This is a re-post of an article originally published in February, 2013.
Dr. Arkady Lipnitsky, DC is the Director of Chiropractic and Rehabilitation at Pain Physicians NY and specializes in treating and preventing many of the muscular and skeletal health problems that plague musicians and athletes. He started out as a skilled massage therapist and eventually graduated from New York Chiropractic College. He has been a practicing chiropractor for the past 15 years with a narrow specialty in rehabilitation, treating some of the most difficult cases in musicians and dancers, including multiple herniated discs, spinal stenosis, chronic repetitive injuries and many others. He frequently works with musicians to provide them with cutting-edge, non-surgical therapies and teach them therapeutic exercises that they can incorporate into their lifestyles so they can continue to practice their art free of pain and avoid surgery. Dr. Lipnitsky is, additionally, a fellow of the American Back Association and North American Cervicogenic Headache Association.
I talked to Dr. Lipnitsky about the foundation of his practice and the causes of some of the most common injuries and conditions he sees in the musicians that come to him for treatment. He also shared some advice for musicians that want to avoid injury so they can stay healthy and continue to play music professionally for many years.
Thanks so much for taking some time to talk, Dr. Lipnitsky. How did you decide to specialize in treating/preventing the problems that plague musicians?
I started as a massage therapist, when I was relatively young and then decided to go to chiropractic school. I’ve spent about 15 years practicing as a chiropractor with a pretty narrow specialty in rehabilitation. I’ve always been interested in figuring out how we can modify patients’ lifestyle and also teach them how to change the things they commonly do to prevent them from getting the overuse syndromes and get them to a point where they can be out of pain and seek ongoing help from different medical providers. My specialty is different from regular medical physiatry, because aside from offering knowledge, rehabilitation and manipulative medicine, I can actually put my hands on the patient, show them the difference between what is unhealthy and healthy and teach them how to stay out of pain.
The main problem I see with professional musicians – and not just professional musicians, but also professional dancers and athletes – is that they engage in the repetitive motion of practicing and performing every day and throughout their entire career. And that repetitive motion is what causes most of the muscular and skeletal problems that they acquire. As an example, someone who is playing guitar or any stringed instrument has a certain posture that is usually pretty poor. And that person has a relatively weak core, because most of the musicians, in my experience, don’t really spend much time exercising, watching their posture and keeping their core muscles in proper tune to withhold all the stress and weight of the guitar. And then there is repetitive motion of the wrist, elbow, shoulder and neck. So, over time, this transfers into an overuse syndrome. That person will slowly, repetitively tear muscle, tendon and ligament tissue. And it is a natural aspect of our bodies to repair themselves. But unfortunately, because that person keeps reinjuring, that repair process has no time to take place. And instead of a normal, healthy muscular or tendon tissue, that person will develop a scar tissue that further restricts motion of the wrist, shoulder, elbow, joint, etc. and will eventually cause either significant tears or degenerative changes.
Rehabilitation is not just about getting someone to function well for the time being. It is about changing something in the patient not only relevant to the problem area, but to the other parts of the body – the way they stand, engage the muscles, the way the lower back affects the shoulder, etc. The muscles in everyone’s body are interconnected. Reinjuring the shoulder over and over again and bringing the shoulder forward constantly is going to indirectly cause a lower back problem. That linkage is often missed in the industry, altogether. Quite honestly, I think musicians who went through formal classical training at places like the Julliard School and other major music schools had quite an extensive education regarding posture and how they should be sitting and standing. But over time, this is often forgotten. And many others do not have this education.
What are the most common injuries you see in guitarists, bass players and drummers? And what can these people do to prevent these injuries?
For guitar players, the most common problems are wrist problems, carpal tunnel syndrome, tendonitis of the thumb, inflammation of the elbow and extensor tendon. I think an even more common problem is shoulder impingement syndrome. Because of the slouching of the shoulder forward and the position of the playing hand, you will get a chronic impingement of the tendon underneath the acromial process of the shoulder, right next to the collar bone. And you will see a slow tear of this part of the shoulder, eventually resulting in one of the main tendons of the shoulder tearing off completely.
This can be prevented by working on posture. And posture is all about training the core, because the core is what keeps the posture engaged. To work on this, you need to go back to basics, to some floor exercises to train the core, along with some Theraball exercises. These exercises are widely available on YouTube and different websites. We actually have our own DVD that we give to patients that offers core exercises.
The main idea is to start training the main engaging muscles of your body that will keep your spine, main bones and joints in check. Keeping those healthy will prevent many problems that will take place in your extremities. The core is the main engager that will keep us upright, keep our shoulders from rotating forward and the tendon from being compressed. This is the most basic of any rehabilitation and what we usually start with when working with our own patients. Once we see the patient is properly engaging the core and getting a proper sense of posture, we can move on to some others. For example, there is the Alexander Technique, which trains people how to sit up very tall and straight if they play a keyboard/piano and have to sit down for long periods of time. They have to keep main back muscles engaged to prevent themselves from leaning forward and putting stress on the shoulder, elbow and wrist.
Those would be some basics for any musician starting the rehabilitation process. Of course, we can only teach these techniques. It is then musicians’ responsibility to take these techniques, learn them and practice them in order to prevent chronic injuries.
Sometimes it is difficult for musicians to understand when the problem needs to be addressed. A lot of them wait for the condition to become chronic before seeking help.
And is there any advice you can give people about how to identify the difference between muscle fatigue and unhealthy pain?
Let me offer an example by talking about a regular workout: If you went to the gym and felt your muscle was tired, you would take a certain amount of days off to let the muscle recover. Muscle tissue will grow when it expands and then slowly contract and heal. It will scar if you keep stressing it. The same thing applies to practicing an instrument. If you feel a burning sensation in your muscle, it means that muscle has expanded; it filled with blood and the fibers are slowly starting to tear. You have to give it a few days to rest. I understand that sometimes taking time off is impossible. But not taking the time is what will prevent you from playing for many years to come.
Are there any quick fixes if you find yourself on tour and experiencing pain, but need to play?
You’ve probably noticed during the Olympics that there will be many athletes with different colored bands and tape around their arms. That’s Kinesio tape. Japanese scientists created this tape for a very specific purpose. While it creates some stability, it’s not a stabilizing tape; it’s a tape that allows the slight lift of the skin and the top muscle layer, so drainage can kick in significantly faster. What happens is that you get blood circulation and oxygen to the affected area 20 or 30 times more than usually. It’s amazing how well this tape works.
Practically every one of the professional athletes, dancers and musicians I work with use this. I teach them how to use it to treat their specific injuries, and it’s widely available online and in many athletic stores. If they forget, there’s always a video on YouTube. If you have a chronic problem, don’t wait for the pain. Tape the elbow, the wrist, whatever it is. It doesn’t restrict any motion. Your movement is still exactly the same. Sometimes it actually enhances your movement. But you get more controlled motion. The tape controls a certain muscle activity in flexion and extension without deviating from the proper elongation of the muscle. It immediately treats it without medication.
Besides that, there are a lot of other products on the market. For example, I love using Omega-3. It’s a great anti-inflammatory agent. Aside from working for blood vessels and other things in our bodies, it actually helps decrease inflammation without the use of Motrin, Advil or other anti-inflammatories and helps the soft tissue to heal.
Another great product for muscle tissue is arnica gel. Arnica is a flower, so it’s all natural. If you feel a strain or sprain in any part of your body, start rubbing on arnica gel every three, to four hours, and it really significantly reduces swelling, bruising and inflammation of any soft tissue.
I think the extent of what some musicians do to warm up before they play is crack their knuckles or move around their wrists a little bit. Are there non-instrument-related stretches people should be doing to warm up?
Absolutely. Musicians are no different from athletes. They have to know what their action will be in the next several hours and prepare for it. As a musician, you need to stretch ligaments and muscles and get blood circulation going at the joints before and after every practice and performance. That’s a given thing that you need to learn how to do.
Obviously you would teach people who work with you how to stretch in depth. But are there some basic stretches that can help musicians warm up?
To warm up, you want to start with larger muscles and then narrow it down to smaller muscles. General warm-up for the upper body muscles would start with rotational motion of the shoulders, then rotational motion in all directions of the elbows and the wrists. Then you narrow it down to ligaments and tendons and manually stretch the wrist and all planes. For example, you can use a desk or another hard surface to put your palm down and stretch, which gets at the wrist and the flexors and extensors in the elbow. And you can do a deep, manual stretch of the shoulders by just bringing the arm behind your back and bringing the other arm behind your neck and take a rope or cord in between and pull in both directions.
It’s helpful for me to evaluate the functional changes and functional deficits in the patient and address these functional deficits with a proper exercise routine. I don’t like it when I see a patient come in that already has a frozen shoulder or a torn extensor elbow tendon or a chronic condition – which I see with a lot of guitar players – where the extensor tendon in the thumb gets swollen to the point of affecting the sleeve of the tendon and there is inflammation up to the elbow. At that point, the problem has advanced to the point where it might require significantly more therapy, injections or medication in order to heal. I’d rather see a patient when that person first starts seeing the symptoms. Then, aside from treating the symptoms, I can teach them what to do to prevent tears from taking place. Then, that musician can take that knowledge and hopefully not have to see me for many years just by practicing the techniques provided.
Are there any parting words of advice you can give to musicians about maintaining their muscular and skeletal health?
I always say that you cannot build any stability if there is no mobility. That’s a very well-known fact. And it’s pretty much a guideline for any rehabilitation or treatment that I provide to any patient. If your joint is not moving, working out the joint and the muscle in order to stabilize it is useless. You have to break the adhesions and the scar tissue and rebuild the flexibility of the joint. It doesn’t matter if it’s the spine, a hip, elbow or wrist. If there is no mobility, it will never be stable. You have to first rebuild the mobility and make sure there is a full range of motion – hopefully a painless range of motion – with minimal scar tissue buildup around the tendon that guides that motion. Then you can address the stability issue when you start working out a tendon or a muscle that will stabilize the joint and keep it nice and steady no matter what activity you are doing day to day – working in front of the computer or playing guitar.
Here is another quick example: I was treating a couple of patients I have been seeing for about a year. They are very famous ballroom dancers. They just came back from a tour, and they were complaining of little aches and pains here and there – nothing specific. I did the most basic functional assessment: functional movement screening (FMS), when we challenge the patient to do extremely basic daily activity, for example, squatting by the wall. And these people have been on their feet, dancing, since they were probably seven-years old. They are 30 now and practice 10-12 hours per day, six days per week. They should be iron strong, stronger than almost anyone who would walk into my office. Both of them failed on the most basic things, because they have used exactly the same muscles over and over again, ignoring the fact that the other muscles are inhibited by the over engagement. And they’re creating a false pattern, which creates a pathology. In this case, I have to peel all the way back and give them the most basic exercises, which look extremely silly to them because they are so simple, but allow them to rebuild tissue.
It’s kind of like someone who builds up all their chest and upper body muscles in the front but neglects the back.
Right. They built the whole front chain but forgot about the back. And related to that point, anyone who sits for 10-12 hours per day or even five, to seven, whether it’s in front of the computer or in front of the piano has to work on their back muscles. And I have a lot of patients who play the piano with symphonies, etc., and they have absolutely no back chain muscles. The legs, the butt muscles and the lower back muscles are absent, because of sitting all day. And of course, their posture will not be engaged at all. A lot of them have spinal stenosis and changes in the mid back that makes them hunch forward. They also start to get compression around the chest because the shoulders are forward. It creates a whole range of problems and often ends up with them experiencing poor breathing. And these are people who are very educated and thus should know better than to let this happen. But we can all get caught in the routine of doing what we do every day and forget about basic health.
My website provides resources for people even if they are not my patients. If anyone wants more information about what they see there, I have free informational DVDs about basic core training that I put together with my physical therapists. Instead of just giving patients a sheet of paper to repeat an exercise that they will eventually forget to do properly, the DVDs give a breakdown of all the exercises. And it will hopefully give people some ideas about what they need to practice. Then, if they need additional help, they can come to us.
To learn more about Dr. Arkady Lipnitsky and the work he does with musicians and to get more information about his core training and exercises DVDs, visit the Pain Physicians NY website. You can also follow his practice on Twitter and Facebook.