This is Dr. Richard Norris from the National Arts Medicine Center, and I'm going to be
speaking today on medical problems and orthopedic considerations of cellists and bass players.
First of all, in order to understand and prevent injuries, we have to understand what are the
contributing factors.
I have divided these somewhat arbitrarily into extrinsic, in other words, things that
occur outside the body and intrinsic factors, things which occur within the body, with the
understanding that this is a rather artificial distinction.
The most common of the extrinsic contributing factors are abrupt changes, with emphasis
on the word abrupt, changes in practice time or intensity.
These too often occur most commonly during summer chamber music festivals or towards
the end of a semester with juries and examinations coming up or for professionals at particularly
busy times.
Abrupt changes in teachers and instruments also require a decrease in the practice time
and intensity in order to avoid overuse injuries.
And it's not that one teacher's style is better than another's, but that if a teacher changes
the way you bow or finger, you're going to be using your muscles differently and you
need to back off a little bit.
Also abrupt changes in instruments, if you switch from instruments that are different
size or different quality, et cetera.
In terms of the repertoire, we're going to go into this a little bit later, but there
are some pieces and some styles of music that perhaps have an increased risk of injury with
them.
Instrument quality and size, particularly as it pertains to body size, is something
important to note also.
Cellos do come in various sizes and a person must try to make sure that the one that they
have is suitable for them and comfortable to play and not just to have a cello because
you like the sound or the quality of the instrument, although certainly that's important too.
Inadequate rehabilitation of previous injuries is something that's often overlooked.
The neck strain or back strain or tendonitis that's rested just until the person can go
back to playing but that the pain still lingers on by Murphy's law is likely to flare up
at the worst possible time.
What constitutes adequate rehabilitation is full restoration of strength, flexibility,
range of motion, strength, endurance, and coordination.
Once those parameters have been fully reestablished, then rehabilitation can be considered to be
complete.
Also other hand intensive usage is important.
Someone might have great technique and practice habits at the instrument, but develop overuse
injury from typing on the computer or gardening or other hobbies that require hand intensive
usage.
So one must take care with this as well.
Among the intrinsic factors, probably the most common is faulty technique.
This was a typo on the slide, but I loved it so I left it in.
It says faculty technique, which is a whole subject in and of itself.
But regarding faulty technique, the most common ones are excessive force and either gripping
the bow or pressing down on the strings or holding the instrument in an awkward or stressful
posture.
Also, psychological states such as stress often manifest themselves as increased muscular
tension, which then predisposes towards muscular injuries.
And while depression may not directly contribute to injury, if one is drinking too much, smoking,
not eating properly, not sleeping well, not generally taking care of oneself, this has
an impact on injury healing.
General physical conditioning in terms of strength and flexibility certainly have a
lot to do as far as posture goes and as far as injury prevention goes.
If one has to play in an awkward position, the better general physical condition one
is in, the less the risk of injury.
Physical variations, especially things such as hand size and length of the arms, can play
a relationship to injury as well.
And finally, gender can be a factor.
A study that was done by the International Conference of Symphony and Opera Musicians
in about 1986 showed a higher incidence of overuse injuries in young females, especially
the ones that played larger instruments such as cello and bass.
And while the implications of this are not entirely clear and certainly shouldn't discourage
women or young women from playing these instruments, it may mean that they need to pay more attention
to things such as general physical conditioning, posture at the instrument, smart practice
habits and the like.
Moving on, this is Kato Havash who says a violin should be held tenderly.
Don't do to this neck anything you wouldn't do to your own.
The point being, use of excessive force in playing the instrument.
Often we talk about the grip on the bow and gripping the instrument.
The instrument should not be clenched in the hands or the bow shouldn't be squeezed very
tightly between the hands because this will lead to strain.
We all have a tendency to over grip, whether it's talking on the telephone, driving a
car, writing or playing a musical instrument.
In my opinion, this has to do with something called the primitive grasp reflex, which we
see in all healthy normal infants up until about the age of nine months, whereby if something
is placed into their hands, they reflexively grasp onto it.
So this is something that's really built into our nervous systems even though this
obligatory response disappears about age nine months.
We all have this innate tendency that we have to consciously train ourselves to hold the
instrument in a relaxed fashion.
One of the ways that we can help have a more relaxed grip on the instrument is by improving
the interface between the bow and the hand.
The frog of the bow is not optimally designed to fit the hand as we would think of when
we're studying ergonomics, for example, which is the science of making the tools fit the
worker rather than vice versa.
The end of the bow is smooth, it's slippery, it's hard and it doesn't really fit the hand.
This can be improved, as you can see here, by slipping some rubber tubing over the end
of the bow and that improves the grasp.
I like to go one better than this and use something called coban, which stands for cohesive
bandage.
It's kind of like a stretchy paper ace bandage that's self-adhesive.
It will not stick to the bow, but it sticks to itself.
And by wrapping this around the end of the bow, when one holds the bow, it will actually
mold to the hand and also give improved traction, absorb perspiration, etc.
It should be changed fairly frequently because it can get tacky after a while, but it's very
inexpensive and available through almost all surgical supply stores or one can contact
3M directly through toll-free information.
Here it shows the tail end of the bow being built up to give support for the pinky.
This person's pinky kept sliding off the bow and they had problems stabilizing.
Notice also that it's wrapped under the index finger and can cushion this area and prevent
numbness and nerve entrapment from pressure against the bow.
One also has to be careful not to use excessive force with the left hand in pressing down
on the strings, but only use as much force as is necessary to get a clear sound.
In this regard, it's important to have the proper height bridge because if the bridge
is too high, the strings will be higher off the fingerboard and it will require more pressure
to press down on them.
And one has to be cognizant of using a summer bridge in the summer and a winter bridge in
the winter.
In terms of muscle strain when one is using excessive tension, it's very common to have
strain in the trapezius muscles.
This is the muscle seen in the top left corner between the neck and the shoulder.
This is a view from the back.
The right half is a deeper dissection, the left is the more superficial muscles.
And between the point of the shoulder and the base of the neck is the upper part of
the trapezius muscle.
Regardless of the instrument, this muscle is often tensed and raised and people develop
chronic muscle pain in this area.
I've often thought why this muscle, why do people tend to hold tension in this muscle
and I think that I have some answers.
Back in cave person days when beasties used to leap out of the trees onto our necks, it
had survival value to hike up your shoulders and tense up your shoulders to protect your
neck in the face of danger because your neck is a very vulnerable structure.
Well, the thing is that even though these beasts are now extinct, we still have the
same tendency to tense up in the face of imagined threats.
One of the ways we treat this in the clinic is by the use of biofeedback.
One can see in the upper left hand corner on the right trapezius muscle is a surface
electrode and this is hooked up to the biofeedback machine and the cellist is watching the level
of muscle tension on the screen while she's playing.
And this is pretty much what she sees.
The two lines, one for each trapezius muscle, are constantly moving and as she tenses up
the spikes go up and as she relaxes the line comes down.
The goal of this training is to use the least amount of muscle tension compatible with a
good musical result and a good musical sound.
This strain can also be from a head forward or a forward head posture or position.
This sometimes is just simply due to poor posture but it can also be due to the fact
that the lighting may be poor or the parts may be poorly copied or the person may need
glasses and they're not wearing their glasses and so they're kind of squinting and thrusting
their head forward.
Thrusting the head in a forward position has the effect of increasing the strain on the
muscles in the back of the neck.
For example, if the head weighs approximately 10 pounds, thrusting it forward three inches
increases the effect of the weight up to 30 pounds so there's three times as much stress
on the muscles in the back of the neck and the upper shoulders.
So it's no wonder that at the end of the day that these muscles are strained.
Another consideration here that we'll get into later when we talk about sitting has
to do with the tuning pegs often not permitting the head to be brought back into a neutral
position.
We'll discuss this in more depth later.
We're going to go on and talk now about nerve entrapment at the elbow which while not a
common problem is a serious one and one that chelus may be particularly prone to especially
in the left arm.
The ulnar nerve which is seen here running along the pinky side of the forearm passes
in the groove in the funny bone groove behind the elbow on the inner side of the elbow.
This nerve runs all the way down into the hand and is extremely critical because it
innervates all the small muscles of the hand which are responsible for fine motor coordination.
It also gives sensation to the hand as you can see in the top left hand corner in the
pinky and half of the ring finger which is indicated.
So numbness in the pinky and ring finger often has to do with entrapment of the ulnar nerve
at the elbow, the so-called cubital tunnel syndrome.
Now this is a cross section of the elbow and in the upper left hand corner you can see
the ulnar nerve represented by a black dot within the cubital tunnel which is a fibro-osseous
tunnel.
In other words it has a fibrous roof and a bony floor.
In the top picture the elbow is held out straight what we call an extension and there is ample
room for the nerve in the tunnel.
In the bottom half in the illustration B the elbow is flexed and there is a passive mechanical
narrowing or closing down of the cubital tunnel resulting in compression of the ulnar nerve.
This forms the basis for the so-called elbow flexion test that we do in the office.
When the elbow is held in a flexed position if the test is positive it provokes pain and
numbness and pins and needles radiating into the fifth finger and sometimes part of the
fourth finger.
This is because the nerve is being stretched and squeezed at the elbow in the funny bone
groove also known as the intercondylar groove.
In fact pressure measurements that were done within the cubital tunnel in 10 patients with
documented cubital tunnel syndrome revealed that the pressure when the elbow was bent
or flexed was 63 millimeters of mercury and when the elbow was out straight was only nine
millimeters of mercury.
This illustrates the dramatic increase in pressure on the ulnar nerve at the elbow when
the elbow is flexed.
Now this is critical for the cellist because in the left arm when playing in the first,
second and third position the elbow is nearly maximally flexed and for much of cello playing
these are the commonest positions.
Note that even up in thumb position the elbow barely opens up to 90 degrees and this is
not to say that all cellists develop cubital tunnel syndrome but certainly if one starts
to feel numbness or pins and needles in the pinky or pain at the elbow one should be aware
that this may very well represent cubital tunnel syndrome and this is a fairly serious
condition again because the ulnar nerve innervates the muscles that coordinate the movement of
the fingers.
If it's severe enough the way that I treat this is with a hinged splint.
The problem is that you just can't remember to not bend your elbow and people bend their
elbow hundreds of times a day so repeated elbow flexion or sustained elbow flexion is
particularly problematic.
This splint has a hinge that's adjustable so that you can allow full extension but it
blocks flexion at whatever degree you want to set it at.
Usually I'll start off only allowing the person a few degrees of extension and then as the
symptoms decrease gradually dial in more and more flexion at the hinge.
Once they're up to 90 or 100 degrees of flexion as shown here and they're still asymptomatic
then we start to wean them off the brace and hopefully the nerve will quiet down and this
won't resume.
Notice also the person is leaning on their elbow.
This is something that has to be strictly avoided as well because the nerve is very
superficial at the elbow and susceptible to compression so one has to be careful not to
lean the elbows on hard surfaces.
Another nerve entrapment which is not uncommon in cellus is entrapment of the radial nerve
at the wrist.
This is often confused with tendonitis because there is a common type of tendonitis called
de Quervain's tendonitis that occurs in the very same area.
In fact in this illustration where you see the arrow labeled radial nerve directly underneath
that are two tendons which run through a sheath and the very same thing which aggravates the
nerve aggravates those tendons.
When those tendons are inflamed it's called de Quervain's tendonitis.
When the nerve is irritated it's called sensory radial neuropathy or radial neuropathy.
They have similar findings except with the radial nerve problem there is numbness in
the distribution of the nerve as indicated in the picture and there may also be a sensation
of tingling or pins and needles felt.
Now the provocative position for both the tendonitis and the nerve as illustrated here
in the top when the hand is supinated in other words when the palm is facing you as you can
see in the very top most illustration the nerve is not compressed by the two tendons
in the forearm whereas when the palm is face down as in the bottom part of that top illustration
the two tendons scissor over the origin of the nerve.
In fact at the bottom of that illustration is a circle which represents an enlargement
of the area where the nerve emerges from between those two tendons showing how those tendons
scissor around the nerve when the hand is palm down.
Also on the bottom half of the illustration when the wrist is extended or cocked back
the nerve is relaxed when the wrist is flexed the nerve is stretched and bringing the thumb
into the palm of the hand which is not shown further stretches it.
Now where do we see this okay at the up bow especially as the bow nears the frog the wrist
is pronated or even slightly hyper pronated it's flexed and the thumb is adducted into
the palm opposite the middle finger and so if one experiences a numbness in the area
of the radial nerve or pain at the base of the thumb then what one could simply do at
least during practice is to avoid coming too close to the frog say for example avoid the
last 25% of the bow to avoid placing the wrist in this position.
It's also important not to compress the nerve externally with watches or bracelets etc.
Okay nerve entrapment can also occur in the neck or in the cervical spine this is a cross
section of the spine at the neck and the nerves are indicated in yellow coming off the spinal
cord and emerging through a little canal that's called the foramen which means window in Latin.
The nature of these foramen are that when the head is tilted to the side as seen in
the leftmost illustration where it says lateral bending the foramen on the concave side become
narrowed.
When the head is rotated as seen in the far right illustration the foramen on the concave
side also become narrowed compared to the neutral position seen in the middle.
This shows the nerves this is a side view of the neck and it shows the nerves emerging
from the canal there's a little enlargement that circle represents an enlargement so you
can see the nerves coming from between each pair of cervical vertebrae.
Now if you have arthritic changes there's a narrowing of the openings so the nerves
may already be compromised without turning or rotating the neck.
This can have an effect in cello playing particularly if as you can see in this illustration from
the Kennedy Center this is their principal cellist John Martin if the music stand is
to the right so that your head is turned to the right in other words if you're sitting
outside stand and you're bowing on your A string towards the frog of the bow so that
your arm is way across your body there is a twisting that happens at the neck and this
can cause radiating pain down the arm especially if those foramen are already narrowed by arthritic
changes.
This is a condition that's known as thoracic outlet syndrome and it's a different type
of entrapment.
As you can see the right arm is extended over the head in the illustration and this causes
a stretching of the nerve and blood vessels and potential site of entrapment in three
different places.
The first one is between the neck muscles which you can see in the illustration.
The second one is underneath the collar bone actually between the collar bone and the first
rib and the third site is underneath the head of the pectoralis minor which is the muscular
insertion where the nerve and blood vessels kind of take a U turn just before they go
up the arm and enter the arm.
The pectoralis muscles are often tight in cellists because they play with their arms
in front of the body and so these muscles can become shortened unless they're specifically
stretched.
The neck muscles should be stretched as well.
I should say that the thoracic outlet syndrome presents with sensations of fatigue or heaviness
in the arm.
One can get numbness although it's more often the whole hand as opposed to numbness just
in the pinkies like the cubital tunnel syndrome or numbness just in the thumb index and middle
finger as in carpal tunnel syndrome.
Coldness of the hand is another sign of this.
This is an illustration that shows what's called an arteriogram, an injection of dye
into the blood vessels and then an x-ray taken.
This was actually from a cellist that was having severe signs of coldness in the hand
and pain and there was strong suspicion that there was significant compression of the blood
vessels going down the arm.
The top photograph is normal and the bottom one you can see there's a break in the column
of dye within the blood vessel where the compression is occurring and this person eventually needed
surgery to correct this condition.
Again one shouldn't be frightened by this because this is rather rare that one needs
surgery.
However, the condition itself is fairly common and most often responds to a conservative
program of stretching the neck muscles, stretching the pectoral muscles and strengthening the
postural muscles.
This is a good stretch for the pectoral muscles, sort of the stick them up position bringing
the arms back behind the plane of the body and it helps if you take a deep breath when
you do this and hold the stretch for about 10 or 15 seconds.
One can do this at frequent intervals.
I had said we would talk about repertoire as it pertains to injuries.
Some composers music tends to be a lot more difficult to play than others.
Philip Glass for example, even though I love his music, is reported by many of my patients
to be very difficult in terms of its repetitiveness and rapidity and can actually predispose
to injury.
Some other composers should probably carry a warning from the surgeon general.
I'm told by my patients that the Rosenkavalier is particularly a long, difficult opera with
lots and lots of playing for the strings and very little place to rest and we've seen
a number of Rosenkavalier injuries in our opera patients.
Temperature can also play a deleterious effect, especially working in the cold.
The polar string quartet seen playing here for a black tie audience may be a sight gag,
but playing in cold in general can result in impairment of manual performance.
This is due to a loss of cutaneous sensitivity.
In other words, you can't feel for example, or you can't feel as well, how hard you're
pressing down on the strings or perhaps for intonation.
There are changes in the characteristics of the synovial fluid in the joints, which is
the fluid that lubricates the joints.
Cold causes a thickening of the joint fluid so that it's harder to move the joints.
There's a loss of muscle strength and there's also a slowing of nerve conduction in the
cold so that the hands don't respond as quickly to the motor impulses from the brain.
In terms of technique and posture, one of the things I would like to point out, especially
in terms of shoulder problems, has to do with the risks of bowing all the way out to the
tip of the bow, particularly on the A string.
This puts the shoulder in a position of abduction, which means brought away from the body or
held away from the body, and internal rotation, which means somewhat turned in.
This can cause a pinching or compression of the rotator cuff in the shoulder.
The rotator cuff and the bursa are the two structures that get impinged.
On the left-hand side, the long arrow points to the rotator cuff, which is a tendon, and
the short arrow points to the bursa, which is like a collapsed sack whose purpose is
to help the tendons to glide more smoothly over the bony areas.
In illustration B on the right-hand side, you can see when the arm is abducted or brought
away from the body, the head of the humerus or arm bone, which is the bottom arrow, pinches
the tendon and the bursa up against the acromial arch, which is the upper arrow.
That's the bony arch that forms the very top of the shoulder.
What can we do to avoid this from happening when bowing out to the tip of the bow on the
A string is that one can rotate the cello slightly in towards the bowing arm so that
one doesn't have to internally rotate quite as much.
In fact, if you watch many cellos, especially people like Yo-Yo Ma as they play, the cello
is constantly slightly in motion, being brought in towards the bowing arm when playing on
the treble strings and brought back to a more neutral position when bowing on the bass strings.
This really helps a lot to decrease the strain on the right shoulder.
Notice the smile on the cello's face in this picture because she's rotating the instrument
in towards the bowing arm.
In terms of the bass, the shape of the instrument is important as well, particularly if the
player is of short stature.
Here this student is playing up in thumb position, but she's having to lift her elbow way up
in the air in order to avoid impinging the underside of the wrist against the front edge
of the bass.
If she didn't do this, if she didn't lift her elbow and arm up, then she would impinge
as seen here.
Now, partly this could be avoided by having a more sloped shape to the upper part of the
bass as opposed to somewhat more squared off configuration as seen here.
And this fellow is taller and so he doesn't have the same kind of problems.
Also, the bass has much more sloping shoulders providing easier access to thumb position.
Let's talk a little bit about the angled end pin and what it does and sort of the physics
behind it.
This of course was popularized by Rostropovich, although I don't believe he was the inventor
of it.
In any event, what it does is it allows the cello to be held at a much more steeply inclined
angle without having the end pin have to be excessively long or stick out excessively
far in the front.
A lot of people like to have the cello at more of an angle because then gravity assists
the arms and one doesn't have to use as much muscular force in either bowing or pressing
down with the left hand.
The drawback however is that the bowing arm is brought up higher and so there's more risk
of shoulder impingement as we saw in the earlier slides.
Another thing that it does by the way is it brings the end pin more directly underneath
the instrument so there's not as much weight thrown back against the shoulder and so it
makes it easier to sit up straight when one plays.
And of course in terms of strain it's not just playing the instrument but getting it
home after the concert and if one is a small player as seen here then one has to be strong
first of all and second of all maybe be clever in getting the instrument around.
It always seems to be unfair, you can see on the left the big guys play the little instruments
and the little guys play the big instruments.
So carrying the cello for example hanging it from the end of the arm and we've weighed
the cello in the case can weigh up to about 35 pounds.
This can actually be a source of shoulder strain as well.
You see one of the things that happens in the bottom illustration which represents the
rotator cuff, the sort of darkened area is the muscle and then there's the rotator cuff
tendon and then showing it inserting into the bone and what this illustration is showing
is the blood supply to the rotator cuff.
Part of it comes from the muscle and part of it comes from the bone but there's an area
where they meet that has a relatively poor blood supply which is called the critical
zone.
Now on the right hand side of the lower illustration the downward arrow which says traction under
is what happens when you hold a weight in your arm.
There's traction that happens on the rotator cuff and the two large white arrows at the
critical zone show the cuff becoming relatively avascular, in other words the blood flow being
shut off to this area of the tendon when you hang a weight in your arm.
So it's not quite like the impingement that we saw before but you can get rotator cuff
problems from carrying your cello in your hand especially for long periods of time.
Okay, regarding back disorders we already mentioned carrying the instrument.
There are a number of instrumentalists that have a relatively high incidence of back disorder.
The first one or the highest is cello, then harp, piano and double bass.
Cellists have a particular problem in that the instrument is more or less constraining.
If you sit and watch a violinist during a string quartet they're often moving around
quite a bit in their seat whereas the cellist is more or less kind of stuck there by the
instrument.
Also as we mentioned sometimes the tuning peg makes it difficult to sit up straight
and then there are the back problems from carrying the instrument around.
For example here with the bass it's an awkward instrument to get around and so the back is
often not in an ideal posture here leaning to the right in order to accommodate the instrument.
Wheels can be very helpful in this regard.
Some cello cases have built in wheels as seen here.
Wheels can be added onto the case or onto the instrument.
Cellists are also carrying the stool around many times as well.
This patient of mine actually had a backpack arrangement affixed right to her case.
She went to a mountaineering store and had waist straps and shoulder straps put right
on her cello case.
Now she's able to carry it around like this which is putting most of the weight on the
hips not even on the shoulders and this was very satisfactory.
There are lightweight practice instruments that are available.
This one is called the Traveiello and for people that do a lot of traveling and want
to take their instrument along to practice this may be a good alternative.
This is Ernest Nussbaum from Bethesda Maryland.
You can't quite make out his address in the lower left hand corner but he is in the phone
book and if anyone is interested in a Traveiello give him a call.
This is a sculpture I came across of a lightweight Traveielist playing his Traveiello.
I thought that was pretty funny.
Let's talk a little bit about chairs and how it relates to back pain in playing the cello.
The chair was really devised as a device for ruling not really for working.
The King Tut's head is cut off here in this slide but it's an ancient Egyptian sculpture
showing the chair as a throne not really designed for working.
The mechanics of sitting are such that the spine on the left hand side is in the ideal
or neutral position with the normal lumbar, lumbar meaning the low back, normal lumbar
curvature or lordosis.
In the middle picture when one is sitting on a flat chair there is a backwards tilting
of the pelvis, notice the white arrow within the black of the pelvis or hip bones that
causes a flattening of the lumbar spine and a loss of the lordosis.
This isn't so bad if you're leaning back against the back rest of the chair but as
most of you know most cellists do not use the back rest of the chair they sit forward
in the chair so they can get the cello between their legs and so there's a slumping of the
low back or a flattening out of the low back that causes strain of the back and causes
the head to be relatively thrust forward.
In the rightmost illustration we see the effects of using a forward sloping seat once again
placing the pelvis in the upright or neutral position and restoring the lumbar lordosis
in an effortless manner, in other words you don't have to use a lot of back muscles to
sit up straight when the seat slopes forward, you do have to use a lot of back muscles to
sit up straight on a flat seat and this causes fatigue and strain.
This shows the effect on the pelvis and low back of various seat angles.
On the left side if the seat slopes backwards there is even more of a reversal of the lumbar
lordosis and backwards tilting of the pelvis, this really causes a lot of back strain.
Now what seats slope backwards?
Very common for folding chairs to slope backwards, the idea I suppose being to encourage you
to sit back into the back rest but if you're trying to play a cello in a backward sloping
chair this can cause an enormous amount of back strain.
In the middle and rightmost illustrations we see the effects of a very slightly forward
sloped seat or a more radically sloped seat, on the right hand side it nearly completely
straightens out the spine using the forward wedge.
This is just an illustration of the slumping of the low back that occurs with sitting on
a flat chair with the hips and knees at 90 degrees, total reversal of the lumbar lordosis
and a curvature of the spine.
Here is a cellist sitting on a chair that slopes backwards causing a lot of back strain.
If you tip the seat forward, kids know this instinctively and they'll tip the chairs onto
the front legs, makes it much easier to sit up straight.
Now the idea of a wedge cushion to alleviate back pain has been around for a long time.
This is an illustration of a horse cab from the turn of the century and the drivers since
there was no back rest found very quickly that if they sat on a flat cushion they would
get back pain but if they used a forward slope then they would have no back pain.
In fact if you think about riding a horse the reason you don't need a back rest when
you ride horseback is that your thighs slope downwards which in effect brings the weight
of your torso directly over your sit bones so you're balanced and there's no force
acting on you to kind of force your back backwards.
So here is the foam wedge cushion.
This is called the Ergo Kush and it's available from Alimed, A-L-I-M-E-D which again you can
find through toll free information, 800 information.
They're up in Dedham, D-E-D-H-A-M, Dedham, Massachusetts and the cushion is dual layer.
The top one inch is a soft open cell foam and the bottom two inches is firm closed cell
foam.
The soft foam gives comfort, the closed cell foam gives firmness and support so the whole
cushion doesn't squash down and flatten down.
And basically I'll back up here, you can see that it converts a backward sloping seat into
a forward sloping seat.
It's very lightweight and easy to carry around and many professional cellists around the
country use them including Jules Eskin at the Boston Symphony and many members of the
National Symphony.
And here are cellists.
It doesn't quite make it into a forward sloping seat here because the seat is so radically
sloped backwards but at least it turns it into a more or less level seat.
Here's another example of just a plain foam wedge being used to create a forward sloping
position and again making it very easy to sit up with a nice straight back with very
little muscular effort.
Regarding posture and sitting in back pain, one of the common mistakes particularly that
beginners at the cello make are having the instrument be straight up and down as you
can see here and the torso leaned to the, in this case to the viewer's left, to the
player's right so the spine is crooked, the instrument's straight but the spine is crooked.
So one needs to make sure by checking in the mirror that you first set yourself straight
and then place the instrument and the instrument will by necessity be sloping slightly to your
left.
Now one of the new inventions that I think is really interesting and maybe very helpful
in terms of posture is called the posture peg but this is a removable tuning peg so
that after you finish tuning the instrument you just simply pull the peg out.
It's got kind of a square rod that fits into a square hole and this has the effect of leaving
a flat profile on the side of the instrument that faces the left side of the head and neck.
This would allow in effect the person to sit with the head in a much more upright position
as you can see in the bottom compared to the top illustration with the tuning peg in and
the head forward.
Again, the forward head posture causes a lot more neck and upper back strain.
Now we all talk about playing a musical instrument but we should be aware that it really is work
to play an instrument.
The sign says in Finnish musicians working is taken at the Kumo Chamber Music Festival
in Finland where I was a number of years ago.
It's a gorgeous place if anybody has the interest to go there, it's sort of like the Tanglewood
of Finland where players from all over Europe come for the summer.
In any event, therapeutic exercises are very, very important for musicians and since cellists
are particularly prone to back pain I'm going to quickly go through a series of back exercises
that one can do.
First of all, abdominal strengthening by doing sit ups and remember these are just crunches
in other words you're not coming all the way up which can strain the back but you're just
coming part way up.
This is really adequate to strengthen the abdominal muscles.
Stretching the low back in this position, this could be held for about 30 seconds.
This is called the cat of the camel position, the next one will be the cat and they're done
in sequence so you go from this one to the next one which is called the cat, in other
words arching your back.
This gives flexibility to the spine and strengthens the spine.
The cobra pose from yoga which also is for flexibility of the low back.
The so called boat pose where one is just kind of resting on the hips with the upper
torso and both legs lifted off the floor of the table.
This is an excellent exercise for strengthening everything from the back of the neck muscles
all the way down to the buttocks and the hamstring muscles.
Again you would hold this posture for about five seconds then let it down.
If hyperextending the back is uncomfortable then you can roll up a pillow and put it under
the hips so that you start off in a flexed position and then when you arch up you'll
only come to a neutral position of the spine and it won't cause hyperextension of the low
back.
Of course prevention is the best treatment of all and prevention really has to do with
general physical conditioning for strength and flexibility and a good general physical
conditioning program should contain elements of cardiovascular conditioning such as aerobics,
jogging, biking, nordic track, what have you.
Something for strength such as light weight training and flexibility such as yoga or stretching.
Then specific exercises for strength and flexibility because each instrument has their own specific
demands.
So as we mentioned cellists need to focus in on a back program and also make sure they
stretch the pectoral muscles which tend to get tight from the typical posture of playing
the cello.
Then body awareness regarding posture and tension, in other words proper posture can
only be brought about through awareness of the body.
Things like Alexander technique and Feldenkrais technique are excellent in this regard as
is yoga and meditation.
And then smart practice habits and by this we mean taking frequent breaks perhaps a five
minute break every half hour or every hour.
Not practicing very difficult or awkward passages over and over and over again but limiting
the practice time of a difficult passage to two or three minutes perhaps and then going
to something easier and then coming back.
And just generally being aware of one's health and having good healthy habits.
I'd like to leave you with a paraphrase and a thought from St. Francis who said life or
in this case a musical career is a long hard road.
Be kind to your ass for it bears you.
Thank you.
Thank you for your presentation.