The Integrated Approach Dr. Teresa Dybvig, Director

Playing-related Injuries of Pianists: Prevalence, Overuse, and Focal Dystonia
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Can retraining help pianists with dystonia play again? In a word, Yes! Read more from director Teresa Dybvig

See previous discussions on Piano Technique on The Well-Balanced Pianist Forum.

There is much to be said about injuries in musicians. The first thing that I should say is that I am not a physician of any type, I am a piano teacher trained in the Taubman Approach to Piano Technique (among other things). As such, I don't work from symptoms or diagnoses, but from the degree of coordination, or incoordination, in a person's technique.

What follows is the result of a question a perceptive reader asked about a number I used to have on my web page, and some thoughts about two diagnoses many musicians receive. The question of prevalence of pianists' and other musicians' injuries is important to me only insofar as it shows that there really is a problem in our field. The question of the name, "Overuse Syndrome," comes from a concern of mine that it is masking the real problem. The thoughts about Focal Dystonia are based on my experience, and the experience of other Taubman practitioners and students. This is in no way a comprehensive review of research, diagnoses, or treatment.

The wish for coordinated research between Taubman practitioners and medical professionals and researchers is sincere and heartfelt.

Prevalence of Pianists' Injuries

How many musicians are injured from playing? My short answer is approximately 65% - 80%. But read on! Researchers have been trying to determine what percentage of instrumentalists suffer from pain and injury since at least the 1980's.

One of the earliest researchers, Australian orthopedic surgeon Hunter Fry, published several papers during the 1980's showing the prevalence of injury ranging from 5% to 80% of musicians. The musicians studied ranged from secondary (high) school through professional. One of his studies reports the alarming news that out of 98 high school instrumentalists studied, 63% of females and 49% of males suffered from injury.

In a 1996 paper, F.J. Bejjani, G.M. Kaye, and M. Benham give an overview of numbers obtained to that point from many different studies. Again, the range of numbers is very wide: 8.5% to 76%. It is often difficult, reading these papers, to sort out how many musicians studied were keyboard players and how many played other instruments, but in Bejjani et al.'s review (1996), most studies that looked into gender and instrument variation found that more women than men report injury, and more keyboard and string players than other instrumentalists report injury. Fry's 5% and the reviewed 8.5% (see more below) are unusually low. Christine Zaza, reviewing 7 different studies for a 1998 paper, reports between 49% and 87% of respondents experienced pain of any severity in playing. These percentages are in the range most seen in these reports. Spotti, Tamborlani, and Converti recently reported at a music medicine conference that 78% of the Orchestra members of La Scala sought help for playing-related musculoskeletal injuries from the theater's clinic.

One important factor is the identification of the study population of musicians. An interesting study highlights the importance of this factor. Manchester and Flieder (1991) and Manchester (1988) calculated an incidence of 8.5 new cases of injury per 100 music majors, based on the number of students seeking help at the student health services associated with a music school. The contrast between this incidence rate of 8.5% and the much higher rates of injury reported in other studies (mostly over 50%) suggests that most music majors with injuries do not seek help from their school's health services. They may seek help from doctors outside the university (as suggested by the authors, and as evidenced by the very low rates during the summer months), those with a no-pain, no-gain ethic may not seek help at all, and others may have sought help within alternative therapies. Thus, how the sample of injured musicians was obtained, and the assumed population of musicians from which they were drawn, have substantial effects on the results of the study.

Still, 49% is quite far from 87%. Why do these numbers differ so greatly from one study to the next? How can we make sense of them? First, we must ask, what question did the researchers ask? You would think it would be an easy thing to measure how many pianists are injured, but it is not. What is an injury? What is pain, for that matter? One person has told me repeatedly that she does not have pain when she plays, but she can only practice an hour a day because after that, her elbow starts to hurt. That sounds like pain to me, but she has found a way to make it insignificant, and I doubt she would report it as playing-related pain if asked a simple question by a researcher. Others have told me they are not injured as long as they don't play pieces with... fill in the blank: octaves, broken octaves, fast running passages, chords, etc. To my mind, the limitation that person places on his repertoire is a sign of limitation, at least the kind of incoordinate technique that could lead to injury. Others have told me that they have no pain, but that it was unbearable the previous night, or the previous week. That sounds like pain to me, but again, if a researcher asked simply if someone were currently experiencing pain, I don't think a person with that mindset would indicate that they had pain associated with their playing. Focal dystonia is painless, but crippling, in that there is a loss of control over certain areas of the playing mechanism. Questions that ask only about pain will not elicit reports from those suffering from this frightening condition.

Therefore, the questions researchers ask, who they ask questions of, and the precision of the wording of the questions, will greatly influence the report they receive. When asked to report what Fry considered the widest range of possible pain, (i.e. the least possible, Level 1, being pain on one site, while playing, which goes away when one stops playing, and the greatest possible, Level 5, being loss of capacity to use the hand because of disabling pain and loss of muscle function), 64% of musicians in his study reported injury. This is a number generated from several organizations; it is alarming to note that in one of the orchestras he studied, 80% of the members reported injury. For some reason, he saw fit to remove all those with what he considered the least possible pain; then only 42% of musicians reported injury. Zaza (1998) also favors studies that exclude "mild complaints," which she does not define in her 1998 paper. Those exclusions bring down the reported percentages in her overview to 17% for high school students and 47% for university music students. Since she refers to seven studies, and doesn't include all their definitions, it is not possible to know how the different researchers define "mild complaints," though Zaza refers to them as "mild and transient complaints," and "mild, everyday complaints." If it is a twinge experienced once in one practice session, that is indeed mild and transient. Fry's Pain Level 1, pain on one site while playing, which goes away when one stops playing, is not transient, or even necessarily mild. It is recurring, and most likely interferes with the musician's performance.

Some researchers limit the number of body parts they ask about. If a researcher asks only about pain in the wrists and hands, thinking that the hands are the part that do the work and would be the only part affected, musicians will not report back, neck, shoulder, or even upper arm pain. This could lead to significant underreportage of injury. According to a study (Greico, 1989) cited in Bejjani and Kaye (1996), while 22% of pianists reported disorders of the forearms/wrists, 50% reported back disorders.

Some researchers have reasons for limiting body parts studied: they may want to go on to study the efficacy of, for example, a certain wrist surgery or cortisone shots to certain muscles. However, if a researcher wants to know how many musicians are injured, period, limiting the number of body parts studied seems self-defeating. Similarly, unless researchers are trying to understand treatment for a particular kind and duration of pain, it seems obvious to me that limiting the type and duration of pain and/or discomfort would lead do underreportage. Specific questions about whether musicians limit their repertoire or practice time could be very revealing. Zaza (1998) reports on a study in which she asked a fantastically open question, except that she specified that it be a "current" "pain, weakness, numbness, tingling, or other symptoms that interfere with [their] ability to play [their] instrument at the level [they] are accustomed to."

I doubt that Hunter Fry would find pain that occurs only while he is working acceptable. Throwing out the numbers of musicians who do would imply that he feels this level of pain is acceptable for musicians. In fact, many musicians do accept it, but I think that is because they see no other option. However, in my experience, pain while playing is only an early step towards greater injury, if the reason for the pain is not addressed. I have seen that if habits don't change, the pain will increase in severity, in parts of the body affected, and in the amount of time in a day the person experiences pain. In just a year or two, the researcher wouldn't be throwing them out when he threw out those with the mildest injuries. Indeed, Dawson (1995) reports that so many of the patients he had seen were "repeaters," in that they have come in for more than one problem over a period of time, that only 94 people accounted for 242 of the 1000 cases he reported. Since people came in up to 7 times after their first visit, it is logical to assume that their first complaint, even if mild, was a harbinger. Similarly, Manchester and Flieder (1991) report that roughly one-third of the patients they followed had had a previous performance-related hand problem.

It is important to note that a person experiencing pain while playing is at least partially distracted from the music, and likely to compromise accuracy and sound quality to avoid aggravating the painful spot.

I want to reiterate here that the experience of Taubman practitioners is that sometimes very simple changes of habit can help a person avoid pain altogether, and play their instrument better as well.

Overuse Syndrome

There is much discussion on the subject of the name, "overuse syndrome," in the medical literature. The most compelling arguments against this name come from Heinz Lippman (1991) and Alice Brandfonbrenner (2001). Dr. Lippman argues for the term "misuse," based on the fact that the conditions they are describing usually come from misusing, rather than overusing, the body. He cautions that "Since 'overuse' implies a need for therapeutic rest, it may cause unwarranted disuse, which remains second best to appropriate use in otherwise healthy musicians" (p. 60).

Brandfonbrenner, while not arguing against the term, states that musicians who stay totally away from their customary activity (i.e., playing their instrument) "convert from what might have been a temporary inconvenience to full-blown chronic pain syndromes" (p. 45). I have heard musicians say that calling some musician's injuries "misuse syndrome" would be tantamount to blaming the victim. Fry (1986b) argues passionately against this diagnosis, out of concern for the feelings of the patient, and, among other things, out of concern that if this name were in common circulation, it might deter musicians from seeking help.

I would say I would have been classed as one of misusers at one time in my life, and yet I feel most musicians can probably handle the truth well enough. As a matter of fact, hearing that one has "misuse syndrome" would be positive news, especially if it were followed by concrete means of changing one's use. It would mean a musician's body may be perfectly up to the task of playing his instrument, and that he only has to change his use of the body to get out of trouble and play well without problems.

Focal Dystonia

Before giving you a short review of the medical literature, I want to say that my observation is that people with involuntary movements share a set of behaviors in the areas of torso posture, wrist/hand alignment, movement into the key, and mindset (Dybvig, 2007). For illustrations, you can check out the poster I presented at the 2007 National Conference on Keyboard Pedagogy showing many of the physical alignment problems I have observed in these pianists, side by side wth more coordinate alternatives. It is my experience that when all of these behaviors are addressed concurrently, the situation of people suffering from these frightening conditions can turn around as quickly as the situations of pianists suffering from other playing-related injuries. This conclusion is based on observations of mine and Nina Scolnik's of about 20 people with involuntary movements, and our work with 15 students. These students had been diagnosed with either focal hand dystonia or tremors (intention, essential, and "age-related"), or had not consulted a physician and therefore not received a diagnosis. I have been conducting a study with Nina Scolnik to assess the effectiveness of this integrated method, and I hope to have the numbers available soon. I was heartened recently to learn that a similar integrated approach is in use at a Parisian hand clinic, L'Institut de la Main, under the direction of Raoul Tubiana. It is impossible to determine from either article I cite (1997, 2003) how complete the overlap is between our methods (and I look forward to learning more specifically about their methods!), but I am thrilled that a medical expert is advocating an integrated retraining program. He also concludes that with patient cooperation in retraining, real improvement is possible, and that prevention is also possible. The 2003 article (Tubiana, 2003) reveals the success of his work with his colleague Philippe Chamagne (who has his own 2003 article): of 145 patients with dystonia whom they saw between 1992 and 1999, 35 discontinued treatment, but 85 (59%) experienced improvement, 39 (27%) so much that they returned to performance.

Other researchers are beginning to advocate retraining. Even in 1991, Reginald Cole et al. stated, "The disorder is so highly task specific that changing the technique of playing may solve the problem." Eckart Altenmüller indicates that he has seen this to be true; he mentions that retraining with experienced teachers can be effective (2003), though one cannot change a technique overnight. He names a couple of teachers in Europe who have helped people recover from dystonia (Philippe Chamagne and Laurent Boullet). I'm not surprised he doesn't mention any Taubman teachers -- working in Europe, he probably hasn't seen the results of Taubman work (not to mention that musicians don't usually do the kinds of revealing quantitative studies that could allow medical researchers to develop confidence in their work). Recently, Hans-Christian Jabusch and Altenmüller (2006) concluded a review of treatments for dystonia with the suggestion that behavioral retraining should be included in all treatment approaches. Rae de Lisle, a highly respected teacher in New Zealand, also recently reported good results with one of her three retraining pianists (2006). In a review of focal hand dystonia and possible treatments, Peter Lin et al (2006) state, "Attempts should be made to improve the situation with changes in the technique of accomplishing the task."

Medical solutions seem to be improving a bit for musicians with focal dystonia. In 1995, Alice Brandfonbrenner stated that a diagnosis of focal dystonia was, for a musician, "almost as devastating" as news of a life-threatening illness, and notes the "disappointing success rate in treating focal dystonia" (p. 127). In 2001, she stated that "the outlook is not yet rosy for these musicians." The newest treatment, botulinum toxin -- a poison that paralyzes muscles and whose long-term use may cause the treated muscles to atrophy (Lin et al, 2006) -- has apparently helped some people (Cole et al, 1991, Jankovic, 1991, Jabusch 2004), and it appears that the most experienced physicians are improving at applying it well. Still, it most be noted that, keyboard players who are treated with botulinum toxin must avoid repertoire require the hand to be open (Jabusch, Zschucke, Schmidt, Schuele and Altenmüller, 2005). Still, some people are experience positive results: Schuele et al (2005), report that 6 out of 84 patients (7%) were able to discontinue treatment, because of reported lasting improvement, and 13 of 84 (15%) reported marked improvement. 7 out of 20 pianists, or 35%, reported moderate or better improvement. Injections must be made at exactly the right place, and a temporary but often significant weakness often precedes improvement. Injections must be repeated regularly, as the effect wears off. A small percentage of people develop antibodies to the toxin, a significant percentage (31%) of people show no improvement, and a few people even experience deterioration of their abilities. A larger retrospective study of 144 patients with focal dystonia, comparing different treatment methods, states that 49% of patients who were treated with botulinum toxin experienced "alleviation of symptoms," though they do not state how much symptoms improved or whether the musicians could return to playing at concert level (Jabusch, Zschucke, Schmidt, Schuele and Altenmüller, 2005). It appears from a chart in the paper that approximately 6 or 7 of the musicians experienced a worsening of their symptoms: the specific number was not stated, but if the number were 6, the percentage would be 8.4%. They note that keyboardists benefit from this option only when they avoid repertoire that "requires a wide hand span and extreme lateral finger motion" (which I believe would mean chords that require the hand to be very open, and large intervals).

How much more preferable it would be to simply learn one's own natural alignment and the movements that would support it. Jabusch and Altenmüller (2005) show that behavioral retraining "alleviated symptoms" for 50% of those who received it in their clinic (again, there was no report of how much the symptoms were alleviated or whether the musicians could return to playing at concert level). And I reiterate that I have seen that pianists with diagnoses of dystonia can turn their situations around, by applying the core concepts of alignment, balance, and movement embodied in the Taubman Approach to Piano Technique and bodywork disciplines such as Yoga.

Work on mindset is also important for these pianists. Tubiana (1997) mentions the importance of work on mindset. Jabusch, Müller, and Altenmüller found that, compared with healthy musicians, more people with dystonia have particular anxiety disorders (social and specific phobias), and also a significantly greater tendency toward perfectionism. All these problems predate the dystonia, so they were not a result of the trauma of being injured(Jabusch, Müller, and Altenmüller 2004) -- and may have contributed to cementing the dystonic movement in the brain (Jabusch and Altenmuller 2004). There have also been studies linking OCD to dystonia (Bugalho et al 2008, Cavallaro 2002). These results have led me to redouble my efforts, without presuming to practice therapy without a license, to help foster a healthy mindset for practice and performance in my students.

Jabusch, Altenmüller and their colleagues at the Hannover Institute for Music Physiology and Musician's Medicine have done some of the most interesting recent research on dystonia. In a 2006 Medical Problems of Performing Artists review of work on dystonia, Altenmüller's 2003 article was mentioned as the one to read if you were to read only one article on dystonia. From my more limited experience, I agree. To explain what happens in the brain of musicians with dystonia, he first has to describe what happens in the brains of healthy musicians, so he has to describe the brain, and... you get the idea. It's long and comprehensive and fascinating. They found, for example, that the reflection in the brain of the fingers of musicians with dystonia shows an overlap, while the fingers of healthy musicians are separated in the brain. This makes perfect sense to me, as the incoordinate position many dystonia sufferers hold their hands in precludes movement of the fingers. Dr. Altenmüller feels that splinting to eliminate movement of the other fingers is a possible answer. Candia et al. (2003) at the University of Konstanz report some improvement with splinting for eight consecutive days, but they caution that that particular study does not show whether or not the benefit would be long-term. A teacher retraining pianists through the Taubman approach would help them learn to move without molding their hand into an unnatural position or restrictring free movement through splinting. De Lisle et al. (2006) agree; they state, "...our impression is that external aids can contribute to unnecessary tension in the forearm."

People with dystonia affecting the embouchure should note that in Schuele et al's (2005) study, all of those with embouchure dystonia reported a worsening of symptoms upon treatment with botulinum toxin. Do your research if you are considering this treatment. Please do not limit yourself to reading this paragraph; I have not read very much about embouchure dystonia. Someone else may have discovered an effective treatment.

Taubman teachers do not think or behave like medical researchers, collecting data, and doing follow-up studies. However, there is good anecdotal evidence supporting the efficacy of retraining through the Taubman approach in changing the situations of people who have dystonia. It is heartening that respected medical researchers working with dystonia are beginning to look even more seriously at this option.

In case you are wondering, there is very little coordination between medical researchers and practitioners, and Taubman practitioners. This is unfortunate, because both groups have something to offer the other. Taubman teachers, being trained in music rather than statistics, do not know how to study a problem quantitatively. We are knowledgeable, but few of us can support anything with data. We work anecdotally, which has worked rather well so far, but it is very possible we are missing important information because of our unsystematic methods. Of course, the information is variably useful to those of us who are not physicians, but several concepts should urge us to be sober and proceed carefully when helping another person to change technique. For example, Brandfonbrenner (1995) reports that 8 of 58 patients with dystonia trace the onset of their problem to an intensive attempt to change their technique. We would rightly counter that not all changes in technique are equal. However, do we always make sure a student makes changes gently? Do we do enough to ensure that enthusiastic but inexperienced Taubman teachers approach their work with injured musicians soberly? Do we encourage radical changes only when necessary? Meanwhile, research physicians could learn many sophisticated solutions from Taubman teachers, that would obviate the need for splints, muscle relaxers, and botox. For example, Taubman practitioners know the fingering and movements that render the opening of Bach D Minor Invention comfortably playable, and the concepts behind the fingering and movements. Such knowledge would be invaluable to a music medicine professional.

The lack of communication between the fields probably stems from several sources -- for example: a lack of common language, a difference in attitudes, goals, and solutions, a certain rigidity of attitude and thinking on both sides, and pride. Research physicians are among the most educated people in the world, with a PhD in research in addition to a medical degree. The best Taubman practitioners are similarly hugely educated. For example, I have a doctorate in piano performance (and all the requisite former degrees) and 22 years of study in a specialty. We are all knowledgeable, successful, eager to improve, and proud of our accomplishments. I hope that someday an open-minded Taubman teacher will hook up with an open-minded music medicine researcher. Together they could change the lives of whatever percentage of musicians are injured. Maybe they could help them skip the injury stage altogether. Now, that would be something to be proud of.


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Learn where to find Teresa Dybvig's article on dystonia and other involuntary movements, and read some questions and answers generated from the article.