​by Dr. Mike Fink
originally published by Pittsford Performance Care 

It is not uncommon for an athlete to think about an injury as having to do with a muscle, tendon, ligament, or bone. We do not traditionally think about injuries as having to do the the brain. The truth of the matter is that from a scientific perspective most all injuries can be traced back to the neuron system. The brain controls all functions and systems of the body with no action occurring short of a neural signal. With these points in mind we can conclude that to achieve optimal injury recovery and performance, a neural perspective must be employed. Read on to learn how.

Central Integrative State Defined:
The total integrated input received by a neuron at any given moment and the probability based on this state that it will  produce a response.

“Neural/Brain Health”

The definition above is very important to the remainder of this post. I would encourage you to think about the Central Integrative State (CIS) as the overall health of the nervous system at any given time and the likelihood that it will allow for optimal performance of the body. Keeping in mind that the brain controls the body we can extrapolate that the health of the rest of the systems is directly related to the CIS.

The performance of an athlete is directly dependent upon activation of the muscular system with proper speed, sequence, and symmetry. This system is directly under neural control. A weakened CIS will alter one of the three variables of motor contraction listed above. This causes a deficiency in the supportive role of this system leaving other structures such as tendons, ligaments, bone, or nerve susceptible to injury. We are beginning to see the role that the brain plays in performance and injury prevention. To understand further check out this previous blog post. How then does the athlete apply this information to stay injury free?

What Negatively Affects the CIS?

The following list briefly speaks to variables which can diminish the CIS.

1. Stress
2. Poor Sleep Patterns
3. Poor Diet
4. Dysfunctional Movement Patterns/Poor Posture
5. Injury History
6. Poor Footwear

All of these, if present, send negative stimuli to the brain which will eventually have a deleterious affect on all systems of the body. When addressing musculoskeletal injuries this piece cannot be overlooked.

How is my CIS?
An individual cannot determine their brain health with a simple test or questionnaire.  The CIS is dependent upon many variables and can change from moment to moment. Thinking through what negative influences from the list above may be present in your life would give some insight into your CIS. The presence of injury is one strong indicator of a weakened CIS which we focus on heavily when working to correct and prevent injuries. We know this because in most cases for an injury to arise there had to be some delay or dysfunction neurologically which allowed the system to be vulnerable to force insult.

While challenge exists in an individual’s ability to self-assess their CIS, we are able to utilize a precise system of muscle testing to determine the speed, symmetry, and sequence of muscle activity. The objectivity of the muscle testing can give insight into the CIS through its ability to properly engage the muscular system. For example if all muscles in the lower extremities produce contractions with strong force and reactivity we can extrapolate that the neural system is functioning with a fairly strong CIS. If there are members of the muscular system which reveal weak, delayed, or asymmetrical muscle firing we can conclude a weak CIS.

How Can we Improve the CIS?
To improve the CIS we can engage in activities which are opposite of those listed above as neural stressors. These include eating proper nutrition, enjoying quality sleep, eliminating stress, taking care of injuries, engaging in proper movement patterns, and wearing good footwear. For more info on footwear check out this previous blog post. These are all activities which will send positive fuel to the central nervous system increasing the CIS and overall body performance. The role that we play from a clinical standpoint in improving the CIS is to fix injuries and correct neural imbalances. Correcting this negative stressor is especially important for the athlete or active individual if they wish to continue in activity long term.

Main Point
How then should the reader respond to this? I would recommend keeping these following three thoughts in mind:

1. Make decisions daily in all areas of your life to improve you neural health.

2. Take care of pain and injury when they present to avoid continued and further damage. Do this by addressing the true underlying insult leading to tissue damage.

3. Choose activities to engage in which will not over stress the system and find a healthy level to enjoy them. For help in making this decision check out a this previous blog post.

I would like to encourage individuals to think through how this could apply to them and how take steps toward achieving an improved CIS to prevent injury and enjoy activity and daily life. Questions are welcome!

​by Dr. Mike Fink
originally published by Pittsford Performance Care

by Ainsley Kilgo

Strengthening and conditioning is paramount to optimal music making and performance. There seems to be a lack of specific information regarding healthy regimens for musicians, something The Healthy Musician Project is dedicated to pursuing. As a recent graduate from the Eastman School of Music with a Bachelor’s degree in Saxophone Performance and Music Education, I want to help other musicians improve their spinal health for increased freedom in playing. Music making is an elite sport that requires the body to be resilient and strong. I hope to share my experiences as a student, educator, dancer, and Pilates pedagogue with musicians everywhere.

I am a 5’3, 128 lb female, representing a minority of saxophonists I know. I used to study dance extensively from age four through middle school, so when I began studying music seriously I had a good understanding of injury prevention and body awareness. I knew I would have to strengthen my body to survive the sheer amount of hours expected to hold and play the saxophone in music school. At Eastman I was required to play the soprano, alto, tenor, and baritone saxophones. Each one exerts different challenges on the body. Over the course of four years I learned how to condition my core (abdominal and back muscles) to avoid injury and promote healthier posture in my playing. This journey started at the very beginning of my freshman year and continues today.

After my first week at Eastman I knew it was time to get serious about strengthening my back. After seven days of more playing than I had ever done before, I was left with intense, painful muscle knots in my upper back. I promptly joined the YMCA across the street from school and learned to use the weight machines – especially the pull down, seated row, and back extension. I used a small weight while paying full attention to what muscles I was targeting and how my back was moving. An Eastman friend told me about a Pilates class at the Y that I "had to try." I took some Pilates classes as part of my dance training, but I recalled them being repetitive and boring. I ended up being convinced to go to the class later that week with friends. The YMCA Pilates class uses a yoga mat, a ring made of rubber and foam, and a long weighted bar. While these tools seem like they would make the class harder, movements were more focused and easier to complete with these guides. Even though my core was on fire and it hurt to laugh that first week, I was hooked! After that single hour I didn't even notice the knots in my upper back that were troubling me. From that moment I knew I needed to continue Pilates to get relief from the intense daily saxophone playing I was doing. 

The form of Pilates offered at the Carlson Rochester YMCA is called Integrated Movement=Xercise (IM=X for short). Joseph Pilates, a famous dancer, founded Pilates as a conditioning program for elite New York City ballet dancers. IM=X is an approach based on movement research that uses exercises from the Joseph Pilates method designed to be accessible to people from all walks of life. There is an emphasis on spinal elongation – creating space between the vertebrae. This methodology also draws from Alexander Technique to promote healthy breathing and alignment. The class is a series of exercises designed to strengthen the core. A strong core creates a healthy back, something that is truly essential for all musicians to play effectively. 
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After studying IM=X Pilates for four years at the YMCA, I decided to pursue this training method that can be so beneficial for musicians. I traveled to the IM=X Pilates headquarters in New York City days after graduating from Eastman to study with one of the main founders of IM=X. I now teach Pilates at the University of Rochester Goergen Athletic Center and am so excited to share this method with a variety of students. I hope to create a career where I can help others reach their full potential physically and musically by helping them create more efficient bodies. A healthy core and back can open doors to improved movement, stability, and endurance while performing – something that I wish for all musicians.

by Drew Worden & Chelsea Nelson

A Testimonial by Grace Choi
I started playing the piano at age 3, and my hands remained the same size since then. OK, that was a huge exaggeration, but with some truth to it. All of my life, I have experienced countless comments and reactions from people regarding my "tiny hands." I still remember the awkwardness I felt after playing for one particular competition as a child. The judge called me up after the performance and uttered, "How do you play with such tiny hands?" as she flipped my hands back and forth in disbelief. 

Despite people's observations, I did not grow up thinking my hands were too small to play the piano, and managed to pull off an intense amount of practicing throughout high school and college. But my world as a pianist fell apart during my senior year in college, when I sustained a performance-related injury in my hands, wrists and arms. When reaching an octave on a standard sized keyboard, my hands had to stretch out of alignment and into the danger zone of this injury. I knew I wanted a career centering in piano performance and pedagogy, and since I couldn't grow my hands larger... I started looking into other options. 

From 2007-2009, I worked with Dr. Leone at SMU Meadows School of the Arts in Dallas, TX on an "ergonomically-scaled piano keyboard" (ESPK). The ESPK replaces the action of the standard piano so that it is ergonomically scaled for those of us with smaller hands. At SMU, I studied and performed on a DS5.5™ built by Steinbuhler & Company that has a 5 1/2 inch octave as opposed to the conventional 6 1/2 inch octave. For me, the adjustment was instantaneous. I was amazed that my hands no longer felt small; for the first time, I felt like a big person at the piano. Coupled with this delightful surprise, there was also a painful realization that this is the confidence and physical comfort most people feel at the piano.

I found the ESPK to be much more than a gadget you can slide into the piano, but an important tool that aids in musical expression and ergonomic, pain-free playing. Pianists and listeners will be happy to know as well that the ESPK does not compromise the sound of the original keyboard. During my time at SMU, I mainly worked on Romantic and Contemporary repertoire on the ESPK, and ended up playing the second half of my Master's recital with it. Contrary to fears about using both keyboards, I was able to transfer Chopin Sonata No. 3 from ESPK to standard and performed the piece as a finalist at the TMTA Young Artist Competition in 2009.

Using the ESPK has enabled several personal victories in my playing: 1) more power and sound with less energy spent, 2) better phrasing in lyrical lines that are often compromised at the standard keyboard, and 3) less chance for a performance-related injury to happen or reoccur. I have benefited both musically and physically by using the ESPK, and I know I will continue performing on one and researching its benefits and long term effects.

The number of people that are dedicated to advocating ESPK is growing, and we are now proud to have an international competition that allows contestants to compete on an ESPK. I would encourage more pianists to think outside the box, and seek different ways to enhance performance. If ESPK can provide a more musical, healthy performance for some pianists, I see no reason to avoid at least trying it. Especially if you have hands the size of a 3-year-old like me.

How does Grace's story resonate with you? Have you tried the ESPK before? Do you have students that would benefit from using the ESPK? Share your thoughts with us in the comments below. 

Online Resources
Dr. Carol Leone: http://www.carolleone.com
Dallas International Piano Competition: http://www.dallasipc.org
Pianists for Alternate Size Keyboards: http://www.paskpiano.org, https://www.facebook.com/pask.piano
Small Piano Keyboards: http://www.smallpianokeyboards.org
Steinbuhler & Company: http://www.steinbuhler.com

Grace Choi is currently pursuing her Doctor of Musical Arts degree in Music Education at the Eastman School of Music. She is the first pianist to be accepted to this unique doctoral program at Eastman, and was recently awarded the Teaching Assistant Prize for Excellence in Teaching.

We love featuring stories from active musicians who would like to share their experiences with injury onset, recovery, and prevention. Hearing from musicians anecdotally drives our initiatives for injury prevention and facilitates dialogue between performers and health care professionals. Today we’re featuring a testimonial from classical guitarist Katrina Leshan, who is completing her Masters degree at the Eastman School of Music this May. 

A testimonial by Katrina Leshan

I began my first semester of grad school at Eastman practicing about three hours per day, and was making good progress. About a month into the semester, I started feeling some rigidity in my right hand as I practiced. This sensation quickly progressed, and even with a slow warm up my hand would start to stiffen and swell within five minutes of beginning to play the guitar. It felt like my hand was made out of wood, and that no matter how hard I tried I could not communicate with the individual fingers the way I was used to.

I cut back significantly on practice time, but around November I couldn’t play at all without severe pain in my right hand. I visited a highly-recommended orthopedic surgeon that had helped many other Eastman musicians, and within moments he found what he thought was a ganglion cyst in my right wrist. After confirming the presence of the cyst with an MRI, the doctor recommended surgery to remove it. During my second appointment, I brought my guitar and showed him how certain placements of the hand hurt more than others. He told me I could keep my wrist completely straight to help alleviate the pain. But that is improper classical guitar technique and would make it impossible to play accurately. So, with no other options, I agreed to have surgery to remove the cyst.

Prior to having the cyst removed, I saw Sue Callan-Harris, the physical therapist at Eastman. She was extremely sensitive to my issue, and respected the journey I was on towards reclaiming my ability to play. She asked me to bring my guitar to the appointment, and observed my entire body as I played. Sue was especially interested in the tension I carried in my right shoulder as I played, and hypothesized that this tension may have been the root cause of the cyst.  Because I raised my shoulder so much while playing, I was shortening the tendons in my arms and through my wrist. The friction caused by those shortened tendons and the bend in my wrist could have caused the cyst. This, coupled with a frequency of cysts in my medical history as well as my family’s, made a lot of sense. Sue developed a program for me that involved relaxing my shoulders, breathing more during playing, and strengthening my posture and sitting position so that I would carry less tension when I play. 

I had the cyst removed in an outpatient procedure on January 6, 2014. Sue and my doctor told me it was very important to move my hand and fingers as much as I could as soon as possible, to prevent unnecessary rigidity. The day of, I was already typing on my computer to keep my hand active. I wore a bandage for three weeks, and then began PT again to strengthen all areas of my body that were causing this ailment. I even started putting my tender hand back at the instrument, and slowly recuperated.

The interesting part about not being able to play for the majority of my first year of graduate school was that I really enhanced my ability to listen. Once I finally started playing again, a lot of the mental chaos and dodgy technique I had was actually gone. I had been surrounded by such inspiring musicians for six months while I didn’t play, and they taught me a lot about good technique just by making great music around me.

I finished the year strong, but was still suffering emotionally from the aforementioned traumatic event. I started experiencing a lot of stress during the summer, and with it came that wood-like feeling in my right hand again. I actually grew another cyst almost four months after I started playing again. This time, I knew what I was dealing with, and examined my technique. I was once again employing poor technique and playing with tension, so I practiced slowly and always in front of a mirror. I didn’t want to go through with surgery again, so I still have the cyst in my wrist in exactly the same spot it was before and I’m still seeing Sue for physical therapy. Even more importantly, I am managing stress well and remembering to breathe deeply through my practice so that I can play for three hours per day again. I still have days where my hand feels too stiff to play, so I usually apply kinesio tape or Penetrex, which is an inflammation formulation cream. The combination of these two things got me through my graduate recital and juries.

One last important element of my practice time has been my focus on remaining loose and in constant motion. As a musician who has to sit while I play, I force myself to stand and move around every fifteen minutes. I learned from a Tai Chi instructor that the body is happiest when it is loose and fluid, and this is absolutely true for me. The combination of all these healthy practice methods has helped me decrease physical tension and mental anxiety.

If I could offer a bit of advice to other guitarists who experience wrist issues, it would be to find the stressors in your practice or in your general day-to-day life that cause tension while you play. It’s amazing how much of our mental anxiety translates into physical issues, so being sure that you are calm in your mind increases the chances of having a calm body. I also maintain that constant movement during practice, i.e. getting up and jumping around or just bending over and swinging your arms, makes all the difference in the world. The healthier the guitarist, the greater the opportunity to make beautiful music.
                                                                                                                                                                                                                —Katrina Leshan

How does Katrina’s story resonate with you? If you’re a performer, have you had similar experiences? If you’re a health care professional, have you worked with musicians like Katrina before? Share your thoughts with us in the comments below.