Dr. Serap Bastepe-Gray, along with Dr. Alexander Pantelyat and Sarah Hoover, D.M.A., are the leaders of the Johns Hopkins Center for Music & Medicine. Using a multidisciplinary approach that involves physicians, nurses, music therapists, physical/occupational/speech therapists, somatic educators and practitioners of complementary and integrative medicine, the Center’s goal is to promote research and to help restore and preserve the proficiencies and talents of musicians all over the world.

Dr. Bastepe-Gray, a physician and a virtuoso guitarist, is the Director for Peabody Occupational Health and Injury Prevention Program, serves on the Performing Arts Medicine Committee of the Maryland State Medical Society, the Research and Education Committees of the Performing Arts Medicine Association and the Musicians’ Health and Wellness Committee of the International Society for Music Education. She holds joint appointments at the Johns Hopkins Department of Neurology and the Peabody Conservatory. Her expertise comprises pain and playing related musculoskeletal and neurological upper extremity disorders that affect musical performers.

It was Stay Thirsty Magazine’s privilege to visit with Dr. Bastepe-Gray in Baltimore for this Conversation and to learn about the Center’s important work.

STAY THIRSTY: Johns Hopkins recently established a Center for Music & Medicine where you practice in the areas of performance health and wellness and injury prevention and rehabilitation. How did this Center come about and what is its mission?

DR. BASTEPE-GRAY: During my student years at Peabody, I had a first-hand encounter with a playing related musculoskeletal problem, from which I was able to recover using my medical knowledge and the help of my teachers in optimizing my biomechanics on the guitar. When the word got out, I had become somewhat of an unofficial healer for the Peabody students with similar issues. When I became a faculty member at the Peabody Conservatory, students continued to knock on my door seeking help with their pain and other symptoms that made it difficult for them to practice and perform on their instruments.

In the two decades that have passed, heightened interest in musicians occupational health resulted in a body of epidemiological studies that indicated that about four out of five musicians deal with at least one episode of playing related musculoskeletal problem sometime during their careers. However, despite ongoing interest among health care practitioners over these two decades, no trend in decreasing the percentage of playing related musculoskeletal problems was happening. Clearly, we were missing a few links in the knowledge chain that would prevent such problems and that would help injured musicians return to play with long term relief.

As an individual with professional training in both the medical and musical fields, and one with personal experience with playing related injury who was able to come out on the other side with a positive resolution, I realized that I had a responsibility to initiate change that will lead to better understanding of the mechanisms of playing related disorders in musicians so that we can design more effective preventive programs and treatment protocols for musicians.

At the same time, my colleague Dr. Alexander Pantelyat, a faculty member of the Johns Hopkins Department of Neurology and an accomplished violinist, was very interested in researching the healing power of music. Although the restorative and therapeutic properties of music have been known to humans since the beginning of history, and the recent body of research provided evidence, we have little knowledge of the mechanisms behind all this.

In the fall semester of 2014, with unprecedented support from Peabody Dean Dr. Fred Bronstein and the Chair of the Neurology Department Dr. Justin McArthur, Dr. Pantelyat and I began collaborating to develop an initiative to bring together the expertise, wisdom and resources that lay within the School of Medicine and the Peabody Institute for the benefit of the musicians and non-musicians alike. On January 23, 2015, in a meeting between the senior administrators and interested faculty members from Department of Neurology and the Peabody Institute – and with an endorsement from Leon Fleisher, piano icon and Andrew W. Mellon Chair at the Peabody Conservatory – we officially co-founded the Center for Music & Medicine to bring music and medicine together with a dual vision:

1) Making music and rhythm an integral part of treating neurological illness
2) Improving the health of musicians worldwide.

Under the leadership of Dr. Sarah Hoover, Peabody Associate Dean for Innovation, Interdisciplinary Partnerships and Community Initiatives and co-director of the center, we have clarified and developed our mission to leverage Johns Hopkins Medicine’s world-class expertise and excellence in research and clinical care, and the Peabody Institute’s world-renowned performance training for musicians in order to develop research, clinical care, education and outreach projects that bring music, science and medicine together to benefit patients, health care workers and musicians.

Our mission includes:

1) Discovery and treatment of the underlying causes of health issues affecting musicians.
2) Exploration of neural mechanisms that underlie music perception and kinesthetic learning for the development of prevention education and evidence-based pedagogy for musicians.
3) Development of music and rhythm-based therapies that improve patient quality of life and address symptoms of Alzheimer’s disease, Parkinson's disease, stroke, autism and other conditions.
4) Creation of innovative roles for performers in clinical settings to provide a direct benefit to patients and health care providers using musical performance as medicine.
5) Educating physicians and others at Johns Hopkins Medicine on the dynamics of musical performance and interventions.

Johns Hopkins Center for Music & Medicine

STAY THIRSTY: When a musician, such as yourself, experiences a performance injury, what are the proper steps to seeking and obtaining treatment? How does the new Peabody Clinic fit into the picture?

DR. BASTEPE-GRAY: I think the most important step is to be able to discriminate the symptoms of a disorder or injury from transient pain or discomfort, which is temporary and does not interfere with practice and performance. Musicians are notorious about waiting too long before seeking treatment which suggests a bias among musicians to categorize discomfort as a transient issue that will go away on its own.

Ongoing or repetitive pain or other symptoms such as tingling and burning sensation or loss of motor control are good reasons to seek help from a board-certified physician with an interest in musicians playing related disorders. New pain during practice may be a warning pain the tissues are subjected to levels of stress that almost or slightly exceeded their capacities. The best strategy is to stop and wait for about 20 minutes. If the pain goes away, it may indeed be a warning pain. Analyzing the passage during which the pain was perceived to correct mechanics, (for student musicians, asking their teacher for help) and making sure the duration and intensity of practice sessions are within the limits of the tissue capacities will usually resolve the problem. New pain that does not go away with rest most likely indicates the development of a new problem. I recommend temporary cessation of any playing activity and seeking medical help immediately. Student musicians can consult with their teachers and their institutions to identify the local physicians from whom they can seek help. Additionally, the Performing Arts Medicine Association has a referral web page that lists health care professionals who are interested in treating musicians along with their location and contact information.

Our onsite clinic at Peabody, established in collaboration with the Johns Hopkins Physical Medicine and Rehabilitation Department, is one of the rare clinics for performing artists that is housed within the grounds of a conservatory. It provides convenient access to hand therapy, occupational therapy and physical therapy and presents opportunities to develop innovative treatment approaches through collaboration between music and health care professionals. Currently the clinic is open to Peabody students, faculty and staff and we are planning to expand our services to our alumni and musicians at large over the next few years.

STAY THIRSTY: What are the key neurological and physiological processes that the human body goes through in learning and in performing music?

DR. BASTEPE-GRAY: Neuroscientists describe mastering a musical instrument as one of the most significant achievements of the human brain, requiring highly sophisticated skills including fast and coordinated auditory, visual, perceptual, emotive and motor processing skills.

Practice provides multi-modal stimuli to the brain. Due to the ability of the brain to reorganize itself, referred to as neuroplasticity, a distinct multi-modal network of highly connected perceptual-motor pathways develops in musicians brains through neurochemical adaptation, circuitry formation and network enhancement processes. The changes in the brain as a result of active engagement in instrument practice and performance over years is so profound that musicians brains differ in connectivity even at rest as compared to non-musicians.

Another consequence of practice in a musicians mind is the formation of a multi-modal imagery of the performance of a given repertoire: musicians, in their minds eye, can see, hear and feel themselves playing a particular piece without actually physically performing that piece. This multi-modal imagery not only serves as a basis for mental practice (or visualization as musicians like to call it), but it also happens online during performance: musicians, a split second before they actually move to produce a sound on their instruments within the piece they are playing, experience the visual, auditory and perceptual sensations of making that movement. This so-called online imagery, which is for the most part unconscious, triggers motor anticipation, thus optimizing and smoothing out the actual motor component of performance.

Practice also provides stimuli to functionally condition and adapt the musculoskeletal system to the demands of playing an instrument by inducing ultrastructural, biochemical and metabolic changes in muscles and tendons. Just like a session of exercise, a session of practicing results in disruption of myofibrils and cytoskeleton in muscle cells, increased collagen breakdown in tendons and increased muscle metabolism and metabolic waste production. This initiates an adaptive response in the musculoskeletal system for structural and metabolic remodeling towards a better contractile machinery, efficient neuromuscular junction, increased capillarity and better oxygen utilization.

Most musicians believe that they are improving during practice. In reality, most of the neurological and physiological processes that lead to adaptation happen after the practice is over, beginning during the recovery phase and continuing for several days. Sleep, as we now know, is very important for memory consolidation as well as decreasing muscle breakdown and facilitating remodeling. In a study conducted at the Johns Hopkins Laboratory for Computational Motor Control and published in Journal of Neurophysiology in 2015, Sarah Pekny and Reza Shadmer showed that practice alone was not sufficient to result in increased efficiency of motor output, but 6 to 24 hours spent away from practice was a required element for optimization of effort. Similarly, studies indicate that after a session of exercise, recovery of muscles and tendons can take as long as 24 to 48 hours, while the remodeling process continues for 7 to 10 days or even longer. In athletics, this improvement that happens 24 to 48 hours after the practice is called silent training. I believe this is one of the many useful concepts musicians can adapt from sports for training for better practice outcomes.

STAY THIRSTY: How important are the periods of rest between practice sessions?

DR. BASTEPE-GRAY: Short periods of rest, about 5 minutes every half an hour of practice, are important both for giving the brain and musculoskeletal structures time to clear some of the metabolic waste products and replenish nutrients and energy, thus preparing them for the next session of practice. Longer periods of rest and sleep are essential for allowing the adaptive processes to happen in the brain and in the musculoskeletal system, leading to motor learning and functional conditioning.

STAY THIRSTY: What is the value of warming up and cooling down before and after practice sessions and performances?

DR. BASTEPE-GRAY: Warm up provides a bridge that moves the mind and body of the musician from daily activities to focused practicing. Although increasing tissue temperature and tissue flexibility by increasing blood flow to those tissues that will work during practice and performance is one of the objectives of warm up, the primary physiological objective of warm up is neural activation in musicians and athletes alike. This activation facilitates retrieval of motor and perceptual memory and optimizes motor output. Warm up can also act as a psychological anchor: elite musicians and athletes have a routine for warm up which becomes a cue (a trigger) for successful performance by facilitating management of nerves” and by triggering entry into peak performance zone.

A good initial routine for musicians warms up the tissues that are going to be used in performing the instrument and activates task specific motor programs. Before picking up the instrument, about 5 minutes of gentle movements of the body and arms that increase gradually in range, intensity and complexity help initiate this process. Warming up on the instrument (about 10 minutes) involves idiomatic previously mastered material. It begins with sequences of low complexity such as scales and arpeggios at moderate tempos and in mid-range dynamic levels and progresses towards more complex and high intensity material.

Cooling down is important after strenuous exercise to bring heart rate gradually to normal levels and prevent pooling of blood in large muscles of the lower limb. Although this aspect does not readily translate to musicians’ work, cooling down with gentle dynamic stretches (stretching like a baby without pushing on or leaning into a prop) might facilitate relaxation of muscles and restoration of resting state length-tension relationship of the muscles.

Dr. Alexander Pantelyat, Sarah Hoover, D.M.A. and Dr. Serap Bastepe-Gray

STAY THIRSTY: What role do mental strategies play in a musician’s overall physical and performance health?

DR. BASTEPE-GRAY: Once in a conference, a physical therapist colleague of mine who works with athletes, having watched a piano student practice the same passage over and over again, was astonished with the need of the student to do so many repetitions of a passage that sounded fine each and every time. Although there is a certain amount of repetition that is necessary to acquire a new motor skill or to explore different ways of phrasing a passage, often musicians – especially student musicians – repeatedly play already learned and mastered material because the execution of the material does not feel reliable. We know from research in the work force in other industries that repetitive movements, especially if they involve high force production or upper limb positions that require going out of the mid-range of motions in arm and finger joints, will eventually lead to musculoskeletal disorders. This perception of low reliability in the face of repeated successful performances is the product of the mind and without training the mind, we cannot train the body to command an instrument.

Mind and body are interconnected in intricate and complex ways and separating one from the other can lead to artificial distinction. In the field of athletics, this connection and interdependency has been recognized long ago and mental skills training is an important component in the development of skills for elite athletes. This type of training has yet to become commonplace in music schools, and conversations about mental training in musicians usually focus on performance anxiety management and occasionally the benefits of mental practice or visualization. In reality, musicians, just like athletes, require a variety of mental skills that precedes and supports management of performance anxiety. Thanks to the field of sport psychology, a large body of research has been done to identify mental skills necessary for successful performance. These skills are often explained as a pyramid, categorized into levels, beginning from basic skills such as attitude and motivation at level one at the bottom of the pyramid and continuing with preparatory skills, where visualization would be an area of focus.

Performance skills, which includes performance anxiety management, are usually listed at the highest level in the mental skills pyramid. These skills are believed to be learned and can be improved with instruction and practice. These concepts can be translated well to musicians work and with continued research will yield supporting evidence that can be successfully integrated into the overall training of musicians. In the meantime, here are some points to think about:

1. Clarify and develop mindsets. The basic level 1 skills, such as attitude, motivation, commitment and goal setting depend on ones mindset. Having the right mindset for the right circumstance aligns these skills more clearly for that circumstance. For example, practicing to acquire new repertoire or new motor skills requires conscious focus, problem solving and learning – the musician is an explorer, teacher and student at the same time. On stage, on the other hand, performance requires a flow-state with subconscious intuition taking over, kept in-check only with short moments of conscious attention – the musician is at the service of the music, bowing to the audience having presented the gift of music in a shared journey of emotions flowing with created sound. Clearly the attitudes, motivation, commitment and goals of practice and performance have some significant differences. Student musicians, who are usually more concerned about learning to play a particular work of music or being able to successfully execute a difficult passage, spend much time in the practice mindset. They would benefit from guided self-reflection to identify their root motivations in wanting to become musicians and their artistic philosophy as a first step towards building their performance mindsets as a support to publicly displayed creativity.

2. Build a performer button. Having identified the level 1 mental skills necessary for performance, the next task is to identify and build triggers to switch to this mindset before the performance. Olympic athletes, especially the ones that are alone in the arena such as divers, swimmers, golfers, and ice skaters, receive training to build, practice and use these performance triggers to get into their peak performance zones. For musicians, these triggers can range from a warm up routine, an imagery sequence with self-affirming statements (for example, seeing yourself in your minds eye stepping into a circle of golden light with your instrument and telling yourself that within this circle of light you are the master of time), the sound of the latch of an instrument case opening or the anticipatory silence of the audience right before beginning performance on stage and more. Again, identifying and practicing these triggers to switch to performers mode is the key for successfully building and activating the performer button at will.

3. Practice performing. Most often, performance practice is understood as performing a mastered excerpt or an entire piece to an imagined or real audience. This of course is an essential element of performance preparation and performance experience cannot be substituted with anything else. Most often, student musicians believe that in order to allow themselves to play any material like a performer, they need to first master all musical and technical aspects of the material at hand. This perpetuates practice mindset does not allow for opportunities for frequent triggering of the performer and turns the performance into a hard-to-attain reward for practice. In reality, a musician can perform within the performance mindset a single note, a short motif, or a phrase with temporal adjustments to fit the technical demands of that short material to the current technical abilities. Interspersing performance of short amounts of material in this way will not only inform the more deliberate practice of that material to improve task specific technical and musical skills but will also create opportunities to practice the performer mechanism.

4. Learn to find your musical fingers now. Perceptual motor studies demonstrate that there are both short term and day-to-day fluctuations in these skills within the same person. This is not surprising because our perceptions can be influenced by both internal and external factors. How much we have slept, what time we woke up, our mood, the weather and many other factors like these can cause small shifts in our interpretation of sensory information, the quality of our attention, our reaction time and more. External factors such as the temperature, humidity, may change the response of our instrument to touch. Have you ever seen the occasional student that can sit in a masterclass for two hours with their instrument nicely tucked in its case, and when their turn comes, they can pick up their instrument, tune, and begin playing for the master without a hitch? That student can sense where their perceptual and motor abilities currently are right before they begin playing and can adjust their playing strategies accordingly so that they can perform successfully. On the other end of the spectrum, there is the student who would sit outside of the masterclass room until it is their turn to play, repeatedly performing excerpts with the hope that they can somehow find the fingers that they had the other day when they performed the piece in the one ideal way that they think it should be performed each and every time. Clearly, developing this perceptual-motor adaptability requires not only learning to pay attention to our internal sensations, but also an understanding that todays performance can only arise out of todays abilities. One way to develop this mental skill of on-demand perceptual motor ability gauging would be to pick up the instrument at odd hours, under different conditions, and perform a selected piece as if on stage, finding strategies during this performance to adjust the demands of the piece to where the fingers are, followed by a reflection of internal sensations and adjustment strategies.

5. Commit to performance to minimize the impact of mistakes. The recommendation during practice is to learn from mistakes i.e. pay attention to mistakes and solve the problem which is great advice but then the same person who spends hours conditioned to pay attention to mistakes so that they can identify and solve the problems to eliminate them is expected to not pay attention or be bothered by the mistakes during performance. What is the solution for this conundrum? We are what we practice if during practice we stop every time we make a mistake so that we can analyze and solve the problem, this behavior will spill into the performance modality. Similarly, if we do not balance the time spent on technical hygiene in practice with exploration and refinement of musical expression on the same excerpt, the mistake-catching thought processes will spill into the performance. And further, if we do not spend time practicing the performing of that excerpt within our performer mindset, the practice mindset will spill into performance. One way to negotiate all this would be by committing to the performance of the selected short material during practice, rain or shine, from beginning to the end, with phrasing decisions, returning to mistake-solving process only after the completion of the performance of the intended material. The selected material can be as short as a motif or as long as the entire length of the work depending on the goals of the practice. This mental skill of committed performance in the face of mistakes until the performance of the intended material has been completed will reduce the impact of mistakes on the overall performance quality on stage.

6. Build a strong memory chain with retrieval triggers. Although we can encode large motor programs into our long-term memory, short term memory is like the RAM of a computer, it has limited capacity to hold information. For this reason, we retrieve motor programs in chunks, where these chunks can go under automatic planning and optimization before execution. A musical work, as we are performing it, is then retrieved in the form of a chain of small chunks. In order to avoid hesitation or memory blocks, each chunk will need to trigger the retrieval of the next chunk. It is common knowledge that practicing small meaningful musical phrases or phraselets is an effective way of learning a new piece since they allow focused work in small amount of material. This facilitates encoding motor programs that are executed cleanly and eliminates the distractive effects of the upcoming chunk on the learning of the chunk at hand.  Practicing in chunks also has the advantage of tapping into our preferential memory: we tend to remember beginnings and endings of an event better than the middle. By dividing the piece into practicable areas with their own beginnings and endings, we are creating more points within the piece for our preferential memory to latch onto. However, if these musical chunks are not hooked to each other from the earlier stages of encoding, the triggering of them in a connected memory chain will be hampered. One way of achieving this is to extend the practiced chunk to include the first note (or chord) of the next chunk that comes in the piece. This overlap will serve as a trigger for the next chunk. As the performance of each chunk becomes comfortable, practicing these chunks in backwards order by beginning with the last chunk of the piece and going backwards by chunk, increasing chunk size by “hooking together” two or more chunks would reinforce the association of these areas with each other within the scheme of the entire piece and will strengthen the memory chain. Spending some time understanding the general architecture of the piece, phrase structure, noticing patterns, repeated material, etc. would add declarative memory into the memory process, adding to the associations between the chunks and the entire work, creating another layer of strength to the memory chain.

7. Visualize. Mental practice, or visualization is a well-studied mental skill in sports and in the field of motor rehabilitation of patients after stroke. Although it requires more research in how to best integrate it into the overall training regimen of musicians for increased motor learning efficiency, it is nevertheless an important mental strategy among elite musicians. Research in sports show that there are good visualizers and bad visualizers, and that visualization skill can be improved by practicing visualization. As I mentioned before, performance involves an unconscious online imagery of the performance that activates and optimizes motor output a split second before the actual notes are sounded. Visualization involves conscious access to this imagery to trigger the performance in the minds eye and ear and this ability to access this imagery becomes more fluent with practice. Studies show that the practice of imagined performances activates similar networks in the brain to those activated by the actual physical performance, with the implication that the more times these networks are activated the more they will strengthen. Research in the rehabilitation field shows that sandwiching mental practice of a short motor action between two actual physical performances of it has the most beneficial aspect in improving the performance. Visualization can be used in chunk practice in this way. In addition to facilitating motor learning and enhancing retrieval process, integrating visualization into practice in this way reduces the number of physical repetitions, and can decrease the exposure to playing-related biomechanical loads in musicians.

In addition to its benefits in motor learning and motor performance quality, visualization can be used to increase overall performance success through visualization of the preconcert routine, activating the performer button and the beginning and ending of successful performance on stage.

8. Trust silent training. Skill building takes time. In the athletic world, there is a 3+3 week rule: it takes at least 3 weeks to acquire a new skill and another 3 weeks for the skill to stabilize to be consistently executed on demand. Since musicians work often involves very high levels of cognitive demands in addition to motor demands, it is logical to conclude that skill emergence and stabilization would most likely take a somewhat longer amount of time. Additionally, some skills take longer to develop as compared to others. For example, with good training, it is possible to notice changes in flexibility in a few days but a noticeable difference in reliable speed and agility may occur over the span of weeks and months. Complex skills will take longer time to acquire than simple skills. Most of the frustration in student musicians come from expecting improvement too quickly, often over the span of a day of practice. When the expected goal has not been reached, many people will respond to this goal blockage by increasing the behavior to regain the goal accompanied by feelings of anger. Repeated goal blockage will then result in decreased motivation to reach the goal often accompanied with feelings of sadness. In the musicians case, this translates as increased repetitive practice with increased risk for injury, followed by self-doubt.

It is important to remember that most of the skill improvement will come during the recovery phase after the cessation of the practice. Accepting this and trusting that your training will result in the necessary changes in your brain and your musculoskeletal system in the fullness of time will help decrease repetitive frustration, an urge to engage in fruitless repetitive practicing and self-doubt.

9. Embrace your butterflies. Performing in front of audience is exciting as well as stressful Studies show that there is an inversed U-shaped relationship between performance quality and nervousness: while too little or too much nervousness can interfere with performance quality, a certain level of nervousness is beneficial, helps sharpen the focus and fuels the energy necessary to sustain this focus during a concert. However, nervousness also changes the feel of the instrument-musician interface. Accepting that nervousness comes with the territory and repeated exposure to on-stage performance helps adapt to these changes. Not many musicians suffer from too little nervousness, thankfully, however, excess amounts of nervousness before or during performance seems to be an issue for a lot of musicians.

The first stage of response to immediate threat has been described as the alarm stage in a stress model developed by Dr. Hans Selye, a Hungarian endocrinologist. This stage begins with a shock phase, where the body releases adrenaline which is the neurochemical agent behind the symptoms of nervousness such as increased heart rate and trembling. Shock phase is followed by the counter-shock phase where the body reverses most of the physiological signs of the shock phase. These phases can be as short as few minutes or can last up to 24 hours. Interviews with soldiers indicate that while they feel very nervous the first day of combat, they usually feel less nervous the second day. One of the strategies that musicians use is to begin getting nervous early, for example in the morning hours of the day of an evening performance. This strategy has the potential to allow completion of the shock phase to take advantage of the temporary physiological recovery during the counter-shock phase.

10. Practice self-pep-talk. Much has been said about controlling negative self-talk and replacing it with positive self-talk to maintain a happy life and enhance mental toughness for better performance. Aside from the life changing potentialities of these recommendations, research has shown that motivational self-talk, such as I got this, and instructional self-talk, such as shoulder up, increases performance success in athletes. Training in motivational and instructional self-talk is one of the components of an overall mental training program in elite athletes and can be easily translated to musicians work.

Wellness Immersion

STAY THIRSTY: How important is hydration and nutrition to a musician?

DR. BASTEPE-GRAY: Very important! Musicians, who are sometimes referred to as small muscle athletes, need healthy and fit bodies and minds. Hydration, nutrition, sleep and exercise are important factors in maintaining health. Studies show that dehydration decreases endurance and performance quality in athletes. Sipping water throughout the day rather than drinking large amounts of water infrequently is recommended to maintain hydration. Sports nutrition, a complex science and art, provides some insights for adapting nutritional strategies to support musicians practice and performance. In general, protein intake is shown to facilitate recovery after a hard work out session. Complex carbohydrate intake about 2 hours before a long practice session or performance together with continued hydration provide fuel for muscles. However, there are significant differences in the ways that musicians use their bodies as compared to athletes, and more research is needed to help translate these strategies to musicians nutritional needs.

STAY THIRSTY: Aside from the physical recovery from an injury, how are the psychological implications of that injury addressed?

DR. BASTEPE-GRAY: Most musicians, like athletes, begin training in childhood and engage in practice and performance activities that continue throughout their life-span. Due to the constant engagement of the musician in musical tasks throughout their lives, and the not yet fully understood effects of music making on cognitive reward systems, engagement in music making has a high valence of meaning. Several qualitative studies reveal that disruption or loss of participation in music making impacts musicians in a manner similar to the loss of a close family member. For student musicians, there is the added burden of falling behind in skill acquisition as compared to their peers. Strong doubts of self-worth, guilt, and feelings of anxiety are magnified, especially in the face of an unpredictable length of recovery in long term injury. Implemented by a counselor, processes such as Socratic questioning, guided discovery, reframing and journaling would be helpful in reorganizing thought processes. Training in stress management techniques such as deep breathing, progressive muscle relaxation or guided imagery helps in dealing with anxiety and stress. Preserving musician identity by engaging in musical activities that do not require physical work on the instrument, for example theoretical analysis of musical works, comparative listening of performances of selected repertoire by various musicians, reading and analyzing pedagogical texts will also be important. Education on the genesis of injury, daily tissue capacity, injury first aid and pain management techniques empowers the injured musician to be an active participant in their recovery process. Appropriate therapy to promote tissue healing and a well-designed gradual return-to-play program with biomechanical adjustments usually results in an overall decrease in symptom levels and overall increase in practice and performance tolerance over several weeks. However, recovery is not a smoothly linear process and symptoms can often fluctuate from day to day, making it harder for the injured musician to gauge their recovery. Keeping a pain log helps to demonstrate overall benefits of the rehabilitation program in reducing discomfort and in increasing capacity to play.

STAY THIRSTY: What are the proper habits young musicians should employ so that they are able to reduce time spent recovering from injuries in the future?

DR. BASTEPE-GRAY: Here are my recommendations to young musicians for a healthy, long and successful career:

1.    Keep your body and mind healthy, keep your instrument user-friendly.
2.   Control the daily wear and tear on your upper limbs – understand that everything we do with our hands, not just playing, has an impact on tissue capacities.
3.   Make a habit of warming up and cooling down.
4.   Set clear goals and time limits for practice and use a timer to remember to give breaks (~5 minutes every 30 minutes of practice).
5.   Avoid sudden increases in daily practice time.
6.    Respond to fatigue and pain immediately.
7.   Habituate fluent movement – strive for biomechanical efficiency, ease of play; allow musical gestures to guide physical gestures.
8.   Use reduced-force techniques, such as etouffee (muffled sound) or soft dynamic levels, for repetitive practice to learn the choreography of a new piece.
9.   Alternate mental practice with physical practice.
10. Employ efficient motor learning strategies.
11. Practice and improve mental skills to support performance success.
12. Be patient and trust your training.
13. Give yourself permission to be an artist.
14. Develop a plan to translate performance success to career success.
15. Learn to deploy your strengths to work around your limitations.

STAY THIRSTY: What innovative treatments and strategies are being developed to help professional musicians stay at their peak health?

Wellness Immersion

DR. BASTEPE-GRAY: Seeing that playing related injuries or disorders are very common in musicians, rather than a traditional treatment model, an integrated cycle of injury management is a more effective strategy to keep professional musicians at their peak health. Similar to FEMAs cycle of disaster management, our injury management cycle includes preparedness, response, recovery and mitigation phases. Our clinic at Peabody is part of a concerted effort to change culture in order to increase capacities in managing our students’ playing related health problems. The onsite location of the clinic and various preventive programs provide opportunities for meet and greet between the students and the rehabilitation staff, supporting the preparedness phase of the management cycle. The response phase is accomplished by providing students with walk-in advisement sessions in the clinic where the staff can recommend adjustment of practice duration and intensity, guide the students for setting appointments with a physician from our Music & Medicine team or initiate the referral process for physical/occupational therapy as needed. The recovery phase of our injury management cycle benefits from the proximity of the clinic to our world-renowned music faculty. This proximity facilitates our efforts to integrate the faculty’s experiential wisdom and expertise on the instrument into the design of gradual return-to-play programs to rebuild the playing capacity of the injured musicians. Musculoskeletal screenings in the beginning of the academic year and prevention programming such as Peak Performance Fundamentals serve the mitigation phase.

Despite progress in other industries, the field of musicians’ occupational health is still lagging behind in understanding and minimizing exposures to work related biomechanical hazards. This knowledge gap is due to lack of tools to quantify these exposures in musicians. In response to this, we are currently developing a series of “smart” musical instruments that can measure the forces the musicians apply onto the sound producing mechanisms of instruments during practice and performance. Coupled with movement tracking equipment, these smart instruments will provide us with a tool to conduct functional performance assessments, similar to a runner’s assessment in a running clinic. This will allow our rehabilitation staff to design interventions to correct faulty biomechanics to facilitate recovery and to prevent re-injury.


All opinions expressed are solely those of its author and do not reflect the opinions of Stay Thirsty Media, Inc.