Kyle Miller’s notes on “The Neurology of String Instrument Performance”, a presentation by Dr. Steven Frucht, M.D.

The following post is by Kyle Miller.

A special guest

On December 12th, 2012 (12/12/12) the ACHT studio welcomed a renowned guest speaker. The speaker was Dr. Steven Frucht, former Columbia University faculty member and current Director of Movement Disorders at Mount Sinai Medical Center. Himself a trained violinist who has grappled with serious physical injury, Dr. Frucht regularly meets with and treats musicians who suffer from dystonia or any of a multitude of performance-related injuries. Dr. Frucht guided the ACHT studio through a wonderfully informative tour of his profession, and we are fortunate to have heard him speak – even those among us musicians who have thus far successfully avoided physical injury have much to gain from the teachings of an expert neurologist. Now, it is my great pleasure to recount some of the ideas that Dr. Frucht shared with us in his presentation.


The way they play

Dr. Frucht opened the evening with a discussion of physical ability, both innate and acquired. This exploration revolved around a central question: why are some musicians able to practice and to perform for hours each day, maintaining excellent physical condition, while others continually struggle with performance-related injuries? To address this question, Dr. Frucht focused on the development of extremely successful performers, those who are frequently hailed as masters of their instruments and appear to possess supernatural physical ability. He alerted us to the important role that the mirror neuron system plays in the development of such legendary skill. This system is largely responsible for a person’s ability to imitate observed action. An example: If beginner violist Jane Doe, who possesses a highly developed mirror neuron system, sees a master violist draw a breathtakingly buttery downbow, she can translate her visual “footage” directly into physical sensation. She intuitively knows how to reproduce the observed motions with her own body. Jason Doe, also a beginner violist but in possession of a mirror neuron system much less developed than Jane’s, witnesses the same action and simply wonders at the physical feat, unaware of how to achieve such success himself.

The ability to mimic physical actions is extremely valuable to an aspiring string player because it allows her to bypass many physical obstacles that for others may take years to overcome. However, an advanced mirror neuron system is useless without something useful to observe. Dr. Frucht thus stressed the invaluable role that skilled mentors play in the cultivation of prodigious talent. He posited that no great string player has achieved success without the help of a great teacher, someone whose physical technique can serve as a model for imitation. Of course, imitation is not the only effective pedagogical tool, and the ability to imitate is not the only distinguishing attribute of a gifted young string player. The phenomena surrounding the mirror neuron system simply help us to understand how some musicians develop at extraordinary rates and quickly establish physical techniques that are ergonomically sound.

What makes a master violist’s technique worthy of imitation? Dr. Frucht made his answer to this question clear: the most accomplished musicians all value and cultivate efficiency in their physical approaches to playing. Efficient use of the body promotes physical well-being and yields satisfying resonance, while inefficient motions stifle resonance, contribute to exhaustion, and ultimately result in injury. Dr. Frucht played several video clips of virtuosic performances delivered by famous violinists – among them Jascha Heifetz (with slow-motion, close-up video footage of his left hand moving nimbly about the fingerboard), the young Yehudi Menuhin, David Oistrakh, Itzhak Perlman, and Michael Rabin – and asked us to look for a fundamental similarity between these artists’ techniques. The similarity was immediately apparent: all of the violinists moved very little as they played. These stars had developed astounding physical efficiency, wasting no energy on superfluous motion. This physical economy allowed each of the violinists to execute virtuosic passages easily, reliably, and without fatigue in performance; and prior to the performance, it had enabled them to foster this reliability through injury-free repetition in the practice room.

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Basic anatomical and physiological concepts – knowledge is power!

Throughout his presentation, Dr. Frucht divulged enlightening nuggets of information about the way our bodies work. In reference to the aforementioned master violinists’ physical efficiency, he listed the few areas of the body – emphasis on few – in which muscle operation is essential to string playing: the upper thorax, the shoulder girdle (formed by the clavicle and scapulae) and the upper limbs. By convention, string playing is not possible without muscle movement in these regions. Large motions in other parts of the body, however, are extraneous. Another example: If violist Jennifer Doe wishes to play her four-octave arpeggios with greater ease, she will not make any progress by lifting her left leg into the air. This example does not imply that one should actively hold in place the parts of the body “non-essential” to string-playing. Locking these muscles is just as inefficient as using them to make large, unnecessary motions.

Dr. Frucht described the amazing control that we have over our muscles, using the biceps as his example. One of the basic functions of the biceps is to move, through contraction of the muscle, the forearm and hand toward the shoulder. As simple as this function is, we are able to control it in a multitude of ways through selective firing of motor neurons. We can command the biceps to contract at a variety of speeds; we can resist the contraction or stop it at any point; and we can even continuously flex the muscle without any actual movement of the forearm. Of course, such great freedom demands equally great responsibility. If not carefully monitored, these last two abilities can quickly lead us string players from the realm of firmness – efficient use of muscle – to the realm of tension – inefficient, detrimental use of muscle. If we repeatedly engage a muscle in a tense manner – something that is very easily within our power to do and is often difficult to detect given the amount of processes that we need to monitor as we play – then we risk serious injury. Once again, everything distills to efficiency. We should ask our muscles to do what is needed of them, and nothing more.

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After his discussion of muscles, Dr. Frucht turned to the anatomy of the hand. He began by announcing that the hand is divided into two major parts. Dr. Frucht pointed out that in at least one stage of their motor skill development, human babies use only one of these parts to grasp most objects: the part formed by the thumb, the index finger, and the middle finger. When a baby in this developmental stage reaches out to grasp a small object, he extends these three digits and curls them around the object. Given its association with reaching and grasping, Dr. Frucht called this first part of the hand the exploration part. The exploration part is especially nimble, and we use it to complete delicate tasks that demand precision. The other part of the hand, comprised of the ring finger and the pinky finger, offers us greater power. We add this second part to the first when we need strength to accomplish a task. To illustrate the significance of this anatomical division, Dr. Frucht referred to the act of changing a light bulb. His example, slightly modified for print: After violist Jeremiah Doe (we will assume, in spite of recent folklore, that he is capable of changing a light bulb himself) locates his box filled with fresh light bulbs, he reaches out to pick one up. Without thinking about the action, he naturally picks up the bulb using only his thumb, index finger, and middle finger. Violist Jeremiah Doe then proceeds to screw the light bulb into the desired socket. This action requires greater strength, and Jeremiah now instinctively holds the light bulb with all five of his digits in order to improve his chances of success.

Dr. Frucht emphasized the significance that the twofold division of the hand holds for us as string players. Armed with knowledge of this division, we can appreciate that the third and fourth fingers of our left hand – the latter finger already disadvantaged by its size – are not as naturally suited as the other two fingers to the nimble movements we constantly demand of them. Dr. Frucht illustrated the gravity of this anatomical imbalance by informing us that many injuries arise from overuse of the muscles that control the left pinky finger. In the right hand, the twofold division is linked to the forearm’s rotation. When we pronate the right forearm, we shift the balance of contact between the hand and the bow towards the “exploration” part of the hand. Contrariwise, supination favors the “power” side of the hand. This balance shifts naturally as we travel the length of the bow in either direction, correcting angles and allowing the pinky side of the hand to accept the dangling weight of the bow as we approach the frog. In this way, the design of the hand naturally conforms to the way we use the bow. We favor the power part of the hand when we bow near the frog, the area of the bow that offers the fullest resonance. Farther away from the frog, we balance onto the exploration part of the hand to execute rapid bow strokes and to realize delicate timbres with ease. Dr. Frucht noted that some violinists and violists maintain a pronated forearm and favor the exploration side of the bow hand at all times, keeping a consistent hand shape throughout the length of the bow. He explained that this approach to bowing is inefficient. It requires that the pinky, in order to maintain its shape, exert additional force to fight against the weight of the bow as the player approaches the frog. This extra effort fatigues the power side of the right hand and significantly reduces resonance.

Next, Dr. Frucht discussed the left wrist. He explained that flexion of the wrist tilts the hand toward its palm side, while extension of the wrist tilts the hand toward its back side. Dr. Frucht holds that for violinists and violists, the most ergonomic, neutral position of the left wrist is one of slight extension. If you look at your palm while your hand is in this position, the hand will be leaning slightly away from you with respect to the forearm. The neutrality of this position becomes apparent when one tosses one’s left arm up into playing position (without the instrument) and allows the wrist to “jiggle into place” without controlling it. As we play, we sometimes deviate from this position through the contraction of muscles in the wrist. Certain technical demands of viola playing, including large stretches, may require this deviation momentarily; but consistent departure from a neutral wrist orientation can overwork the wrist’s muscles and lead to injury.

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At one point in his presentation, Dr. Frucht briefly guided the ACHT studio’s attention to two important nerves in the arm: the ulnar nerve and the median nerve. Both nerves travel the entire length of the arm, down to the fingertips, and are responsible for much of the physical activity we engage in as string players. The median nerve extends through the wrist’s carpal tunnel and feeds primarily into the exploration part of the hand, and the ulnar nerve travels underneath the elbow and through the power part of the hand. While both nerves are prone to damage through compression, Dr. Frucht warned that the ulnar nerve is especially at risk from the physical demands of string playing.


What leads to injury?

Misunderstanding or unawareness of any of the concepts detailed above can lead string players to physical injury. Dr. Frucht also explained that discomfort and minor injury very frequently develop into more serious physical issues because a performer attempts to hide the problem. There is great social pressure within the musical community – students and professionals alike – to produce and to perform regularly, and many injured musicians fear that a missed rehearsal or performance is a missed career opportunity. All too often, these musicians are ashamed of their injuries and continue to perform in spite of them, avoiding at all costs the negative judgment of their peers. This behavior carries the injured player ever farther away from a path to recovery, as physical strain, coupled with attendant anxiety, continues to accumulate through physical activity. After describing this scenario, Dr. Frucht recommended that the musical community learn from the injury policies employed by many sports leagues. In Major League Baseball, injured players are placed onto a “disabled list” and thus granted aminimum amount of time off – an amount that varies based upon the nature of the injury and the projected recovery time – from public performance. Other professional sports associations have adopted similar lists. While musicians often speak of their injuries in hushed tones, embarrassed by them, sportspeople are pragmatically open about their physical conditions, regarding injury as an ever-present danger that demands prompt treatment and careful recovery.

Dr. Frucht concluded his presentation to the ACHT studio by presenting a list of “ten common pitfalls” that lead to injury for musicians. It may be helpful to note that many of these hazards involve sudden changes, whether switches between activity and inactivity or alterations to daily routines. I follow Dr. Frucht’s form by concluding with the list:

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