THE MATURING FLUTIST STEPHEN A MITCHELL MD ANGELA

THE MATURING FLUTIST STEPHEN A. MITCHELL, MD ANGELA MCCUISTON, BM, MM, ETC PERFORMANCE HEALTH CARE COMMITTEE

WHO IS THIS GUY AND WHY SHOULD I BELIEVE ANYTHING HE HAS TO SAY? • Treating professional musicians for over 40 years • Member NFA & Performance Health Care Committee • Formally know as Dysfunction Committee (long story) • • Founding member, former president PAMA Spouse of professional flutist Singer with experience touring internationally He’s getting older and feeling it, just like you

MATURING: DEFINITIONS • PC way of saying “deteriorating”, according to some youngsters • “Chronologically challenged” • Inaccurate word for this talk since: • aging is inevitable but maturing is optional

SOBERING FACTS: • You grow old or die young. Period. • All parts wear down with time. People are no different than cars, except that there are no “trade-ins” • “Middle age is when you still believe you’ll feel better in the morning” Bob Hope

% OF POPULATION OVER AGE 64 1900=4% 2020=17% AGINGSTATS. GOV

POLITICAL PRESSURE TO DELAY RETIREMENT • 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-67 -years-old. • CNN Money. com 8 -1 -2008

PRACTICAL PRESSURES TO WORK LONGER • Poor planning when young to set up a pension plan • Poor rate of savings for Americans • Easy credit = high debts, loans, credit card • Never getting debt free with 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 employed • “When I told my doctor I couldn’t afford an operation, he offered to touch up my x-rays. ” Henny Youngman

PLEASURABLE PRESSURE TO WORK LONGER • Still enjoy the challenge • Performing is still fun – beats being an office gopher in a cubicle • Makes us special – few can do what we do • 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 18911967 • “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” DYLAN THOMAS • What are the details of what to EXPECT as we age? • How will 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 my teeth?

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. ” Oscar 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 for these factors)

WHAT TO DO FOR B&J ISSUES • Avoid unnecessary joint trauma • Use non-injurious practice & exercise methods • Treat any hormone abnormalities • Anti-inflammatory meds MAY slow permanent damage • Keep weight down • Exercise early, smart, and forever

MUSCLE ATROPHY • Sarcopenia: gradual decrease in the ability to maintain skeletal muscle function and mass. Associated with aging but 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” Groucho Marx

POSTURE • No proof that bad posture is unavoidable • Requires more work to prevent it: muscles get weaker (sarcopenia) and discs between vertebra shrink • Practice good posture early and keep it up (Remember, Quasimodo was a percussionist, not a flutist)

CO-PRESENTER TIME -

THE MATURING FLUTIST ANGELA MCCUISTON B. M, M. M. , NASM-CPT, CES, SFS, CETI-CES

BEING UNHEALTHY IS EXPENSIVE • The American Association for Retired Persons and the Administration on Aging report that in 2006, only 39% of older people rated their health as excellent or very good. • More than 85% of older adults suffer from at least one chronic health condition and in 2005, this accounted for 57% of the nation’s total health care expenditures. • These expenditures totaled $362 billion and averaged $12, 566 for every older adult (4, 6). It is naïve to expect that Medicare can handle these costs, particularly considering the working population who contribute funds to Medicare is decreasing.

WHY SHOULD OLDER ADULTS STRENGTH TRAIN? • Resistance training programs produce physiologic changes that result in a variety of strength adaptations. A welldesigned resistance training program can delay physiologic degeneration and produce optimal neuromuscular efficiency. Participation in a strength training program may enhance insulin sensitivity, bone density, body fat reduction, and increase metabolism (1). Evans WJ. Exercise training guidelines for the elderly. Med Sci Sports Exerc. 1999; 31(1): 12 -17. • In short – you delay aging and its effects

WHAT ARE THE BENEFITS TO ADAPTIVE STRENGTH TRAINING? The benefits of adaptive programs include: � Physiologic $ Improved cardiovascular efficiency $ Enhanced endocrine function $ Decreased body fat $ Increased metabolic efficiency � Physical $ Increased tissue tensile strength $ Increased cross-sectional area of muscle fibers $ Increased bone density � Performance $ Increased neuromuscular control $ Increased endurance $ Increased strength $ Increased power

CARDIOVASCULAR EXERCISE BENEFITS AND GUIDELINES Neuromuscular Cognitive Psychologic Increase Oxygen to Muscles Increased Cognitive Function Decreased Resting Heart Rate and Resting Blood Pressure Increased Rate of Muscle Contraction Decreased Brain Lesions Increased Metabolic Rate Improved Motor Unit Recruitment Improved Mental Alertness Improved Oxygen Exchange Capacity

GUIDELINES FOR CARDIORESPIRATORY TRAINING • If you’re not exercising regularly, start with 8 -10 minutes of Light to Somewhat Hard perceived Exertion. Work up to 30 -60 minutes of continues exercise, followed by 5 minutes lighter cool down. • When you can maintain this RPE or HR for 30 minutes 2 -3 x’s a week, progress to Intervals: after a 5 minute warm up, get your HR up to where you perceive effort as Hard for 1 minute, lower it for 3 minutes, repeat 3 times, followed by 5 -10 minute cool down. • This is adequate for most adults. If you’re a cardio stud, come see me for the next level!

FLEXIBILITY TRAINING • Start with SMR/Foam Rolling Foam rolling is contraindicated if you have osteoporosis, spinal stenosis, low back pain, veracose veins or obesity Can use other tools like a theracane, stick or lacrosse ball Technique Acute Variables Cues SMR • • 1 -2 Sets • Maintain Pressure • minimum of 30 seconds • Find the tender spot little discomfort is appropriate Follow with static stretch Static Stretching • • 1 -2 sets • Hold for 30 -60 seconds • Do not bouce Use after foam rolling and exercise Avoid before max effort • Dynamic Stretching • • • 1 set 10 repetitions 3 -10 exercises • • Done as a warm up after SMR and static stretch Neuromuscular reeducation

FLEXIBILITY TRAINING EXAMPLES AND CAUTIONS o. Start on the ground or a stable surface and progress to more unstable o. Always have balance assistance available

COMMON PROBLEMS Upper Crossed Syndrome Flutist Problems

UPPER BODY HELP • Upper Crossed Syndrome • Flutists can have a bilateral asymmetry in the neck • What to do Stretch: Chest, Front of Neck Strengthen: Rotator cuff, back of neck, upper back • Chin Tucks 5 -10 reps, place hand on front of neck to make sure of no front engagement • Upper Trap Stretch: Hold side of chair 30 sec • Prone T’s and Y’s 10 -15, progress to weight

BALANCE TRAINING AND INJURY • The shortening of tendons and ligaments reduces joint range of motion by as much as 25%, while cross-linking leads to stiffness (1). In addition to a weakening of cartilage, any injury may lead to a decrease in joint stability due to the lack of blood supply to the cartilage, tendons, and ligaments (1). • Stability is an important training adaptation because it increases the ability of the kinetic chain to stabilize the lumbo-pelvic-hip complex and joints during movement. • Aldwin CM, Gilmer DF. Health, Illness, and Optimal Aging: Biological and Psychosocial Perspectives. Thousand Oaks, CA: Sage; 2003

SCARY STATS ABOUT FALLS o 1/3 of adults over the age of 65 experience an accidental fall each year o. If an older adult does not sustain a serious injury as a result, many develop a fear of falling again, which limits physical and social activities o. More than 18 million emergency room treatments in 2004 o. More than 400, 000 bone fractures in 2004 o. Almost 16, 000 deaths from fall injuries in 2005 o. Approximately 25% of older adults dying within a year of sustaining a hip injury due to falls Vellas BJ, Wayne SJ, Romero LJ, et al. Fear of falling and restriction of mobility in elderly fallers. Age Aging. 1997; 26: 189 -193.

BALANCE TRAINING: WHAT AND HOW • Train Your Core! Glutes, Abs, deep core and low back • Stand on one foot and lift your arch – reach leg backwards • Start with 1 -4 exercises 12 -20 reps or upto 30 seconds each

MEAT AND POTATOES: STRENGTH TRAINING Make sure you have proper form: Brace, Shoulders back and down, Feet straight Start with just a few exercises 1 -4 for 12 -20 reps very slowly Progress to less reps with more weight Get a trainer who is specialized in Senior Training to show you how when you are first starting. This will ensure you don’t hurt yourself. Always start with SMR and static stretching Follow with Core moves Add in Strength Follow with cardio and/or stretching

SPECIAL POPULATIONS o. Diabetes and Obesity o. Arthritis o. Cardiovascular Disease o. Cancer o. Stroke

SPECIAL POPULATIONS, CONT. • Make sure your trainer is aware of any special conditions you have. • Cancer – Exercise is VERY beneficial for you. If you’ve been prescribed a compression sleeve, WEAR IT. • High Blood Pressure – use caution with isometrics, don’t hold your breath and don’t lift any cars starting out • Diabetes – if you have peripheral neuropathy or retinopathy, take breaks frequently, have well fitting footwear and take balance precautions. Monitor your blood glucose levels before and after exercise • Arthritis – do not stay in a fixed joint position for more than 30 seconds. Keep motions smooth and controlled, no jerky movements. If any exercise causes pain in the joint (not the muscle) stop immediately and regress the exercise. • Shoulder Impingement: vital to stretch the chest and avoid overhead pressing • Osteoporosis – engage in high load lifting: Lift heavy stuff where you fatigue at 6 -8 reps.

WHAT EXERCISES ARE BEST FOR FLUTISTS? • Rows of all kinds • Planks and core stability exercises • Glute strengthening exercises: bridges, step downs, clams • Tricep extensions • If in doubt, focus on the back of your body

WHICH EXERCISES SHOULD I AVOID? • Chest presses, bench presses, pushups (unless you’ve got great scapular stability and core strength) • Situps • Anything with weight on an unstable surface when you’re first starting. Don’t be this guy. If it feels scary or wrong, don’t do it!

TAG TEAM TIME • -

BRAIN AND NERVOUS SYSTEM • Steady decline in some cognitive skills starts in 30’s: more problems with new memories than old • “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 • None of the above are good news for doing fast runs

WHAT TO DO FOR BRAIN AND NERVES • Keep mentally active. Exercise the brain like a muscle • 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 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.

WHAT TO DO FOR HANDS AND FINGERS • Avoid unnecessary injury (rugby, handball) • Avoid overuse, misuse when practicing • Ergonomicly match instrument, chair, music stand, computer, etc to the individual. • Persistent pain is BAD. Do not think macho is smart. 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. www. nwortho. com

RESPIRATORY FUNCTION (WIND) • Several factors alter the mechanical function of the lung with age. • 1) a decrease in power due to fewer muscle fibers and a decrease mechanical advantage • 2) an increase in lung tissue stiffness, decreasing elastic recoil of the lungs and ultimately a change in structure and function of the chest wall due to a loss of intervertebral spaces • 3) a stiffening of the chest wall from changes in ribs, sternum and articular cartilages making the chest less expansible.

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 (yoga, etc) • Treat asthma with maintenance med, avoid rescue med

EMBOUCHURE • 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, lose feedback • Mouth gets dry (fewer glands, more medication use) • Lips & tongue move slower

WHAT TO DO ABOUT EMBOUCHURE • Brush and floss like mama told you • Keep your own teeth even if it costs more • More water, less Dr Pepper • Biotene products for more lube • "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 your arms are getting shorter National Institute of Aging, NIH

MORE AGING EYES • In your 60’s, the 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 or with bad stage lighting • Cataracts, glaucoma and macular degeneration are the most common problems of aging eyes • Good luck reading hand written 1/32 nd notes !

WHAT TO DO ABOUT AGING EYES • Regular eye exams to catch problems early • No smoking ! (increases ocular pressure) • More light needed to read by • Different eye glasses for different tasks • Don’t waste money on bogus “Bates eye exercises” squishing your eyeballs • Keep them well lubricated

EAR DISORDERS AND AGING • Hearing loss or distortion • Tinnitus (ringing in ears) • Wax and infections of canal • If you missed the hearing talk I gave, email me @ voicedoctor@hotmail. com and I’ll send you a link to it.

HEARING LOSS • 1 in 3 over age 60 have significant hearing loss • Worse with vascular disease, noise exposure, certain medications, and family history • Injury in orchestra players likely BUT is difficult to prove how much due to musical job American Speech-Language-Hearing Assoc

WHAT TO DO ABOUT POSSIBLE HEARING LOSS • Get a baseline hearing test by age 40 • Ear check if change noted by you or family/friends • Avoid unnecessary loud noise (i. Pod, concerts, lawnmowers, power tools) • Hearing protection every chance (ER-20, Mack’s Hi. Fi Ear Plugs, shooters muffs, etc) • Hearing aids if needed. Will need MANY adjustments to get it just right

IMMEDIATE TX FOR NOISE BLAST CAUSING IMMEDIATE LOSS AND/OR RINGING • Get away from all noise, rest, no stressing • NAC (N-Acetyl-Cysteine) is an over the counter med and can be effective in reducing hearing loss/tinnitus from noise trauma. Immediately start 900 mg of NAC three times daily for a week • No good if wait until 3 -5 days after the trauma. • Rarely any risks taking it, but clear with your Dr.

TINNITUS (RINGING) • Common problem over age 40 (men > women • Usually due to injury to tiny inner ear nerve “hair cells” • Frequently Hx of noise exposure • Any vascular disease can cause it • Meniere’s disease special case with different treatment NIDCD. NIH

PREVALENCE OF TINNITUS NIDCD. NIH

WHAT TO DO ABOUT TINNITUS • Use noise protection for ears • White noise to drown out silence • Reduce stress & stimulants (caffeine) • Bio-feedback & hypnosis may help • N-Acetyl-Cysteine may help • Hearing aid-like maskers ($$)

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 block the ear canal and allow bacterial growth, causing infections

WHAT TO DO ABOUT EAR WAX • No car keys or Q-tips ! • Mineral oil ear drops if dry & itchy • Swimmer’s ear drops if hurts (1: 1 vinegar & alcohol) • Wax softener w bulb syringe to wash ear if blocked with wax, hair dryer (low setting) to dry water • See your ENT doctor if all else fails

STRESS • Most medical problems are worsened by stress • Ian James 1997 BAPAM survey from 56 world wide orchestras showed stress was a serious problem with the instrumentalists • Top Ten stress makers: (drum roll please)

10: money worries 9: making mistakes when performing 8: medical problems affecting work performance 7: incompatible stand partner 6: disorganized rehearsal time 5: illegible music 4: playing an 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

STRESS CONTINUED • there is no such thing as a separation of mind and body -- the very molecules in our bodies are responsive to our psychological environment • If you’re headed for trouble, try prayer, meditation, yoga, exercise, or other stressreduction techniques. If those fail, see your doctor for professional help

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 Carson • “Age is strictly a case of mind over matter. If you don’t mind, it doesn’t matter. ” Jack Benny • (both lived until 80)

FOR THE YOUNG FLUTISTS: • from a W. Va lunch counter • “Don’t criticize the coffee. You may be old and weak yourself someday”