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19 minutes reading time (3733 words)

Medical issues facing adult students

"Growing old is not for the weak in spirit." Although I've heard this adage countless times, I finally know what it means. For me, 2010 ushered in a series of medical mishaps, medications, and miracles. I'm now a cancer survivor, yet I feel that surviving the myriad of prescriptions is another story.

I always knew I would grow older, but I never really, really understood that things go wrong with the body as it ages. So far I've not suffered problems with arthritis, although I'm one of the lucky ones. I can't say the same about depression or menopause. These conditions kick my butt on a daily basis.

The side effects from medications cause me the biggest problems. It is infuriating when I say "left hand" instead of "right hand." Occasionally a graduate assistant gives me the look, which means "what the heck are you talking about?" How long before their patience wears thin? I know I am sick of being sick.

I chose the subject of this column before my own challenges were apparent. I am fortunate that the Committee on Adult Learning (part of the National Conference on Keyboard Pedagogy) agreed to take on the task of educating us on typical conditions found in aging, as well as educating us on commonly used medications and their side effects.

A little bit of understanding goes a long way. I ask that you look seriously at the content of this article and remember that no matter how irritated you are with your adult students, I guarantee those students are twice as frustrated with themselves.

My battle with dystonia                                                                              by Bette Sloat Franke

It was about 1982 that oromandibular dystonia and cervical dystonia invaded my life.

After the removal of my dental braces, I developed temporal mandibular joint dysfunction, commonly known as TMJ. My natural bite had been destroyed by the extraction of four teeth.

The unknown in this scenario was a facial tremor, undetected by TMJ doctors. I spent ten days at the Pain and Stress Center, seeing doctors and a psychologist, learning biofeedback, attending physical therapy, and swallowing muscle relaxants. It didn't work.

While my husband and I were moving to Illinois, I felt my head being pulled downwards. I could not hold my head up, and sleep was impossible because of the relentless spasms. I did not know what was happening to this mom of two grown children, active realtor, performing pianist, and educator's wife. It seemed as if I had become someone else.

I began my search for help again. I was treated by a chiropractor, had acupuncture, took physical therapy, and talked with a psychologist. My symptoms remained.

Life didn't stop. I continued to play piano at church and took high-level piano lessons. Playing the piano was (and is) my refuge from dystonia. While focusing on the music, I could ignore the pain for a while.

The search for a cure continued. A well-known neurologist in the Chicago area told me I had Parkinson's disease. My husband and I knew this was incorrect. Another neurologist gave me a prescription for Artane, which eased the pulling and spasms, but offered no diagnosis. The Artane lasted one month, and I was back to my search. Another doctor prescribed a much-needed sleeping medication and a supplemental medication to calm my spasms. He also injected the muscles in the back of my neck with something similar to Novocain, which gave me relief for twenty- four hours.

About then I discovered another blow: short-term memory loss. I could not memorize my music, nor could I keep a simple part-time job. In 1994, the turmoil in my physical life took its toll on my home life: my husband divorced me. Devastation was added to my already struggling mind and emotions.

I decided to move back to Arizona, since now I had no husband or a diagnosis. At least I had a ray of hope—my doctor in Illinois had suggested I see Dr. Drake Duane in Scottsdale. Could it be that my thirteen-year search was over?

Within fifteen minutes, Dr. Duane told me I had oromandibular dystonia and cervical dystonia; or spasmodic tortecollis. He began botulinum toxin (Botox) injections immediately and prescribed medication. My orange pill box contains three neurontin, three lorazapam, one luvox, and one halcyon (for sleep), taken daily. Thankfully, I can still play the piano in various places in my area, and teach daily.

According to the Dystonia Medical Research Foundation (DMRF), there are more than 300,000 people with dystonia in this country alone. Dystonia is a neurological movement disorder that causes twisting, repetitive, and patterned movements as well as abnormal postures. It is neither a psychological disorder, nor does it affect intellect. It is not fatal, but chronic.

Dystonia takes many forms and has many names. The most common are:

  • Blepharospasm. Excessive blinking of the eyes.
  • Cervical dystonia. Pulling and twisting of the neck to one side or another. The neck may be held in a fixed position to either side, or up or down.
  • Oromandibular dystonia. Jaw muscles pull the mouth open or closed involuntarily. The tongue may be involved. There may be difficulty opening the mouth, affecting chewing and speech.
  • Spasmodic dysphonia. Strained, breathy, or whispered voice, which involves muscles inside the larynx,
  • Occupational dystonia. Sometimes called "writer's cramp," the hand and forearm muscle contract during writing. This is often found in professional musicians. 
  • Focal dystonia. This affects the muscles of vocal chords, neck,hands, eyes, mouth, and feet.
  • Dystonia-parkinsonism (RDP). Slowness of movements, poor balance, speech and swallowing problems, which can be sudden or over hours or days. RDP usually occurs in adolescence or young adulthood.
The music community is not immune to the affects of dystonia. Leon Fleisher's career was radically changed after the onset of focal dystonia that partially crippled his right hand. He said the condition is in remission, but not cured. Deep tissue massage, called rolfing, combined with injections of Botox, have greatly reduced his symptoms.

"Musicians with Dystonia" was founded in 2000 by Glenn Estrin, a former french horn player affected by embouchure dystonia. He travels to various conventions and symposia to raise dystonia awareness.

There is no cure for dystonia at this time, but there is hope. Deep brain stimulation has been used successfully on a woman who could only walk backwards. The National Institutes of Health (NIH) is funding a six-million dollar award aimed at forming a multicenter Dystonia Coalition to advance clinical research on primary focal dystonia.

The most important aspect of our teaching students with dystonia who are able to learn piano is to not place that student under stress of any kind. Stress adds to the symptoms of dystonia. Keep the repertoire simple, and adjust expectations.

Teachers, if we can help just one student avoid thirteen or more years of pain from an unknown source, we have accomplished a great service!

What medications are your adult students taking and what effect do they have on the lesson? 

by The Adult Learning Committee of the National Conference on Keyboard Pedagogy
Introduction by Jackie Edwards-Henry

In a perfect world, our piano students would always be motivated and eager to learn. They would possess at least some talent or aptitude. Their good work habits would be impeccable, leading to steady progress and successful accomplishment of their goals. We don't live in a perfect world. The diseases of the mind and body common in aging adults may be the culprit for struggles with work habits, steady progress, and success in performance rather than waning interest or lack of ability. Doctors are quick to prescribe medications that might control the diseases, but the side effects bring on conditions even more startling than the original illnesses.

Members of the Adult Learning Committee researched and interviewed teachers and students concerning three of the most common physical and mental challenges faced by adult students for which medications are frequently prescribed: arthritis, menopause, and depression. We recommend two websites for more comprehensive information: the Arthritis Foundation at http://www.arthritis.org and Dr. Christiane Northrup's website: http://www.drnorthrup.com. Enter "perimenopause" and "menopause" in Dr. Northrup's search feature.

Although we acknowledge challenges created by arthritis, menopause, and depression, we often overlook the side effects of their accompanying medications. Piano study can provide a much-needed diversion and stimulating alternative therapy for adult students overwhelmed by their conditions. Good piano teachers employ many skills and teaching techniques when dealing with mainstream students, including patience, understanding, flexibility, and creative approaches to problem solving. The same skill sets are necessary to successfully assist "medically challenged" adults. However, a larger "dose" is needed (pun intended). The reward for teachers is the knowledge that we have simultaneously shared the gift of music and, hopefully, on some level, facilitated healing.

Arthritis                                                                                                                 by Pamela Pike

While we tend to associate arthritis with older adults, both osteoarthritis and rheumatoid arthritis can affect younger adults in their twenties and thirties. As teachers, we must be aware of both the debilitating effects of the disease and the side affects of common arthritis drugs. Some side effects may impair the student's ability to learn, play, and move with ease at the keyboard. However, playing the piano can still be an important means of creative and personal expression for arthritic students if we accommodate for some of these side effects.

Osteoarthritis, the most common form of arthritis, occurs when the cartilage around the joints breaks down, causing bones to rub together. Symptoms of osteoarthritis include pain or stiffness in joints after periods of inactivity or excessive use, a grating or catching sensation during joint movement, and bony growths at the margins of affected joints.Common drugs used to treat the pain are acetaminophen and non-steroidal anti-inflammatories. These drugs actually help to reduce stiffness and pain in sufferers.

Rheumatoid arthritis (RA) is an autoimmune disease. The body's immune system attacks the thin membrane that lines the joints, causing chronic inflammation and pain of the joints.2 RA can damage the joints, cause a great deal of pain and inflammation, and eventually damage major organs including the lungs, heart, and eyes. The disease tends to strike joints symmetrically, which is to say that if one's left hand thumb joint is affected, her right hand thumb will also likely be impacted. Although it is a chronic, incurable condition, sufferers of RA can experience periods with relatively few symptoms, and then suddenly and without warning have a painful flare of symptoms.

Fatigue is a side effect of most of the drugs commonly used to treat RA. Methotrexate can impair kidney function, and Prednisone can impair eyesight. Other prescribed medications lead to severe swelling of extremities. Prolonged use of medications can cause failure of major organs, including the kidneys. If medications are discontinued, withdrawal may cause even more problems playing the piano.

In response to these problems, a newer class of drugs, called Biologic Response Modifiers (BRM), blocks the inflammatory chemical that causes swelling. At present, the FDA has approved eight of these drugs for use. However, most people have to try several different drugs before they find some relief from symptoms.

Marcy, one of my students, received her diagnosis while still in her forties. Her early piano training was outstanding and she "could have become a music major." She started experiencing severe stiffness in her fingers in her mid-thirties. She says, "I never used to have to warm up before playing. I could just sit down and play. Then, I remember getting ready to play duets with a friend and my hands were very stiff. I felt like there was no amount of warming up that was going to get my fingers moving. It was like trying to move my fingers with my hands immersed in really thick mud."

Marcy feels constantly tired—probably a side effect of the continuous pain she feels. During a flare up, her sleep worsens, which in turn leads to more pain. It is a vicious cycle for Marcy. Yoga seems to help with the symptoms. Gentle piano practice is a part of her overall plan for dealing with RA.

Betty, the student of a colleague, was diagnosed with both osteoarthritis and rheumatoid arthritis about ten years ago. She tried many drugs over the years, most recently trying an IV-infused BRM drug, but found that it didn't have much impact on her physical symptoms. The side effects were so severe she discontinued this form of treatment. She found Oxycontin, a powerful and addictive pain medication, was most helpful in controlling her pain.

Betty returned to the piano (she played as a child) shortly after her diagnosis. She believes continuing her piano lessons has "probably helped her hands, even though [she] can only progress so far." There seems to be a "brain fuzziness" that inhibits learning new music. "These drugs really do seem to affect my brain, which is frustrating," she says. Her hands are weak, stiff, and sometimes control of her fingers is impossible. She notices her focus wanes, due to pain, when she sits for long periods of time.

On the other hand, the laughter that occurs during lessons "is the best therapy" for Betty when dealing with her condition. Weekly piano lessons have been one of the activities that she has been unwilling to give up as her disease has progressed. She is determined to do what she can, while still recognizing her limitations. She constantly adjusts her goals and practice time around what she can realistically accomplish.

Being educated about arthritis has vastly influenced my teaching. Knowing about my students' medications gives me advance warning (and patience!) when side effects occur. I work with my students to set realistic goals for their piano study. If their symptoms flare up, goals are adjusted. Stress can really exacerbate the pain and swelling symptoms of RA. Therefore, I carefully monitor the three areas of piano study that can cause stress: the lesson, practice expectations, and performance.

Arthritic students may not be able to play repertoire at quick tempi or reach all notes in big chords. It helps to be flexible by altering tempi, using simplified editions, and redistributing notes. Alternative and unconventional fingerings for students who experience pain and stiffness in some fingers should be explored.

Menopause                                                                                                         by Ramona Kime

While the side effects of many medications may affect our older students' capabilities, in some cases, the effects of not taking medications may also affect what our students can do. For example, while some lucky women sail through menopause with very few symptoms, most menopausal women experience a variety of irritating symptoms if they don't take hormones in some form.

Hormone replacement therapy is available in both synthetic and alternative forms. Synthetic hormones are what most people think of when considering hormone replacement. These are accompanied by the threat of serious side effects. The alternative, or natural, form of hormone therapy is not as well known by most women. Both help with fluctuating hormones. Unfortunately, recent research has connected replacement therapy with breast cancer, so many women are choosing to live with the symptoms of menopause.

Menopause symptoms mimic symptoms of medication taken for depression. Night sweats disrupt sleep, often causing chronic tiredness. "Fuzzy brain" affects the flow of conversation, as thought processes become more difficult. Headaches, mood swings, and anxiety are also side effects of menopause. These symptoms make it difficult to concentrate on piano studies.

Judy, a student in her sixties, chose not to take hormone replacement therapy, but was frustrated with her inability to think as clearly as she used to. "I just can't seem to process words, either in speaking or in listening to others!" she exclaimed. For Judy, demonstrating concepts rather than using words was a big help in her lessons. Written comments in her music were important for her—she liked the visual feedback while practicing at home.

To help students with "tired brain," teachers should take their time explaining things, watch the student for feedback, and be prepared to explain the concept differently. If students are feeling particularly frustrated, switching to simpler pieces or concentrating on only one or two concepts per piece may help.

Luckily, there is a lot of information available about menopause. You can find information not only about symptoms, but ways to reduce their severity. Dr. Christiane Northrup's book, The Wisdom of Menopause, and her website, www.drnorthrup.com, are among the most comprehensive sources of information about all aspects of menopause, including alternative approaches to hormone replacement therapy.

The biggest help we can give to our menopausal students is patience, compassion, and encouragement. Being tuned in to the needs of our students from week to week—and helping them feel comfortable expressing their needs—will make piano lessons for menopausal students a more pleasant and enjoyable process, well into their later years.

Depression                                                                                              by Janet Buswell Finch

In 1990, depression was the fourth largest disease among people worldwide. By 2005, twenty-seven million Americans, ages six to adult, were taking antidepressant medication. It is estimated that by the year 2020, depression will be ranked as the second most common disease in the world, surpassed only by cardiovascular disease. At present, it is estimated that fifty-eight million people in the United States alone are affected by depression. As a result of these staggering statistics, antidepressant drugs are now ranked at the top of the list of most commonly prescribed medications in the United States.

Medication is often prescribed to people suffering from depressive illness due to a decrease of certain chemicals (neurotransmitters) in the brain that are responsible for "mood." The antidepressants stimulate chemical changes in the brain, causing an increase in the levels of neurotransmitters. The interaction among neurotransmitters, hormones, and brain chemicals has a profound influence on overall health and well-being. When this interaction is functioning normally, focus and concentration are good and we feel more directed, motivated, and vibrant; when the interaction is inadequate, these energizing and motivating signals are absent and we feel more stressed, sluggish, and out of control.

Neurotransmitters have two purposes—they deliver sound (music) to the brain, and they are responsible to our emotional response to music. Research has revealed that the nerve pathways require a neurotransmitter called dopamine. The action is critical in mediating a response that we perceive as rewarding: the beauty that we experience in music most likely has a chemical basis in the dopamine molecule.

While antidepressant medication may relieve some of the symptoms of depression and heighten cognitive function, most of the medications have accompanying side effects and dangers. Although side effects may vary from one medication to another, and from person to person, many adults experience the same effects, such as fatigue, nervousness, headaches, dry mouth, blurred vision, difficulty sleeping, fuzzy thinking, and daytime drowsiness.

In a recent interview, music students shared their personal experiences in dealing with the side effects of anti-depression medication: "Antidepressants take the warm feeling of music away. Now it feels empty. Major chords don't ring and the beautiful melodies are grayed out." Another student shared that "the side effects blunt out my musical emotions." Another states "I can practice, but I miss the excitement, and now I don't enjoy the piano like I used to. The notes don't seem to evoke the same emotion."

How does this knowledge affect us as teachers, our teaching methods, and the weekly lesson? Most teachers are not selected based on their awareness of wellness. Furthermore, unless teachers have personal experience with depression and treatment side effects, or experience in dealing with students struggling with those issues, learning challenges may be misinterpreted as laziness, disinterest, or lack of ability. Identification of students suffering from depression and awareness of treatment side effects can help teachers work with those students to design appropriate practice techniques and performance goals.

What can we do when we have an adult student whose thinking is "fuzzy," and who is struggling to learn or memorize a piece of music? One teacher, experienced in dealing with such students, shared her strategy: "I avoid pieces that are written in minor keys, choose shorter pieces, and coordinate scales to the pieces to help with a firm sense of pulse, helping focus and muscle control. Most of all, I am extra patient and expect only what the student is capable of giving me." In addition, the technique of dividing and teaching pieces in small, manageable sections is particularly important for students dealing with depression and antidepressant medication. This technique prevents both students and teachers from being frustrated and overwhelmed.

As teachers, it is our responsibility to be aware of the conditions of our students that require medications, and to strive to obtain a working knowledge of the impact of those medications on cognition. In particular, we must be alert and prepared for the potential learning difficulties that may surface as a result of prolonged use of antidepressant medications. We must strive to create positive learning experiences for our students. The importance of a good piano teacher can never be overestimated. Being sensitive to the conditions and needs of our students, educating ourselves accordingly, and applying that knowledge in our teaching will enable us, as piano teachers, to make a stronger statement and greater difference in the lives of our students

References

Nielson, L. A. with Rosfeld, M. (September/October 2010). Technique and Musicality: The indispensable and eloquent duo. Clavier Companion.
Dystonia Dialogue (2009) 32/2.
Dystonia Dialogue (2010) 33/1. 
www.Dystonia-foundation.org
www.wemove.org 

1. http://www.arthritis.org (American Artritis Foundation).
2. Ibid. 

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Progressive progressions
January/February 2011
 

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