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

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:


July 15, 2013

Disdain for Classical Music


An hour before last night’s performance the musicians had taken showers in our little downstairs motel, dressed, and were loading their car for the trip to the Playhouse (with no showers and too few dressing rooms). 

Relatives unexpectedly dropped in after dining on sandwiches at the Jigger Shop. The line at the ice cream bar was far too long so they had time to kill. 

“We’re going to the concert,” they said. 

Taken aback by the intention, atypical for this particular group, I asked, “the concert?” 

“We go to a Tabernacle concert every summer.” 

“What’s playing,” I asked. 

“Don’t know, but we go every year.” (I looked it up: they were singing hymns in the Tabernacle last night.) 

“Do you like to sing?” I asked. 

“No.”

“I have a proposition for you,” I said as we watched the three young musicians carry their instruments to their car, the women wearing colorful long silk dresses. “I’ll drive you to our concert, park right in front, and give you tickets” (to hear Beethoven, Shostakovich and Schubert).

Steadfast resistance mixed with irritation. They would never in their wildest dreams go to a “classical music” concert.

They drove off to the Tabernacle.

I sensed actual disdain and assume it to be fairly common among the public. I see it on the faces of people passing the back of the open Playhouse during concerts and rehearsals, but was a little surprised when it came from a relative to whom we have repeatedly extended hospitality. 

I would react similarly if encouraged to go to a NASCAR race or a tractor pull. So maybe the resistance has something to do with fearing hours of enforced boredom. Oh yes: cultural, educational, socio-economic, etc, etc.

It’s so sad. The concert by the Trio Terzetto proved to be one of our best in many years. The elite cognoscenti in the audience, here in rural Buggyland, went wild.

As Paul Krugman said today about behavior in our government: “I don’t fully understand it, but it’s a terrible thing to behold.”

July 8, 2013

Gretna Nymphs and Angels

Not only does Gretna Music occasionally host 'certain nymphs' like Syrinx, we also have angels. Nancy Hatz is one. Perhaps you could call her our violin angel.

Nancy will soon be able to say she has an earthbound angel for a century. Although she is still two years short of that point, I can now predict it for certain because the state has renewed her driver’s license for 4 years and that will take her well into her second century. She missed Brahms by only 18 years! Nancy, and until recently her late husband Russell, were Gretna residents  and neighbors of mine. 


Midori and Nancy Hatz in 2007
Last year Nancy moved to the second floor of Traditions in Hershey, but very soon thereafter had to move again -- with her Steinway grand piano -- to the first floor because the second floor was reassigned to ‘assisted living,’ a service that she didn't need. 

Nancy has been in our audience for almost every concert since 1975 and always comes backstage afterward to thank the artists and exchange memories. You may recall that she sponsored the concert by Midori several years ago. 
Sarah Chang and Nancy Hatz in 2013

Like this one, that concert honored the memory of Russell with whom she was “The Music Department” at Susquehanna University for many years. One legend has it that Russell, a violinist, was a founding member of the Juilliard String Quartet. The last music Nancy and Russell played together was the same Brahms Sonata in d minor played for 625 people by Sarah Chang and Andrew von Oeyen last Wednesday evening. 

Nancy is still passionate about nurturing young musicians and does that with the Harmonia Music Association in Lebanon, an affiliate of the Pennsylvania Federation of Music Clubs.

We are always on the lookout for angels.