About neuroscience and music (mainly classical). Exploring the relationship of music and the brain based on experience of two careers.

November 24, 2013

Alternative Medicine; Four Ways to Spot a Quack

In my experience musicians turn more often than average to ‘alternative medicine' for help with problems, or just with hope to improve their health. The list includes the “Three ‘R’s,’” Reiki, Reflexology, Rolfing, and chiropractic, acupuncture, massage, vitamins and a zillion 'dietary supplements’ (and don't forget coffee enemas).

Reasons for this preference aren’t difficult to divine: medical ‘providers’ can be cold, rushed, clinical, and expensive; many musicians can’t afford health insurance (see Nov 16); health recommendations change often as science stumbles along a tortured path toward truths, offering complex answers to simple questions like, “Should I be taking Lipitor?” And finally, as imaginative people, musicians may be tempted by magical and exotic claims and practices.

A book I just finished can be a good earthbound guide: Do You Believe in Magic? (HarperCollins 2013) by Paul Offit, M.D., a skeptical mainstream medical authority at Children’s Hospital in Philadelphia. Dr. Offit discusses the immense alternative medical industry.

He does not, as you might expect a mainstream academic to do, reject alternatives, but instead shows some can actually work, even as well as conventional medicine and surgery in certain situations. They work through the placebo response: a proportion of people with symptoms, pain or headache for example, will obtain relief from a sugar pill. Studies reliably show a success rate of around 30%, or higher, if the therapist is caring and convincing. The placebo response is not a product of trickery or deception; it accompanies actual physiological/chemical changes in the brain, such as production of endorphins, similar to changes evoked by other means like talk therapy and medications.

Acupuncture, for example, is one way of triggering the placebo response. It includes ritual, tradition ('proven over centuries'), positive expectations, value (cost), and perceived competence of a skilled practitioner exhaustively trained in an ‘ancient art.’ The needles don’t even have to puncture, just prick, so long as the patient experiences the other magical wonders. If the stage directions are followed and the performance goes well, acupuncture can generate a response in the brain and the patient may experience relief, albeit usually temporary. 

If you believe in them and their method, capable and caring practitioners of most alternative methods, chiropractors to reflexologists, can trigger your placebo response. Of course in the long term, the elephant in the room for all therapies is time; the body, given time, has remarkable power to heal itself. Back pain, for example, will naturally resolve in seven weeks in 85% of episodes, regardless of what happens during that time. Impatience may take us to a therapist who will, of course, accept the credit.

Such 'laying on the hands’ by the alternative industry may be what is missing in encounters with mainstream physicians, those who conduct an interview while typing and staring at a video terminal. Healthcare without the caring.

As in mainstream medicine, alternative practitioners include the incompetent and even charlatans. Bias may lead both to do what is good for their revenue in place of what serves the health of their patients. The number of unnecessary surgeries and drug prescriptions over the last century probably matches the scale of money spent on unproven therapies and supplements.

In sixteenth century Holland the word “kwakzalver” meant a pitchman who quacks like a duck while promoting salves and ointments. The word translated to English became “quack,” anyone who proffers false cures. One of Offit’s chapters, “When Alternative Medicine Becomes Quackery” lays out telltale signs.

Offit's first sign of quackery is a recommendation against conventional therapies that are helpful or even lifesaving. “Chinese herbal therapy for people with HIV looks much more promising” (than western medicine). That was published by Andrew Weil eight years after AZT had been shown to decrease HIV replication. 

One of my favorite medical laws is: “when you go to jiffy lube, you get an oil change and when you go to a [surgeon, chiropractor, etc] you get [whatever s/he has been trained to do]." If a chiropractor tells you that cracking your back will benefit your breast cancer as effectively as medical therapy, he’s a quack. Any practitioner who claims any of the above alternative methods will cure any life-threatening disease like cancer is a quack.

The second indicator of quackery is promotion of potentially harmful therapies without adequate warning. Before cracking your neck a chiropractor should disclose to you that such manipulation has caused strokes. I saw that happen in a child and similar cases appear in medical journals. 

All substances, whether ‘natural’ or ‘synthetic,’ ‘medication’ or ‘supplement’ (economic and political distinctions, not medical ones), have risks and can harm. (Calling a substance a 'dietary supplement' allows it escape the watchful eye of the FDA.) Acupuncture needles have been extracted from lungs and can spread infection.

A third quackery indicator is the draining of patients’ bank accountsAlternative practitioners like Weil and Deepak Chopra are industries, now online, that peddle vitamins, herbs, supplements and proprietary ‘formulas’ as well as books that have made them and others like them (and TV evangelists) millionaires. The efficacy of most formulas are based on the claims of celebrities using their authority as graduates of the Today Show or Oprah.

Finally, the fourth way of crossing the line into quackery is by promoting magical thinking. Offit cites the example of useless titanium necklaces claimed to cause “longer lasting energy, less fatigue, shortened recovery time, and more relaxed muscles.” They are favored by baseball players, and are modern equivalents of copper bracelets to prevent arthritis. No evidence shows they channel electricity for health. (I'm tempted to put football helmets on the same list. They prevent lacerations of the scalp but not injuries to the brain.) Artists, I suppose are more prone to thinking in magical terms, energy fields, meridians, and astrology, than in the tedious, time-consuming and more complex universe of science.

November 16, 2013

Health Insurance for Musicians: 'Obamacare'

by Carl Ellenberger, MD

Like all other artists, musicians are among the Americans most likely to lack health insurance. A recent survey* disclosed that a whopping 55% of musicians don't have it. The majority of those (88%) say they can't afford it. Most of the uninsured are freelancers who, under the current system, would have to buy expensive individual policies. 

Those results suggested to the surveyors that artists "are exactly who the Affordable Care Act (aka "Obamacare") was designed to help" and stand to benefit most from because now they can shop for policies on the exchanges or find themselves eligible for Medicaid in their state and not be excluded by pre-existing problems or exorbitant cost. 

Unfortunately, musicians (and non-musicians) also say they are confused by new law, not surprising in view of the well-funded efforts aimed at confusing them. 

In my view, it would be good to try to clear the confusion sometime in the next several months. Despite its recent temporary notoriety, you could do worse than starting at https://www.healthcare.gov.

*The Future of Music Coalition

November 5, 2013

Edward MacDowell; the best composer you don't hear

One of our board members and Chair of the Department of Fine and Performing Arts at Elizabethtown College, E. Douglas Bomberger, has just published "MacDowell" a marvelous biography of the composer Edward MacDowell (Oxford Press, 2013).

MacDowell enjoyed what we might call rock-star celebrity (absent the income) around the turn of the 19th century. Although born in the US, he earned that reputation by writing and performing his works, mostly for the piano with or without orchestra, in France and Germany over 12 years. Partly because of this fame the president and trustees selected him to serve as the first Chair of Music at Columbia University in 1896. In accepting, MacDowell had a grand vision: 
“First, to teach music scientifically and technically, with a view to training musicians who shall be competent to teach and compose. Second, to treat music historically and aesthetically as an element of a liberal education." 
Like Robert Schumann and Hector Berlioz before him, MacDowell was also one of the greatest musician-writers about music. Some of his writing survives, including the notes for his introductory music class. You can download "Critical and Historical Essays" for free from iBooks.
"…in speaking of this art, one is seriously hampered by a certain difficulty in making oneself understood. To hear and enjoy music seems sufficient to many persons, and an investigation as to the causes of this enjoyment seems to them superfluous. And yet, unless the public comes into closer touch with the tone poet than that objective state which accepts with the ears what is intended for the spirit, which hears the sounds and is deaf to their import, unless the public can separate the physical pleasure of music from its ideal significance, our art, in my opinion, cannot stand on a sound basis."
Although recordings of his Piano concertos by Van Cliburn and Earl Wild gave his music a boost decades ago, his music deserves more hearing. I now take Edward MacDowell more seriously and suggest we all should. Douglas Bomberger's book is a good way to start. I downloaded To a Wild Rose from imslp and sat down to the keyboard for the first time in many years. I am also investigating the mysterious neurologic illness that ended MacDowell's life too early, at age 46.

October 2, 2013

Concert halls and peanuts in a boxcar; the question of scale

Avery Fisher Hall at Lincoln Center seats 2738 people. When Bernard Labadie conducted the New York Philharmonic there in March for the Bach Variations Festival, critic Corinna da Fonseca-Wollheim remarked in the NY Times:
"...Bach’s suites, with their gleaming trumpets, are at heart festive works of chamber music, and in this hall they came across as mild-mannered and diffident. The subtle sparkle and refined textures of the violin concertos didn’t stand a chance."
She went on to say that another problem was that a true "historically-informed performance" (HIP)* of music from Handel and Bach's era requires more than 'paring down' vibrato and 'a couple of rehearsals with a visiting conductor,' even when you are talking about the New York Philharmonic and a conductor with M. Labadie's prodigious abilities.


On October 14 in Leffler Performance Center, we intend to remedy those  problems!



Drey Schwanen
What we call a 'concert hall' made its first appearance in Bach's home town, Leipzig, but not until 30 years after his and Handel's deaths. In 1780, 'because of complaints about concert conditions and audience behavior in the tavern' (Drey Schwanen, left), the mayor and city council of Leipzig offered to renovate one story of the Gewandhaus (a building used by textile merchants and the city's arsenal) for the orchestra's use. They had room for 500 seats (below).


Alte Gewandhaus, 1781

Zimmermann's Coffee House




So, during their lives, most of Bach and Handel's works were performed in smaller places like taverns, coffee houses (especially Zimmermann's, left) and churches, places where 'acoustics' would have ranged all over the map but were generally less problematic because the spaces were small.





Talking simply about scale, the enclosed volume of most of these concert-hall precursors was certainly far smaller than that of Avery Fisher Hall, built to accommodate the largest number of paying patrons to hear a massive modern "symphonic" orchestra such as dreamed of in the 19th century by megalomaniacal composers like Berlioz and Scriabin. (The mystical Scriabin imagined concerts covering entire countries!)

Talking about both scale and acoustics, Musser Auditorium at Leffler Performing Arts Center at Elizabethtown College would seem to be just about right for the October concert of Les Violons du Roy, conductor Bernard Labadie, and mezzosoprano, Stephanie Blythe. We should hear the entire range of the "gleaming trumpets...and all the subtle sparkle and refined textures" of the program. For comparison, Musser, seating about 800, is close in size to the original Gewandhaus, and to the Leipzig Singakademie where Mendelssohn conducted the revival of Bach's St. Matthew Passion (1829), finally overcoming the formidable century-old challenge of the complexity of the score, multiple choruses, soloists and orchestras. 

Musser Auditorium at Leffler Performance Center
photo: Joel Fan
A Baroque orchestra is about the same size as a chamber orchestra. "Chamber," (or "Kammer") initially distinguished secular from religious music, a 'room' from a 'sanctuary,' and implied small scale and intimacy between players and listeners. Indeed, premieres of what has become the core of chamber music--by Schubert, Beethoven, the Schumanns, Brahms--often took place in rather crowded small spaces which listeners eye-to-eye with the players as many old drawings suggest. In churches, small orchestras were necessary to fit into the choir or chancel.

The October 14 concert will also eliminate the problem of large symphonic orchestral musicians playing in an unfamiliar 'baroquey' style. Les Violons do that every day. Far from the 'authentic' early music performances of yore -- the authenticity often a gimmick or a substitute for competency -- historically-informed performances bring this music to a life that you may have never experienced before. The genius of Bach and Handel, as with Mozart, Beethoven and other 'old masters,' is that their music speaks to us centuries later when brought to life by performers like you will hear on October 14. The result is as contemporary and exciting as Jay Z or Lady Gaga! (but perhaps out of kilter with our current "loud, violent, shouting" cultural moment -- see previous post below). 

Of course none of this matters to Stephanie Blythe. Her pianissimo can reach the back row of the Metropolitan Opera House, and no doubt even the back of Avery Fisher.

____
*If you have read this far, you might like to read the late Bruce Haynes' The End of Early Music; A period performer's history of music for the twenty-first century.





September 30, 2013

Quarterback or Concertmaster? A 'no-brainer!'

"...[football's] real advantage is that it’s louder, faster and more violent [than baseball] — which is to say, better in tune with our cultural moment. 'We are a shouting culture now….'" 
--"Is the Game Over?" Jonathan Mahler, New York Times, Sept 29


If we are we indeed experiencing a cultural change (a "moment?"), it starts in childhood. 

Football encourages, they say, team spirit, character, and self-confidence, but also starts a process that can lead to chronic traumatic encephalopathy ("CTE" will soon become a household acronym) and joint replacements.*


An orchestra or band can also foster those same qualities while respecting the brain and developing all its capabilities when it is most receptive (and at the same time most vulnerable to trauma).





*Stern, RA, et al, NEUROLOGY, Aug 21, 2013: "Consistent with earlier reports of boxers, our findings suggest that there may be 2 different clinical presentations of CTE, with one initially exhibiting behavioral or mood changes, and the other initially exhibiting cognitive impairment. The behavior/mood group demonstrated symptoms at a significantly younger age than the cognition group.... almost all subjects in the behavior/mood group demonstrated cognitive impairments at some point…." 

It's more than just occasional concussions. See here.

Addendum: New research suggests a relationship between head impact exposure, white matter integrity, and cognition over the course of a single football season, even in the absence of concussion, in a cohort of college athletes. Neurology 2014;82: 63-69.

Addendum: In a preliminary study comparing the brains of 50 college football players and 25 matched controls, researchers found that playing football was associated with reduced hippocampal volume on magnetic resonance imaging. (The hippocampus is where memory lives.--ed) Singh R, Meier TB, Kuplicki R, et al. Relationship of collegiate football experience and concussion with hippocampal volume and cognitive outcomes. JAMA. 2014; 311:(18):1883–1888.

September 17, 2013

Steinway v. Baldwin

It happens often. At the reception after a concert the pianist, quietly, confidentially, and as if the words were about to come as a revelation, says to me, "You ought to get a Steinway."

Yeah. Right!

Our Baldwin concert grand is at least 30 years old and has been the butt of harsh comments from dozens of pianists, especially when we get behind in maintenance. And that can be a challenge out here in the Gretna jungle. But we never fail to tune and tweak it right before a concert, even if there is only one short piano work on the program.

One problem is illustrated by what happens to a harpsichord, an all-wooden instrument lacking the iron frame of the modern piano. A few years ago we tried to keep it stable in a climate-controlled room until just minutes before a concert, then swiftly rushed it to the outdoor hall (in Dave's pickup), tuning it minutes before curtain time. To our horror, as it soaked up the humidity during the 2-hour performance, its pitch went up almost a half step and several keys refused to budge. (We were lucky that singers can transpose!) Now we move it into the Playhouse days ahead and allow it to soak all the dampness it can hold. Then we tune.

I can think of better ways that $125,000 could improve our music than by replacing a Baldwin with a Steinway, but that's a non-issue anyway because we will never face that luxurious choice. And we do have a brand new Steinway in Leffler Hall at Elizabethtown College that we use for our Monsters of the Steinway" series, resuming with Gilles Vonsattel on March 15.

In early years we rented pianos from a local piano dealer. Inexplicably on the second floor of a 19th C. building and overseen by an ancient and irascible proprietor, I thought the place must have branched off from the Wieck Piano Fabrik in Leipzig, but the pianos had mostly Japanese names. Legs punctured the rotting floors of the old Playhouse and felt came unglued from hammers at the most inopportune times. Then in 1982 we rented a majestic Baldwin from York because our schedule included Dave Brubeck at the beginning, Marian McPartland in the middle, and George Shearing at the end. I, and they, were quite happy with the instrument and the cost to buy it was only slightly more than a small BMW.

That was when the late great gastroenterologist Bob Dye served on our board. I can't even begin to imagine the conversation he had with one of his musically-inclined patients lying supine on his examining table, but the piano became ours. The Big Baldwin has served with distinction and has proud scars to prove it.

You may have noticed that pianos (now we must call them 'acoustic pianos') have lost more value than a 1959 Plymouth (or books and records). Most without a Steinway decal (OK, and maybe a few others like Bösendorfer and Fazioli) are worth roughly their weight in cement. Everyone is holding their breath to await the fate of Steinway, recently purchased by Steve Case, founder of Amazon. Well they should, in view of the story of how Baldwin left the stage. I read a version of the story by Richard Conniff in the current (Sept/Oct) Yale Alumni Magazine.
"Baldwin was a piano company that had transformed itself, by a series of acquisitions, into an insurance giant and Wall Street darling. When it announced its latest acquisition in the summer of 1982, Jim Chanos [Yale professor and investment analyst, subject of the article] got the job of figuring out if the proposed deal would be good [for his clients, i.e., investment titans]. 'And I started looking at this mess of a company and couldn't figure out how they were making money and what their disclosure forms were saying….'" 
 "Then one night…his phone rang…. [An anonymous caller] proceeded to point Chanos to public files of correspondence between Baldwin and state insurance regulators in Arkansas. Those files turned out to be a beginner's guide to financial shenanigans. The regulators had belatedly discovered, among other things, that Baldwin was improperly using insurance reserves to finance its acquisitions."

Four months later Arkansas seized the assets of Baldwin-United and Chanos became a financial detective (notorious or celebrated, depending on your viewpoint) who later uncovered scores of other financial shenanigans including those of Enron, Tyco, Worldcom, and the subprime mortgage mess.

See Wikipedia for a more comprehensive version of the Baldwin story, but the company, now a subsidiary of the Gibson Guitar Company, makes pianos, mostly uprights I suppose, in China (a country, according to Chanos, "on an economic treadmill to hell.")

I think I appreciate our old Baldwin even more. Now it's in hibernation until next summer. It's old but has low mileage. 

September 4, 2013

Summer 2013 Ends with Enescu

We still have the Elliott Carter Figment for Cello to look forward to, next Sunday evening. 

Oh yes! And the Enescu String Octet in C Major, Op. 7 played by the combined Momenta and Daedalus Quartets. Beethoven's "Harp" Quartet (my favorite) separates Carter and Enescu.


George Enescu, 1881 - 1955
You may never again in your lifetime have a chance to hear either the Carter or the Enescu, so please put this 'postscript' concert of our season prominently on your refrigerator door. Yes, I know, Gretna usually settles into wintry slumber after Labor Day. I guarantee that you will not have difficulty parking this Sunday evening before the 6:30 pre-concert opening performance by students Sean Brown, violinist, and Audrey Rutt, pianist. (N.B.: the Jigger Shop is closed for the season.) 

[Sunday, September 8, 7:30, Mt. Gretna Playhouse]

Looking down this page I see I have a little more space for a few mementos from our summer.


A happy Momenta and Charles Abramovic acknowledging a standing ovation after their stunning and thundering Elgar Piano Quintet.




Rehearsing the Boccherini Guitar Quintet, Allen Krantz and Momenta. Allen's re-premiered Piano Quartet (this time without Hurricane Irene in the background) commissioned by Paul and Irena Merluzzi, received a marvelous performance by Momenta and Abramovic.




The house behind the Playhouse built by John Cilley who also built the original Playhouse in 1894. The circular porch serves as box seat. (Inquire at the box office. If you pay enough, we'll cut down the rhododendrons.)


Postscript to Mar 5: "What (if anything) Ails Classical Music?"

My Mar 5 post has become the most popular post since I began this blog. 

The following is a more passionate answer to that question by James Brinton. It appeared recently on Norman Lebrecht's Slipped Disc* in response to a remark by Deborah Borda (LA Phil) about the decline of orchestra subscriptions.
'Within 20 years, the subscription rate will be down to 15 or 20 percent. It makes it a real challenge financially and artistically. This is an on-demand society now.’
Perhaps more blunt than I, Brinton responds: 

"Many assume, wrongly, that there is some defect in classical music causing this. It’s unpopular, old-fashioned, elitist, etc. None of that is true; classical music is timeless and accessible to anyone willing to give it a chance. In reality, classical is the victim of:

"1. A multi-billion dollar marketing effort on behalf of high ROI (return on investment) rock, pop, and hip-hop (most of which isn’t worth burning); capitalism at the expense of culture. If the same amounts were spent marketing classical, the problem would disappear." 


(I don't view this mainly as a marketing problem -- see Mar 5 -- but certainly more marketing could help immensely. But read on…. -ed.)

"2. More than half a century of declining educational standards and penny pinching which have gutted music education, music appreciation, and classical exposure–even as the pop marketers were capturing ever greater share of young minds." (Yes!)

"3. Self-absorbed, entitled, orchestra board members who feel that, because they contribute, they somehow own an orchestra (See Minnesota). This is coupled with a spreadsheet approach to culture; many of these people and the administrators they hire are chained to the idea of profit when, in fact, cultural institutions are non-profit organizations and demand a different managerial approach." 


(Those dangers emerge during some periods in some organizations. And 'profit' may be necessary when you are digging out of hole dug in previous years. -ed.)

"3a. These people also carry a CEO mindset into the fray in which employees are costs to be minimized, either in numbers or salary. They fail to understand that orchestral musicians ARE the art they think they are supporting, instead they consider them mere overhead. And because they know almost nothing about what it takes to become an orchestral musician, they undervalue their greatest resource." 


(But some orchestra musicians may not understand that it takes far more than good playing to get people in the seats and pay the bills. Like it isn't: "You play. They come." -ed.)

"4. A generation of culturally illiterate managers (See M. Henson) who have attempted to solve financial problems over the bodies of musicians rather than approaching them sanely. This is the managerial equivalent of saying, 'Kill the baby, then you won’t have to worry about day care.'” 


(Hmmm!? Maybe sometimes.  -ed.)

"5. A headlong charge, especially in the US, toward the lowest common denominator in terms of public art, culture, and education. Never an intellectual country, the US has become blatantly anti-intellectual in everything from its politics to its thinking about education (See Texas’ rejection of instruction in “critical thinking”)." 


(And 46% of Americans reject the science of evolution!)

"6. A generation of bureaucrats so drenched in pop that they lack almost all familiarity with, and respect for, classical music. Some of these people are so ill-informed that they can’t differentiate between hip-hop and classical music (See Germany’s Theresa Bauer versus the University of Music and Performing Arts, Mannheim*). Bureaucrats unable to appreciate culture should not administer state culture programs."

"All these things have to be addressed, and we have little time left to address them." 


(With Charles Rosen, I remain optimistic because so many children and young people still want to play classical music, despite all these obstacles. After the smoke clears, maybe not in my lifetime, 'classical music' will continue on, probably in many different ways. -ed.)

--James Brinton (my editorial comments in italics)

*Now see Mar 5: "What (if anything) Ails Classical Music? A Neurologic Diagnosis."

*Slipped Disc post on Deborah Borda

*The Minister for Science, Research and Art, Theresia Bauer (member of Parliament from the German Green Party) has proposed closing down the courses of study in orchestral music and the music education programs in Mannheim and Trossingen. (here)

July 29, 2013

Take care of your brain; build cognitive reserve

A study from the Rush University Medical Center in the July 23 issue of NEUROLOGY in my mailbox today addresses the question: can we do anything to slow down late-life cognitive decline? 

"The results suggest yes -- read more books, write more, and do activities that keep your brain busy...," according to an accompanying editorial.

The study suggests also that the more of that you do (or have done) at ALL stages of life--even in childhood--builds more 'reserve' that you can draw upon in late life to compensate for the almost inevitable processes -- little strokes, Parkinson's, Alzheimer's, and other chronic neurologic diseases of all kind that may affect our brains as we age. The concept of 'cognitive reserve' has been suspected before but this study provides support for it.

I suspect the NYTimes and AARP will find it eventually. The methodology did not determine whether passive watching of films and videos, 'educational' or not, or any of the 'brain exercises' sold by 'experts,' have a similar effect, but I would bet that seriously listening to (as opposed to just hearing) music would, as would intently listening to a scholarly lecture. The effects were small but statistically significant. More research is needed.

Discussing their results the authors point out that in addition:

"Neuroimaging research suggests that cognitive activity can lead to changes in brain structure and function that might enhance cognitive reserve. Thus, occupations (e.g., professional musician,[27] London taxi driver[28]) and leisure activities (e.g., playing Baduk[29]) that challenge particular cognitive functions are associated with differences in the gray and white matter of brain regions that support the cognitive functions. Importantly, longitudinal studies have documented regional increases in gray matter volume and white matter microstructural integrity over temporal intervals ranging from a few hours[30] to several years[11] in persons engaged in diverse cognitive activities, including studying for a test of medical knowledge,[10] apprenticing as a London taxi driver,[11] reading mirrored words,[31] deciphering Morse code,[32] learning novel color names,[30] and performing cognitive exercises.[33–36]"

So you see why I write so much! Or you might conclude I have exhausted my reserve!

July 26, 2013

Get Inside Mt. Gretna: 29th Annual Tour of Homes

What is the fascination some people have in looking into other people's homes? I don't have it but am very happy others do -- because for 29 years the Annual Tour of Homes has been a lifesaver for Gretna Music. 

We are fortunate in Mt. Gretna to have quaint old cottages, some petrified since before the turn of the 19th century, but scrupulously maintained to stay that way by loving owners, only some of whom are in a chain of inheritance connected to the original owners. Other owners relate stories of stumbling into the place--variously called "Camelot," Shangri La" or "Culture Gulch," the latter by the Philadelphia Inquirer--by accident, immediately falling in love with a lonesome neglected cottage and pouring their heart and soul into its restoration. Floors at a slant, walls in which the same layer of chestnut serves as both inside and outside, furniture and appliances (and one entire house) from the Sears Roebuck catalog in 1925, and a plethora of Amish quilts.

Some of the durability may relate to the chestnut trees which predominated in the Gretna forest until summarily wiped out by a blight early in the last century. At least those trees that survived immolation in the fires at the nearby Cornwall Iron Furnace that forged cannons for George Washington. 

One day walking through the Campmeeting kicking acorns along the way I suddenly noticed I was kicking chestnuts. Looking up I saw two adolescent chestnut trees behind the Tabernacle that somehow had escaped the blight, perhaps the only ones that did. I carried about 25 home and now I have a chestnut tree in our garden (as if we didn't already have enough trees!) soon to celebrate its fifth birthday. Maybe by the time it comes of age a cure for the blight will be discovered.

You can find similar neighborhoods in Chautauqua NY, Petoskey, MI, Pacific Grove, CA, and many other former sites of stationary Chautauquas, most preserved in the same way. They served the purpose of summer schools before colleges and 'festivals' got into that business. Representatives from some of them are meeting now in Mt. Gretna, The Chautauqua Trail organization, for lectures, performances, and just hanging out. Their Sunday Service in the Playhouse, July 28, is open to all. Rumor has it that Abe Lincoln will speak.

The Mt. Gretna Campmeeting, where most of this year's open homes are situated, is celebrating their "Listing" in 2013 on the National Register of Historic Places. The Mt. Gretna Historical Society can show you a lot of history and is Tour stop #3.


Drawing by Bruce Johnson, also responsible for our 'bass-in-the-trees' logo

Why am I happy to see more than a thousand visitors tramping all over town once a year, maps in hand? It is our way of getting support from the large segment of the public that would never think of contributing to classical music or jazz, endeavors which, like opera, symphonies, and museums, receive less than 50% of their operating costs from ticket sales. In past decades much of our traditional support has disappeared: corporations keep their profits, foundations turn to the hungry and sick, governments cut spending. Large opulent performing arts centers, like 8-bay fire halls, continue to proliferate, but they don't make the art that helps us be more human.

The Tour is on Saturday, August 3. Tickets in advance are cheaper. Visit gretnamusic.org to see where you can buy them near you.

July 21, 2013

Musicians with Dystonia: practice makes imperfect

by Carl Ellenberger, MD


The music of Robert Schumann remains vital and wondrous in the universe of classical music. Perhaps we should thank 'dysfunctional brain plasticity' for it. At the age of 19 when he was studying law against his wishes while also a piano student competing with his teacher's daughter Clara, with whom he was in love against her father's wishes, drinking too much, actively searching for his sexual identity, feeling anxious and depressed, and fighting loneliness after his teacher took Clara away for months, Schumann began to lose control of the middle finger of his right hand. He tried various remedies to no avail, including mechanical contraptions and also a cutting-edge medical treatment of 1831, "inserting the ailing extremity into the moist belly of a slaughtered animal." Thereafter, Schumann turned from performing to writing music and writing about music(1).


Background

At the intersection of two major domains, modern medicine and musical pedagogy, dystonia of musicians seems to have been largely appropriated by the medical domain, especially since the recent surge of interest in medical problems of performing artists. When Schumann sought medical help, he found a quack remedy. Quack remedies exist today, as do misguided ones, such as surgical cutting of ligaments and tendons. Though neuroscience now could offer him a better understanding of the problem thanks to accumulating observations of cases and neuroimaging, modern medicine could probably not restore Schumann's full ability as a pianist. Botox injections and various drugs and behavioral therapies may partially help some victims -- but often at the expense of side effects incompatible with playing an instrument.


One obstacle is that we face many diverse individual examples of the condition. Though we can easily divide them into two broad categories: extremity (arms and fingers) and embouchure dystonia, each musician has his or her own version and no single solution fits all cases like insulin improves diabetes. But we have achieved better understanding of the basic nature of all these problems: they originate in parts of the brain. Unfortunately, there they are subject to myriad influences, including genetic heritage, character, personality, life style, toxins not limited to alcohol, sleep patterns, emotions, life stress and performance anxiety.


Even some of the conventional statistics like prevalence are uncertain because they derive from self-selection of subjects, self-evaluation ("on a scale from 1 to 10"), and data collected retrospectively by interviews and questionnaires.  The diagnosis in many of these cases may not be certain. Swallow this 'conclusion' from an expert in the field:
"Taken together, epidemiological findings indicate that the amount of workload of the respective body part, the complexity of movements and the degree of spatial and temporal sensorimotor precision as well as the level of social constraints associated with the musical performance were related to musician’s dystonia."
So our understanding is still limited as we try to help.

What is Dystonia?

Dystonia of musicians may be a dead-end branch of the evolutionary tree, a maladaptation that happens when the human brain (of certain vulnerable humans; see below) is called upon time after time to do one of the most complex motor tasks of all, beyond the limits of capability of most of us, like playing a Schumann (not to mention Scriabin or Rachmaninov) etude.(2)


Dys (bad) tonia (muscle tone) means involuntary muscle contraction, the inability to not contract muscles when that would be appropriate, as when controlling each finger independently or shaping an embouchure. The resulting loss of control is not due to weakness. When a flexor muscle contracts, its opposite, an extensor muscle, must relax; if both the biceps and triceps contract at the same time, the forearm doesn't move or performs a clumsy writhing movement as both muscles try to prevail. The long-recognized generalized familial form of the condition, dystonia musculorum deformans, affects most muscles usually early in life. The focal form, often "task specific," usually involves small integrated groups of muscles used repetitively for years to perform the same particular task. Dystonia in musicians is task specific.

A common form of task-specific focal dystonia, writer's cramp, illustrates a key characteristic of task-specific dystonia: it usually appears only when writing with a pen or pencil, not for example, when typing or using a knife or fork. A violinist may experience dystonia, usually in the left hand, only when playing the violin, not the viola, as most violinists don't do very often. My teacher had it when he reached his 60's; he became unable to control his third and fourth fingers independently only when playing the piccolo not the flute. So it is clear that sensory input--signals sent back to the brain from muscles and joints as they contract and move--plays a role. The problem involves sensory-motor integration.(3)

In a minority of cases dystonia may spread from one task to another -- from playing the flute to typing, for example -- illustrating that some individuals may indeed have a genetic vulnerability. 

Writers can sometimes minimize cramping by using a fat pen -- that feels different in the hand than a thin one and sends slightly different signals back to the brain. Such a maneuver is called a 'sensory trick.' A similar one may be employed by victims of torticollis, involuntary head turning. If they gently touch the side of the chin on the side the head turns to, using no effort to overcome the rogue rotator muscles, the torticollis may stop--temporarily. Musicians can learn sensory tricks too (see below).

Typically, the disorder comes in varying degrees as well as different patterns and locations.

Who has Dystonia?

Well-known musician's with dystonia include pianists Leon Fleischer and Gary Graffman and violinist Peter Oundjian of the Tokyo Quartet, turned conductor. They and other victims, like Schumann, turned their careers around in mid-life and made other distinguished musical contributions. But musicians with lesser degrees of the problem, those unaware that they have it, and those who have not chosen to 'out' themselves for fear of losing engagements, may confound the statistics of its prevalence, now thought to be about 1 percent of all classical musicians.

Uncertainty also attends the observation that men are far (6:1) more often affected than women; a large "gender bias." Classical musicians are mainly affected not only because they practice Ericsson's 10,000 hours to compete for limited opportunities, but also probably because they are subject to more strict restraints than jazz and pop musicians. You don't, for example, play a difficult Chopin Etude in an easier key, rewrite an Elliott Carter quintet to make it playable up to tempo, or turn repeated failed articulations in the trumpet opening of Mahler 5 into your signature jazz style. You have to 'nail' the notes exactly as written, exactly at the right time, and without the advantage of three strikes.

Some musicians who believe they have dystonia may actually have one of a variety of other neurological problems that mimic dystonia. (That's why a neurologist with special competence is necessary, see below).

Embouchure dystonia(4), more recently recognized, is most difficult to overcome; few of its victims can continue their careers (some have; see below). Instrumentalists most affected by any type of dystonia seem to be: pianists > guitarists > violinists > flutists > clarinetists > trombonists, roughly in order of the perceived complexity of execution. Like many of the numbers above this data come from the German musical community(5).


What causes dystonia?


Ironically, in the past the cause of musician's dystonia was thought to be "overuse," that is, overuse of the machinery: muscles, tendons, joints, 'chops.' But now we know that to the extent that the term "overuse" applies, it more aptly refers to overuse of a part of the brain. Musicians who play casually or technically simple music are rarely affected because they don't have to practice 'over and over' for many hours. In one sense (and only one sense) the problem seems to me comparable to wheels making ruts in a road by using the same path over and over; eventually the ruts become too deep and your carriage can't go anywhere but to follow the ruts, even if they go to the wrong place.



I really don't intend to contribute the term, "brain ruts," to the discussion, but I will try to simplify a little pathophysiology. Also critical for 'muscle memory' that musicians speak about, impaired sensory-motor integration underlies dystonia(3): one parcel of the cerebral cortex sends command signals to the fingers or embouchure which, in responding, send signals back to another parcel. Both the initial motor message and the sensory reply are 'integrated' and routed to other parcels some of which record that activity. The recording -- a growing library of 'muscle memory' -- helps facilitate, or prompt, the same activity each time it occurs again, first by enhancing chemical transmission (neurotransmitters) in the connections activated, and eventually by building more anatomic connections to help perform that particular task. The enhanced neurotransmission may explain why you improve by multiple repetitions of a passage during one session; the enhanced anatomic connections probably explain why the passages you learn today stay with you longer--much longer if you're in your 'sensitive' adolescent learning period. Ultimately, innumerable repetitions build a network of lasting connections to enable fingering, for example, an F to F#. Of course numbers of cells and connecting elements involved number in millions.


One indicator of brain 'plasticity' is the enlargement of a specific area of cerebral cortex (gray mater on the brain surface) in response to the intensity and duration in which that area is called upon for use. For example, the areas of motor and sensory cortex activated by fingering a violin with the left hand in the right hemisphere of the brain, expand with practice to larger size than the corresponding areas in the left hemisphere because the fingers of the bowing right hand, while not unimportant, perform less complex individual tasks. 



Areas, and thus actual volume, of brain cortex expand (we see this by MRI) because as they develop more fibers (axons), connections (dendritic spines, synapses), brain cells, and support matrix. Motor and sensory cortical areas for fingers and lips lie adjacent to one another in the frontal and parietal lobes. They overlap to some degree and theoretically, at least, expansion of the network for one finger could invade the network of another and vice versa. I wonder whether facial movements of violinists and pianists -- obvious when filmed close up (see a video of Leon Fleisher playing, or conducting) -- reflect this proximity of the fingers and face in the cortex; activity in the finger area spilling over into the face and lip area. Obviously, this observation and theory predict the likelihood of embouchure dystonia is increased in musicians with finger dystonia and vice versa; some data suggests this may be true. Exactly what happens on a microscopic or cellular level to cause dystonia also remains uncertain. 


Studies have shown that at least some musicians with dystonia have a genetic vulnerability for it: their brain's neural firmware may have been abnormal from birth. And evidence suggests that their individual finger areas in the cortex are indistinct or overlapping, at least more than in the rest of usMost of them, of course, would never have noticed their defect if they hadn't stressed it by long hard practice, though some -- more than among the general population -- might have experienced other forms of dystonia, such as writer's cramp, torticollis, blepharospasm (eye closing), etc, or noticed it among family members and/or ancestors. Exactly what this inherited firmware defect is, and the genes involved, have not yet been determined but evidence comes from thorough exploration of family histories and techniques like functional MRI and electrical recording.


Finally, every human symptom, like 'headaches, pain, dizziness and blackouts' (a neurologist's daily bread), can be caused or magnified by depression and anxiety, often unrecognized by the victim, and related to stress. Musician's dystonia is no exception. Enduring a divorce, a succession of failed auditions, or performance anxiety can contribute. There are good reasons to incriminate the increasingly rigorous orchestral audition as a causative factor. Perfection is the goal when you compete with hundreds of other candidates for one chair, but there are inevitable casualties in the process as evidenced by so many principal players felled by dystonia.


Origin of dystonia in musicians, photo from (5)


What to do?

"Treatment" doesn't seem to be quite the right word, at least in the sense of medical treatment. Neuroscience has provided a better understanding of musician's dystonia but treatments based on this knowledge so far -- Botox, medications, behavioral therapy -- have only raised hope and succeeded partially in a few isolated cases. Prescribed rest periods have rarely helped in my experience. 


That said, an important first step is to consult a physician -- in almost all cases a neurologist -- who has special competence and experience in evaluating musicians. (If a consultant does not request you to bring your instrument to the consultation, he is not one of them.) Such consultants are rare because the problem is rare and few neurologists have seen any patients who have it. This step is important because  a host of other neurological problems can mistaken for dystonia, like ulnar neuropathy, early Parkinsonism, etc. 

If the diagnosis is indeed dystonia, the neurologist will assess the possibility that the one potentially effective purely medical treatment might be helpful and to what degree it might help. (That degree is rarely 100%). That treatment is a very targeted injection into carefully targeted small muscles to weaken those that inappropriately contract when they shouldn't. Choosing the one or more small muscles is a very difficult task.(6)

For now I believe that good problem-solving music teachers may also offer promising strategies. Most are based on the principle of relearning (reprogramming, rebooting, or restarting in computer jargon) 'from scratch' in the realm of the particular problem; be it bowing, fingering in some wind players, embouchure shaping, and others. This slow, starting-over change in practice behavior might, as in aphasic stroke patients regaining ability to speak, generate alternative networks and pathways in the brain, a detour around the ruts in the road, if you will. 


This method was used successfully by trombonist David Vining who described his struggle with embouchure dystonia to Chamber Music Magazine(7). His strategy was to restart his trombone career by practicing musical passages while just blowing into the instrument without buzzing his lips. Only months after playing "air trombone" did he begin again to learn how to produce a sound as if he were a child learning it for the first time. Any wind player could try the same strategy.


That strategy falls into the realm of "sensory tricks" as mentioned above. Similarly, flutists have had variable/temporary success by applying tape to the lip plate or perhaps even by changing to an instrument with a different "feel," or installing variety of 'handles' on their instrument so that holding it sends different signals to the brain. String players, of course, can try instruments of different sizes and perhaps balance. (I am not aware of any attempts to play 'left-handed' like a baseball batter, or of pianists changing to the harpsichord or organ.)


One might ask whether musicians who learn 'bad' playing habits from the start may be more vulnerable to dystonia later. I am not aware of evidence addressing that question. That information would be difficult to obtain and bad habits for one teacher may be tolerable or normal habits for others. (Think of Glenn Gould.) Nevertheless, Vining believes that his initial intense approach to playing, that I have observed in other trombonists, employing more effort than necessary to create an embouchure, may have contributed to his problem. When he restarted after studying the Alexander and similar techniques, his new approach was more 'laid back' and relaxed. Certainly some bad habits can lead to other problems down the road like pain, fatigue and tendonitis. 

You might also ask how one might minimize from the beginning the risk of 'contracting' dystonia in the first place. The answer is, of course, we don't know, but that won't stop me from speculating. I would say to young musicians: relax, lay back, don't push, practice slowly and deliberately and stop before you become frustrated with any particular passage. You can always try it again tomorrow. Substitute regular daily practicing -- one or more sessions -- for long intense sessions in which you try to completely master a difficult passage all at one time. In the beginning, we learned to play fast passages slowly, gradually building up to the necessary tempo.  Take any passage that elicits dystonia and slow it down to a speed that avoids the problem and then play that repetitively. Every day. And others like it that employ the same fingers that you can play over and over without dystonia. Wear new ruts into the road.


If something like dystonia appears only after a period of playing, or if intense practicing seems to make a passage worse, stop playing and start again an hour or more later, or tomorrow. Avoid anger and frustration Take a break! If you tend to be tense when playing, by all means investigate one of the relaxation methods like the Alexander technique. 


We are at a similar point in understanding sleep disorders. We don't have a universal single/simple treatment that fits all. But we do know enough about the problem to begin to develop recommendations under the heading of "sleep hygiene." So what I recommend here is perhaps what we might call "practice hygiene." In both cases, especially dystonia, we are also talking about a process that takes months if not longer -- perhaps as long as it took to master your technique when you were in junior high school -- and an effort that never ends.


Personally, I have learned that dystonia can be more of a problem when one is insecure with any passage of music, because of inadequate practice or rehearsal, so that another aspect of 'rehabilitation' can be to learn potentially troublesome passages cold, starting slowly, even to the point of learning them by memory. Greater confidence minimizes the chance of any problem, including dystonia. Often when working on difficult passages I have to stop myself and think, 'relax, lay back," the planet will not stop rotating if you don't immediately get this right! Of course, a variety of relaxation techniques, good sleep habits, exercise -- all healthy life-style activities in general, can help to reduce stress and improve the chance of success. All easy enough to say, not necessarily to accomplish, especially with a audition approaching, and by no means a cure for every problem.

Readers with dystonia may have tried some of the above strategies that might apply to them. Because I suspect that we hear more about career-changing failures and too little from those who have succeeded, especially to the point of being able to continue playing, their stories could be helpful. Click on 'Comments' below.


Understanding the basic science underlying dystonia could be the first step in overcoming it by altering and adapting practice techniques. This is not a condition where doctor shopping or, "You're the doctor, treat me," often succeeds. When a competent neurologist has confirmed the diagnosis, one alternative might be, 'ask a good music teacher' -- a teacher experienced in solving all kinds of problems. Teachers, too should take heed, especially the demanding slave-driver types. (I can only wonder what contribution Schumann's old teacher, Fred Wieck, made to his distresses.) Or talk to colleagues who have overcome a problem and consider adapting their methods to your problem. For now, however, prognosis remains uncertain and careers continue to be altered.




Leave a Comment. Are there any success stories?


*Further reading: