Posts Tagged ‘Rehabilitation’

Hand Surgeon and Professor of Piano joint BAPAM clinic

Wednesday, May 1st, 2019

There are intrinsic relationships between health and performance excellence, and educational and clinical expertise in the performing arts. In overcoming medical problems, specialist diagnostic and medical expertise can be complemented by performance technique and lifestyle and health-related guidance. In a new joint clinic at BAPAM, Mr Mark Phillips, Hand Surgeon, and Penelope Roskell, Professor of Piano at Trinity Laban, are exploring this opportunity for clinicians and educators to provide each other with unique insight and feedback. We asked them to tell us more about this innovative approach.

Could you explain the idea behind the joint clinic and why you decided to do it?

Mark Phillips: In my experience when treating musicians I found quite an overlap between the physician’s knowledge and the specialist physiotherapist/hand therapist’s knowledge, who’s an expert in musicians. But I soon realised there was a huge gap for the third element which is filled by the expert tutor on that instrument. I happen to be a trumpet player so as a musician I have some insight into the patient but that’s not enough when it comes to some of the issues they face. I can relate to some of the psychological performance issues, but the expectation patients have is of someone that can really understand how the technical demands of the instrument interface with the physiological problems they’re having and anatomical problems they may have and the outcome of the clinical assessment.

Penelope Roskell: The knowledge we have between us is enormous. My students have included musicians with injuries for 40 years, and so we fill in the gaps. Seeing musicians together in a joint clinic is very important because you can then see the whole picture and then decide on the best way forward. Sometimes it may be steroid injection and sometimes it may be surgery. But sometimes it may be that a tweak or a change of technique will solve that problem and reduce the need for further intervention. So, seeing them together we can get to the root cause, which we can’t always do if seeing them independently.

How do you decide if a patient would benefit from this dual approach? What can a patient expect at a typical joint session? How do you each approach the patient?

How do you prepare for a joint clinic session?

Mark Philips: Normally I will contact Penelope to say I’ve got a patient or she may say she has a student. We will both select patients for this clinic.

Penelope Roskell: Sometimes Mark will send me over a video of that person playing, so I’ll have a chance to look at it and pick out the obvious problems about what I think may be causing it. I’ll also have a clinic letter which will give some sort of background.

Mr Phillips: We then meet up for a coffee and chat about the patient. So then the patient comes in, and if it’s my patient I present it to Penelope and on one occasion Penelope presented the patient. And then we do the history in the normal way, present findings and run through it all. I then suggest what may be the anatomical or physiological problem and how that relates to this person’s technique. The technique may have worked well for a long time but now there’s a problem which is unique to them. Looking at the technique can help if I’m referring to Penelope. Or similarly if Penelope is referring to me is there a way that some of my interventions such as hand therapy or injections or my approach to examination would throw some light on the matter. It’s that overlap which is invaluable really.

Penelope Roskell: So for instance one of my students came to the last clinic and she had problems for the last year and had come to me for that reason. And Mark gave her quite a different diagnosis to what she had been given in the past, which then informed me. So now we are working slightly differently in the lessons that I have with her privately, having now had this intervention from Mark and he also suggested a steroid injection which we are waiting to see the results to. We can then see the whole picture about the ways forward, because there isn’t always one solution. A patient may need a steroid injection or piano playing adjustments to the technique.

Mark Phillips: It’s multi-faceted, there may be Alexander Technique, hand therapy and it may be someone looking at their posture. I learn so much by looking at Penelope tutoring at the piano in terms of elbow position, shoulder position and what impact that has in terms of the way the fingers lie on the key for example. Each presentation has its own unique cocktail of remedies really.

There are complex multi-faceted problems by the time they come here and it comes down to how we triage these patients essentially. I don’t bring every pianist to this clinic.

Penelope Roskell: It’s inevitably going to be someone with a piano related injury. If they’ve broken their wrist by falling down the stairs then they should go straight Mark. Whereas it’s different when it’s something like accumulated stress from years of playing with a technique which is a tiny bit off balance. They may be very experienced players and their technique has lasted them well, but there’s something that just tips it over.

Mark Phillips: What I see in my patients is that half of them have the same problem as everybody else and that may affect how they use their instrument. And the other half have instrument related problems and it may be a combination of the two. And say if someone broke their wrist a year ago and it may be throwing out their elbow, their shoulder or their posture and it may well be a good way down the line that it’ll come to me that a session with Penelope would be helpful. Because it may be to do with their elbow and shoulder which may be making some notes inaccessible and we can work around. They’re so unique each of these cases an each of them would have their own relative roles for the two of us sitting together and discussing the case. It would be good to extend this to guitar, violin and cello and get tutors to do a similar thing. And it’s pretty unique, I don’t think there’s anyone else out there in the world doing it.

What do you feel are the benefits of having an educator in a clinical setting?

Penelope Roskell: It is a very formal environment which is a positive thing and it focusses everything which is very important.

It is a sort of pilot, it’s the first of its kind and I think it is very valuable and let’s hope that other clinics may take the idea from this and develop that further.

What are the direct benefits for patients of having the educator and clinician in the same room in a clinical setting?

Mark Phillips: We often find that patients are often reticent about coming to these clinics. They really don’t want to look at their own techniques and I suppose they remember back to days when they were being tutored and they feel self-conscious. They have to want to come to this clinic and to be looked at. It isn’t like going for a piano lesson or being taught. We are looking to see whether there’s anything about their technique that may be in anyway connected to the clinical problem they have. So we’re not trying to look at the way they play from any other perspective than that. People play in lots of different ways. Also videos are really useful, anyone with a smartphone can record themselves. When we look at them we can slow them down, go back over a sequence, look at it carefully, look at it together and see how that relates to their clinical problem.

Penelope Roskell: There is something different about the joint clinics, because I’m there involved in the consultation I’m able to ask them questions from my own point of view so that I’m well informed as to how best to help them in the future. Because a piano teacher is not qualified to diagnose and that is absolutely number one and nor am I qualified to answer questions that students sometimes ask me, like should I have that steroid injection or that operation and it’s not for me to advise on that but in this situation between the three of us we can discuss the best way forward viewing it from all the different angles.

Any challenges you are finding with the joint approach?

Mark Phillips: It’s 30 minutes long, which is short. We are just getting into our flow by half an hour.

We haven’t had a chance to find out what patients think, especially how they feel about the added value of seeing us both together.

The four patients we have seen in this format have individually expressed to us they thought it was a good session and it stimulated a lot of discussion and ideas. It would be great in the future to include a hand therapist and do a proper multi-disciplinary clinic. Hand surgeons always work very closely with hand therapists. Because there are so many different joints in the hand and different diagnoses. In the hand you’ve got unique problems to one finger or there will be a combination of problems. So your hand therapy is always bespoke, it’s all tailor made to that patient so you have to discuss each patient individually and with musicians it’s even more so.

Certainly with the three most commonest instruments this is going to be a major area of growth in the next ten years and it’s very exciting.

During the half an hour the patients sense the trust we have with each other (Penelope: we work very well as a team, we both have a lot of respect for each other’s knowledge. So I think they go away feeling they’re whole picture has been seen and assessed and we are seeing them as an individual with a problem that can be resolved.)

All patients have been bought over by the end of the 30 minute sessions. You can see the reticence and slight nervousness at the start of the half an hour turning into trust and outpouring of confidence and sharing of the problem and by half an hour we are in to the nitty gritty aren’t we. The output of that is usually I will see them again or Penelope will see them again.

What they can do is continue seeing Penelope for a while and see me in the clinic two months later and see how things have been going on in the meantime. And because we know each other well we can send secure emails back and forth and stay in touch.

Chartered Society of Physiotherapy on Rehabilitation for Musicians

Wednesday, September 13th, 2017

The Chartered Society of Physiotherapy have published an informative article on Rehabilitation for Musicians in their Frontline magazine. Sarah Upjohn – a key clinician in our physiotherapy team in London – and BAPAM registered physiotherapist, Patrice Berque, share their expertise, with contributions from BAPAM and the Musicians’ Union.

Read the article here.

Alison Loram Muscle Function Research Published

Friday, March 24th, 2017

Alison Loram is a BAPAM-registered Alexander Technique teacher with expertise in the technique’s application to performance and practice, and ergonomics of instrumental playing/singing. She is a graduate of UCL’s Performing Arts Medicine MSc, violinist and research scientist. Her current research work investigates muscle function and motor control, and strategies of changing habits associated with chronic pain, injury and performance limitation.

The first of the papers directly associated with this research has recently been published, and is open-access. You can read the paper here:

Proactive selective inhibition targeted at the neck muscles: this proximal constraint facilitates learning and regulates global control.

Other articles explaining and verifying the techniques used in the experiments and analysis have also been published. For example, the use of ultrasound imaging to determine the change in neck muscle activity was completely novel and so the method had to be set out, explained and the analyses processes, not just of the data but of the images themselves, had to be documented, peer-reviewed and published.

The technical paper Real-Time Ultrasound Segmentation, Analysis and Visualisation of Deep Cervical Muscle Structure is also open access.

Volunteers Needed for Movement and Balance Study

Thursday, June 9th, 2016

Are you interested in how your body works when you move? A new study being undertaken by physiotherapist, Janet Deane, may be of special interest to performers engaging in physically active practice. Janet, who previously helped many performers as a BAPAM clinician, is now working within the NHS recruiting healthy participants for a spinal study for Arthritis Research U.K.

The overall goal of the project is to examine movement and balance strategies in order to understand and improve back rehabilitation.

Janet is looking to recruit healthy participants (with no low back pain) over the age of 40. Everyone taking part will receive a free MRI scan (30 mins) of their low back (worth £200) and a 2 hour biomechanical assessment of their spine and lower limbs at Charing Cross hospital at Hammersmith.

If you’d like to find out more about taking part please contact Janet Deane by emailing j.deane@imperial.ac.uk.

All volunteers will receive a detailed information sheet before confirming participation and may leave the study at any time. The study has been approved by both the NHS and Imperial ethics committees.

Christopher Wynn Parry (1924 – 2015)

Friday, April 17th, 2015

Performing Arts Medicine lost a great practitioner, friend and advocate in February with the death of Dr Christopher Wynn Parry. Kit, as he was known to countless friends and colleagues, grew up strongly influenced by his maternal grandfather, the eminent surgeon Lord Moynihan. After Eton and Oxford, his chosen career path into surgery was interrupted by TB from which he made a slow recovery and was subsequently advised not to continue with rigorous surgical training.  He opted for the medical specialty of Rheumatology but soon fell under the influence of Sir Herbert Seddon, Professor of Orthopaedic Surgery at Oxford, who was researching, with the help of the Medical Research Council, nerve injuries, their treatment and prognosis, and the most troublesome neuropathic pain.  He was proud to be one of ‘Seddon’s Boys’, the others being young surgeons, many of whom would become eminent in hand surgery and with whom Kit remained professionally close.

After Oxford, Kit took his skills and knowledge into the RAF where he became Director of Rehabilitation at the combined services rehabilitation centres at Chessington and Headley Court. He established specialised services for neuro-rehabilitation and peripheral nerve injuries which, with Kit’s enthusiasm and skill and with the large number of injured soldiers providing clinical experience, soon became nationally and internationally renowned. He was also an early researcher into EMG as a diagnostic tool. The results of this work were summarised in Rehabilitation of the Hand, published in 1958, which was the first such specialised text in English and which ran to 3 editions and 3 reprints. Another result of this work was the recognition of Rehabilitation as a separate sub-specialty and the development of the Diploma in Physical Medicine, which Kit established, subsequently training a generation of young doctors. All the while he worked closely with hand surgeons at the RAF Plastic Surgical Centre and at the Royal National Orthopaedic Hospital (RNOH).

Retiring from the RAF, he was persuaded to establish a centre for neuro-rehabilitation and peripheral nerve injuries at the RNOH. This became nationally and internationally renowned and continues today.  A by-product of this work was Surgical Disorders of the Peripheral Nerves, co-written with professors Bonney and Birch, a book of which Kit was very proud.

On retiring from the NHS, he continued to work privately in rehabilitation in the Devonshire Hospital in London and the King Edward VII Hospital in Sussex but he devoted an increasing amount of his considerable energy to his interest in musicians.

Kit was always interested in music. As a pupil at Eton (where a Dixieland jazz revival was taking place led by a fellow pupil, Humphrey Lyttelton, who was to become Britain’s foremost jazz trumpeter), he sang in the choir but also played trombone in a jazz band. He continued choral singing in adulthood as a tenor in the Bach choir. His interest in musicians’ medical problems stemmed from Sunday soirees held by his friend and neighbour, the conductor Sir Charles Mackerras. At the conclusion of these gatherings Kit was often besieged by the performers with their medical problems.  He and Ian James, another like-minded doctor, realised the gap in care for such musicians, many of them with very limited financial resources, and in 1989 created BAPAM, a charity charged with providing medical advice and care to performers which continues to this day.

He carefully monitored all those attending with upper extremity problems, ultimately publishing his findings and observations in over 1000 cases. He noted that only 40% had a recognised ‘organic or structural lesion’ and that many were suffering as much from misuse or a mismatch with the instrument with tired, aching arms as were suffering true overuse. He also noted the contribution to the performers’ physical problems made by psychological and emotional factors, not helped by job and financial insecurities and the demanding and sometimes destructive lifestyles of the performer.  He was an eloquent speaker and took this message to music schools, cajoling pupils and their teachers to respect the physical nature of music making and to avoid injury. He also highlighted the sometimes appalling conditions instrumentalists were exposed to and forced to work under, such as cramped orchestral pits and inadequate venues, suffering for their art and being thankful they had a paid gig. For this work he was elected an honorary member of The Royal College of Music in 2011.

I had the privilege and good fortune to observe Kit in his RAF time at his upper limb neurological clinics and, over the last 20 years, to work with him at BAPAM and with many of his musician patients. He encouraged us to develop an MSc in Performing Arts Medicine and he was proud to give the inaugural lecture to the first cohort of students at University College London in 2011. We combined our clinical and surgical experiences in The Musician’s Hand which was published in 1997, which was, again, a first in the English language and of which he was duly proud. He states in the preface ‘an apology for this book from a physician and a surgeon is that we not only love music but believe it to be fundamental to civilised living’ and this sums up Kit.

Many national and international honours were bestowed upon him and he was particularly proud of being elected, as the only non-surgeon to have been so honoured, President of the British Society of Surgery of the Hand in 1982.  He continued working until health problems forced him to reluctantly retire from BAPAM in 2014. We shall miss him.

Ian Winspur, London, 7 April 2015

Health, Injury and Prevention Workshop for Musicians

Monday, June 10th, 2013

Kathy Whitehouse, cellist and cello teacher with a special interest in posture and injury prevention, has organised this interactive workshop for musicians covering common playing related injuries; particularly the hand, shoulder and back; how they may be prevented and treated.

Guest speaker: Mr Ian Winspur

Mr Ian Winspur is a Consultant Plastic and Hand Surgeon, who has focused his interests and specialisation in Hand Surgery and the management of complex hand problems. He has a specialist interest in the musician’s hand and has helped many professional musicians to maintain comfortable performance and continued careers in the face of hand conditions or post-trauma. Mr Winspur is co-author of The Musician’s Hand with BAPAM’s Dr Christopher Wynn Parry.

Dr Simon Shaw: GP, specialist registrar in rehabilitation medicine, dancer and movement practitioner

Dr James Inklebarger: Tutor in Osteopathy and Specialist in Exercise and Sports Medicine

Kathy Whitehouse, LLCM: Cellist, Cello teacher with a special interest in posture and injury prevention

June 22nd 2013, 2 – 5 pm

London College of Osteopathic Medicine
8 / 10 Boston Place
London
NW1 6QH

Cost £35

Musicians, please take your instrument

Booking: 0207 262 1128

Bookings limited to 15 places

Please note this event is not organised by BAPAM

 

Musicians’ Dystonia Research – Call for Participants

Wednesday, January 4th, 2012

Are you a musician with focal hand dystonia?

An NHS team co-ordinated by Dr Mark Edwards (who is also Neurology Advisor to BAPAM) is conducting research into musicians’ dystonia. A number of exciting projects with the aims of better understanding this condition, and hopefully developing new treatments, are currently running.

The team are recruiting enthusiastic musicians for a retraining programme to help establish the most effective treatment strategy.  The studies will be conducted at the Institute of Neurology in Queen Square, London which is a leading UK establishment in dystonia research. The work is co-ordinated by Senior Lecturer Dr Mark J Edwards and two PhD students, Dr Anna Sadnicka and Dr Panagiotis Kassavetis. At this time the team is specifically recruiting musicians with dystonia affecting the hand.

If you have this form of dystonia and are interested in taking part in studies (or if you are healthy and wish to register as a healthy volunteer) or have further questions please contact: Dr Mark Edwards, Sobell Department, 33 Queen Square, UCL Institute of Neurology, London, WC1N 3BG.

Or email Dr Edwards via: m.j.edwards@ucl.ac.uk.

Note: BAPAM is not involved with organising or overseeing this project.