Musicians Health

The hedonistic lifestyles of certain musicians will be familiar to many readers, but the unexpected dangers of playing a musical instrument may not.

Aware that I have an interest in musicians’ health, last week a medical colleague alerted my attention on Twitter to an interesting article in the October 2013 edition of Der Hautarzt (German dermatology journal), describing a condition I hadn’t heard before of called ‘fiddler’s neck’.

Fiddler’s neck is a condition where the afflicted violin (or viola) player develops an unsightly mark on the neck — just beneath the angle of the jaw. Although not that well recognised among dermatologists, it is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition (of quite different aetiology) seen in teenagers. The abnormality is due to an area hyperpigmentation and lichenification of the skin due to the rubbing of the instrument on the neck (erythema, scaling, cyst formation, scarring and inflammatory papules or pustules also occur). The article describes the development of a ‘violin hickey’ in (an undoubtedly embarrassed) 72-year-old lady.

Reading about this curious affliction prompted a ‘knight’s move’ wander through the literature on instrument-specific afflictions — and there’s lots to choose from.

Violinists who succumb to violinist’s hickey are also, presumably, susceptible to a condition known as ‘fiddler’s jaw’ (a condition akin to temporomandibular joint disorder, which comes about because of the way the violin is ‘clamped’ between the angle of the jaw and the shoulder), ‘fiddler’s finger’ (Garrod’s pads of the dorsal interphalangeal joints of the left index and middle fingers) and ‘pizzicato paronychia’ (infection in the nail-fold in string players secondary to pizzicato playing). A similar condition can also develop in pianists.

‘Fiddler’s neck’ is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition seen in teenagers
Jazz aficionados will immediately recognise the ballooned-cheeked appearance of ‘Satchmo’s syndrome’ in trumpet player ‘Dizzy’ Gillespie. The condition, originally named after Louis ’satchel mouth’ Armstrong, occurs in trumpet players, trombonists and French horn players comes about as a result of rupture of the orbicularis oris muscle (due to high pressures generated while playing high notes). Pressing the hard metal mouthpiece hard against the soft tissues of the lips without warming up can also cause injury; Freddie Hubbard, the well known jazz trumpeter, allegedly tore his lip during an “ill-advised high-note cutting contest” with another trumpeter, according to the Jazz Times in 2009.

Other hidden dangers of playing wind instruments include ‘flautist’s chin’ — a dermatological condition brought about by irritation from saliva and possibly nickel allergy, and ‘clarinetist’s cheilitis’ (perhaps explaining the ubiquity of the ‘jazz goatee’ in certain musicians). The spread of herpes, HPV and hepatitis have also been described due to the use of instruments that have not been cleaned properly (again, much like ‘violin hickey’, other aetiologies may need to be considered).

Both ‘guitarist groin’ (lower-limb DVT due to the pressure of a guitar held in the classical posture for long periods on the flexed thigh) and ‘guitar nipple’ have also been described. The latter is a form of ‘traumatic mastitis’ and was originally described in a letter to the BMJ in 1973. The case series describes a series of younger female guitarists, who all developed a cystic swelling about the base of the nipple. The cause, it seems, was the playing of full-sized guitars (by younger musicians) and direct trauma to the nipple area by the instrument.

Shortly after the ‘guitar nipple’ report was published, the BMJ published a letter describing an intriguing condition known as ‘cello scrotum’. The eight-line letter, published in 1974, describes the case of a professional cellist who developed an inflamed scrotum which, the author suggested, came about as a result of playing the cello for several hours a day.

Whereas the accuracy of the report was later questioned by other commentators (one suggesting that scrotal friction against the supporting chair was more likely to be responsible than direct cello trauma, per se), it was frequently cited in the literature over the years until the original author finally wrote to the BMJ in 2008, admitting that the case had been fabricated. The original letter had actually been signed and submitted by the Chairman of a brewery in Suffolk (the husband of a doctor) as a practical joke — never expecting that it might be published.

Hopefully there’s no practical jokers among the authors of the reports of the other conditions described.

This article was originally published in The Medical Independent

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In: Blog, Musicians Health, The practice of Medicine

Comments Off on Learning from Bruce Springsteen

We can all learn something from Bruce Springsteen.

Even those who aren’t fans of Springsteen’s music will be aware that his live performances, even now that he is in his mid-sixties, are legendary for their duration and for their intensity. He is also extraordinarily articulate and insightful about the psychological process of performance. In an interview with David Remnick for the New Yorker in 2012, he gave some insights into the complex mix of emotions which explain the intensity of his own style of performance;

With all artists, there is a tremendous push toward self-obliteration that occurs onstage. It’s both things: there’s a tremendous finding of the self while also an abandonment of the self at the same time. You are free of yourself for those hours; all the voices in your head are gone. Just gone. There’s no room for them. There’s one voice, the voice you’re speaking in.

Springsteen’s observations about performance will have resonance for those who simultaneously lose and find themselves while caring for others. Healing like music, can act like a drug – with sometimes unintended benefits for the prescriber.

Fleisher-T02[Artemis]

Two Hands

Sep 03

If you have a spare 18 minutes, you could do a lot worse than watch this profoundly moving documentary about the concert pianist, Leon Fleisher.

Fleisher’s early career was devastated by the development of a rare neurological disorder known as finger dytsonia. The movie, directed by Nathaniel Kahn, was nominated for an Oscar in 2007.

The documentary details the development of his condition, the effect it had on his ability to play and the lengths to which he went to look for a solution.

Although the condition effectively ended his early playing career, Fleisher later changed to teaching music and conducting & performing music originally commissioned for a one handed pianist. The then, 30 years later, returned to playing with two hands.

Its a well told story about musicianship, the price of perfectionism, loss and acceptance and poetic justice.

It features some beautiful music, and an insight into a fascinating man. 

“the experiences I have gone through as a result of all of this, the extraordinary joys and pleasures that have come from teaching and through the left hand literature and through the conducting – i don’t think I would give those experiences and joys up. If I had it to do over again I’m not that sure I would have changed anything. There was a lot of despair and misery and unhappiness but there were commensurate ecstasies; and you can’t really expect to have one without the other”

 

Leon Fleisher – Two Hands from Thomas Duperre on Vimeo.

Galway hosted Irelands’ first Performing Arts Medicine Conference in October of this year.

The theme of our inaugural conference was the health of musicians. Our panel of speakers included health care practitioners from diverse specialty backgrounds such as Neurology, Psychiatry, Rheumatology, Primary care, Psychology, Anatomy, Occupational Medicine, Occupational therapy, Osteopathy and of course, our patient experts.

I have included a selection of those presentations from the day which focused on the musicians hand. 

I hope you enjoy them.

Dr. Fiona Molloy, Consultant Neurophysiologist (Beaumont Hospital) speaks about Hand Dystonia in Musicians.

 Katherine Butler, Hand therapist (London Hand Therapy Clinic) speaks about rehabilitation of the musicians hand (with some emphasis on hand dystonia).

Mr Ian Winspur, Consultant Hand surgeon (London) talks about his 25 years experience of surgical aspects of managing the Musicians Hand

 

Here’s the panel discussion with all 3 experts, chaired by Dr. Juliet Bressan, Director of the Dublin Performing Arts Centre.

 

 

Panel Discussion on The Musicians Hand from Ronan Kavanagh on Vimeo.

This years Musicians’ Health conference took place in Galway on Saturday October 13th. We were lucky enough to hear from a number of patient experts who told of us their experience of living with musicians’ injuries.

I have included presentations from  two of these – Enda Scahill (of We Banjo 3) and Johnny Donnelly (formerly of The Sawdoctors). Their unique insight into musicianship and mechanisms of injury was for me, one the best parts of a fascinating and entertaining day.

I will be posting other videos from the conference here over the coming days and weeks. I hope you enjoy them.

 

 

Anyone who’s been reading  Keith Richard’s excellent autobiography will be impressed how he has survived many years of rock and roll, drugs, booze and complicated women. Those with more than a passing interest in rheumatology might have noticed that Keith’s fingers may be aging slightly less well than the rest of him.

These pictures, taken by Francesco Carrozini  makes it obvious to this rheumatologist, that Keith has well established osteoarthritis (OA) of his fingers.

Most of us who live long enough will get OA in some shape or form and it is by far the commonest form of arthritis.

The particular type of OA that causes the swelling in the distal finger joints is known as ‘nodal OA’  – so called after the hard and bony ‘node’ like swelling it causes in affected joints. Nodal OA can be very painful at the outset (as the bony swellings enlarge) but it is not uncommon for the pain to ease up a bit once the joint stiffens up and no longer moves properly. Its easy though to see how OA of the fingers could cause significant problems for any player.

Anyone who’s even tried to learn a few basic guitar chords will realize how much force and dexterity are required in the fingers of the fret hand to play an F barre chord – simultaneously firmly holding and index finger across all six strings and at the same time getting the middle ring and little fingers to hold three other strings.

All guitarists (soloists in particular) need a high degree of dexterity to allow their fingers to move quickly around the fretboard with precision and considerable strength. And that’s just the left hand! In addition to the difficulties caused by pain and stiffness of the joints, the enlarged bony nodes can get in the way and make unwanted contact with guitar strings.

Although there has been some speculation in the media that his playing may have contributed to the development of his arthritis, there’s no evidence that playing any instrument wears joints out quickly. Musicians get arthritis, just like the rest of us.

Playing related pain is very common in guitarists though and occurs in between 70% and 80% of them.  Most problems relate to the fret hand and wrist (i.e. the left for most players), low back and neck. Guitarists also suffer from shoulder impingement, tennis elbow, wrist tendonitis, carpal tunnel syndrome, finger tenosynovitis / trigger finger and non specific forearm pain. The symptoms relate primarily to the postures adopted playing the guitar, supporting a heavy instrument, moving heavy amplifiers and equipment, long hours of practicing without breaks, increasing practice time to quickly after a lay-off and lack of aerobic fitness. Stress, sleep disturbance and depression will also influence how these performers experience pain and how they present.

Over the years Keith Richards has also made changes to his playing technique which might have made it easier for him to perform as he gets older. In the late 60’s he started using a form of guitar tuning called ‘open tuning’ (which allows a more economical use of the fretboard compared to standard tuning) and started using a 5 string guitar (a standard guitar has 6 strings). On describing this adaptation, he says;  ‘there’s a million places you don’t have to put your fingers. The notes are there already’.Keith Richards’ continued ability to perform in one the most  hardworking bands in the world is likely to relate to far more than changing his guitar tuning or to his legendary physical constitution. For Keith Richards and for most musicians, giving up music is simply not an option. His observations about the addictive qualities of music and performing give us an insight into the addictive qualities of creating and performing music;  ‘a far bigger drug than smack. I could kick smack. I couldn’t kick music. One note leads to another, and then you never know quite what’s going to come next, and you don’t want to. It’s like walking on a beautiful tightrope.’

Health care providers encountering musicians need to be as persistent and as creative as the people we’re caring for in finding solutions to keep them playing. Remember that losing the ability to play music is for many musicians, akin to losing part of themselves.

PS. It has of course occurred to me that by drawing attention to Keith Richards in this way, that I might offend him in some way. Bearing in mind his propensity to throw knives at people who have upset him in the past, I include a link to the Keith Richards Merchandise site to take the edge off his ire. His autobiography, Life, is excellent too.

Dr. Ronan Kavanagh is one organisers of ‘Keeping the Show on the Road’  of Irelands’ first international conference on Musicians’ health which takes place Saturday October 13th 2012 Radisson hotel Galway