Maturing Flutists: Problems and Solutions

Stephen A. Mitchell, MDPerformance Health Care CommitteeNashville, TN

Who is this guy and why should I believe anything he has to say?

Treating professional musicians for over 30 years

Member NFA & Performance Health Care Committee Formally know as Dysfunction Committee

Founding member PAMA Spouse of professional flutist Singer with experience touring

internationally and recording He’s getting older and feeling it

Maturing: definitions

PC way of saying “deteriorating” according to some youngsters

“Chronologically challenged” Delicate but inaccurate word for

this talk since: aging is inevitable but maturing

is optional

Self Test You know you’ve been playing the

flute for too long when: You tongue while whistling You hold pens upright on your knee You can play 4 different Bb’s You’ve had a piccolo stuck to your

tongue

Sobering Facts:

You grow old or die young. Period. All parts wear down with time.

People are no different than cars, except that you can’t trade in. Some religions beg to differ

“Middle age is when you still believe you’ll feel better in the morning” Bob Hope

People over age 64 1900=4% 2020=17%

agingstats.gov

Political pressures to delay retirement age

“Full retirement age (also called "normal retirement age") had been 65 for many years. However, beginning with people born in 1938 or later, that age gradually increases until it reaches 67 for people born after 1959.” www.ssa.gov

Other political pressure

The American Academy of Actuaries, which advises policymakers on risk and financial security issues, wants any potential solution the White House and lawmakers might consider to include raising the retirement age from the current range of 65-to-67-years-old. CNN Money.com 8-1-2008

More political pressure to come

“The age of retirement should be raised to 85 by 2050 because of trends in life expectancy, a US biologist has said.” Paul Rincon BBC News, 2-17-2006

The kids in the audience can stop being so smug now

Practical pressures to work longer

Poor planning when young for pensions

Poor rate of savings for Americans Easy credit=high debts, loans,

credit card Never tuning in Dave Ramsey

More practical pressures

Social Security is not adequate and the USA has not gone socialist ………….yet

Direct & indirect taxes increasing High cost of health insurance if self

employed “When I told my doctor I couldn’t afford

an operation, he offered to touch up my x-rays.” Henny Youngman

Pleasure pressures to work longer

Enjoy the challenge Playing is still fun – beats being an office

gopher in a cubicle Makes us special – few can do what we

do –”amaze your friends” Can keep sounding impressive by

dumbing down the repertoire – like moving from the blue tees to the red tees in golf but less embarrassing

Mischa Elman, violinist 1891-1967

“You know, the critics never change; I’m still getting the same notices I used to get as a child. They tell me I play very well for my age.”

“Do not go gentle into that good night, Old age should burn and rave at close of day” DThomas

What are the details of what to expect as we age?

How an these impact playing flute? What can I do now, if young(er), or

what should I have done in past? What can I do now that I’m having

problems besides wail and gnash?

The ugly details of what to expect

The fingers, the wrists, the shoulders, the back, the hips, the feet, the neck, the brain, the nervous system, the lungs, the teeth, the jaw, the eyesight, the hearing are all adversely affected by aging and activities of our youth.

“No man is rich enough to buy back his past.” O. Wilde

Bone and Joint disorders Arthritis: 60% of population will be

symptomatic by age 65 and it accounts for 25% of all primary care doctor visits

Women comprise 60% of cases Incidence goes up with age Worse with excess weight, hormone

changes (menopause), lack of exercise, and repetitive injuries to joints (i.e.: flutists are usually 3 for 4)

What to do for B&J Avoid unnecessary joint trauma Use non-injurious practice methods Treat hormone abnormalities (+ -’s) Anti-inflammatory meds to slow

permanent damage Keep weight down Exercise early, smart, and forever Choose your parents wisely

Muscle Atrophy Sarcopenia: gradual decrease in the

ability to maintain skeletal muscle function and mass, associated with aging, unknown cause.

Can be slowed by exercise but need to start exercising early to minimize looming permanent muscle cell loss

“Getting older is no problem, you just have to live long enough” G Marx

Posture No proof that bad posture is an

unavoidable part of aging Requires more work to prevent as

muscles get weaker (sarcopenia) and as discs between vertebra shrink

Practice good posture early and keep it up (Quasimodo was a percussionist, not a flutist)

Key component to many therapies

Brain and Nervous System Steady decline in some cognitive skills

starts in 30’s: more problems with new memory skills than old memory skills

“With increasing age the occurrence of the (jaw)reflex was reduced, the latency was increased, while the amplitude was decreased. Those findings are probably related to the general age related changes in the muscular tissue, the sense organs, the peripheral nerves and especially the central nervous system.” A. E. Kossioni

What to do for brain and nerves Keep mentally active. Exercise the brain like a

muscle Keep emotional links active to other people Avoid alcohol. It can kill brain cells and destroy

nerve function and cause tremors Aggressively treat diabetes and vascular

disease and never smoke. These clog the blood vessels that carry the only oxygen the nerve cells receive. Once they are dead, they are usually gone for good

Hand and Finger

Hand function decreases with age in both men and women, especially after the age of 65 years. Deterioration in hand function in the elderly population is, to a large degree, secondary to age-related degenerative changes in the musculoskeletal, vascular, and nervous systems. E Carmeli

What to do for hands and fingers

See previous slides Avoid unnecessary injury (rugby, handball) Avoid overuse, misuse when practicing Ergonomic rules and tools to match instrument,

chair, music stand, computer, etc to the individual.

Persistent pain is BAD. Do not think macho is wise. Find the cause and fix it immediately

If injured: RICE (rest, ice, compression, elevation) immediately

RICE Therapy Rest: Reduce activity, splint the injury, and

keep weight off area Ice: Ice packs reduce pain and swelling.

Applied for 20-minute periods to avoid ice burn. Remove packs for intervals of 40-60 minutes before reapplying.

Compression: Lightly apply an elastic wrap so that it reduces swelling. If it seems too tight or causes swelling below the wrap, loosen it.

Elevation: Holding the injured part above the level of the heart. www.nwortho.com

After RICE Therapy Restore strength: begin after 60 - 70% of

normal motion has returned. Restore motion and flexibility: warm up

before exercising and stretch after. Stretching improves muscle flexibility by approximately 20%.

Restoring balance: the use of a balance board or do one-legged exercise.

Finally: use a brace to provide additional support and protection for the first few weeks. www.nwortho.com

Respiratory Function (wind)

Several factors alter the mechanical function of the lung with age.

1) a decrease in motor power due to fewer muscle fibers and a decrease mechanical advantage

2) an increase in parenchymal compliance decreasing elastic recoil of the lungs and ultimately a change in structure and function of the chest wall due to a loss of intervertebral spaces

3) a stiffening of the chest wall from changes in ribs, sternum and articular cartilages making the chest less expansible. BK Ross

What to do about lungs Never smoke !!!!!!!!!!!!!!! Avoid pollution Diet: high fruit and vegetable intakes have

been most consistently associated with protective benefits in visual loss, cataracts, respiratory disease, and cancers such as breast, stomach, and colorectal

Deep breathing (ALA, yoga, etc) Treat asthma with maintenance med, avoid

rescue med

Embouchure

Status of teeth and gums mainly dependent on how well they were cared for in the preceding decades

“floss them now or toss them later” Dentures don’t have nerves Mouth gets dry (fewer glands, more

medications) Lips & tongue move slower

What to do about embouchure

Brush and floss like mama told you Keep own teeth even if it costs more More water, less Dr Pepper Biotene products "If I had known I was going to live this

long I would have taken better care of myself"Hermann Doernemann at age 110

Aging Eyes

less able to produce tears retinas thin with risk of detachment lenses gradually turn yellow and

become less clear In 40’s focusing on objects that are

close up may become more difficult Either that or arms are shorter

National Institute of Aging, NIH

More aging eyes In 60’s colored portions of your eyes

(irises) stiffen, making your pupils less responsive & difficult to adapt to different levels of light

Become sensitive to glare, problem when driving at night

Cataracts, glaucoma and macular degeneration are the most common problems of aging eyes

What to do about aging eyes

Regular eye exams to catch problems early (stitch in time)

No smoke (increase ocular pressure) More light needed to see by More eye glasses for different tasks Don’t waste money on “Bates eye

exercises” squishing your eyeballs Keep eyes well lubricated

Ear Disorders and Aging

Hearing loss or distortion Tinnitus (ringing in ears) Wax and infections of canal

Hearing loss

1 in 3 over age 60 with significant hearing loss

Worse with vascular disease, noise exposure, some medications, family history

Injury in orchestra players suspected to occur but difficult to prove

American Speech-Language-Hearing Assoc

What to do about hearing loss Baseline hearing test by age 40 Ear/hearing check if change noted by

you or family/friends Avoid unnecessary loud noise (iPod,

concerts, lawnmowers, workshop) Hearing protection every chance (ER-

20, ER Custom plugs, Mack’s HiFi Ear Plugs)

Hearing aids if needed. Fit is key

Immediate Tx for noise blast

NAC (N-Acetyl-Cysteine) is a precursor to glutathione and may be effective in preventing hearing loss from noise trauma. Clinical trials are using 900 mg of NAC three times daily to reverse the effects of noise trauma. Therapeutic window for preventing damage is 3-5 days after the trauma. OTC med Bielefeld, et al

Tinnitus (ringing) Common problem over age 40 (men

> women Usually due to injury to tiny inner ear

nerve “hair cells” Frequently noise exposure history Any vascular disease can cause Meniere’s disease special case with

different treatment NIDCD.NIH

Prevalence of Tinnitus NIDCD.NIH

What to do about tinnitus Protection same as hearing loss Testing to be determine if it is a

treatable or more hazardous problem White noise to drown out silence Reduce stress & stimulants Bio-feedback & hypnosis may help N-Acetyl-Cysteine may help Hearing aid-like masks

Wax and ear infections

As ear canal skin ages, it dries, sheds more dead skin cells

Ear wax glands reduce in number and effectiveness with time

These mix and either block the ear or fail to prevent bacteria from growing in the canal, causing infections

What to do about ear wax

Keep the car keys and q-tips OUT of the ear canal

Use mineral oil drops if dry & itchy Use swimmer’s ear drop if hurts Use wax softener and bulb syringe to

wash ear if blocked with wax See your doctor if all fails

Stress

Most of the problems listed so far are worsened by stress

Ian James 1997 BAPAM survey from 56 world wide orchestras showed stress was a serious problem with the instrumentalists

Top Ten list of causes of most severe stress: (apologies to D Letterman)

10: worry about finances9: making mistakes when performing8: medical problems affecting work7: incompatible stand partner6: disorganized rehearsal time5: illegible music4: playing orchestral solo3: having problems with instrument2: incompetent conductor1: conductor who saps your confidence

Stress continued

73% had moderate to severe stress from working with a conductor who sapped their confidence

61% had severe to moderate stress with incompetent conductors

Definition of an assistant conductor: a mouse trying to become a rat

Rob SteinWashington Post Staff WriterTuesday, November 30, 2004

Scientists have identified the first direct link between stress and aging, a finding that could explain why intense, long-term emotional strain can make people get sick and grow old before their time.

there is no such thing as a separation of mind and body -- the very molecules in our bodies are responsive to our psychological environment

Washington Post continued If someone appears headed for trouble,

doctors could recommend meditation, yoga or other stress-reduction techniques, she said.

"The findings emphasize the importance of managing life stress, to take it seriously if one feels stressed, to give your body a break, and make life changes that promote well-being," Elissa Epel, psychiatrist UCSF

Philosophy of Life Choice

“I know a man who gave up smoking, drinking, sex, and rich food. He was healthy right up to the day he killed himself” Johnny Carson

“Age is strictly a case of mind over matter. If you don’t mind, it doesn’t matter.” Jack Benny

(both lived until 80)

The Sign in the West Virginia lunch counter read:

Don’t criticize the coffee. You may be old and weak yourself

someday