Maturing Flutists: Problems and Solutions

1. Maturing Flutists: Problems and Solutions Stephen A. Mitchell, MD Performance Health Care Committee Nashville, TN

2. 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

3. 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

4. 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

5. 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

6. People over age 64 1900=4% 2020=17% agingstats.gov

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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.”

14. “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?

15. 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

16. 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)

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Ear Disorders and Aging • Hearing loss or distortion • Tinnitus (ringing in ears) • Wax and infections of canal

34. 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

35. 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

36. 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

37. 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

38. Prevalence of Tinnitus NIDCD.NIH

39. 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

40. 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

41. 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

42. 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)

43. 10: worry about finances 9: making mistakes when performing 8: medical problems affecting work 7: incompatible stand partner 6: disorganized rehearsal time 5: illegible music 4: playing orchestral solo 3: having problems with instrument 2: incompetent conductor 1: conductor who saps your confidence

44. 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

45. 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

46. 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

47. 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)

48. The Sign in the West Virginia lunch counter read: • Don’t criticize the coffee. • You may be old and weak yourself someday