pianomap : Pianist's Injuries: Movement Retraining is the Key to Recovery
By Thomas Mark
5. Why Many Pianists Do Not Recover
To say that to cure an injury we must remove its cause sounds too obvious to require emphasis, but in fact movement retraining, which is the way to accomplish this, very often does not happen. There are several reasons why injured pianists often do not get the retraining that would cure their injuries.
Many injured pianists don't understand the need for retraining or don't believe in the possibility of moving differently to play the piano. After all, they play the piano the way they always have done, the way they were taught to play. Rather than admit shortcomings in their technique they (or their teachers) may insist that the injury has "nothing to do" with piano playing but has some other cause (this is almost never true). Consequently, when first injured they rarely look for someone to analyze their technique, identify the technical problem and find a solution. Instead they resort to transparently poor strategies like denial, wishful thinking, or "toughing it out." They say "I'll rest over the weekend and it will be better on Monday," or "I guess I just overdid it, I'll take it easy for a while." Sometimes the first symptoms are even welcomed, and people say "I must really be making progress in my practicing, I can feel it in my arms" (the "no pain no gain" fallacy). Or else, misled by discussions in the literature, they say "I just tried to do too much without proper warm-up; I'll be careful always to warm up from now on," or "I guess I need to exercise and develop strength in my fingers." As the injury persists and they become desperate, they go to doctors, physical therapists, chiropractors, accupuncturists, nutritionists, massage therapists--the list is endless. All of these professionals can help, especially in treating the acute condition, but only to a limited extent. They are not trained to do what is really necessary, namely teach the person how to play the piano without danger of re-injury.
This brings us to a point that it is vital for pianists to recognize: pianists' injuries are rarely medical problems, they are movement problems. An injury would count as a medical problem if it were caused by illness or trauma. Occasionally this is the case; carpal tunnel syndrome, for example, can be caused by diabetes, and arm pain can be caused by a fracture or sprain. These conditions are appropriately treated by medical science. But (according to some authorities) such cases account for only about 5 percent of pianists' injuries. It follows that roughly 95 percent of pianists' injuries are not medical problems; they do not come from illness or trauma but from the way the person habitually uses his body. This explains why health care professionals are rarely of much help to pianists who seek a permanent cure. An injured pianist does not need a doctor, he needs a teacher, and the solution to the near-epidemic of pianists' injuries will come not from therapy but from education.
Becoming injured can be emotionally devastating for a pianist. If a person's thoughts, aspirations, and, perhaps, very livelihood center around the piano, then to be unable to play one's best, unable to play without pain, perhaps unable to play at all, is a dreadful experience. Injured pianists often become deeply depressed and discouraged. The injury can become a stigma and the injured pianist feels isolated, rejected, inadequate, and humiliated. Depression and a sense of hopelessness can themselves be obstacles to recovery. An injured pianist desperately needs emotional support and understanding from friends, relatives, colleagues, and teachers.
Unfortunately, many colleagues and teachers, though well-intentioned and sympathetic, can offer only limited help. Typically, they offer moral support, which is essential, but few have a clear understanding of the causes of injures or the conditions for recovery; few have the information they need to prevent injury in their students or show an injured pianist how to recover. What I described a few paragraphs back as "transparently poor strategies" are the ones most often invoked by teachers and pianists at all levels. This is understandable; after all, the required information is not part of most music curricula, pedagogy classes, or conservatory programs. On the assumption, natural enough but usually mistaken, that the problem is a medical problem, not a movement problem, teachers and colleagues may send the injured pianist for medical treatment or therapy. Such treatment rarely produces a complete, permanent cure, so teachers and colleagues feel helpless, frustrated and anguished along with the injured pianist. The general problem will be solved only when sound information is part of every pianist's training. When teachers have the information and students, from the very beginning, are taught the principles of stress-free movement, pianists' injuries will no longer occur.
Piano periodicals and books on technique are not generally very helpful to the injured pianist. Few discussions of pianists' injuries emphasize movement retraining and the strategies they do recommend are not especially effective, either for avoiding or for curing injury. These include "building endurance," "developing strength," taking frequent breaks, warming up, "pacing ourselves," and the like. In themselves, I have no quarrel with any of these suggestions; all are good things to do, and they may contribute to our ability to resist injury. But they are not the full answer; someone can do all of them and still be injured. For example: suppose my way of playing octaves involves forcefully flexing my wrist. There are anatomical reasons why repeated forceful flexion of the wrist is dangerous; it is, in fact, one of the common causes of carpal tunnel syndrome. Therefore, if that is how I play octaves I am risking injury. Even if I take breaks, warm up before practicing, and so on, it will still be true that with every octave I play I will be stressing the tendons in my wrist. If I use stressful movements to play octaves, then telling me to avoid injury by warming up before practicing the Sixth Hungarian Rhapsody is like telling a smoker to take some deep breaths before lighting up in order to avoid lung cancer. Warming up and deep breathing are great, but they don't remove the cause of the problem. Just as lung cancer is caused by smoking, not by failure to do lung exercises, so pianists injuries are caused by stressful movement, not by failure to warm up, take breaks, and so on.
How does it come about that a good pianist may play in a way that stresses the body? I think there are two principal reasons. First, most people's technique is not deliberately chosen. That is: the person does not analyze the movements needed to play a passage and practice those movements. Instead, the person just finds a way, by hook or crook and trial and error, to get to the right notes. With constant repetition the movements become habits. Sometimes, movements acquired this way will be efficient. But there is no guarantee. Our bodies can become used to inefficient movements as well as efficient ones, and when we are used to them, the inefficient ones feel "natural." I have heard pianists with techniques full of potentially injurious movements describe their technique as "natural" and "relaxed."
The second way in which people come to move stressfully is that they are taught stressful movements. No teacher would knowingly teach harmful movements. But too few teachers understand the principles of efficient movement, and some ways of moving that are dangerous to our health are firmly established in traditional pedagogy. I shall give only one example: playing with "curved fingers."
The expression "curved fingers" is vague, so let us be more precise. When we hold our hands in a relaxed position hanging at our sides, the fingers assume a gently curved position. I shall call this the "natural curve" and it is indeed the appropriate position for the fingers in playing the piano. But some methods instruct students to bend the two end joints of the fingers, resulting in a more pronounced curve than the "natural" one. I shall call this curled fingers, and it is potentially injurious. The reason curled fingers are dangerous is that the two end joints of the fingers are moved by the flexor muscles on the lower side of the forearm. Holding the fingers curled requires maintaining the contraction of the flexor muscles. Lifting of the fingers, on the other hand, is accomplished by contracting the extensor muscles on the top of the forearm. Therefore, if I lift my fingers while maintaining the "curl" of the two end joints, I am using flexor muscles and extensor muscles simultaneously; in other words, I am co-contracting. Co-contraction is one cause of injury; there are pianists who have suffered injury from playing with curled fingers (see Beth Tomassetti's story in Oregon Musician, Fall, 1995).
That playing with curled fingers is stressful is not just an opinion for people to accept or reject as they choose. It is a fact of anatomy. There is no way, anatomically, to lift our curled fingers without co-contracting. No amount of practice, no exercises aimed at "finger independence" or "strengthening the fingers," no amount of telling ourselves to "relax"--none of these will change the way our bodies are made. The anatomical fact is that if we play in this position we are risking injury. Yet playing with curled fingers is not only tolerated, it is advocated by some piano methods. There are beginning methods that tell students to use a pencil to line up the tips of the fingers into a straight line--a recipe for producing co-contraction. If the student plays that way and practices diligently, no one should be surprised if injury is the result. (Let me point out again that although "curled" fingers are dangerous, the "natural curve" is correct; the "natural curve" is not what I am arguing against. Also, I am well aware that not everyone who plays with curled fingers winds up injured. Some people are lucky, their bodies are more resistant, or whatever. But that does not alter the facts presented here; after all, some people smoke for sixty years without developing lung cancer, but smoking is still the cause of lung cancer.)
The movements that can cause injury do not necessarily feel bad or painful. Indeed, they are not dangerous in non-repetitive tasks. They are dangerous for pianists because piano playing is extremely repetitive. One handbook on stress injury considers "highly repetitive" any tasks requiring 1500 or so repetitions per hour. That may sound like a lot of repetition but it is nothing compared to piano playing. The hourly rate of repetition for sixteenth notes at a metronome setting of 120 is 28,800, a number that might give a health inspector apoplexy. In fact we can play sixteenth notes at 120, but we can't use just any motions to do it; some motions safely permit that level of repetition, and others do not.
Learning a less stressful way to move at the piano means abandoning old physical habits and replacing them with new ones. This is possible to do, though it takes time and application. But there is a deeper problem as well: the old ways may be embedded not just in our bodies but in our minds. Suppose I have been injured by my way of playing octaves. But suppose further that I was taught to play octaves by a teacher whom I deeply admire. Learning a new way to play octaves may cause me to modify my opinion of my former teacher. It may force me to re-think many aspects of my own teaching and playing, and I may be obliged to conclude that things I formerly believed sincerely were not actually the best. In short, movement retraining forces me to examine myself and my relationship with the piano, and I must be prepared to question and change my attitudes and beliefs. Even if the results make the effort worthwhile, the process is not easy.>> 6. Two Obstacles to Understanding
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Pianomap is created and maintained by pianist/teacher Thomas Mark.
Dear Dr. Mark,
I am a physical therapist practicing in Tampa, Florida. I have read your article on pianists' injury. I agree with your approach. When I see musicians (and any other clients), I always work with correction of body movement, habit retraining- never just a temporary fix. Kinesthetic sense is vital to proper movements, and unfortunately, this tends to be overlooked. I am also surprised that many higher level music students do not have exposure to classes or discussions in injury prevention.
Hoang C. Le, PT, MPH