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Famous Performer's Maladies


Leon Fleischer

During the first months of 2004, Leon Fleisher generated the first set of headlines: Forty years after a condition called focal dystonia suddenly had forced the two outer fingers of his right hand to clench and curl , their use has been restored by botulinum toxin, one of the most poisonous substances known. Receiving injections of Botox—the diluted form of the bacteria—every six months, Fleisher is back at the keyboard.

Fleischer recorded a new CD and has been ramping up his touring schedule. An edge over other pianists acquired because of the dystonia is that long ago he has mastered those rare piano works written solely for the left hand.

Administration of botulinum-A toxin (Botox-A) to the abnormally contracting muscle has been effective in reducing the involuntary contraction in several types of dystonia, most notably blepharospasm, torticollis, and spasmodic dysphonia (Cohen et al 1989: Rivest et al 1991; Tsui et al 1993). Patients with simple cramps attributable to single muscle recruitment appear most favorable for injection. Although systemic difficulties are uncommon and no episodes of anaphylaxis have been reported, Botox produces localized weakness and requires repeated administrations. Each injection costs as much as US$400. An initial injection of 60-80 units of type A Botox into the afflicted forearm muscle or its motor endplate produces 30-60% improvement, lasting 13-15 weeks. Further injections provide benefit for shorter periods. Type A Botox is one of six available subtypes, each differing in heavy chain (binding domain), and light chain (inhibits acetylcholine availability) and antigenic potential. It is likely that Botox-B, a successor, may produce lower levels of weakness that the A type (Sloop et al 1997). Doses commonly used are one-fiftieth of those producing human death.

Intramuscular injections of botulinum toxin ( Botox) are followed by a dose-dependent focal paresis which can be used to treat several focal movement disorders. Botox injections are recommended as effective for the treatment of blepharospasm, hemifacial spasm, and cervical dystonia (torticollis). Focal dystonias elsewhere (for example, writer's cramp) can often be treated with similar success. Others, such as oromandibular dystonia, are more difficult to treat. In the case of more generalized dystonias, some focal muscle spasms can be treated with success by local intramuscular injections. New indications are still being investigated, for example in focal tremors and spasticity. Side effects are in general slight and disappear at the end of toxin effect. In general, it is necessary to repeat the injections after a couple of months, due to a cessation of effect after regrowth of nerve terminals. New injections have similar effects even over years of treatment.

Even though the usefulness of Botox in patients with focal dystonias, hemifacial spasms, tremors, and other disorders causing muscle spasms has been demonstrated by a number of clinical trials, it is important to continue searching for new and more effective neuromuscular blocking agents. It is hoped that as a result of better understanding of the pathophysiologic and etiologic mechanisms of dystonia, symptomatic therapy will be ultimately replaced by therapeutic interventions designed to actually alter or cure the cause of this neurological disorder.



An unprecedented keyboard technique - Glenn Gould

Canadian pianist Glenn Gould presents a unique case study concerning the influence and interdependence of physical and psychological factors in the artistic development of the musician. Based upon review of his medical history, it has been stated that in biomechanical terms, Gould may have been almost completely unsuited for a career at the piano. There is persuasive evidence that for virtually his entire career Gould struggled against and adroitly finessed critical limitations in upper body, forearm, and hand movement. Gould’s unpublished 1977-78 diary details the second of two major physical crises that disrupted his playing, the first of which preceded his departure from the concert stage. The second crisis, which began 5 years before his death, strongly suggests that he had developed focal limb dystonia. If this is so, his subsequent return to the recording studio would represent an unprecedented example of a musician’s recovery (or partial recovery) from that disorder through retraining.

On his technique, Gould states:

Gould Relaxing on his personal chair, customized for him by his father


“Like my former teacher at the Royal Conservatory, Signor Alberto Guerrero, I have developed a playing technique which involves a rather hunch-backed approach to the piano. It has its advantages and its disadvantages. On the positive side I gain finger clarity, better definition and feeling. On the negative side, it’s difficult for me to get a really big sound, as in some of Liszt’s fortissimos … Sometimes I get so carried away in a performance that my shirt-tail comes out or, as some friends have complained, I look as though I were playing the piano with my nose. But these aren’t personal eccentricities – they’re simply the occupational hazards of a highly subjective business” (Gould, undated letter).

The first crisis occurred in 1959, following an incident at Steinway and Sons in New York. Gould reports that Willilam Hupfer, chief Steinway Piano Technician, trying in a coarse way to be friendly, slapped him on the back. The move was a shock and surprise to Gould and caused him to subsequently experience a sense of fatigue, aching and incoordination of the left arm and especially the left hand. Gould sought a number of treatments, including massage and chiropractic treatments. Although Gould returned to the stage after this incident, his ambitious concert schedule was in a steep decline from that point forward.

The second crisis occurred in 1977-78. Curling movements of the fourth and fifth fingers, especially in the left hand, typical of pianists with focal dystonia happen frequently during this time. Evidence of this can be obtained from films. In earlier films, abnormal finger movements are rare. Films immediately prior to that period may indicate a dystonia, but are not conclusive. Gould however, did stop all performances for a period of approximately one year.

Gould almost certainly developed a mild thoracic outlet syndrome in his teen years (as do many teenagers, when rapid lengthening of the spine predisposes them to slouch) and may have had the misfortune to have as a teacher a man who – if Gould’s assertion is correct – thought this was the ideal posture for playing the piano. Almost certainly, as well, he had areas of muscle tightness in the neck and upper back and around the scapula (as reported by the chiropractor who saw and treated hi in early 1960). To complicate matters further, it is not unlikely that Gould’s apprehensiveness about playing, from the beginning, was as much a reaction to an uncooperative musculoskeletal system, as to any purely psychological stressor. The two are not mutually exclusive, and in fact would have reinforced and aggravated one another.

Since Gould recorded again 3 years of so after his second crisis, did he ultimately solve the problem? Did it eventually subside on its own? Or did he simply discover a way to play around it? Whichever explanation is true, this is certain: Gould may or may not have been a confirmed hypochondriac, but he was no fool. He was as deeply in tune with his own body as he was with music, and when the hand problem forced him to stop work in 1977, with his career at stake and apparently convinced no doctor could help him, he turned his studio into an experimental laboratory with his own body as the object of inquiry.


Gary Graffman

By the age of 20 Gary Graffman made a name for himself as a classical pianist both in America and world-wide. The next three decades saw him touring, performing solo as well as with symphonies and orchestras. He was at that point known as one of the greatest living pianists of all time.

With great success Gary Graffman played until 1979. He then suffered an injury to his right hand. Upon visiting numerous physicians, his symptoms were referred to as “bizarre” and “exotic”.

One of Graffman’s greatest contributions to Music Medicine is having admitted his injury in public. In 1981 a New York Times article written by dancer critic Jennifer Dunning, entitled “When a Pianist’s Fingers Fail to Obey”, described Graffman’s and Leon Fleischer’s injuries. He also published an article “Dr. Can you Lend Me an Ear” In the 1986 the first issue of the quarterly journal "Medical Problems of Performing Artists". Here he described the lack of understanding he experienced from all the doctors he had visited. He relates: “My blood pressure was checked, my urine analyzed, my inner ears probed, my chest thumped, and finally, my brain scanned. (“Brain’s fine!” the technician cheerfully informed me. “Nothing there!”)

A deluge of letters to Graffman followed the publication of these articles by afflicted musicians As Graffman said "... instrumentalists' hand problems - somewhat like social diseases - were unmentionable. Understandably so: If a performer is still performing, or hopes to get back on the road soon, he'd be crazy to advertise his disabilities. Nobody wants a wounded pianist. There is an oversupply of healthy ones. Admitting difficulties is like jumping, bleeding, into piranha-filled waters.”

In 1986, he was appointed director of The Curtis Institute of Music, a world-renowned conservatory. His musical genius shone again in 1993 when he once again performed regardless of his injured right hand. He joined with Andre Previn and the Curtis Institute's Symphony Orchestra to perform Ned Rorem's Piano Concerto No. 4, written specifically for the left hand. With more than four decades of concerts, recitals and performances, Gary Graffman proved that anyone, despite obstacles, can succeed as a musician.




Mr. Leisner is an extraordinarily versatile musician with a multi-faceted career as an electrifying performing artist, a distinguished composer, and a master teacher. Regarded as one of America's leading classical guitarists, his superb musicianship and provocative programming have been applauded by critics and audiences around the world. He has been acclaimed as "a triple-threat performer" by The New York Times and a "serious, exploratory and imaginative musician" by The Boston Globe.

Mr. Leisner's career as a guitarist began auspiciously with top prizes in both the 1975 Toronto and 1981 Geneva International Guitar Competitions. In the 1980s, a disabling hand injury, focal dystonia, cut off his blossoming performing career in mid-stream and plagued him for 12 years. Through a pioneering approach to technique based on his understanding of the physical aspects of playing the guitar, Leisner gradually rehabilitated himself. Now completely recovered, he has once again resumed an active performing career, earning accolades wherever he plays.

During the time he was unable to perform, Mr. Leisner became a highly respected composer noted for the emotional and dramatic power of his music.

A revered and distinguished teacher, David Leisner is currently co-chairman of the guitar department at the Manhattan School of Music and taught at the New England Conservatory for 22 years. His lively master classes have been featured at such institutions as the Royal Academy of Music, the Royal Northern College of Music, Graz University, Yale University, USC, the Cleveland and Peabody Institutes of Music, San Francisco and Cincinnati Conservatories, and many schools and music festivals around the world.

Can particular syndromes enhance performance?

Not all ailments necessarily hinder an artist’s performance. Nicolo Paganini . Musical magician and Marfan mutant? . an article published in JAMA dated 2 January, 1978, Dr. Myron R. Shoenfeld advances the theory that Paganini was born with Marfan's Syndrome: "The long, sinuous, hyperextensible fingers of his left hand gave his fingers an extraordinary range of motion and freedom of independent movement on the fingerboard, while the laxness of the wrist and shoulder joint of his right upper extremity gave him the pliancy required for masterful bowing. The evidence for this hypothesis necessarily is inferential, but, I believe, convincing and even compelling. ...The picture clearly emerges, then, of the Marfan habitus; a tall, thin man with long fingers and hyperextensible joints.





Paul Wittgenstein

Paul Wittgenstein, ( May 11, 1887 – March 3, 1961), Austrian born pianist, did not suffer from a performance induced injury, but he did play an important role in the creation of many of the currently popular piano works for the left hand. Wittgenstein’s injury came in the form of a tragic accident during the outbreak of World War I, upon the assault on Russian Poland. It was then that Paul was wounded and taken prisoner; Russian surgeons had to amputate his right arm. Perhaps because he grew in an extremely successful industrialist family, Wittgenstein’s resolve was quite remarkable. A novel – “The Crown Prince”, by John Barchilon is based on his life accomplishments: After a year of captivity, he was exchanged and repatriated. He continued to serve in the military until the end of the war. It was then that he began practicing piano again, only with his left hand. After several years, he began performing in public, again to great reviews, some listeners even thinking he must still have at least two hands. His efforts were hailed as new heroism by a battle-scarred Europe. Upon his success, he used his influence to commission new piano left hand alone works, among them Benjamin Britten’s Diversions, concerti by Hindemith and Prokofiev. The work which became synonymous with his name however is Maurice Ravel’s Concerto for the Left Hand.





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