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From the July/August 2020 issue ofAcoustic Guitar | By David McCarty

Playing guitar is a pain. At first, we suffer through blistered fingertips, overstretched tendons, fatigued muscles, and limited range of movement. With practice, those hindrances pass and we play easily.

Until we can't.

Acoustic guitarists, like everyone, must manage physiological changes due to aging, often including hearing loss, arthritis, and repetitive use injuries, that can make it difficult to continue playing guitar well. What would you endure if a disabling illness or injury kept you from playing guitar? Would you opt for invasive orthopedic surgery and a potentially long and painful recovery? Or, say you're a top-line Nashville touring pro. Could you hide a significant noise-induced hearing loss for years in fear of the silent stigma on hearing loss rampant in Music City's cutthroat studio scene?

I spoke with five guitarists who've faced such setbacks and pushed through to resume their playing careers. Their experiences may provide practical advice for those dealing with repetitive stress injuries and aging issues. And they could give you just the tools you need to avoid incapacitating medical conditions that might affect your playing years from now.

Bob Minner, photo courtesy of Bob Minner

Hearing Issues
Of the issues mentioned above, hearing loss is perhaps the cruelest for acoustic musicians. There's no cure. The noise of modern living itself can damage hearing, and exposure to high-decibel sounds, like loud concerts, poses special risks for musicians. Modern hearing aids, by their very design, reproduce musical sound terribly, so your beautiful guitar might sound like a toy. And when you're a professional musician, the stigma of admitting you deal with noise-induced hearing loss (NIHL) can be a deterrent to even seeking help. Needless to say, all this takes a psychological toll, as well.

Just ask Bob Minner. "If you're a musician for any length of time, playing gigs for ten or so years, you've got hearing loss," Minner says flatly. "The type of hearing loss and amount is a variable. It's a case-by-case thing."

Minner, well-known in flatpicking circles, holds the lead acoustic and rhythm guitar chair in the Tim McGraw Band. Over years of touring and playing everything from clubs and festivals to large arenas, recording in Nashville's super competitive studio scene, and field jamming, Minner's learned a lot about how acoustic guitarists can—and can't—cope with hearing loss.

It starts by recognizing and admitting your hearing is affected. "At first, you ignore it. You turn your amp, TV, stereo, up more. But eventually you reach a threshold where you notice things sound different," Minner explains.

He also had to overcome an unfair if understandable prejudice. "When musicians talk about hearing loss, there's a stigma that can make other musicians look at you and not want to hire you or work with you," Minner confides. "But those musicians probably have hearing loss, too. Being silent about it is a way to protect themselves. We take pride in being pro musicians, so we often deny the reality of that."

Indeed, one highly prominent Americana musician with 90-percent hearing loss from a blast of feedback in his monitors declined to be interviewed for this article because of the stigma associated with musicians with NIHL. For Minner, overcoming that obstacle was only his first step. When he did seek help, just locating an audiologist with experience treating
guitarists proved difficult, even in Music City.

Minner's audio testing in an anechoic chamber answered a lot of questions. He already knew he had some hearing loss in his left ear. The testing not only found NIHL in both ears, it provided a revealing audiogram showing a significant difference in the frequency response between his left and right ears. That gave Minner's hearing team the data they needed.

Using those charts, Minner was fitted for hearing aids programmed to boost or dampen frequencies differently between the two ears, like a parametric EQ for each side. The aids helped him hear his wife, Ginger, better in noisy restaurants, which is all they're really engineered to do. It helped his life, but he still noticed a big difference in his perception of musical sound when using hearing aids.

"When I listen to a great acoustic guitar, my response to the guitar isn't the same as someone with better hearing," he says candidly. "I can still tell what's good and what's bad, though. But you have to realize that regardless of cost, nothing will replace how you hear your instrument."

Brian C.J. Moore, Ph.D., emeritus professor at University of Cambridge in the UK, is a world-leading researcher studying how NIHL affects the human perception of musical sound. He's also an expert in the shortfalls of electronic hearing aids when used by musicians. And he empathizes with Minner's fate. "I played guitar, first in rock bands and now jazz. That triggered my interest in music and sound perception," Moore says. It also helped cause his own case of NIHL.

Moore's research aims to quantify the mechanisms by which high-pressure noise damages the hearing organs, and how that damage affects our perception of musical sounds. Loud noise hitting the outer hair cells of the cochlea, for example, triggers a damaging metabolic effect leading to irreversible damage, he explains.

"The inner ear is highly metabolically active. So if the hair cells are stimulated too much, it causes metabolic damage to the muscles, as can happen to the muscles of a marathon runner. The noise is poisoning the outer hair cells," Moore notes. Intense transient sounds, such as a loud feedback accident, also can cause mechanical damage to the cochlea.

To his fellow guitarists seeking hearing enhancement, Moore offers this advice: Check the frequency response of any hearing device you intend to use. Most only go from 200–5,000Hz, which is adequate for speech recognition, but terrible for music because it cuts out the highs and lows that make music so enjoyable.

"So tell the audiologist you need aids with as wide a frequency range as possible, and then set up a special music program to make the best use of that range," he counsels. An upper range of at least 10,0000Hz is best.

Feedback reduction software in hearing aids can play havoc with musical sound perception, he adds, so ensure that feedback reduction is minimized or deactivated in the music mode. And try to use open or semi-open earpieces that allow a mix of the signal from the aid and the natural sound source to reach the eardrum to allow bass sounds to be heard naturally.

But even with specific programming, current systems designed to boost human speech lack the technology to adequately reproduce musical sound. Working in conjunction with Moore, Earlens (for whom Moore is a paid consultant) has developed a hearing aid technology that addresses many drawbacks musicians experience with conventional aids.

Unlike conventional hearing aids that act like a tiny audio system that receives external sound and sends highly processed sound waves to the eardrum, the Earlens system uses a tiny transducer placed in contact with the eardrum itself to physically vibrate it, explains Drew Dundas, Ph.D., the company's head of audiology and product development. The physics of speaker technology in the sizes that can be placed in the ear canal, he explains, limit the available audible bandwidth with conventional hearing aids. Earlens addresses those limitations.

"The unique method of action—directly driving the tiny bones of the middle ear via a custom (audio) lens placed in contact with the eardrum—allows for much more efficient energy transfer into the ear," Dundas says. An ear, nose, and throat specialist performs the non-surgical placement in a quick initial appointment, followed by sessions with an audiologist to calibrate and adjust the listening experience for the user."

Moore adds, "My Earlens aids cover a very wide frequency range from 100–10,0000Hz with the ear canal fully open. I can get much more amplification without acoustic feedback, so there's no need for a feedback canceler. I find I can hear a lot more music that way."

Judith Kay, photo by Jim Lawson

Repetitive Stress Injuries
If fingerstyle guitarist Judith Kay won't shake your hand when you meet her, don't take it personally.

"To this day, I do not extend my right arm or hand. A hard handshake can reinjure me and set me back for three to six months," the Delaware-based professional guitarist and teacher explains. "There are many things I can't do or that I have to rule out: no tennis, no playing drums. Anything like trying to catch a ball is out of the question. I do nothing that sends strong vibrations up my arm."

Kay suffers from thoracic outlet syndrome (TOS). According to John Hopkins Medicine, the thoracic outlet is the ring formed by the top ribs, just below the collarbone. TOS occurs when nerves or blood vessels are compressed by the rib, collarbone, or neck muscles at the top of the outlet. It manifests in three varieties, including neurogenic TOS, which crippled Kay's professional career for years. Symptoms include pain or weakness in the shoulder and arm, tingling or discomfort in the fingers, or one or both arms that tire quickly. In the worst cases, TOC causes atrophy—shrinking and weakness—of the pad of the thumb and the muscle of the palm that leads to the thumb.

But TOS often is misdiagnosed. In an acute stage for five years, Kay went from doctor to doctor without relief. She had to quit playing entirely and spent years with reflexive sympathetic dystrophy (RSD), searing electric nerve pain, running along first her left and then right arms.

"I thought I would never play again. But then, miraculously, I did find the right doctor and was able to start again," Kay explains.

After exploring other treatments such as acupuncture and Rolfing, it wasn't until she began therapy with Emil Pascarelli, MD, a New York–based physician who literally wrote the book on avoiding and treating repetitive stress injuries, that Kay found relief.

"He was a guru for people with RSIs, especially musicians," she says of the late doctor.

Focusing her passion on a new challenge, Kay worked with Dr. Pascarelli and a referral physician to adapt his principles to how guitarists should warm-up, practice, exercise, and perform.

"What I learned is muscles work in tandem. As a guitarist, we put our arms around the instrument, lengthening the trapezius [the large muscle used to tilt and turn the head and neck, shrug, steady the shoulders, and twist the arms] and shortening the pectoralis [the large muscle in the upper chest fanning across the chest from the shoulder to the breastbone]. When they get out of balance, bad things happen," Kay says.

To combat her TOS, Kay and her physicians developed a personalized, 90-minute routine of stretching and exercises aimed at restoring muscular balance. She also underwent triweekly deep-tissue massage treatments she says were crucial for her recovery. Kay's website (judithkay.com) includes RSI links and her recommendations for other guitarists.

"Musicians need to work out and treat themselves like they're sit-down athletes," she says. "We need to be in shape like a marathon runner or a weight lifter. So I started to get my muscles all back in balance." Kay also now advocates for better awareness of the risk RSIs pose to musicians of all ages.

"I'm trying to get a change in this issue," she notes. "College programs and music schools are woefully remiss for not having RSI prevention programs in schools. Music colleges and conservatories all need to have an awareness and education program about issues like mine."

Dan Henkel, photo by Phil Cramer

When Arthritis Strikes

Fingerstyle guitarist Dan Henkel knows what it's like to have an orthopedic surgeon cut out a wrist bone, drill a hole through a bone in his thumb, sever a tendon, then pull that tendon through the hole and attach it to a different spot in his painful, arthritic left thumb. It's not as fun as it sounds, he darkly assures.

Henkel, who has studied and played classical and fingerstyle guitar semi-professionally since college, was diagnosed with severe osteoarthritis in both thumbs. The pain made playing guitar almost impossible. He underwent ligament reconstruction and tendon interposition (LRTI) surgery, the most common remedy for his condition, in hopes of playing again.

An expert on the procedure, David S. Ruch, MD, chief of hand surgery at Duke Health in Durham, North Carolina, wrote in an article on LRTI for the Arthritis Foundation that many patients respond well to conservative medical measures such as anti-inflammatories, splints, activity modification, and limited steroid injections.

Henkel had a different experience. "I have osteoarthritis in both thumbs, so basically there's no cartilage left. It's bone on bone, which was quite painful," the retired Indianapolis PR executive reflects. "Five years ago, my left hand hurt so much from playing too much music that I couldn't play at all for 18 months."

The LRTI procedure Henkel chose removes the arthritic joint surfaces and replaces them with a cushion of tissue that keeps the bones separated. The surgeon removes all or part of the trapezium bone in the wrist. A nearby tendon is detached at one end, then passed through a hole drilled in the thumb metacarpal. The tendon is rolled like an anchovy and placed into the space where the bone was removed, with a success rate of over 90 percent.

"Most patients achieve complete pain relief and mobility equal to that of a healthy thumb, with results lasting at least 15 to 20 years," Dr. Ruch wrote.

But like all surgeries, LRTI has drawbacks. Patients endure a lengthy, painful recovery. They may also may lose pinch strength, making it difficult to grasp and hold objects, a definite problem for guitarists. LRTI also noticeably shortens the thumb, which can limit reach and mobility when playing guitar. None of that intimidated Henkel.

"It took eight weeks before I had [thumb] function back," he reports. "I took a travel guitar and strung it with silk-and-steel strings so I could do some playing," Six months later, Henkel felt reborn as a musician and now loves taking his Taylor out of its case again.

"It's like a gift," he says. "One good outcome of this is I rediscovered the fundamental joy of playing guitar again. The physical manipulation of the instrument. The vibration hitting your chest. The beauty of the tone. I've been relearning pieces I first learned 30 years ago, but hopefully I'm playing them more musically now," he says, adding, "It's like being reunited with someone you love."

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David Crosby, photo by Bobby Bank

Alternative Relief

David Crosby knows loss and reunion. The two-time Rock and Roll Hall of Fame member and avid blue-water sailor has two bad shoulders that have endured broken bones and four dislocations. He's also developed RSI hand injuries over his long career as a guitarist.

"I've recently developed two things that affect my guitar playing. I have tendonitis causing 'trigger finger' in the middle two fingers of both hands, and I'm developing arthritis," the 78-year-old legend says. "It's not enough to stop me playing, but I do have those things going on that I treat with CBD."

The longtime cannabis advocate recently founded his own company to grow and produce CBD oil and cannabis products. Croz uses CBD extensively to mitigate the pain and soreness of his RSIs and orthopedic injuries.

"I use CBD two ways," he explains. "I vaporize flower that's high in CBD to get it that way. The other way is I rub a topical cream into both shoulders, sometimes my neck, and on my hands when they're hurting."

The biggest appeal of CBD, Crosby adds, is the lack of significant side effects or addiction, unlike opioids and NSAIDs [nonsteroidal anti-inflammatory drugs]. "With opioids, you know the problem; use them for three weeks and you can get hooked. And NSAIDs are terrible for the liver," he emphasizes. "CBD doesn't have a negative side effect. It ameliorates the pain and acts as an anti-inflammatory. My sincere belief is that once we teach people how to use CBD, it's going to be huge."

Healthy Habits

So what's the takeaway for players young and old who want to have a long, healthy relationship with the acoustic guitar?

Coping with hearing loss is a huge challenge. Prevention is uppermost. Bob Minner and Brian Moore advocate using custom molded earplugs that attenuate all frequencies when attending any loud event or concert. Avoid loud music through earphones. Pay attention to any pain or discomfort in the ears that could signal damage to the auditory organs and immediately reduce exposure. Take hearing breaks regularly during the day, and especially before a gig, like Minner does, to minimize fatigue and ear strain. And work with an audiologist if you need hearing aids to maximize their ability to reproduce musical sound as naturally as possible. I've taken my gorgeous Will Kimble mandolin into my audiologist's office so she can adjust frequencies in my aids as I play, with only partial satisfaction.

Unlike Judith Kay's TOS, Dan Henkel's genetic arthritis didn't have a prevention option. The lesson they stress is paying attention to all pain when you play. When it hurts, something's not right. Seek medical attention, and work on a personal program of stretching and strengthening now to ward off or delay RSIs. Get a solid critique of your playing posture, and work slowly to improve it and become more efficient.

And never give up seeking help until you find it.

David McCarty plays guitar and mandolin and has opened for David Grisman and Ricky Skaggs. He has been coping with hearing loss, traumatic orthopedic injury, and essential tremor as a performer for years. Follow McCarty on Twitter @mcgroup53.

BEYOND BARRES
Easy alternatives to difficult chord shapes

The dreaded F chord, which requires a first-finger barre across all six strings, is the most challenging grip for most beginning guitarists to play cleanly and consistently. This shape can also become problematic for older guitarists who have been able to form it without difficulty for many years.

The good news is that there are some fine alternatives that are less demanding on the fretting hand—and no less musical. Example 1 shows three alternatives to the F barre chord. The first shape involves wrapping the thumb around the neck to grab the sixth-string F. If that's uncomfortable, you can do the F chord with the fifth (C) in the bass, as shown in the next frame, or just play the triad's three notes (F, A, C) on strings 4–2. Example 2 extends these concepts to F minor chords.

Similarly, instead of playing an F7 barre chord, try the three-note shape depicted in Example 3, which could be alternatively fingered with the first, second, and third fingers on strings 6, 4, and 3, respectively. This voicing eliminates the chord's fifth, C, which can be thought of as an inessential tone. In fact, do away with the root (F) for an F7 that's even easier to form; the second shape contains only the flatted seventh (Eb) and the third (A). And here's something cool: In the key of F, you can move the F7 shape down one fret for the IV chord (Bb7) or up one shape (C7) for the V; three chords for the price of one easy shape. —Adam Perlmutter

Tell Us About Your Home Remedies
Have you experienced (and hopefully overcome) any age- or playing-induced medical issues, including those not covered here? Have any advice to share with your fellow players? If so, send an email to Editors.AG@stringletter.com and we'll pass it along.

This article originally appeared in the July/August 2020 issue ofAcoustic Guitar magazine.