellor who is
free of his or her own personal environmental preoccupations, is able to
open herself to the client´s comunications and engage actively with him in
his personal explorations.The counsellor respects the client´s potential to
be creative for himself, and to make his own value choices in the light of
his own particular cultural, social and political background."

Privacy and confidentially are of course the basis of such a therapy and
the client is free to explore patterns of feeling, thinking and behaviour
that appear to be sources of trouble. New ways of living are experimented
with and various values and personal meanings clarified. It is very
important to realise that a musician can have problems with his or her
music without having any other psychological grievances. As we have already
seen, music alone can be quite a trouble maker. . .Therefore, at the start
of psychotherapy, the counsellor asks the musician a lot of questions about
his occupation, such as when the person started to play, whether the person
liked the particular instrument or whether that instrument was chosen by
someone else. Whether the parents were encouraging or not, and whether they
had high expectations or none at all. The person is asked about his aims
and motivation and if he realises what it means to be a fulltime musician.

One of the very first issues which are tackled is that of time management.
Sometimes, a lot of worries, not to mention a general malaise and even
depression, are quite simply generated by a chaotic or poorly planned
timetable. The initial homework of someone taking therapy would then be
directed at a more efficient organisation of daily study, practicing,
household chores or whatever it is. The person´s all important business
side needs looking into and often the counsellor will be helpful in
constructing some form of a finanicial plan to help the impractical and
sometimes starving musician make a fairly decent living.

One of the main problems, as mentioned earlier is that of stage-fright. As
I have tried to show, all kinds of unresolved problems with parents are
often projected to the audience. Therefore it is important to go to the
stage where the whole trouble started and try to build up the person´s
general selfconfidence. The person needs to grow up in a sense. He has to
come to terms with himself and become an independent adult. The struggle
with the father, mother or the whole family has to end and this means that
the pattern of anxious reaction to parental influences must be neutralised.
The sufferer of excessive stage-fright is usually obsessed with other
people´s attitude and sometimes this is generated from what psychologists
call a "fundamental
attribution error". In other words, one has a tendency to attribute all
sorts of negative happenings that go around to faults one has done, even
though one may be completely innocent of the whole thing. So there is a
feeling a tremendous guilt and anxiety that if one makes the slightest
mistake, the world may go to pieces. As Peter Feuchtwaenger says: "A war in
the Gulf is more important than a wrong note in a concert". A change in
attitude is therefore necessary  and this logically comes about with
enhanced self esteem. Having a higher self esteem means of course that
there is less need to prove oneself and there is less at stake when
performing in front of an audience. In addition to this there are a
number of techniques that deal with stage-fright. Since this thesis is not
about that per se  , I will only mention those commonly known methods of
creative visualisation and  autogenic training. Some tricks, which in my
opinion are quite stupid, consist of thinking that the audience is nothing
but a bunch of fools and idiots with no sense of the difference between a
good and a bad performance. Then there are the beta-blockers which I
refered to in the introduction. For some, they mean the end of shaky hands,
sweaty palms and cold fingers. All this has been dealt with in previous
dissertations and I will therefore not repeat again it here.

Josephine, was unwilling to tell me about all the intimate details of her
therapy. However, she did reveal to me what cured her. It was very simple:
She did not go to Germany. She decided that she needed more time to come to
terms with herself, and that she as a person was more important than being
a famous pianist. The pressure was off and her arms and fingers began to
move again. This may sound quite incredible, but it is true all the same.
The mind can have such an influence over the body that a deep fear may be
totally paralysing. The body appears ill, but it is the mind which needs
the healing.

A physical injury basically means two things. Either the person will get
better or not. The therapy has to solve the psychological problem which may
have been the cause and also help the person to deal with negative feelings
which the injury may result in. The  ego must be boosted and its strength
maintained at all costs. Permanently losing the ability to play is a
terrible loss, because for most musicians the instrument has become a kind
of an extension of the body. Playing the piano is for pianists
". . . a physical as much as a psychological need, since they feel unwell
and uncomfortable if they cannot play. In Freudian terms it is the id , the
creative
instinctual child who needs to play, which is the most powerful part of
their psyche. The toy with which the child is entirely absorbed and
obsessed, is the musical instrument and the sounds that come out of it.
They identify, each with his particular instrument as part of the self.
After all, an instrument is only a tool but it symbolises so much more. "

A musician very often describes his first experience of music in childhood
as something holy or religious. A collegue of mine was five years old when
she was first exposed to a piece of classical music, and she felt wonderful
rapture at hearing sounds which obviously came from paradise. I have been
told many similar accounts. Music at first is like a mystical revelation;
studying it, practicing and listening to it is a completely natural and
almost a magical process. For some, this wonderful glamour never ceases.
Others, however meet new teachers with some radical ideas about how to play
the piano. . . Still others, as we have seen, have injuries and some have
to stop playing for a while. And as previously mentioned, a re-examination
of one´s technique may be a necessary stage on the road to recovery. In
these instances, one becomes
suddenly conscious of a natural function. I have mentioned this destructive
self-consciousness in relation to dystonia. Becoming aware of one´s habits
and attempting to change them is far from being a bad thing, but the magic,
which has been such a huge motivation, does have the tendency to disappear
in the process. With that childlike wonder lost, playing the piano is not
as attractive as it used to be. At this stage, many consider other
vocational options even though the injury or dystonia has healed.  Some
don´t leave entirely but try instead to find the vanished spiritual
dimension in some or another religious system alongside the music. A few
even resort to alcohol and drugs, thinking:
"where there is dope, there is hope". How to regain one´s motivation after
the often difficult recovery is a problem which many counsellors don´t know
how to solve. Perhaps, there is a question of time here. The correction of
habits and, in the words of Carola Grindea, the liberation of the body,
does take time to integrate completely. One has to re-train the body, then
forget it if the Spirit is to enter again. Or as Alfred Cortot would have
it, the way is "from the knowledge of the physical to the perception of the
metaphysical". In other words, the "new" body is no longer the object of
attention. Instead the mind soars to the heavenly realms of music, and the
physical hands, fingers and wrist become a vehicle for the voice of God. .
.

In the sad cases of never being able to play again, however, the counsellor
can help in choosing career alternatives. The advice would be based on the
knowledge of personality types and the vocations apart from music which
attract similar temperaments. The Myers-Briggs type indicator which is
based
on the theories of the  psychologist Carl Jung is very often used. It
divides people as follows:
"Extraversion: Outer focus or Introversion: Inner focus. Sensing: Realistic
focus or Intuitive: Imaginative focus.
Thinking: Objective focus or Feeling: Sympathetic focus.
Judging: Planning focus or Perceptive: Improvising focus.
Each person will have a natural preference for one or the other function.
Thus, though able to use both (e. g. Thinking and Feeling), they will tend
to make use of the weaker function less often or less naturally than the
stronger or preferred function."

Each musician would be tested individually, and his or her personality
assessed. The personality type of the average classical musician is in most
cases classified as extravert, intuitive, judging and feeling. According to
Andrew Evans, the similar or same type of person is also found in the
following groups:
1. The Clergy.
2. Health teachers.
3. Actors.
4. Writers.
5. Painters.
6. Composers.
7. Counsellors.

When recovery becomes so difficult that the musician begins to consider
other vocational possibilities, money obviously becomes a cause for
concern. If the pianist´s only means of income is giving concerts, it may
not be so easy to suddenly find a teaching job. And even if there are a
number of willing students available, the routine of being a pedagogue
takes time to settle into.

Obviously this is the extreme case, since most pianists already have at
least a handful of pupils. But even then, the many consultations, expert
opinions and therapies cost a lot of money. Unfortunately, not many
charities are around to supply this need, and only very few musicians get
the financial support necessary. The Royal Society of Musicians of Great
Britain has recognised the problem, however. The 1987 Royal Charter stated
its intentions as
". . . the relief of poverty and sickness among (a) professional musicians;
(b) former professional musicians and persons aspiring and intending to
embark on a career as professional musicians; and (c) the families and
dependants of any of the foregoing, priority being given to Members of the
Society. . . over persons who are not Members."

It should now have become obvious that suffering musicians need a lot of
help.  Sympathy and understanding are probably the most important factors.
Above all, the average musician is a sensitive human being. Even though we
have been classified as judging types who need to plan our lives, we are
also both feeling and intuitive. Therefore our emotions are often in
turmoil, and we are easily stirred by great feelings. It seems to me that
all the great musicians have been like that. After all, how could we, as
artists, be otherwise? Therefore, in the words of Dr Wynn Parry, the
musician needs a guru, a person with whom to talk. With a growing knowledge
of all these different problems,  teachers, GP´s and even one´s spouse will
become more aware of the issue and therefore automatically be able to offer
the sympathy and understanding which the musician deserves.

------------------------------------------------------

CONCLUSION

To sum up I think it is relevant to relate the story of my own case. I have
a personal experience of Performing Arts Medicine due to a physical problem
connected with my piano playing. It was diagnosed as a dystonia. I was
still in difficulties when I began studying this new branch of medicine for
the purpose of writing the present dissertation. Now, however, I seem to be
cured.

I am a concert pianist. I do not give many concerts a year, but I do play
some of the most difficult pieces in the piano repertoire, and have been
doing so since the age of thirteen. Four years ago, I began to encounter
strange difficulties at the piano. For some reason my right hand was not
working as it used to. Every time I had to do a descending scale or
arpeggio, the thumb and the second finger would somehow be in the way.
After I had pressed the latter down, it did not relax immediately
afterwards. When the thumb went down to play the next note in the passage,
the second finger was quite stiff and had a tendency to curl. After I had
pressed down the thumb and wanted to pass over it with the third or the
fourth finger, the second would somehow hit the thumb or stumble over it.
Also, the thumb, like the second finger, would not relax in order to let
the other fingers continue.

This condition did not happen all of a sudden. I had always noticed that
the second finger of my right hand seemed to lack a certain dexterity, and
this was more noticeable in descending passages than when I played
ascending notes. It did not bother me though, because I could play most
things anyway. However, the majority of pianists find descending with the
right hand and ascending with the left easier than the other way round.
With my right hand it was the opposite. My left hand posed no problems;
there, both the thumb and the second finger were completely relaxed and did
what they were supposed to do.

Very slowly and insidiously, this slight difficulty grew to the point that
in 1987 it had developed into a problem which I could not solve. It began
when I had to play Chopin´s Barcarolle in public. The Barcarolle is not
such a difficult piece, but it does feature a rapid descending passage at
the very end which has to be played quite clearly and brilliantly. I had
played it some months before without any problems. Just before this
performance, however, I noticed that I would involuntarily stop for a
moment somewhere in the middle of this final passage. It was caused by that
strange stiffness of the thumb and the second finger which I described
above. Why, I did not know. It did not happen all the time, though, but
enough to make me feel insecure. I was like an actor who had suddenly
developed a stutter.  No methods of practising that I knew seemed to work.
No tricks, either. I became extremely worried, but decided to go through
with it anyway, hoping that I would be saved by some miracle. Of course no
miracle happened. I played the Barcarolle without difficulties, but when I
came to the end of it, the final passage went to pieces.

What was wrong with me? Nobody around seemed to be able to help me. I asked
some of the local piano teachers for advice, but most of them just made fun
of me. What was more, my problem was usually dismissed as being "in my
head", and if I forgot about it, it would go away. In any case, nobody had
heard about a similar condition before.

However, I could not forget about it. And the problem did not go away. As
time went by I discovered to my horror that my repertoire had become
extremely small. I had to avoid all works containing rapid descending
passages which had to be executed with the right hand alone. This meant
that I had to wipe out from my concert programmes most of the sonatas by
Beethoven, Mozart and Schubert, and a lot of others too. Unfortunately I
love Beethoven, Mozart and Schubert. Therefore I was determined to solve my
problem.

It should not be hard to imagine my sense of humiliation. I had played
music such as the second piano concerto by Brahms, the b-minor sonata by
Liszt, the Appassionata by Beethoven, and now I could not play a simple
descending scale! What was worse, no matter what I tried, the condition
remained, and even grew worse. I was optimistic, though. Somehow I knew
that I would eventually get over it. I hoped that if I just practised
slowly, I would get my hand back to normal sooner or later.

Yet a whole year passed without improvement. I went to see a neurologist
who did some tests on me but nothing showed. I even went to an
acupuncturist who stuck a needle between my thumb and second finger,
guaranteeing that I would be back on the road in three months. But the
three months passed and nothing happened. Then I went to see Jean Gibson
whom I have mentioned. She examined me and found that my right arm was
extremely stiff. She pointed out to me that it was almost completely rigid
when I was playing and, additionally, my shoulder would move forwards when
I placed the hands on the keyboard. This, she explained, impaired the
agility of the arm. She also noticed that I was not articulating enough
with my thumb. The thumb of my left hand was much freer, not to mention the
second finger. We also discovered that my right thumb was sadly lacking in
independence from the second finger, so every time I moved the former, the
latter would move involuntarily as well. Her advice was this: loosen up
your arm! She also gave me an exercise which is borrowed from the
Feldenkrais Method. It has to do with the development of a sense of
differentiation by making slow, circular movements with the thumb without
moving the second finger.

I went home and tried to practise what Mrs. Gibson had taught me. There was
some improvement, but not much. In retrospect however, I think that this
lack of progress was because I, like Michael, had never given the slightest
thought to my arm during playing. I had had good teachers who were always
telling me how important the arm is, but somehow it never registered in my
mind. Therefore, when I began to try to do what Mrs. Gibson had advised me,
I automatically focussed on developing the agility and articulation of my
thumb but forgot about the arm.

It was only several months later that I had my moment of truth. Something
happened. I suddenly understood what I had been doing wrong. The problem
was not really in the fingers. If I relaxed my arm while playing, I could
do things that I had been unable to do for a long time. I am not saying
that the whole problem went away just like that. But at least there was
tangible improvement.

Why had my arms been so tense ? Was it simply a bad habit, or was there a
deeper cause for it? I have tried to show how physical problems and
injuries can be the result of anxiety and depression, and that these
negative emotional states have commonly affected the population of
indisposed musicians for quite a while before their physical disorders
appeared. I was not an exception. For a long time before my troubles began,
I had suffered from the common doubts about the musical profession which
afflict so many musicians. I did not really know if I wanted to become a
pianist, and if I did, whether I was good enough to make it on a
professional scale. I was also miserably afraid of failure in case I
attempted to go for the top, and I often reasoned that it was better not
even to try.

The ability to let go of the muscles of my arm was without any doubt the
result of a major psychological breakthrough. Just before I "discovered" my
arm I had made a final decision. I was going to be a full time musician and
to play as much as I could. It had nothing to do with making money or going
to Hollywood. It was the inevitable conclusion based on the simple but
powerful discovery that I love music and I love to play the piano, nothing
more, nothing less. I did not care about the rest. Even ending up as a bar
pianist in Detroit would not change it.


After that, things went uphill. I met Dr Mosaraf Ali, mentioned previously,
who discovered some more stiffness in my right arm. He gave me a thorough
massage and told me how to do it myself. The muscle which moves the second
finger was very tight and it took me a month to loosen it up. This helped a
great deal, as did my regular piano lessons with Carola Grindea who taught
me many things which I had forgotten. The most important one was that, due
to tension, my wrist was turned inwards instead of outwards when I played.
By correcting it, I found it much easier to do that which I had found so
difficult.

All of the foregoing has led me to conclude that I can accomplish very
little if I am not relaxed. I think the same applies to most of mycolleague
s.  A healthy, relaxed attitude to music, music making and the music world
seems imperative. Most, if not all of the methods of treatment which I have
explored in these pages: physiotherapy, the Feldenkrais Method, the
Alexander Technique, Yoga, counselling and the building up of a healthy
piano technique focus on the release of tension in one form or another. As
I have said before, stress is a fundamental issue in Performing Arts
Medicine. Relaxation in the fullest sense - a relaxed body and a relaxed,
healthy mind - is what should characterise a happy pianist who enjoys his
art and who will never, never  have to visit a Performing Arts Clinic.

------------------------------------------------------

NOTES

1. Murry Hope, author of THE PSYCHOLOGY OF HEALING.
2. Wallace, H. : "Performance-Related Injuries - a Dark Continent?", p. 396.

3. Graffman, G. : "Doctor, Can You Lend an Ear?", p. 5.

4. Bowers, F. : SCRIABIN, Vol. 1, p. 168.

5. James, I. : Private Interview.

6. Wallace, H. : "Performance-Related Injuries - a Dark Continent?", p. 400.

7. Grindea, C. : Private Interview.

8. Mentioned in "Doctor, Can You Lend an Ear?" by Gary Graffman, p. 6.

9. Wallace, H. : "Performance-Related Injuries - a Dark Continent?".

10. Ibid., p. 399.

11. "Medart International", Brochure, p. 1.

12. Critchley, M. & Henson, R. A., eds.

13. James, I. : "Medicine and the Performing Arts, the Stage Fright Syndrome",
p. 8.

14. Fry, H. : "What´s in a Name? The Musician´s Anthology of Misuse", p. 38.

15. Ibid., p. 38.

16. Hochberg, F. H., Leffert, R. D., Heller, M. D. & Merriman, L. : "Hand
Difficulties Among Musicians"., p. 1870.

17. Fry, H. : "Occupational Maladies of Musicians: Their Cause and
Prevention", p. 59.

18. Fry, H. : "What´s in a Name? The Musician´s Anthology of Misuse", p. 36.

19. James, I. : Private Interview.

20. Bell, D. S. : ""Repetition Strain Injury": an Iatrogenic Epidemic of
Simulated Injury"", p. 281.

21. Ibid. p. 281.

22. Hochberg, F. H., Leffert, R. D., Heller, M. D. & Merriman, L. : "Hand
Difficulties Among Musicians", p. 1871.

23. Fry, H. : "Overuse Syndrome in Musicians: Prevention and Management",
p. 728.

24. Lockwood, A. H. : "Medical Problems of Musicians", p. 226.

25. Graffman, G. : "Doctor, Can You Lend an Ear?", p. 4.

26. Acheson, R. M., Chan, Y.K. & Clemett, A. R. : "New Haven Survey of
Joint Diseases XII: Distribution and Symptoms of Osteoarthrosis in the
Hands With Reference to Handedness", p. 284.

27. Lederman, R. J. : "Nerve Entrapment Syndromes in Instrumental
Musicians", p. 46.

28. Ibid., p. 46.

29. Graffman, G. : "Doctor, Can You Lend an Ear?", p. 5 & Grindea, C.,
Private Interview.

30. Lockwood, A. H. : "Medical Problems of Musicians", p. 224,

31. Ibid. p. 224.

32. Sheehy, M. P. & Marsden, C. D. : "Writers´ Cramp", p.472.

33. James, I. : Private Interview. See also Lockwood, A. H. & Lindsay, M.
L. : "Reflex Sympathetic Dystrophy After Overuse: the Possible Relationship
to Focal Dystonia", p. 117.

34. James, I. : Private Interview.

35. Walton, J. : BRAIN´S DISEASES OF THE NERVOUS SYSTEM, pp. 334-349.

36. James, I. : Private Interview.

37. James, I. : "Medicine and the Performing Arts, the Stage Fright
Syndrome", pp. 8-9.


38. Lockwood, A. H. : "Medical Problems of Musicians", p. 225,

39. Laurence, D. R. & Bennet, P. N. : CLINICAL PHARMACOLOGY, p. 380.

40. The use of Laser, Ultra-Sound and Interferential according to Simpson,
E. :  Private Interview.

41. Brochure entitled "Information and Use of the Rosedale Web", exercises
nos. 1 & 2.

42. Spire, M. : "The Feldenkrais Method: an Interview with Anat Baniel", p. 159.

43. Feldenkrais, M. : AWARENESS TRHOUGH MOVEMENT, pp. 33-36.

44. Spire, M. : "The Feldenkrais Method: an Interview with Anat Baniel", p. 161.

45. Ibid. p. 160.

46. Wallace, H. : "Performance-Related Injuries - a Dark Continent?", p. 400.

47. Jones, F. P. : BODY AWARENESS IN ACTION, p. 151. Cited in Murray, A. :
"The Alexander Technique", p. 132.

48. Cohen, L. A. : "Role of Eye and Neck Proprioceptive Mechanisms in Body
Orientation andMotor Coordination", p. 7.

49. Rosenthal, E. : "The Alexander Technique - What It Is and How it
Works", p. 53.

50. Ben-Or, N. : "The Alexander Technique - Its Relevance to Performance",
p. 41.

51. Wallace, H. : "Performance-Related Injuries - a Dark Continent?", p. 400.

52. THE HEALING BRAIN is mentioned in Hope, M. : THE PSYCHOLOGY OF HEALING,
p. 34.

53 Ibid., p. 241.

54. Tubiana, R. & Chamagne, P. : "Functional Anatomy of the Hand", p. 83.

55. Vovka Ashkenazy: Private Communication, 1978.

56. Grindea, C. : Private Interview.

57. Cited in "In Pursuit of Perfection: Career Choice and Performance
Anxiety in Musicians" by J. J. Nagel, pp. 140-141.

58. Ibid., p. 142.

59. Ibid., p. 141

60. In case I risk giving offence, let it be stated that I am not implying
that all housewives fit this mother-image. Far from it, indeed, as the
cases show. . .

61. Spitz, L: Private Interview.

62.The presence during two weeks of five symptoms out of the nine listed
below meets the criteria for a major episode of reactive depression.   (set
by the American Psyciatric Assoiciation Diagnostic and Statistic Manual III
(Revised Edition) These symptoms are:

Robson, B. E. & Gillies, E. : "Post-Performance Depression in Arts
Students", p. 139.

63. Storr, A. : THE DYNAMICS OF CREATION, p. 104.

64. Ibid., p. 104.

65. Spitz, L. : Private Interview.

66. Robson, B. E. & Gillies, E. : "Post-Performance Depression in Arts
Students", p. 137.

67. Robson, B. E. & Gillies, E. : "Post-Performance Depression in Arts Students"
p. 139.

68. Spitz, L. : Private Interview.

69. Ibid.

70. Ibid.

71. Cited in Butler, C. : "Counselling Music Students", p. 20.

72. The process of counselling musicians as described to me by counsellors
Martin Lloyd-Elliot and Andrew Evans.

73. Feuchtwanger, P. : Private Interview.

74. Butler, C. : "Counselling Music Students", p. 21.

75. Grindea, C. : Private Interview.

76. Evans, A. : Private Interview. See Lloyd-Elliot, M. & Evans, A. : THE
AVERAGE MUSICIAN.

77. Lloyd-Elliot, M. & Evans, A. : THE AVERAGE MUSICIAN, p. 2.

78. The Royal Society of Musicians, Brochure, p. 2.

------------------------------------------------------

BIBLIOGRAPHY

Acheson, R. M., Chan, Y.K. & Clemett, A. R. : "New Haven Survey of Joint
Diseases XII: Distribution and Symptoms of Osteoarthrosis in the Hands With
Reference to Handedness", Annal of Rheumatic Disorders, Vol. 29 (1970), pp.
275-286.

Bard, C. C., Sylvestre, J. J. & Dussault, R. G. : "Hand Osteoarthropathy in
Pianists", Journal of the Canadian Association of Radiologists, Vol. 35
(1984), 154-158.

Bell, D. S. : ""Repetition Strain Injury": an Iatrogenic Epidemic of
Simulated Injury"", The Medical Journal of Australia, Vol. 151 (1989), pp.
280-283.

Benham, B. : "Am I Too Tall ?", ISSTIP Journal No. 6 (1990), pp. 30-33.


Ben-Or, N. : "The Alexander Technique - Its Relevance to Performance",
ISSTIP Journal No.1 (1983), pp. 39-42.

Bowers, F. : SCRIABIN, Kodansha International Ltd. Tokyo 1970.

Butler, C. : "Counselling Music Students", ISSTIP Journal No. 5 (1988), pp.
2025.

Cohen, L. A. : "Role of Eye and Neck Proprioceptive Mechanisms in Body
Orientation and Motor Coordination", Journal of Neurophysiology, Vol. 24
(1961), pp. 1-11.

Critchley, M. & Henson, R. A., eds. : MUSIC AND THE BRAIN,  William
Heinemann, London 1977.

Feldenkrais, M. : AWARENESS THROUGH MOVEMENT, Arkana, London 1990.

Fry, H. : "Occupational Maladies of Musicians: Their Cause and Prevention",
International Journal of Music Education, Vol. 2 (1984), pp. 63-66.

Fry, H. : "Overuse Syndrome in Musicians: Prevention and Management", The
Lancet, Vol. 2 (1986), pp. 728-731.

Fry, H. : "What´s in a Name? The Musician´s Anthology of Misuse", Medical
Problems of Performing Artists, Vol. 1 (1986), pp. 37-38.

Goodman, G. & Staz, S. : "Occupational Therapy for Musicians with Upper
Extremity Overuse Syndrome: Patient Perceptions Regarding Effectiveness of
Treatment", Medical Problems of Performing Artists, Vol. 4 (1989), pp. 914.


Graffman, G. : "Doctor, Can You Lend an Ear?", Medical Problems of
Performing Artists, Vol. 1 (1986), pp. 3-6.

Grindea, C. : "Running a Performing Arts Clinic in a Music College", ISSTIP
Journal No. 6 (1990), pp. 11-14.

Grindea, C., ed. : TENSIONS IN THE PERFORMANCE OF MUSIC, A SYMPOSIUM, Kahn
& Averill, London 1978.

Hochberg, F. H., Leffert, R. D., Heller, M. D. & Merriman, L. : "Hand
Difficulties Among Musicians", JAMA, Vol. 249 (1983), pp. 1869-1872.

Hope, M. : THE PSYCHOLOGY OF HEALING, Element Books, Dorset 1989.

"Information and Use of the Rosedale Web", Brochure, Rosedale Research Ltd.
London 1990.

James, I. : "Medicine and the Performing Arts, the Stage Fright Syndrome",
a privately published report, London 1988.

Laurence, D. R. & Bennet, P. N. : CLINICAL PHARMACOLOGY, Churchill
Livingstone, London 1987.

Layzer, R. B. & Rowland, L. P. : "Cramps", New England Journal Of Medicine,
Vol. 285 (1971), pp. 31-40.

Lederman, R. J. : "Occupational Cramp in Instrumental Musicians", Medical
Problems of Performing Artists, Vol. 3 (1988), pp. 45-51.

Lederman, R. J. : "Thoracic Outlet Syndromes, Review of the Controversies
and a Report of 17 Instrumental Musicians", Medical Problems of Performing
Artists, Vol. 2 (1987), pp. 87-91.

Lederman, R. J. : "Nerve Entrapment Syndromes in Instrumental Musicians",
Medical Problems of Performing Artists, Vol. 1 (1986), pp. 45-48.

Lederman, R. J. & Calabrese, L. H. : "Overuse Syndromes in
Instrumentalists", Medical Problems of Performing Artists, Vol. 1 (1986),
pp. 7-11.

Lloyd-Elliot, M. & Evans, A. : THE AVERAGE MUSICIAN, Arts Psychology
Consultants Ltd., London: year not indicated.

Lockwood, A. H. : "Medical Problems of Musicians", The New England Journal
of Medicine, Vol. 320 (1989), pp. 221-227.

Lockwood, A. H. & Lindsay, M. L. : "Reflex Sympathetic Dystrophy After
Overuse: The Possible Relationship to Focal Dystonia", Medical Problems of
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"Medart International", Brochure, Hoboken Congress Organization, Rotterdam 1991.

Merriman, L., Newmark, J., Hochberg, F., Shahani, B. & Leffert, R. : "A
Focal Movement Disorder of the Hand in Six Pianists", Medical Problems of
Performing Artists, Vol. 1 (1986), pp. 17-19.

Murray, A. : "The Alexander Technique", Medical Problems of Performing
Artists, Vol. 1 (1986), pp. 131-132.

Nagel, J. J. : "In Pursuit of Perfection: Career Choice and Performance
Anxiety in Musicians", Medical Problems of Performing Artists, Vol. 3
(1988), pp. 140-145.

Ornstein, R. & Sobel, D. : THE HEALING BRAIN, Macmillan, London 1988.

Pearson, R. M. : "The Musicians´ Clinic", ISSTIP Journal No. 5 (1988), pp. 3334.

Robson, B. E. & Gillies, E. : "Post-Performance Depression in Arts
Students", Medical Problems of Performing Artists, Vol. 2 (1987), pp.
137-140.

Roos, D. B. : "Thoracic Outlet Syndromes: Symptoms, Diagnosis, Anatony and
Surgical Treatment", Medical Problems of Performing Artists, Vol. 1 (1986),
pp. 91-93.

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Medical Problems of Performing Artists, Vol. 2 (1987), pp. 53-58.

"The Royal Society of Musicians of Great Britain", Brochure, London, year
not indicated.

Sheehy, M. P. & Marsden, C. D. : "Writers´ Cramp - a Focal Dystonia",
Brain, Vol. 105 (1982), pp. 461-480.

Spire, M. : "The Feldenkrais Method: an Interview with Anat Baniel",
Medical Problems of Performing Artists, Vol. 4 (1989), pp. 159-162.

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Tubiana, R & Chamagne, P. : "Functional Anatomy of the Hand", Medical
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Zamoyski, A. : PADEREWSKI, Collins, London 1982.



Private Interviews with the following Persons:

Benham, Bill., teacher of the Alexander Technique, London 1991.
Evans, A.ndrew, counsellor at Arts Psychology Consultants Ltd., London 1990.
Feuchtwanger, Peter., piano teacher, London 1991.
Grindea, Carola., piano teacher, chairman of ISSTIP and director of the
Performing Arts Clinic at the LCM, London 1991.
James, Dr. Ian, chairman of the Bristish Association of Performing Arts
Medicine, London 1990 & 1991.
Lloyd-Elliot, Martin., counsellor at Arts Psychology Consultants Ltd.
Pearson, Dr. Richard. M., director of the Musicians´ Clinic, London 1990.
Simpson, E.lisabeth, physiotherapist, London 1991.
Spitz, Dr. Lydia., psychiatrist, London 1991.
Walters, Roselyn., teacher of the Feldenkrais Method, London 1991.
Wynn Parry, Dr. C. B.,  Director of Rehabilitation at King Edward VII
Hospital in Midhurst and consultant for the Performing Arts Clinic, London
1991.

A number of patients who wish to remain anonymous, London 1990-1991.

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