FEATURE

Note: We hosted a special event on this topic in the Guitar Talk Forums on Friday, August 11. Author Hassaun Ali Jones-Bey was on hand to discuss guitar-related injuries. The threads from that discussion are still active, and you are welcome to post additional questions or share your experiences and wisdom online. Read more about Jones-Bey at his Web site.

Guitarists’ hand injuries are most often due to the repetitive stress of playing for hours on end without taking adequate breaks. Even though disabling pain may show up in the lower arm or hand, most injuries result from a chain of events that starts in the head. Creative mixtures of rest and playing are as essential to healthy musicians as creative mixtures of silence and sound are to good music.

Maintaining a healthy lifestyle and attitude toward music can go a long way toward helping you avoid injuries and heal them when they do occur. To get some advice on this area of perennial concern to guitarists and other instrumentalists, I talked to health-care practitioners who deal with musicians’ injuries as well as professional guitarists who have successfully avoided or recovered from debilitating injuries.

A HEALTHY PLAYING ENVIRONMENT

Repetitive strain injury (RSI) is the most common diagnosis that Lillie Rosenthal, M.D., makes in her practice as a specialist in physical medicine and rehabilitation at the Miller Health Care Institute for Performing Artists in New York City. Her patients often arrive complaining of burning pain or aches anywhere in their hands, arms, and neck. "It’s usually a multifactorial problem," she says. "Musicians are playing for several hours without taking a break, they often have poor posture with and without the instrument, and they may be mentally stressed, which greatly affects the body. I often see people who have been playing for many hours before a performance or a recital and haven’t paid attention to the basics."

Rosenthal stresses the importance of warming up with stretches before touching the instrument and taking breaks every 20 to 30 minutes. Musicians should take breaks away from their instruments, stretch, and move around. Rosenthal herself is a dancer, not a guitarist, so she leaves the details of her recommendations to the patient, but she emphasizes that establishing some sort of preventive routine is essential to the long-term healing process. "You can give the musician a pill and say, ‘Hope you feel better,’" she says, "but the problem is likely to return unless the whole practice or playing environment changes."

Assessing the practice and playing environment is also a crucial step for Robert Markison, M.D., a hand surgeon in San Francisco who specializes in performing artists’ upper extremity problems. But for Markison, a jazz musician who plays a variety of wind instruments, the problems originate with the musician’s approach to making music. "I need to know if they perceive music making as an unbelievably steep learning curve, which they can only surmount by practicing four, six, or eight hours a day," he says. "I try to perceive whether there might be harmful behavior based on insecurity, or whether somebody is a mature musician experiencing normal wear and tear."

Both physicians stress the importance of healthy lifestyles, including rest, diet, exercise, fitness, good playing posture, and proper instrument fit as crucial factors in restoring and maintaining a healthy music-making physiology. But ultimately no amount of exercises or procedures will overcome chronic, harmful playing and practice patterns. "You are doomed if you play too many hours during the day," Markison says.

KNOWING WHEN NOT TO PLAY

The difficulty comes with putting this advice into practice. For instance, classical guitarist Scott Tennant’s practice sessions with the Los Angeles Guitar Quartet are four hours long. And his heavy practice days, when he is preparing for a big project or imminent deadline, start when he gets up in the morning and don’t end until he goes to bed at night. Transforming such a demanding schedule into a healthy environment for playing and practice involves, he says, "playing a certain way, and knowing when not to play."

The first rule is to stop playing until the pain goes away, not try to work through it. "I don’t sit back down until I feel totally refreshed and recovered," Tennant says. "That might be the main reason my aches and pains don’t turn into big problems." Even without pain, his upper limit for a physically and mentally comfortable practice session is a little over one hour, followed by a break of a similar length. "If I have a problem I can’t solve in my practice, I will take a break and I won’t go back to practice until my head is clear," he says.

Nonetheless, such heavy practice days are far from his daily norm of two or three hours. On LAGQ rehearsal days or when other activities interfere, his practice time might only consist of half an hour on some particularly tough material. "A concentrated half hour is better than nothing," he says. "I do that a lot. I also practice in my head when I don’t have my guitar." He also goes for days at a time without practicing at all. "I try to balance my really heavy periods of playing with really short heavy periods of nonplaying," he says. "I find it healthy for my head, too--not just for my body."

THE PATH OF LEAST RESISTANCE

Many musicians form healthy practice habits in the process of recovering from injuries that occur at crucial points in their careers. In 1987, self-taught fingerstyle guitarist Brian Gore was about to present his repertoire professionally. But a heavy schedule of practice, playing, and translating books from German into English resulted in a painful case of tendinitis that lasted for about three years. "It got to the point where it hurt when I woke up in the morning," says Gore. "It progressed from carpal tunnel syndrome to bursitis in my shoulders. And then I got diagnosed with thoracic outlet syndrome. It got so bad that I couldn’t open the door."

Gore’s journey back to his present career as a professional fingerstyle guitarist and founder of the touring International Guitar Night began with a visit to a general practitioner. The doctor recommended wrist surgery, which Gore chose not to undergo. He ended up in massage therapy, yoga classes, acupuncture, and psychotherapy instead--all focused on poor posture and tense shoulder muscles. After three months, the problem went away and Gore began performing again. The problem then returned and plagued him for another six months. "But because I did the yoga, I could work with it," says Gore.

Gore’s album The Path of Least Resistance (Acoustic Music Resource) got its name partially from the less aggressive playing style he adopted to reduce tension in every aspect of his music. Realizing that a lot of the inspiration for his works on steel-string guitar came from music that was originally played on less physically demanding electric and nylon-string instruments, he lowered his string gauges and worked to increase his hand strength. "I use a mixture of medium- and light-gauge strings now," he says, "and that’s very important, because if you just use light strings and you’re working in anything that’s lower than a D, you’re going to have problems with intonation."

To build strength without increasing tension and the risk of injury, Gore used classical and jazz guitar exercises to work on his strength and technical issues rather than trying to work out specific problems that arose in his own pieces. "If you bring your stress into your music, you become prone to injury, and a lot of stress in music comes from confusing the tasks with the project," he says. "If you have technical challenges within a piece of music, you have to look for ways outside that particular piece to solve those challenges."

The path of least resistance also extends to Gore’s new compositional approach in which, for example, he no longer uses five strings for something that can be accomplished with three. He has also adopted an elaborate routine for daily practice: yoga, followed by 20 minutes of left-hand strengthening exercises from Scott Tennant’s book Pumping Nylon, followed by arpeggios and scales and more yoga before he begins playing.

FIGHTING DEPRESSION

Peace of mind can help avoid injury, but injury can also devastate a musician’s peace of mind, according to Richard Kendrick, who teaches classical, jazz, and rock guitar at the Mission San Jose School of Guitar in Fremont, California. Kendrick was injured five years ago while working on his master’s degree in classical guitar performance and playing music seven days a week. He was practicing five hours a day, teaching, and playing gigs on classical, steel-string, or electric guitar.

"It was summertime and I should have been taking it easy, going to the beach or relaxing, because I had already paid my dues," he recalls. "I had already put in nine months of hard labor at graduate school. But getting ready for my last year, I was going to push it all the way through and be the ultimate classical player."

One day, Kendrick returned home after five hours of practice and a minirecital. He was absent-mindedly cracking his knuckles by hyperextending his fingers backward when something went wrong on his left index finger and Kendrick found himself lying on the floor in excruciating pain. "I went into an immediate state of denial," he says. "Being one unit away from my master’s degree, I wasn’t going to believe that I had done anything to myself by cracking my knuckle." Kendrick was sidelined from playing with a severe muscle strain for five and a half months.

He is fully recovered now, but Kendrick still thinks about the injury and the depression and anxiety that prolonged his recuperation. He had initially tried to continue his five-hour-a-day practice schedule without using the injured finger. When he did decide to seek medical attention, he bounced from doctor to doctor, which led to conflicting treatment regimens. "Bouncing from doctor to doctor was not a good thing to do," he says. "But I was completely desperate, and nobody seemed to understand the gravity of the situation. I couldn’t play. I was one year from my master’s, and I was jacked up. I was in horrible shape--depressed and still trying to give lessons on keyboard. It was pathetic."

That depression is all too common, however. "Depression goes along with these injuries, even if they persist only for a very short time," says Rosenthal. "Most musicians are afraid to admit that something is wrong, because it’s a highly competitive situation. They tend to ignore it and it gets worse. And that’s a really tough problem."

FOCAL DYSTONIA

The toughest problem that Rosenthal has to deal with is focal dystonia, because medical science has no idea what causes it. Several fingers on a musician’s hand just curl up and stop responding. There’s no pain.

In 1984, classical guitarist and composer David Leisner was about to sign a recording contract when several fingers on his right hand stopped working. He had won prizes in two major international guitar competitions. "My career was definitely on the upswing," he recalls. For five years Leisner went to experts in Western as well as Eastern medicine with no results. His attempts at treatment stopped after he underwent an eclectic Eastern therapy that had helped numerous musicians with different problems but seemed to make his condition worse.

A couple of years later, he started playing again using only the thumb and index finger of his right hand, and he resumed concert performances in 1991. "I was doing wild things with my thumb and index fingers that nobody could believe I was doing," he says. "But I was doing it, and I was making a good sound and a good impression."

A conversation in 1992 about using large muscle groups started Leisner on the road to recovery. "I had this image of swinging at the string with my arm from the elbow down," he says. "One big lever from the elbow down to the tip of my finger." He attempted that motion for about five minutes and found himself moving the ring finger that he had not used in eight years. He eventually visualized a connection between his fingers and a spot in the back of his shoulder, at the apex where the arm meets the torso, and he continued to work with visualization and exercises for three more years. It took about a year for him to recover full use of his middle finger in concert and another year for him to recover full use of his ring finger. Full recovery of his hand came in 1996.

During the course of his odyssey, Leisner saw a doctor who advised him to take up swimming. Even though the swimming didn’t help his focal dystonia, Leisner remains grateful for the advice. "I feel a lot healthier," he says. "And I understand a lot of things I didn’t understand before about how the body works and about relaxation as opposed to working."

Whenever he gets the opportunity, Leisner instructs other musicians with focal dystonia in the method that helped him. "I show them the basic idea. I show them exactly where the muscles are and how to feel it in the string or on their instrument," he says. "And then they have to take it from there and apply it." So far he has had more success helping individual musicians than communicating his methods to medical professionals. Part of the problem may be that his healing technique contains just as much art as science. He likens it to learning to play an instrument. "There are shelves of books written on technique for any instrument, and so few of them have mastered a really accurate way of describing technical things so that a person can just read the description and go do it on the instrument," says Leisner. "You’ve usually got to show it to somebody. And this, unfortunately, is no exception."

PRESCRIPTIONS

So what can you do to avoid injuries like these? Markison’s and Rosenthal’s prescriptions include a wide range of elements—from adopting a healthy music-making attitude and lifestyle to exploring various therapies and general hand-care advice.

According to Markison, musicians with the lowest risk of injury also tend to have a range of musical and nonmusical pursuits that provide creative and fulfilling opportunities even when their hands are not engaged with their instruments. "What you want to do is measure out beautiful music over a long lifetime and not assume that if you don’t get it in the next six months you’re done for," he says. Teaching, composing, arranging, improvising, and maintaining some involvement in other arts and social networks are all positive factors that lessen the risk of injury.

Rosenthal recommends aerobic exercise, drinking a lot of fluids, maintaining body flexibility, and getting plenty of sleep. She also stresses the harmful effects of smoking, drinking, and staying out late, which can prove challenging for musicians who travel frequently or who spend a lot of time in environments where smoking and drinking are the social norm.

Breathing and relaxation are also key factors, according to Markison, and he recommends meditation and breathing exercises. "String players are not good breathers," he says, "because breathing is not embedded in the mechanics of music making unless you are a wind player." Markison recommends Effortless Mastery by Kenny Werner, (published by Jamey Abersold) as a guide for more relaxed playing and breathing.

Markison also recommends improvisational source material in the Jamey Abersold jazz catalog for developing a more relaxed approach to making music, and Reed Kotler’s Transkriber software as a computerized aid to memorization of recorded music. Classical guitarist and composer Richard Iznaola has also provided an easy-to-follow guide for developing good practice habits in a concise 24-page booklet, On Practicing: A Manual for Students of Guitar Performance (see Resources).

Markison also stresses the importance of warming up before playing. He begins his examination of patients with a handshake. "The greatest risk group has cool hands," he says. He adds that poor circulation is bound to worsen when performance anxiety constricts the blood flow even further. "You’re not fit to play music until your hands are warm," Markison says. "You can increase microcirculation by prehydrating with at least a pint of water." In some cases, he also recommends boosting poor circulation by wearing fingerless gloves that can be custom-made to extend from the forearm to the palm.

Pumping Nylon by Scott Tennant, available in both book and video formats, contains comprehensive exercises for building strength and a daily warmup routine. The book also touches on aspects of breathing and performance anxiety, and the video gives additional postural and hand-placement guidance primarily for classical guitarists.

Other hand-care suggestions from Markison include contrast baths--for tendinitis, he recommends soaking your arms and hands in cool water for a minute and then in warm water for a minute (not ice cold or red hot). Repeat the cycle a couple of times (for a total of about four minutes). He also recommends massaging the hands and arms from time to time with hand cream or lotion, proceeding from the fingertips up toward the elbows. Gentle stretches are also important--from the forearms into the palms, palm up and palm down, stretching the wrist backward and then forward, and individually moving the fingers to get the tendons gliding independently. Some physical and mechanical stresses can be addressed with exercise programs, yoga, massage, or acupuncture, and therapies like the Alexander Technique can improve the body’s relationship to the instrument.

Sometimes a change of instrument or accessories can have an effect. Rosenthal asks her patients questions like: Have you changed your instrument recently? Have you changed the strings? Did you change anything on the fretboard? Has the style of your music changed? Have you been traveling more than in the past?

So what’s the bottom line in avoiding or recovering from injury? Kendrick seemed to sum it up with the following words of advice he received from a friend: "You don’t want to be a slave to your instrument."

RESOURCES

BOOKS

Ricardo Iznaola, On Practicing: A Manual for Students of Guitar Performance, Chanterelle, www.chanterelle.com

Scott Tennant, Pumping Nylon, Alfred Publishing, (818) 891-5999, www.alfredpub.com

Kenny Werner, Effortless Mastery, Jamey Abersold Jazz, (800) 456-1388, www.jajazz.com

STRING LETTER BOOKS

Stay relaxed when you do a gig. Discover what every musician should know before going on stage with Performing Acoustic Music.

Keep you guitar in the best possible playing condition. Learn about basic guitar maintenance and home repairs in the Acoustic Guitar Owner's Manual.

WEB SITES

Alexander Technique, www.alexandertechnique.com

Dystonia Dialogue, www.dystonia-foundation.org

Reed Kotler Music, www.reedkotler.com

David Leisner’s experience with focal dystonia, www.davidleisner.com

The Miller Health Care Institute for Performing Artists, www.millerinstitute.org

Musicians and Injuries, www.engr.unl.edu/ee/eeshop/music.html

Excerpted from Acoustic Guitar magazine, September 2000, No. 93.

 Return to Top