Daria White, a 19-year-old sophomore at the College for Visual and Performing Arts at George Mason University (GMU), has been playing the clarinet since she was 9. Since coming to college, her playing time has increased dramatically -- and so has the pain in her wrist, up into her arm and shoulder.

"My thumb lost feeling for several hours," she says. For a while, White couldn't play more than 15 minutes at a time. "That really kills your performance," she says.

She suspects the clarinet itself is to blame. The instrument weighs about two pounds -- not a whole lot, you might think, until you hold it up for sustained playing with only the thumb and mouth for balance. "Everyone who does it has wrist pain," says White. She has seen a number of doctors about the condition, including a neurologist. She's had a battery of tests, from an MRI to painful electromyography, but the doctors can't find any explanation for her pain. The medical advice she has gotten so far: Lay off the clarinet. "That sent me into orbit," she says, noting that the doctors don't understand that music is her major and future career, not just something she noodles around with in her spare time.

White's problems are far from unusual. For years studies have shown that musicians are at high risk for injury, especially repetitive strain injuries that affect the small muscles in the hands. A decade ago, a doctor at the National Rehabilitation Hospital in the District surveyed students at Catholic University's Benjamin T. Rome School of Music and found that 76 percent of them had suffered music-related injuries severe enough to keep them from playing for more than two weeks. Those numbers mirrored the first landmark survey by the International Conference of Symphony and Opera Musicians in 1986, which found a high incidence of musculoskeletal problems among instrumentalists.

Some researchers believe those numbers have only gone up because of the competitive nature of today's music world, and that injuries are affecting younger and younger musicians. Washington area doctors say they see a rash of serious injuries in kids as young as 12 and 14 after summer music camps, where their playing time jumps to as much as eight hours a day. Hours of practice combined with the muscle-stiffening pressures of stage fright often take their toll on musicians' bodies, says David Sternbach, director of GMU's Center for Arts and Wellness, who is trying to integrate injury prevention into the university's music curriculum.

"The practice room is hazardous to your health," he says.

Don't Ask, Don't Tell

While movies often cast the geeky kid with the cello as the high school anti-jock, playing music can tax small muscles in much the way competitive sports strain the larger ones. Jennifer Gamboa, past president of the performing arts special interest group of the American Physical Therapy Association, likes to refer to musicians as "upper-extremity athletes." Says Gamboa, "A lot of times this is a new concept for musicians as well."

Musicians' injuries are as numerous as their instruments: fiddler's neck, tuba lips, violinist's jaw, horn player's palsy -- even guitar nipples and harpist's cramp. The poor bagpiper is threatened by fungus that often grows inside the instrument. And the flutist? "The flute is a biomechanically impossible instrument to play," says Scott Brown, chief of the department of physical medicine and rehabilitation at Sinai Hospital in Baltimore and a musician himself.

Like athletes, musicians tend toward the "no pain, no gain" philosophy of practice, craning chin to violin and maintaining other unnatural positions for hours on end. Reflecting on the hand injury that derailed his legendary concert piano career nearly 20 years earlier, Leon Fleisher told an interviewer in 1985, "There was something macho about practicing through the pain barrier. Even when my hand was exhausted, I kept going. Although I thought I was building up muscle, I was, in fact, unraveling it."

Musicians admit they don't like to talk about injuries and are often reluctant to seek medical help. Concert pianist Gary Graffman, whose career was ended by a hand injury, wrote in 1986, "Nobody wants a wounded pianist. There is an oversupply of healthy ones. Admitting difficulties is like jumping, bleeding, into piranha-filled waters."

After 25 years with the National Symphony Orchestra (NSO), Milt Stevens, who is now the orchestra's principal trombone player, has seen many of his colleagues felled by injuries, some permanently. Yet he says that musicians keep their ailments under wraps for fear of losing their jobs. Right now, for instance, with rumors flying that NSO conductor Leonard Slatkin is clearing out deadwood, Stevens says, injured orchestra members are "not going to go running to [Slatkin] to show him what's wrong. One reason I can talk about it is, I'm not injured."

One more reason musicians try to ignore their pain as long as possible: They're some of the most under-insured professionals in the country. Once they do go for help, though, musicians like White find that their frustrations continue in the face of a medical profession that doesn't necessarily speak their language.

Unacceptable 'Remedy'

Musicians' injuries can be difficult to diagnose and rarely show up on X-rays or MRIs, says Brown, who is also past president of the Performing Arts Medical Association, a national group of doctors and other medical professionals committed to improving performers' health care. Most tend to be lumped into the vague "overuse" category that includes other occupational disorders like carpal tunnel syndrome. They can still be disabling. Tendinitis in the shoulder very nearly ended the career of Max Weinberg, the drummer for Bruce Springsteen's E Street Band.

Pianist Fleisher spent 30 years playing only left-handed concerts after excessive practice caused the fourth and fifth fingers of his right hand to curl under and stop functioning when he was 37. Psychiatry, lidocaine injections, traction, hypnosis, L-dopa, acupuncture, EST -- you name it, he tried it. Later, Gary Graffman joined him in making the rounds, seeing more than 40 doctors.

In the early '80s, Fleisher and Graffman went public with their stories, bringing musicians' health care needs into the open for the first time. Until then, many doctors believed such injuries were psychosomatic -- a byproduct of the same artistic temperament that some have linked to musicians' high rates of substance abuse.

"The traditional medical community has not been very sympathetic to musicians' problems," says Brown. "The usual recommendation is 'stop playing,' " which for most musicians is simply not an option." Despite recent progress, he says, "Arts medicine is still 20 years behind sports medicine."

Part of the problem is that what may seem like a nuisance injury to most people -- such as a strained pinky -- can be a career-ending disability for a musician. Jan Dommerholt is a physical therapist who played the clarinet and saxophone in the Netherlands' military band and now treats musicians in his Bethesda pain clinic. He says, "Small changes can make an enormous difference in a musician. Most health care workers don't appreciate the complexity of what musicians do to play their instruments."

Finding a medical professional who understands musicians' special needs can be a challenge, particularly in Washington. Daria White's clarinet professor, Brian Jones, likens the quest to an "Underground Railroad for musicians." While Washington is home to thousands of performers, it is one of the few big cities that doesn't have a medical facility dedicated to their health care, like New York's Miller Institute for Performing Artists and the Cleveland Clinic's Medical Center for Performing Artists.

Therapy Scaled to Fit

But help is out there, and musicians say it's worth the effort to find it. When injured musicians make an appointment to see Dommerholt, he does one thing doctors rarely do: He asks them to bring their instruments. He checks their posture while they play and asks about their work environments. "Do they play in the pit and can't see anything so they slump over the music? The physical environment of the orchestra pit is abysmal," he says. That evaluation often shows that the instruments are the source of the problem.

Dommerholt says he had one client with myofascial pain syndrome in his knuckles; an orthopedist told him he'd never play guitar again. As it turned out, the man had large hands and his guitar neck was so thin that he had to use a pincher grip to play. Once the man got a wider-necked guitar, the problem went away.

Gamboa says another reason for seeking specialized care is that traditional physical therapy doesn't always work for musicians. A pianist, for instance, may have pain in the hand and wrists, but trying to strengthen the hand muscles with weights or practice drills by Charles-Louis Hanon may only make the pain worse. Wrist pain, she says, is usually caused by tightness or strain in the neck or upper shoulders from bad posture.

In her Arlington studio, Gamboa tries to improve musicians' posture and then build their strength and endurance to maintain that posture. She also works to limit their practice time. But rather than waste her breath telling them to stop playing, Gamboa offers a substitute -- shadow practicing -- for example, playing piano on a tabletop.

Some musicians have also found relief from alternative therapies. Fleisher returned to the stage with both hands in 1996, after discovering Rolfing -- a form of deep tissue massage that loosened the muscles in his forearm. Others swear by movement training such as Feldenkrais or Alexander techniques.

Three years ago, finger-style guitarist Nicholas Thompson, an editor with Washington Monthly magazine, was derailed by wrist pain after playing gigs every weekend and practicing two to six hours a day. His doctors treated him for carpal tunnel syndrome. For 21/2 years, Thompson endured acupuncture, steroid shots, wrist braces, massage, huge doses of ibuprofen. At work, he tried voice-activated software, a pen mouse, typing while standing up. Nothing helped. The last doctor wanted to operate. Thomson declined.

Recently, he moved to New York, where he saw a doctor who had treated some musicians. The doctor referred him to an Alexander technique teacher who completely changed the way Thompson played the guitar. The transformation was almost instantaneous. "It seems to have cured all my symptoms," he says.

Thompson has a new CD out and is touring once more. With what he knows now, he says, "Sometimes I watch other people perform and I think, 'Oh, my God, you're going to get hurt.' "


Stephanie Mencimer is a piano-playing freelance writer and a contributing editor of Washington Monthly magazine.

Pity the poor tuba player: Listeners get a rich sound; he gets cracked, swollen lips. Instrumentalists, say experts, are prone to idiosyncratic injuries. Neck too thin?

Body too wide? Instrument design or misfit can be a cause of pain. "The flute is a biomechanically impossible instrument to play," says Sinai Hospital's Scott Brown in Baltimore. Regular playing breaks can reduce problems. Some musicians say they've found relief from alternative therapies like Rolfing.