Things Are Seldom What They Seem

Little Buttercup’s wisdom

Little Buttercup’s wisdom, “Things are seldom what they seem,” quoted from Gilbert & Sullivan’s HMS Pinafore, can be liberally and usefully applied to many occasions. Here it serves as a segue to discuss how musicians can find quality medical care, and no, this is not an oxymoron. As I probably need not tell you, the general public’s perception (including that of many of my colleagues) of what you do for a living is indeed “playing,” a misnomer if ever there was one. However, I’m here to tell you that there are people dedicated to your well-being who understand the risks of orchestral musicians for occupationally-related injuries. Furthermore, they also understand that even non-musically-induced maladies, such as arthritis or physical trauma, can impact performance. In fact, the diagnosis of many problems common in musicians requires a unique combination of medical skill and musical knowledge.

How does one go about getting the specialized care required by musicians? In this article I will look briefly at what advice is available, and give you some of the pros and cons regarding selecting care, to help you arrive at better-informed decisions that can best serve your needs. Specifically, I will talk about self-diagnosis – what I refer to as diagnosis by stand partners or hearsay, medical information on the World Wide Web, non-traditional medical care, and traditional medical care. By necessity this discussion will be general, and inevitably cannot cover every conceivable situation or alternative. But I offer it as an attempt to provide some common sense guidelines for getting sound medical advice.

For starters, here are a couple of sweeping statements about medical symptoms and diagnoses typically confronted by instrumental musicians. The good news (as implied by Ms. Buttercup) is that the vast majority of problems are not the serious problems they at first may seem to be, but are self-limited and often will go away with quite non-specific care, even self care. Therefore the first job of a musician confronting a medical problem is to self-assess with discretion. This should include questions such as:

• 1. Has this ever happened before and, if so, what did I do about it?
• 2. How did it resolve, etc.?
• 3. Did I do anything different in the recent past, musically or otherwise, that might be responsible?
• 4. How and when does it bother me most?
• 5. Does not playing make a difference, etc.?
• 6. What happens if I back off from playing to a degree, or entirely if necessary, for 2-3 days?
• 7. If I use some ice, take some ibuprofen or similar drug, and wait?
• 8. How long should you wait?

No absolutes exist in most medical affairs but here, as always, use common sense. If the condition clearly is waning after a few days of simple measures, stay with what’s working. If it remains, gets worse, or if you are worried about it (never a helpful feeling when you’re ailing), get some professional help.

At the risk of sounding arbitrary and judgmental, let’s talk about some sources of health information about which I, a physician dedicated to the care of musicians since the 1970s, have serious reservations. That is, I readily admit to some bias that comes both from training, and from years of working with ailing, as well as healthy, musicians.

Self-Diagnosis

A lot of people, musicians and others but especially musicians, are scared stiff of something “bad” happening to their health that might affect what is both their livelihood and their passion. Often they have an inborn distrust of people in my profession, some of it based on past negative personal experiences, on hear-say, on miscommunication, and on unrealistic expectations (“cure me!”), or simply because they are generally apprehensive.

Thus the natural instinct is to go for trust: authority figures such as parents, spouses, significant others, stand partners, teachers, or other musicians known to have had their own medical misfortunes. This is understandable, but not realistically the way to get informed and medically-credible advice. The seeming same symptoms in more than one individual may have entirely different underlying explanations. Only people trained to take an appropriate history, do physical evaluations, and perform what is referred to as a “differential diagnosis,” are qualified to give potentially reliable advice.

I like to say in this regard that more people walk into my office with a diagnosis of carpal tunnel syndrome, based on their stand partner’s diagnosis, than emerge from my office with that diagnosis. Differential diagnosis takes experience and can lead us into grey areas. It is frequently difficult to make accurate and specific diagnoses on any patient, musician or not. The unique feature of musicians as patients, and why the specialty of performing arts medicine has taken off to the extent that it has, is that the symptoms with which musicians present are often subtle.

Musicians’ symptoms are not the stuff on which most medical texts are based, so careful practitioners must know not only their medicine but also their music. More often than not, one needs to put together the risks under which the musician performs (instrument, repertoire, technique, hours, and especially intensity of playing), and one’s knowledge of anatomy, physiology, pathology, and psychology. Even this broad approach to evaluating a musician patient may not lead to a positive diagnosis, although it often helps us rule out some conditions and can give us a ballpark idea of the problem at hand, which is sufficient to give reasonable therapeutic advice.

Medical Information on the Internet

The lay press often does contain good scientific medical information, but how to appropriately apply this information is a different matter. As we all know, there is so much information available on the Internet that it is impossible to discern which information is reliable and which comes from totally anecdotal, biased, and scientifically misinformed and misleading material.

The difference between information from scientific sources and from some of what is published in the lay press is that there is documentation. (To everyone’s distress, especially those of us who consider ourselves “scientists,” none of this is 100% reliable, as uncovered with the stem cell work recently published in one of the most highly prestigious scientific journals.) But as is particularly true of material from the Internet, there is absolutely no way of documenting where this information comes from. Anyone can post anything on the Internet. This is not necessarily intended to be misleading – it may come from one person’s experience and is described from a totally subjective point of view. But it is scientifically unsophisticated.

Reading never hurts anyone, but when reading medical information that comes from unknown sources on the web, particularly case reports, the information must be regarded with a high degree of suspicion. There are, indeed, many web sites that do provide absolutely scientifically reliable information for reading by the general public. Nevertheless, to go the next step from reading by a non-medically trained musician to interpreting medical symptoms is a hazardous step, and can lead to both unrealistically pessimistic or optimistic self-diagnoses.

Alternative Care

A discussion of the wheres and whyfores of what is referred to as “alternative care” cannot be adequately examined in a brief article. There are many different types of such care out there, and even that which has the same label, e.g., “chiropractic,” can mean entirely different approaches, one from the other. There are two givens here.

• 1. The first is that many people, perhaps artists in particular, gravitate with a sense of trust towards alternative care. I think this comes both as the result of some successful encounters, and from the aforementioned distrust of traditional medicine. There is also what is often a mis-perception – that such care is less costly.
• 2. The second given is that the training and understanding of the cause of illness and injury is often poles apart, due to the differences in training and philosophy regarding the explanation of disease between traditional and alternative care practitioners. The issue that those of us in the traditional camp have with alternative care is that much of it has not been subjected to rigorous, scientific inquiry and measurement, as has traditional medicine.

Those things said, I will say that all of us do some things right and succeed, but all are fully capable of errors of commission or omission, or just bad luck. The concern is that when the diagnostic criteria are not specific to a particular problem, then the treatment may not only be inappropriate but may be injurious, and that delay in more specific and traditional therapy may even result in an increased level of pathology and disability.

Instrumentalists can find help from a variety of sources that (and again I admit to some bias) is increasingly informed and understanding of what can happen to you, even in the absence of characteristic textbook-type presentations. Rarely is anything that happens a true emergency, so multiple opinions are frequently the way to go – certainly if anything invasive is suggested, such as injections or surgery.

In many cities in the US and in Europe, there are people who have made it their business to provide excellent care to musicians. However, that does not always mean that a definitive diagnosis can be made, and usually means that there is more than one way of treating medical problems.

The organization founded in 1989 in Aspen, the Performing Arts Medicine Association (PAMA) has a web site, www.artsmed.org, that provides names of practitioners geographically closest to you. (These are names of people without any specific accreditation but who belong to the group, and at least have a demonstrated interest and hopefully expertise). Some clinics advertise on the web, and some orchestras keep the names of physicians who have served their members well in the past.

One practical issue is financial. HMOs and PPOs may or may not understand that a musician really does have special problems, and that sports medicine physicians, rheumatologists, or neurologists, absent some experience with playing instruments themselves or informing themselves, do not automatically fill the bill. Currently the delivery of all medical care tends to be something of a nightmare. All I can promise you is that there are people available for you, and that your medical musical health is of supreme importance.

Don’t allow your anxiety, impatience, or frustration in accessing care to compromise your ability to play at your top level. Do remember that most of the things that happen to musicians are more nuisance than threat, but neither should they be ignored or mistreated, by you or your caretakers.

Alice Brandfonbrener holds an M.D. from Columbia College of Physicians and Surgeons. She is on the faculty of the Medicine and Physical Medicine and Rehabilitation Departments at Northwestern University Medical School in Chicago. She is the founder of the Medical Program for Performing Artists at the Rehabilitation Institute of Chicago, and for 20 years served as the editor-in-chief of the journal, Medical Problems of Performing Artists. She was co-editor of the text, Performing Arts Medicine, has written chapters for many books, contributes articles to medical and musical journals, and is a frequent lecturer.