Compliments of the CMS Committee on Musicians’ Health
The Musicians’ Health Committee, comprised of medical professionals and music faculty, all strong advocates for musicians’ health, is happy to bring you a Q & A column for this month's CMS Newsletter. If you like this idea, please send us your musicians’ health-related questions which we will direct to our committee members, or other professionals with whom we have contact, to be answered in future newsletters. Gail Berenson and Linda Cockey, Committee Co-Chairs.
Q: “What’s the connection between psychological well-being and physical well-being while trying to stay healthy or when dealing with an injury?"
Answered by Dr. John Chong and Dr. John McMillan: February, 2021.
Dr John Chong, the Medical Director of the Musicians’ Clinics of Canada, has treated musicians with repetitive strain injuries, motor control problems, anxiety, depression, neuropathic pain, nerve entrapments, and stress-related disorders since 1986. His clinical and research interest is regulation of the autonomic nervous system using neuro-biofeedback techniques for the prevention of repetitive strain injuries, focal dystonia, chronic pain, depression and substance use disorders. He was a founding member, current Treasurer and past President of the Performing Arts Medicine Association, and an avid collaborative pianist and golfer.
Dr. John McMillan has been in practice as a physician at Musicians’ Clinics of Canada since 2011. Prior to his medical studies he obtained Bachelor’s and Master’s degrees in piano performance at the University of British Columbia in Vancouver, Canada.
A: The short answer is that “it is all connected” and we could leave it at that. But in 1948 the World Health Organization (WHO) adopted the definition of health is “… a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (https://www.who.int/about/who-we-are/constitution). Through the intervening decades this definition has stood up well, requiring not a single amendment. This is in part because subsequent research has borne out the interconnectedness and inseparability of these three dimensions of health, showing how a change in one often accompanies a change in another. The evidence-based response that follows is based on a 12-step approach to the neurobiology of stress and our clinical experience at the Musicians’ Clinics of Canada.
In the context of the life of a healthy performer, a balanced state of psychological health and social connectedness, coupled with good health habits including adequate nutrition and sleep, will help to maintain a healthy immune system. These are essential for repairing the daily wear and tear on body structures that inevitably accompanies dozens of hours per week of practicing, particularly during the college years. If a student remains mindful, pays attention to subtle signals when this balance is being disrupted, and corrects the imbalance at an early stage, they have a good chance at staying injury-free.
In the case where a performance-related musculoskeletal disorder (PRMD) has occurred, the value of improving psychological health must not be overlooked. Patients often come to our clinic with the approach, “If you can just fix my hands/embouchure/vocal cords, that will fix my life.” In a few isolated cases this might be true, but in the majority we usually counsel that if the patient can fix their life, it will be the start of fixing their PRMD. For these patients, the issue often exists in their minds as a malfunctioning physical structure; this structure is typically just the last link in a chain of insults that connects, via biochemical processes known as the “allostatic load”, to a pattern of thoughts and behaviours (https://macses.ucsf.edu/research/allostatic/allostatic.php). In re-establishing a healthy psychological state and shifting the balance from distress to “eustress,” the biochemical factors that favour tissue repair repopulate the system, which increases the chance that a lasting and resilient return to optimal physical health will occur. (https://positivepsychology.com/what-is-eustress/)
Consider the following “12 tone” concepts and associated links provided.
- New Frontier of Neurobiological Evidence – Brave New World (https://www.normandoidge.com/?page_id=1042)
- Neural Networks of Musical Performance – Singing in the Brain (https://www.oliversacks.com/books-by-oliver-sacks/musicophilia/)
- What Fires Together Gets Wired Together – Monkey See Monkey Do (http://danielcoyle.com/the-talent-code/)
- The Mind-Body Connection - When the Body Says No (https://drgabormate.com/book/when-the-body-says-no/)
- Homeostasis, Allostasis, and Allostatic Overload – Stuck On No Off (https://www.youtube.com/watch?v=AYFZAYenR20)
- What Happens to the Vagus Stays in the Vagus - Curious George? (https://www.stephenporges.com/books)
- The Stress-Pain-Inflammation-Depression-Disease Connection - Three Stooges Gone Wild (https://donnajacksonnakazawa.com/the-angel-and-the-assassin/)
- Targeted Humiliating Criticism – Whiplash (https://www.youtube.com/watch?v=7d_jQycdQGo)
- Biological Aging - Gang of Four Telotubbies (https://www.grandcentralpublishing.com/titles/dr-elizabeth-blackburn/the-telomere-effect/9781455587964/)
- Anxious to Make It Not Break It – One Wrong Note You Die? (https://global.oup.com/academic/product/the-psychology-of-music-performance-anxiety-9780199586141?cc=ca&lang=en&#)
- The Body Keeps the Score – Healing Journey (https://www.penguinrandomhouse.com/books/313183/the-body-keeps-the-score-by-bessel-van-der-kolk-md/)
- Tuning the Music Education Environment – Creating Resilience (https://oxford.universitypressscholarship.com/view/10.1093/acprof:oso/9780198525356.001.0001/acprof-9780198525356)
This will take some time to digest and reflect on what you have found exploring the links and leads generated by these significant contributions from the last decade or so. Then consider the formulation of an integrative approach summarized in the first “State of the Art Review” of the PAMA/NASM Task Force on Psychological Health.
The narrative in this document will fill in the blanks hopefully transforming how a student or educator could form a conceptualization to answer the question posed from a wellness prevention or an injury rehabilitation perspective. Also, other contributions from this team of PAMA consultants can be reviewed to expand perspectives about psychological health in music education.
Many of the possible means to achieve or re-establish psychological balance have been outlined in the excellent January 2020 article in this series (“Juries and Final Exams Are Approaching: How Do I Help My Students with End-of-the-Semester Stress?”).
To this list (which includes stress management techniques such as mindfulness practices, imagery, and breath work; adequate sleep; healthy nutrition and hydration; realistic goal setting and planning; and safe practice habits), we would add regular exercise (cardio, strength training, yoga/Pilates – all are potentially game-changers for musicians of any kind). Also, in certain cases, antidepressant or other psychoactive medications can be a useful adjunct, at least in the short term while re-establishing balance, and thus a medical consultation can be beneficial. Psychotherapy and psychoeducation can play a vital role in both treatment and prevention.
Finally, with particular focus on the college setting, a nurturing academic environment with understanding, acceptance and connectedness as cornerstones can contribute immensely to re-establishing or maintaining optimal physical and psychological health and building resiliency for what lies beyond. “The prevention of overuse is the control of use” has been the classical ergonomic approach to injury prevention and health promotion but it is time with this new psychophysiological evidence to refine the conceptualization to “the prevention of performance traumatic stress disorder (PTSD) is the control of psychological maltreatment (abuse) in music pedagogy”. Increasing the awareness of performance stress in the educational milieu will go a long way to support a “call to action” at a policy level and reduce the morbidity and mortality of PTSD.
Much like the history of reduction of harm from tobacco and asbestos exposure, not only evidence is required to change the state of the status quo, but the will to make the necessary policy changes must be in place, an example being the past NASM/PAMA collaborative initiatives on hearing health, neuromusculoskeletal injuries, and psychological health. The recent CMS webinar on “Tuning the Mind and Body of Musicians” could be a point of departure to initiate constructive dialogue at the local institutional level.