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:“How can we utilize ‘practice performances’ to prepare for an upcoming performance?"
Answered by Vanessa Cornett: October, 2021.
Vanessa Cornett is Professor of Piano and Piano Pedagogy at the University of St. Thomas in Minneapolis–St. Paul. She is author of the book The Mindful Musician: Mental Skills for Peak Performance.
A: Bill Moore famously said, “For the most part, athletes are ‘players’ who practice while musicians are ‘practicers’ who play.” Moore, a psychologist who worked with both athletes and musicians at the University of Oklahoma, understood the difference. And, although we musicians love to refer to ourselves as performers, the truth is that we are professional practicers. Most musicians spend exponentially more hours in the practice room, often alone, than they do performing in front of a live audience. Of course, there are exceptions, but a few questions remain. How do we help our students develop strong mental skills for public performances? How can we best help them engage in “practice performances” to hone those skills?
We can first acknowledge the difference between practicing to improve a skill and practicing to prepare for a performance. And, hopefully, our students will learn that running through a piece periodically in the practice room is not sufficient. When I was in graduate school, I would give at least five practice performances, usually more, in front of a friendly audience before attempting a degree recital. Once the demands of full-time university teaching took hold, I was proud of myself if I could manage to scrape together a couple of practice performances ahead of a faculty recital. But then I heard Noa Kageyama speak at a national conference a few years ago. The curator of the immensely popular Bulletproof Musician website mentioned that a well-known professional musician in New York City gives 40 practice performances before playing in front of critics, paying audiences, or studio microphones. Once I worked through my astonishment at the number 40, it quickly made sense to me: That is how consummate professionals seem to play with such natural ease.
But what can you do if your teaching situation does not allow for regular practice performance opportunities? In my experience, even if you have the luxury of holding weekly performance classes, those do not provide sufficient performance experiences for the average music major. The shift from professional practicer to professional performer requires students to take the initiative each week to find creative solutions for more performance opportunities.
Musicians can think of practice performances as representing low-stress, moderate-stress, or high-stress experiences. (If something feels like a “no-stress” situation, such as performing for oneself in one’s living room, it will be a less helpful option for developing performance skills.) Stress, however, is a subjective phenomenon. Since the same event may be interpreted as stressful for one student but not stressful for another, it is important for each student to understand how she usually feels in different performance situations, or performing for different people. I have my students create a personalized chart, in the style of a timeline or bar graph, by arranging their perceived stress levels of certain experiences from lowest to highest. By working their way through progressively more stressful experiences over time, they can better learn to recognize and manage various performance challenges.
Lower-stress experiences might include performing for friends or family members, for a personal video recording, or in a studio performance class. Moderate-stress performances might include non-degree studio recitals, community performances in hospitals or retirement homes, or perhaps end-of-semester juries. For some musicians, live-streaming a practice recital will feel like a moderately stressful situation, but for others, it will feel like a high-stakes event. Most students will view degree recitals, selective masterclass performances, auditions, and competitions as high-stress situations. A good course of action is to engage in as many moderate-stress performance situations as possible before a high-pressure event. Before or in between the moderate-stress experiences, students can experiment with daily low-pressure performances.
Instructors can also help increase the stress level of some practice performances by introducing adversity training to interested students. This technique is effective only when students are already well prepared for a performance, when they are performing only for the teacher and/or a small group of fellow studio members, and when they are interested in practicing handling distractions. When my students request this (and to be clear, it is not for all students), I will occasionally distract them by coughing or creating other extraneous sounds, making the lights flicker, or introducing other stimuli so that they can practice noticing how they best manage these unexpected events. In adversity training, the “adversities” themselves should be noticeable but relatively benign. I would never introduce this type of practice without first alerting my students and seeking their consent.
Musicians were obliged to stop giving live concerts during the pandemic; many stopped performing altogether. As we gradually return to a life of regular performing, practice performances will become an even more essential component of preparation. The truth is that, after many months of pandemic-related anxiety and trauma, we may not be the same performers we were in early 2020, and that’s to be expected. Teachers can practice exercising compassion and self-compassion as we begin to strengthen our performance skills and fill our society, once again, with live music.
A few resources for teachers and students
Cornett, Vanessa (2019). The mindful musician: Mental skills for peak performance.
Greene, Don (2002). Performance success: Performing your best under pressure.
Kageyama, Noa. Bulletproof musician website and blog. https://bulletproofmusician.com/
Klickstein, Gerald (2009). The musician’s way: A guide to practice, performance, and wellness.
McAllister, Lesley (2013). The balanced musician: Integrating mind and body for peak performance.
Moore, Bill (2010). Playing your best when it counts: Mental skills for musicians.
Savvidou, Paola (2021). Teaching the whole musician: A guide to wellness in the applied studio.
Q:“What Happens When Practice Meets Sleep?"
Answered by Lois Svard, DMA: August, 2021.
Lois Svard, DMA, Professor of Music Emerita, Bucknell University, Lewisburg, PA, has lectured extensively on the applications of neuroscience for the study and performance of music, writes a blog, The Musician’s Brain, about music, the brain, and learning, and is the author of a forthcoming book The Musical Brain: What students, teachers, and performers need to know, to be published by Oxford. She is also a member of the musicians’ health committee.
A: We don’t tend to think of sleep in connection with practice. In fact, many students have fewer hours of sleep prior to lessons, juries, or performances because they are trying to get a few more hours in the practice room. But learning and memory continue long after we have finished our physical practice. In fact, sleep may be the most important part of the learning and memory process, both for declarative memory, which is all the facts and details about the piece, and procedural memory, our “motor skills” memory. We need sleep to prepare our brains for encoding new material, to consolidate what we have just practiced and learned, and to ensure that we have access to memory when we are under stress, which we often are when performing.
Researchers have found that sleep before learning is important to prepare the brain to properly encode declarative information. This is all of the information about key changes, fingerings, bowings, structure of the piece, spellings of chords, chord changes, etc. If you don’t have adequate sleep, areas of your brain that are normally involved in encoding information don’t function properly. Other brain areas try to compensate, but that’s like B team players trying to compensate for the first string. You don’t get the same results.
Sleep after practice is important to consolidate procedural memory. In a study at the University of Texas, researchers taught music majors a melody on the piano in the evening, tested the students for speed and accuracy, and sent them home to sleep. After a night of sleep, the students had improved in speed and accuracy by 11%, with no additional practice. That’s a pretty strong recommendation for sleep.
And finally, it’s the rare musician who can perform without some level of stress. Swedish researchers looked at the impact of sleep deprivation on both declarative and procedural memory. They found that when participants in the study slept for only four hours and were then subjected to stress, they did fine with procedural memory. But there was significant impairment of declarative memory. In other words, if you don’t have adequate sleep when you encounter the stress of performing, you aren’t going to forget how to play your instrument when you are onstage, but you may very well have a memory slip because you have forgotten some detail about the music.So instead of heading to the practice room late at night, go to sleep instead. You will be better prepared to learn new music, to consolidate what you have already learned, and be better equipped to handle the stress of performance. What could be a more enjoyable practice strategy than sleeping!
Q:“What are the effects of loud music, stress on musicians… and what is glial excito-toxicity?"
Answered by Dr. Marshall Chasin: June, 2021.
Dr. Marshall Chasin, AuD., Reg. CASLPO, Doctor of Audiology and director of research and chief audiologist of the Musicians' Clinics of Canada. Dr. Chasin has the experience and knowledge to help musicians with their specific hearing needs. As a founding member of the Hearing Instrument Review Panel, he has reviewed many new hearing aids, which allows him to choose from the very best for clients. He is author or editor of eight books on hearing, hearing loss prevention, and hearing aids. He is an adjunct associate professor in Audiology at the University of Western Ontario; an instructor in Linguistics at the University of Toronto; and an adjunct research associate at the State University of New York (SUNY) at Buffalo.
A: The isolation due to COVID19 has underscored how multi-factorial anyone’s health can be and musicians are no exception to this vulnerability. The sound levels of the music and the duration – together give us the “dose” - are major issues in hearing health. Recent research has shown that at the smallest molecular level, the effects of loud noise and music are quite similar to that of stress. The physiology of hearing health has only been described for about a decade now but for years both researchers and clinicians have noted that a stressed individual is more susceptible to a wide range of ailments ranging from cardiac and kidney issues to hearing loss. The process is called “glial excito-toxicity” but the English translation may be more enlightening. A person undergoing stress (or isolation) has higher levels of Cortisol which is a stress hormone emitted by the adrenal glands. These very small molecules can cross the blood-brain barrier and facilitate the creation of Glutamate in the brain. Glutamate, like its more familiar cousins Seratonin and Dopamine, are neuro-transmitter messengers that carry the neural signals from one nerve to another. High levels of Glutamate (which can be brought about by loud noise and/or stress) can be toxic to the hearing mechanism.
During COVID19, isolation and stress caused some musicians to develop a “stress response” which has altered and, in some cases, damaged the auditory pathways required for hearing speech and music. Stress and isolation can be the big killer—not just for our hearts and metabolic processes, but also for our hearing mechanism. Hearing protection, moderation, and environmental control of loud music is very important, but stress reduction is also a major factor.
We all should be seeking out stress reduction opportunities for hearing loss and musicians as this is just as important as doing our pushups or working on our cardio. See Chasin’s blog at www.hearinghealthmatters.org/hearthemusic or www.MusiciansClinics.com for additional information.
Q:“How did the COVID-19 era change the Data on Sound Exposure and Musicians?"
Answered by Dr. Heather Malyuk: April, 2021.
Heather Malyuk, AuD, owner of Soundcheck Audiology in Northeast Ohio, is known internationally as a clinician, public speaker, and educator in the field of music audiology. She is the creator of the first-ever video hearing wellness curriculum designed specifically for the music industry. She received an undergraduate degree in Music History and Literature from the University of Akron and earned her Doctor of Audiology (AuD) degree from Kent State University. Dr. Malyuk is actively involved with the American Academy of Audiology, having recently co-authored the clinical consensus document for Audiological Services for Music Industry Personnel and she serves on the executive council for the National Hearing Conservation Association. In addition to her clinical and educational work, Dr. Malyuk is a consultant for various companies in the audiology sector and is a Research Scientist with Gateway Biotechnology Inc. and The University of Akron where she is currently researching cochlear synaptopathy, tinnitus, and the effects of COVID-19 on the music industry. Dr. Malyuk is also a violinist. For more information about Dr. Malyuk, visit www.soundcheckaudiology.com
A: While we have lessened sound exposure, we lost many other things. This is an opportunity to take time to learn more about hearing wellness. While musicians are glued to their ear-monitors and headphones, it is important to have quality ear-phone solutions to reduce sound and fatigue.
I’ll always think of March 2020 as “that time when the music industry went silent.” The onset of the COVID-19 era hit many industries but I think it hit the music industry the hardest; maybe I’m biased!
Before COVID-19, I worked as a full-time music industry audiologist and the majority of my patients were either from pro-orchestras or musicians and crews from tours. By the end of April 2020, one month into the cessation of concerts, I was being contacted by patients with statements like “my ears are feeling better than ever,” “my tinnitus is not as bad as it was a few months ago,” and other similar sentiments. Those comments made me very curious about sound, our industry, and how sound exposure changed for us and our peers in this era of silence. To address my curiosity, I developed a small survey study through which I disseminated 54 questions via SurveyMonkey to individuals from my patient base and the patient base of Sensaphonics Hearing Conservation, a Chicago-based musicians’ clinic. Over 11,000 music industry professionals were contacted via email and social media. Roughly 2,700 of them opened the email and, ultimately, 400 completed the survey. These music industry professionals represented:
- 13 countries;
- 15 job types within the music industry;
- Ages 16-77;
- 24 genres;
- 12 work environments;
- Touring and stationary professionals were equally represented at 47% and 53% of respondents, respectively;
- and 30% identified as biologically female.
These demographics are especially exciting in hearing research as this research discipline tends to focus on classical musicians. A review of musician-relevant hearing research was completed by Di Stadio and colleagues in 2018. That review of the literature found that 78% of studies focused on classical musicians. This is likely because classical musicians tend to be more accessible and relatively “easier” to study, especially in large ensembles such as orchestras as they are stationary. In the data I have recently collected, I was able to represent 24 genres, with the top 4 being Rock (51%), Classical (45%), Pop (41%), and Jazz (30%), but others include Rap, Worship, Metal, Country, Electronic, and more (even Zydeco!) Respondents were permitted to select more than one genre.
I gathered some fascinating data on these musicians including information on incidence rate of hearing disorders, use of hearing protection and in-ear monitors, as well as comparisons of stress and tinnitus with non-musician populations. I wish that I had the space here to explain all the data! While I don’t, I do have space for one aspect of the data set: changes in sound exposure since the onset of the COVID-19 era. I asked respondents how many days per week they were exposed to sound both before and after COVID-19 shutdowns and restrictions. I then asked the same question regarding hours per day they were and now are exposed. Figures 1 and 2 below show the data. For a hearing conservationist, this might look like great news (lessened sound exposure!), but for those of us in the music industry, we know the heartbreak that these figures represent. These figures represent lost work, lost communities, and, for some, lost careers. While those of us in the industry are aware of the drastic, traumatic changes in our day to day lives, this type of data collection gives voice to our shared experience.
I hope the future of sound in music is full, rich, and frequent! I do hope that our industry gets back to the pre-COVID stats on sound exposure, and I really hope that during this period of relative “silence,” our beloved industry is taking the time to learn about hearing wellness. Anecdotally, I have been receiving questions from music teachers and touring professionals across the USA. The questions I’m receiving are about in-ear monitors and headphones to use while teaching online and while touring digitally. We know that listening to a student during a video conference lesson is not the same as being in person. There are earphone solutions now available that allow the wearer to tune the earpieces to what sounds “best” to their own hearing and equipment through which they are streaming. Sometimes being able to adjust the sound of earphones or headphones can allow the user to maintain a safe volume and reduce fatigue. I believe we will continue to see an increase in the use of ear-level devices, especially for music educators, in the days ahead.
Please contact me with any questions about hearing wellness in the COVID-19 era! I can be reached at [email protected]
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.