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I. Onset
II. Retraining
III. Postscript
In 1998 I applied for tenure at the University of Kansas, recorded a solo CD and we had our second child. These major projects and the life change of our growing family created a lot of stress and sleepless nights. About a week after receiving tenure, a call came from the trombone search committee at the Cincinnati College-Conservatory of Music to inquire about my interest in their position. Of course I was interested; not because I was unhappy at KU so much that I was reluctant to turn down a golden opportunity to climb the career ladder.
In the summer of 1999 I began my duties at the Cincinnati Conservatory by serving on the faculty of the Mendez Brass Institute, hosted by CCM. I recall house hunting amidst the conference duties of playing chamber music, delivering masterclasses and joining the Summit Brass on a few selections. I also recall not playing well and feeling terrible about starting a new job on the wrong foot. Specifically, I was assigned to play in a low brass ensemble with some of the most famous brass players in the world. The selection was a soft chorale and I couldn’t make any entrances clean and on time. Little did I know these were the first symptoms of dystonia.
After the conference, CCM started up in earnest and we moved our young family across the country. My symptoms were quickly worsening at this point; I could not center pitches in the middle and low register, my attacks were getting later and later and I could not reliably play a smooth phrase. I looked everywhere for a solution, starting with various brass teachers. Many of them said I did not have anything serious and I just needed to work through things as usual. I finally ended up asking my doctor, who sent me to a neurologist who finally offered the diagnosis of dystonia. This particular neurologist was not a musician and suggested that I switch instruments to saxophone (!)
The next thing I did was consult with some other neurologists who were specialists in the problems of musicians. Upon talking to these doctors, I finally understood the situation; it had been 4 years since the first signs of trouble in 1998 up to this point: May of 2002.
Here are a few details, including my theory of what caused the dystonia:
1. I believe the stress levels that I describe above contributed to the development of this condition but they were not the only factor. Lots of musicians go through stress and never develop dystonia; in part, it’s a question of how you handle the stress.
2. I did not change equipment, play too high, play too loud, or experience any sort of sharp trauma, so in my case, these variables could not have played a role.
3. I think that if I had stayed at Kansas, I still would have gotten dystonia but it would have taken longer to develop; the stress of the new job probably accelerated things. By the same token, if I had stayed at KU, I may not have had the same strong incentive to retrain.
4. Here are what I believe to be all the factors which caused me to develop dystonia:
A. The stress described above.
B. I was under some misunderstandings about breathing which created tension and reduced my breath support. The reduced air flow created an imbalance in my embouchure, requiring the muscles to work harder than necessary. There was a cumulative effect of this imbalance over decades of playing. For more information on this issue, read my Breathing Blog.
C. I defined trombone playing as an athletic activity and exerted a corresponding athletic, isometric effort to play. This created a sort of global tension throughout my body that contributed to the situation.
D. I have an obsessive, “type A” personality which magnifies the effect of the above points.
E. I have a genetic pre-disposition: I believe there must be an “x” factor that explains why some musicians can experience points A-D above but do not develop dystonia.
5. In my case, the development of dystonia took years, not days. It was the slow, subtle accumulation of tension in my body that created the right conditions for the dystonia to develop.
There are no reliable medical treatment options for embouchure dystonia so I had to find different ways to get better. There was a great deal of trial and error involved and in the end, it was a cocktail of therapies which allowed me to resume my career. Here are the things which helped me recover:
1. Alexander Technique lessons
2. Feldenkrais lessons
3. Body Mapping
4. Working with Jan Kagarice to cultivate healthy breath support and better understand what was going on in my brain
5. Learning about neuroplasticity and applying some of these concepts to my own retraining regimen (which involved playing a lot of “air trombone”)
6. Cultivating a new way of playing
7. Reinforcing all of these concepts many times on my own before attempting them in front of others
1. Alexander Technique lessons
2. Feldenkrais lessons
3. Body Mapping
The first 3 strategies helped to alleviate the tension in my body. Years of misuse had deadened my ability to sense the tension, so to me, the tense version of playing trombone was normal; I had lost the perspective of what tension-free playing felt like. Alexander, Feldenkrais and Body Mapping did not cure me but they did allow me to re-discover tension-free playing and brought my body back to muscular neutrality, providing a healthy foundation upon which to pursue the other strategies of retraining.
4. Working with Jan Kagarice to cultivate healthy breath support and better understand what was going on in my brain
5. Learning about neuroplasticity and applying some of these concepts to my own retraining regimen (which involved playing a lot of “air trombone”)
When you want to perform a task, the neurons in your brain send signals to activate the appropriate muscles to achieve the task. Certain neurons are devoted to certain movements and these neurons fire in sequence to form a pathway of instructions from your brain to the appropriate muscles. When one develops dystonia, the pathway gets fuzzy and there is a sort of confusion among the neurons. A pianist, for example, may have lost the discreet difference between moving the third and fourth finger of the right hand. The individual pathways for these two fingers may now bleed into each other. As a result, when the player tries to move one finger, both fingers move together even though this is not the player’s intention. The “instruction manual” for moving an individual finger now says to move both fingers.
Understanding how the movement is initiated in the brain provides an important clue for how to fix the problem. Relieving the tension in my body by using the first three strategies in the above list was extremely helpful to me, but even after I re-discovered tension-free playing, the aberrant neural pathways still existed in my brain. To truly retrain, it was necessary to create new, healthy pathways to circumvent the old broken ones. It was not enough to be relaxed; I had to be proactive about defining a new way to play.
This is where my recovery takes on an experimental aspect that may be somewhat controversial to doctors and scientists. Is it possible to create new neural pathways to circumvent old broken ones? Neuroplasticity suggests there may be ways of doing this, although more traditional research suggests the aberrant pathways are inaccessible and permanent.
6. Cultivating a new way of playing
For me, since the trouble was in my embouchure, it made sense to redefine what an embouchure is—this new definition would serve as the foundation of the new way to play. There is a famous book called The Art of Brass Playing by Philip Farkas which contains photos of members of the Chicago Symphony brass section forming an embouchure with a mouthpiece visualizer. I learned about brass playing, in part, by reading this book and looking at these photos.
The photos, however, are two-dimensional; they lack movement. Dystonia includes the lack of movement and uncontrolled movement as its symptoms, so the photos represented the old way of playing. For me, the new definition of embouchure must include movement, as follows: “An embouchure is a three-dimensional entity in motion which is produced when air moves past lips.” This new definition of embouchure represents the new way to play; it’s different than the old way because it includes air flow as part of the embouchure. This is a meaningful distinction to a brass player.
7. Reinforcing all of these concepts many times on my own before attempting them in front of others
In order to circumvent the aberrant neural pathways that cause dystonia, it is necessary to create new, healthy pathways. The old pathway was created through hundreds of thousands of repetitions playing in a certain way; in order to create a new pathway, I had counter all those old repetitions with sufficient repetitions to establish new, healthy movement patterns.
It felt like the aberrant pathway was made of beach sand and every time I got close to it, I would fall in and it would be impossible to claw my way out because the sand would give way. What was needed was a way of making the new pathway more permanent and reliable. The discreet movement of creating an embouchure—that is, preparing my facial muscles to play the right pitch—would invariably result in too much muscular activity and ultimately create a spasm of the facial muscles one would normally use to create the tone.
Imagine we could measure the muscular activity on a scale of 0-10. No activity would be a 0 and a spasm would be a 10. Just to assign an abstract value, a healthy embouchure might require about a 3. Every time I would initiate the formation of an embouchure, my meter would go all the way over to 10 even though I didn’t want it to (like the pianist’s fingers moving in tandem against her will). That’s the groove in the beach sand; it seems to suck you in against your will.
Here is an excerpt from The Mind and the Brain by Jeffrey Schwartz,
"Merzenich's findings suggest that lab animals need something like 10,000 to 100,000 repetitions to degrade the initial representation of a body part; Byl therefore suspects that people require a comparable number of repetitions of a therapeutic exercise to restore normal representation."
(page 220 of The Mind and the Brain, by Jeffrey Schwartz)
Now I had a measuring system and a goal—I just had to put them together and find a way of establishing the new habitual movement pattern. If I could find a systematic way of logging at least 10,000 non-spasmic repetitions, perhaps I could establish a healthy new movement pattern.
I found a phrase that I knew would be particularly treacherous for me to try and play:
I figured if a spasm was 10, I should begin by countering with repetitions on 0, or no muscular activity. If I amassed enough repetitions, thinking in the new way, perhaps I could establish a new habitual movement pattern that did not lead to spasms. I had to ensure that I was thinking about the new way of playing so I made index cards with cues like “count on the air” and “an embouchure includes air flow.”
At first, each repetition was like playing “air trombone.” I would blow a generous amount of air through the instrument while thinking the new thoughts and moving the slide and tongue just as though I was playing. Admittedly, there was no tone —just air moving through the horn—but there was also no spasm. I wanted to amass lots of repetitions spasm-free in order to create the new pathway in my brain, so I counted repetitions. My cue cards served to help me tally repetitions; each time through the phrase I would turn over the card and look at the next card.
I knew I had to get to at least 10,000 repetitions in order to establish a new movement pattern (like the monkey), but what I didn’t know was whether or not this would eventually result in re-establishment of muscular control. When I was retraining, I would do between 25 and 100 repetitions a day and nothing else—no warm up, no long tones, etc. To effectively create the new pathway there can be no going back to the old way ever.
When I got to about repetition number 3,000 or so, I went to blow through my phrase as usual and sound spontaneously came out. This was quite surprising because my muscular activity measure was still at 0 and I thought I would have to bring it up to about 3 to initiate sound. This was the moment when I knew I would be OK; I had systematically created a new, healthy movement pattern which allowed me to create the tone without a spasm. From this point forward, it was a matter of completing my 10,000 repetitions (which I did) and reinforcing the new pathway.
I now play like this all the time. The new way of playing, for me, is basically air trombone and “0” on my muscular activity scale. To this I have added an acute sense of pitch awareness by singing in my head as I play. I can’t duplicate the old way of playing because I don’t really remember how I used to play clearly enough.
I don’t think my methods will work for everybody but perhaps my story will inspire those in trouble to be creative about devising their own recovery strategies. If you have been rendered mute by dystonia or some other injury, by all means seek help, but don’t wait for someone to present you with a magic bullet.
In my case, changing the way I think about producing the tone was the key, so look at how you are playing and scrutinize the traditional pedagogy of your instrument. Perhaps there is a modification that will be the key to your recovery as well.
Mountain Peak Music is the publishing company I started to share some of the concepts and strategies I learned through this experience. The items offered promote health and wellness and innovative teaching to all musicians, injured or healthy.