TTTV070: Avoiding Pianistic Injury with Dr Bronwen Ackermann

Tim: Bronwen, welcome to the call today.

Bronwen: Thank you, Tim.

Tim: Thank you very much for coming on. It's a Friday afternoon here in Australia, and I'm sure you, like me, are just itching for a class of wine or something. I certainly am.

Bronwen: Exactly.

Tim: But today, we're here to talk about something that's very interesting for me, which is all about technique, and particularly you as a physio. That's, I think, one of the things you do. But getting a specialist on to talk about ways in which we as teachers can help give our students the most fluid and comfortable technique, and avoiding giving them any sort of starters of getting injured, which would just be a terrifying thing. So hopefully we can chat about some of those things today. But before we begin, can you just give everyone a quick overview on some of the music-related roles that you have at the moment?

Bronwen: Okay, so one of my... I've been a physio since, well, the late '80s, and I started getting involved with musicians surprisingly early on. I did start in late sports performance like a lot of physios do, but I was working in an unusual clinic that had a lot of performing artists coming there as well. I'd played instruments myself as a kid, so when I starting seeing musicians...and I certainly saw some other actors and dancers and things as well, but the musicians had intrigued me, because as a child I played a few different instruments, but hadn't obviously gone on to pursue music in any sort of serious way. But I just assumed that... I had quite a, I guess, catastrophic soft palate injury playing the clarinet, and it certainly stopped me playing. And at the time people, actually, my doctors kind of laughed at me and said they never heard of it, and now I think we know a little bit more about some of these injuries. But I was sort of intrigued that a lot of the professional musicians I was working with didn't know more. I thought, "Okay, I was at school, I might have been unlucky." And then I realized, actually, there just wasn't health information readily available, and you know, all these performers were coming in with injuries that I really felt could've been much better prevented just by the slightly better habits. So very early on, right at the beginning of the '90s, I got interested in this and that led to me going on tour with orchestras...from '95, I've been on lots of international tours with a few different orchestras.

These days I've been touring with the Australian Chamber Orchestra. I've toured in the past with Sydney Symphony and New Zealand Symphony, and my job's to keep people on stage. One of the interesting things with this role is that I obviously get to meet a lot of international performers. Obviously, we have quite a few piano soloists on tour or pianists traveling with the orchestra as part of this, but I became very interested in the sort of lifestyle habits, way they practiced, all sorts of things that quite frankly just weren't as health-based as they are in things like sports medicine and other medical domains, and it sort of started off this interest in trying to find out more and do more. You know, there's only a limited amount you can do as one physio trying to take on this problem that was hard to understand because there wasn't a lot of information easily available. And it led to me doing a PhD, actually. So I was working in this clinic seeing a lot of musicians, and I opened my own clinic actually down in Canberra for 10 years and, again, saw a lot of performing artists, particularly musicians down there.

And I ended up doing a PhD looking at ways to prevent musicians' injuries, and this actually now has sort of led to me going back to Academia. So I still do physio, I still do music physio. I just see musicians now, and for a range of things, not actually anymore just dealing with injuries necessarily, also dealing with performance-related issues. So sometimes the teacher sends someone to me going, "Oh, their finger's doing a funny thing on the piano. Can you work out what it is?" You know, they might not actually have a pain or injury, per se. So I went back, did a PhD, and then kind of got absorbed in the process of trying to problem-solve, if you like. So now, through a series of events, I ended up... My current role, I guess, is working, teaching anatomy in the medical school, so I teach applied anatomy. And actually, next year, I'm starting a series of courses for musicians on anatomy, too, because I think some basic applied anatomy is super important to understand, just not too overwhelmingly complex in terms of details, but complex enough that you kind of understand why some things are important and why some folklore is good and some folklore is bad.

Tim: There's a lot of folklore around.

Bronwen: There's a great rate.

Tim: Yeah.

Bronwen: Oh, yes. Oh, yes.

Tim: I have to say that one of my...

Bronwen: And sorry, last role... Sorry, yeah.

Tim: Yeah. No, go on.

Bronwen: I was gonna say, the last thing is I'm also editor of the "Medical Problems of Performing Artists" journals, so there is actually a journal that focuses specifically on trying to lift the awareness of issues in performing artists and trying to find solutions to them.

Tim: There you go. I had no idea that existed. "Medical Problems of Performing Artists" publication. So that's Googleable, is it? People could find that?

Bronwen: It is indeed.

Tim: Fantastic.

Bronwen: It is indeed.

Tim: I must say that one of the very first blog articles I ever wrote was about two things. One was about weight training for pianists because I was starting a weight training program and I was practicing piano at a reasonably high level, and so I was trying to do some research and there wasn't a whole lot of research about that, so I just decided to try and do things my way and I wrote about that in an article. But I also, as part of that, decided to look into actually how the hand works because it's phenomenal, it's phenomenally complex. And I really hadn't got an appreciation until I saw... I quite like medical stuff, so I actually saw someone pull a hand and arm apart. What do you call that? Dissecting.

Bronwen: Dissect, dissect, yeah.

Tim: Fascinating. And I had no idea that all your fingers are all controlled from... I don't know if they're called muscles, but whatever...in your arm, in your forearm and your upper arm, right?

Bronwen: Forearm.

Tim: Yeah...

Bronwen: Oh, completely, yeah.

Tim: It's amazing, and so all of those things, what do you call them that pull the fingers up and down? All the ligaments are they? I don't know.

Bronwen: Tendons.

Tim: All the tendons.

Bronwen: Tendons.

Tim: Yeah, they've all gotta go through that tiny little carpal tunnel in your wrist and so that's why getting the wrists in the right position, I guess, is really important. We're gonna talk about that a little bit later on, but yeah, I find it fascinating. And it's just bewildering that it actually works at all.

Bronwen: I know, it's pretty clever.

Tim: So look, you have an extraordinary number of articles to your name. I was looking some of them up before... I'll read a couple of them out because I think they're...the titles are just amazing. "The difference between standing and sitting in three different seat inclinations on abdominal muscle activity in chest and abdominal expansion in woodwind and brass musicians" was one that I found in "Frontiers in Psychology." "The usefulness of on-site physical therapy-led triage services for professional orchestral musicians - a national cohort study." And I also found, "Finger movement discriminations in focal hand dystonia: the case study of a cellist." And I thought, "Wow." I mean, you have covered an enormous range of issues of instruments of context. So, right up from the front of our discussion, what's been your most enlightening or important finding, do you find, in this area?

Bronwen: It kind of depends on how you define 'enlightening'. I think one of the things that I'm working on particularly at the moment that's really important is, I guess, the interaction between how your mental state is, so whether you're feeling depressed, fatigued...I mean 'fatigued' in a mental sense, also muscle fatigue, and how likely that is to impact on developing pain or movement dysfunctions when you're playing. So in a strange way at the moment, I'm kind of absorbed in the complexity of it all, because we've been looking...we just published a study this year with a violinist actually, but we're doing a similar thing at the moment. I'll talk about the piano stuff in a minute, but where we looked at things like what happens when you have pain to the muscles that you use when you're playing.

And we see really quite different muscle patterns happening for the people that have pain compared to the people that don't have pain. And of course, while it's hard to say, was it the way that they moved that caused the pain, or are they now moving strangely because of pain? Either way, it's important. We're sort of seeing a change and we're also seeing changes in muscle activity pattern if people are feeling particularly stressed. And this in a very interesting area, because I think, while I want to talk about the physical side more, I've worked quite extensively with psychologists collaboratively, if you like, in these projects because you know, I really have to respect that there's a lot of, perhaps partly due to misinformation, but there is a lot of fear around injury and so people get terrified that if something goes wrong, that's it, it's the end of their career, rather than perhaps knowing some rational first steps to take to try and manage the injury, not over practicing as a...not reacting to an injury by practicing more or, perhaps just as bad, doing nothing for three months, and that's also not a particularly good strategy.

So then of course, you get depressed because you have this pain in playing it, and it makes it much harder for people like me to work with something that probably was a physical strain then becomes all kind of convoluted. So I'm looking a lot at fatigue, pain, and muscle activity during performance at the moment, so it's kind of not the simplest answer, but it's a very, kind of fundamental answer in terms of how we can try and prevent people hurting themselves. And possibly with piano, one of the big issues is this over practicing issue, practicing beyond the point of fatigue. Once your muscle's out of fuel, it's out of fuel. You've gotta stop and refuel. If you don't, you're just gonna change what you do or start hurting yourself. You know, some of these fundamental things, you know, how much is too much? Such an interesting thing to try and delve into.

Tim: Yeah. I mean, most of my audience are teachers of, I guess, beginners, intermediate, lower level students. There might be some teachers of the really advanced. But I mean personally, I've never taught any student at a tertiary level that's likely to practice too much, too hard, too long. So that hasn't been an issue for me so much, but I'm really interested to talk about, right from the beginning, are there some things that we should be keeping an eye on as piano teachers when we have our young students play for us?

Bronwen: Yes, I think a very fundamental thing that perhaps sounds super simple is make sure your kids have had something to eat or drink before they play, I mean, just to help their muscle fuel and concentration. How they sit at the piano is really, really important from very early on, and I know while watching all my three kids go through piano training, of course, their teacher was good with watching this. But of course, as they're growing, we have to modify and teach them. There's sort of some tricks you can teach kids, too, helping them sit in a way where their reach is enhanced. So there's a bit of a tendency to perch the kids too far forward on the piano stool, so thinking, "Oh, they're little, so we'll perch them right at the front so they can get their feet on the stool or the floor" or whatever you're using. But you have to be careful not to perch them too far, because what happens is the way the pelvis is designed even in little kids is there's an inherent... You have to make sure the child doesn't feel like they're slipping off the chair even subconsciously, you have to make sure that if they leaned forward, they would be in no danger of slipping. That's one of the simplest things to do is get them to sit and then get them to reach their arms out, you know, reach towards each end of the piano and lean forward, and just make sure they feel nice and secure in their seat.

Tim: Stable.

Bronwen: Yeah, and when kids hit their growth spurt, too, they tend to slouch a lot partly because bones grow faster than muscles, so the muscles actually have a bit of trouble just keeping up with the bones, so they get tired a lot quicker. So in that stage, we have to kind of reset them. Sometimes, they might even need to stand up and move around a little bit between pieces or something that you're teaching just to try and flush some blood through the muscles and get them to reset posture. So their sitting posture is super, super important, and sitting in a way where the pelvis is enough on the seat that they're not gonna slip off so they need to stick their bottom out as they sit down and sit on the front side of the stool, but not so much that they don't have some feeling of securities that they can lean forward and not feel they're slipping.

Tim: Yeah. And I know that a lot of the time when you're getting really young kids to play with the pedals, If there's no pedal extender or a box, they'll half stand up almost. I certainly see that. Is that a bad thing?

Bronwen: It's not ideal. Sometimes, in that case, it's better to have them on a chair with a wedge cushion, like to get them...or use a chair that has an incline. I know most studios don't have that, but even if you have the piano stools...

Tim: An incline forward?

Bronwen: Yes, incline forward so that they're actually supported in a way where they can still have their pelvis on the seat, but it almost puts them in a position where it's much easier for them to reach the pedal. I was gonna say almost puts them towards the standing direction sort of sitting, so easier for them to get good support and still use their balance.

Tim: Yeah, and I mean for arms parallel to the floor is what I've always been recommended.

Bronwen: Right, so what we wanna try and do is keep the wrist in what for the wrist is a good range, that's sort of where the arm position comes into it. But generally, the knuckle should be slightly higher than the wrist. Now, that's sort of the amount, if you put your arm out with your palm facing towards the roof and just relaxed your hand, you'll find your knuckles fall a little bit below that front part of your wrist. So your hand just sits there in a curl. That's approximately a functional hand position. So if you just stick your arm out straight, let your hand relax, it usually falls in a roughly functional position. It's quite similar to holding a normal size glass of water or something. It's that holding a glass of water, but face down. So we want slight knuckles...

Tim: Yeah, so the top of the wrist isn't necessarily perfectly in line with the top of the hand? It'll be a little bit...

Bronwen: No, in fact, it should be a little bit up.

Tim: Yeah, okay.

Bronwen: And then in that case, roughly parallel to forearms with the floor, that's right. And we certainly...if you sit the child properly, or anyone, if you sit properly on the chair where you have good support of your pelvis, one of the, I think, really key things that kids should understand from the beginning is the concept of how three-dimensional movement helps reach in piano performance. So for example, if you've got your arms in front of you and they're tending to chicken wing or stick their elbows out as they're perhaps growing a little bit, trying to adjust to their size...if they're sitting in a good position, they can actually take their weight a little bit backward kind of towards the sit bones of their pelvis, which should be right at the back kind of of how you're sitting when they're playing in front of them. And as they go to the either end of the keyboard, then they put weight forward more onto the very upper part of their thighs that's on the chair or perhaps even their heels on the floor. But this kind of, this movement of the body backward and forward helps keep your arm parallel. Piano players tend to do a lot of two-dimensional crabbing sideways up and down the chair and it's actually unfortunate. Really, from the beginning, they should realize that a little bit of forward and backward is actually quite essential to keep your trunk aligned in a way that helps your arms achieve an ideal position.

Tim: And that's made me think about one of the techniques that I've followed for some time which is the Taubman technique. Are you familiar with that?

Bronwen: Yep.

Tim: So what are your thoughts, from a medical practitioner's perspective, of what the Taubman technique teaches in regard to rotation and free movement and in-out movements and that sort of thing?

Bronwen: I think a lot of these kinda different piano techniques have merit. There's interesting... Because of the work I do, I try and, I guess, tune into all the different techniques, so I'd done some research on Taubman and been involved with one of the people, one of the pianists in Australia who'd done some research on Taubman, Therese Milanovic. Yeah, and then I've also met Barbara Lister-Sink and some of these other people who have other movement freedom techniques on the piano. And it's interesting, because they come from different angles and are actually working on slightly different things, but they sort of work on components of anatomical release.

So I have to say as a physio, in my kind of particular special interest, is the way we move and how we use muscles, this kind of applied, musically applied anatomy, I guess, is my thing and I am... The rotation that...like when Dorothy Taubman herself did a basic anatomy course, and for her, that rotation unlocked a lot of issues, and it truly is quite an important fundamental movement to orient your palm in space. I mean, you're going...you're sort of in more pronation when you're pressing with your thumb and more supination with your little finger, there's a little bit of rotation happening all the time just in basic techniques. I don't think that the various...and I'll just use completely wrong physio babble terms here, but I think that sometimes when you play the piano, you need to think of it a little bit flexibly, that yes, that rotation technique...there's a lot of areas where that might be a predominant thinking, but the wrist drop technique or whatever that's called...I mean, this is also very useful in certain kind of playing and even the rolling forward or the pushing back with the arms, I find that there's all sorts of ways we can release or encourage freedom of movement that's not only rotation. But rotation's very important, so I think there's a lot of value in that Taubman approach, but I also think there's...it can be even bigger than that, that depending on what you're playing, you might find that instead of focusing on rotation, you wanna focus on arm extension and releasing tension that way or taking your fingers, following through past the keyboard and towards the music direction and towards the actual piano. That direction might work better with what you're playing.

Tim: It's about freedom of movement ultimately, though, isn't it? If a student is ever fixed and rigid in their playing, that's gonna be causing tension, that's likely...may have some issues down the track, but if there's a continual kind of freedom of movement, that's a good thing. That's my kind of approach, I guess.

Bronwen: One hundred percent.

Tim: Yeah.

Bronwen: Yeah, yeah. So anything, where you're stiff is working twice as hard as when you're not stiff, in a way, because you are using the opposite muscles to stop the other muscles working too much. So it seems that you're creating a bit of World War III in your forearms, and this is not good for anyone. The other kind of thing that creates too much work is kinks in the wrist. So if your wrist is really bent whether it's sideways or up in the air... Muscles, when you bend out of bounds, so to speak, when your wrists are way out of bounds and they're there for too long...so if your thumb, say, was in line with your forearm and you had your wrist kinked to the little finger side...and you see that a lot in kids learning piano. Sometimes they're a little...I feel like they're not reaching enough with their thumb or they just don't realize that the middle finger is the center of alignment of their hand, but with that kind of position, you lose a lot of power. So muscles need to be in a...they have more strength if they're in the middle of their range, or even if they're slightly lengthened they still have strength. But when they're shortened...so when you do this kind of kinks in your movement, you make the muscles on the front of your arm too short and then you have to use all of them to get the job done. So if a muscle's short, it can't contract effectively, so you have to use all of the muscle fibers. If the muscle's in the middle, it can contract quite effectively, so you might only have to you use half of the muscle fibers. So on average, when you're playing with a really kinked hand, it's going to be 25% harder than if you don't play with a kinked hand. And this sort of means, when you have students doing this, that they just can't practice as long as the other students, they're gonna get tired faster.

Tim: I have always found it interesting that we look at some of the famous artists out there, the big name from the past, Glenn Gould and his incredibly low sitting position, Horowitz's very flat hands...he never looks like he's doing...like he's just playing with flat hands. How do they get away with it, these artists that seem to be breaking all the rules?

Bronwen: I guess when we talk about "getting away with it," I don't mean this to be negative, but people like Glenn Gould actually had a pretty awful medical history. Like he had pain and problems all the time, he had a lot of performance anxiety. He actually was probably an example of someone who was a brilliant musician, but his positioning and technique wasn't doing him any favors, actually. There's a lot of medical literature written about Glenn Gould, but there are a lot of techniques out there, but there's a lot of body shapes and structures and even when you talk about composers or something, you know, and you look at Mozart vs. Rachmaninoff or something, this is people who've written around a completely different dimension. This is a whole other big thing I'm quite interested in, the size of your hands, what you're playing, how do we get these little kids playing this big repertoire on these big keyboards. These modified keyboards are certainly interesting, this idea that perhaps we should do what other instruments and doing...

Tim: And make three-quarter size or whatever.

Bronwen: Yeah, and grow with them. It certainly seems possible on any other instrument with muscle memory and things to adapt, so I don't think it's an impossible concept. But I think with these performers, for me, you're talking about muscle efficiency and flow and this movement from the center, like when you were talking about this kind of freeing the arm and letting that rotation and force transmit. Nearly always with these players, even if they look slightly different, that they're, A, not tense or co-contracting in their hands. And they're usually somehow supporting with their body position. So usually, there will be...there's a much better... Like, I've watched this a lot in a lot of performance over the year, and I think for me, this idea that if I see the body is already showing the intention towards the hands going to be, where the hand is going to be going and playing, we already think, "Well, it's easy for the hand to finish off. They position themselves in a way where this was very accessible for them and they could move." So I guess with some of these players, with some like Glenn Gould, they just have horrible problems and you don't know about it until after they've passed away.

I work quite a lot with piano players and I just think it's not uncommon for people to have issues, but the higher-level ones like the really famous people that I've worked with, I think the interesting thing with them is if anything feels not fluid for them, like...this is again going to the other extreme, but if anything feels like there's a break in fluidity or whatever, this is when some of them have come to see me...like way before they're getting injuries or anything, they just want something to...they feel there's some impediment to that freedom. As I said very often, it might be something like where their arm or shoulder is or how they're sitting, or something like this that's just creating a slight block.

So with kids, to get that freedom... With anything, when you're starting young, where we go from the state where what it's called in motor control is you reduce your degrees of freedom. So basically, you kind of try and lock up stuff that moves too much like your wrists and shoulders, for example, to try and find the keys when you need to find them. So we start stiff when we're beginning, but the kind of job then, which I'm sure a lot of piano teachers do a really good job, is that they need to, as soon as they're getting that positional sense and getting some stability in their hand shape, then they need to be releasing any unwanted tension back through the chain of their arm. So it's like once they find it, then they need to release it and work into soft fingers, if you like, and really good support from the center.

Tim: Raising shoulders is certainly something I see in students if I assess them or I've even noticed it at competitions sometimes, and that to me...and sometimes it's kind of a dramatic thing that...I can't imagine that's a productive movement, particularly if you're trying to play down into the piano and your shoulder's coming up. That's not gonna help, is it?

Bronwen: Right, right. And very often, the body's in the wrong spot when you see that happening. So very often, the shoulder's up because they're pushing down, maybe their hand position isn't in the most ideal spot. But often, they're pushing down and their shoulders are going up, it's a very ineffective way of transmitting forces. So often their body's in the wrong spot. They need to bring their chest forward a little bit more. Usually, they need to stick their bottom out a bit more but when they're sitting get their chest forward. Second thing, obviously, is they might need to warm up before they're playing, they might be feeling quite stressed obviously. One of our big stress spots is those muscles at the top of our shoulder, and we can tend to hoist them up under our ears when we're stressed.

And in fact, to warm them up, swinging your arms around in circles and doing some kind of body rotations and just trying to get the blood flowing...and while you're doing that, try to really slow your breathing down so that...normally, we breathe 12 to 15 times a minute, and we know that if we half that, so breathing about six times a minute...so usually, we suggest in for four seconds out for six seconds. If you can get the blood flowing and slow your breathing down at the same time, it can really help take the edge off that kind of anxiety and have the muscles warm and ready to play but also get rid of the fears of tension.

Tim: I think this is an excellent tip for everyone because most often, when we think about warming up for playing, we're thinking about, instantly, scales, arpeggios, bang straight into it. And you're actually saying, "You know what? Don't even touch your instrument. We should do some breathing, we actually need to chill out."

Bronwen: Absolutely.

Tim: I was gonna talk about warming up later on. Why don't we talk about it now? Just have you got a few routines that would help us guide our students?

Bronwen: Yeah, so for starters, before they even sit down, so while they're standing up, the spine...because you gotta sit for a long time, your hips and your pelvis and your back can get stiff as well. So to start with, doing things that are...like if you get them to reach towards your toes and then unroll your spine, trying to unroll, if you like, slowly so you're really uncurling your spine. And then put your hands on your back and look up to the roof, so you go from forward to right, looking up, and do that a few times, but just gentle, curling, rolling movements. And you keep it moving, you don't hold a stretch at that time. And then do it over to the side, so running like your left hand down your left leg towards your toes and putting your right hand over your head, going to the other side, so doing some side to side movements like that. Usually, I'd start with the forward-back, side to side, and then start the rotation. So if you kept your legs about hip-width apart, bend the knees a little bit and rotate, let your arms swing around almost like you’re patting yourself on the back, like rotate your trunk...

Tim: Rotate your torso, yeah.

Bronwen: ...one way and then the other. Yeah, rotate your torso. If you get that part moving, you can do it...you don't have to be tight with this. With warm up, you don't wanna feel pain or stiffness. You can be quite loose, just go nice and far, feeling that movement. Then when you get...then you can come out of that sort of semi-squat and do some arm circles, a bit like backstroke and freestyle just swinging your arms around in big loops to try and get your shoulders a little bit warmed up. Usually, then I get people to do an arm warm up. So make, if you like, a fist, taking your hands to the front of your shoulders.

Tim: So holding your hands up, both arms in front of you, vertically, with your fists in front of your face?

Bronwen: Yep, vertically, right. And then touch your shoulders with them so to speak and then you're going to open your fingers out and take your arms straight, point your hands behind your back. So you've now sort of swung your arms down in front of you, taking your arms right back behind, and have the palms facing behind you, so you know, if someone was behind you they can kinda clap you on the hands. So you're trying to get...sort of getting rotation and arm movement and getting just some finger, gentle warm-ups. And the last one then is with your arms. Usually, you get people to hold their hands together, like clasped above their head, not on their head but just a bit above it. because we don't wanna put them on your head and squash it. But just a bit above it, and then gently try and look over one shoulder at a time and just let the arm you're looking towards be nice and gentle, don't kinda pinch your neck, but just turn your head to look backwards on each side nice and gently.

Tim: Brilliant.

Bronwen: And that should be with a little bit of back roll. So that little routine, if you run through that, it gets your spine and your shoulders, and even to some extent your hips, all nice and mobile before you sit down.

Tim: Free.

Bronwen: That's right.

Tim: And then a little bit of breathing, a little bit to relax and...
Bronwen: Right, so when you do it, if you can do it with...if you're feeling really stressed...interestingly, with warming up, we can rev ourselves up or bring ourselves down. So we can just warm up with this kind of "getting in the zone" behavior. So if you're feeling really stressed, when you do your warm-ups, do them nice and slow and try and breathe slowly as you do it. You can focus on the counting, just very rhythmical. If you're actually not feeling excited enough about the performance, we still want to breathe relatively normally then, not necessarily slow it right down, and do the movements sometimes a little bit quicker like get the blood going, get yourself a little bit excited. I often say to people, if you look at the guys at the 100-meter sprints in the Olympics, they're never doing really slow, gentle stuff. They're jiggling, right, they're like, "Okay, I've gotta be..."

Tim: Swimmers as well.

Bronwen: Exactly, so it depends if you wanna bring yourself down or bring yourself up, but warming up's really good for that, really good for that.

Tim: No, that's great. So that's very effective there.

Bronwen: But before it, start with a warm-up.

Tim: Yes, yeah. And then, is it about playing scales for a pianist, scales and arpeggios? Is that a useful activity, in your opinion? Or as other people recommend, just get straight into your repertoire, use that as your warm-up? Don't obviously do the hardest thing first. Play easier things and not too fast. Or would you say, "Yeah, do some scales"?

Bronwen: I'm probably gonna be saying things that you all know, but I would say the very first thing, perhaps you're thinking about it when you're warming up, is you're thinking about what it is that you're trying to make better today on the piano. If you're trying...once you're really warmed up, if your main goal is to play through a piece of repertoire, then play through your piece of repertoire. If you're trying to work on a particular fingering technique, then it's going to be more useful for you to potentially work on...with learning a new skill, the best way we can do it is come at it from different angles, so we might use some scales, some arpeggios to try within a context of working on a particular technical skill that we wanna improve. So I have to say, I think this is really something that students need to do from the very beginning, from the littlest child... We help them a lot with telling them what to practice, but they need to sort of think about whether they've practiced in a way that they got what they wanted out of it, and is that perhaps enough.

Tim: Yeah, starting with a goal is vital. It's been so hard for kids to do, I find.

Bronwen: It is, but as they get older, this should be something that they're encouraged to do more. So when they're really little, you might mention it and you have to take control of that. But as they get older, that should be really part of the process, because it's something that I think is so critical in not getting injured is that you have done, you've had... There's two things, like one is really think about what you want to get out of playing. And then the second thing is, at the end of your practice session, reflect on whether you did it or not. I mean, a lot of people practice stuff they can already play because it's all very nice to do that because you think, "Gosh, I sound awesome." But probably, it would have been better practicing half as long and focusing on the stuff you actually really needed to work on more.

Tim: One hundred percent.

Bronwen: So I think on the physical side, we see this tension and stress and things build up. Oh, sorry. The one other thing I wanted to say, when you finish your practice session, be nice to yourself. Strangely enough, if you get off and you think, "Oh gosh, that was a really terrible practice session," it's quite bad for motor skill learning, and you need to think, "Well, was I in the right state before I started? Had I had something to eat and drink? Had I warmed up? Did I think about what I was going to practice? Or was really just one thing bad and everything else was fantastic? And I should first say, "Well, all of that was terrific, and here's this one thing that I could work more on.""

Tim: One other question that I've been wanting to ask you is sometimes as teachers, we'll have a student who's playing something and they'll say, "Ah, it really hurts in my hand," or, "My wrist really hurts." When should we be worried about that? Or should we always be worried about that?

Bronwen: Correct. So we should always be concerned, if you like at a level, if they say it's sore. If you say, "When did it get sore?" and they say, "Oh, it's been getting sore over the last five minutes," then we can think, "Okay, stop, have a break, shake it out a bit. Just give it a little rest," or potentially stop the lesson a little early and then check on it next time. So transiently, sometimes it's a fatigue-related symptom and a mild fatigue. And when kids are tired, they should stop. If you go through it, it'll start to hurt. If you stop then, it's fairly simple. But it is telling you...pain is nature's way of saying "Something's not going so well here." It gets more complicated when you get older and sometimes you have recurring pain. That's the other one we have to be a bit careful of, is pain that keeps coming back.

When pain keeps coming back, this is not normal. This is telling you that either you're not organizing your practice sustainably...like again, you could look at external things like eating, drinking, warming up, whatever. If it's hurting regularly, there's either something you're doing when you're playing or something you've done to yourself in an episode of playing that needs actual looking at. So if your teacher or you can't easily problem-solve it, you should really get on to someone as quickly as you can. Generally, if you have either someone like a doctor or a physio who's health-trained...like, you need to go to someone who actually understands what injuries are about and can guide you in the right direction. And usually, if you go early, you only have to go maybe once or twice or something and it's fixed, but usually you take a couple of days, let it settle. The general rule of thumb we have is called rice [SP]. They just say, you rest it initially, if it feels a bit sorer than it should. If it's swollen, you put ice on it and maybe an elastic bandage or something. That doesn't happen so often in music that it's swollen like that, but you still might find that ice soothes it. And certainly to try and just rest until it settles. But usually, rest is only needed for a day or two, that's usually the maximum time. And then we actually try and get people to start using it gently and find how much it's recovered. And if it's feeling pretty good, we'll just build up your session again a little bit gently, and often, doing a few smaller practice sessions rather than a really big one over the few days will allow it to kind of strengthen back up and recover. But if pain is not settling, especially if it's been going on for longer than a week, you should go and get direction, because really what it's about is having someone give you a list of what you should and shouldn't do. You should never...

Tim: And particularly... Yeah, particularly, I was gonna say, the advanced level too. If you're teaching an advanced student who's practicing a lot and they've got pain, that needs to get sorted out.

Bronwen: It absolutely does, and part of this stuff I was talking about at the beginning...what we know happens with pain is you are gonna use your muscles differently. So I often say to the advanced students, "You know, you've worked so hard on your technique and all these years of trying to get something that you think is perfect, and then you're overplaying and you're in pain. And I'm telling you, your body is going to to try and protect itself, so you're going to develop compensations, and this is not helpful to where you wanna go, so pain does unhelpful things." And also, your body starts to focus on the pain whether you like it or not and so you become a little hypersensitive to pain too. This isn't meaning that you're a wimp, this is actually meaning that your brain...because pain's a thing the brain tells us, right? So if we do something in the first place and strain a muscle, then this message goes up to the brain and says, "You know you've strained a muscle? This is bad, you should stop" and gives you this pain sensation. If you're doing that often, it gets to the point where even if your muscles tired, your brain might say, "Oh, something's happened in that muscle again. You've probably torn it again, so you've gotta stop." So you'll feel pain even if it's just tired so you have to be really, really careful about not letting pain drag on, because it starts to confuse the way your brain interprets the messages.

Tim: Okay, well, look...

Bronwen: But yeah, so long-standing pain is not good.

Tim: Yeah. We're gonna wrap it up quite soon, but I'd like to ask you little quick fire, a couple of pianist...the problems that we have piano teachers see all the time, well, quite often with students. Have you got any tips for them? Now, I'm putting you on the spot because I don't know if you'll know about these, but quite often piano students playing and pinky's raised up in the air. Have you come across that and have you got any quick tips for us as teachers?

Bronwen: Yeah, well, this is actually one that I would say in relation to the little fingers lifting up, there's two reasons that sometimes happens. So just check the middle finger is aligned with the forearm because the middle finger is actually the center of the hand, and people should be spreading out from that. And people, if they've drifted...like often this little finger lift happens with a bit of a...it's trying to lead the hand so you've got this what we call ulnar deviation, your hands in this position and your little finger's trying to do a job it shouldn't have to do. Your forearm should be...your forearm if you like should be moving and your little finger... Sorry, I'm not sure, how this is exactly coming across verbally, but when you're going in that little finger direction, when you're ascending the keyboard on the right hand or descending on the left, we have to make sure that the forearm is kind of leading the action. This flow of movement from center out, so often that little finger will be lifting up if it's...well, maybe your elbow's sticking out, your little finger's sticking out, but your wrist is way back down the keyboard somewhere. You haven't kept that chain together.

Tim: Yeah, it's feeling like instead of the arm being aligned with the third finger it might be out and therefore the pinky's...and if you're moving to the right, the pinky's kind of pulling to the right or trying to push, leading that way. Okay, so the first thing to do is just check the alignment of the arm and that there is freedom in the arm to move the wrist and everything forward.

Bronwen: And that the wrist and that that freedom or that movement of the forearm is happening, sort of leading the finger into position rather than the finger thinking it's gotta drag the arm up the keyboard because that's never gonna happen.

Tim: Okay, cool.

Bronwen: And sometimes, one really simple thing to help that movement...often I just close the piano lid, because keys are very distracting, and get them to wipe their hand up the lid as if they're wiping dust off it. You can do it on both sides, it just reminds them of the essence of that movement and then saying you've gotta keep more of that.

Tim: Oh, that's a great idea.

Bronwen: Yeah. So they keep more of that movement and then they come on the keys and you try to maintain that feel of that flowing movement. And it just seems a really easy way for them to regain that sort of...

Tim: Yeah, everyone listening is gonna be dusting in mid-air, air dusting. But I get the movement now, yeah.

Bronwen: Yeah, if you bring a duster and your kids clean the piano every week, that's great.

Tim: Exactly. Okay, another one we see a lot of...

Bronwen: Sorry, one other thing is check the thumb strength, sorry. If they've been doing that, the thumb often becomes a passenger. Like your thumb, often people, when they're doing this as well, because their middle finger hasn't been in line with their forearm, so they've been in line with their thumb...

Tim: Oh yes?

Bronwen: It's like people are leading...they're kind of leading their position from the thumb side of their wrist, rather than the middle finger being more or less the center and everything opening out from it, and just check their thumb is strong.

Tim: Okay.

Bronwen: So you can even put a rubber band around their index finger and thumb and get them to take their thumb out, away from their little finger if it's really weak, just to show them how to use it. But just make sure they're remembering to use it.

Tim: Cool. All right we've got time for one more, which is the old buckled knuckles, so students whose last knuckle joint bends backward when they play.

Bronwen: So again, hand positioning sense. So one thing I get them to do is I call it the...usually, this is again, that they're getting to the piano, they're stopping their forearm a fraction too early and they're poking at it, if you like, so it's a two...but their arm's going down and then they're pushing into it and their fingers buckle, especially if they're double-jointed like a lot of kids are. With those kids, I get them to actually to practice putting their hand...like you help them put their hand in a good shape on the keys, so you sort of help align them in that ideal shape and try to let them then come off the keys with their whole forearm, so you lift their arms, say, I don't know, 20 centimeters up in the air, and then get them to try and land it, feel the gravity effect on their arm, if you like, but control their finger moving, because often what they do is...

Tim: And land and play the keys?

Bronwen: Yes.

Tim: Yes.

Bronwen: Land and play the keys, so they...and then get them to repeat it and try to get this idea, their fingers are almost like what your legs do on a trampoline. A lot of kids have jumped on trampolines and it's kind of a similar idea, that they feel that their hands are actually shaping to the keys and the action of the fingers is actually transmitting what's happening in the arms. So often, these kids haven't...they're blocking that forearm support of action and just that simple, if you like, trampoline bouncing cords can really help them get that idea of how to shape and control, because you'll find if you can get that forearm weighting action happening and a little bit of practice of just the fingers being a controller, you'll resolve the problem.

Tim: All right. Well look, obviously this is a very massive topic, but it's great to revisit it. I've had a few different podcasts over time about different aspects of technique, and I love talking about it, I find it fascinating. And thank you very much for giving some more opinions on it. I think we can only learn from it. Now, you've got a...I think you've got an exercise DVD for musicians as well, have you?

Bronwen: I do. Yes, yes. I'm at Sydney. Maybe people could...

Tim: Do you wanna tell people just quickly where they can find that?

Bronwen: Yeah, so it's probably best to email me at Sydney Uni, so it's bronwen.ackermann@sydney.edu.au. So at that address you can write to me and I'll send you the details about the DVD, so this was one that was specifically exercises for musicians, and I have some warm-ups on it too.

Tim: Fantastic, great. Brilliant. Well, look, thank you again for your time today. I think we've both earned a little Friday afternoon drink.

Bronwen: Absolutely.

Tim: And I look forward to keeping in touch with you down the track.

Bronwen: Great, thanks for having me on the show.

Tim: You're welcome. Thank you, bye.

Bronwen: Bye.