Interview: Cornelia Suhner - Our founder and Honorary President Pia Bucher, a kinesiologist for many years, has been directly affected by the massive restrictions on therapy services. In this interview, she gives examples of what this means for professionals like her, both professionally and privately.

Pia Bucher, you are a complementary therapist and work with musicians. What issues do they come to you for therapy with?

In the music industry, you are exposed to numerous stress factors that can lead to job-specific physical and psychological complaints. Typical issues include stress during performances, criticism, time pressure, muscle tension, posture, breathing and, in the case of brass players, embouchure dysfunctions. In the case of focal dystonia, we work together with SMM specialists on an interdisciplinary basis.

Why did you specialize in music as a kinesio-logist?

As a professional musician myself, I struggled with focal dystonia and had to give up my career for medical reasons. I therefore decided to found a musician's medical institution: that was the birth of SMM in 1997. My aim was to provide help at an early stage and to offer a central point of contact and advice for musicians' medicine in Switzerland. At that time, I completed body-oriented further training and training as a kinesiologist.

Music Kinesiology MK is a special field of applied kinesiology that deals with practical music issues and stress reduction in musicians. After many years of experience as a stage performer and instrumental teacher, this was the right approach for me. My work today - supplemented by further training in music medicine - includes retraining for brass dystonia and performance coaching for musicians.

Due to the professional ban in force until the end of April, there are severe restrictions on the care of clients. Protective measures and practice hygiene are still mandatory. How have you personally experienced the lockdown?

One positive sign was the sudden calm in everyday life and the deceleration. In the world of music, the usual everyday stress and pressure was suddenly gone: no concerts, rehearsals, auditions and no more traveling. Therapy sessions were suddenly no longer urgent - there were no more "acute cries for help" due to performance stress or musical complaints. My clients took much more time to practise and deepen the new practice structures, to rehearse concerts in peace... Where necessary, further measures could be discussed over the phone.

Have the topics and questions of those affected changed during the lockdown?

Corona has paralyzed the music scene - there is a great deal of uncertainty.

Many freelancers are experiencing existential hardship due to the loss of income.

New topics are: financial situation, existential fears and future prospects or the stress of unfamiliar online teaching or face-to-face teaching with distancing rules.

What consequences and after-effects do you expect for your clients and for you as a therapist?

A general rethink is taking place. Innovative concepts are in demand. The challenge demands flexibility and creativity in all areas.

Can you take anything from your therapeutic or personal experiences during this time into the "new normal"?

Slowing down is a valuable enrichment. It creates space to try out new possibilities or initiate your own creative processes. Innovative impulses - such as online training or supplementary forms of teaching - give rise to trust and confidence in the potential of digitalization.

Website of Pia Bucher:

> www.sana-musica.ch

Felicitas Sigrist -- The measures required to combat the coronavirus pandemic are having the same effect on many musicians as a professional ban through no fault of their own. Long-prepared events and regular commitments have been abruptly canceled - and for some, all sources of income have been lost. With the expected economic slump, the music industry is likely to recover only slowly. In this stressful situation, not only economic but also psychological effects are to be expected.

People often initially react to shocking changes/strokes of fate with bewilderment. They then take action to secure their existence until they finally find emotional coping strategies. In this phase of imminent threat, acute stress reactions such as impulse outbursts, panic, anger or grief can occur. Some people develop excessive fears about the risk of contracting the coronavirus and need appropriate psychological help.

More often than such acute reactions, psychological disorders are to be expected in the medium term if the emergency situation persists and little can be done to influence it. The consolation that the drastic measures can be overcome collectively will also fade with the easing of measures. Helplessness, feelings of powerlessness and even unemployment are risk factors for mental illness. On the one hand, previously compensated complaints, such as tinnitus or chronic pain, can intensify. On the other hand, depression, substance abuse and suicidal crises can increase. If those affected or their relatives observe increased behavioral patterns such as circling thoughts, sleep disorders, loss of concentration, emotional numbness, social withdrawal, irritability and difficulty with impulse control, it is important to seek help. This is especially true when thoughts of being tired of life become apparent. The SMM counseling center can make an initial assessment of the problem and provide professional support.

"Crises are opportunities", they say. Many people can grow from crises - this is called post-traumatic growth. However, expecting this in advance is cynical and trivializes hardship. There are also people who are broken by crises. Requirements and resilience are individual. Resilience to cope with the impending period of uncertainty can be demonstrably promoted with supposedly banal everyday habits: maintaining a daily structure, sleeping regularly and sufficiently, eating a balanced diet and exercising - just 150 minutes of moderate-intensity exercise per week has an antidepressant effect. Social contacts are helpful, as long as not only the current distress is discussed, but also positive things are exchanged, which steers thoughts in a different direction. It is important to be able to talk authentically about your own emotional state, but to limit yourself to a circle of trusted people. Various methods of mindfulness practice have proven to be effective in dealing with crises more calmly. These teach the ability to focus on the present moment and not allow thoughts of the past or future to dominate and weigh you down. In medical terms, this reduces the physiological symptoms of stress and causes less long-term damage to health.

The break in the performance calendar can be used to review and, if necessary, optimize your own music-making. Have habits, postures or playing techniques crept in that could cause long-term health problems? An analysis with the help of a specialist with knowledge of music physiology is also useful as a preventative measure - the advice center can also put you in touch with specialists for this.

As we have already seen in the two months since the lockdown, the need for music has not diminished. Music enables something essential: contact even without physical contact - a feeling of connection even at a distance.

Dr. med. Felicitas Sigrist

... is a psychiatrist and music psychotherapist and heads the SMM's counseling center for musician medicine. She can be contacted at beratung@musik-medizin.ch.

Cornelia Suhner -- To stand on stage and express yourself through your instrument, voice or as a conductor, it is not enough to be relaxed. The body needs support and stability so that playing motor skills feel free and effortless and music-making is accurate. The questions are: where - and how? In order to help musicians discover this, the Dutch pianist and physiotherapist Gerrit Onne v. d. Klashorst developed the so-called "exercises of the primal forms of posture and movement". They form the core of Dispokinesis, which was developed around 1950 especially for musicians and stage artists.

Dispokineters basically teach nothing new. Rather, they are masters both in eliminating artificially learned, inhibiting patterns and in uncovering, eliciting and developing the potential that lies within each individual. The core idea: the "Urgestalten" exercises are used to work through the human straightening process from lying down to crawling, sitting and standing. In the process, incorrect postures can be recognized and changed and the natural posture and straightening reflexes (front foot, legs, pelvis/lower abdomen) can be rediscovered and experienced. In this way, musicians find their way back to the original posture they acquired as a child.

The characteristics of "this" natural posture are dynamic stability in the lower body and, as a result, freedom in the upper body with relaxed shoulders and permeable arms and hands. Such a natural "disposition" is a basic prerequisite for fine motorized, light movements (fingers, lips, tongue), well-functioning breath control or a freely vibrating, brilliant sound.

Two further important areas are added to the exercises of the Urgestalten: in order to maintain a physiologically sensible posture when making music, the instrument is individually adapted to the body with a wide range of ergonomic aids. In addition, Dispokinesis offers special exercises (for all instruments, singing and conducting) to optimize instrumental and artistic skills - such as imagination and learning aids for fine motor playing technique, playing feel, breathing, dosing and differentiation skills and much more. The goals are expressive variety, stage competence and minimal use of force for maximum sonority, lightness and virtuosity.

Dispokinesis is taught both in individual sessions and in smaller groups - so that personal feedback is always possible - as well as in workshops and seminars. If necessary, Dispokineter work together with doctors and other therapists. This way of working is suitable for all those who want to improve their ability to play and express themselves and to exploit their full potential in sound creation. It is used preventively or as a pedagogical concept, but above all also for indications such as postural, movement and breathing disorders, as well as for playing inhibitions (embouchure insecurity, cramps, loss of sound, depressed high register, bow or lip tremors...), pain syndromes, stage fright or loss of control.

Cornelia Suhner

... is a flautist and works as a Dispokineterin, performance, expression and mental coach in Zurich and Bern.

> www.cornelia-suhner.ch

> www.vivace-musikermedizin.ch

Salome Zwicky - They stand for uncertainty, rejection, timeout, reorientation and existential fear. The question often arises not only as to whether the work was done incorrectly, but also as to whether self-blame and feelings of guilt can be the result. Young female singers in training or at the start of their career are usually affected. Men do not have nodules, longer vocal folds seem to be immune.

Nodules are caused by any unfavorable form of voice production - not just when singing. They are thickenings of the mucous membrane in the middle section of the vocal folds due to unfavorable phonation - hence the technical term phonation thickening.

The air flows through the closed vocal folds and creates a vibration at their edge. The air flow rubs and sucks on the mucous membrane, most noticeably in the middle of the vocal folds. To protect itself, the over-stressed mucous membrane thickens, similar to how the skin on the hands or feet develops calluses under pressure and friction. However, the thickening of the vocal folds worsens the vibration properties, so that even more unfavorable pressure is required for phonation - a vicious circle is created.

Not every nodular change is a phonation thickening. Genuine nodules are symmetrical, i.e. they are roughly the same on both vocal folds. Nodular findings on only one vocal fold are almost certainly another change, for example polyps or cysts. Unlike nodules, these do not disappear even if the voice is spared. Genuine nodules, on the other hand, can become smaller or disappear if the voice is rested for one to two weeks (only quiet, effortless speaking, no singing in full voice). However, this temporary caution does not solve the problem; the thickenings will reappear under increasing strain. It is important to tackle the actual cause.

If real nodules are found, the first question is therefore the cause, and the form of therapy is derived from this. The harmful "too much" on the vocal folds is made up of the mechanical force and a time factor. In other words, it depends on how you produce sounds (muscular balance, subglottic pressure), but also how often and for how long you sing in this way. If nodules are discovered by chance, it is important to know that they only need to be treated if there is a simultaneous voice disorder. Some singers sing without any problems with the beginnings of nodules.

The therapeutic approach is always similar. Put simply, you have to learn to make sounds - especially loud or high-pitched sounds - resonate instead of being forced. The power to sing must be drawn from good breathing and body technique and not generated by laryngeal muscles. The same principle applies to speaking in everyday life, in the classroom and on stage and is also followed in speech training, vocal pedagogy or voice therapy (speech therapy). Breathing control, support and marginal voice training relieve the larynx. Proven aids are LaxVox or - brand new - the Doctor Vox voice mask. For some singers, individual areas of the vocal technique need to be changed. This takes time, but is essential for continued professional success. Surgical removal of the nodules is only necessary in a few cases and only makes sense if the incorrect vocalization is corrected at the same time.

Phonation thickening is not a bad thing. They show that the type of vocal strain has led to a dead end and are a warning signal for those affected to rethink and optimize the way they handle their voice. It is worth the effort. The important interaction between therapy and pedagogy offers the opportunity to get to know one's own voice in greater depth and thereby acquire mindfulness and a healthy technical foundation. It will literally "untie the knot".

Salome Zwicky

... from the SingStimmZentrumZürich (www.sszz.ch) is a specialist in ORL with a specialty in phoniatrics.

SMM - Prevention and health promotion in the music profession are key objectives of the Swiss Society for Music Medicine. A horn class and a presentation by Peter Knodt, lecturer in trumpet didactics at the University of Applied Sciences and Arts Northwestern Switzerland (FHNW), will introduce the topic at the Basel Music Academy. Knodt interviewed graduates and the team of horn teachers on the subject and sees inter-institutional cooperation, suitable individual skills profiles and shared artistic and pedagogical convictions as important factors for health and lasting satisfaction in everyday working life.

Knodt's discussions will be supplemented by Horst Hildebrandt, Director of the Swiss University Center for Music Physiology, with thoughts on self-help concepts that play a decisive role in prevention and therapy. He will show how helpful a mixture of perception training, tone regulation, strength building, movement, breathing and posture training can be - supplemented by techniques for rapid regeneration and muscle and fascia care.

At the symposium, Rheinfelden psychiatrist Andreas Schmid will show where professional musicians find strength and recovery when they reach their limits. He will discuss the sources of resilience that prevent crises of creativity, exhaustion or even mental illness. His lecture will cover the general principles of resilience and their practical significance in everyday life as a musician.

The Zurich music physiologist Oliver Margulies presents concepts for anchoring a music physiology program at music education institutions. They go back to the pilot project "Music Physiological Counseling" developed by Horst Hildebrandt at the German music school in Lahr in the 1990s. It developed into the music physiology teaching and counseling programs that exist today at the music academies in Zurich and Basel. The lecture provides an insight into two projects supervised by Margulies since 2010 at the Vorarlberg State Conservatory and at the Zurich Conservatory of Music. These include individual counselling for teachers and their students, teacher training, stage training, support for gifted students, access to research projects and specialized counselling at the ZHdK.

Elke Hofmann is a digitalization officer and lecturer in aural training at the Basel University of Music. She reflects on the digital transformation that makes information available anytime and anywhere. The rapidly changing new technologies require additional availability, flexibility and communicativeness and therefore also make demands that can be perceived as stressful.

Those taking part in the symposium can attend two workshops in addition to the presentations. One is entitled "Who moves - wins: making the most of physical resources with FBL Functional Kinetics". Music and movement physiologist Irene Spirgi Gantert will show how physical and psychosocial resources are closely interrelated. Strengthening physical resources involves dexterity as well as flexibility, endurance and strength exercises.

The second workshop is dedicated to "The joy of musical expression - Dispokinesis for musicians". Flutist Karoline Renner will show how the method offers solutions for pain, breathing problems, lack of success when practising and performance anxiety, among other things. The aim is to improve your own instrumental and artistic skills. The workshop gives a first impression of the connections between physical and mental posture and how self-esteem can be developed through self-observation.

Dominik Ettlin - The lower jaw is a horseshoe-shaped bone. Its two ends form the temporomandibular joints with the base of the skull. The position and movements of the lower jaw are regulated by the activity of the masticatory muscles. Disorders in the temporomandibular joints or muscles usually manifest themselves with clicking or rubbing noises accompanying movement and/or pain, for example when chewing or yawning. Occasionally, the opening of the mouth is restricted (temporomandibular joint blockage). The symptoms typically fluctuate over time and depending on the position of the lower jaw.

The lower jaw is in a relaxed or physiological floating position when the upper and lower teeth do not touch when the lips are closed. Unphysiological movements or postures such as excessive gum chewing, frequent teeth clenching or night-time teeth grinding can promote overloading of the masticatory system. The lower jaw also adopts a persistently unphysiological position when playing certain wind instruments or singing. Popular expressions such as "doggedly approaching a task" or "gritting your teeth and getting through it" or "chewing on a problem" reveal the close link between chewing muscle tension and emotions. Accordingly, emotional stress can also lead to tension and discomfort in the masticatory apparatus.

Good quality scientific studies on the subject of temporomandibular joint complaints in musicians are few and far between. In a Dutch study, music students complained more frequently than medical students of complaints in the areas of hands, shoulders, neck and jaw. A survey of 210 students found a significantly higher risk of developing temporomandibular joint complaints in those who played wind instruments compared to musicians of other instruments. An even more detailed analysis of the distribution of complaints by instrument was provided by a survey of 408 professional musicians from two classical orchestras in Germany. Because making music with woodwind instruments (flute, bassoon, clarinet and oboe) requires a persistently unphysiological lower jaw posture, it is not surprising that functional disorders and pain in the temporomandibular joint were described more frequently in this group. What is surprising, however, is that similar complaints were experienced just as frequently by people who played stringed instruments.

Other risk factors such as night-time teeth grinding and persistent jaw clenching could at least partially explain this observation. This is because these risk factors frequently describe people under stress, which in turn is associated with increased chewing muscle tone and jaw and facial pain. Around half of 93 professional violinists in Portugal reported suffering from stage fright, with a clear correlation with jaw joint pain. Excessive singing is also thought to be a possible cause of TMJ, but reliable data is not available.

In summary, musicians complain of jaw complaints with variable frequency. According to currently known data, these cannot be clearly attributed to playing a particular type of instrument. However, the impairment is highest for singers and wind instrument players. Health-promoting training is now recommended at music training centers. Instruction on recognizing stress and tension during training is useful, as young musicians, for example, suffer more from stage fright than experienced musicians. It also makes sense to impart knowledge about tinnitus and other hearing disorders, which are frequently associated with jaw problems, at an early stage. Both preventively and therapeutically, the focus is on dealing with emotional stress, optimizing body awareness and learning relaxation techniques.

PD Dr. med., Dr. med. dent. Dominik Ettlin Interdisciplinary pain consultation

Center for Dentistry,

University of Zurich Plattenstrasse 11, 8032 Zurich

The references can be found in the online version of the article at:

>

Daniela Gut - Many cases of musicians with tinnitus and hearing loss are known from history. Beethoven is probably the best known case. His hearing began to deteriorate at the age of twenty, and this was accompanied by the onset of very disturbing tinnitus. Later, he even lost his hearing completely, but the tinnitus persisted. The cause of this problem in Beethoven's case has not yet been clarified. Otosclerosis, a progressive bony fixation of the stapes, or neurolues, a late form of syphilis, have been discussed. Attempts were made to solve this mystery by exhuming the body. Unfortunately, however, the rock bones (bones containing the auditory apparatus) were missing, so that no new findings came to light.

Musicians are exposed to high levels of noise throughout their professional lives. Be it in the orchestra, during rehearsals or when teaching. The greatest noise exposure is generated by their own instrument.

In the case of noise damage, a distinction is made between acute and chronic noise trauma. In acute noise trauma, there is a brief, strong noise impact - like a gunshot. The typical frequency for this is 6000 Hz. Chronic noise trauma is defined as prolonged exposure to noise with a sound pressure level of over 85 dB.

Both disorders can lead to the development of tinnitus. The latter is defined as any form of ringing in the ears. It can be a tone, but also a hissing, buzzing and so on.

"Tinnitus" is therefore more of a symptom than a diagnosis. The causes are very different and do not even have to originate in the ear. Examples include temporomandibular joint problems, cervical spine problems and vascular problems: both arteries and veins can cause flow noises. Not to be forgotten are medications, above all psychotropic drugs, loop diuretics and high doses of aspirin. With the latter, the tinnitus is reversible. Tinnitus can also occur with psychiatric illnesses - for example, depression or burn-out syndrome.

Tinnitus can be associated with certain ear diseases.

Even a banal ear plug can cause tinnitus. After removal, however, the noise disappears. Tinnitus also usually occurs with inflammation of the ear canal and middle ear. This is also usually reversible once the inflammation has healed. Tubal catarrh, where fluid forms behind the eardrum and leads to hearing loss without pain, is usually accompanied by tinnitus. Tinnitus is often the first symptom of otosclerosis. This disease runs in families. Progressive hearing loss can be significantly improved by surgery.

Then there are diseases of the inner ear, such as sudden deafness and Ménière's disease. The latter consists of a triad of rotary vertigo, tinnitus and hearing loss. This last category also includes acute and chronic noise trauma.

The question now arises as to whether anything can be done to protect the ear. According to studies by Freiburg music physiologists Bernhard Richter and Claudia Spahn, the musician's emotional attitude to a piece has proven to be very important. And, of course, hearing protection measures. These range from emergency solutions such as absorbent cotton to foam earplugs (Oropax) and preformed hearing protectors. The safest and most suitable for musicians are otoplasts (Elacin), which are made to fit the ear canal and offer varying degrees of sound attenuation. In general, all hearing protection measures are not particularly popular with musicians, as on the one hand protection should be provided and on the other hand artistic sound production is altered. It is assumed that only around a sixth of all musicians protect themselves.

In conclusion, I would like to leave you with my favorite quote from Wilhelm Busch: "Music is often not perceived as beautiful, as it is always associated with noise.

Dr. med. Daniela Gut

... is a FMH specialist for ORL with a practice in Zurich

SMM - "No pain, no gain - progress must suffer" was once the motto of music students and professionals. Those days are thankfully over: today, pain is seen more as a warning signal from the body. They are prompts to review rehearsal routines, posture and mental attitudes. "Warning Signal Pain" was the title of the 16th symposium of the Swiss Society for Music Medicine and the Swiss Performers' Foundation in the Marianischer Saal in Lucerne. The event was moderated by SMM President Martina Berchtold-Neumann in her usual style. She also enriched the day with a recreational trance under the motto "Vacation from pain"

Psychiatrist Stefan Büchi, who is Medical Director of the Hohenegg Private Clinic, began the topic by pointing out that the concepts of pain and suffering need to be separated. He emphasized how important it is to find out how sufferers subjectively integrate pain into their lives. Only when the doctor has differentiated access to the subjective experience of pain are healing processes possible. To this end, Büchi and a Swiss-British team have developed a visualization method (Pictorial Representation of Illness and Self Measurement, PRISM). It allows illness, social and family situation as well as the relationship to work to be represented in abstract images. This enables patients and helpers to take a differentiated, shared view of the pain experience as part of the healing process.

Sports physician and orthopaedist Katja Regenspurger, who works in Halle (Saale), pointed out, among other things, that around half of all musicians struggle with musculoskeletal complaints. They are noticeably often caused by instruments with an asymmetrical playing style, especially flutes, violins and violas, but the piano also provokes above-average overuse. The so-called isometric static work, i.e. remaining in certain postures, and the repetitive strain on small muscle groups typical of musicians have an influence here.

Widespread back pain is usually the result of a lack of balance and stabilization in the deep back muscles. According to Regenspurger, pain can be avoided with conscious exercise practice. This includes taking sensible breaks, warming up and relieving the musculoskeletal system through mental practice. Under no circumstances should you practice into the pain or suddenly increase your playing load.

Horst Hildebrandt, Oliver Margulies and Marta Nemcova from the Zurich University of the Arts (ZHdK) and Urs Schlumpf from the Lucerne Cantonal Hospital reported on the practice of musician consultations. It became clear that pain problems, like many other health problems in music practice today, are approached on a highly individual basis. As the example of a pianist with an unfavorable hand posture showed, the corresponding analyses of complaints are complex and require a high degree of special instrumental and physiological expertise. Today, this is a matter of course in Swiss musician consultations.

Neurophysiologist Robert Schleip from Ulm, in turn, was connected to the Lucerne audience via modern video live streaming. He presented the latest developments in fascia research. Their importance for pain problems is being increasingly recognized. Fascia - connective tissue that is closely linked to the autonomic nervous system - has many more movement sensors and pain receptors than can be found in muscles and joints and therefore contributes significantly to pain problems.

SMM - Experiencing pain is part of everyday life as a musician. They can hinder or even end careers. Unless they are understood as a signal to manage artistic ambitions or professional obligations in such a way that the health and integrity of the body are not endangered. Whereas in the past, biting through and ignoring physiological and physical resistance was seen as a sign of misunderstood professionalism, it is now clear that only intelligent, informed consideration for one's own physical well-being can guarantee a long and satisfying life as a musician.

At the SMM symposium, psychiatrist and psychotherapist Stefan Büchi - who is Medical Director of the Privatklinik Hohenegg - points out that pain is never a physical phenomenon to be viewed in isolation, but a fundamental experience that includes cognitive, emotional and social aspects in equal measure. He also discusses the consequences of this understanding of pain for therapy.

Anke Steinmetz, President of the German Society for Music Physiology and Musicians' Medicine (DGfMM), will explain that in addition to one-sided and often prolonged static stress, instrument-specific and ergonomic aspects also play an important role in the development of pain. According to the specialist in physical and rehabilitative medicine, successful therapies for chronic pain syndromes generally require multimodal interdisciplinary treatment concepts.

Robert Schleip, head of the fascia research group at the University of Ulm, will present the latest findings from international connective tissue research with relevance for music medicine. Fasciae (connective tissue) form a fine-meshed network that envelops and penetrates muscles, bones and organs. They are also found in the skin, cartilage, bones, joints, tendons, brain and spinal cord. Among other things, Schleip discusses preventive fascia training to prevent overuse injuries and the role of fascial mechanoreceptors in proprioceptive body perception.

One presentation is dedicated to practical guidance on self-help. Specialists Horst Hildebrandt, Oliver Margulies and Marta Nemcova from the Musicians' Consultation at Zurich University of the Arts (ZHdK) will demonstrate the repertoire of self-help options - in addition to so-called bottleneck stretches and self-massage techniques, including optimized interaction of fine motor components with orderly support and postural motor skills.

In a second presentation, Urs Schlumpf, Beate Walter and Katja Bucher contribute their experiences from the musicians' consultation at Lucerne Cantonal Hospital. They show how local muscular overstrain can be mixed with technical errors.

Sustainable rehabilitation is only possible thanks to an interdisciplinary approach in which the diagnosing doctor, the treating physiotherapist or occupational therapist and the responsible music teacher arrive at a unité de doctrine.

5 SGARM credits will be awarded for the event in the Marianischer Saal in Lucerne, which will be moderated by SMM President Martina Berchtold-Neumann. Registration is open until October 15 via the SMM website at the bottom of the symposium page (www.musik-medizin.ch/aktuelles-symposium) or at the SMM secretariat.

Peter Schönenberger - "God put the diagnosis before the treatment". Many a medical student hears this phrase from their instructors when they want to come up with a treatment for a symptom. Our advice center also occasionally has to respond to inquiries that directly ask for a specific treatment technique without any preliminary clarification having taken place. For example, in the sense of "I am suffering from pain; can you recommend a hand surgeon". This is not helped by the fact that many diagnoses are imprecise or inaccurate. Terms such as rheumatism, burnout and tendinitis are among them.

Basically, medical examinations for musicians also follow the same principles as all conventional medical examinations. Preliminary information is collected. Knowing of any other illnesses, the complaints that are relevant to music-making are specifically investigated. Information about the environment is important both for the search for the causes and for the planning of therapies. On the one hand, the physical examination collects general findings and - in the case of frequent complaints of the musculoskeletal system - necessarily assesses posture and function on the instrument. The clarification can take place in a musician's medical practice or a corresponding university contact point and can be supplemented by an interdisciplinary assessment.

The example of a young alto horn player is intended to illustrate what has been said. For didactic reasons, the description of the problem does not exactly match the actual medical history. The musician attends a secondary school and has been playing the alto horn since she was eight years old, currently in two formations. Following a fracture of a carpal bone in her left hand at the age of fifteen, pain remains in her left wrist. This was later joined by pain in her right wrist. She is right-handed and has to write a lot by hand at school. Neither after immobilization in a cast three years ago, nor later, did she ever receive physical or occupational therapy. The wrist pain becomes severe after an hour of playing music and forces her to change the support position of her left hand (photos). It also occurs on the right when writing. The young woman is exempt from all hand activities in school sports.

The musician attends the consultation of the Bern specialist group for musicians' health. Due to the evidence of wrist arthritis on the MRI, a rheumatologic evaluation is requested. Fortunately, an inflammatory rheumatologic disease can be ruled out. However, there is a clear general hypermobility of the joints, which is responsible for the irritation of the wrists. Due to the lack of muscle development after the accident, the loose joints and the freehand holding of the instrument weighing almost two kilograms, the muscles from the hand to the shoulder blades became tense and caused pain radiating into the hands (trigger point pain).

In several occupational therapy and physiotherapy sessions, which take place in the musician's region, the forearm muscles causing the pain can be relaxed and strengthened. In addition to dynamic stabilization of the lax joints with tapes, the young musician also receives instructions on how to take breaks during individual practice. Over time, she will be able to play with less pain for longer. The partial dispensation from school sports can soon be relaxed.

Dr. med. Peter Schönenberger

... is a FMH specialist in general internal and occupational medicine and Vice President SMM.

Martina Berchtold-Neumann - Unfortunately, pain is a very common topic in musician's medical consultations and is a leading symptom in the majority of musician-specific illnesses. A distinction must be made between acute and chronic pain. The IASP (International Association for the Study of Pain) describes the following differences: Acute pain has a warning and protective function. It is usually linked to recognizable triggers, is usually localized and can be described, and is accompanied by autonomic and endocrine activation and stress reactions. Chronic pain is defined as pain lasting three to six months or longer. It can occur both in connection with a persistent illness as well as detached from structural changes as an independent illness.

Chronic pain is increasingly shaping the way we live our lives. It is characterized by complex biological, psychological and social interactions. Acute pain usually triggers appropriate behaviors. Going to the doctor can ensure that someone takes care of this suffering. Chronic pain, on the other hand, loses its positive protective effect. Living with pain becomes the normal state with the risk of a resigned attitude to life. The treatment of chronic pain requires patience and perseverance as well as a multimodal and interdisciplinary approach.

There are two aspects to pain - on the one hand it is a sensory perception, on the other an affect. You cannot speak of pain without also addressing the adversity in it - it evokes the motivation to get rid of it as quickly as possible. Moreover, pain is a tyrant. Usually without much notice, it breaks into our lives and makes its presence felt. From this moment on, it occupies our existence. It takes us captive.

Epidemiological studies reveal a fairly consistent picture: 40 to 60 percent of orchestra members and instrumental teachers at music schools suffer from back pain that interferes with the practice of music. But even students suffer from physical complaints. It can be assumed that at least 45 percent of them visit a consultation due to music-specific health problems.

The therapy of pain

Physical and psychological dysfunctions interact in the development and chronification of pain. Pain makes the limits of performance visible. If one's own body was previously instrumentalized in order to be able to make music - often against obvious physical warning signals - it now takes center stage itself and demands "its right". Musicians must therefore engage in self-reflection and critically question their practice, behavior, habits and obligations. These include questions about the self-concept, performance orientation and attitude towards the music profession. While temporary abstinence or a reduction in instrumental playing can be successful in the case of acute pain, chronic pain requires a much more fundamental rethink of the entire concept of life. This can usually only be achieved with the support of specialists from the fields of medicine, psychology, physiotherapy and other therapeutic disciplines.

The Swiss Society for Music Medicine (SMM) has such a pool of specialists throughout Switzerland who can be consulted depending on the individual problem. This year's symposium "Warning Signal Pain" in Lucerne will also provide an insight into the topic. The most important current views and experiences, including those from our musician consultations, will be presented and discussed here.

Martina Berchtold-Neumann

... is a qualified psychologist FSP and President SMM

This year, the symposium of the SMM will be dedicated to " la douleur comme signal d'alarme ". It will take place on October 27 in Lucerne.

> www.musik-medizin.ch

Karoline Renner, Sieglinde Fritzsche, Susanne Schlegel* - - Music physiology training at German conservatoires has improved significantly - both in terms of quality and quantity. As a result, orchestras have also become more aware of the need to take responsibility for their own health care. At the Südwestdeutsche Philharmonie Konstanz, for example, a cycle of health-promoting activities has been developed over two seasons since 2016. These "health days" are divided into lectures, workshops and consultation hours. The conceptual arc of the event cycle ranges from the "tangible" physical stresses to the "subtle" psychological content. Health days do not offer blanket solutions, they can only provide impulses and make possible paths tangible, which the individual musician can use individually and on their own responsibility.

Orchestra musicians are subject to strict hierarchies during their work. A clear regulation of communication forms proves to be very useful during artistic work. However, it is superfluous or even harmful to carry hierarchical thinking and learned speechlessness into the rest of everyday working life. Frustration and feelings of powerlessness build up, real opportunities to exert influence are overlooked and misunderstandings remain unresolved.

In Constance, attempts are being made to change such communication patterns. For example, there is a model of active feedback from the musicians at the regular conducting courses for young conductors. The aim is to make these projects known in other orchestras and to hold health days once a year if possible.

Other orchestras have entered into partnerships with medical facilities or music-medical institutes and are supported by them as part of a complex health management program. Not all orchestras attach the same importance to this. Different financial and time resources play a role here.

Eleven years ago, the German Orchestra Association (DOV), the professional association of professional orchestras and radio choirs, formed the Health and Prophylaxis Working Group (WG). Its members are active members from various professional orchestras and radio choirs. With staff and logistical support from the DOV office, they are involved in the comprehensive and complex field of musicians' health. They promote developments and make musicians' medical knowledge and new prevention options accessible.

The direct work of the working group in the orchestras can currently be seen in the "Willibert Steffens soundproofing project". The DOV provides sound insulation walls specially developed for orchestral use for loan to the orchestras. The project is combined with personal advice from one or two members of the working group in order to pass on the necessary knowledge and existing experience and to get to know the working environment of the respective orchestras. A long-term vision is a network of health officers in the individual orchestras who work closely with the working group to promote the health of their colleagues.

*Karoline Renner and Susanne Schlegel are members of the Südwestdeutsche Philharmonie, Sieglinde Fritzsche is a member of the Mecklenburgische Staatskapelle Schwerin.

Horst Hildebrandt, Oliver Margulies, Marta Nemcova - If you examine the sources on the centuries-old traditions of violin pedagogy as well as the musicological contributions of recent decades, you will discover the following: There are often only imprecise or contradictory recommendations on individually suitable instrument positions or ergonomic aids (for example chinrests, cushions and shoulder rests).

The existing recommendations could be influenced, among other things, by the individual anatomical requirements of the school founders who formulated the recommendations. It was not until the 1970s that the enormous range of individual anatomical characteristics that are experienced as facilitating or limiting on musical instruments was systematically researched. In 2009, the handbook that was instrumental in this research was handed over to the Zurich University of the Arts by its founder Christoph Wagner and further expanded by the team of authors of this article (www.zzm.ch).

In view of the worrying number of complaints among high string players and the increasing demand for music physiology support for everyday teaching, a research project recently completed at the Zurich University of the Arts and funded by the Swiss National Science Foundation, the Ernst Göhner Foundation and the Swiss University Center for Music Physiology (www.shzm.ch) has produced the first scientifically sound results on individually suitable violin positions.

Other cooperation partners were Barbara Köhler (Zurich University of Applied Sciences) and Matthias Nübling (Gesellschaft für Empirische Beratung).

The cross-sectional study Objective Criteria for the Individual Selection of a Physiologically Advantageous Violin Position investigated over a period of several years how instrument position, muscle tension and the feeling of exertion in the left arm are related. Data was also collected on individual biomechanical and muscular hand and arm characteristics.

A preliminary study at the Musikschule Konservatorium Zürich with 24 students of different playing and age levels laid the foundation for the subsequent data collection under laboratory conditions with 15 violinists playing a given tone sequence in four standardized violin positions. In addition, comparative data was collected when playing with the usual position and ergonomic set-up. The standardized violin positions were tested without chin rest and shoulder rest in order to enable an objective, comparative analysis and to be able to incorporate playing traditions of historical performance practice.

Initial evaluations of the various phases of the research project show that clear differences can be measured between the various instrument positions in terms of objective muscle activity and subjective feeling of exertion across genders.

Based on the results of the study, a laboratory-independent test procedure was also developed for everyday teaching at all training levels. This procedure has already been presented at a workshop for the European String Teachers' Association ESTA. The results and test procedures presented make it possible to make physiologically sound recommendations regarding ergonomic optimization for playing high string instruments in everyday professional life. They also facilitate the prevention and treatment of activity-specific health problems.

Inspired by the results obtained, a chinrest model was developed in collaboration with the Wittner company under the name of Zurich which, thanks to various height and angle settings, allows adaptation to individual needs and different head positions, even while playing, in order to prevent fatigue. (www.wittner-gmbh.de/neuheiten.html)

SMM - In recent decades, musicians have come to realize that self-help concepts are of great importance in both professional and amateur circles. As Horst Hildebrandt, Head of Music Physiology at Zurich University of the Arts (ZHdK), will explain at the symposium, this applies both to common musculo-fascial complaints and to psychosomatic stress situations. According to Hildebrandt, the activation of individual psychophysical resources is playing an increasingly important role in promoting health and dealing constructively with job-specific stress.

Markus Weber, Head of the Muscle Center/ALS Clinic at St. Gallen Cantonal Hospital, will talk about the highly complex neuronal processes involved in making music and their disruptive factors. These include impairments of concentration, attention and memory as well as chronobiological aspects (working hours), pharmacological influences (medication) and psychosocial stress.

Maja Storch, Director of the Zurich Institute for Self-Management and Motivation (ISMZ), will show how an innovative form of goal formulation helps people to act more and more often in the way they would like to: so-called motto goals are an element of the Zurich Resource Model (ZRM), a self-management training program that systematically involves the unconscious. It succeeds in addressing the unconscious directly and feeding the intention to act into it.

In a fourth lecture, mental coach Reinhold Bartl - he is head of the Milton Erickson Institute Innsbruck - will present hypno-systemic concepts, training tools for "developing your own coherence in demanding professional contexts".

Two workshops round off the program: Reinhold Bartl will show how musicians can deal with irritations (discords) in their professional development in a meaningful way, both in individual situations and with a view to "form crises" in everyday life, during practice, rehearsals and concerts. Finally, Berlin doctor Giovanna Eilers will provide insights into the practical application of the CRM self-management method to complement Maja Storch's presentation. Anyone who wants to can try this out for themselves in the workshop for their own topic.

The one-day symposium, which runs from 10 a.m. to 5 p.m., will be chaired and moderated by SMM President Martina Berchtold-Neumann.

More information and a registration form can be found on the web at:

> www.musik-medizin.ch/aktuelles-symposium

Andreas Burzik -Practicing in the flow is a method that aims to lead musicians into a state of deep fusion with what they are doing when practicing an instrument. It enables the experience that conscious, deliberate control of the practicing process can be abandoned in favour of a process that unfolds from within and is guided by sensory perception. Basis of the Practicing in the flow is a highly refined perception in the key sensory channels, the sense of touch, hearing and kinaesthetic sense of movement.

The sense of touch, for example, is about the points at which a player has direct contact with their instrument. Optimal and effective power transmission to the instrument is expressed in the feeling of a "rich" connection to the body of sound. Listening is about developing a subtle sense of sound. Basically, the sound quality produced when practicing should please the player. This sounds like a banality. However, if you observe musicians practising, you will notice that their attention is often caught up in other aspects and that the beauty of the sound does not constantly play an important role. (For intonating instruments, it is then a matter of sensitizing oneself to an intonation organized by the overtones, which leads to a fusion of sounds and an extremely satisfying "passing on" of the sound from note to note).

In the case of intonating instruments, a sensitization to intonation organized by the overtones is then important. This leads to a fusion of sounds and an extremely satisfying "passing on" of the sound from tone to tone.

The kinaesthetic feeling of movement is about the quality of effortlessness. What is meant here is not complete relaxation or limpness, but a physical feeling of not straining, light, flowing action, a feeling of swinging. Surprisingly, many instrumental methods lack a consistent and subtle involvement of the whole body in one's own playing. Many musicians play their instrument using only their arms, a form of movement that never occurs in everyday life. It leads to muscular tension and is probably the cause of numerous musical illnesses. Needless to say, a "paralyzed" body also costs sound. Musicians who resonate produce significantly more overtones and a wonderful, "full-bodied" and sustainable sound.

Once these "guiding feelings" have been established in the decisive sensory channels at the beginning of a practice sequence, the student can begin to work on the current literature. The first steps in approaching a piece then consist of inviting the sounds of this piece into your "comfort zone", so to speak; they consist of a playful and consistently musically designed exploration and cultivation of the sounds of the piece and the sensations experienced, without paying attention to note values, ties, phrasing, tempi, dynamics or interpretations.

With growing confidence in listening to and feeling the piece, a clearly perceptible will to approach the desired concert version emerges, to try out the ties, tempi, dynamics and different interpretative versions. The personal comfort zone begins to expand, it starts to pulsate. The result is a flowing back and forth between risky excursions and a retreat and playful "recreation" of processes in which disturbances in contact with the instrument or the sound were perceived. In this way, the comfort zone expands pulsatingly until, in the best case, it encompasses the desired concert version.

Practicing in the flow does not feel like "practicing". It is rather a highly concentrated and highly committed performance of the piece, which is based on an extremely short feedback loop between sensory perception and creative action and requires no mental interference. Trustingly and patiently surrendering to this process, which is controlled from within, is one of the mental challenges of Practicing in the flow.

Andreas Burzik

... is a qualified psychologist and trained violinist. In addition to his international teaching and seminar activities, he works as a psychotherapist and coach in his own practice. 2007-2016 Mental coach of the Orchestra Academy of the Bavarian Radio Symphony Orchestra, Munich.

More information at

> www.flowskills.com