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A high percentage of musicians suffer from misuse/overuse injuries and performance

anxiety. The Performing Arts Medicine Association researched performance injuries and

performance anxiety among musicians and found overuse injuries and stress/anxiety health

problems among 75% of performing artists beginning in the 1980’s.

More recently, Help Musicians UK commissioned the University of Westminster and

MusicTank to undertake the largest known study into the working conditions of musicians. Of

the 2,211 self-selected respondents who took part in the industry-wide survey, 71.1%

believed they had experienced panic attacks and/or high levels of anxiety and 68.5% reported

they had experienced depression. Some of the factors affecting these statistics included work

environment, physical demands of rehearsals and performing schedules.

At conservatories, the factors include fear of making mistakes, memorizing the music,

teacher expectations, juries, competitions, the message of having to win – these are all

factors that cause depletion and feelings of not being good enough as well as muscle overuse.

However, the depletion has a grave significance for the musician: for, in addition to increasing

susceptibility for injury and increased stress and anxiety, it deprives them of their intrinsic joy

in music-making.

Some sports teams are given resilience training and work at operating as a cohesive

team, valuing one another equally. Their performances show positive results. This has

tremendous implications for our performing arts population and quantitative data along with

subsequent qualitative reports can have far reaching effects in changing the culture within

which we operate as musicians.

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During my years in Cleveland, Ohio I was privileged to serve on staff at the Cleveland

Clinic Wellness Center and on faculty at the Cleveland Institute of Music. At the Institute, I was

given the freedom to create courses in Optimal Performance complete with a Biofeedback Lab

where my students “lived.” Students learned about neuro-muscular health and anxiety, and

visits from guests provided additional information on vocal health, hearing health, nutrition and

exercise. Most importantly, they learned important basics of psychophysiology and gained an

understanding of the complex mind/body connection.

I also provided Biofeedback neuromuscular assessments on all incoming

undergraduates. Muscles can fire at a very high rate for a long period of time before pain and

inflammation set in. Catching those signals and making students aware of how to optimize

those muscle firing patterns became my calling card.

Since 2007, I had begun to investigate using heart rate variability Biofeedback for

performance anxiety and stress. I began working with HeartMath platforms and went on to

become certified as a HeartMath Clinician and HeartMath Trainer. This was quickly added to my

toolbox for musicians.

Now I had the powerhouse tools to create transformation as it requires both. The mind

and body are intimately linked. Just consider this: when you overuse a muscle or sprain an

ankle, you have an immediate accompanying worry/anxiety/stress that begins the chatter in

your brain of “will I be okay?” And, when you are anxious about an upcoming audition, lesson

or performance, how do your muscles feel? They tend to brace, tighten up, become

constricted.

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These were the two tools that my students found in my Biofeedback Lab and the same

two tools I used at the Cleveland Clinic. My assignments for my students were to use the lab

several times a week, recording tests with data in both programs and experimenting with

changes in diet, exercise and finding other avenues for relaxation.

I bring you one of my student’s stories documenting his self-directed transformation

through my course: Andrew Poxon.

Andrew’s StoryIn his own words: Over the summer, I injured my left arm by overusing it. I was nervous

about starting at CIM in the fall, so I felt compelled to practice constantly during June and July.

Desperate to be prepared for my first semester, I ignored initial warning signs in my arm, such

as pain and tightness. I thought they would go away on their own and did little to change my

routine or practice schedule. By August, the pain had become so severe I could barely play, and I

was told by doctors the best solution was complete rest for a few weeks. This period of rest

included my first two weeks at CIM, and it was during this time that I learned about the Optimal

Performance Health class.

I signed up for the class hoping to learn specific ways to reduce tension in my left arm

and hand while playing, which undoubtedly contributed to my initial injury. I also wondered

whether there were certain aspects of my technique that were detrimental to my arm, which

might have caused the problems. Essentially, my overarching goal for the class was to learn

how to most quickly return to optimal physical health, and then stay there.

Quickly after meeting with Dr. Riley privately and attending the first couple classes, I

realized that I needed to work on more than just my physical health. It became clear that there

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was a connection between the physical and mental aspects of my health, and that to improve

the physical, I needed to also work on the mental. The anxiety that I experienced over the

summer caused me to practice too much, but that wasn’t the only way it played a role in the

injury. It also caused or contributed to an underlying tension that was constantly present,

causing overexertion of the muscles in my arm while I was practicing and hindering the normal

recovery process when I was not. This anxiety was then aggravated by the inability to practice

during my first weeks at CIM. Over the course of the semester, I learned how to better deal with

this anxiety, while simultaneously working on physical aspects of my technique that can reduce

the risk of future injury. Although the injury sustained over the summer has yet to fully heal, I

am better able to cope with it, practicing more efficiently and not letting the resulting anxiety

overwhelm me.

The physical aspects of my health have been clearly documented with the

ProformaVision software. At the beginning of the semester, the stress and anxiety I was feeling

caused me to carry around an excess amount of tension in my shoulders. Even when not playing

guitar, or doing any type of strenuous physical activity, my shoulders were constantly being

overused. This can be seen in my first ProformaVision session, in which I was simply working on

sitting down and standing up without using muscles in my shoulders, which was entirely

unnecessary. The red lines represent my forearm extensor muscle activity and the blue lines the

upper trapezius activity in my shoulders.

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This image shows how my shoulders (monitored by the blue lines) were constantly being used,

even when just sitting and standing. The process of standing up, as I was doing in this capture,

caused an elevation in muscle usage from an already high baseline. I was eventually able to

lower the baseline by concentrating on relaxing my shoulders and learning to not carry tension

in them. The shift was partly physical, but largely mental. Once I felt the difference between my

shoulders tense and relaxed, I was able to identify when I was overusing my shoulders and

make the shift. It wasn’t difficult, but it required awareness, which I previously lacked. Later in

the semester, the baseline for my shoulders was much lower.

A more difficult adjustment to make was using my shoulders less while actually playing

guitar. Rather than lifting my left arm to the guitar engaging the deltoid, I raised my shoulder as

well, causing unnecessary stress and pain. This can be seen in the following capture:

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The peak for my left shoulder was over 200uV while playing a piece by S.L. Weiss. By working on

lifting my left arm from the deltoid and thinking about embracing the guitar as if it were being

given to me, rather than holding it or grabbing it, I was able to significantly reduce the use of

my left shoulder while playing the same piece as seen in the graph below:

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In this later capture, the peak for my left shoulder was only about 40uV, an enormous reduction,

and I began to feel some relief.

Similar changes occurred in my forearms. At the beginning of the semester, I was

overusing my forearms, the baseline while playing hovering around 100uV, with peaks much

higher. I realized that this was due to constantly holding tension in my hands while playing.

Rather than using the minimum amount of pressure required to fret a note cleanly, I constantly

applied a great deal of pressure, without paying attention to when, if ever, that tension was

being released. The most important change that reduced the usage of the forearm muscles

while playing was learning how to use the minimum amount of pressure to play notes, and then

release as much tension as possible, giving the hand and arm small periods of rest during

pieces. Due to the technical demands of the guitar, sometimes elevated use of the muscles in

the forearm is required, but being able to reduce the number of those moments and releasing

the tension immediately following those moments, helped allow me to reduce the overall usage

of my forearms. This can be seen in a capture taken toward the end of the semester in which I

played a scale (in this screen I was only monitoring my forearms, no shoulders):

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Each small peak occurred when I fretted a new note, but the subsequent lulls were caused by

reducing the amount of strength I needed, from the amount required to fret a note to the

amount required to sustain that note. Even the highest peak however was only about 40uV, a

significant reduction from earlier in the semester.

These physiological changes that occurred were produced by subtle adjustments to

technique, along with substantial changes in mindset. As I mentioned, at the beginning of the

semester I was constantly experiencing a great deal of anxiety, with no positive outlet for it. I let

it build up, and it manifested itself in the way I carried my body and the way I played guitar. By

finding positive methods to deal with anxiety, the amount of tension in my muscles when doing

specific activities like playing guitar, and in general when merely walking or sitting, was

reduced. HeartMath techniques helped with this.

At the beginning of the semester, and throughout my life, I’ve dealt with anxiety in all

kinds of situations. I often obsess over little occurrences and interactions throughout the day,

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and I constantly worry about my future, in the short and long-term. It was this anxiety that

caused me to ignore early warning signs over the summer as my arm was being overused, and

the same anxiety that caused me to practice more than I should have in the first place.

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The heart-focused breathing technique has helped me learn how to compartmentalize

my thoughts and emotions, giving me more control over what I’m feeling. Rather than get

bogged down in negativity that has built up, I am able to focus on the positive aspects of

whatever the situation might be, not allowing the typical negative feedback loop that I

previously succumbed to so frequently.

By focusing on a positive emotion, I raised my coherence and was then able to use that

positive mindset to think rationally about the situation from a standpoint less clouded by

anxiety and worry, allowing me to sustain that higher level of coherence. This type of shift has

affected my music-related anxieties, both in performance and in practice. Here’s a graph

showing my progress:

In November of that year, I had a performance with a chorus at Baldwin Wallace

University. I was particularly concerned about it because I had never played with a chorus

before, and it was a twenty-minute piece of considerable difficulty with many solo moments for

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the guitar. About thirty minutes before the concert began, I used the heart-focused breathing

technique, focusing on positive emotions such as gratitude for being able to perform the piece

and trust in the work I had put in to prepare, rather than negative ones such as nerves and fear

of making mistakes. This helped put me into a mindset that allowed me to focus on giving the

best performance I could, rather than obsessing over small mistakes as they happened. This is

considerably different from comparable past performance situations I’ve been in, where the

focus on mistakes has taken over and hindered the performance.

The heart-focused breathing and other HeartMath breathing techniques have also

allowed me to overcome anxiety and stress while dealing with my arm injury. At the beginning

of the semester, I was depressed because of the inability to practice as much as I wanted to. I

constantly felt that I was falling behind where I should be due to lack of practice, that I was

letting down my guitar teachers who accepted me into CIM, and that the injury was derailing all

my plans and expectations for life at CIM. These feelings were overwhelming, but ultimately, I

realized they were unnecessary and could be dealt with in a positive way. Heart-focused

breathing on a regular basis allowed me to be grateful for the opportunities I was still being

afforded despite the injury and allowed me to find positive outcomes of the injury itself. For

example, rather than practice several hours a day like I did before the injury, I spent

considerably more time analyzing the music theoretically, listening to and studying music I

never had time to before, and arranging music for the guitar, all activities that did not require

me to actually play constantly. By focusing on these types of activities and the positive emotions

associated with still being productive, I was able to overcome the anxiety caused by the injury.

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Despite my initial intention for the class, to focus solely on the physical aspects of my

health and guitar playing, the changes that have occurred mentally and emotionally have been

just as significant as the physical changes that have occurred. It is clear to me that the physical

adjustments and changes I made throughout the semester would not have been possible

without the mental and emotional ones.

Touching base with Andrew almost two years later, I am happy to report that he

remains pain free and continues to reap the benefits from both the neuromuscular work and

the HeartMath techniques. He has also continued to arrange pieces for guitar, something he did

when he was not able to play initially when he started the course.

The body does not lie – the body cannot lie. Seeing is believing. The data shown on

those graphs documents the powerful psychophysiological changes that Andrew was able to

create. By the end of the semester Andrew had established a new baseline by choosing lifestyle

choices that enhanced resilience and by analyzing and adapting the way his body interacted

with his instrument. A powerful story of transformation and the good news is that it can be

achieved by everyone with diligent work, education and patience.