Stephen Proser on Navigating Two Injuries
Back in 1990, several months after starting my first full time job as second horn of the New Orleans Symphony, I started feeling occasional sharp pain in my top lip, on the right side, on the red line where the mouthpiece contacts and crosses the lip. I was usually seated in front of the tympani during this period and feel that the beginnings of my issues relate to this. This pain was only occasional for the next few years as I moved on to the Alabama Symphony and then the Utah Symphony.
During my first few years here in Salt Lake, in addition to my schedule at the Symphony, I accepted significant amounts of outside work. In time, the large amount of playing I was doing clearly was having a negative effect on my lip. The pain was getting more severe and more regular – in particular, right around my embouchure break. By the fall of 1996 I started to feel that, in addition to pain, my sound had lost its luster and was dull and gray-sounding. I decided to take three weeks off work at this point. Ultimately, it turned out that this would be all the time I would take off. During this period, I became aware of the work of Lucinda Lewis, former principal horn of the New Jersey Symphony. She advised me to contact Dr. Simon McGrail in Toronto. Dr. McGrail asked me to see a neurologist here in Salt Lake to rule out nerve damage. Those tests were negative. I had no nerve damage. Then I flew out to Toronto for an appointment with Dr. McGrail. He diagnosed me with a thinned out lip muscle (obicularis oris) through overuse and prescribed isometric exercises to strengthen the muscle. He also advised me to return to work, as he thought that I would not do any more damage to my lip. He was actually more concerned that I would do further damage to my psyche by not working.
I did the isometrics religiously for the next months. After eighteen months of exercise I felt back to full strength. I would say that I continued doing the isometrics for at least six months beyond this point. I also did them occasionally after returning from vacation or other times when I felt the need. I should report that I continued to feel occasional pain for years after my recovery.
My sound did eventually return and my lip regained its health. The one negative change: before the injury, I could play very softly with little effort. Soft playing is now not as easy for me. I attribute this to the build-up of scar tissue in my lip. There is just more mass there to have to vibrate now.
Here are some of the things I learned from this experience:
- Just as we are right or left-handed, we are right or left-faced, and these correspond. In my experience, lip injuries happen on the weak side. This is the side that needs to be strengthened. One might avoid injury in the first place by doing the isometrics prophylactically.
- Ice and ibuprofen work. Particularly 800 mg timed release Ibuprofen. Prescription only.
- Take a day off every week. You won't forget how to play. Take a week or two off in the summer. If you can take a week off in the winter, do it. We are small-muscle athletes and we need recovery time.
- One can only play the horn a certain number of hours per day and week. Know your limits. Turn down work (if you can afford to) if it exceeds your limits. I only play the Symphony schedule and occasional chamber music now.
- If you feel pain, put the horn down.
Now, onto my second story. It's about TMJ (temporomandibular joint disorder.) I now realize that I have had this disorder since I was a teenager, but it took many years for it to have an effect on my horn playing. Sometime around 2005 I started to notice a little wobbling in my sound in the low register. As I'm a low horn player, this concerned me. This is my bread and butter range. My job depends on me being solid in the low register. At the time, I just couldn't figure out what was going on. I watched myself carefully in the mirror. Everything looked right, but there was this shaking. Was it focal dystonia? Did I have a neurological problem? Why did it present only in the low register? Believe it or not, this went on for years, getting worse and worse. I was ashamed of the way I thought I sounded, but could not make the wobbling go away. I was approaching fifty years old at this point, with a family to support. The thought of having to find a new career at this point was overwhelming.
I don't know why I didn't ask for a TMJ diagnosis years earlier. I suppose it was because I had never heard of anyone "recovering" from TMJ. In fact, TMJ had forced our third horn into an early retirement years ago. I must have feared that her fate would have to be mine. So, I resisted the idea that I had TMJ.
Finally, in desperation, I asked my dentist to recommend a TMJ specialist. I went to my appointment, x-rays were taken, and a diagnosis was made. I had TMJ, with some bone loss at my temporomandibular joint (jaw) on the right side. The weak side again!
TMJ is generally caused by grinding the teeth during sleep. This places a great amount of stress on the jaw as well as grinding down teeth. Many people experience significant pain with this disorder, although I do not. To prevent the grinding, a splint (mouth guard) was made for me. The grinding seems to be a physical reaction to anxiety. So, successful treatment of TMJ requires treating both medical and psychological conditions.
My TMJ dentist also prescribed physical therapy for me in addition to the Alexander Technique lessons that I was already taking. Some of the exercises I learned I still do to this day, a good seven years after diagnosis. More importantly, at one of my PT sessions I discovered that they had electromyograph (biofeedback) machine. I asked if I could bring my horn in to the next appointment and get hooked up to the EMG. Sure enough, the electrical signals that the EMG recorded indicated that, while playing, I was clenching my jaw very hard on the right side. Why? I believe that because of the bone loss, the joint had become "sloppy." In order to prevent the joint from slipping while was playing, I was clenching. The worse my jaw got, the more I clenched. Eventually, I was clenching so hard that the tension was being transferred into my sound. I had to learn how to play without clenching. I realized that the EMG might be able to help teach me how to do this. However, going into PT every day was not an option. After a bit of research, I discovered that I could purchase a small portable EMG for home use. I practiced the horn daily with the EMG attached to my jaw, listening and watching the feedback carefully. I slept with it on, because it has an alarm that will wake you if you exceed the parameters that you set. I did homework and chores with it on. I also did significant work on the sources of my anxiety. I won't go into detail on this, as every individual will need to find their own way to a semblance of inner peace. I will say that Cognitive Behavior Therapy has been shown to be very effective. Depression and anxiety are threats to our playing. Help is available.
On the whole, I feel I am now doing the best playing I ever have. I hope that my stories are cautionary tales for those who are willing to listen. Seek help early. Don't wait for things to get really bad as I did. Twice. On the other hand, I hope that those of you that are suffering can know that recovery is possible. Physical and mental health are possible. You are not alone. Please feel free to contact me if I can be of any help.
Best regards,
Steve Proser
4th Horn, Utah Symphony
Adjunct Professor of Horn, University of Utah
stephenproser@gmail.com