Maturing Flutists: Problems
and Solutions
Stephen A. Mitchell, MD
Performance Health Care Committee
Nashville, TN
Who is this guy and why should I
believe anything he has to say?
 Treating professional musicians for over 30
 Member NFA & Performance Health Care
 Formally know as Dysfunction Committee
 Founding member PAMA
 Spouse of professional flutist
 Singer with experience touring
internationally and recording
 He’s getting older and feeling it
Maturing: definitions
 PC way of saying “deteriorating”
according to some youngsters
 “Chronologically challenged”
 Delicate but inaccurate word for
this talk since:
 aging is inevitable but maturing
is optional
Self Test
 You know you’ve been playing the
flute for too long when:
You tongue while whistling
You hold pens upright on your knee
You can play 4 different Bb’s
You’ve had a piccolo stuck to your
Sobering Facts:
 You grow old or die young. Period.
 All parts wear down with time.
People are no different than cars,
except that you can’t trade in.
 Some religions beg to differ
 “Middle age is when you still
believe you’ll feel better in the
Bob Hope
People over age 64
Political pressures to delay
retirement age
 “Full retirement age (also called
"normal retirement age") had been
65 for many years. However,
beginning with people born in 1938 or
later, that age gradually increases
until it reaches 67 for people born
after 1959.”
Other political pressure
 The American Academy of Actuaries,
which advises policymakers on risk
and financial security issues, wants
any potential solution the White
House and lawmakers might consider
to include raising the retirement age
from the current range of 65-to-67years-old. CNN 8-1-2008
More political pressure to come
 “The age of retirement should be
raised to 85 by 2050 because of
trends in life expectancy, a US
biologist has said.”
Paul Rincon BBC News, 2-17-2006
 The kids in the audience can stop
being so smug now
Practical pressures to work longer
 Poor planning when young for
 Poor rate of savings for Americans
 Easy credit=high debts, loans,
credit card
 Never tuning in Dave Ramsey
More practical pressures
 Social Security is not adequate and the
USA has not gone socialist ………….yet
 Direct & indirect taxes increasing
 High cost of health insurance if self
 “When I told my doctor I couldn’t afford
an operation, he offered to touch up my
Henny Youngman
Pleasure pressures to work longer
 Enjoy the challenge
 Playing is still fun – beats being an office
gopher in a cubicle
 Makes us special – few can do what we
do –”amaze your friends”
 Can keep sounding impressive by
dumbing down the repertoire – like
moving from the blue tees to the red
tees in golf but less embarrassing
Mischa Elman, violinist 1891-1967
 “You know, the critics never change;
I’m still getting the same notices I
used to get as a child. They tell me I
play very well for my age.”
“Do not go gentle into that good night, Old age
should burn and rave at close of day” DThomas
 What are the details of what to
expect as we age?
 How an these impact playing flute?
 What can I do now, if young(er), or
what should I have done in past?
 What can I do now that I’m having
problems besides wail and gnash?
The ugly details of what to expect
 The fingers, the wrists, the shoulders,
the back, the hips, the feet, the neck,
the brain, the nervous system, the
lungs, the teeth, the jaw, the
eyesight, the hearing are all
adversely affected by aging and
activities of our youth.
 “No man is rich enough to buy back
his past.” O. Wilde
Bone and Joint disorders
 Arthritis: 60% of population will be
symptomatic by age 65 and it accounts for
25% of all primary care doctor visits
 Women comprise 60% of cases
 Incidence goes up with age
 Worse with excess weight, hormone
changes (menopause), lack of exercise, and
repetitive injuries to joints (i.e.: flutists are
usually 3 for 4)
What to do for B&J
Avoid unnecessary joint trauma
Use non-injurious practice methods
Treat hormone abnormalities (+ -’s)
Anti-inflammatory meds to slow
permanent damage
 Keep weight down
 Exercise early, smart, and forever
 Choose your parents wisely
Muscle Atrophy
 Sarcopenia: gradual decrease in the
ability to maintain skeletal muscle
function and mass, associated with
aging, unknown cause.
 Can be slowed by exercise but need
to start exercising early to minimize
looming permanent muscle cell loss
 “Getting older is no problem, you just
have to live long enough” G Marx
 No proof that bad posture is an
unavoidable part of aging
 Requires more work to prevent as
muscles get weaker (sarcopenia) and
as discs between vertebra shrink
 Practice good posture early and keep
it up (Quasimodo was a percussionist,
not a flutist)
 Key component to many therapies
Brain and Nervous System
 Steady decline in some cognitive skills
starts in 30’s: more problems with new
memory skills than old memory skills
 “With increasing age the occurrence of the
(jaw)reflex was reduced, the latency was
increased, while the amplitude was
decreased. Those findings are probably
related to the general age related changes
in the muscular tissue, the sense organs,
the peripheral nerves and especially the
central nervous system.” A. E. Kossioni
What to do for brain and nerves
 Keep mentally active. Exercise the brain like a
 Keep emotional links active to other people
 Avoid alcohol. It can kill brain cells and destroy
nerve function and cause tremors
 Aggressively treat diabetes and vascular
disease and never smoke. These clog the blood
vessels that carry the only oxygen the nerve
cells receive. Once they are dead, they are
usually gone for good
Hand and Finger
 Hand function decreases with age in
both men and women, especially
after the age of 65 years.
Deterioration in hand function in the
elderly population is, to a large
degree, secondary to age-related
degenerative changes in the
musculoskeletal, vascular, and
nervous systems.
E Carmeli
What to do for hands and fingers
See previous slides
Avoid unnecessary injury (rugby, handball)
Avoid overuse, misuse when practicing
Ergonomic rules and tools to match
instrument, chair, music stand, computer, etc
to the individual.
 Persistent pain is BAD. Do not think macho is
wise. Find the cause and fix it immediately
 If injured: RICE (rest, ice, compression,
elevation) immediately
RICE Therapy
 Rest: Reduce activity, splint the injury, and
keep weight off area
 Ice: Ice packs reduce pain and swelling.
Applied for 20-minute periods to avoid ice
burn. Remove packs for intervals of 40-60
minutes before reapplying.
 Compression: Lightly apply an elastic wrap
so that it reduces swelling. If it seems too
tight or causes swelling below the wrap,
loosen it.
 Elevation: Holding the injured part above
the level of the heart.
After RICE Therapy
 Restore strength: begin after 60 - 70% of
normal motion has returned.
 Restore motion and flexibility: warm up
before exercising and stretch after.
Stretching improves muscle flexibility by
approximately 20%.
 Restoring balance: the use of a balance
board or do one-legged exercise.
 Finally: use a brace to provide additional
support and protection for the first few
Respiratory Function (wind)
 Several factors alter the mechanical function of
the lung with age.
 1) a decrease in motor power due to fewer
muscle fibers and a decrease mechanical
 2) an increase in parenchymal compliance
decreasing elastic recoil of the lungs and
ultimately a change in structure and function of
the chest wall due to a loss of intervertebral
 3) a stiffening of the chest wall from changes
in ribs, sternum and articular cartilages making
the chest less expansible.
BK Ross
What to do about lungs
 Never smoke !!!!!!!!!!!!!!!
 Avoid pollution
 Diet: high fruit and vegetable intakes have
been most consistently associated with
protective benefits in visual loss, cataracts,
respiratory disease, and cancers such as
breast, stomach, and colorectal
 Deep breathing (ALA, yoga, etc)
 Treat asthma with maintenance med, avoid
rescue med
 Status of teeth and gums mainly
dependent on how well they were
cared for in the preceding decades
 “floss them now or toss them later”
 Dentures don’t have nerves
 Mouth gets dry (fewer glands, more
 Lips & tongue move slower
What to do about embouchure
Brush and floss like mama told you
Keep own teeth even if it costs more
More water, less Dr Pepper
Biotene products
"If I had known I was going to live
this long I would have taken better
care of myself"
Hermann Doernemann at age 110
Aging Eyes
 less able to produce tears
 retinas thin with risk of detachment
 lenses gradually turn yellow and
become less clear
 In 40’s focusing on objects that are
close up may become more difficult
 Either that or arms are shorter
National Institute of Aging, NIH
More aging eyes
 In 60’s colored portions of your eyes
(irises) stiffen, making your pupils
less responsive & difficult to adapt to
different levels of light
 Become sensitive to glare, problem
when driving at night
 Cataracts, glaucoma and macular
degeneration are the most common
problems of aging eyes
What to do about aging eyes
 Regular eye exams to catch problems
early (stitch in time)
 No smoke (increase ocular pressure)
 More light needed to see by
 More eye glasses for different tasks
 Don’t waste money on “Bates eye
exercises” squishing your eyeballs
 Keep eyes well lubricated
Ear Disorders and Aging
 Hearing loss or distortion
 Tinnitus (ringing in ears)
 Wax and infections of canal
Hearing loss
 1 in 3 over age 60 with significant
hearing loss
 Worse with vascular disease, noise
exposure, some medications, family
 Injury in orchestra players suspected
to occur but difficult to prove
American Speech-Language-Hearing Assoc
What to do about hearing loss
 Baseline hearing test by age 40
 Ear/hearing check if change noted by
you or family/friends
 Avoid unnecessary loud noise (iPod,
concerts, lawnmowers, workshop)
 Hearing protection every chance (ER20, ER Custom plugs, Mack’s HiFi Ear
 Hearing aids if needed. Fit is key
Immediate Tx for noise blast
 NAC (N-Acetyl-Cysteine) is a
precursor to glutathione and may be
effective in preventing hearing loss
from noise trauma. Clinical trials are
using 900 mg of NAC three times
daily to reverse the effects of noise
trauma. Therapeutic window for
preventing damage is 3-5 days after
the trauma. OTC med Bielefeld, et al
Tinnitus (ringing)
 Common problem over age 40 (men
> women
 Usually due to injury to tiny inner ear
nerve “hair cells”
 Frequently noise exposure history
 Any vascular disease can cause
 Meniere’s disease special case with
different treatment
Prevalence of Tinnitus
What to do about tinnitus
 Protection same as hearing loss
 Testing to be determine if it is a
treatable or more hazardous problem
 White noise to drown out silence
 Reduce stress & stimulants
 Bio-feedback & hypnosis may help
 N-Acetyl-Cysteine may help
 Hearing aid-like masks
Wax and ear infections
 As ear canal skin ages, it dries, sheds
more dead skin cells
 Ear wax glands reduce in number and
effectiveness with time
 These mix and either block the ear or
fail to prevent bacteria from growing
in the canal, causing infections
What to do about ear wax
 Keep the car keys and q-tips OUT of
the ear canal
 Use mineral oil drops if dry & itchy
 Use swimmer’s ear drop if hurts
 Use wax softener and bulb syringe to
wash ear if blocked with wax
 See your doctor if all fails
 Most of the problems listed so far are
worsened by stress
 Ian James 1997 BAPAM survey from
56 world wide orchestras showed
stress was a serious problem with the
 Top Ten list of causes of most severe
stress: (apologies to D Letterman)
10: worry about finances
9: making mistakes when performing
8: medical problems affecting work
7: incompatible stand partner
6: disorganized rehearsal time
5: illegible music
4: playing orchestral solo
3: having problems with instrument
2: incompetent conductor
1: conductor who saps your confidence
Stress continued
 73% had moderate to severe stress
from working with a conductor who
sapped their confidence
 61% had severe to moderate stress
with incompetent conductors
 Definition of an assistant conductor:
a mouse trying to become a rat
Rob Stein
Washington Post Staff Writer
Tuesday, November 30, 2004
 Scientists have identified the first direct link
between stress and aging, a finding that
could explain why intense, long-term
emotional strain can make people get sick
and grow old before their time.
 there is no such thing as a separation of
mind and body -- the very molecules in our
bodies are responsive to our psychological
Washington Post continued
 If someone appears headed for trouble,
doctors could recommend meditation, yoga
or other stress-reduction techniques, she
 "The findings emphasize the importance of
managing life stress, to take it seriously if
one feels stressed, to give your body a
break, and make life changes that promote
well-being," Elissa Epel, psychiatrist UCSF
Philosophy of Life Choice
 “I know a man who gave up
smoking, drinking, sex, and rich
food. He was healthy right up to
the day he killed himself” Johnny
 “Age is strictly a case of mind over
matter. If you don’t mind, it
doesn’t matter.” Jack Benny
 (both lived until 80)
The Sign in the West Virginia lunch
counter read:
 Don’t criticize the coffee.
 You may be old and weak yourself

Maturing Flutists: Problems and Solutions