SMM - It is still not a matter of course for orchestras to be open about the less idyllic aspects of their social and psychological inner lives. They are all too happy to present a beautiful picture of making music together in harmony to the outside world. Health and social irritations are usually taboo.

Hans-Peter Achberger lifts this curtain with a work on patterns of dispute and conflict in art collectives that can be traced back to the creative processes. Achberger is a percussionist and member of the Philharmonia Zurich, the orchestra of the Zurich Opera House. The book he is presenting is a slightly revised version of a master's thesis. He originally wrote it as part of a course in mediation and conflict management at the European University Viadrina in Frankfurt (Oder).

Based on numerous interviews with his fellow Phiharmonia musicians, he develops an interesting model of patterns of disruption in creative and psychological interactions within the collective. The areas of friction are based on an excessive focus on certain aspects and are divided into four main groups: Firstly, fixations on outside influences play a role. These can be administrative processes, the audience, the acoustic conditions of a room or the size of the ensemble. The second area that Achberger sheds light on is the orchestra members' focus on themselves. This includes, for example, the fear of losing one's image, especially when one has to realize that the quality of one's own playing depends not least on the playing of others.

The third circle in the model is formed by excessive attention to interactions, i.e. to the "we". This includes, for example, arguments about questions of intonation or the choice of instruments and decisions about sound and interpretation. Finally, the fourth highlights the excessive focus on the other person, on the you. These include expectations of the artistic quality of the other person or possible competitive constellations, for example when it comes to questions of succession for the position of section leader.

The verdict is clear: "The classical orchestral music profession," the author concludes, "generates a dazzling array of social disorders typical of the profession, which can make living and working together in the orchestral community more difficult and cause personal suffering." (page 132)

Achberger also wonders how all these conflicts, which are often subcutaneous or pushed to one side, could be better dealt with or resolved. The recipe is basically obvious, even if it is more difficult to follow than expected. According to the author, what is needed is "a culture of exchange, of talking together about all those disruptive processes" (page 131). This requires institutionalized spaces in which "the meaningfulness of conflicts can be discussed and personal disturbances can be communicated" (ibid.). Due to their size, however, symphony orchestras are no longer in a position to act appropriately and purposefully without competent mediation.

Literature reference:

Hans-Peter Achberger: The ear-to-ear conflict. Disturbance patterns in musical interaction. Volume 19 of the Viadrina series on mediation and conflict management. Wolfgang Metzner Verlag, Frankfurt am Main, 2020.

SMM - At this year's symposium, we are delighted to welcome Geneva-based music psychology pioneer Klaus Scherer and Salzburg-based pain specialist Günther Bernatzky as keynote speakers. He is a member of the presidium of the ÖGfMM (Austrian Society for Music and Medicine). The society is younger than the SMM, having been founded in 2009. In our eastern neighbor, however, the subject of musician's medicine has been embedded in rich interdisciplinary activities since the 1970s. These were initiated by Herbert von Karajan in 1969. The conductor came from a family of doctors in Salzburg and initiated work on music psychology, music physiology and music therapy at an early stage.

Interdisciplinarity has characterized Austrian research into the effects and consequences of music ever since. In 1973, the physicist Juan G. Roederer began organizing seminars on the interaction between the brain and music in Ossiach in the province of Carinthia, and in 2001 the Research Network Man and Music was founded at the Mozarteum University in Salzburg. The "Mozart & Science" conference series launched by the International Music and Art Research Association Austria (I.M.A.R.A.A) in 2006, which brought together music psychology, neuromusicology, music therapy, music medicine and numerous other disciplines, also contributed greatly to the dialog between the specialist fields. In 2004, music psychologist Richard Parncutt also founded the "Conference on Interdisciplinary Musicology" (CIM) conference series in Graz, which has since gained worldwide recognition.

The ÖGfMM also looks beyond the boundaries of individual disciplines. It explicitly promotes the "interdisciplinary cooperation of those involved in the training and professional support of musicians, such as instrumental and vocal teachers, occupational scientists, natural scientists, instrument manufacturers, doctors, dentists, physiotherapists and related areas of the higher medical-technical specialist service, sports and musicologists, music psychologists, Alexander teachers, Feldenkrais teachers, music therapists, occupational therapists and mediators of other similar forms of therapy".

Günther Benatzky's research and teaching is also highly interdisciplinary. He is a specialist in pain physiology and therapy for various diseases (migraine, renal colic, back pain, tumor pain and others), has studied the effect of music and singing on various diseases (pain, Parkinson's, dementia, depression, old age), as well as its effect on animals. He has also helped to develop user-friendly music playback devices for the elderly and teaches musician's medicine at the Mozarteum Salzburg. We are delighted to welcome him to Switzerland.

Body-oriented work in music

The motto of the 18th SMM symposium is "One goal - many paths", body-oriented approaches in music. The keynotes by Günther Bernatzky and Klaus Scherer will provide insights into bodywork and its various methods. The range of body therapies in music is almost unmanageable. It can therefore be difficult to find out which method might be the most suitable for those seeking help. The symposium offers the unique opportunity to get to know numerous forms of bodywork in everyday musical life in the form of short lectures and presentations as well as in personal discussions at a table fair. More information can be found in this music magazine on page 39 of the SMPV.

The 18th SMM Symposium will take place on October 23 at the Stapferhaus Lenzburg. Details and a registration form can be found at:

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

SMM - When a person is said to have to "swallow empty", this indicates that they are tense and possibly overwhelmed in a situation. In German, this phenomenon is metaphorically described as "Kloss im Hals" (a lump in the throat). Musicians are all too familiar with situations like this when they find themselves on stage and are confronted with expectations of a perfect performance. The physiological side effects of stage fright are more than noticeable. Even well-prepared professionals can notice in such anxiety-inducing moments how their motor skills and cognitive perceptiveness are impaired without being able to influence them. It is therefore surprising that science is not yet able to explain the interplay between physiological states and cognitive attitudes.

Based on interviews with 258 pianists, neuropsychology researchers Shinichi Furuya, Reiko Ishimaru and Noriko Nagata from Japan's Kwansei Gakuin Institute have identified eight behavioral, psychological and physiological factors that contribute to the phenomenon. These include attention distracted by the presence of the audience, an inability to recall motor sequences as a matter of course, perceptual disorders (such as tunnel vision), neuroticism and memory failure.

According to the team, two hypotheses to explain the phenomenon are commonly discussed. One - let's call it the distraction hypothesis - explains the impaired performance by the fact that under stress, attention is diverted from the actual task to irrelevant events. The second - the hypothesis of conscious monitoring - assumes that performance is impaired because well-practiced processes no longer run automatically as they do in relaxed situations, but are subjected to explicit control again, laden with anxiety. The urgent feeling of not failing in such a situation leads to the conscious control of movement sequences being sought.

The Japanese team's data suggest that it is mainly distraction that determines the reactions. However, the team does not conceal the fact that other studies have suggested that both phenomena play a role - both the distracted focus and the need to control movement sequences that take place in flow under normal conditions.

Assistance must be defined individually for those affected. The catalog of possible measures includes behavioral therapies, the written formulation of fears before such a situation, coaching or mental training. Exercises to better control muscle tension can also be helpful. For example, uneconomical muscle strain when playing the piano can be reduced by practising sequences of movements with different rhythms. This can counteract excessive attention, which can lead to unnecessary muscle tension, for example, and thus impair temporal precision when playing the piano. The team is skeptical about drug treatment. For example, taking beta blockers could even increase the risk of motor misbehavior - because they dampen the activities of the sympathetic nervous system.

Original article

Shinichi Furuya, Reiko Ishimaru, Noriko Nagata: "Factors of choking under pressure in musicians", Plos One, January 2021, https://doi.org/10.1371/journal.pone.0244082

SMM - The ability to hear absolutely has been strikingly re-evaluated in recent decades. Since the 19th century, it has been romanticized as a distinguishing feature given by nature or God to "true" music professionals. It was almost taken for granted that absolute listeners were more accurate in their perception and reproduction of music than non-absolute listeners. Accuracy, in turn, was unquestioningly regarded as a sign of quality. More accurate playing was often equated with more expressive playing. According to the narrative, absolute listeners were therefore regarded as a separate caste of virtuosos of emotional expression.

However, these simple connections between emotionality, precision and absolute hearing are increasingly being questioned today. A dissertation by neuroscientist Teresa Wenhart, supervised by music physiologist Eckhart Altenmüller, makes a significant contribution to this. Recently, the author writes in the summary of the work, two studies have reported an increase in autistic personality traits in musicians with absolute pitch. Several case studies and studies with small samples had found frequent occurrences of absolute pitch in autistic people. In addition, similar brain connectivity in terms of over- and under-connectivity of the brain has been reported in several studies of both populations. However, it is still unclear how this coincidence can be explained. Irritating for the traditional narrative of the connections between music, absolute pitch and emotionality is that the ability for cognitive empathy is not at all or only weakly developed in the case of autimus, as a study by Bons, Egon van den Broek and Floor Scheepers ("Motor, emotional, and cognitive empathy in children and adolescents with autism spectrum disorder and conduct disorder", Journal of abnormal child psychology. Volume 41, Number 3, April 2013, pp. 425-443).

Since the critical period for the formation of absolute pitch overlaps with a period of detail-oriented perception during normal child development, a detail-oriented "cognitive style" typical of autism, that is, "the predisposition to process incoming sensory information in a particular way, could serve as a common framework for explaining the similarities."

Wenhrt examined a total of 64 music professionals, using electroencephalography, measurements of autistic symptoms and auditory and visual experiments, among other things. In general, absolute-hearing listeners showed more autistic characteristics than relative-hearing listeners. The observed effects suggest that absolute-hearing listeners tend to have more detail-oriented processing and less contextual integration than relative-hearing listeners.

This is also evident in the brain structures. According to Wenhart, a typical human brain has an efficient network of strongly interconnected modules (segregation) and few cross-connections between these modules (integration). In her study, however, absolute-hearing subjects showed largely reduced integration and segregation as well as reduced interhemispheric connections compared to relative-hearing subjects.

The study suggests that absolute pitch and autism may be linked by similarities in cognitive style and brain connectivity. According to Wenhart, inconsistencies in the results also reflect the heterogeneity of absolute hearing as a phenomenon.

Literature:

Teresa Wenhart: Absolute pitch ability, cognitive style and autistic traits: a neuropsychological and electrophysiological study. Dissertation (University of Veterinary Medicine Hannover), Hannover, 2019.

SMM -- After concert activities were reduced in the spring and resumed after the summer vacation, some SMM therapy practices recorded a surprising influx. Musicians had obviously neglected their over-scheduled instrumental and sports activities during the forced break and were no longer in shape to cope with the new challenges.

There is a danger that this will happen again with the renewed halt to concert life. This is exacerbated by the fact that it is impossible to plan. At the moment, no one knows when the strict federal and cantonal measures will be lifted again. However, the impossibility of planning is one of the biggest obstacles to maintaining routines and determination.

After this summer's experiences, it seems certain that the end of the enforced break will bring major challenges. Performances in orchestras are likely to be particularly intense - not least due to the need to catch up. This can mean that the weight of your own instrument, for example, can cause unfamiliar physical problems. Increased tension can accentuate pain that could previously be kept below a threshold of disability with regular therapy, music-specific exercises or sporting activity. Uncertainty about technical and motor skills on the instrument can create performance anxiety and thus stress, which in turn significantly increases the risk of tension and cramps.

We know the risk from a comparable situation: students tend to increase their practice times considerably in the short term before exams. This shock to the body can then lead to the body going on strike at the very moment when maximum presence, top physical condition, precision and virtuosity are required for an exam. In addition, the lack of a concert routine - which many of you otherwise take for granted - can also lead to performance anxiety and nervousness after a long break.

In sports circles today, it is taken for granted that individual "fitness" must also be carefully planned and maintained outside of everyday competition. Making music at a professional level is comparable to top-class sport, especially when it comes to physical demands. However, musicians still lack an awareness of problems comparable to that in the world of sport.

Naturopath Samuel Büchel works in Spiez and at the Wallner practice in Bern, which is located in the immediate vicinity of the Bern Symphony Orchestra's concert venue. He is familiar with the worries and needs of orchestra musicians and advises them to use the time as calmly as possible in order to be ready for the restart of concert life. Anyone who is already undergoing therapy or regular physical exercises should not discontinue them under any circumstances. After a break, pain can occur when resuming a concert that would not occur under normal conditions.

Perhaps you would like to use your forced break to start a new over-routine? Try out new fitness and movement exercises or musician-specific activities and physical exercises and integrate them into your everyday life as a musician? Perhaps you've been meaning to work intensively on your sound, breath or embouchure for a while? Bring more ease into your fine motor movements or finally tackle your stage fright?

Alone or with professional support - now would be the time to realize such plans and to treat yourself to these development opportunities. We look forward to hopefully seeing and hearing you live on stage again soon, dear musicians!

Wolfgang Böhler* - The Swiss Society for Music Medicine (SMM) brings together under one roof specialists from the fields of medicine and a wide range of therapeutic approaches, as well as scientists and professional musicians. A central concern of the SMM is to encourage constructive dialog between these groups. However, it also wants to help musicians who are struggling with specific health restrictions or are simply interested in putting their music-making on a sustainably healthy footing.

We are proud to have doctors in our circle who can offer medical solutions for music-related illnesses at the highest level. In everyday life, however, people seeking help from the world of music are usually closer to trusted individuals with low-threshold therapy services than medical specialists, who generally have to cope with the hectic pace of clinics or surgeries. The variety of methods, schools and techniques in the therapy jungle can be confusing. The decision in favor of a technique is then often a matter of chance - usually based on personal encounters or recommendations.

With the 18th symposium, the SMM would like to offer those seeking help the opportunity to get to know some of the most important body-oriented approaches in music in one place and at the same time take the opportunity to talk to their representatives without obligation. The therapists should also be able to approach each other on this day. A motto that the American epistemologist Nelson Goodman once coined for philosophy should apply here: those offering therapies should no longer be judged according to which schools and world views they represent, but for which problems they develop solutions.

A world premiere to kick things off

We are delighted to announce that we will be opening the symposium with an unusual world premiere. It is a highly interesting work by the clarinettist and saxophonist Fabio da Silva, who is currently studying at the HKB. Rugueux 2, a game between live performance and pre-produced sounds for baritone saxophone and bass clarinet, is a low-frequency performance accompanied by a pre-produced tape. The instruments, which mix very well, especially in the low frequencies, approach microtonally specific frequencies. Multiple sounds are filtered, creating stronger and weaker frictions.

*The music psychologist and music producer Wolfgang Böhler has been President of the SMM since January of this year.

In cooperation with the Swiss Performers' Foundation SIS, the Bern University of the Arts HKB, the Swiss Music Pedagogical Association SMPV and the Swiss Association of Music Schools VMS.

Various recognized and proven forms of body-oriented approaches in music will be presented on stage and at tables. Keynote speakers are Klaus Scherer (music psychologist and founder of the Geneva Center Interfacul-taire en Sciences Affectives) and Günther Bernatzky (founder of the Salzburg Pain Institute and board member of the Austrian Society for Music and Medicine).

Saturday, October 24, 2020, 9.50 a.m. - 5 p.m., Bern University of the Arts, Papiermühlestrasse 13a, 3014 Bern. Costs: SMM members, students and employees of the BUA: CHF 30; non-members CHF 90; first-year students free admission.

The protection concept of the symposium will be adapted to the current pandemic situation and the corresponding cantonal and national regulations and recommendations in a timely manner. There may therefore be changes to the program at short notice.

Information and registration: Phone 032 636 17 71 or www.musik-medizin.ch, registration deadline: October 10, 2020.

More info:

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

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:

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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.