For a long time, it was believed that musical skills are rarely acquired and used to advantage in old age if they were not acquired in childhood or at least as a young adult. However, as the Zurich neuropsychologist Lutz Jäncke will show at the 12th Symposium of the Swiss Society for Music Medicine (SMM), work on the special expertise of professional musicians has led to the realization that the human brain is much more plastic than previously assumed, even into old age. According to Jäncke, the plasticity of the brain also means that the non-use of mental functions can lead to neuroanatomical and neurophysiological degradation. Against this background, a new and different picture of ageing is emerging, which is much more strongly influenced by self-initiated and self-controlled cognitive functions than previously assumed.

Music journalist Corinne Holtz, who heads the CAS "Musical Learning in Old Age" at Bern University of the Arts, will report that older people at music schools represent a growing target group with diverse potential. Singing in a choir is an obvious choice. Karl Scheuber, choirmaster and former head of the ZhdK study area, will also show how a colorful repertoire of songs, movements and sounds can be built up and expanded with conscious seriousness, mutual empathy, breathing techniques and the joy of the versatile treasure of our vocal memory, which is appropriate for old age. Even a significant loss of natural hearing ability need not be an obstacle. Zurich master acoustician Michael Stückelberger will explain how hearing aids can be adapted with the help of competent acousticians so that they are also suitable for the enjoyment of music and not just for speech comprehension.

Hans Hermann Wickel from the Department of Social Work at the German University of Applied Sciences in Münster will present music geragogy, the discipline of musical learning and musical education in old age. It aims to enable people of all ages to participate actively and receptively in music. The spectrum ranges from instrumental and vocal lessons to making music in choirs or senior ensembles, as well as participation in intergenerational groups and music programs for the very old, or even multimorbid and dementia patients.

Singing is also the focus of the presentation by Eberhard Seifert, Head of Phoniatrics at the University ENT Clinic of the Inselspital in Bern. He explains the physiological basis of sound production and how it changes over the course of a person's life and how this can be dealt with with regard to the ageing process.

Maria Schuppert, who works as a professor at the Center for Musicians' Health at the Detmold University of Music, explains that excellent musical performance on instruments can be maintained into old age, provided there are no limiting underlying illnesses, and Hans Martin Ulbrich, former oboist of the Tonhalle Orchestra Zurich, points out that former professional musicians need to be able to let go. This - and the former professional will not conceal this - can be difficult if, among other things, poverty prevails in old age and there is no money to live carefree, or if an illness forces you to give up your career prematurely.

I often advise patients who come to my practice to integrate music into their lives as a resource against exhaustion syndrome. The situation is different when musicians come to me complaining of exhaustion. In this case, it is the social and personal conditions surrounding music that give rise to burnout symptoms. Music then becomes a source of worry and stress and loses the positive meaning that may have led to this particular career choice.

But what actually is burnout? According to Matthias Burisch (Matthias Burisch: Das Burnout-Syndrom. Springer. 2005, 3rd edition), seven phases are decisive, with clinical and pathological relevance arising from the fourth phase onwards:

First phase of the first warning signs (you work overtime or at weekends to cope with the workload)

Second phase of reduced commitment (you become more silent, develop a negative attitude towards work)

Third phase of emotional reactions (feelings of inferiority and pessimism develop)

Fourth phase of decline in cognitive abilities (concentration/memory disorders, increase in errors and reduced motivation)

Fifth phase of flattening of emotional and social life (for example, loss of previously loved leisure activities)

Sixth phase of psychosomatic reactions (muscular tension, sleep disorders, increased alcohol consumption)

Seventh phase of depression and despair (feeling of futility and fear of the future)

It should be noted that chronic fatigue syndrome can always have a physical cause. On a psychological level, too, a distinction must be made, mainly from depression, but also from chronic fatigue syndrome, generalized anxiety disorder, eating disorder or substance abuse (alcohol or tranquillizers). We call this differential diagnosis.

If there are no findings here, work can begin on the musician's professional environment and personality: The specific nature of the professional environment can promote the problem of burnout. In the case of orchestral musicians, for example, this could be overly busy schedules and communication problems with superiors, while in the case of music teachers it could be the more difficult children and group lessons, to name just two things for the sake of brevity. In both groups, bullying between colleagues and between hierarchies plays a major role. Solutions in this area lie in the structure of the workplace and the colleagues, which must be looked at separately in each case.

But musicians can also work on themselves and learn various strategies to prevent burnout. Psychology distinguishes between different personality types. For example, it has been shown that "a strong identification with the practice of music in combination with great ambition and a lack of ability to distance oneself leads to risk pattern A in a third of music students, which is characterized by excessive stress and susceptibility to performance" (Claudia Spahn et al.: MusikerMedizin: Diagnostik, Therapie und Prävention von musikerspezifischen Erkrankungen. Schattauer, 2011).

This provides clues as to what the musician can improve: He must take the warning signs of the phases mentioned seriously and quickly find cognitive and emotional solutions. In addition to mental training, such as learning to keep your distance, various well-known relaxation techniques can help on an emotional level. I have had very good experience in my practice with the technique of self-hypnosis, in which relaxation also occurs, albeit as a positive by-product. Much more important are the therapeutic suggestions that become effective in this process and that can be adopted as a coping strategy in everyday life.

The scientifically based examination of the musician's hand helps to optimize the interface between hand and instrument. This can be important in the prevention of playing-related health complaints and in questions of performance optimization with regard to movement sequences on the instrument. To this end, Christoph Wagner developed a method for the systematic examination of the musician's hand at the Max Planck Institute for Occupational Physiology in 1964: the Biomechanical Hand Measurement (BHM). The BHM was then used in research and teaching at the Institute of Music Physiology at HMTM Hannover and was transferred to the Department of Music Physiology/Music and Preventive Medicine at ZHdK in 2009, together with all the equipment and databases. The newly founded ZZM is part of the ZHdK's research focus on musical interpretation.

The BHM comprises up to 100 instrument-specific hand characteristics. It records the musician's hand according to playing-relevant categories such as hand shape and size, active mobility, passive mobility and strength. Passive mobility as an indicator of the ease of playing movements can only be recorded in a differentiated manner using the laboratory's specialized measuring instruments. The digital evaluation of the measurements leads to their graphical representation, the hand profile. This shows the individual values of the hand in comparison to the data of professional musicians in the corresponding instrument group, i.e. the relative advantages or limitations of the individual hand. From this, practical consequences for practicing, training, playing technique and choice of literature, ergonomic solutions and so on can be derived. The unique instruments and the comparative possibilities with instrument-specific data from more than 50 years make the BHM a unique scientific procedure to this day.

... to the practice

The interdisciplinary musician's consultation hour, which is accessible at the music academies, records a particular accumulation of pain and tension in the area of the upper extremities during the several hundred consultation hours per year. In this initially laboratory-independent context, a form of examination derived from the BHM is also suitable for use in music education: The Pragmatic Hand Evaluation according to Christoph Wagner (PHE). This provides an overview of 25 individual hand characteristics. The hand laboratory can then be used for more detailed clarifications.

At the music academies in Zurich, Basel and Stuttgart as well as at the Vorarlberg State Conservatory, the objective assessment of hand characteristics is regularly referred to in seminars and further training courses in music education. The individual requirements of the upper extremities are also increasingly being taken into account in music medicine consultations. Ongoing basic research complements the activity profile of the ZZM. This also contributes to the training of musicians at all levels, as has long been a matter of course in sport in the context of performance diagnostics and prevention.

Professional singers often only seek help when concerts have to be canceled or recording dates postponed and the existential pressure increases. However, pressure further detunes the body instrument that most directly influences the sound of singers. Above all, the control circuit of breathing - posture - laryngeal suspension becomes confused, incorrect and compensatory tensions are the rule, which can lead to vicious circles.

The voice of 24-year-old B., a student at a jazz school, repeatedly breaks away uncontrollably in the upper range, and the pitch is associated with great effort. The specialist diagnosis: hyperfunctional dysphonia, incipient nodule formation. B. has a clear idea of sound, she wants to have a soulful, full chest voice even in the high register. She tries to achieve this by pulling up the chest register and provides too little support. First, a vocal relief program is put together so that the voice can vibrate freely with little pressure. Then we work "classically" on developing the head register sound and B. discovers that this can also be very full and direct, but with less pressure. Now it's all about mixing the different timbres in the high register, as well as improving the support technique, a singing program and vocal hygiene measures. In the second half of the therapy, the exchange with B.'s singing teacher is lively and fruitful.

In the case of 51-year-old freelance opera singer M., many factors come together: Back problems after an accident, pre-existing asthma, major weight loss in a short space of time and the onset of hormonal changes. The voice suddenly breaks completely or detonates in the middle and higher registers, the vibrato sounds flabby, sustained notes are not possible, nor is legato or piano singing. Is the voice part adequate? The speaking voice is hardly affected. Some engagements are unsatisfactory, the pressure is great. Specialist diagnosis: functional dyspho-nia/dysodia. The therapy is as varied as the causes in M.'s case. In addition to consistent fitness training to rebuild postural muscles and physical therapy work, M. works with a singing teacher and with me. Initially, the aim is to find out why her voice is breaking. In some cases, the support and voice position have to be significantly adapted to the new physical conditions.

Once the basics are working reasonably reliably again, the decision about the focus of each lesson lies more and more with M. Is it about pelvic floor involvement, edge shifting, vocal approach in the high register, vowel equalization, specific examples from the upcoming literature? We listen to tapes of engagements and exchange ideas with the vocal coach and the specialist. In the beginning we see each other frequently, but over time the intervals between the sessions become longer and are more like supervision sessions.

With professional singers - as with amateurs at a different level - it is always about the same basis: adjusting the instrument. This means the interaction of the state of tension and the cooperation of the transverse structures pelvic floor - diaphragm - vocal folds - base of tongue - soft palate, i.e. the erection and the "inner posture". In addition, there is work on the "outer posture", the torso and breathing muscles as well as the head posture, which determines the suspension of the larynx. In addition, economizing the pressure balance at the vocal cord level and optimizing the sound space (the "embouchure tube") and articulation. Strengthening self-awareness and (re)building confidence in one's own competence in dealing with the voice are central towards the end of the joint journey.

For years, the promotion of gifted and talented children, integration and inclusion have been part of the mission of music schools throughout Europe. In Germany, the projects "Jedem Kind ein Instrument" ("An instrument for every child") and "Klingende Kindertagesstätte" ("Musical day-care centers for children") marked the beginning of music-making for children of all ages and in large groups. In Switzerland, basic musical training, classroom music-making and projects with a wide variety of focuses have been expanded.

Publications and modules in training and further education have developed basic principles for structuring lessons that allow every child to experience and learn music. In order to create equal opportunities for all children in group music lessons, accompanying measures have been defined in addition to the actual music didactics. These make it possible to design integrative music lessons in a variety of ways and in accordance with new pedagogical findings. Based on the didactics of music and movement, theories on the promotion of perception and various learning theories, the following structuring theories can be helpful.

Integrative music lessons are designed to be diverse - different types of learners are also important in music lessons. Rhythmization, which designs the lessons in a variety of ways at different levels, makes it possible for everyone to participate in the lessons according to their abilities.

Integrative teaching is designed to be perceptible and tangible - playing an instrument requires the whole body to be aware of the surface of the body as well as internal organs, especially respiratory functions. Differentiation of movement, including balance structures, is also required. For music lessons, it has proven useful to differentiate between near and far senses. Near senses are all senses that are directly related to the perception of the body and its differentiated use. The ear and eye are distant senses. Musical experiences, for example in the form of body percussion sequences, become tangible and perceptible.

Integrative music lessons are designed with movement - musical creation is also movement and requires coordination and dexterity. Clearly designed pulse and rhythm movements alternating with making music on the instrument support learning and concentration. Movement and sitting on the chair are designed in a lively alternation. With this focus, the physiologically relevant use of chairs for music should also be considered.

Integrative music lessons are designed to be audible and visible - visual and auditory structures in the classroom create orientation and deeper opportunities for concentration. This creates an aesthetic of lesson design that conveys redundancy with the dynamics of artistic processes in general. The quality of the auditory structure means music lessons in which phases of joint music-making and experimentation alternate with sequences of silence. A clear visual focus takes into account aspects of the design of musical material, the arrangement of the teaching setting in the room as well as the specific type of instruction and conducting.

The score of integrative music lessons has different voices - children learn in different rhythms. For the composition of the music lesson, this is a phenomenon that can be used artistically. Just as each piece of music is created with different voices, the lessons are also structured in a differentiated way. In arrangements made especially for the group, there are basic elements that are played by everyone, more differentiated parts and even solos, as well as parts for simple grooves and individual accents.

Literature

Long version of the article:

By far the most common and also the most serious movement disorder in musicians is musician's dystonia. In its full form, it is characterized by the loss of fine motor control of complex movements on the instrument. Pain is not a primary symptom of dystonia. However, it can occur as a result of excessive muscle tension. The most common symptoms of advanced hand dystonia are involuntary curling or stretching of individual fingers and/or abnormal wrist postures. Occasionally, short-lasting muscle contractions (myoclonic dystonia) or involuntary trembling (dystonic tremor) can also dominate the symptoms.

Those affected often report a strong feeling of tension in the forearm while playing music. This is due to the simultaneous activation (cocontraction) of antagonistic flexor and extensor muscles. Patients only report a feeling of weakness in less than 5 percent of cases. It is difficult to diagnose hand dystonia in the early stages of the disease, and it remains particularly difficult to differentiate it from overuse injuries. In this case, patients often only report subtle difficulties with fast, regular movements on the instrument. There is obviously a "gray area" between this and disorders that should rather be described as "over-exercising" or "muscular fatigue". It is important to distinguish such very common movement problems from incipient dystonia, as the former responds very well to retraining, and anti-inflammatory and muscle relaxant drugs are also effective. Overall, the chances of recovery seem much better with this form of movement difficulties, which is why we do not refer to it as "incipient focal dystonia", but prefer the diagnosis "dynamic stereotype". This term comes from sports science and stands for incorrectly practiced movement habits which, in contrast to focal dystonia, can be corrected more easily and enable a correct movement sequence by consciously directing attention.

A particularly interesting area is embouchure dystonia in wind players. In the early stages, it often manifests itself in subtle inadequacies of intonation, predominantly in a particular register or playing style or in a clearly defined dynamic range. In advanced stages, the problem usually extends to the entire range of the instrument and to all dynamic ranges; control over embouchure, articulation and breathing is then no longer guaranteed in any playing style. However, the diagnostic spectrum for embouchure dystonia is also much broader. In a new study by Dr. Steinmetz and ourselves, 1817 questionnaires on embouchure difficulties were distributed to all brass players in German orchestras. The response rate was 32 percent. Of the 585 brass players, 60 percent reported embouchure problems at the time of the study, with around 30 percent reporting tongue stoppers and difficulties in the high register and 26 percent cramping of the embouchure muscles. Surprisingly for us, 10 percent reported that they had already had such difficulties with their embouchure during their orchestral work that they were unable to work. It was also interesting to note that 40 percent of those who had embouchure problems had already successfully overcome an embouchure crisis in the past. It would certainly be medically unjustified and psychologically very clumsy to classify this high percentage of wind players as "affected by dystonia", especially as, fortunately, many of them successfully overcome these crises. We are therefore in the process of drawing up new classification guidelines. The trigger factors (overload or not), the severity and manifestation of the symptoms, the presence of "islands of well-being", the family history (are there relatives with neurological movement disorders) and the presence of psychological symptoms (anxiety problems or not) all play a role. The prognosis for recovery through retraining is good for musicians who develop movement problems after overuse, who have mild symptoms, who are able to make music repeatedly without major complaints, who have no relatives with dystonia and who tend to suffer from stage fright.

Children and young people face particular physical and psychological challenges. On the one hand, their bodies change considerably while they are learning to play an instrument, to which they have to react with constant ergonomic adjustments. On the other hand, they find themselves in complex areas of tension between their own, as yet unresolved life plans and the expectations of parents, schools and friends. On October 26 in Zurich, renowned experts discussed these issues - expertly and knowledgeably moderated by Ticino doctor Adrian Sury.

Elisabeth Danuser, Head of Continuing Education at the ZHdK, pointed out another challenge in the first presentation of the day at the symposium led by SMM founder Pia Bucher: "School classes and music-making classes are becoming increasingly heterogeneous in terms of attention and previous training. It is therefore important to develop individual strategies for teaching and practicing music. ZHdK music physiologist Horst Hildebrandt then offered an overview of the initiatives and institutionalization of health care at music schools and colleges in German-speaking countries. With the Lahr Music Physiological Counseling Center, which he founded in 1993, he was a pioneer in Germany in providing services for music schools. Whereas musicians with such problems previously had to turn to doctors who were unable to recognize their professional or activity-specific problems as such, today they are supported by specially trained experts in their training and everyday working life, now also at the conservatoires themselves.

Christine Bouvard Marty, President of the Swiss Association of Music Schools (VMS), formulated rules for inclusive music lessons. In view of the increasingly complex tasks, this faces special challenges. In addition to the variety of teaching methods, the speaker emphasized the multiple sensory aspects: Making music with children and young people must involve all the senses and, above all, the adolescents' desire to move, so that they can constantly harmonize their musical practice and body image anew.

In workshops, music physiologist Oliver Margulies, who works in Zurich, and Frankfurt-based physiotherapist Alexandra Türk discussed the anatomical and physiological characteristics of young musicians. Margulies presented the diagnostic possibilities for musicians' hands, which were developed in Hanover in pioneering work by Christoph Wagner. His Hannover Hand Competence Center has since been taken over by the ZHdK. Alexandra Türk used the example of an adolescent graduate of the Zurich Conservatory to illustrate the effects of physical changes on instrumental playing. Girls in particular, who are growing rapidly at a certain stage, have to pay attention to phenomena such as a "hunched back" and a recalibration of their sense of balance.

Lucerne rheumatologist Urs Schlumpf pointed out that instrument-specific complaints tend to increase in children and young people. However, the increased demands in an increasingly competitive society can be met with child-friendly instrument variations, consistent warm-up programs and clever division of overtime and playing time. Finally, Zurich child and adolescent psychiatrist Dominique Simon put some of the increasingly inflationary psychological and social disorder diagnoses of children into perspective and pleaded for a more relaxed approach to so-called "difficult" music students.

Depending on the study, between 40 and 75 percent of professional musicians struggle with pain in muscles, tendons and nerves, the so-called RSI syndrome (repetitive strain injury). However, there are very few detailed findings in the specialist literature on the epidemiological, biomechanical and ergonomic aspects of such ailments. The rare studies are hardly comparable or generalizable in terms of study design, methodology or the size of the groups studied. Recommendations are usually limited to references to stretching exercises and breaks.

In order to gain differentiated insights into the syndrome, teams from the Royal Conservatory in Brussels, the Accademia Vivaldi in Ticino, the Free University of Brussels and the Thim van der Laan University of Applied Sciences for Physiotherapy in Landquart, among others, have collaborated on the MoReMu (MOtor learning and REpetitive strain injuries in Musicians) project. The aim of the project is to investigate the influence of local muscular fatigue and performance stress on muscle coordination.

Among other things, ultrasound examinations, complex audiovisual observations, but also surveys on everyday life, general health, eating habits and ergonomic conditions have been carried out. Students in Brussels and Ladquarter, for example, have drawn up questionnaires as part of their Bachelor's and Master's theses, which are intended to provide meaningful information about the corresponding stresses and strains in musicians' everyday lives. The SMM recruited doctor Adrian Sury and two physiotherapists from Ticino from among its members, who took part in the study free of charge.

For the first time, spatial data on the biomechanics of instrumental playing has also been collected for MoReMu using sophisticated technical methods - combined with so-called electromyographic methods. This involves using needle electrodes to measure potential fluctuations in individual muscle activities. The role of different playing techniques, such as vibrato, spiccato or legato in the case of strings, can also be delineated in this way. The Swiss contributions to the study also include investigations into the ergonomic effects of different shoulder rests for violinists.

The interdisciplinary cooperation between different institutes and disciplines could be groundbreaking and help to develop complex, holistic strategies to prevent RSI and other health problems. The various partners in the project are concentrating on individual aspects such as exercise strategies and ergonomic considerations, but also the importance of sporting activity and nutrition in strengthening RSI-preventing music-making.

Initial methodological discussions have shown that various factors are important for the success of the studies. For example, the measurement methods must be able to register subtle variations in technical execution on the instrument. Moreover, the three-dimensional measurement of movements on the instrument has shown that it is not easy to determine which micro-movements can be assigned to which notes played. The researchers are therefore also experimenting with software instruments that have been developed for speech recognition.

The first results of a pilot study were presented at the 6th International Conference on Sport, Leisure and Ergonomics in Liverpool in 2007 and at the 3rd World Congress of Musicians' Medicine in Milan in 2008. In Switzerland, the first measurements were carried out in November 2009 and April 2010 with pupils from the Accademia Vivaldi Muralto and students from the Conservatorio di Musica di Lugano - with the approval of the Ticino Ethics Committee.

However, it has not yet been possible to achieve robust, definitive results from this pioneering project. Problems with funding, which is not secured for the continuation of the project, are currently having an inhibiting effect.

Like adults, children also have limits that they cannot simply cross. For some, it is a lack of fine motor skills; for others, a crisis at school puts limits on their musical enthusiasm; still others come from a non-musical family and have to assert their will to practise at home. How can professionals deal with the different children and their needs?

It is useful to structure and rhythmize (!) the lessons with a varied but predictable sequence. Lesson topics such as colors, seasons, certain composers or musical styles can be used to integrate the child's interests. It makes sense to keep the lessons simple but varied and to appeal to the children's different senses.

The basis for successful and enjoyable teaching is a good relationship with the child. This includes knowing their preferences, family and sibling structure, strengths and weaknesses, at least to some extent. The basis for this is a binding contact with the parental home. Young children in particular are often still somewhat unsure of how to move between the poles of "home - instrument - music teacher". The teacher's relationship with the parents should not be limited to giving practice tips. Parents can tell from the child's mood whether the teacher values the child and whether they, the parents, are welcome as partners in the music education process.

The "fidgety" child with ADHD (Attention Deficit Hyperactivity Disorder) often shows daytime fluctuations with increased distractibility towards the evening. They benefit best from lessons in the early afternoon. Some, but by no means all, children with ADHD are also rather clumsy when it comes to fine motor skills. They are very aware of whether the teacher has confidence in them. The stressed child may have worries that they would like to discuss. If a relationship is sustainable, it should be possible to motivate the child to seek solutions with parents or other adult caregivers, or even to seek professional help. The temptation to be the child's only confidant or even to take on the role of a therapist must be resisted.

Music teachers are challenged in many ways every day. However, regular communication with class teachers or parents - also by telephone - prevents conflicts and disappointed expectations on both sides.

Dr. med. Dominique Simon

Child and adolescent psychiatrist and systemic psychotherapist

Supervisor in her own practice in Zurich.

> dr.simon@hin.ch

> www.ausbildungsinstitut.ch

Georg von Arx - Watery or even watery eyes often only occur in special situations. During demanding visual activities such as reading, working on a PC or making music, even slightly watery eyes can lead to a considerable reduction in performance. Common causes of watery eyes are conjunctivitis, dry eyes, eyelid malpositions, drainage obstructions in the draining tear ducts and much more. These causes will not be discussed in detail here.

Functional disorders that do not appear to have an obvious cause are more important for musicians, as they are difficult to control. In the interplay of local and central control factors during visually demanding activity, a central reduction in the blink rate, i.e. controlled by the brain and nervous system, causes increased evaporation of the tear film and thus a relatively dry eye.

The more we concentrate on our visual task, the less frequently we blink. The tear film becomes unstable, breaks up and causes a "dryness irritation" of the cornea, which in turn triggers increased, sometimes excessive tear secretion via a reflex arc. This can be exacerbated in particular by insufficient lighting (for example in the orchestra pit), as we then reflexively "tear open" our eyes even more and blink even less frequently. Optimum lighting of the music stand (without glare!) is therefore also important in this respect.

Blinking is a rapid, usually involuntary and unnoticed closing and opening of the eyelids (eyelid closure reflex), which primarily serves to maintain the tear film and thus the optimal optical quality of the visual system. We normally blink about 12 to 15 times per minute, i.e. every 4 to 6 seconds, over an average period of 300 to 400 milliseconds. The dark phase caused by eyelid closure is not consciously perceived, as visual perception is suppressed in the relevant areas of the brain shortly before blinking.

Monotonous visual work, especially, as already mentioned, with inadequate lighting of the work area and work with high visual demands lead to staring at the work area with a decrease in blink frequency of more than 50 percent. Frequent but brief interruptions to work for a few minutes can improve the moistening of the cornea sufficiently so that there is no increased reflex tear secretion and therefore no watery eye.

Crying can be an expression of strong emotions such as pain, sadness, helplessness, fear, feelings of deep hurt and injustice. These emotionally induced tears do not play a role in professional musicians in that they have learned to control their emotions in the course of their work. The "tear center" is connected to various regions of the brain, such as the limbic system ("emotional center"), but also to the frontal brain. The functions of the frontal brain concern the reception and processing (control) of sensory information for perception, thinking, language, motor operations, activity, movement and action control, voluntary movements and actions, consciousness, higher intellectual processes and emotional-affective aspects of behavior.

Nevertheless, a particularly "touching" piece of music can touch the corresponding emotional "button" and make us cry, which can then cloud our clear view of the sheet of music. It is not uncommon for poorly corrected defective vision to cause watery or even watery eyes. This is because the eye then has to work much harder to see well. Visual aids that are individually and optimally adapted to professional needs can provide a remedy.

Dr. med. Georg von Arx

Ophthalmologist FMH

Admedico Eye Center

Fährweg, 4600 Olten

> info@admedico.ch

In particularly demanding pieces of music (such as some passages of Franz Liszt's 6th Paganini Etude), the intervals between the individual finger movements must not exceed 30 milliseconds. They must also be realized with the utmost precision. In comparison, the fastest intervals achieved by non-experienced musicians are rather modest (approx. 150 milliseconds). A number of studies have shown that more than 10,000 hours of training are required to achieve professional playing performance. Such intensive training leaves "traces" in the areas of the brain involved in expertise control. In particular, the areas of the brain involved in the motor areas sometimes show considerable anatomical and neurophysiological changes.

The neuroanatomical studies published to date on this topic have shown that in pianists, the primary motor areas that control the fingers have become particularly large in both hemispheres. These changes in size are reflected in a larger volume of neuronal tissue, but also in a larger cortical surface area in the hand motor cortex. In addition to these differences in volume, changes in the cable systems that connect the motor areas of the brain with the hands and legs can also be identified.

These anatomical peculiarities are likely to have developed in the course of motor learning. The earlier they started music training, the more pronounced the anatomical changes tend to be. There are also marked differences between musicians, depending on which instruments they play. In pianists, the two hand motor areas on the right and left hemispheres are particularly large and more strongly connected. In string players, on the other hand, who have to train the fingers of the left hand in particular, only the right-sided hand motor cortex has become anatomically conspicuous or larger. Special anatomical adaptations are also found in the corticospinal tract, which connects the hand motor cortex with the hands and arms.

In addition to these specific adaptations in the motor system, there are also neurophysiological peculiarities in the functional coupling between the motor and sensory areas - especially between the motor and auditory cortex. The neurophysiological activations in the motor areas of the brain in pianists are, as mentioned, particularly adapted to piano playing. This special adaptation can also be recognized by the optimization of neurophysiological excitation in the brain areas involved. In pianists, these are lower neurophysiological activations in the motor areas when playing the piano than in untrained people. Apparently, as a result of frequent practicing, the most suitable neuronal circuits have been established to enable the motor processes.

As a result of practising, highly trained pianists have established an automated error control system that allows them to unconsciously recognize and control motor errors while playing. However, error control does not affect the action that has just been performed incorrectly, but rather future actions.

It is remarkable that such neurophysiological and neuroanatomical adaptations not only occur in early childhood and adolescence, but also in adulthood and - what is particularly interesting - also in old age. In this respect, the acquisition of musical playing skills is not only reserved for young people, but is also possible in old age. It is possible that the human brain is plastic for a lifetime, so that music-making can be acquired well into old age.

Prof. Dr. rer. nat. Lutz Jäncke

University of Zurich/Psychol. Institute

Chair of Neuropsychology

> lutz.jaencke@uzh.ch

It is quite natural for a violinist, for example, to initially attribute pain while playing to the instrument. There are more than enough sources of error. Small deviations in posture, in the modulation of muscle tension or at the delicate contact point between body and instrument have far-reaching consequences.

In every musician's everyday life, however, there are other activities that put strain on the musculoskeletal system. Working at the computer or in the garden, sporting activities or housework - all of these activities can be performed more or less carefully and can also trigger pain in the musculoskeletal system. At this point, therefore, we would like to talk about a completely inconspicuous source of pain: the sleeping position.

During a consultation, a violinist reports pain in her neck that has been present for years and radiates into her right arm. The pain is normally only troublesome in phases with frequent long rehearsals, especially of course in connection with particularly demanding pieces. Clarifications and adjustments regarding posture and instrument position were made repeatedly. They also had a positive effect.

Over the course of the last year, there have been repeated phases in which the musician has felt electrifying twinges in her arm. This symptom has occurred more frequently in the last two weeks and is also the reason for the consultation. The main finding during the examination is a reduction in strength in the triceps muscle - as an expression of an impairment of the seventh cervical nerve root.

The patient's descriptions contain no obvious indications of an important role for sleeping position. Pain that is particularly severe early in the morning or nocturnal position-dependent pain could be such signs. Only the remark that the right arm used to fall asleep at night even more than it does today draws attention to sleep.

I always take a sleep history, especially in the case of long-term complaints that do not improve sustainably despite adequate treatment. I also often ask people to show me the sleeping positions they have adopted. This is of course a very uncertain area, as we move around a lot more at night than we think. Who can say what position they sleep in during the deep sleep phases?

Our violinist has a habit of holding her right arm up when sleeping on her right side and also overstretching her head. This can have a negative effect on the space for the nerve roots as they exit the spinal canal. Because she only uses a very flat pillow, her head is also overstretched when lying on her back. This also has an unfavorable effect on the already limited space between the nerve roots and vertebrae.

Preventing or changing a sleeping position is not easy. As we can only exercise conscious control during waking phases, other tricks are needed. I usually recommend attaching a disturbing object to the pyjamas on the side to be avoided. A spray can lid that is placed in a sock and then pinned in place with a safety pin fulfills this function well. In this way, the affected person immediately turns away from the problem position and not only when a painful irritation of the nerves forces a change of position.

In our patient, this way of controlling her sleeping position and the use of a slightly higher millet pillow had a very direct effect on her progress. Within three weeks, there was a steady improvement. The decisive factor is obviously that by avoiding the nocturnal nerve irritation, physiotherapy can now bring about not only short-term but also lasting changes.

Dr. med. Christoph Reich-Rutz, Zurich

Specialist in rheumatology and manual medicine

> www.christophreich.ch

Wind players are highly trained musicians. They produce the finest art on their instrument with maximum physical effort. In doing so, they exemplify the unity of body and soul on a daily basis. When we talk about pressure, flow and coordination in the following, we should not forget that most problems in the pneumology consultation for musicians concern breathing and not simply the lungs. The physical parameters are important, but they do not fully describe breathing. Even more than in sport, music requires the use of the soul. It often has a disruptive effect after accidents, in cases of excessive demands, anxiety, exhaustion or overuse. This is why medical practitioners work closely with professions that focus on the emotional or mental function of breathing.

Every healthy person is capable of blowing. They can blow out a candle or blow up a dandelion. You create pressure through the exhalation muscles (chest) while stabilizing the inhalation muscles (diaphragm) and control the pressure and flow in the throat/larynx. Singers already form the notes (vibrations) here, trumpeters a little later with the lips and woodwind players in the reed or pipe. So it would be quite simple. However, the art form demands virtuosity and therefore top performance.

Frequent inquiries confirm that knowledge of technical data is useful. The average pressure is described in millimeters of mercury (mmHg) and is about 5 mmHg when whistling, 10 mmHg when speaking, 20 mmHg when blowing out a candle (at 50 cm) and 60 mmHg when blowing up a balloon. The flute requires a minimum blowing pressure of 0.5 mmHg (average pressure 1-6 mmHg), while the oboe requires 28 mmHg (average pressure 30-48 mmHg). The oboe requires a maximum flow rate of around 150 ml/s (milliliters per second), whereas the flute requires 612 ml/s. The tuba, on the other hand, demands 1700 ml/s from the musician. The maximum blowing pressure for the C trumpet is 120-130 mmHg and for the piccolo trumpet even 170-180 mmHg. The blowing pressure increases depending on the volume and frequency of the notes produced.

Can small children play the trumpet? Yes! Because at 7 mmHg (minimum blowing pressure) a sound is already produced and on average 13-42 mmHg is enough to make simple but beautiful music. So nobody will forbid the child to blow out the candle (60 mmHg). But if you want to play symphonies by Mahler and Strauss or a Brandenburg Concerto or be the lead trumpet player in a big band, you will have to achieve the above-mentioned peak pressures. As all music teachers know, it is not the instrument but the literature and playing technique that are decisive.

In the 1960s, many data (including the above pressure values) were measured in several studies. Lung measurements in wind players/singers vs. healthy controls showed an average of 1 liter more total volume and ½ liter more first-second volume in young musicians than in non-musicians. However, this advantage was lost in 45- to 54-year-old musicians. The reason? Cigarette consumption canceled out all training.

Not all breathing is the same. Every yogi or meditator knows and lives this. You breathe differently when making music. Musicians breathe according to the music, according to phrases. They usually breathe out long and slowly and then quickly inhale the right amount of air for the next phrase at a suitable point. Think of the different flow rates of the instruments (see above). It becomes clear that a tuba player has to breathe differently to an oboist.

There are few illnesses or injuries to the respiratory organs that are caused by making music. As described at the beginning, breathing disorders often occur when body and soul are no longer in balance. By far the most common conditions we see in the consultation are lung diseases or injuries that interfere with music-making. It seems that the wind music teachers have done their job well.

Dr. med. Peter Jules Gerber, FCCP

Lung practice Bern West

Holenackerstrasse 85/B 04

3027 Berne

www.lungenpraxisbernwest.ch

Tel.: 031 992 55 56, Fax: 031 991 86 24

pj.gerber@hin.ch

In their daily work, musicians are exposed to sound levels that have a damaging effect on hearing above a certain dose. And so, unfortunately, even Mozart becomes noise for the ears at some point. Much is being done to protect them from hearing damage, and there are good, sound-neutral hearing protectors, both off-the-shelf and customized. The problem, however, is that very quiet music comes out of nowhere, and in order to hear such passages and cues with 100% accuracy, even a small amount of hearing protection is too much for many people.

It's just a shame when the orchestra tutti produces volume levels of 90 or 100 dB in the next movement. What happens then is what the ear doctor calls the "c5 depression": a noise-induced hearing loss that manifests itself most strongly in the area of the five-letter c at around 4000 Hz. This is exactly where the consonants that are important for understanding speech are located. If the hearing is damaged there, the table becomes a fish and the river becomes a kiss, which can lead to embarrassing situations.

It is well known that those affected try to get by without hearing aids for years. They develop different strategies to cover up the hearing loss: one of them is to avoid difficult situations, such as the acoustically notorious cocktail party. If "normal people" find it so difficult to wear hearing aids, how much more difficult must it be for musicians to imagine performing in front of an audience with hearing aids? For many, almost unthinkable.

Modern hearing systems are very small and can be almost perfectly concealed, provided you have the right hairstyle. For those without the necessary hair, however, the devices are not so inconspicuous. They either sit behind the ears, with a small tube in the ear canal, or they sit directly in the ear. Unfortunately, you can often still see them there because the electronics are too big for the ear canal.

Recently, however, there are now truly 100% invisible hearing systems. These are placed four millimetres in front of the eardrum and remain there for up to four months, day and night. In contrast to conventional high-performance hearing systems, they are equipped with relatively little technology and functionality. They work with the so-called "Wide Dynamic Range Compression", according to which the amplification is constantly adapted to the acoustic environment.

You have to imagine that signals in a quiet environment are amplified disproportionately and that signals in a loud environment are attenuated by means of compression. For the hearing impaired, this has the dual advantage that quiet signals can be heard and that loud signals are not perceived as unpleasant. The maximum volume that the devices generate across the entire frequency range is 103 dB. This means that a brilliant "grand finale" with the devices will be somewhat less loud than in reality. This is because the deep and acoustically tight fit of the devices almost acts as hearing protection.

Not every musician or music lover will accept this limitation. For those who have no problem seeing their hearing systems, very powerful technologies are available that can process input levels of up to 106 dB. It is important that you seek professional advice and work with your hearing care professional to program the system based on your own music. This requires specialist knowledge and the appropriate infrastructure.

If you don't want your hearing aid to be visible, I can fully understand that. I wore conventional hearing aids myself for 15 years until I switched to these new, invisible ones. I understand everyone who wants a discreet solution.

Either way, if you can no longer hear the conductor's announcements or the pianissimo of your colleagues, you should do something as soon as possible.

> www.stueckelberger- hoerberatung.ch

N. has been working in the orchestra for six months with a 100% position. She is currently practising and rehearsing difficult orchestral pieces and complains of pain in her shoulders and neck. In the first lesson, I discuss with her the connection between situations, thoughts and physical sensations.

To get to the bottom of these connections, you need a fine, free, sensual attention. I give N. an observation sheet. In the next lesson she says: "When I was hurrying with the cello on my back, I felt hectic, breathless and tense in my back and neck. Becoming mindful while doing this had a pleasant and calming effect".

In the third lesson, N. is a little sad because she realizes "how I keep tensing up". I recommend that she reads the chapter about his own story in F. M. Alexander's book The Use of the Self. In it, he describes the development and methodology of his technique. After reading it, N. will be amused by the human stubbornness to insist on ingrained patterns.

I instruct her to lie down on the table. She relaxes as I guide her with my hands and words, which she finds very soothing. After about twenty minutes, she should sit up, be mindful during the movements and avoid unnecessary tension, especially in the neck muscles. In order to perceive inappropriate tension, it is advantageous to perform movements slowly at first. Over time, the quality of movement can also be assessed at a faster pace. N. rolls onto his side, pushes his legs over the edge of the table and sits up.

Her sitting on the table is now very upright and relaxed at the same time. She finds raising her arms light-hearted and playful. As I instruct her to play a short musical sequence "in the air" without a bow, she tenses her neck a little, collapses slightly on the right side of her chest and raises her right shoulder to compensate. Only when I ask her how her right side and neck respond to the raising of her arm does she realize it. She also notices that her arm is no longer quite as free as before. Using my hands and words, I work with her not to fixate on the goal of "making music" when raising her arm, but to strive for the goal and at the same time pay attention to the means of achieving it.

In the fourth lesson, I work with N. sitting down and on the instrument. She complains that she still does not have confident control of the bow arm and that her sound is impaired as a result.

A favorable approach to the organism as a whole means a good balance of tension and relaxation and working with the appropriate amount of energy for the situation. Making music requires muscle tension in the right place, at the right time, for the right duration and in the right dosage. N's pelvis is tilted backwards on the chair. I don't work with her directly on the bow arm, but my aim is to bring her head, neck, torso and legs into better balance.

When she is looking for "good posture", she soon feels a familiar pain in her lower back. I let her experience how she can balance on the sitting bones as if on runners. For this to be possible, she needs freedom in her hip joints. I ask N about their exact location. In her imagination, the hip joints are much higher than in reality. She looks at my little plastic skeleton and is amazed at how flexible her pelvis is and how her feet make better contact with the ground when she adapts her body image to reality.

This straightening of the pelvis results in a higher tone in the lower abdomen, while the shoulders and neck muscles relax at the same time. N's right arm now feels flexible, relieved and alive in my hands. "It's like my body is thawing out," she says.

In the fifth lesson, N is pleased that she has repeatedly succeeded in using and integrating the experiences gained in our lessons. She feels more energy and joy and occasionally a new sense of oneness with the instrument. After a work-related break, we will deepen our work in two months' time. In addition to handling the instrument, we will then work on various everyday movements as well as with the breath and the eyes.

> www.sylvia-baumann.ch