Interest in Arts Medicine Swelling to Crescendo : Ailing Musicians, Dancers and Actors Are Seeking Help at Specialized Clinics

Violist John Jake Kella was on holiday. The Metropolitan Opera season was over, the American Ballet Theatre season was over, and the chamber music groups he played with were taking a breather. Kella put his viola on the shelf and spent most of two months reading, writing and pursuing assorted projects.

When New York-based Kella, under contract with both the Met and ABT orchestras, took down his viola again for the current season, he assumed he could go back to playing with the same intensity he had before his vacation. “But my left shoulder said no. It wasn’t ready.”

In pain and unable to raise his arm for nearly a week, the 38-year-old musician packed his viola and headed to St. Luke’s/Roosevelt Hospital Center where he performed a mini-recital for Dr. Patrick J. Fazzari, director of rehabilitation medicine. The physician “watched the way I moved, the intensity that I played with and spots where the injury was. (Then he explained) why it had occurred and what exercises I could do to prevent it happening again.”

Acute Tendinitis

Diagnosed and treated for acute tendinitis of the rotator cuff, a group of muscles that surround the shoulder, Kella is one of a growing number of musicians, dancers, actors and others being treated at specialized arts medicine clinics in such cities as Cleveland, Chicago and New York. Summarizes Dr. Alice Brandfonbrener, editor of the new journal Medical Problems of Performing Artists, and founder of an annual conference on arts medicine in Aspen, Colo.: “There’s a crescendo of interest.”

San Francisco’s Performing Artists Clinic opened at UC San Francisco in April, and discussions are under way to launch a similar clinic locally. Ear, nose and throat specialist Martin Hopp said that he and partner Dr. Robert Feder last summer approached a local medical center about incorporating such a facility there.

‘Performance Evaluation’

“There’s a tremendous population and wide variety of performing artists located in the Los Angeles area,” Hopp observed. “Individualistic problems associated with their profession often are not the routine medical problems taught in medical school.”

In New York, for instance, the newly expanded Miller Health Care Institute for Performing Artists of St. Luke’s has created a “performance evaluation” room complete with piano, mirrored walls, rehearsal barre, even a “sprung” floor to replicate the performer’s professional environment. There is also video equipment so that doctor, performer and teacher can critique together what the performer is doing that might be contributing to the problem. Says institute medical director Dr. Emil Pascarelli: “We look at how violinists hold violins the same way (our colleagues) evaluate the golfer’s swing and the batter’s stance.”

Majority in Pain

And many violinists are in pain, physicians say. Dr. Fadi Bejjani, director of the Orthopedic Center for the Arts at New York’s Hospital for Joint Diseases, estimates that about 70% of professional musicians will be ailing at some point in their lives.

Consider the Los Angeles Philharmonic. Personnel manager Irving Bush figures that “at one time or another, just about everyone has a problem. Some just live through it, keep working and are comfortable enough to continue playing. Gradually it disappears or they play with some degree of pain throughout their careers.”

Bush reports tendinitis, sore necks and shoulders, and neurological pain in the string section; hernias, dental and facial muscle problems in the brass section. Philharmonic trumpet player Boyde Hood adds that during summer’s Hollywood Bowl sojourns, brass players breathing deeply “find ourselves coughing and getting chest pains. When the smog is bad, it really affects the way you play, and if you’re downwind from the smoke during a fireworks concert, you have to be real careful breathing.”

What they do for love. One local musician says he tends to scrape his cuticles raw on the steel strings of his electric guitar. Max Weinberg, the drummer in Bruce Springsteen’s E Street Band, woke up the day after the band recorded “Born in the U.S.A.” and couldn’t move the fingers on his left hand; he later had surgery on each of seven injured fingers.

Dangers of Dancing

Medical journals almost routinely document the nutritional and skeletal problems of ballerinas. One article in the New England Journal of Medicine earlier this year, for instance, found that in a survey of 75 dancers from four professional ballet companies, the prevalence of scoliosis, a curvature of the spine, was 24%; the incidence of fractures was 61%.

Dancing can be dangerous. Orthopedic surgeon Dr. Dan Silver, for example, had to tape dancer Julie Janus’ arm following her performance with the Joffrey Ballet here. “The choreography called for (Janus and another dancer) to interlock their arms. Apparently they missed their timing and his full body weight pulled against her frail arm, causing a partial tear of the muscle.”

Sports Medicine Link

The waiting room in Silver’s Westwood office features Joffrey brochures alongside copies of Running Times, Tennis and Ski magazines, and many physicians consider dance medicine an outgrowth of sports medicine. (Dancers like Mikhail Baryshnikov, for instance, have profited from the same advances in arthroscopic knee surgeries that marathon runners have.) Orthopedic surgeon Dr. William Hamilton, doctor to Baryshnikov and colleagues, quips that his partners take care of the Mets “and my teams are the New York City Ballet and the American Ballet Theatre.”

Treatment varies. Violist Kella, for instance, was treated with anti-inflammatory drugs as well as with ultrasound and physical therapy. And both Kella and Weinberg were taught to approach their work the way runners and other athletes approach theirs. Now Weinberg warms up before performances, and literally cools down afterward, soaking his hands in ice water for 25 minutes after each concert. Kella, in turn, does 20 minutes of exercise both before and after rehearsals and performances.

Film Approach

“I try not to get directly involved with the patient’s playing technique,” says St. Luke’s hand therapist Caryl Johnson, a graduate of the Juilliard School of Music as well as a registered therapist. “If we feel a problem resulted from (the musicians’) way of using their instruments, we film them playing those instruments and show them the film. Together we can discuss their posture and physical approach to the instruments.”

Johnson tries to put together a personalized exercise program for each of her patients and, often, suggests or even makes adjustments in playing postures. In the case of a clarinet player, for instance, she made a splint out of plastic designed so that the clarinet’s weight would be transferred from the musician’s thumb to his forearm.

Bejjani thinks as many as 90% of artists’ ailments may be due to repetition, and other physicians agree. “(Violists like Kella) have to elevate their arms over and over, and the problem becomes one of chronic wear and repetitive trauma,” orthopedist Silver said. “Dancers have their own pattern, but again it’s primarily overuse.”

An ailment that may be irritating to most of us can be devastating to a performer. “Minor changes in voice to someone who doesn’t use his voice for a livelihood may not even be detected, or he’ll forget about it during the day,” Hopp said. “(But) a small cold minimally affecting the nose or throat can take . . . an opera singer from a virtuoso performance to a very mediocre performance.”

Faulty Technique

Bejjani says several factors must be considered when diagnosing and treating performing artists: “Musicians and dancers start at a very young age, so that whatever is happening is happening through the growth spurt. (There is also) the whole stress of performing and competition, the irregularity and intensity of their schedules. . . . Their task is dictated to the millisecond and they have to follow a certain tempo regardless of pain.”

Dancers also can suffer from faulty technique, New York osteopath Richard Bachrach said. “Most injuries in any sport or physical activity are caused by technique problems--such as not holding the tennis racquet right--and it’s the same with dancers,” said Bachrach, who runs New York’s Center for Dance Medicine. “There’s no contact, no racquet or golf club, no football to throw but a body to move. So if you don’t move it right, you’re going to get hurt.”

‘Disaster’ File

For musicians, the problem can be the music itself, therapist Johnson said. “I keep a file of disaster passages for each instrument. We can analyze them and (observe) what Liszt, say, might have done easily with his hands that this patient finds more difficult. Intensity can also create a problem by increasing tension in muscles which impede playing rather than contribute to playing.”

Other causes can be more elusive. Hopp recently examined a singer who was losing his voice in mid-tour. In addition to standard questions, the doctor asked a few untraditional ones: “A major part of his exam was comparing his current tour with his previous tour--the songs he sang, how he sang them and in what environment. It turned out that in this tour, he had a new smoke machine blowing fog into the stage. And as he described the show to me, I realized the big difference was the source of the smoke (which) was affecting his voice. When he eliminated that, his voice got better and he was able to finish his tour.”

The Anxious Performer

There’s also performance anxiety, adds psychiatrist Peter Ostwald, co-director of the San Francisco-based Performing Artists Clinic. “It takes a certain amount of very critical physical coordination to play a musical instrument, and performance anxiety can produce physical symptoms which interfere with the competency of the musician. For example, a singer might find it difficult to have adequate abdominal support of his voice if he has butterflies in the stomach. Or a violinist’s bow might begin to tremble.”

Ostwald said the anxious performer can be treated with a beta-blocker--a drug most commonly used to treat high blood pressure, but prescribed in such cases to remove the undesirable physical symptoms of stress--or by analyzing through discussions why the anxiety has become so severe. Stress can also result in gastric acid heading up from the stomach into the esophagus and throat, and Dr. Dale Rice, chairman of USC’s ear, nose and throat department, said that he and other physicians often wind up putting singers on antacids as well as more obvious throat medications.

When disaster strikes midway through a dance, theater or concert tour, health professionals recommend “selective rest” and temporary measures to get the performer through without permanent damage. “There’s none of that nonsense about going to bed for 10 days,” actress Barbara Rush says. “You say you can’t. I have a show tonight.”

Since you can’t tell an ailing musician to stop playing, just like you can’t tell an ailing Olympic runner to stop running, doctors often improvise. For instance, Pascarelli of St. Luke’s rushed to the rescue when pianist Rosalyn Tureck hurt her back prior to a Carnegie Hall appearance. The physician messengered ice packs to her rehearsal hall, prescribed medication that would dull the pain but not knock her out during the performance, and made himself available during the concert should she need him. “My heart was in my throat,” he confesses, “when I saw her pick up and move that heavy (piano) stool.”

Musicians, dancers and other artists long suffered in silence. Then came the well-publicized disabling hand problems and treatment of pianists Gary Graffman and Leon Fleisher in the early ‘80s. San Francisco’s Ostwald applauds their courage in going public, adding that “I’m not sure it helped those people very much, but it created a focus of interest and concern among the public in general, among physicians and (among) other artists who then felt able and courageous themselves in terms of seeking treatment.”

Only Left-Hand Pieces

Graffman today plays only left-hand pieces and is employed as music director at the Curtis Institute of Music in Philadelphia. “If it happened to someone else, and was publicized as much as it was in my case,” Graffman said, “the first time there was the slightest possibility of a problem, I would have contacted the doctor.”

Some doctors feel performers are still not likely to seek treatment for injuries. Orchestra members are protected by unions, Graffman said, but soloists would probably keep quiet, “if they can play. . . . A conductor can find any one of 10 people who could play the same piece.”

Dancers also often ignore their problems, Bachrach added. “They feel they are invincible or worry that if (potential or current employers) find out about it, it would be a catastrophe, and their careers would be over. They think if you miss one class, you know. If you miss two, the teacher knows. And if you miss three, the whole world knows. And they’re right. This is not a part-time occupation.” Adds Pascarelli: “A performer viewed as disabled is not going to get work.”

Yet the situation is clearly improving. “It took (pianist Gary) Graffman at least five years to come in and today we see people whose problems began less than five months ago,” says Boston-based Dr. Frederick Hochberg, one of a team of physicians who treated Graffman.

“People are now aware that there are centers throughout the U.S. with physicians willing to try to understand hand or arm difficulties in terms of musical technique,” says Hochberg, a member of Massachusetts General Hospital’s Musical Medicine Department. “Before these centers, the most common diagnoses were unrelated to the playing, so people would see inflammation of a tendon or muscle and pay no mind to the fact that this problem had occurred in their colleague in the same way.”

Local Interest

While Los Angeles still has no specialized clinic like those in New York and San Francisco, several area doctors and hospitals do provide such care. Orthopedist Silver, who runs a Monday evening dance clinic as well as an annual seminar for dancers, says he also hopes to organize a similar seminar for musicians, singers and other performers in the summer of 1988.

Individual local doctors also express considerable interest in treating artists. “The whole reason I went into medicine was to treat dancers,” says Beverly Hills orthopedist Dr. Ilona Hirsch, a former dancer. “I realized that most physicians aren’t particularly interested in taking care of dancers. They don’t make good patients, because they don’t follow directions, (and they) want instant cures. They believe anybody that promises them something instantaneous. . . . And unlike professional athletes, they don’t have multi-million dollar contracts.”

Other physicians around the country indicated a similar passion for dance or music, and many play musical instruments themselves. Chicago-based Dr. Alice Brandfonbrener, who directs Northwestern Memorial Hospital’s Medical Program for Performing Artists and started the medical journal in her field, raised a son who plays cello with the St. Paul Chamber Orchestra and a daughter who plays viola with the Harrington String Quartet (in Canyon, Tex.).

Equally important, these arts-minded doctors speak the same language as their patients. Boston orthopedist Dr. Robert D. Leffert, for example, wrote in HMS Health Letter earlier this year that when a pianist says “I notice a bogginess when I attempt to play the Beethoven E-major sonata” he means, “I notice a new stiffness in my right hand when I try rapidly alternating two keys.”

A Different Story

Arts management is more sympathetic today, adds Los Angeles Philharmonic executive Bush, a member of the orchestra himself for 20 years. “Twenty-five or 30 years ago, if a musician was sick too much, he could lose his job. Today it’s a different story because everybody’s extremely vocal and musicians have much more job security than they’ve ever had. When musicians are ill, they have medical and disability insurance, sick leave and more avenues and procedures for (complaining and redress).”

Yet it remains difficult to advise successful professionals to change techniques that work. “How can I tell Misha (Baryshnikov) to change?” asks his physician Dr. Hamilton.

Better to start with young people. Experts frequently talk to students and faculty at music schools, and Chicago physician Brandfonbrener alone was in Indianapolis in September for the Indianapolis International Violin Competition, at the Curtis Institute of Music in Philadelphia in October, and the San Francisco Conservatory of Music in November.

“It’s a revelation to me that something as simple and direct as doing 20-minute warm-ups and cool-downs can mean so much to my longevity as a performer,” says violist Kella, back to playing full-time again. “It is also very exciting that there is such dialogue between the arts professions and the health-care professions. Doctors can help performers, and performers can help train physicians in how to care for us.”

Times librarian Tom Lutgen contributed to the research on this article.