After Surgery: All the machines!

So I know that this surgery stuff doesn't really seem relevant for MUSICIAN'S health,but since heart disease is one of the major issues for everybody, maybe it can help a musician or two. Just so many things I learned through this process, such as a DNR does not "expire", you need to ask your surgeon what size valve they are putting in, little things that wouldn't have occurred to me prior to this experience. And of course, one thinks that if the surgery is a success, then all is well. Not always the case. A successful surgery can actually cause other things to happen which can lead to unanticipated problems.

So here we are and the doctors have decided that Mom needs to be reintubated. At that point, she just needed help with breathing. But then a number of things happened. First, the heart muscle went into shock. The part of the heart that had been deprived of blood when the valve was so small, was now receiving the appropriate blood flow. It was not used to this and this sent the "healthy" side of her heart into shock. So a balloon pump went in to support that side (the left) of the heart. Next the kidneys started to fail. By this time she was unconscious and showing signs of edema or fluid retention. Her body was swelling, and she wasn't processing liquids. It was at this point that I actually arrived in the States, having been out of the country teaching prior. The doctors used the term "multi organ failure" when I was speaking to them, and I got the next available plane back to Miami. When I saw her in the Surgical ICU unit, she was unrecognizable. Her body was swollen, she was unconscious, and every machine available was plugged in to her, except dialysis. That was added the next day. She was unresponsive and it really did not look good. To add to that, I couldn't enter the room, having come down with a cold on the plane. I could wear a mask and sit outside the door and call to her. So that is what we did. My sister and I were at the hospital almost 24 hours a day, talking, singing, reading and connecting with her. We were also very present with the doctors and the nurses. Everything that was done, we discussed with each other and with them. The only problem was when we were discussing her DNR, signed in 1995. We were told by one doctor that it had "expired". This doesn't happen. For the record, unless it is rescinded by the person who originally filed it, a DNR stays in effect. Fortunately we did not need to implement it. After the dialysis started, her situation began to improve. One by one, the machines were removed, beginning with the dialysis machine. Then the aortic pump was removed, then other apparatus, until we were left with the ventilator. I informed the doctors and nurses, that they had better make sure it was the correct time to take her off the ventilator, because it wasn't going back, so they were aware of necessity of making sure that they didn't do it too early. And when it finally came out, we were on the way. But there were still a number of hurdles to overcome. Next: ICU psychosis (who knew?)

The Surgery and Beyond

So the surgery to replace Mom’s heart valve was supposed to be a minimally invasive procedure where they would make an incision between the ribs and replace the valve without having to crack the breastbone etc. Needless to say, this is NOT what happened. It turned out that the blood vessels surrounding the valve had grown too calcified to allow for this type of procedure. Additionally, because the original valve was too small, the space into which the valve needed to be inserted was not sufficient. This was not determined until after they had opened up the chest. At this point another series of bypasses were required in order to create room for the new mechanical valve that they wanted to put in. So all of a sudden we went from a minimally invasive 1 procedure surgery to an open chest with multiple procedures required. The surgery also took considerably longer than originally anticipated. All of this made the outlook for recovery less than optimal.

While in surgery, of course she was intubated, a machine was substituting for her heart and her body temperature was lowered to minimize the risk of damage to the brain. In the recovery room, she remained intubated as they slowly warmed the body and began to try to bring her back to consciousness. The goal is to remove the breathing tube and other machines as soon as possible and get the patient up and running fairly quickly. This actually increases the chances of a full recovery. It also is the only way to assess whether there has been any loss of brain function. Only when the patient is conscious and can respond to stimuli and questions can their mental status be evaluated. By the second day, they had removed the ventilator. Unfortunately she wasn’t responding as they had hoped. She seemed disoriented, in a lot of pain, and really not recognizing her surroundings. Now here’s the thing. Mom has a DNR. The hospital was fully aware of the DNR, it was in her file etc. However, one thing to remember, is that when a procedure is performed in support of another surgical procedure, it may not be subject to(nor should it be subject to) the restrictions that come with the DNR. If she had had a heart attack and entered the hospital with a DNR, they would not have intubated her nor performed any extraordinary life saving procedures, including ventilators etc. But this is a different set of circumstances. She agreed to the surgery, so she agreed to the supportive care following the surgery. Therefore, if reintubation is needed that can and possibly should be done. This is exactly what happened. The plan was to reintubate and then support her through the next couple of days until she was stronger and began breathing on her own. Unfortunately things went from bad to worse at this point.

Next: All the machines!

About that Heart Valve.....

Okay so here's the thing. This may not be a "musician" issue, but it is one we all should know about. The first thing is if you need to get a heart valve replaced, make sure you ask what size they are putting in. Things you didn't know you needed to know right? And for an adult it should "never be less than a 21". The quote is from a cardiologist at Mt. Sinai hospital in Miami. Also just a point of preference here. If they are putting in a porcine (pig) valve, know that it will last tops 10 to 15 years. So it is sort of like planned obsolesence. If they give you a porcine valve, they don't expect you to live longer than that or they expect you to have another incredibly complicated risky surgery later in life. So how do I know these things? Well, Mom had a heart valve replaced in 2003, along with a triple bypass. A porcine valve. Almost immediately, her cardiologist said that he was noticing stenosis in the valve. He said that we should plan on another surgery in the relatively near future. Needless to say, Mom was not particularly enthusiastic about the prospect. At this point, we started alternative treatments, acupuncture, herbs and energetic healing techniques to try to avoid this. She did very well with this and the stenosis was controlled, it didn't get any worse. When she moved in with us, we kind of let that therapy lapse, new routine and all and then all of a sudden she got dizzy one day. Two days later, she is in the hospital, being prepped for a replacement of the same valve that had been replaced not 7 years earlier. But now she is older, the blood vessels have calcified more and the surgery is just more difficult. To a man, every doctor consulted stated that her original replacement valve was just "too small". The bypasses were working wonderfully, but the valve was not working well at all. So here we were again, but now she is 7 years older and the surgery is risker the second time anyway. But we went for it because the really was no alternative. There are no drugs to treat a heart valve that is slowly closing and at this point it is really a sort of "pipe" problem. When you are in your 80s, one fall from a dizzy spell brought on by the blood not being pumped through the heart can be a life threatening experience. And there was no way to tell when it would happen again, no warning signs or anything to give one a chance to sit down and wait it out. So here we were.

That's the thing about this sort of condition. One day you are going about your business, the next day, in the hospital, prepping for major surgery. Signing all those DNRs, consent for treatment, surrogate etc. forms. And it seems as if you have no control over your life. The doctors just tell you what you need. They don't offer you options, they just say things like "we'll come in the morning and bring you down for your pre-surgical tests". "NO getting out of bed without the nurse". For an active independent person, it is a humbling and overwhelming experience.

Next: surgery!

Acupuncture for Musicians

The practice of acupuncture is one of the most ancient healing techniques still in use today. It is part of a larger system of healing known as Traditional Chinese Medicine, or TCM. TCM is based on the theory that a healthy person is in balance, both with himself and nature. Illness is caused by being out of balance or harmony, with either oneself or nature. Chinese medicine views the body as a reflection of the universe. This is consistent with the philosophical basis of this form of healing, the Taoist philosophy. As in Greece, the ancient Chinese healers were also philosophers and based their observations and treatments on the Taoist tradition, which believes in the oneness of all things.
According to Chinese tradition, in order to maintain health, one must strike a balance between the yin and the yang. These are two opposing, yet complementary energies, that are imbued in everything in the universe. Health, in Chinese medicine, is not a state that one arrives in and stays, but rather a constant fluctuation and adjustment process. When our bodies cannot adjust to some influences, either external or internal, then we fall ill. The Chinese medicine tradition views the body as a whole, composed of yin and yang aspects. Organs and systems are either yin or yang, and each yin organ or system has its' complementary yang organ or system. In the Chinese tradition, there is a system of energy that links all the organs and other aspects of the body. This energy is called "qi" or "chi". This energy system is the vital life force for the body. It is invisible. It circulates throughout the body through pathways known as meridians. These are alsoinvisible. These meridians are located throughout the body and connect the entire body, from its surface to deep within the body. For this reason, acupuncture that is performed on the surface of the body can have a profound effect on systems and problems deep within the body.
The existence of this energy system has been scientifically proven. Energy points on the skin have been identified with Kirlian photography, and when a radioactive isotope is injected at an energy point, it will travel on the path or meridian described in TCM. There has been a significant amount of research done into TCM, qi and related disciplines such as Qigong.
The purpose of acupuncture is to restore a balanced flow of qi within the body. There are certain points on the body where the qi may become blocked or excessive. An acupuncturist will insert a very fine needle into a specific point to free the blocked qi or to restore its correct flow. The practitioner may twirl the needle or use a weak electric current sent through the needle to stimulate the point. There is no blood even though the needle does penetrate the skin. The needles are very fine and are inserted in such a way that they slip past blood vessels and nerves. Traditional needles were bamboo, but those most widely in use today are surgical steel. The same acupuncture points can be accessed through pressure or heat, although this last practice is not used widely in the United States. Acupressure, the concept of applying pressure to the acupuncture points, has much in common with shiatsu massage, a technique from Japan, with its' roots in Chinese medicine. (see Shiatsu and acupressure in this paper). Moxibustion, or the application of heat to an acupuncture point, involves placing smoldering herbs over or on the site of the acupuncture point.
The most common use for acupuncture in the Western world is that of pain relief. It has also been used for treating drug addiction, weight loss or gain, nausea from morning sickness or chemotherapy, and smoking. There are few, if any, scientific explanations for how it works, nevertheless, it is known to relieve symptoms of pain for chronic conditions, after and during surgery, childbirth and other conditions. There actually has been a considerable amount of research done, but most of the studies show serious flaws.45
In order to diagnose a particular problem, a traditional acupuncturist would use four techniques. The first is inspection. This means observing the patient. This includes inspections of the tongue and its' coatings, the eyes, the complexion and the excretions of the patient. It also includes listening to the patients voice. The second aspect of diagnosis is listening. This includes listening to the breath, speech and being aware of the odors of the body. The third step is to take a detailed history of the patient. This would not be a medical history in the Western allopathic tradition, but there would be particular questions which the practitioner would ask that would relate specifically to the condition from which the patient was reportedly suffering. The previous observations would help the practitioner direct the questioning. The last step in diagnosis is palpation. This includes a pulse examination. In Chinese medicine there are 29 different types of pulse, each having its' peculiar traits and conditions. It would also include palpation of the body in general and of the acupuncture/acupressure points in particular. Those points at which qi is blocked or out of balance, are frequently tender to the touch. Along with acupuncture, the therapist may prescribe herbs and dietary changes to support the patient.
The article "One Approach to Acumoxa Therapy for Pain Due to Tendinitis of the Hand. Wrist and Forearm" is a technical article that appeared in the American Journal of Acupuncture. Nevertheless, it can give the lay reader an idea of the treatment modality that could be used to treat problems of the wrist and hand with acupuncture. The author mentions that in her practice, this type of pain in the hand and forearm is one of the most common that she treats. She first reviews the Western medical definition of Carpal Tunnel Syndrome. She then explains the problem from the perspective of Traditional Chinese Medicine. (The explanation is technical and will not be understood by most readers.) She then explains the diagnostic technique used in Traditional Chinese Medicine. This could be helpful to the lay reader as it would educate them on what to expect from the practitioner of TCM. The author then goes on to explain the treatment program forthe problem. Again, the explanation is rather technical, but it could give the lay reader an idea of the time frame for treatments, and what to expect. The author also has a section on Self-Care. It is short and comprised of those suggestions that the author uses to support her therapy. The last section of the article is a series of case histories. The author gives one example where treatment was totally successful, one in which it was moderately successful and one that the author found to be a failure. She explains the reasons for the differing rates of success. There is also a table with the success rates, showing that the author has either cured or had great improvement in approximately 68% of her patients. She displays an 18% rate of some improvement. 12.5% of her patients showed no improvement.46 She also briefly refers to surgery in the last section of the paper. She states that while she does not see those patients for whom surgery was a success, those who had surgery and come to her office for treatment, seem to be no better off after the surgery. One of her goals is to help patients possibly avoid surgery. The author also discusses, within the context of the article, some methods that are not covered in this paper. Moxibustion is explained briefly in this paper in the section on acupuncture. The author of the article also details the use of particular herbal preparations.
Acupuncture is mentioned in the following books or materials, reviewed in the Self Care chapter of this paper, as a possible treatment for musicians or others with hand or upper body pain: The Musician as Athlete by Dorothy Bishop (page 81); How to End Your Carpal Tunnel Pain Without Surgery by Kate Montgomery (page 72); Play It Safe by Christine Zaza (page 86): and the website Musical Online: musicians and injuries by Paul Marxhausen (page 92).

Trigger Pont Therapy Work

Out of all the therapies that I researched, this is one of the most promising. It allows the musician or person with the problem to be in charge of their own care, at least for part of it. One of the books referred to below, "The Trigger Point Therapy Workbook" by Claire Davies should in my opinion be on every musicians shelf. It is helpful to have some professional trigger point work done prior to try it on your own, but if that isn't possible, this book can teach anyone how to work their own trigger points out, even the difficult-to-reach ones in the back. This book is available at Borders and online.
Trigger Point Therapy
Trigger point therapy is not a form of massage, nor is it related to acupressure as it may seem at first glance. Trigger point therapy has its' roots in Western medicine and there are studies using diagnostic tools such as microscopes that have been used to observe trigger points. A trigger point is a knot or contraction in the muscle and/or myofascial tissue that keeps a constant tension in the muscle and any muscles or ligaments that are attached to the contracted area. Because of the constant contraction, circulation is reduced, as is the removal of waste products generated by cells and tissues. The area is also deprived of oxygen and nutrients because the circulation is restricted. This in turn causes the muscle to contract even further, creating a cycle of pain that continues to worsen as time passes. The theory of trigger points states that the pain that is felt by the patient, more often than not, is "referred" pain. This means that the pain may appear in one area of the body, while the "trigger" for the pain (the trigger point) is actually in another, seemingly unrelated, area. An example of this might be pain in the wrist or hand that results from a knot in the forearm just below the elbow.
Many chiropractors and massage therapists are now becoming aware of trigger point therapy and are using it in their practices. It is, however, a fairly simple theory and most people can learn to treat themselves. There are trigger points that are located out of reach, (for instance in the back area), but there are tools that have been designed by practitioners of massage that can enable the patient to treat even these areas.
It is the contention of some practitioners of trigger point therapy that much of the pain suffered by people is the result of undiagnosed trigger points. Treatment of myofascial trigger points for the relief of pain is not part of the normal education of doctors. The fascia is the layer of tissue that surrounds the muscle. When there is a prolonged contraction of the muscle, as in the case of a developing trigger point, the fascia becomes hard or tight and inflexible. Although there has been material published regarding this therapy since the mid 1980s, it is still primarily the province of massage therapists and other alternative therapists.
Diagnosis of trigger points is relatively easy. They are extremely painful when palpated or pushed. This may seem to indicate that one should avoid them. The therapy for relief of the pain is just the opposite. The trick, however, is to find the trigger point that relieves the pain that is being experienced. The causes of trigger points are similar to those that cause other muscle problems. One of the most common causes is overuse of particular muscles. This relates specifically to musicians. Those caused by this type of problem tend to recur unless the root cause of the problem is resolved. This may include changing the workstation, taking frequent breaks, or changing position in the performance of any work that requires repetitive motion. Other causes of trigger points can be being overweight, carrying heavy bags, briefcases, babies etc. or, for men, carrying their wallet in their back pocket and sitting on it. Trigger points can also be caused during an accident or fall, when the muscles contract suddenly. Other causes can be injections, surgery, or even a skeletal imbalance, whether genetic (as in one leg shorter than the other) or created through surgery, ill-fitting shoes or other causes. Some trigger points are very persistent and seem to return despite repeated treatments. This is usually because the motion or factor which caused the trigger point in the first place has not been resolved. Other reasons may be that the body is genetically not symmetrical, lack of physical activity which can cause stiff muscles, and repetitive movement. Another cause of trigger points can be poor nutrition. Lack of minerals, such as calcium, iron, magnesium and potassium can negatively impact muscle function. Certain vitamins are also necessary to maintain optimum muscle health. These include the vitamins B1, 6 and 12, vitamin C and folic acid. Lack of these vitamins may be either from inadequate intake or from environmental factors that destroy these vitamins before the body can use them. Some of these influences may be smoking, dieting, pregnancy, alcohol, certain medications including oral contraceptives and antacids.
Treatment of trigger points takes three forms. The first, performed only in a doctor's office, is injection of the trigger point with an anesthetic, usually procaine. This is difficult, because the trigger points can be quite small, and it requires skill on the part of the practitioner. The second method for treating trigger points is called spray and stretch. This involves spraying the skin with a refrigerant that numbs the skin, then stretching the muscle and thus the trigger point. This also requires a doctor or other practitioner to perform. The third method, the only one that can be done by the patient, is massage. The massage must be deep and firm in order be effective. The downside to this method is that because trigger points are, by their nature, very painful to touch, it may be difficult for the patient to apply the requisite amount of pressure in order to release the trigger point. This can be learned, however.
The book The Trigger Point Therapy Workbook is designed for the patient to learn to self-treat this condition. While the author recommends professional massage as the best method to treat trigger points, he postulates that self-treatment has a number of advantages, including being able to treat whenever needed and being able to identify points and pressures accurately. The book has a section on the theory and history of this type of therapy, including some of the common causes of trigger points. There is a chapter on how to perform the massage correctly. Then the book is divided into sections of the body. The author shows which trigger points in which areas of the body create "referred" pain in other areas. There is a section specifically on Carpal Tunnel Syndrome, as well as an entire chapter on pain in the arms and hands. The section on Carpal Tunnel Syndrome is included in this chapter. At the beginning of the chapter, the author provides an easy-to-read chart that details various areas in which pain may be felt, such as the outer elbow or outer forearm. Under each heading there is a list of the trigger points that can be the cause of this pain and the page in the book where one will find out how to locate them. Upon turning to the referred page, one finds an illustration that details where the pain is, the corresponding trigger points and how to massage them. Upon looking at the illustrations of the patterns of pain, one can see that they correspond to many of the problems that are experienced by musicians. On page 107, for instance, the thumb and wrist just above the thumb is shown as the area of pain, while the trigger points that cause this pain are in the upper area of the arm. In the section "Causes", the author states "Oboe, clarinet, and some saxophone players often suffer from chronic pain and numbness in the thumb of their right hand, which has to continuously support the weight of the instrument. Though the thumb itself may seem to be the trouble because that's where the pain is felt, the real problem is in the brachialis muscle which has to stay contracted all the while the instrument is being played. In addition to frequent trigger point massage, a wind player should put the instrument down at every opportunity and let the arm hang at the side, allowing the brachialis to lengthen and relax."42
Just skimming this section and glancing at the illustrations of where pain may occur covers almost all of the conditions experienced by musicians. The author illustrates the trigger points which will relieve pain and other conditions such as numbness and tingling in these areas. The rest of the book covers other areas of the body, such as the lower back, the chest and abdominal areas and the legs and lower extremities. The book is well illustrated, easy to read and explains the theories and techniques in a manner that makes it easy to learn how to perform the treatments. The index is also very helpful. It can direct the reader immediately to the pages which correspond to the particular condition in which they are interested.
The article "Position Paper on Trigger Point Injections", available online at www.dringber.com/tpoint, is an article that is appealing to the medical community to find funding for the study of Trigger Point Therapy. There is one mention of musicians in the article. The article states that cases have been presented at the American Academy of Physical Medicine and Rehabilitation that show that Trigger Point Therapy has been useful in treating focal dystonia, a particularly difficult condition to treat. There is no further reference to the case and it is not included in the bibliography of the article. Nevertheless, because focal dystonia is such a difficult condition to treat, the reference is included in this paper.
The on-line article "About Myotherapy: Bonnie Pruden Myotherapy" is more an advertisement for a particular type of therapy than an objective statement. Nevertheless, the article contains a definition of trigger points and an explanation of the therapy. For this particular style of therapy, the patient must be "cleared" by an allopathic practitioner, thereby eliminating any illness as a cause for the pain. The article has one line about musicians, stating that " For athletes and performing artists, relief is usually immediate and followed by enhanced performance".43
The book Performing Arts Medicine mentions trigger point therapy in the chapter entitled "Therapeutic Management of Instrumental Musicians". This book points out that while this must be considered as a potential cause of pain in the musician, most practitioners are not trained in the recognition and treatment of these trigger points. The section on this aspect of treatment covers how to diagnose and treat this condition. The authors also state that "There are no radiographic or laboratory findings in MPS (myofascial pain)."44 The authors also include the clinical characteristics of trigger points. These authors recommend as treatment massage, compression of the point, electrotherapy, cold spray and stretch, and as a last resort, injections.
In the chapter titled Self Care, the following material either recommends or mentions trigger point therapy: Shoulder, Upper Back and Neck: Free Yourself from Pain (page 69 ) and Carpal Tunnel Syndrome: How to Relieve and Prevent Wrist Burnout (page 71) both by Rosemary Atencio, recommend trigger point therapy; Susan Weiss in The Anatomy Book for Musicians (page 74) recommends trigger point therapy; Play It Safe (page 86) by Christine Zaza, recommends trigger point therapy ; and the website Musicians and Injuries (page 92) by Paul Marxhausen recommends trigger point therapy.

Visualization Technique for Your Best Performance

Well it has been a while since my last post. I wanted to post something USEFUL, rather than just informational. I have taught this to kids as young as 10 and they really liked it. It works with older performers as well. Actually this technique can be used to prepare for any type of performance not just a musical one. The trick is to really visualize oneself in the exercise and allow your mind to assist you. If you tend to have certain bad habits performing, add those in to your visualization and make it your own personal script. Good luck and enjoy. Let me know how it goes, those of you who do try it!

Visualization Technique for Peak Performance

Adapted from that of Dr. Konefal from CAM at the Miller School of Medicine University of Miami

1. Sit in a comfortable chair and relax. Imagine a screen in front of you at a comfortable distance with all the knobs you need to adjust color, sound, clarity etc.

2. Imagine yourself on the screen either getting ready to perform or performing.

What would you change or tweak to improve your performance?
Are you sitting or standing the way you want?
Are you holding tension in your body where you should be relaxed?
Are your shoulders creeping upward when you want them settled into your shoulder sockets?
How does your playing sound? What would you change? Rate? Volume? Ease of fingering? Breath?

3. Are you connecting with the audience? If not, imagine the connection from your sense of self in the image, through your body, into your instrument, out across space and reaching the audience.

4. Make any other adjustments until you are pleased with your playing.

5. Bring the image of yourself on the screen into yourself sitting relaxed in your chair.

6. Check to make sure this feels good.

7. If you need to make any other corrections to your playing, put the image back on the screen and make the corrections. Then.,, bring the image with the additional corrections inside.

8. Check again.

Eastern Massage for Musicians

Eastern Massage - Traditions and Practice
Eastern bodywork traditions are based on ideas about how the body functions that are somewhat different from that of Western massage. In general, Eastern bodywork therapies are based on the idea that the body contains energy. This energy flows through the body along certain pathways. The energy and the pathways may have different names in different types of therapies, but the theory behind the therapies is the same. These types of therapy purport to either strengthen energy flow or to restore energy flow where it has been blocked. Most of these therapies do not claim to be "cures" in the traditional sense. Rather, these therapies focus on enhancing the quality of life. Most of these therapies are presented as therapies designed to complement other therapies, be they traditional or alternative.

Shiatsu
Shiatsu is a Japanese form of massage that has its' roots in Chinese medicine. The practice of Shiatsu combines traditional massage with acupuncture. Through this therapy, the practitioner seeks to restore the body's energy balance. The energy, or "qi" as it is called, flows through the body on pathways known as meridians. There are points along these meridians where the qi will gather. If there is tension, injury or illness, these points can become blocked and the qi will not flow freely. In Chinese medicine, these sites are called acupuncture points, and they would be treated with needles, moxibustion or possibly cupping. In shiatsu, these points are called tsubos and they are treated with a finger pressure massage. According to Traditional Chinese Medicine the qi comes in two forms, yin and yang. In this tradition, yin is a quiet, deep, female energy, while yang is surface, active and male. Too much or too little of either, throughout the body or in specific sites in the body, can cause illness or injury. In Traditional Chinese Medicine, balance between the two types of qi is obtained through various treatments, herbal preparations, diet and exercise. Shiatsu strives to balance these two types of energy, as well as release blocked energy. The third aim of shiatsu is to bring about balance among the Five Elements. The Five Elements in Chinese medicine are Fire, Earth, Water, Wood and Metal. These are the same elements which make up the universe according to Chinese tradition. The human body, according to Traditional Chinese Medicine, is a microcosm of the universe. Different organs, characteristics and meridians are associated with each element. An imbalance among the Five Elements will result in a weakness within the body, which will leave it more susceptible to disease or injury.
Shiatsu uses gradual, gentle, rhythmic pressure on the tsubos and the meridians to release the qi and balance the various energies. Usually applied with the fingers, this pressure can also be applied with the elbows, hands, and feet. While there may be a feeling of pressure as the muscle releases, there should be no sudden or severe pain. Unlike Western or Swedish massage, the client remains fully clothed and there is no oil used. The treatment will usually take place on the floor or on a very sturdy table. The practitioner will first treat the Hara, which is the area between the pelvis and the ribcage. This is considered to be the seat of the energies in the body. Then the practitioner will move on to treat the meridians and the tsubos with pressure. The practitioner will end the session by returning to the Hara. The client is encouraged to breath deeply throughout the treatment, and pressure is applied during the exhalation period. Some shiatsu pressure points can be stimulated by oneself. There are a number of books that show the various points and will show the reader how to apply pressure.
Shiatsu practitioners do not usually diagnose illness or injury. Shiatsu is used primarily as prevention therapy and does not purport to cure illness. There are certain conditions for which shiatsu may be contraindicated, such as contagious diseases, heart conditions, disorders of the lungs, kidney or liver, cancer and infectious skin diseases. Many massage therapists are trained in several type of massage, shiatsu being one of the more common modalities practiced. Anyone interested in finding a massage therapist who specializes in shiatsu can contact the American Massage Therapy Association.
Acupressure
Acupressure is sometimes confused with shiatsu, but in fact they are two different systems. They operate from the same philosophical basis, but acupressure predates shiatsu. While shiatsu is used primarily as a preventive therapy, acupressure purports to treat specific diseases or conditions. Acupressure is basically the same as acupuncture, but acupressure applies pressure to the points of therapy, while acupuncture uses needles to stimulate the variouspoints. Different practitioners make different claims regarding both acupuncture and acupressure. Some claim that they can cure diseases, combat obesity and improve circulation. Others view them as preventive therapies, while others concentrate on their uses as a methods of relieving pain.
In order to fully understand the theories on which both acupuncture and acupressure are based, one would need to study the entire system of Chinese medicine. This system has a long tradition, well over two thousand years, and is very complex, combining elements of cultural beliefs as well as medicine. Like shiatsu, acupressure is based on the concept of qi, or energy. The purpose of both acupuncture and acupressure is to relieve blockages of qi that occur alongthe meridian. The meridians are channels of qi which flow through the body. When these are blocked, or the flow is not balanced, illness or susceptibility to injury and illness can occur. Pressure applied to acupoints or along the meridians will restore or balance the qi, thus relieving the condition that troubles the patient.
There have been studies on acupressure, some of which have shown it to be effective for pain relief and relief of nausea. Research has also shown acupressure to be effective in treating headaches and chronic backache. 37
While research has shown acupressure to be somewhat effective, it has yet to determine why the treatment is effective. It could simply be the endorphins released by the pressure, or the relaxation from a hands on treatment. In cases of serious disease or injury, acupressure should be used as a complementary therapy, that is one that is used in conjunction with other therapy. Pregnant women and those with open wounds or varicose veins must communicate these conditions to the therapist. To find a therapist in acupressure, one can contact the Acupressure Institute in Berkeley California or the American Oriental Bodywork Association in Syosset New York.38
The book Finger Acupressure: Treatment for Many Common Ailments, has a section on wrist pain. This volume is very succinct. It has a short section at the beginning of the book that explains how to perform the technique. It also has several warnings, explaining those conditions, such as pregnancy or severe cardiac conditions, for which this technique is contraindicated. Then the volume has various conditions listed in alphabetical order and the corresponding acupressure points. Wrist pain is the last entry and one point is indicated for treatment. The book is illustrated with photographs to help the reader locate the acupuncture point.
The book Performing Arts Medicine, edited by Robert Sataloff, Mary Shaheen and Alice Brandfonbrenner mentions the use of both acupressure and shiatsu in the chapter entitled "Therapeutic Management of the Instrumental Musician." There is no explanation, just a brief sentence that state "Muscle energy and acupressure or shiatsu massage are other forms of manipulative treatment used to strengthen weak muscles, stretch tight myofascial structures, and mobilize joint restrictions."39

Lomilomi
Hawaiian Lomilomi massage does not use the Chinese system of meridians, but it was influenced by the Chinese system and is used as a therapy by the Hawaiian people who developed it. There are many components to, and versions of, Lomilomi. The physical component includes different massage techniques that can be compared to those used in Swedish massage, although Lomilomi predates that technique. It should be noted that this is a traditional Hawaiian form of massage and that there was no written language in Hawaii for many years. Therefore, the practice was passed from teacher to student. The practice was outlawed for a period of time prior to the 1970s, due to laws that discriminated against the native Hawaiians and their traditional beliefs and practices. Therefore, it was only kept alive in secret. Not until the 1980s was this practice "discovered" and research and study began to take place.
Lomilomi uses massage strokes, but it also uses herbs, heat, and salt in treatments. There is also a strong spiritual component to traditional Lomilomi. The practitioner must clear all negative thoughts, as these are believed to contribute to physical problems. The goal is that the recipient of the treatment also break all negative connections and relationships and correct wrong thoughts. A traditional Lomilomi practitioner always calls upon a higher power forspiritual guidance. "Lomi-lomi always encompassed body, mind and spirit."40 Lomilomi resembles European massage more than Eastern massage, as the strokes that are used tend to focus on the circulatory systems (blood, lymph and interstitial) rather the meridians. The practitioner uses oil on the skin to aid in the process. Before the session, a healer will pray and center themselves in order to be able to serve "as a conductor of... energy, and direct it into the tissue or body part that seems blocked or is in a state of distress."41 The recipient is also expected to try to get into the "proper state of mind." There are exercises that the patient can do to assist in this process.
When the session begins, the practitioner "assesses" the patient. The practitioner uses the art of haha (to feel or palpate) to assess or diagnose the patient. After identifying the problem, the practitioner concentrates on the healing process and the desired result. There is no one set routine for lomilomi. Each practitioner develops his or her own style. There are certain strokes and techniques that are used, though the application may differ from practitioner to practitioner. These strokes have traditional names from the Hawaiian language. Many of these are similar to the strokes used in Swedish massage. The Hawaiian name and the Swedish equivalent will be included where applicable. If no comparison is appropriate, there will be a short description.
kahi - comparable to "therapeutic touch" or light efflurage
opa - kneading
kupele - comparable to petrissage
kaomi - pressing down - also used to indicate compressed thought
lomilomi - the tissue is moved in every possible direction
la'au kahea - breathing life or mana (energy ) into the person
hamo - to anoint with oil
The patient may also do an internal cleansing, eating a diet of high fiber fruit to cleanse the small and large intestine, followed by a drink of diluted sea water to complete the cleansing. The practitioner may also employ the use of hot stones wrapped in leaves placed on areas of the body, or the use of sticks that are curved to massage areas. The practitioner may also use ho'upu'upu, which is the implantation of a positive thought or idea, before, during, and after the physical treatment. There are also various herbal remedies, using plants native to Hawaii, that are used by Lomilomi practitioner. These could be taken internally are applied externally, as with a poultice.
The book Hawaiian Lomilomi: Big Island Massage, is an excellent introduction to the practice of lomilomi. While making no reference to any of the conditions that trouble musicians, it explains the techniques and has photos which illustrate the various strokes used in the practice. It also addresses the spiritual component of the practice. There is an interview with a lomilomi practitioner in the appendix of the paper, and in that interview the therapist addresses some of the problems experienced by musicians. With that information, this book takes on a greater significance.
Massage and acupressure are recommended in more books that are written specifically for musicians than any other form of therapy. They are also recommended frequently in other books that have a program of self care that is not necessarily directed specifically to the musician. In the chapter titled Self Care, the following material either recommends or mentions one or both of the therapies: Shoulder, Upper Back and Neck: Free Yourself from Pain (page 69 ) and Carpal Tunnel Syndrome: How to Relieve and Prevent Wrist Burnout (page 71) both by Rosemary Atencio, recommend massage and acupressure; How to End Your Carpal Tunnel Pain Without Surgery (page 72) by Kate Montgomery recommends massage and acupressure; Susan Weiss in The Anatomy Book for Musicians (page 74) recommends massage; The Musician as Athlete (page 81) recommends massage; Play It Safe (page 86) by Christine Zaza recommends massage; and the website Musicians and Injuries (page 92) by Paul Marxhausen recommends massage. Lomilomi massage is listed by Dr. Wynn Steinsnyder as one of the massage therapies that can be useful for musicians. (see appendix for interview with Dr. Steinsnyder and a Lomilomi practitioner.)