The existence of specialists in the rehabilitation of the Musician, a necessity
Musicians are a population group that frequently suffer from musculoskeletal problems related to their practice. Their approach requires adequate knowledge adapted to the needs and capabilities of each instrument, and few occupational therapists, physiotherapists or kinesiologists have specialised in this field of rehabilitation.
The existence of specialists in the rehabilitation of musicians is a necessity, and Noemi Álvarez Vázquez is one of the leading professionals in this field. Her work as an Occupational Therapist and her experience in the music support her extensive knowledge and clinical experience.
Introducing Noemí, Occupational Therapist and Specialist in the Rehabilitative Treatment of Musicians
Noemí is an Occupational Therapist with a passionate interest in hand therapy, especially in fractures, carpal instabilities, tendon rupture or neurological affectation of the hand and fingers.
She currently directs the Reconecta Rehabilitation Center in Avilés, Asturias, Spain, and is also part of the Urimas project (Musician’s Integral Rehabilitation Unit in Asturias), the first integral rehabilitation unit for musics.
Noemi has already written about her work and experience with ReHand on her Reconecta website.
Interview with Noemí Álvarez
We interviewed her and this is what she told us:
How did you decide to start into the world of music rehabilitation? Do you play an instrument?
“Yes, I have always been closely linked to music. I went through many instruments (piano, drums, bass, and even singing), but there was always one that I came back to, the guitar, formerly Spanish guitar, now acoustic guitar.”
Have you suffered any musculoskeletal problems associated with your practice? Anyone close to you who has suffered from it?
“Yes and no. I mean, from a biopsychosocial model, there were moments in my life where several concerts coincided together, plus the inexperience on stage. That meant that when I was on stage, the anxiety I felt translated into muscle fatigue. It never led to the injury, but it is true that I became more and more aware of this “playing with tension” and not only the forearms, as was my case, but also tension in the jaw.”
Musicians are patients who frequently seek help at physiotherapy centers. The members of the ReHand team have treated more than one patient for entrapment neuropathies or non-specific pain, but with a large psychosocial component (stress, studies, hours of practice, etc.). They are very particular patients so we would like to know your experience. What pathologies do you usually receive in the consultation? Are they usually related to the technique? What do you think about the psycho-social factors?
“What I usually see are specific finger problems. Hand pathologies are associated with staying for a long time in one position with an instrument, for example, a clarinet. It is true that URIMAS has been formed this year, and I can proudly say that it is the most beautiful project I have. We do not have a physical headquarters as such, but we have our centers to make assessments and treatments (either together or individually).”
“In my case I also receive low strings, both guitar, and bass players -the problem is that there is already a very integrated model of work with pain-. I have had to create very original splints because the patient has told me directly that he/she had to keep playing. Then you look for or invent how to support a joint without taking away sensitivity.”
Pain in the Musician
Pain is a patient’s own unique experience, which is influenced by many factors. In this regard, do you see any particularity in the pain of musicians? Do musicians usually know the complexity behind musculoskeletal pain? Or do they follow the mechanistic vision?
“It strikes me when I go to Jams or when I talk to musicians in general. I realize they have all felt pain at some point in their career, yet they don’t give up.
“Meaningful occupation is over pain perception. In addition, we also encounter the psychological barrier of “if you can’t play then you are not up to it, because another musician played with a fractured finger“. And for example, in the case of guitarists, they can have a bandaged hand or a broken finger and continue to play. I have seen that, and even cases of drummers playing until they bleed and not being aware until they see the blood!”
“There is usually a lot of stimuli, light (but a lot of light), very high volume, sometimes alcohol, and a premise of “no pain, no gain”. Somehow there has been an apprenticeship of pain normalization.”
“even cases of drummers playing until they bleed and not being aware until they see the blood!”
How do you educate these patients on something as complex as pain? Do you use any material?
“I try to be realistic and work on the instrument itself. To strengthen the specific musculature to protect that musician. For example, a bass weighs around 4kg. If we always rehearse standing up, and that back is not toned -maybe not- but some discomfort may appear.”
“When I ask if they have been to rehabilitation before, they usually say yes, and I ask them about this subject, mostly because I believe that what gives us the most realistic view of the damage is in the occupational analysis -this is the essence of OT-. If I do not analyze the movement pattern, the gestures, the beliefs, the musician’s motivation, how can I modify anything? It is very difficult.”
“When I talk to patients about pain, I try to avoid this word unless they mention it -then yes, I adapt to the vocabulary-. I also try to make clear the idea of pain does not have a single variable. Just as it does not appear from one day to the next (trauma aside), neither does it readapt from one day to the next.”
“The final essence of any rehabilitator has two lines, on the one hand, avoiding pain as much as we can, and on the other hand, being careful of not affecting the hand function.”
“Of course. If we take into account the concept of function, it is very difficult to analyze it outside the real context of the person. What’s more, in consultation they usually play very well placed, then you go to a concert, or to a rehearsal and then everything changes.”
“So no, I don’t use any specific material. The most important thing for me is the education for the patients, to make them understand the basics of the treatment and to make them understand that this management is theirs, the decision to do it or not to do it. “
“Surprisingly, people react well. One of the protests I’ve heard is, “They ask me to play with my back straight and I can’t.” I don’t know to what extent, playing with a straight back correlates with more pain.”
“What I see on a daily basis is that the musicians who get injured the least are usually people who manage themselves very well on an emotional level and are able to feel the movement.”
Musician’s Focal Dystonia is a motor disorder in the practice of the instrument that can sometimes lead to the end of a professional career. It is estimated that 1% of all professional musicians suffer from the well-known Focal Dystonia, a figure higher than other population groups such as those engaged in writing, golf, or dart throwing. (Altenmüller E et al 2009)
Could you tell us what exactly Musician’s Focal Dystonia is?
“I know of a few cases, but realistically, I haven’t had to deal with any yet. The description of dystonia – informally – is the development of maladaptive plasticity. That is, there is an over-representation of that movement in the brain and the moment the precise movement is requested, for example, playing a piano key, the dystonic movement is automatically generated.”
How do you usually approach Focal Dystonia? Do you use exercise or manual therapy? what do you usually evaluate?
“The goal and the complexity of this process is to displace an automatism and generate another one so strong that it displaces the previous one (in this case a functional movement). I don’t know how manual therapy impacts, to be honest. Although it is a useful tool, it is not my priority. In the end, as an occupational therapist, the essence is in the analysis of the activity and manual therapy.
I repeat the idea that I have never treated dystonia, but there are standardized scales that allow us to know the degree of dystonia that the person has, for example, the Tubiana and Chamagne Scale (TCS). It is also important to do an Occupational Profile of the person considering even the emotional part.
The goal of rehabilitation is to distract the brain so that the dystonic movement does not occur (environmental modification, virtual reality, task-oriented motor learning, changes in activity…)”
How do you plan a motor retraining session in these patients? How do you evaluate the changes?
“Well, in a first session I would try to explain to the patient what motor retraining consists of, the reasons for choosing their treatment, and resolve doubts regarding what is happening to them. It is very important that the person has the information about what is happening, so it will be easier for him/her to make decisions.”
“On the other hand, I would try to set realistic medium-term goals. Dystonia, even if it is detected early, is going to run its course, with all that entails. It is important to plan expectations.”
“In terms of technique, I would try to use conscious processes (non-automated processes) in accordance with the new learning. I would also include a very strong part of differential learning. What is very clear to me is that I would talk to Jaume Rosset Llobet again to ask him for some advice.”
Remember to visit our Post about…
The most personal part: the music itself.
Speaking of music, I couldn’t let the occasion pass… Tell us which are your three favorite bands or the ones you listen to the most nowadays! Any favorite style? I know Janis Joplin is one of your weaknesses… 😉
“Uah, my three favorite styles are Rumba -flamenco guitar-, Funk and Pop Rock. As for favorite groups, there are so many… lately, I’m very attached to Country – I have a group of this musical style-. It’s difficult to have a favorite band. I tend to go by periods, but I love Foo Fighters. Janis is without a doubt a legend, she can’t be missing in our repertoire, and I even give myself an air -physically speaking-.”
Any instrument you’d like to learn to play?
“All of them. I tried the bagpipes once, but I got dizzy just by taking a breath. I went through guitar, bass, drums, voice, piano ….. The one I dedicate the most time to is the guitar -it’s also the easiest to take to places-. Actually, I was always intrigued by the violin and the saxophone.”
What would you recommend to those who want to train in Hand Therapy or in the approach to the Musician from Occupational Therapy or Physiotherapy?
“Regarding Hand Therapy, building a knowledge base of anatomy and clinical reasoning. There is not a specific training that will give you all the knowledge you need, that is impossible, but a good base in anatomy, splinting and the most frequent pathologies in hand therapy, can help you a lot in building knowledge. Experience is a rank, and that is time, but if we do the search the other way around (having a clinical case in mind) it is much easier to know what you need.”
“As for musicians, I think being straddling the two worlds gives a very different perspective, you see things that other people who haven’t been on stage don’t think about. There are several formations in Barcelona in terms of musicians. Anyway, each instrument is different, it could be interesting to focus on one sector.”
Altenmüller E, Jabusch HC. Focal hand dystonia in musicians: phenomenology, etiology, and psychological trigger factors. J Hand Ther. 2009 Apr-Jun;22(2):144-54; quiz 155. doi: 10.1016/j.jht.2008.11.007. Epub 2009 Mar 10. PMID: 19278826.