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Medical News & Perspectives
October 16, 2019

A Day in the Life: Performing Arts Physician Saves Careers by Fine-tuning Artists’ Form

JAMA. 2019;322(17):1637-1639. doi:10.1001/jama.2019.15208

Maria Reese, MD, still remembers landing in a Tennessee emergency department with a knee injury as a young dancer. The prognosis was grim: she would never dance again. Reese recently recalled “being devastated and thinking I'll prove that to be wrong, I'll get back to dancing.” And she did.

Dara Grennan, MD/American Medical Association

But she also remembers thinking that an athlete wouldn’t have been written off so easily, with a career-ending prognosis before treatment or rehabilitation. She came to the stark realization that “sometimes people don't necessarily understand what performing artists do, how much it's a part of who they are, and the pull towards that passion.”

Reese has that understanding. Her medical career is devoted to helping performing artists pursue their passion without pain. To develop her skills as a performing arts physician, Reese completed a physical medicine and rehabilitation residency and a sports medicine fellowship at the Rehabilitation Institute of Chicago, now known as the Shirley Ryan AbilityLab. Five years ago, she became director of the AbilityLab’s Performing Arts Medicine Program, where she works with a team of physicians, therapists, and trainees that treats professional and amateur instrumentalists, actors, and dancers from around the country.

Since Reese took over, one of the program’s goals has been outreach. “[T]here's this large cohort of adolescents, young adults, and older adults who are not perhaps cared for in the most ideal manner,” she said. Referring physicians generally don’t make the connection between performing artists’ musculoskeletal problems and sports medicine clinicians’ musculoskeletal expertise. Many artists simply aren’t referred for appropriately specialized care at a performing arts medicine clinic or even a sports medicine clinic.

By the time they come to Reese’s clinic, a lot of patients have seen multiple physicians, perhaps primary care physicians, orthopedists, neurologists, or physical therapists who’ve given well-meaning but ultimately useless advice. “Many [artists] have been told, oh, just stop playing, just rest. Well, that doesn’t really work because, A, they can’t just rest sometimes and, B, rest is not the solution for a chronic issue [because] of course, once they go back, [the pain] resumes.”

am: Minor Changes, Major Relief

Her days begin early, getting her 3-year-old ready before the nanny arrives at 6:45 am. Year-round, her commute is a bike ride through Chicago in every kind of weather. She spends about half her time at the AbilityLab and half in the orthopedic department at Northwestern, where she’s an assistant professor. Most days are spent in outpatient clinics, where about a third of her patients are performing artists.

Instrumentalists often present with chronic overuse symptoms—a violinist with numbness in her bow arm or an oboe player with jaw pain, for example. Others may have had an injury or illness such as stroke that affected their performing ability.

When undergoing stroke rehabilitation, for example, the focus is often not ‘how’s your playing coming?’ but rather ‘how’s your walking and everyday activities?’ explained Reese, who instead works with musicians to recover their instrumental skills.

New patients frequently ask if they should bring their instrument to their first appointment, to which Reese answers a resounding “Yes!” To localize the source of their symptoms, she needs to watch their interactions with their instrument. She’ll closely observe how a guitarist—whose fretting hand is so painful that he plays with only 2 fingers—holds the neck of his guitar or how a drummer with shoulder pain sits on her throne.

Treatment often consists of minor adjustments in form, which Reese terms micro changes. The challenge for musicians is maintaining those subtle adjustments. Performing arts clinicians often use kinesiology tape or braces as proprioceptive reminders to help artists break yearslong habits. A violinist with medial elbow pain from holding the bow with a hyperflexed wrist might have the wrist taped in a neutral position while playing. During rehearsal, performers sometimes set alarms on their phone at 15-minute intervals as reminders to check that they haven’t reverted to old habits.

Other performers work with a physical or occupational therapist to strengthen specific muscles to make changes that will lessen their symptoms. Performing arts medicine therapists can be quite specialized: one of AbilityLab’s therapists focuses on orofacial issues in wind instrument players. Those patients might have jaw pain, but the issue is typically not just the jaw, according to Reese. Usually there’s “some neck issues, shoulder issues, something else that's contributing” that needs to be identified and corrected. Reese also works with specialists outside the AbilityLab. Singers might be referred to the ear, nose, and throat clinic, and flutists with thoracic outlet syndrome—the compression of nerves or blood vessels between the collar bone and the first rib—are sent to vascular surgeons.

Reese’s patients are hopeful that they’ll finally find relief, but many fear that they’ll receive career-ending news like she did in that Tennessee emergency department. New patients’ fear can be almost palpable, but she said “can’t” is the last thing she ever tells them. “I say we're going to find ways to keep you going. We may have to make a few changes [but we will] bridge that divide between medicine and artistry,” Reese noted.

Spreading the Word

Reese sees performers from all backgrounds: classical, rock, and jazz musicians; young dancers from programs like the Joffrey Ballet Pre-Professional program and professionals from Hubbard Street Dance Chicago; actors from the city’s many improv and theater companies; young people still auditioning for their big break and amateurs in other careers who still love to perform. Some travel cross-country to the AbilityLab, particularly elite artists. After establishing the source of their symptoms, Reese arranges appropriate local follow-up for out-of-towners and provides detailed therapy recommendations for their local clinicians.

But the reality is that not all artists can access this specialized care due to proximity or other barriers—there’s a reason they’re known as “starving artists.” So Reese and her colleagues work to expand awareness and access. They advise sports medicine colleagues outside the AbilityLab and the Northwestern health system, lecture at other rehabilitation centers, and give injury prevention seminars with performing arts physical and occupational therapists.

Fortunately, performing arts medicine is a relatively low-tech specialty because clinicians rely on solid, old-fashioned clinical skills. Reese and her colleagues carry out diagnostic ultrasounds during clinic visits, but more expensive testing like magnetic resonance imaging or procedures like steroid injections are rarely needed.

The good news is that the ranks of performing arts medicine clinicians are growing, including the residents and fellows Reese trains at the AbilityLab. More artists in more areas of the country now live near a specialist than in the past.

pm: Actors, Theater, and Family

At Chicago’s Lookingglass Theater Company, located in the historic Chicago Avenue Pumping Station near the Water Tower on Michigan Avenue, Reese holds early-evening clinics for the actors. Theaters and movie sets are hazardous environments and acting is a strenuous pursuit. Stage actors endure tremendous strain on their bodies and voices while performing in 8 shows a week for months at a time. Neck and shoulder injuries and low back pain are common.

At Lookingglass, the theater-in-the-round staging means the actors move heavy scenery themselves. A recent production, Mary Shelley’s Frankenstein, was quite physically demanding, including lifting other actors, climbing through trapdoors, and aerial work. Reese works with individual actors who have chronic issues, watching how they interact with a prop or a piece of scenery. She also holds screening clinics at least once every production, identifying points in the production with high potential for overuse injuries and providing injury-prevention recommendations to the entire troupe.

The Performing Arts Medicine Program has similar arrangements with many Chicago-area arts organizations including Chicago Shakespeare Theater, the Goodman Theatre, Steppenwolf Theatre Company, and the Ravinia Festival, a performance venue north of the city, which is the summer home of the Chicago Symphony Orchestra. At Ravinia, Reese and her colleagues are available for acute problems that arise with visiting artists during rehearsals, and they attend every performance: “For every Ravinia concert, [if] a performer or instrumentalist needs something, we're there.”

Nowadays, Reese is more likely to supervise her fellows by phone rather than attending evening performances herself. Any dancing is with her toddler son, and since August, she and her husband have an infant daughter at home as well. After her bike ride home, evenings are family time and often include a walk or run along the Lake Michigan shoreline. She catches up on charting, academic manuscripts, and preparing lectures at night after her family is asleep.

Inspiration

Reese credits family for helping to inspire her support for artists. Her grandfather, Mario Maccaferri, was an accomplished classical guitarist born near Bologna, Italy, who toured Europe and performed in films in the 1920s and 1930s. Family legend has it that he broke his right hand while swimming in a pool during a break from filming in France. He designed his own rehabilitation program by playing as much as possible and started performing in local cafes. But he was embarrassed because it wasn’t his best work. His solution? He wore a mask while performing and became known as Le Guitariste Masqué, or the Masked Guitarist. In the end, he had to abandon his performance career. Fortunately, he had skills beyond guitar-playing: he became not only a world-renowned luthier but also an inventor and manufacturer with a particular interest in plastics. He designed the plastic ukulele that became a worldwide craze in the 1950s.

Rehabilitation medicine has come a long way since Maccaferri’s self-imposed rehab program. Reese wants artists to know that hope and help are available from performing arts medicine clinicians who understand the physicality of what artists do as well as the creative process.

“An artist is an athlete plus a storyteller,” Reese said. “They have to keep the vision and keep the persona while they’re having pain. You can’t [let them lose] their ability to tell that story.”

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