Update on tennis elbow - preventing future injury

Well it's been 3 weeks since I used my left arm to any great extent on the guitar, and the pain has subsided considerably, particularly after a fairly intense dose of NSAIDS for a week due to another injury (fortunately doesn't impact guitar playing) Got a consult on adjusting my practice schedule to prevent this happening again - some surprising advice, and some not so surprising.

The not-so-surprising was that the injury was probably caused by too much tension - ie gripping the guitar in a "death grip."   I don't think I'm that bad when playing normally (my guitar teacher might disagree)  though I could definitely stand to lighten up a fair bit.    The real culprit so far as this injury goes was practicing slurs (a lot) using way too much pressure - particularly multiple hammer-ons in sequence.  I blame practicing "Oriental" for that.   I think it's because my fingers are still confused about where the pressure needs to be quickly applied (and equally quickly removed) so they all just go for it at maximum force.   So I guess I'll be working on it extremely slowly (as if I haven't heard that before!) to get that sorted out.

Also not surprising was that at my age (definitely not to be disclosed) I should not be practicing more than 45 mins in a row - evidently blood supply starts to become reduced after that, presumably resulting in less removal of toxic products of exertion etc etc.    So uninterrupted 2 hr practice sessions are out...    After the 45 mins, I'm to stop and ice the injury for 5 mins.

The surprising advice was to warm up the whole body for 5 mins before practicing - yes - large muscles, running, jumping jacks, stair walking, knee bends etc.  Gosh I haven't done exercise like that in about 4 years (and jumping jacks are definitely out on a broken ankle).  However I can manage sit ups and kneebends so I guess its not out of the question.  I don't know if I was too horrified to ask why during the consult, but I suppose as a means to get the hands warmed up and blood flowing it's efficient.  Also probably compensates somewhat for then sitting for 45 mins...

So the routine is -
Large muscle exercises 5 mins
Practice including guitar warm up 45 mins
Ice 5 mins
Rest 5 mins

And if you want to practice more, repeat the whole thing.  Yikes! I can tell you that I'm not used to this amount of (admittedly limited) callisthenics but it does seem to shorten the overall time before my brain and fingers reconnect with the fretboard. That may be wishful thinking though.   On the other hand, a 1.5 hour practice session now takes 2 hours.  And I'm totally tempted to eliminate the second set of 'large muscle exercises' prior to the second 45 mins, or at least reduce it to a few situps and push ups.  Though given that the arm has been cooled down by ice, probably I shouldn't be so tempted. Has anyone else had to adjust their practice schedule to prevent injury?

Tennis Elbow

Ok I got the official diagnosis - tennis elbow or lateral epicondylitis - and the cortisone shot into selfsame common extensor tendon - painful!  After the pain of the injection subsided over a couple of days, the general pain subsided somewhat but more practice over the weekend for a performance at Chestertown guitar festival (great fun - workshops, concerts, fun with friends) put me right back at square one -   which is -  I can play just fine without pain, but gripping or twisting or even extending my left arm at all other times is quite painful, and the common extensor tendon and associated muscles down the forearm are sore when pressed.    So this is finally making me contemplate a serious change in my practice attitude - probably long overdue - only youngsters can go at something with abandon until they quit from mental and physical exhaustion and not suffer consequences!  Fortunately we have a month long break from orchestra rehearsals after this week, which will allow me to rest it pretty much entirely.  The question is, how can I accelerate recovery and change what I'm doing to prevent it happening again?

While waiting for medical, advice about what to do next I've been reading up on tennis elbow.  Yes Google to the rescue - however I'm only reading posts from physical therapists or MD's - so much misguided information out there, particularly on medical issues.  It seems the current thinking is that tennis elbow is not so much an "tendinitis" but more of an "tendinosis."    Tendinitis indicates inflammation (pain, swelling, redness, heat) whereas tendinosis just means there is something wrong with the tendon but we don't really know what it is.  Hmm.    The post by Paul Ingraham was the most informative I found - a list of therapies that have been found in some cases to work (or not), including the original study references.   I tried a bunch of them - I think in my case I have a bit of both tendinosis and myositis because the muscle hurts in addition to the tendon, so I have tried icing, and when it was particularly sore it did seem to settle it down.  However the 2 things to date I have found to be most beneficial are massage (both longitudinally along the muscle and the so-called "friction" massage across the tendon) and stretching or stretching with mobilization (read the article to find out what this is - but easy to do at your desk at work).  Plus rest of course.  This  means not using the left hand on the guitar.  Or does it?  I found out today that if I don't use the thumb (at all) finger pressure does not cause any pain, either on or off the guitar. Thus I have a potential way to practice finger placement without exacerbating the condition, with the added benefit that I will hopefully learn to lighten up with the left hand.  Also I fear if I just do right hand exercises, though I know they are good for me,  I will either die of boredom or mess up the right hand or both!

Accordingly, things will probably be quiet for the next month, but I'll post again when I have more input on what I'm doing that caused this in the first place (actually I/m pretty sure I know what I was doing wrong - too much pressure when repetitively practicing a sequence of slurs) what I really need to know is how to change things so I don't do it again!

OH MY! I overdid it..... trying to rehearse without the guitar (!)

I was really enthusiastic to get started practicing my guitar again after a summer where goals were somewhat fluid and messing around became the new norm.  Orchestra rehearsals have started (with some really fun pieces - yes!),  I got a new piece to learn from my teacher (OK I said I didn't want to do any Bach, but apparently it's what I need to be doing so...  Bach it is).  And I went back to concentrating on those pesky slurs....   Maybe there was a little too much enthusiasm - but when my fretting arm started to hurt after practice,  I was thinking  - "it's just like when you start to work out muscles that have been idle - they stiffen up and hurt for a few days until they get used to the new regime".   However a few days later, my arm still didn't feel any better - in fact there was now pain around the elbow in addition to the forearm muscles.  Time to do a little research - i.e. probing around in the elbow region and checking out the internet.  Physical exam turned up a few quite tender spots where the muscles attach around the elbow - rats! the tendons are now involved in addition to the muscle.  Tennis elbow anyone?   Ignoring it is not an option - I am prone to tendinitis and I'm definitely smart enough to desist before I cause a chronic injury.  On the other hand I need to prepare for an orchestra performance coming up in 10 days... it's a quandary.   So my best bet is to get serious about rest  and anti-inflammatories.

The first thing I did was to stop playing the guitar.  Well strictly speaking I am still practicing small amount, but moving my left hand into the correct positions without pressing down, or sometimes just playing the right hand (this involves singing, which can be painful for everyone else, but I'm used to it!)  I'm hoping this will work because most of what I have to do with the orchestra pieces is familiarize myself with the music enough to know the timing and how to play the next part...  for sure I'll have to wait and see if this hands-off approach works though.  Next call up my trusty orthopedic physician and request an urgent appointment for a possible cortisone shot.  I guess they know me too well from when I was heavily into skating, so I get 'fitted in' next week.  In the meantime I dig out the ice pack and apply it on a regular basis and put myself on some anti-inflammatories.

Next problem - what to do about the scheduled 3 hour rehearsal this week?  That's surely not going to qualify as "rest" and I know if I take the guitar, my resolution about not playing will last about 5 minutes.   So I go to the rehearsal sans guitar.  It turns out to be quite useful - I found I could hear a whole lot more of what was going on when I wasn't concentrating on my own playing.  I got all the instructions, and importantly, so long as I followed along with the music, I was getting the same  auditory cues from the other parts that I would have if I was playing, so I don't think I missed out too much.

I came away with one additional piece of information - the 'castor oil' treatment. Huh? ... what's that, you might say - reportedly local application of castor oil and heat has an anti-inflammatory effect that can work wonders.  Being a veterinarian I would have thought I should have heard of this -  sounded like quack medicine to me.    Nevertheless after enthusiastic recommendation from our orchestra conductor I google it - and find that indeed, it not only has a long history of being used to reduce inflammation, the active ingredient is a known anti-inflammatory.  So I repair to the pharmacy for a hot pad and a bottle of castor oil and with my arm swathed in an oily rag and a voluminous heat pad I look a little odd... but do get lots of sympathy for the sore arm! So the sixty four thousand dollar question is,  is it working?  After only a few hours it's probably too early to tell, but after a couple of applications it seems to be helping.  Of course this could merely be the placebo effect - but as they have now demonstrated that the placebo effect usually involves actual physiological changes, I'll take it!  So if the rest doesn't work, maybe the castor oil.  And if not the castor oil, the cortisone shot will almost certainly fix it, at least for this episode. The question remains though, how to avoid this in future?  Will have to pay attention to "smarter" practice...

 

musings on adult learners, self-directed learning and musical vocabulary

There's a lot of learning theory about how adults learn.  As an adult guitar learner I find it interesting to read about it and compare it with my own experience.  Some of it rings true:   yes, I read around the subject and learn things on my own; I do question why I have to practice some things and what the benefit is;  I hear pieces I like and bring them to my guitar teacher to see if I can learn them,  However some of it doesn't - in particular I'm not a fan of self-directed learning.  Ok admittedly I've probably steam-rollered my guitar teacher over the last couple of years into helping me learn what I want to play, but I am also acutely aware of the fact that I often don't know enough to make an informed decision about what to learn. As a some-time educator myself,  I understand the concept of having students reason out the answer for themselves, but it does involve the prior step of giving them or pointing them in the direction of the materials they need to figure out the answer.  In the context of guitar playing - how to give a coherent description of what I feel is missing from a piece I'm playing?   What if I know there is something wrong but can't describe it because I'm really not sure what's going on...

Come to think of it maybe I need to work on my musical vocabulary.  In pathology one of the first things the students learn is the correct way to describe things - for example there are a myriad words that can describe precisely how stuff is scattered about in a tissue (I won't bore you with them, and only being an observer rather than an actual pathologist, I'd probably get half of them mixed up). Anyway, until they learn those terms students have a hard time accurately describing what they are seeing - translating a visual medium to a written one is after all, a long way from intuitive. And in some ways merely knowing the words should open up the possibilities of things to find when examining a tissue - or in the current context, listening to how a musical piece is being played. So the next question is, where to find these magic words?  I suspect my long-suffering guitar teacher will end up with this question, however in my defense he is partially responsible because he didn't like my use of the word "clunky" - which in my opinion perfectly described the mess I was making of a pretty melody.   However I will admit there are probably more precise terms... Question is, where to find them?  Google is remarkably lacking in answers, so perhaps I'll start building a list of suggestions...

Not legato
Chopped up, punctuated, jerky, disconnected

A pronounced beat that shouldn't be there
Metronomic, heavy downbeats, 'beaty'

Opposite to lively...
ponderous, dragging, listless, dead, lifeless, strained

Uneven sound quality
bumpy, erratic, wobbly,

Why should I switch frequently between practicing different things?

Over the summer I "took" one of those free Coursera courses on learning theory.  Quite interesting - it reinforced something I lucked into when I last studied for exams (I think it was in the dark ages but it may simply have been so long ago I have difficulty remembering).   I had a busy first job when I sat for specialty Boards so my learning schedule involved studying in the evening and reviewing it at 6 am the following morning before work.  I passed the exam, and it so happens modern learning theory seems to be confirming this is the best way to make things stick. i.e. learn something, review it when it's starting to disappear.  The course has some other interesting things to say about learning - such things as highlighting is a waste of time, constantly testing yourself works best, and summarizing in your own words is next best.  I can't see that highlighting or summarizing are useful techniques for the guitar, but testing yourself (look away from the music, can you play it?) is certainly a time honored way to get things into memory.  However what I'm particularly interested in at this point is this concept of 'interleaving' - very ably explained by Noa Kageyama in his blog - basically spending practice time switching between different learning activities.  It does what my serendipitous learning schedule did - making you keep pulling things back when they are not quite there, but in the course of a single practice session instead of overnight.... It certainly can be quite frustrating when you are doing it, but there is a lot of research indicating it speeds up the learning process.

Quite apart from learning theory, I now discover there is another reason that its a good idea to switch often between activities, particularly those that are stressful for the hand - and especially if your joints and tendons are not quite as young and resilient as they once were (let's get real here, mine aren't at all young and resilient any more).   Having successfully badgered my guitar teacher for exercises,  I was determined to apply myself. Indeed I thought I'd work in the  "do it 10x without mistakes before speeding up" system at the same time.   Boy was that a bad idea!  Spent way too much time trying to get to the next level, and after just a couple of days I started to get twinges in an entirely new place on my fretting arm.  I have been known to overdo it in the past, but usually ending up with just a slightly sore muscle,  but this was something different...  At least age comes with some degree of common sense, so I abandoned the exercise for a couple of weeks and limited my guitar playing to non stressful things that caused no pain.  Didn't do much to advance my technical skills, but thank goodness the arm pain disappeared.

Now I'm back to practicing the exercise - however I'm limiting the time I'm spending with a timer, and then moving onto something else. I'm even thinking of applying the timer method to all the things I'm working on ... I'll have to let that one sink in for a bit though before exposing myself to the mental pain.  It's a lot more satisfying to work on something for half an hour than it is to pull yourself away when you're just getting it!

Getting distracted: what to do?

I wish I had an answer for getting distracted.  I'm not one of those people who have problems practicing - or at least I didn't think I was.  Guitar for me is something I look forward to, not something I feel I should make myself do.  Mostly anyway.  Although I don't make rapid progress, I assume I am moving ahead slowly, although I have had to resign myself to the fact that it will take a while, whatever "it" is.  How slowly? there's one passage I've been working on that my fingers just don't want to reach cleanly, but over the weeks (no, months) since I started, I'm finally getting it. No problem - eventually I hope to add it to my repertoire but there's no rush.

However over the last couple of weeks I figured I had some preparation to do - both for the start of orchestra rehearsals and for recommencing regular lessons.  Time to get down to business!   I wrote in my handy log book some goals for the week - restricting the number of items on the list so I could concentrate better (and hopefully make some progress before I was put on the spot).  So now the list merely had a few warm up exercises, an exercise given to me by my teacher to "help me learn where the notes are"! (ouch),  a list of orchestra pieces I have to learn over the next several weeks, and section of a recent piece where I need to revamp the fingering on so as not to miss out the ends of the arpeggios.   So far so good...

As the week went on I noticed that the list was getting longer.  How did that happen? Well, when I worked on something not originally on the list (I mean really worked on it - not just playing for fun)  I added it to the list  and gave it a little check mark.  Day by day the list was getting longer, check marks were being added, but painfully few next to the original list items.   Hmmm.  Turns out despite my best intentions, I was actually mostly ignoring the things that needed to get done in favor of things I felt like working on.  There in front of me on the log was the proof - I had probably spent less than half the time on my urgent list items. And what was this I added? "practice flute" ??   Not likely to do a lot for my guitar playing!

My log has thus identified one factor that could be contributing to lack of results - I'm not actually spending much time on the things that I'm using to measure progress!   I do think I'm doing better at "practicing" rather than playing mindlessly -  just not focusing on immediate goals.   So this leads to the next question: if the whole reason for learning guitar is to have fun, do I need to change the way I do things?  I'm doing it to have fun, but part of the enjoyment is the sense of accomplishment from tackling more adventurous pieces successfully...  On the other hand, turning it into work doesn't do it either.  This summer I had a brief period where I focused exclusively on technique to the exclusion of having fun, and I fairly quickly found myself inventing reasons not to pick up the guitar.  Gosh I hope  there's a happy medium.    Maybe I'll try to limit working on additional list items to just one time per day and see how that goes... stay tuned!

What are the 10 most useful things I learned this year?

I know it's not the end of the year, but it is the new semester, and coincidentally it's been exactly 3 years since I started taking group classical guitar lessons (individual lessons didn't happen 'til later).  In fact when I started I didn't even own a classical guitar - I took lessons using an English steel string guitar my mom bought me as a generous and much-appreciated gift to encourage my new hobby.  I figured that was OK - I didn't really intend to learn "classical" guitar anyway, just wanted to learn some  basics.   How wrong can you be?

Anyway, at least in part for my benefit to hammer them home, here are some of the useful things I have learned this year -not in order of importance, just in the order I thought of them :)

1. Exercises improve a lot faster if you use a metronome.  Really.  I practiced one slur exercise for weeks and weeks on and off and didn't make any noticeable improvement until I started practicing with the 'nome - then I made more progress in one day than I had in the previous several weeks.  Why?  it made me slow down then stop and practice the movement in isolation that had been holding things up.  Which leads to...
2. Isolate difficult parts down to the smallest possible movement.  And repeat it slowly until its in muscle memory.  For some reason this is incredibly hard for me - I always want to speed it up before I've actually really got it.  Which leads to...
3. Don't move on until you can do it 10x without errors.  This can be soooo frustrating....  but it works.  I've been applying it to the parts of my pieces where I stumble most often. with  good results.  However it does require patience and I am woefully lacking in that area...
4. Improvising with the rhythm or harmony of a piece you already know can really help you learn the piece more thoroughly.  I'm terrible at reading guitar music - I memorize it way before I can actually play it, and then rarely go back to the notation (unless forced to by my teacher). I also haven't reached the stage where I understand the music I play - apart from picking out the melody line I just play the notes - I know, gotta long way to go.   However I had 3 separate nudges to do some 'improvisation'  recently (once from my teacher in a slightly different context, once from an instructional webcast, and once from folk camp).   Turns out that was exactly the number of suggestions required for me to actually try it.  Most notably I found I had to go back to the music (gasp) to find out which chords were being used and where they were, and to figure out the underlying structure. It was quite educational ;)  I ended up with a variation on the first half of a piece I often play.  I know, not kosher for classical guitar, but I'm just playing for fun so sue me!
5. Learning to sight read is a long slow process.   I wasn't getting anywhere much by using the beginning sight reading books - I know what the notes are if you point to them, but my fingers don't seem to map them out.  I think this means that I should actually do some technical work - scales in various intervals perhaps.  Helpfully, my teacher just gave me a really dastardly exercise (the first of a series, gulp)  that addresses this issue.  Maybe by next year I will be able to report progress in this area.
6. Memorization involves more than muscle memory.  I've heard this so many times,  and I truly believe it, having now blanked out on a regular basis when playing at the nursing home. Unfortunately the fixes for it mostly seemed out of my reach.  Such things as   "visualize the notation in your head" (oh right - that music I haven't looked at in recent history!), or "be able to play the whole piece through with each hand separately without the guitar."   Um.  I must have the wrong kind of brain.  Then out of left field, a suggestion from another musician (non-classical guitar player) seems to have helped.  He suggested practicing the left hand by itself but with the guitar. I thought I already had this until I tried it. Nope.  However it wasn't that hard to relearn the left hand without the aural and RH cues,  and yeah! it seems to be helping.  I have read that the conscious brain gets in the way of your muscle memory when you are stressed - so you need to learn your repertoire with the conscious brain as well as the "unconscious" one (AKA muscle memory).  Seems that learning the LH by itself even with the guitar present must get that conscious brain working -  and speaking of right and left hands...
7. If there is a part that is causing you trouble, practice the right and left hands separately.  I can't tell you how many times this fixed a problem that seemed insuperable, but somehow I never seem to remember it until all else has failed...
8. If you want to be able to play for others, you need to practice playing for others.  I've written a lot about this because it's my personal bailiwick, but my take home message is to start by finding the safest venue you can where it's just not possible to fail.  You aren't doing yourself any favors if you try but crash and burn, because that failure adds even more stress the next time around.  Everyone has a different stress-inducer  - for some it's being on stage, or playing for large numbers of people, or people you don't know, or whatever. For me it's the fear of being judged and found wanting.  Thus my low stress environments have been areas where evaluation (of me) isn't an issue: playing in a public park and for a dementia unit in a nursing home.  And I had to do it many times before the stress started to abate.   I've learned a lot as a result and my confidence is slowly building.   I'm not ready to play for a knowledgeable audience yet, such as the guitar club, and even playing for my teacher still gives me problems, but I can see the next step might be a casual open mic where the audience are not guitarists...   
9. Recording yourself is a humbling experience but incredibly useful. I don't do this enough.  You hear about 10x as much when listening to a recording as when you are playing.  Even if it's just an iphone recording. I'm making a resolution to do it more even as I write this!   And there's a reason that the teacher needs to see your hands if you are learning by Skype.  I've only ever made one video recording (on the iphone again) and it was more mortifying than humbling, but having the picture of what your hands are doing adds another dimension to what you can learn. And as a ski instructor once pointed out to me when we were being videotaped, everyone else has already seen how you ski so you don't need to worry about them!
10. Playing with others jump starts your learning. If you get the chance, join an orchestra or ensemble.  I am learning a long list of things that I doubt I would have got around to yet if not for the orchestra, such as strange exotic rhythms, keeping time (including with strange exotic rhythms ;)), artificial harmonics, percussive techniques, playing repetitions in different positions, extensive use of dynamics ....... oh and being able to play without looking at the fretboard all the time ;)  And last but not least my guitar friends :)