At Norfolk festival, the hills are alive with remedies

The physical sensations of fear are familiar to all of us: the dry mouth, queasy stomach, pounding heart and shaky muscles.

Kyle D. Pruett, M.D., describes it as the sympathetic nervous system's primitive fight-or-flight response, as the human body prepares for the moment when the campfire goes out and the circling saber-toothed tiger decides to strike. But that cascade of symptoms is precisely the last thing a musician wants in the moments before a performance, when small-muscle coordination is critical.

"You do not want Pleistocene-era feelings flowing through your body," Dr. Pruett, a clinical professor at the Yale Child Study Center and a professional tenor, told a group of fellow physicians and performers last summer. Dr. Pruett was one of the speakers and coordinators for the fourth annual Medical Problems in the Performing Arts conference, held at the Norfolk Chamber Music Festival in northwestern Connecticut in collaboration with the Yale Summer School of Music.

Dr. Pruett talked about performance anxiety or, as he prefers to call it, performance awareness. It's one of the most disabling health problems a performer can face, and can cripple a career if left untreated. The conference was designed to explore performance anxiety and other medical problems that plague performing artists, especially musicians. These "small-muscle Olympians," as Dr. Pruett calls them, suffer from health problems ranging from tendinitis to hearing loss, and as a group of patients, tend to be neglected.

"It's basically a misunderstood, undertreated group," says Peter Jokl, M.D. '68, HS '69-73, professor of orthopaedics and rehabilitation and chief of the section of sports medicine.

Dr. Jokl, Dr. Pruett and Martin W. Sklaire, M.D., HS '62, coordinated the conference, along with festival manager Elaine Carroll and director Joan Panetti. The sponsors were the Yale Summer School of Music, the Child Study Center and the sports medicine section.

About 10 years ago, Dr. Sklaire, clinical professor of pediatrics, took a course in Aspen, Colo., about medical injuries to performers. As an amateur piano, clarinet and cello player, he had some idea of the physical stresses musicians face. As a specialist in pediatric and adolescent medicine with extensive experience in sports medicine, he saw a clear connection. "A lot of injuries to musicians are similar to injuries to athletes," many stemming from overuse, Dr. Sklaire says.

The very act of playing an instrument can force the body into unnatural positions, Dr. Sklaire says. "If you're spending enough time, you're going to have aches and pains as a result," he says. For professional musicians whose livelihoods depend on playing, injuries can be more than a nuisance.

Paul W. Brown, M.D., clinical professor of orthopaedics and rehabilitation and of plastic surgery, spoke at the conference about some of the upper extremity problems musicians can face. These include overuse injuries, such as tendinitis, nerve compression or entrapment, and focal dystonia, the loss of control over an individual or group of muscles.

In some cases, a cure can be as simple as a small change in practice habits, such as taking regular rests, or a change in musical technique. Dr. Brown described one patient, a French horn player, who had been complaining of arm pain. He found she was gripping her instrument white-knuckle tight. "The cure here was not medical," he explained. "It was just a matter of changing her musical technique."

Some cases are more difficult, as when the only real treatment is rest, "which professional musicians don't take kindly to at all," he said. Part of the reason musicians may be undertreated is that their livelihood is threatened: They don't want to be told they have to stop playing. On the other hand, musicians tend to be highly motivated, hardworking and interested in their own treatment, precisely because the stakes are so high, Dr. Brown said.

David I. Astrachan, M.D. '84, a clinical instructor in otolaryngology, talked about ear, nose and throat injuries to performers. One of the most serious health problems among musicians can be hearing loss. It's most common in percussionists and violinists, but can affect anyone in an orchestra, and it's often irreversible, he said.

Wind instruments can peak at 123 decibels. "That's jet aircraft noise," Dr. Astrachan said. Using earplugs can reduce the noise by 25 decibels. "That can be all you need to take a potentially damaging sound and make it less damaging," he said; musicians who don't want to use earplugs in performance are encouraged to at least use them in rehearsals.

The conference also included a panel discussion with members of the Vermeer String Quartet, which performed at the festival the night before the conference. Afternoon workshops examined hearing problems, rehabilitation of hand injuries, and relaxation techniques. Though attendance at the conference has been modest, Dr. Sklaire says he and his colleagues want to continue organizing it. "I think we're all committed to perpetuating this," he says.

"As an academic institution, this is the type of thing we should do," Dr. Jokl says. "A university should be a repository of this kind of knowledge."