Musicians get hurt a lot: Paging Dr. Serap Bastepe-Gray

In the summer of 2012, Peabody Conservatory guitar student David Sobel awoke with what he describes as "charley horse of the arm"—acute, breath-stealing pain in his left elbow. The previous night, Sobel had performed at a marathon guitar competition, playing six to eight hours with only a few short breaks.

The next morning, his arm hurt too much to even pick up his instrument, so Sobel scrapped his normal morning routine of coffee and scales. Then he did what many musicians in his situation do—pretend that nothing happened. He refused to open up to peers and teachers, in part denying to himself how badly he was injured, in part afraid of the potential repercussions. Word might spread that he was damaged goods. He could be passed over for a job or a competition. "Your value as a musician depends on your ability to play at a high level," says Sobel. "I was that starving musician who can't pass up a $100 gig."

Image credit: Andrea Ucini

But wishing the problem away proved little help. Each time Sobel tried to play, the pain returned. He saw a massage therapist, but the manipulation of damaged soft tissue in therapy offered no relief, and prolonged time off from playing was out of the question. A week later, the pain still acute, Sobel came clean about his arm during a regular practice session with his teacher, Julian Gray, chair of Peabody's Guitar Department. Gray told Sobel not to worry. He knew just who to call—his wife and fellow Guitar faculty member, Serap Bastepe-Gray, known inside the walls of Peabody as The Healer.

Since her days as a Peabody student in the 1990s, Bastepe-Gray, Peab '96, '99 (MM), had established a reputation as someone who could discreetly restore a musician to health with her particular skill set. There are only so many classical guitar virtuosos in the world, fewer still who also possess deep knowledge of occupational therapy, anatomy, and neurology. Bastepe-Gray is one. She holds a medical degree from Hacettepe University in Ankara, Turkey, and in addition to her roles as performer and educator, she serves on the Performing Arts Medicine Committee of the Maryland State Medical Society. She holds a joint appointment in Neurology at the School of Medicine. She lectures and consults on health and wellness issues for performing musicians and participates as a panelist and presenter for groups such as the American Occupational Therapy Association.

Since the day she unofficially hung her doctor's shingle at Peabody, Bastepe-Gray has worked with dozens of injured students and helped return them to playing or just offered some quick advice. Sobel says he knew he was in good hands. Bastepe-Gray suspected he had lateral epicondylitis, or tennis elbow, and the two developed a recovery plan. Step one: Put down the guitar for a few days. Sobel didn't like the sound of that: "I think I was hoping for a magic pill that would instantly solve my problem and get me back to playing." Instead, Bastepe-Gray prescribed PRICE: protection, rest, ice, compression, and elevation. After three weeks of this, Sobel still wasn't playing guitar but had begun a routine of systematically lifting his elbow and moving his fingers, flexing them and fingering arpeggios and chord progressions in the air. When allowed to play again five months later, he started with only a few minutes and increased the amount of practice by roughly 10 percent every few days, until he could go 15 to 20 minutes without pain. Bastepe-Gray also advised him to use some of the free hours he now had to just listen to music, becoming more mindful of the mood and interpretation of the piece. Nearly seven months after his initial injury, Sobel, Peab '13 (MM), performed his master's recital and has been pain-free ever since.

As many musicians know, Sobel's injury was hardly unique. Performing music requires intricate and precise movements and, according to cognitive scientists, fast and interlaced auditory, visual, and motor processing by the brain. The unique movements involved in playing an instrument need to be repeated hundreds of times on a daily basis—intense training that can, and often does, damage the body. In a profession where taking months or even weeks off can sideline a career, avoiding injury is paramount. With this in mind, Bastepe-Gray and an interdisciplinary group of scientists and musicians at Johns Hopkins have united to create the Johns Hopkins Center for Music and Medicine. The new center, expected to launch in early 2017, will help build scientific knowledge to keep musicians healthy by studying the underlying causes of disorders that affect them. By combining the university's world-class expertise and excellence in research and clinical care, and the Peabody Institute's renowned performance training for musicians, the center's founders hope to improve the health of musicians worldwide.

Musicians get hurt a lot. There were 173,300 professional musicians in the United States in 2014, according to the Bureau of Labor and Statistics. In recent surveys, nearly three-fourths of professional musicians reported past injuries and pain that affected their playing. A 2012 study of musicians in Australia's eight full-time professional orchestras found that 84 percent of the study participants had experienced pain or injuries that had interfered with playing in rehearsals and performances. Fifty percent reported pain or injury at the time of the survey. Of those musicians who recalled at least one episode of pain or injury in the past, fewer than half reported that they had fully recovered.

Common injuries include carpal tunnel (wrist) and cubital tunnel (elbow) syndromes, where pressure on nerves leads to pain, weakness, numbness, and tingling. Sprains and strains from repetitive use can lead to other soft tissue pathologies like tenosynovitis, bursitis, and tendinosis. No instrument seems exempt from inflicting pain, though piano and percussion players have been found to incur more injuries, followed by string players on violin, viola, and guitar. Singers, too, suffer from ailments that include acute laryngitis, vocal cord lesions and hemorrhages, and laryngopharyngeal reflux disease, in which stomach acid travels up the esophagus and reaches the throat.

The majority of commonly cited factors causing pain or injury relate to playing too much. Professionals and music students play on average four to eight hours per day and rarely take a day off. In the past, they usually played through the pain. Specialized health care for musicians has long been scarce and expensive, and just taking a break may not address the ergonomic and biomechanical causes of the injury, meaning it will likely recur. Plus diagnosing musical injuries can be tricky. Under these circumstances, musicians have been reluctant to seek care and, if willing to get treatment, may not know where to find skilled practitioners. "There is a public health aspect to this," Bastepe-Gray says. "Way too many musicians have to deal with the risk factors of playing for too long, too hard, and not having efficient biomechanics."

Bastepe-Gray talks like she plays her guitar: fast and with flourishes. There are traces of her Turkish heritage in her accent. The daughter of agricultural engineers, she moved to the United States in 1992 to conduct spinal-cord regeneration research at the Medical College of Pennsylvania, where she was a visiting scholar. For that research, she worked with mice, and at some point, she says, it was one mouse too many. "I was like, 'I'm not liking this. What else can I do?'" Growing up in Turkey, she had played several instruments, first the mandolin at age 6 and then guitar at age 9. She recalls hearing Francisco Tarrega's masterpiece "Recuerdos de la Alhambra" on television and falling in love with the guitar's sound, immediately asking her parents if she could take lessons, which she did from third grade all the way to medical school. When she arrived in Philadelphia, she wanted to continue learning and sought out guitar teacher John Leonard at the University of the Arts in Philadelphia, who encouraged her to enroll in a conservatory. She auditioned for Peabody and the Manhattan School of Music and got into both, but Peabody felt like a better fit for her unique background. "I thought that Johns Hopkins was a place for generating knowledge and maybe I could later pair [with music] my interest in research," she says.

She was 27. In her junior year, just four months from her end-of-the-year recital, her left elbow began to throb, a dull pain, with a tingling sensation on the pinky side of her left hand.

She realized only then how hard she'd been pushing herself, practicing five to six hours daily and regularly playing gigs in Philadelphia and Baltimore. "I was like, 'Oh, my God. What am I going to do?'" She drove six hours to the Cleveland Clinic's Center for Performing Artists to meet Richard Lederman, who was one of only a handful of physicians who practiced performing arts medicine. He did some nerve conductance tests, which came back normal, and referred her to an orthopedic surgeon, who diagnosed tennis elbow and recommended extended rest. The surgeon also advised her to significantly decrease the amount she was playing and avoid the most difficult pieces in her repertoire. The advice brought out two of Bastepe-Gray's defining characteristics: impatience and stubbornness. "What he said was fine, but it was not OK for me," she says. "We need to work at our art. Every day you're not practicing you feel like you're going backwards."

So she unpacked her medical books. "I was like, 'OK, I know medicine. I know my instrument. I'm going to help myself.'" She began to practice without pushing the strings all the way to the fretboard, focused instead on fluency of movement while applying minimal pressure. She used a capo most practices, cutting down the neck and so reducing how far she had to stretch to form chords. She reorganized her practice schedule, incorporating more rest. A kitchen timer reminded her when to take breaks. She sought input from teachers who pointed out how she could make her bio­mechanics more efficient. When not playing, she went over music in her head, listening to recorded songs and imagining her hands playing the piece.

Her personal program succeeded—she resumed regular practice and performance—and her classmates noticed. Weeks after her recital, viola and violin students began knocking on her rehearsal door. "They were like, 'I have pain here and here; fix me,'" she says. "Back then, the stigma with having pain while you play was quite significant. It could mean you're not good enough, or your technique is not good. People might be afraid they'd lose their scholarship." So they sought her out in secret.

Now they will not have to be so clandestine. The Center for Music and Medicine, which already has enlisted 70 Johns Hopkins faculty members from multiple departments across divisions, joins a relatively small number of hospital- and university-based clinics focused on musicians, including the Performing Arts Clinic at Brigham and Women's Hospital in Boston, the Cleveland Clinic's Center for Performing Artists, and many voice care clinics. But its founders claim it's the first to focus on not just healing musicians but also exploring the healing powers of music; a core vision of the center is to make music an integral part of treating illness. [See sidebar.]

Many trace the field to the work of Lederman and physician Alice G. Brandfonbrener, who in 1983 organized the first Symposium on the Medical Problems of Musicians in Aspen, Colorado. The conference led to the establishment in 1986 of the first journal in the field, Medical Problems of Performing Artists, and then two years later to the Performing Arts Medicine Association.

Lederman, dubbed the godfather of performing arts medicine, is a physician in the Department of Neurology at the Cleveland Clinic. He began seeing musicians in the early 1980s as a favor to the president of the Cleveland Institute of Music. Some of the institute's students had complained of musculoskeletal problems associated with playing. Lederman, a violinist, agreed to observe them applying their craft. "I wanted to see what they might be doing wrong that would foster an injury," he says. "Maybe they had poor posture, or a simple fault in technique." He brought in friends who were professional musicians to observe, looking for any subtle movement that might be injurious. From that, he started to develop a body of knowledge of what to look for and what to correct.

He says the treatment for a musician's injury is similar to how he would treat a nonmusician; what is different is the artist's response to medical assistance. "Musicians tend to have a very specific personality type," he says. "They will often ignore pain that most of us won't. And when you tell them they have to reduce the amount they're playing or take a break, they decline. 'Fix me today,' they say."

When he started working with musicians, there was almost nothing in the medical literature to help him. "In a sense, we started from zero," he says. In 1988, the Performing Arts Medicine Association had 10 members. Today, it has more than 320, including orthopedists, neurologists, surgeons, nurses, therapists, somatic educators, and performers. And in the past 25 years the medical literature has gone from a half-dozen papers to more than 20,000. Lederman estimates he's seen well over 2,000 musicians to date, from students as young as 11 to professional musicians, including some rock legends—he won't drop names—who have passed through Cleveland on U.S. tours. He's worked with several musicians who suffer from dystonia, a neurological disorder characterized by involuntary muscle contractions and postures. The disorder, also known as musician's cramp, affects 1 to 2 percent of the professional musician population. The cause is not known, but researchers believe it results from an abnormality in or damage to brain regions that control movement. There also may be abnormalities in the brain's ability to process information and generate task-specific movement commands.

Peabody pianist Leon Fleisher, a member of the Center for Music and Medicine's advisory committee, lost the use of two fingers on his right hand in 1965 due to focal dystonia, a condition that caused the fingers to curl into the palm. A child prodigy who made his debut at age 8 with the New York Philharmonic, Fleisher had already built a distinguished career when the disorder robbed him of his ability to play with two hands. He continued to teach, started conducting, and began playing a left-handed repertoire before having a lengthy series of operations and then later botulinum toxin injections to regain the use of his right hand in the early 2000s.

Today, the condition still is not completely understood. "We're not sure what might precipitate or trigger it," Lederman says. "We've been able to manage the disorder with some success. [Pianist] Gary Graffman and Leon Fleisher have been great models, two superior musicians who, decades after they were diagnosed, are still fighting it. They are not cured, but through sheer force of will have been able to return to playing."

Bastepe-Gray currently is studying musicians' physical stressors while they are playing. Her first project is designing an instrument, which she has dubbed the SmartGuitar, to measure how much force the fingers apply to the fretboard. She's been collaborating with occupational therapists, biomedical engineers, and members of the Hand-Opening Assistive Device research group at Johns Hopkins, which uses a system of mini-sensors to measure hand force in stroke victims. Instruments like this, she says, can help isolate the biomechanical determinants of musculoskeletal disorders by analyzing the applied force and motions of musicians, in this case guitarists. "If we know a person is pushing too hard on the fretboard—which we're hoping this device can objectively measure—the data can lead to the design of a more efficient technique," she says. One desired outcome, she says, will be to determine the minimal force needed to make a "clean," pleasant sound on a string instrument, so that in the future, for example, doctors could tell someone they are playing 25 percent harder than they need to. The goal is to change behavior, she says, so when players go back to work they won't get reinjured.

Image caption: Serap Bastepe-Gray tests the SmartGuitar, an instrument she designed to measure how much force a musician applies to the fretboard.

Image credit: Innovative Sports Training, Inc.

The data could also help inform the design of instruments that are more user-friendly. To this end, Bastepe-Gray recently paired with Baltimore-based luthier David Pace on the Smart­Guitar Project, which seeks to use scientific data to design an instrument less likely to induce pain. Pace says the most common injuries for guitarists are caused by repetitive stress.

Typically, the fingers of the fretting hand must spread wide to reach chords or melodic patterns, forcing the hand into unnatural positions while it applies force to the strings, which puts additional stress on muscles and connective tissue. Pace recently adopted a curved fretboard for his designs. Traditional guitars have a flat fretboard, which forces the fingers into positions and angles that are difficult and stressful, especially when barring chords. The modestly curved fretboard, Pace says, allows the left hand to maintain a position that results in a more efficient transfer of strength, especially when barring.

Reza Shadmehr, a professor of biomedical engineering and neuroscience and a member of the new center's core faculty, says, "Serap is interested in systems that are falling part—an individual who practices so much there seems to be a negative consequence, and maybe the plasticity in the brain has gone awry." He notes that one objective of the center will be to make sense of a musician's motion patterns to better understand how they could lead to injury, and it will also be important to study healthy professionals who have played without pain for years. What about their technique protects them from injury?

In October 2015, The New York Times ran a sprawling feature on Tommy John surgery, a procedure done on about a quarter of active major league pitchers to repair a damaged ulnar collateral ligament. (It is named after the Los Angeles Dodgers pitcher who first underwent the procedure.) Sarah Hoover took notice of the Times piece. Hoover, a special assistant to Peabody's dean and co-director of the Center for Music and Medicine, describes herself as an Olympics junkie who marvels at the feats of athletes, whom she refers to as "professional movers" likely to get hurt at some point in their careers. "There's a whole industry that supports this group, that provides them with resources to mitigate injuries and to solve problems to get them back in the game," she says. "But do musicians understand themselves as movers, as people who move for a living? People think of them as just producing sounds, but to generate those sounds their bodies engage in muscle movements. With this new center, we want to create a culture that understands these people as movers."

Hoover says musicians are considerably less far along in health maintenance than athletes because they don't have personal trainers who watch out for them every day. No doctor sits in on rehearsals or observes performances.

Only high-level ensembles like the Metropolitan Opera might have a physician on call. "There is a system in place in sports where everyone understands that it's likely someone is going to get hurt, and here is the person literally standing by to help you. We have no analogous model in the arts."

One possible way to prevent injuries, she says, could be the musician's equivalent of the pitch counts used to monitor and limit how many times a pitcher puts maximum stress on his arm. Hoover says there are some occupational health guidelines on how long unionized players and singers can play without a break, but most of a musician's time with an instrument is spent unsupervised. "Whereas someone like Michael Phelps spends almost none of his time in a pool or weight room without coaches and trainers nearby," she notes, "our students spend only one hour per week one-on-one with their primary teacher, their primary external eyes. The rest of the time, they're by themselves. Now, if they're moving in a biomechanically efficient way and don't go beyond their physical capacities then they will probably be OK. But if they are working against themselves and they're stressed, or if they have a certain kind of genetic issue or come to playing with structural issues or abnormalities, these long hours of playing will set them up for injury."

In general, Hoover says, conservatories have been slow to incorporate biomechanics and science into teaching musicianship and technique. She says the center will seek to change the culture at places like Peabody, to train musicians to understand that every movement, and the integrity of that movement in service of their art form, is connected to their health and well-being.

"I have this vision for Peabody students. Peabody has always been known for the performance excellence of its faculty and students. What I would love is for Peabody students to also be known by not only the beauty of their playing but the healthiness," she says. "That could be a distinguishing characteristic of Peabody students. Playing well means playing with excellent technique and nuance, but it also means playing while keeping well. We are so well-positioned here at Johns Hopkins to do this work. If we can't figure out a way to knit together some of these resources and willing partners, I don't know who could."