BY CHANTAL NGUYEN
“Dr Cliff” (as I like to call him during rehearsals with Strathfield Symphony Orchestra) has treated musicians from Australia’s leading orchestras. Based at the University of Sydney, Cliffton Chan is the medical profession’s version of a “triple threat”: a researcher, educator, and clinical practitioner (he’s a physiotherapist) all rolled into one, specialised in making you the healthiest musician you can be.
He’s won a slew of research grants and awards for his work, including the Performing Arts Medicine Association’s Alice Brandfonbrener Young Investigator Award, and the University of Sydney’s Vice-Chancellor’s Award for Excellence in Outstanding Teaching.
Cliffton made a loud protesting noise at my suggestion he start an “Ask Dr Cliff” column or a Dr Phil-style talk show, so we suggested he come chat to us at CutCommon instead. Here, Cliffton tells us about some of the latest developments in performing arts medicine, and offers practical health tips for the instrument-playing CutCommon reader.
Hi Cliffton! Thanks for sharing with us your passion for musicians’ healthcare! Tell us about your background in music and how you came to performing arts medicine.
I started my music journey completely by fate. Like any good 6-year-old whose parents recently immigrated to Australia, I was singing, clapping and playing musical games to the best of my ability. There was in fact a special event, an instrumental selection test, at primary school. I was faced with a giant whiteboard with a large list of ‘words’ I had never seen. Asked to select my favourite three, I remember writing down a word starting with the letter V. Next thing I knew, I was being fitted with a violin.
My passion for music has grown exponentially since, due to a series of amazing music teachers and mentors, two of whom are Kate Taylor and Janet Barltrop.
Despite wanting a professional career in music, my parents didn’t hesitate to tell me I would not have their support if I pursued such a career. Their ‘subtle’ prompting lead me to discover my other interests of helping, healing, and caring for people. Physiotherapy seemed like an ideal suit. But something was still missing after graduating.
Whilst working two physio jobs, I studied music at the University of Queensland. Ultimately, this led me to combine my two greatest passions through a once-in-a-lifetime PhD opportunity with associate professor Bronwen Ackermann at the University of Sydney – working with professional musicians to prevent and manage playing-related problems from the eight premier state orchestras around Australia.
So what sort of work do you do now?
I am very fortunate to do a combination of teaching, researching, and clinical work.
I’m a senior lecturer at the University of Sydney teaching anatomy to allied health students, and clinical exercise prescription to final-year physio students. In my research role, I continue to investigate the factors that influence playing-related problems and how we can best address these. I have also branched out into doing much the same with dancers and people with hypermobility.
I joined associate professor Leslie Nicholson, who is an international expert in hypermobility syndromes, to co-lead the Hypermobility and Performance Lab. It studies how hypermobility influences musicians, dancers, and athletes to how we can better manage people with a condition where many systems of their body are overly ‘stretchy’ (called hypermobility Ehlers-Danlos Syndrome).
And I’m fortunate enough to be able to sometimes put into practice what I research by working clinically at Potts Point Physio here in Sydney.
Give us a rundown on what performing arts medicine actually is.
Performing arts medicine is essentially medical, allied health, and other complementary therapy support for all performing artists. This includes external-instrument musicians, but also vocalists, dancers, and circus performers, just to name a few.
PAM practitioners help musicians achieve their best and fulfil their long-term potential. We do more than just treat injuries – we’re here to make musicians better and provide the support they need to flourish in their artform.
Collectively, we can do quite a lot to minimise and manage physical injuries and psychological problems like performance anxiety and depression. Beyond injuries and psychological issues, we heavily focus on optimising and building performance capacity. So with musicians, I work a lot on how we can keep musicians playing for longer before feeling fatigue, or how to play a passage with more ease and less effort by making some anatomically-sound recommendations to their instrument, set-up, or physical conditioning.
Tell us about your work with professional musicians.
A lot of what we do is education and advice. Knowledge is power – and certainly in the PAM space. Knowing exactly what to do when you have a niggle or pins and needles can sometimes mean the difference between that feeling lasting a few hours to having a legit injury. Sustaining an injury should not be a surprise, as musicians should see themselves as hyperfunctioning individuals, like endurance athletes, simply of the arms and/or facial muscles.
A good case study to highlight PAM at work involves a musician who came to me with progressively worsening upper arm pain and fatigue on both sides. It had started 6.5 weeks ago, when playing duration and pressures increased: a new role in an accompanying capacity, and extra teaching. After taking a full history and physical examination, I discovered postural issues, shoulder muscle strength imbalances, and concerning practice habits (practising in continuous 1.5 hour blocks, multiple times a day). But a major finding was actually poor nutrition. This person’s diet was meals of coffee and chocolate, and maybe a sandwich on the go between performing commitments.
We saw an 80 per cent improvement after just two treatments, a fortnight apart. This case is a great example of how PAM can support performers in more ways than one. The role of education and advice, including about things like nutrition that musicians and non-PAM practitioners might overlook, can help a musician not only survive, but thrive.
What are the most common injuries you see?
The most common injury areas I see clinically would be neck and upper back, shoulders, and elbows. Although I also see wrist, thumb, and embouchure problems often, these tend to be more complex cases taking a little longer to completely rehabilitate despite presenting less frequently.
One of the main contributing factors to these performance-related problems – especially amongst more experienced players – is overload or misuse, when playing load suddenly increases, like accepting a number of gigs with rehearsals all in a very short period, or returning from holidays where playing goes from nil to 25-30 hours a week.
What do you think the industry can do to help musician’s health?
The music industry should really shift the culture around injury and seeing healthcare professionals for support. We should take on the mentality that musicians are hyperfunctioning performers who are susceptible to injury, just like a soccer player is likely to sustain a knee or ankle injury and a swimmer to have shoulder problems.
With adequate prophylactic training and knowledge on how to manage these problems early, these do not have to affect your long-term prospects whatsoever. Therefore, I strongly advocate more health and wellbeing education during a musician’s training, employers of musicians being more aware of workplace health and safety, and a positive attitude towards talking about physical and psychological injuries.
If a colleague mentions they have an injury, be kind and empathetic, rather than being critical of them, placing blame, or even thinking it’s because they are a weaker, bad player. We must bring to light the many misconceptions musicians have around injury, and stop injury concealment issues – because the worst thing musicians can do is delay management when it’s a medical problem.
Finally, musicians should see allied health professionals as facilitators to their playing. There are many ways we can help you play optimally, longer, and easier. We bring a sports science, medicine, or anatomical perspective that can supplement what you’ve been taught about instrumental technique or help you think outside the box, and we are happy to work with you and/or your music teacher to overcome technical obstacles.
What sort of help do you think musicians can or should expect from health care professionals?
We can provide education and advice based on reliable literature, whether this be sleep hygiene for a touring musician, nutrition for a vegan musician, or how to prevent a recurring injury. We strongly advocate that a musician should optimise every element of their lifestyle to maximise their career longevity, staying in tip-top shape.
Of course, everyone is a little different, so there is still a need for trial and error at times; but at least you know the best way to approach whatever the issue is will be somewhere between A and B.
Specific to my area of expertise, music physios are skilled in picking up the subtlest of movement/positional inefficacies or muscle imbalances. By correcting – sometimes with a small change to your posture or instrument position, or maybe a few weeks of some exercises – it could make playing something you’ve been working on for a long time so much easier.
You can definitely expect from us a thorough examination, explanation of what we have identified as contributing factors to your playing-related problem, and developing realistic goals or a treatment plan with you, so you know what to expect in the immediate, short, and medium terms.
In the early management phase, I commonly use manual therapy to obtain some immediate results, teach specific exercises to maintain and further these gains – on or off the instrument, and provide education and advice relating to the problem and to maximise your general performance capacity.
And where would you recommend musicians look for helpful and reliable information if they’re not sure about a health or playing concern?
Australian Society for Performing Arts Healthcare is the peak body for the promotion of holistic healthcare in the performing arts industry. It’s made up of many qualified and highly passionate healthcare providers and musician health and education researchers. They’ve generated a number of free health and wellbeing and performance optimisation fact sheets specific for musicians’ requirements, demands, and challenges.
In addition to many free resources, there is an invaluable Member’s Directory where you can search for any type of healthcare professional, in each state, who has expertise or a strong interest in treating musicians.
Second to this are the United States and British counterparts, who also provide high-quality free health education and advice for performing artists.
As good as free tailored education and advice is, it does not ever substitute for a healthcare provider who sees you for you. If you have the same condition as another musician, how you present and the factors contributing to your problem can be very different. There is always a limitation to even the best evidence-based education and advice. Therefore, if your performance-related problem is not becoming better after fivedays, it is definitely time to see a healthcare provider. This problem is unlikely to just go away with rest. The sooner a healthcare provider can address the issue, we can often keep a musician playing and get you back to full capacity quicker.
What are the essential things you think musicians should know about staying healthy, and being in peak form as a performer?
I think it’s really important that musicians see themselves as upper limb endurance athletes, and therefore you do need to ensure your body is in equally good condition as your musical instrument. Once this realisation has truly sunk in, you will naturally change your lifestyle to become an artistic athlete, taking a little more care with eating, sleeping, hydration, picking up a regular exercise you enjoy, and planning out a realistic and measurable practice schedule.
Finally, musicians should be prepared and equipped with a health and wellbeing toolkit (for example, how to manage common acute physical injuries, and learning emotional first aid) to help overcome the many challenges you face, whether these be physical, or psychological attacks that come with being meticulous artistic technicians surrounded by highly tuned perfectionists.
Once you’ve arrived at this point, I strongly believe you will be much better prepared to tackle the strenuous demands of becoming a musician, and you are much better equipped to a long, fulfilling career.
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