I knew I was going to like my new high school violin teacher, Connie, when she sent me home ten minutes into my third lesson. It was the early 1980s, my family had just moved from upstate New York to Nashville, Tennessee, and the transition to a community whose culture I initially found inscrutable and exclusionary was tough. Missing old friends, striving to make new ones, and consumed by a heavier-than-required course load (my ticket back north to college), I just hadn’t gotten around to picking up the violin that particular week.
So when Connie asked me to play the first movement of the concerto I was working on, I did what I’d often done in middle school lessons—kept mum about my lack of practice and played the piece through, paying close attention to the suggested improvements my teacher had written on my music the prior week. I took no pride in this deception, but it had never failed to impress other teachers, and I’d consistently won honors for my efforts. The last note still ringing, I brought my bow arm down and looked expectantly at Connie.
“Sounds like you haven’t had much chance to practice,” she said, “so I think it would be best if we picked this up next week.”
My body went cold. She meant just this piece, right? “Uh, yeah. OK . . . do you want to hear the étude?”
“Have you spent any more time on that?”
“Not really . . .” I felt faint.
“Let’s leave it here, then. I’ll see you next week.”
And then, because I was still too young to drive, I slunk out of her studio and sat on the curb of the music school driveway for forty-five minutes until my mother arrived to pick me up. No way was I going to go to the school office to ask to use a phone to tell her she had to pick me up early because I’d shamed myself and my family by not practicing enough for my lesson. Mom was going to hear that the lesson had gone “fine.” Beneath the shame, though, a sense of excitement was emerging. Connie expected more of me than other teachers had, which must mean she saw more potential in me than they had or, at least, cared enough to hold me to a higher standard. That felt good. I knew I could achieve more, too, and wanted to. I came from a musical family. Music had spoken to me from a young age, and I needed more language—that language—to express myself. Music was understanding, belonging.
Violin became the consuming occupation of my teenage years, and the gateway to numerous firsts: first encounters with Bartók and Barber, two of my great musical loves; first barely supervised living experience (at an international summer music school); first non-American friends; first kiss, first snog. So intimate was my relationship with the instrument that, hauling it across town and country, I’d find myself absentmindedly patting its case. And sometimes, when I suffered in real life, my violin suffered violence or neglect in my dreams.
I quit playing violin after my first year of college—a rash response to an overwhelming mix of insecurity about my talent, poor chemistry with my new teacher, and frustration at missing out on a lot of campus life due to practice and rehearsals. I felt guilt and dread instead of joy when picking up my violin, and I couldn’t see any way forward with it. I didn’t tell anyone how I felt, not even Connie. There’s no point, I’d thought; I just have to be an adult and make the tough decision. I found the activities I subsequently threw myself into—crew, musical theater, an a cappella singing group—rewarding. But the silence of the instrument lurking under my bed, and the perceived waste of my investment in learning it, nagged at me for decades.
Learning an instrument is embodying it—training your brain to understand its form, feel, and feedback so well that you know how to operate it as if it were part of you. It’s also developing the physical fitness and skill to execute the required moves, because knowing how to do something isn’t the same as being able to do it. This is exactly the kind of work that lay before me in OT, six weeks after the accident. The swollen, scaly appendage attached to my right arm wasn’t my hand; mine had been a perfectly calibrated system that continuously whispered to me about the physical world and automatically shaped itself to my intent. This one was dead silent, immobile, blooming with obstructive scar tissue, lacking one tendon and nursing repairs to many others.
First, my brain had to learn how to instruct it—and its tissues made fit to comply—to the extent possible, since there was no doubt that I’d sustain some degree of permanent impairment. Then Beth and I would have to figure out how I could improvise around my hand’s deficits to perform important tasks, how I could change the way I interacted with the built world so that my impairment did not cause disability. The distinction between impairment and disability was new to me, but immediately resonated. Efficacy is the product of performance and context, not an intrinsic quality of the performer; an impaired hand can be highly useful, just as a technically flawed musical performance can be deeply moving.
That first stage of rehabilitation requires what I’d call practicing, but which some scientists more engagingly call motor babbling, after the vocal babbling babies do to learn language so that they can ask for what they need. Both kinds of babble activate that central/peripheral nervous system feedback loop I first mentioned in chapter 2, which enables us to respond appropriately to our changing internal and external environments.
For example, a vocal-babbling baby attempts to mimic the words of her doting dad, and knows she’s finally got one right when she hears herself produce the matching sound and Dad beams with delight. In motor babbling with my violin, say I want to play a C. I place my left middle finger on the A string. When a C-sharp rings out instead of a C, I know that next time, I need to place that finger lower on the string. I try again and again until I learn exactly where to place the finger on the string to hit a C, and have developed the dexterity to reliably do so.
After massive amounts of such babbling, I get very good at predicting what will happen when I act on my violin in any particular way, so I usually know how to achieve a desired result. When I do make mistakes, I quickly recognize and know how to correct them, and eventually, the basic mechanics of playing become automatic. The violin feels like a part of me, and I can turn my focus to the musical interpretation of a piece.
How does motor babbling achieve this? You may recall from chapter 2 how the brain shapes our experience, for instance by automatically coordinating our initial response to survival threats. Our experience also shapes the brain, causing widespread alterations in structure and function. The brain’s capacity for such change is commonly called neuroplasticity, and motor babbling leverages it to our advantage. Specifically, extensive repetition of an activity signals to the brain that the data streams associated with it are important. So the brain allocates more of its capacity to their processing, and involved neurons undergo physical and chemical changes that strengthen communication among them. The result is higher sensitivity to, and more effective use of, the data, thus better performance of the activities depending on it.
Functional images of string players’ brains suggest this phenomenon at work. A well-known study showed a larger share of processing capacity devoted to data from the players’ left fingers, which are constantly engaged in fine motor movements while playing, than data from their right fingers, which are relatively less active in controlling the bow. The string players’ left-finger processing capacity also exceeded that of nonmusicians in the study.
Repetition alone doesn’t lead to proficiency, though, as anyone forced to play literally any sport with me in school gym class could tell you. Studies suggest that you have to want to improve, whether for satisfaction, survival, or some other personally meaningful payoff. Also, you need to know which movements to repeat to achieve desired results.
Studying violin with Connie, I learned to home in on the smallest, most troublesome fragments of a piece—a convoluted run of notes or an awkward string-crossing—and experiment with different approaches to learning them. Sometimes the best approach is obvious, like practicing a fast section slowly until you can play it all the way through correctly, then gradually increasing the speed.
Other approaches are counterintuitive. For instance, to play a fast, even rhythm (da da da da) perfectly evenly, Connie suggested I practice it in every possible uneven rhythm (DA da DA da . . . da DA da DA . . . DA da da da . . . da da da DA . . . and so on). Then, magically, it felt easy to play the notes evenly. Little by little, through such practice tricks, technique drills, and discipline, a musician’s mastery expands from fragments to measures to phrases to pages, and from technical accuracy to compelling expression.
In OT, too, you break the big performance goals—self-care, work, meaningful pastimes—down into their smallest motor components, and work on each until you master it. Then you gradually string the components together until you’re reaching, grasping, pinching, and placing as best you can. If you think of grasping with your right hand, for instance, you can see that it requires curling every joint of every digit in toward the palm, on a trajectory that leaves sufficient space between digits and palm for the object you want to grasp. My exercise goals thus progressed over several months, from flattening out my hand (which was frozen with fingers ninety degrees to palm after long immobilization to protect healing tendons), to regaining range of motion in every joint of every digit, to moving the digits in a fluid and coordinated fashion, and, finally, attempting useful tasks.
That wouldn’t be the exercise arc for every spaghetti wrist case, though. An effective OT regimen takes into account the fact that every injury, and therefore every surgical repair, is unique—as are the biological, psychological, and environmental circumstances that influence our individual responses to injury and rehabilitation (just as they do in our individual experiences of pain and responses to trauma). We scar in different ways and heal at different rates, for instance, and we don’t always have the time, understanding, and/or confidence to fully engage with the rehabilitation process. Therefore, there was no off-the-shelf OT program that would address my specific circumstances; Beth had to design one using evidence-based guidelines for related injuries and her own clinical experience.
She essentially had just two mechanisms to leverage in doing so: motion and force. Motion stretches out joints, ligaments, and tendons stiff from disuse. It also helps prevent scar tissue from accumulating in the wrong places, by creating friction between surfaces, thus dislodging scar-tissue cells before they take root. Motion can be passive (for instance, my healthy left hand moving my impaired right hand) or active (my impaired right hand moving on its own). Force is the transference of energy from muscles to tendons that takes place during active motion. While any active motion “loads” tendons with some degree of force, more aggressive active motion—like squeezing, pressing, and lifting—loads more.
Striking the right balance between motion and force is tricky, with serious consequences for getting it wrong. Beth had to assign exercises that would load my tendons with just enough force to pull through obstructive scarring—essential because, as Beth liked to say, a tendon trying to glide against scarred tissue is like an ice-skater trying to skate through wet cement—but not so much as to rupture the tendon repairs. To complicate matters, key outcome drivers—how well my body would heal, how much force my healing tendons could bear, how well I would adhere to the exercise regime—were unknowable, at least initially. So Beth would have to start with estimates. She’d also have to account for the unusual extent of my injury, and the strength of Dr. Vargas’s repair, which was a function of the number and location of sutures he’d placed in the tendons.
The solution? An adaptive algorithm hinging on one factor Beth could objectively measure: lag. If you consider that healthy digits describe a (roughly) 180-degree arc when closing from a flat hand into a flat-fingered fist, lag tells you the portion of that arc that an impaired hand must regain in active range, through therapy. Beth calculated this by subtracting my impaired hand’s active range of motion from its passive range of motion. Authors of the algorithm suggested that if active motion lags passive motion by fifteen degrees or more, healing flexor tendons are stuck in scar tissue, and more force must be applied to break them free of it. They also defined a pyramid of exercises that loads increasing amounts of force onto the tendons.
The bigger the lag and the longer it persists, the higher up the force-loading pyramid you go. If you reach the top of the pyramid and still have a big lag, you’re looking at surgery to scrape out the scar tissue that exercises won’t budge. My lag started at 130 degrees, so darned if I didn’t have to climb all the way to the top of that bloody pyramid and spend time in a splint that stretched my repaired tendons so painfully hard that I threw it against my bedroom wall after the first ninety minutes. “Tons of wounds, tons of scar tissue,” Beth said in one of our interviews for this book. But under her careful supervision I pushed through it all, and can now fist-bump with the best of them.
If you’ve ever managed through an extensive rehabilitation program, then you know that it is psychologically, as well as physically, demanding. If you haven’t, imagine you’re a regular in Bellevue’s Upper Extremity Occupational Therapy Room, with an injury like mine. Your wounded appendage already hurts because it’s inflamed, and because your central nervous system is freaking out over the garbled data it’s getting from the transected peripheral nerve. Still, you have to pull and push it in directions it doesn’t want to go, which makes it hurt more. Inflicting pain on yourself is not a skill that comes naturally, and it takes an unusual kind of discipline to override instinctual objections to it.
Pain aside, the exercises are intensely frustrating. There you are, ferociously concentrating on a motor task that, for as long as you can remember, you’ve never had to think about, and you’re apparently getting nowhere with it. The frustration would be easier to bear if the goal were positive, but alas, you’re not acquiring some intriguing skill that will unlock wonderful new experiences. You’re busting butt for a result somewhere between dysfunctional and suboptimal, and you don’t know whether your permanent impairment will be disabling or merely annoying.
The practicalities of rehab—keeping the ever-changing exercise regimen straight, scheduling and commuting to appointments, processing health insurance claims (if you’re fortunate enough to have health insurance)—impose stress. And you’re grappling with all of the above while in an opioid haze and struggling with self-care. In short, rehabilitation demands maximum inner resources, just when you have the least to invest. But somehow, you rise to the challenge.
Everything that helped me cope with the psychological distress of my accident—loved ones, studying science, etc.—also helped me meet the demands of OT. The sense of achievement I derived from performing my OT exercises further fueled my motivation, as did my confidence in the process, predicated on years of violin practice, which had proved how thousands of tiny, isolated movements could add up to an expansive repertoire of fluid, powerful movement. And Beth was just the right teacher for me—talented, attuned to my particular needs, compassionate yet demanding. She was a straight talker, too, who never pretended certainty to encourage me or avoid difficult conversations. If she had dished out a single “You got this!” I’d have doubted everything else she said.
In the best-case scenario, OT results in a body that can do whatever an individual deems necessary and meaningful, and can yield intangible benefits, too. Ability is not a fixed thing, because our bodies, our environment, and what we need and want to do with them change throughout our lives. In its emphasis on adaptation and ends over means, then, OT can prepare people to navigate undesired physical challenges with realistic hope and creativity, and to bear the emotional sense of loss associated with former physical abilities. I didn’t fully appreciate this until I had a violin lesson with Connie in late 2006.
By October of that year, I had returned to work and completed my course of OT, having regained the function I needed to perform important daily activities. And while sensibility in my repaired hand was poor, it didn’t seem to be holding me back in any serious way. Still, I worried. What if my sensory deficit prevented me from engaging in some meaningful activity I hadn’t yet considered? Was there anything I could be doing to prevent that scenario, and the accompanying heartache? I didn’t want to end up like my friend Maggie with the broken wrist, wishing I’d worked harder at recovery.
I dove down a Google hole in pursuit of answers, and even consulted a couple of specialist hand surgeons and therapists. But what I learned was either ambiguous or flat-out discouraging, and this posed a dilemma: Do I continue to invest time, money, and emotional bandwidth trying to beat the odds? Or do I just accept my right hand as it is? I feared regretting the latter. But I was so very tired of working in pursuit of uncertain benefits.
Driven by the same kind of sick, self-defeating curiosity that makes you pick at a scab, I pulled my violin case out from under the bed one day and guiltily swept a path through the thick layer of dust that had accumulated on its canvas cover. Autopilot took over, and I opened the cover and unlatched the hard plastic case beneath with a familiar snap, zip, zip, clotch, clotch that made me smile. I fitted the shoulder rest to the instrument and tucked it between my left shoulder and jaw, picked up my bow and tightened the bow hair, tuned the violin strings, and endeavored a scale. Two strokes in, I lost my grip on the bow and dropped it—something I’d never done, even as a child. I attempted the scale again, then some easy bits of a concerto, with the same result. I took this as a sign that my hopes of improved hand function were futile, and reinterred my violin.
I couldn’t forget the episode, though, or the dilemma that had prompted it. So when I visited Nashville for Christmas 2006, I asked Connie if we could have a lesson instead of our usual lunch date. I told her I wanted her to observe my bow grip so she could discern the error of position or motion that caused me to drop the bow. But what I really wanted was for her to agree that playing with my impaired hand was a lost cause. Then I could abandon that long-nagging dream of resuming violin without “being a quitter,” and stop chasing elixirs for hand dysfunction and regret.
I insisted on taking the lesson sitting on the edge of her bed, rather than standing, because Connie was going to let me play her exquisite, centuries-old violin, an honor she’d periodically bestowed on me in our younger years. Before I picked up the instrument, she reached toward me with her long, angular hands, palms open upward, beckoning for my right hand the same way my surgeons always did.
I extended it to her, palm down. She cradled it at the wrist with her right hand and cupped my fingertips in her left. “Now let your hand hang heavy. I’ve got it, you can let go. Good.” Her gently husky voice, imbued with empathy and confidence, had soothed a great deal of my teenage angst, and still reassured. “Feel that?” she said, alternately bouncing my wrist and jiggling my fingers. “That’s how loose it should feel when you’re playing.” I felt the looseness, and it felt good—a novel experience for my “new” hand, whose numbness often made it feel stiff.
Next, she threaded the frog of her bow (the rectangular piece securing the horsehair to the stick) between my fingers and thumb, inviting me to grasp it and take a few strokes on her violin. I nestled the instrument between my left shoulder and jaw, and slowly drew the bow back and forth across the D string. I managed three strokes before my grip collapsed, and the bow slid through my closed hand onto her bed. “See?” I exclaimed, petulant.
Her eyes told me we were not finished, so I picked up the bow again. Tucking a thick lock of brown-gray hair behind her ear, she leaned in to assess the placement of every finger, while I recited my hand’s deficits: the atrophied thumb, which couldn’t properly oppose my fingers on top of the stick; my unfeeling first three digits, which couldn’t adjust to the moving bow; and my little finger, which, perhaps due to an irreparable transected tendon, couldn’t maintain its footing on the end of the stick.
“Hmm . . .” Connie said, studying my hand on the bow. “Keep your fingers on the bow, but let go of the weight. I’ll hold it in place.” She jiggled the bow in my hand, illustrating the flexibility that was my goal. “Now . . . what happens if you put your thumb here?” she said, tapping the bottom of the frog. Normally the thumb was tucked under the stick, braced between it and a nook carved out of the top of the frog.
“There?”
“Sure,” she said, continuing to explain that the bow grip she and I had learned was the one advocated by Ivan Galamian, a twentieth-century master of the instrument. But violinists had always adapted technique to their unique style and anatomy, from classical legend Jascha Heifetz and his flat-fingered “Russian” hold, to country music virtuoso Mark O’Connor and his thumb-under-frog grip, which Connie had just suggested for me. “I knew a kid at music camp who had six fingers,” she said. “Obviously he couldn’t hold the bow the same way I did, but he figured out what worked for him. And he was good.”
I gave the grip a try. It felt more solid, as my thumb had more purchase on the bottom of the frog, so I could press the stick more firmly against my index finger on top of the stick. “Huh,” I said.
“Holding it that way, can you bounce your wrist?” I could. “Great. And the fingers . . . can they move with the bow, without dropping it?”
I took a few strokes in the new grip. I couldn’t quite strike the requisite balance between firmness and flexibility, but it seemed attainable with practice, and Connie recommended some exercises toward that end. She also suggested constructing a “pinky house”—a popular practice aid for beginning violinists consisting of a divot at the end of the bow where one can lodge the little finger to keep it from slipping. A corn pad usually does the trick. All my objections deftly countered, the ball was now in my court. I handed Connie’s violin and bow back to her.
“You know,” she said, returning them to their case, “you don’t have to play what you used to play. You don’t even have to play violin music. Play anything you like. Just play.” I thought of my favorite songs by Barber and Fauré and felt a hunger in my hands that I hadn’t for many years. Quietly, because I thought my voice might break, I thanked Connie for her help.
She smiled, turning her hazel eyes to mine. “Only problem was, you thought there was a right way to play.”