Demands on bodies of dancers and musicians are unique

By Levi J. Long
Seattle Times staff reporter

JOHN LOK / THE SEATTLE TIMES Nancy Kadel, an orthopedic surgeon and former dancer, speaks at a recent conference exploring medical problems of performing artists.

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As a girl, Cindy Olsen played the piano, clarinet and whatever instrument she could get her hands on.

So it was only natural for Olsen, now 55, to nurture her love of music into a teaching career.

But until recently, the retired elementary music teacher from Marysville would lie awake at night from pain throbbing through her shoulders and shooting down her arm.

"My left arm would tingle and go numb, but not the kind that feels like your arm is asleep, more like a nerve pain," she says. "It felt like sheet lightning running through my body."

As she got older and suffered a few falls and other minor injuries over the years, playing the clarinet for hours at a time worsened the shoulder and neck pain she developed.

One doctor recommended bone surgery as a cure, while another said she needed arthroscopic surgery on her rotator cuff. Yet another suggested steroid injections.

Symptoms of overplaying Musicians who suffer aches, cramps, stiffness or tenderness in the joints and feel weak or fatigued could be overplaying. The treatment is simple: Give your body a rest. Gradually resume practice and slowly increase the duration and intensity of playing. Also consider assistive devices that support the hand, wrist, forearm, elbow, shoulder and neck. Prevention tips For the musician • Start with warm-up exercises to increase blood flow and to stretch out muscles. Try squeezing muscles and moving fingers to prepare to play. Conductors and violinists should do shoulder warm-ups by moving their arms in circular motions. • Perform from a position of rest. This means in a relaxed manner, comfortable to the player and using only the muscles needed for playing the instrument. • Minimize mental tension and play with clarity. Stay focused on playing and don't let other thoughts cloud your mind. This will remind you to sit in a position of rest and to pay attention to muscle use. • Take rest breaks during long practice sessions. • Modify the instrument support, position for playing and posture, and adjust lighting and seating when necessary. • Get regular exercise. For the dancer • Warm up properly. Make sure you prepare your body before each rehearsal and performance. • Stretch daily. • Don't plunge into a new technique. Instead, gradually rehearse and practice the movements. • Understand your pain. Some aches are normal. But recognize there are times when medical attention is necessary, such as if pain affects performance; you have numbness, tingling, weakness, or swelling; or if aches last for more than three days. • Anticipate times when you'll be under greater performance stress. That's when people tend to get hurt because they are pushing themselves so hard. Source: Dr. William Dawson and Dr. Nancy Kadel

"They just couldn't find what was wrong," she says.

Then at the suggestion of a friend, Olsen was referred to the Clinic for Performing Artists at Virginia Mason Medical Center in Seattle. The 16-year-old clinic is one of 20 in the country specializing in performing-arts medicine, treating occupational injuries of the performing-arts community.

Performing-arts medicine is a small specialty and not as well-known as sports medicine. But 20 years after its development, the specialty continues to grow as more and more musicians, singers, actors and dancers seek treatments from doctors who understand their lives and work.

"Most performing artists tend to see themselves as artists rather than athletes," says Dr. Michael Weinstein, medical director of the Clinic for Performing Artists. "But the demands on their body and on different muscles can be unique. Performing-arts medicine offers treatments specific to the artists' needs, and having sensitivity to those demands is needed for doctors and specialists to effectively treat their patients."

Housed in the hospital's downtown campus, the clinic is staffed primarily by three physicians and one physical therapist, though other specialists are on call if needed.

The clinic is organized under the umbrella of Virginia Mason. Musicians are treated under the physical medicine and rehabilitation section, dancers are evaluated by sports-medicine specialists and vocalists are treated by an otolaryngologist.

Since the clinic opened, Weinstein has treated more than 1,000 musicians, with an average of 50 to 75 a month.

After two doctors visits and a couple of physical-therapy sessions, doctors found the source of Olsen's pain.

"Turned out I just needed to learn how to relax my muscles," she says.

Using a diagnostic tool called Surface Electromyography, a physical therapist determined too much muscle tension had built up in her shoulders. Olsen says that, for whatever reason, doctors who'd seen her before never told her about the test.

"Seeing a specialist for performing artists helped me when no one could," she says.

Carpal tunnel and scoliosis

Musicians typically develop medical problems over a long period of time and usually because of the way they play their instruments, says Dr. William Dawson, an orthopedic surgeon in Illinois and chair of the Performing Arts Medicine Association.

	JOHN LOK / THE SEATTLE TIMES During a recent conference in Seattle on the medical problems of performing artists, conferencegoers observe dancers Griffin Whiting, left, and Elizabeth Fuller. The demands of dance can wear out a performer's body if he or she is not careful, says Dr. Nancy Kadel, an orthopedic surgeon and former dancer.

But a sudden change in technique or increased playing time also can cause injuries, Dawson says.

"If you go from jogging a 5K run and then suddenly start doing a 20K, you can imagine the result," he says. "It's the same thing in music, when you suddenly go from one level of activity to another without giving time to adapt."

For musicians, typical problems include pain in the hands, wrist and forearm, followed by shoulder pain and carpal tunnel syndrome, Dawson says.

Just last week, veteran country star Willie Nelson canceled concerts for the next two months to have surgery for carpal-tunnel syndrome, The Associated Press reported.

Musicians who play string instruments often develop muscle-tendon pain from repeating the same movements over and over.

For harpists, sitting sideways and leaning and shifting behind their instrument in a fixed position for hours at a time, over a period of years, can lead to scoliosis, he says.

Conductors, percussionists and viola and violin players can suffer microscopic tears of the rotator cuff, the muscles that cover the shoulder joint.

"Unfortunately we can't do a lot to prevent" rotator-cuff injuries, Dawson says. "The area of the tendons are at the most risk for tearing gradually because they're giving away and can't repair themselves."

Depending on the severity of the injury, doctors might recommend arthroscopic surgery to remove bone spurs and fragments in the torn tissue. Dawson says such an injury could end a career if not treated.

There was a time when musicians shied away from doctors, afraid of a prognosis that would halt their careers.

"But the old standby of 'playing with pain' is over," he says. "If they're wise they'll seek treatment. They can't expect to pop an Advil and hope (the pain) will go away."

Marriage of dance, medicine

For years, Nancy Kadel had loved science and dance. She performed as a student with the Martha Graham Dance Company in New York City for two years until sidelined by a stress fracture — and was treated by a doctor with a background in dance.

More information • Performing Arts Medicine Association, www.artsmed.org • International Foundation for Performing Arts Medicine, www.ifpam.org/ • International Association for Dance Medicine and Science, www.iadms.org/ • Assistive devices for woodwind instruments, quodlibet.com

Kadel soon turned to her other passion.

"I wanted to go to medical school," she says, "and I realized I could combine things that I love: science and medicine and dance."

Kadel is now an orthopedic surgeon and director of the foot and ankle division of the Department of Orthopedics and Sports Medicine at the University of Washington.

She's been treating dancers for the past 13 years.

The demands of dance can wear out a performer's body if he or she is not careful, Kadel says.

"Injuries happen a lot earlier" because most dancers start at a younger age, she says. For dancers, there is also a burden of making difficult movements appear easy.

Sprained ankles are common, and so are injuries to the feet, knees, hips and lower back. Ballet dancers are constantly expanding their "turnout," by pointing their toes to the sides. Over time, this puts added stress on the joints, Kadel says.

She often sees posterior ankle impingement, a stress fracture that is coupled with pain in the ankle, in girls dancing on pointe. "They usually don't need surgery as much and it's usually healed with physical therapy," she says.

Stress fractures in the arch of the foot also are common.

If a dancer has to sit out on a performance because of foot or ankle problems, Kadel recommends Pilates, an exercise regime that strengthens muscles in the core of the body, to keep dancers in shape while staying off their ankles.

Doctors and physical therapists unfamiliar with dance technique might recommend that injured dancers stay off their feet completely.

But for a dancer, that's not an option.

"If you're a dancer, and suddenly you have to stay on the couch for two weeks, that's like a death sentence," Kadel says.

Learning to relax

Johannes van Buuren, a physical therapist at the Clinic for Performing Artists, works with both dancers and musicians.

Van Buuren used Surface Electromyography to diagnose Olsen's shoulder pain by measuring and analyzing electrical activity within her muscles during rest and exertion. Essentially, the machine measures the tension in a muscle.

The clinic has the testing equipment set up in a room with a piano.

The machine can also be used to analyze a dancer's movements.

Van Buuren placed electrodes on Olsen's shoulders and found a high level of tension even before she started to play.

"Even when I was relaxed, the lines on the screen stayed spiked the whole time," Olsen says.

She says she's been keeping her muscles tensed "24-7" without realizing it, a problem van Buuren says is common for many musicians.

"They're always so surprised to see how bad habits cause such high muscle tension in their bodies," he says.

Van Buuren teaches musicians how to relax the muscles they use when they play. For pianists, that means relaxing their hands and forearms.

"The key is to play only using the muscles they need," he says. "And to relax them when they're not in use."

Van Buuren says musicians have to "down train" muscles they shouldn't use as much and "up train" weak muscles they need to play. He also says muscle overuse is often caused by muscle imbalance and bad habits.

"It is more effective to detect these bad habits and muscle imbalances than finding out which muscle or tendon is overused," he says.

For example, he says, a tendinitis treatment may fail because it targets the inflammation but ignores the muscle imbalance or bad habits that caused the problem in the first place.

Maintaining good posture, keeping the chest open and making sure the wrist and fingers aren't bent too far or extended goes a long way in preventing injuries.

"If you're not in balance, the muscles can't work well," he says. "Physical therapists like to say muscle control is pain control."

Levi J. Long: 206-464-2061 or levilong@seattletimes.com

Copyright © 2004 The Seattle Times Company

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