Georg von Arx - Watery or even watery eyes often only occur in special situations. During demanding visual activities such as reading, working on a PC or making music, even slightly watery eyes can lead to a considerable reduction in performance. Common causes of watery eyes are conjunctivitis, dry eyes, eyelid malpositions, drainage obstructions in the draining tear ducts and much more. These causes will not be discussed in detail here.

Functional disorders that do not appear to have an obvious cause are more important for musicians, as they are difficult to control. In the interplay of local and central control factors during visually demanding activity, a central reduction in the blink rate, i.e. controlled by the brain and nervous system, causes increased evaporation of the tear film and thus a relatively dry eye.

The more we concentrate on our visual task, the less frequently we blink. The tear film becomes unstable, breaks up and causes a "dryness irritation" of the cornea, which in turn triggers increased, sometimes excessive tear secretion via a reflex arc. This can be exacerbated in particular by insufficient lighting (for example in the orchestra pit), as we then reflexively "tear open" our eyes even more and blink even less frequently. Optimum lighting of the music stand (without glare!) is therefore also important in this respect.

Blinking is a rapid, usually involuntary and unnoticed closing and opening of the eyelids (eyelid closure reflex), which primarily serves to maintain the tear film and thus the optimal optical quality of the visual system. We normally blink about 12 to 15 times per minute, i.e. every 4 to 6 seconds, over an average period of 300 to 400 milliseconds. The dark phase caused by eyelid closure is not consciously perceived, as visual perception is suppressed in the relevant areas of the brain shortly before blinking.

Monotonous visual work, especially, as already mentioned, with inadequate lighting of the work area and work with high visual demands lead to staring at the work area with a decrease in blink frequency of more than 50 percent. Frequent but brief interruptions to work for a few minutes can improve the moistening of the cornea sufficiently so that there is no increased reflex tear secretion and therefore no watery eye.

Crying can be an expression of strong emotions such as pain, sadness, helplessness, fear, feelings of deep hurt and injustice. These emotionally induced tears do not play a role in professional musicians in that they have learned to control their emotions in the course of their work. The "tear center" is connected to various regions of the brain, such as the limbic system ("emotional center"), but also to the frontal brain. The functions of the frontal brain concern the reception and processing (control) of sensory information for perception, thinking, language, motor operations, activity, movement and action control, voluntary movements and actions, consciousness, higher intellectual processes and emotional-affective aspects of behavior.

Nevertheless, a particularly "touching" piece of music can touch the corresponding emotional "button" and make us cry, which can then cloud our clear view of the sheet of music. It is not uncommon for poorly corrected defective vision to cause watery or even watery eyes. This is because the eye then has to work much harder to see well. Visual aids that are individually and optimally adapted to professional needs can provide a remedy.

Dr. med. Georg von Arx

Ophthalmologist FMH

Admedico Eye Center

Fährweg, 4600 Olten

> info@admedico.ch

In particularly demanding pieces of music (such as some passages of Franz Liszt's 6th Paganini Etude), the intervals between the individual finger movements must not exceed 30 milliseconds. They must also be realized with the utmost precision. In comparison, the fastest intervals achieved by non-experienced musicians are rather modest (approx. 150 milliseconds). A number of studies have shown that more than 10,000 hours of training are required to achieve professional playing performance. Such intensive training leaves "traces" in the areas of the brain involved in expertise control. In particular, the areas of the brain involved in the motor areas sometimes show considerable anatomical and neurophysiological changes.

The neuroanatomical studies published to date on this topic have shown that in pianists, the primary motor areas that control the fingers have become particularly large in both hemispheres. These changes in size are reflected in a larger volume of neuronal tissue, but also in a larger cortical surface area in the hand motor cortex. In addition to these differences in volume, changes in the cable systems that connect the motor areas of the brain with the hands and legs can also be identified.

These anatomical peculiarities are likely to have developed in the course of motor learning. The earlier they started music training, the more pronounced the anatomical changes tend to be. There are also marked differences between musicians, depending on which instruments they play. In pianists, the two hand motor areas on the right and left hemispheres are particularly large and more strongly connected. In string players, on the other hand, who have to train the fingers of the left hand in particular, only the right-sided hand motor cortex has become anatomically conspicuous or larger. Special anatomical adaptations are also found in the corticospinal tract, which connects the hand motor cortex with the hands and arms.

In addition to these specific adaptations in the motor system, there are also neurophysiological peculiarities in the functional coupling between the motor and sensory areas - especially between the motor and auditory cortex. The neurophysiological activations in the motor areas of the brain in pianists are, as mentioned, particularly adapted to piano playing. This special adaptation can also be recognized by the optimization of neurophysiological excitation in the brain areas involved. In pianists, these are lower neurophysiological activations in the motor areas when playing the piano than in untrained people. Apparently, as a result of frequent practicing, the most suitable neuronal circuits have been established to enable the motor processes.

As a result of practising, highly trained pianists have established an automated error control system that allows them to unconsciously recognize and control motor errors while playing. However, error control does not affect the action that has just been performed incorrectly, but rather future actions.

It is remarkable that such neurophysiological and neuroanatomical adaptations not only occur in early childhood and adolescence, but also in adulthood and - what is particularly interesting - also in old age. In this respect, the acquisition of musical playing skills is not only reserved for young people, but is also possible in old age. It is possible that the human brain is plastic for a lifetime, so that music-making can be acquired well into old age.

Prof. Dr. rer. nat. Lutz Jäncke

University of Zurich/Psychol. Institute

Chair of Neuropsychology

> lutz.jaencke@uzh.ch

It is quite natural for a violinist, for example, to initially attribute pain while playing to the instrument. There are more than enough sources of error. Small deviations in posture, in the modulation of muscle tension or at the delicate contact point between body and instrument have far-reaching consequences.

In every musician's everyday life, however, there are other activities that put strain on the musculoskeletal system. Working at the computer or in the garden, sporting activities or housework - all of these activities can be performed more or less carefully and can also trigger pain in the musculoskeletal system. At this point, therefore, we would like to talk about a completely inconspicuous source of pain: the sleeping position.

During a consultation, a violinist reports pain in her neck that has been present for years and radiates into her right arm. The pain is normally only troublesome in phases with frequent long rehearsals, especially of course in connection with particularly demanding pieces. Clarifications and adjustments regarding posture and instrument position were made repeatedly. They also had a positive effect.

Over the course of the last year, there have been repeated phases in which the musician has felt electrifying twinges in her arm. This symptom has occurred more frequently in the last two weeks and is also the reason for the consultation. The main finding during the examination is a reduction in strength in the triceps muscle - as an expression of an impairment of the seventh cervical nerve root.

The patient's descriptions contain no obvious indications of an important role for sleeping position. Pain that is particularly severe early in the morning or nocturnal position-dependent pain could be such signs. Only the remark that the right arm used to fall asleep at night even more than it does today draws attention to sleep.

I always take a sleep history, especially in the case of long-term complaints that do not improve sustainably despite adequate treatment. I also often ask people to show me the sleeping positions they have adopted. This is of course a very uncertain area, as we move around a lot more at night than we think. Who can say what position they sleep in during the deep sleep phases?

Our violinist has a habit of holding her right arm up when sleeping on her right side and also overstretching her head. This can have a negative effect on the space for the nerve roots as they exit the spinal canal. Because she only uses a very flat pillow, her head is also overstretched when lying on her back. This also has an unfavorable effect on the already limited space between the nerve roots and vertebrae.

Preventing or changing a sleeping position is not easy. As we can only exercise conscious control during waking phases, other tricks are needed. I usually recommend attaching a disturbing object to the pyjamas on the side to be avoided. A spray can lid that is placed in a sock and then pinned in place with a safety pin fulfills this function well. In this way, the affected person immediately turns away from the problem position and not only when a painful irritation of the nerves forces a change of position.

In our patient, this way of controlling her sleeping position and the use of a slightly higher millet pillow had a very direct effect on her progress. Within three weeks, there was a steady improvement. The decisive factor is obviously that by avoiding the nocturnal nerve irritation, physiotherapy can now bring about not only short-term but also lasting changes.

Dr. med. Christoph Reich-Rutz, Zurich

Specialist in rheumatology and manual medicine

> www.christophreich.ch

Wind players are highly trained musicians. They produce the finest art on their instrument with maximum physical effort. In doing so, they exemplify the unity of body and soul on a daily basis. When we talk about pressure, flow and coordination in the following, we should not forget that most problems in the pneumology consultation for musicians concern breathing and not simply the lungs. The physical parameters are important, but they do not fully describe breathing. Even more than in sport, music requires the use of the soul. It often has a disruptive effect after accidents, in cases of excessive demands, anxiety, exhaustion or overuse. This is why medical practitioners work closely with professions that focus on the emotional or mental function of breathing.

Every healthy person is capable of blowing. They can blow out a candle or blow up a dandelion. You create pressure through the exhalation muscles (chest) while stabilizing the inhalation muscles (diaphragm) and control the pressure and flow in the throat/larynx. Singers already form the notes (vibrations) here, trumpeters a little later with the lips and woodwind players in the reed or pipe. So it would be quite simple. However, the art form demands virtuosity and therefore top performance.

Frequent inquiries confirm that knowledge of technical data is useful. The average pressure is described in millimeters of mercury (mmHg) and is about 5 mmHg when whistling, 10 mmHg when speaking, 20 mmHg when blowing out a candle (at 50 cm) and 60 mmHg when blowing up a balloon. The flute requires a minimum blowing pressure of 0.5 mmHg (average pressure 1-6 mmHg), while the oboe requires 28 mmHg (average pressure 30-48 mmHg). The oboe requires a maximum flow rate of around 150 ml/s (milliliters per second), whereas the flute requires 612 ml/s. The tuba, on the other hand, demands 1700 ml/s from the musician. The maximum blowing pressure for the C trumpet is 120-130 mmHg and for the piccolo trumpet even 170-180 mmHg. The blowing pressure increases depending on the volume and frequency of the notes produced.

Can small children play the trumpet? Yes! Because at 7 mmHg (minimum blowing pressure) a sound is already produced and on average 13-42 mmHg is enough to make simple but beautiful music. So nobody will forbid the child to blow out the candle (60 mmHg). But if you want to play symphonies by Mahler and Strauss or a Brandenburg Concerto or be the lead trumpet player in a big band, you will have to achieve the above-mentioned peak pressures. As all music teachers know, it is not the instrument but the literature and playing technique that are decisive.

In the 1960s, many data (including the above pressure values) were measured in several studies. Lung measurements in wind players/singers vs. healthy controls showed an average of 1 liter more total volume and ½ liter more first-second volume in young musicians than in non-musicians. However, this advantage was lost in 45- to 54-year-old musicians. The reason? Cigarette consumption canceled out all training.

Not all breathing is the same. Every yogi or meditator knows and lives this. You breathe differently when making music. Musicians breathe according to the music, according to phrases. They usually breathe out long and slowly and then quickly inhale the right amount of air for the next phrase at a suitable point. Think of the different flow rates of the instruments (see above). It becomes clear that a tuba player has to breathe differently to an oboist.

There are few illnesses or injuries to the respiratory organs that are caused by making music. As described at the beginning, breathing disorders often occur when body and soul are no longer in balance. By far the most common conditions we see in the consultation are lung diseases or injuries that interfere with music-making. It seems that the wind music teachers have done their job well.

Dr. med. Peter Jules Gerber, FCCP

Lung practice Bern West

Holenackerstrasse 85/B 04

3027 Berne

www.lungenpraxisbernwest.ch

Tel.: 031 992 55 56, Fax: 031 991 86 24

pj.gerber@hin.ch

In their daily work, musicians are exposed to sound levels that have a damaging effect on hearing above a certain dose. And so, unfortunately, even Mozart becomes noise for the ears at some point. Much is being done to protect them from hearing damage, and there are good, sound-neutral hearing protectors, both off-the-shelf and customized. The problem, however, is that very quiet music comes out of nowhere, and in order to hear such passages and cues with 100% accuracy, even a small amount of hearing protection is too much for many people.

It's just a shame when the orchestra tutti produces volume levels of 90 or 100 dB in the next movement. What happens then is what the ear doctor calls the "c5 depression": a noise-induced hearing loss that manifests itself most strongly in the area of the five-letter c at around 4000 Hz. This is exactly where the consonants that are important for understanding speech are located. If the hearing is damaged there, the table becomes a fish and the river becomes a kiss, which can lead to embarrassing situations.

It is well known that those affected try to get by without hearing aids for years. They develop different strategies to cover up the hearing loss: one of them is to avoid difficult situations, such as the acoustically notorious cocktail party. If "normal people" find it so difficult to wear hearing aids, how much more difficult must it be for musicians to imagine performing in front of an audience with hearing aids? For many, almost unthinkable.

Modern hearing systems are very small and can be almost perfectly concealed, provided you have the right hairstyle. For those without the necessary hair, however, the devices are not so inconspicuous. They either sit behind the ears, with a small tube in the ear canal, or they sit directly in the ear. Unfortunately, you can often still see them there because the electronics are too big for the ear canal.

Recently, however, there are now truly 100% invisible hearing systems. These are placed four millimetres in front of the eardrum and remain there for up to four months, day and night. In contrast to conventional high-performance hearing systems, they are equipped with relatively little technology and functionality. They work with the so-called "Wide Dynamic Range Compression", according to which the amplification is constantly adapted to the acoustic environment.

You have to imagine that signals in a quiet environment are amplified disproportionately and that signals in a loud environment are attenuated by means of compression. For the hearing impaired, this has the dual advantage that quiet signals can be heard and that loud signals are not perceived as unpleasant. The maximum volume that the devices generate across the entire frequency range is 103 dB. This means that a brilliant "grand finale" with the devices will be somewhat less loud than in reality. This is because the deep and acoustically tight fit of the devices almost acts as hearing protection.

Not every musician or music lover will accept this limitation. For those who have no problem seeing their hearing systems, very powerful technologies are available that can process input levels of up to 106 dB. It is important that you seek professional advice and work with your hearing care professional to program the system based on your own music. This requires specialist knowledge and the appropriate infrastructure.

If you don't want your hearing aid to be visible, I can fully understand that. I wore conventional hearing aids myself for 15 years until I switched to these new, invisible ones. I understand everyone who wants a discreet solution.

Either way, if you can no longer hear the conductor's announcements or the pianissimo of your colleagues, you should do something as soon as possible.

> www.stueckelberger- hoerberatung.ch

N. has been working in the orchestra for six months with a 100% position. She is currently practising and rehearsing difficult orchestral pieces and complains of pain in her shoulders and neck. In the first lesson, I discuss with her the connection between situations, thoughts and physical sensations.

To get to the bottom of these connections, you need a fine, free, sensual attention. I give N. an observation sheet. In the next lesson she says: "When I was hurrying with the cello on my back, I felt hectic, breathless and tense in my back and neck. Becoming mindful while doing this had a pleasant and calming effect".

In the third lesson, N. is a little sad because she realizes "how I keep tensing up". I recommend that she reads the chapter about his own story in F. M. Alexander's book The Use of the Self. In it, he describes the development and methodology of his technique. After reading it, N. will be amused by the human stubbornness to insist on ingrained patterns.

I instruct her to lie down on the table. She relaxes as I guide her with my hands and words, which she finds very soothing. After about twenty minutes, she should sit up, be mindful during the movements and avoid unnecessary tension, especially in the neck muscles. In order to perceive inappropriate tension, it is advantageous to perform movements slowly at first. Over time, the quality of movement can also be assessed at a faster pace. N. rolls onto his side, pushes his legs over the edge of the table and sits up.

Her sitting on the table is now very upright and relaxed at the same time. She finds raising her arms light-hearted and playful. As I instruct her to play a short musical sequence "in the air" without a bow, she tenses her neck a little, collapses slightly on the right side of her chest and raises her right shoulder to compensate. Only when I ask her how her right side and neck respond to the raising of her arm does she realize it. She also notices that her arm is no longer quite as free as before. Using my hands and words, I work with her not to fixate on the goal of "making music" when raising her arm, but to strive for the goal and at the same time pay attention to the means of achieving it.

In the fourth lesson, I work with N. sitting down and on the instrument. She complains that she still does not have confident control of the bow arm and that her sound is impaired as a result.

A favorable approach to the organism as a whole means a good balance of tension and relaxation and working with the appropriate amount of energy for the situation. Making music requires muscle tension in the right place, at the right time, for the right duration and in the right dosage. N's pelvis is tilted backwards on the chair. I don't work with her directly on the bow arm, but my aim is to bring her head, neck, torso and legs into better balance.

When she is looking for "good posture", she soon feels a familiar pain in her lower back. I let her experience how she can balance on the sitting bones as if on runners. For this to be possible, she needs freedom in her hip joints. I ask N about their exact location. In her imagination, the hip joints are much higher than in reality. She looks at my little plastic skeleton and is amazed at how flexible her pelvis is and how her feet make better contact with the ground when she adapts her body image to reality.

This straightening of the pelvis results in a higher tone in the lower abdomen, while the shoulders and neck muscles relax at the same time. N's right arm now feels flexible, relieved and alive in my hands. "It's like my body is thawing out," she says.

In the fifth lesson, N is pleased that she has repeatedly succeeded in using and integrating the experiences gained in our lessons. She feels more energy and joy and occasionally a new sense of oneness with the instrument. After a work-related break, we will deepen our work in two months' time. In addition to handling the instrument, we will then work on various everyday movements as well as with the breath and the eyes.

> www.sylvia-baumann.ch

The functional circle of problems that can lead to occupational disability

The extremely high physical and mental demands of the music profession have reached a level that can go far beyond that of a top athlete. The perfectionism of "clinically clean" CD recordings, which has often become the measure of all things today, leaves little room for individual idiosyncrasies. Recordings in the recording studio are polished up with the help of editing techniques and post-processing so that they create the illusion of perfection that no performer is able to achieve in real performance. This ideal of reproduction has become a great burden. Individual performance can be scrutinized and puts performers at a disadvantage. Added to this is the fact that the competitive pressure to fill musical positions has steadily increased in recent decades. The pressure can leave internal traces that are not immediately visible to the outside world. They usually manifest themselves indirectly in moods, dissatisfaction and ultimately despair, which those affected experience themselves as "having to bite through".
Tension and cramps ultimately manifest themselves in psychosomatic diseases of the organs, functional disorders of the musculoskeletal system and malfunctions of the masticatory system. Psychologically induced malpositions of the body are also stabilized by teeth grinding and clenching and vice versa.

The importance of the masticatory system

 The masticatory system plays a central role in the path to occupational disability: Non-blowers compensate and stabilize themselves via the occlusion. Blowers who cannot stabilize the mouthpiece via the rows of teeth shift the tension directly into the motor organ. How does the specialist recognize the involvement of the masticatory system in the many psychological symptoms? It helps to look at the patient's medical history (anamnesis). What stresses, worries, hardships and helpless therapies have those affected already undergone? Which symptoms occur when? The dentist also analyzes the functions of the masticatory system clinically and with analyses using dental models in the masticatory computer (articulator). An interdisciplinary orthopaedic specialist will prepare a functional assessment of the musculoskeletal system. A physiotherapist or psychotherapist can also be helpful in some cases.
We discuss the results on an interdisciplinary basis. This results in a targeted treatment plan. This can include: mental training techniques, physiotherapy, postural corrections without and with instruments ("no overloading without incorrect loading"), bite compensation using selectively constructed occlusal splints to relax the masticatory and musculoskeletal system, harmonization of the bite by removing incorrect contacts or dental reconstruction measures for malocclusions and/or missing teeth (dentures, veneers, implants, crowns).

Accidents require special measures

Accidents - soft tissue injuries to lips and cheeks or tooth fractures and tooth loss due to external influences - can suddenly lead to occupational disability. They require a cautious approach. The physiological changes can be accompanied by psychological impairments. This applies to whiplash injuries, for example. The fateful blow to the neck causes pain and poor posture due to permanent psychological pressure. Those affected feel "a fist in their neck", adopt a forced posture and their intervertebral discs wear out. Permanent pain and occupational disability follow.
Musicians of all ages can be affected. We have developed our own programs for prevention - based on a musician study we conducted between 2001 and 2004 at the Bern University of the Arts on woodwind players: orthopaedic posture and movement analyses were carried out with and without the instrument in a sitting and standing position, as well as functional analyses of the masticatory organ. Treatment was required for around half of the musicians. This experience flows directly into our dental diagnostics and treatment.

Dr. med. dent. J. E. Lahme
Specialist for musician treatments
Schulgasse 18
A-6850 Dornbirn
Tel. 0043 5572 386 333 Fax DW -8
lahme@aon.at
www.zahnart.at