Music and Medicine

 

Tuning Up Musicians
Harvard doctors treat the injuries of musical performers.
by Phyllis L. Fagell
Tuning Up
Kate* was a rising star in a major Broadway musical when she lost her voice. She had always been a powerful singer, able to push herself to the limit. But now, to deliver the same volume, she had to strain her vocal cords. She continued to belt out eight shows a week, until disaster struck.

“I felt my body say, ‘I don’t know what you’re going to do, but I’m going to stop,’” Kate says. She developed bronchitis and coughed for three weeks. Still, she didn’t seek help until a blood vessel on her vocal cord hemorrhaged. She knew then that if she didn’t get treatment, her voice would be in jeopardy.

“A doctor in New York told me I had to stop singing,” Kate says. “But I’d been singing since I was six, and quitting was not an option.” So she flew to Boston to see Steven Zeitels, a laryngologist and head and neck surgeon at the Massachusetts Eye and Ear Infirmary. Zeitels has a reputation in the music industry for saving performers’ careers.

“He didn’t promise anything,” Kate says, “but I trusted him completely.” Zeitels removed the tiny blood vessels and gave strict instructions. She was forbidden to speak one week before and two weeks after surgery. Then, for one week, she was allowed to talk only in moderation.

“He taught me how to stay hydrated, how to eat, how to preserve my instrument,” Kate says. Zeitels stressed the importance of sufficient sleep, voice therapy, and avoiding acidic foods, caffeine, alcohol, menthol, and overuse of her voice.

“I followed every rule,” she says, “and things have changed. I’m getting flown to London to sing for Sony Music, and I’m auditioning well for Broadway shows. Before, I was living in fear. Now I sing with a new light.”


Taking Notes

When Zeitels, always a music lover, joined the Massachusetts Eye and Ear Infirmary in 1990, he realized that no local otolaryngologists were dedicating themselves to treating vocal injuries in singers. “Treating vocalists’ injuries isn’t part of one’s typical training in otolaryngology residency programs,” he says. “I taught myself, patients taught me—it was a real exchange.” About one-third of his patients now are performers; their signed photographs decorate his office walls.

Singers and their coaches tend to notice vocal injuries before an audience can detect them, Zeitels says. “The teachers have amazing acoustic perception,” he adds. “Surgeons like myself are very visual—our instruments allow us to see microscopically. So in a sense the teachers hear everything and are relatively blind, and the surgeons see everything but are relatively deaf.”

At first, singers compensate for injuries with greater air support and muscle control. “They work harder to achieve the same acoustical outcome, so their stamina decreases,” Zeitels says. “Then their acoustical outcome deteriorates—they simply don’t sound as good.” But most performers don’t seek help until “they can’t get through a show.”

At that stage, Zeitels conducts a laryngeal stroboscopy, which enables him to watch the vocal folds vibrate in slow motion. He also does a complete head and neck exam. “At that point, I can make a number of diagnoses,” he says. The most common injuries to singers arise from oversinging, infections, acid reflux, and allergies, which can result in hoarseness, laryngitis, and lesions on the vocal cords.

Any problems that can be addressed without surgery are tackled first. “We may put patients on vocal rest or adjust their activities,” Zeitels says. Reflux, which often arises because singers rely heavily on intra-abdominal support, may be treated with medication or behavior and diet modifications. Dehydrated singers are urged to drink more fluids. And for singers with phlegm on their vocal cords, Zeitels may prescribe mucolytics.

Performers are further advised to correct poor technique by working with a voice therapist. Zeitels refers patients to a few classically trained singers who also are speech pathologists. When famous singers have other demands on their voices besides performing, Zeitels may restrict their press interviews. And he advises young people who are just developing their careers and supporting themselves with second jobs to avoid overusing their voices at work.

When do performers need surgery? “Generally, when there’s a lesion,” Zeitels says. “Most problems associated with the larynx that we treat with surgery are the result of trauma—either from overuse or from past surgery.” To enable further research on the treatment options for such injuries, the Massachusetts Eye and Ear Infirmary has created one of the nation’s first laryngology divisions, which Zeitels now directs.


Surgical Successes

Singer and songwriter Livingston Taylor saw Zeitels as soon as he noticed a thickness in his voice and an inability to hit certain notes. He learned that he was hemorrhaging into his vocal cords. “The alternative to surgery was that I was going to have to move into a station wagon in my mother’s driveway, and that made the option of surgery pleasant indeed,” Taylor says. “Steven removed the vessels, and that was the end of my problem. My singing is better today than it’s ever been.”

For Taylor, deciding to go public with his surgery was not a major decision. But less established performers often fear that disclosure could mean losing singing parts. Says Kate, the Broadway star, “I’ve paid a lot of dues and I’m still paying them. I just don’t have the strength to be the poster child. Producers and casting agents are businessmen. They see us as machines, not people.”

Jane,* an opera singer on whom Zeitels performed surgery, adds that the common perception in such cases is that the singer is at fault. “That’s always been the scarlet letter in this community: ‘Singer gets nodules because she pushed her voice.’”

Despite surgical success stories like those of Kate, Taylor, and Jane, Zeitels cautions, there’s a gray zone. “Vocalists can have a nodule and still sing fine. You have to analyze the situation carefully, because the risk of any procedure is that you can make the problem worse. Singing is their livelihood. It’s their spirit too, who and what they are.”

Gary Cherone, lead singer of the rock band Van Halen and former lead singer of Extreme, came to Zeitels after “screaming too much.” His on-the-road lifestyle and bad habits, such as failing to warm up his voice or to drink enough fluids, were taking their toll. “In rock-and-roll, you let loose,” he says. “Singing correctly is not the first thing you think of. You’re not doing Pavarotti.”

For a while, Cherone was able to camouflage moments when his voice cracked. The volume of the music and the adrenaline rush from performing to crowds helped him compensate. And when that wasn’t enough, he would seek his band’s help. “I’d ask the guys to cover me,” he says. “They’d take the high notes and I’d climb a pole, anything to distract.”

Cherone credits Zeitels with saving his career. “He found the problem just by listening to my voice. At first, when I was in Extreme, my voice was just raspier, which I actually liked. But then little cracks started coming out in rehearsal, and I couldn’t rely on my falsetto.”

Zeitels removed a nodule, and, just two months after the surgery, Cherone performed in the rock opera Jesus Christ Superstar. Then Extreme disbanded and Cherone flew to Los Angeles to audition for Van Halen.

“If I hadn’t had the operation,” Cherone says, “I wouldn’t be where I am now. I love to tour and perform, and I’ll do it as long as I can. My knees will probably give out before my throat.”


Piecing Together a Mystery

Singers are not the only performers who struggle with career-threatening injuries. Fred Hochberg, a neurologist at Massachusetts General Hospital, began treating instrumentalists’ injuries about 15 years ago, when a friend asked him to meet with Gary Graffman, a world-renowned pianist who was having difficulty with his right hand.

“He couldn’t lift his fourth finger,” Hochberg says. “And he wasn’t the only one—he had a list of friends with the same problem. These were pianists who played the same repertoire, what are called the heroic pieces.”

Lifting the ring finger is difficult because it is inextricably tied to the middle and small fingers, Hochberg explains. “The tendons supplying the ability to extend the fourth finger are actually linked to the middle and small fingers. In the 1850s, barbers, who were prototype surgeons, used to cut the junctura, which is the linkage, to give pianists independent movement.”

But that clearly wasn’t an option for Graffman. Despite physical therapy and other interventions, he could not perform another concert. Hochberg was determined to try to solve the mystery.

Perhaps the source of the problem, Hochberg speculated, was the big, orchestral, highly percussive Brahms and Tchaikovsky pieces that Graffman played. Or maybe his training had somehow contributed to the problem, much as a tennis player who learns to serve improperly might develop rotator cuff injuries. After all, the first three patients Hochberg saw with this problem had all been trained by Nadia Boulanger in the same Paris apartment.

Then Hochberg theorized that perhaps Ashkenazi Jews were afflicted with this particular occupational “dystonia,” a painless uncontrolled movement that affected his pianist patients only when they were playing their instrument. But after the gene for one form of dystonia was discovered, Hochberg’s patients tested negative for that genetic abnormality. Was it possible, he wondered, that these virtuosos had achieved their remarkable state of productivity by flouting a particular physiological rule?

“Our best guess is that the same process that provides rapid movement, up to ten times per minute, is also the process that results in dystonia,” Hochberg says, adding that a focal dystonia is not caused by nerve entrapment or damage to the tendon or joints.

Hochberg treated his first few hundred musician patients as part of a clinical team because “no one had any idea what was going on.” The team included an orthopedic surgeon, a physical therapist, a psychiatrist, and a rheumatologist. But the group disbanded several years ago.

“The psychiatrist left first, saying, ‘These aren’t crazy people,’” Hochberg explains. “Then the rheumatologist said, ‘These people don’t have rheumatological problems.’” And by that point, Hochberg and the physical therapist had taught each other what they needed to know to work independently.

Robert Leffert, the orthopedic surgeon on the clinical team, also sought a concrete explanation for the dystonias, which were felling world-class musicians. Leon Fleisher, for example, considered one of the greatest living pianists in the world, stopped performing because of a focal dystonia. He went to see Leffert at Massachusetts General Hospital.

“He had a constant uncontrolled motion,” Leffert explains. “His tendons had become so inflamed that they put pressure on the median nerve at the wrist, and he developed carpal tunnel syndrome. He lost sensation in the thumb, index, and middle finger of his right hand.”

Leffert operated on Fleisher in 1981 to correct the carpal tunnel syndrome, but he could not determine the cause of the focal dystonia. “After the operation, his hand was quiet for the first time in years, so we started physical therapy,” Leffert says. “Using both hands, he gave a piano performance with the Baltimore Symphony Orchestra that was televised around the world. His right hand was still not normal, and only the fact that he’s such a magnificent pianist got him through it.” But Fleisher was not cured. He was forced to turn to piano concertos written for the left hand.

Focal dystonias are not a new problem for pianists. In the 1830s, a hand injury prevented another promising young pianist, Robert Schumann, from pursuing a career as a keyboard virtuoso. When he was 20 years old, Schumann wrote a diary entry about his “numb finger.” Within a few years, his injury ended his career as a pianist, and he turned to composing.

Hochberg is fascinated by Schumann’s injury. “It’s still undiagnosed,” he says. “It may have been caused by some sort of depressive disorder, or it may have been syphilis. He became concerned about the ring finger of his right hand, so he devised a pulley he called the Cigar Box, which elevated his finger above the keyboard and gave it independent function.”


Selective Movements

About two-thirds of Hochberg’s musician patients present not with dystonias but with overuse injuries. “They have a localized inflammation of the joint or tendon, probably due to microscopic tears of the tendon with hemorrhaging,” he says. “Almost invariably, the problem is related to the shoulder. Your arm weighs between 15 and 20 pounds, and even though playing an instrument tends to involve selective movements of the fingers and wrists, your shoulder musculature takes most of the brunt of the movement. Most people can’t stabilize their shoulder while using their fingers.”

Hochberg recommends physical therapy and exercise to return a normal range of movement and to strengthen the muscles needed to stabilize the shoulder. “Playing an instrument is not good exercise,” he says. “You would think the more you play, the stronger your arm would get, but that’s not true.”

Of the thousands of patients Hochberg has seen, fewer than 30 have undergone surgery, most commonly for carpal tunnel syndrome and ulnar nerve entrapments. On average, Hochberg says, patients take three months to recover. During that time, they may only play for ten to fifteen minutes at a time, two to three times a day.

“It’s exceedingly hard for them,” he says. “Younger people see their colleagues passing them by. For older people, it means canceling performances and sometimes being held financially responsible for those cancellations.”


Getting Adjusted

Michael Charness—director of the performing arts clinic at Brigham and Women’s Hospital and a member of the Charness Family Quintet with his wife and three children—has a unique take on what it means to be a pianist with an injury.

“I started treating musicians because of my own injury,” he says. “I was starting to play some difficult pieces. The more I practiced, the more my fingers weren’t doing what they should. They were sluggish, less accurate, and less controlled. I had an electromyogram, which was normal. I had a fairly normal hand exam too, but I felt I had an enormous problem.”

Eventually, Charness underwent surgery to decompress his ulnar nerve on both sides. That was in 1984, and he slowly regained his strength and facility. “It was both frustrating and fascinating,” he says. “I had a debilitating problem, yet my hand appeared normal to skilled clinicians.”

Charness sees focal dystonias as particularly vexing. “It’s a bizarre disorder,” he says. “People who have spent many years acquiring musical skills lose the ability to perform because their hands pull into a position that makes it impossible for them to play. Their ring finger, for example, may pull into their palm when they play a scale going up but not going down. For others it’s a more general degradation, although outside the context of playing an instrument, their hand appears normal.”

When Charness meets with patients, he watches them play their instruments. “We’ve learned how to change people’s position to make it easier to sustain playing,” he says. “For example, it’s common to see violinists with pain in their left shoulder or neck. One of the first things I do is adjust the way they set up their instruments so they don’t bring up their shoulders.”

Violinist Ruth Winters began noticing a problem last summer. She couldn’t play because of pain tingling down both arms from her shoulders. Charness examined the way she held the violin and told her to get fitted with a new shoulder rest, so she wouldn’t have to crank her head down to hold the violin, and a new chin rest to accommodate her long neck. He also sent her to a physical therapist.

“The therapist started working on my tendons,” Winters says. “Apparently they had tightened, and my shoulders were too far forward.” She did strengthening exercises. “I feel phenomenal now,” she says. “I recently performed Vivaldi’s Concerto in A Minor for violin. Even though I’m playing a lot, I’m being much more sensible.”

Other instruments also can cause problems for musicians. The English horn, Charness points out, is a heavy instrument whose weight is borne on the player’s right thumb. “A patient came to me with a problem in her right arm,” he says. “She had an ulnar nerve entrapment. We got hold of a circular clamp that fits around the bell of the English horn and transfers the weight of the instrument from the right hand to the floor, like the endpin of a cello. She was able to play her tour and recover as she did so.”

If double-jointed players have lax joints, Charness fits their fingers with stabilizing rings. Only rarely does he prescribe medication, and then it may be an anti-inflammatory for pain or a betablocker for performance anxiety. But for the common overuse injuries, rest and physical therapy are often the most effective treatments.

That is sometimes easier said than done. “Many work mind-boggling hours,” Charness says. “I had one cellist who practiced 15 hours a day and who told me that all he did was eat, sleep, and play the cello.”

How much practice is too much? “That’s a difficult question,” Charness says. “I think most people ought to be able to get everything done in four to five hours or less. It has to be individualized, but there are some general principles that encompass, for example, not playing for more than 25 minutes without a break.”


Musicians and Physicians

Fortunately, such single-mindedness can often be turned to healthy ends. When world-class musicians focus their phenomenal talent and drive on the reorchestration of their bodies and techniques, Hochberg says, “their compliance is fantastic. Indeed, they become the single most motivated group of patients I’ve ever had.”

The admiration between doctors and musicians is mutual, perhaps because the two disciplines have so many similarities. Musicians and surgeons, for example, have analogous skills, says Leffert. “Both music and medicine require a great deal of discipline, much dedication, and long hours of study. They need more than casual control and coordination of your hands. And they both require artistry.”

“There’s a historical connection between music and medicine,” Charness adds. “Hordes of physicians are also musicians. I once did a four-hands piano piece with a fellow who had soloed with the Philadelphia Orchestra when he was 12. He realized there weren’t many jobs for pianists and so became a physician instead.”

Phyllis L. Fagell was associate editor of the Harvard Medical Alumni Bulletin from 1999 to 2000.

This article appeared in the Summer 1999 issue of the Harvard Medical Alumni Bulletin.

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