A Skeptical Look At “Embouchure Overuse Syndrome”

One of the longest-lived web sites around dealing with brass embouchures is Lucinda Lewis’s Embouchures.com.  On this site and in her two books, Broken Embouchures and Embouchure Rehabilitation, Lewis offers advice for brass players dealing with a range of embouchure issues.  While there are some good suggestions throughout, this essay will deal with the fundamental premise Lewis bases her diagnosis and treatment of embouchure troubles around, “Embouchure Overuse Syndrome.”  On the front page of her web site, Lewis writes:

Are you a brass player who has encountered a painful, debilitating embouchure problem? Perhaps you have been experiencing daily lip swelling and/or  lip pain and lost your endurance and high range too? Maybe your lips feel weak, rubbery, tingly, or numb when you play?  Do you have strange sensations in your lips and face which were never there before that make playing a struggle?  Has this problem been plaguing you for weeks, months, years?

If you have been suffering with debilitating, painful, embouchure confusion, regardless of how long you have been experiencing these problems, the likely cause is embouchure overuse.  99% of such problems are the result of playing more hours or with more intensity than one is normally used to.

As I’ve written here before, I’ve learned that my personal impressions cannot be trusted when it comes to developing statistical information.  When I began research on my dissertation I had convinced myself that I would end up with a great deal of statistically significant data showing how certain physical characteristics would affect a player’s embouchure.  However, when I actually ran the stats, the data didn’t quite show what I expected.  Although Lewis’s resources are not designed for a scientific audience, scientific claims like the above are common in her books and web site.  Physical therapy is no joke – professional therapists go to graduate school, are required to take a licensing exam, and research used to determine which therapies are effective go through a rigorous peer review process before they become mainstream.  Since Lewis is essentially offering physical/occupational therapy for brass players, I think it’s fair to ask how the data was collected and how the 99% figure was determined.

There are many reasons why it’s important to be open and transparent about the methods you use to conduct research.  For one, it allows other researchers to replicate your study and confirm what you discover.  Another important reason is that others can help you spot confirmation bias or errors in your methodology (we’re all subject to these biases, it’s human nature).  It’s also important that when you use human test subjects that you conduct your research ethically and go through an Internal Review Board to protect the health and rights of your test subjects.  Academic and medical journals have a peer review process that looks closely at these issues before accepting an article for publication.

I’ve spent some time looking through academic and medical resources looking for any articles written by Lewis that discusses her research, but not found anything published.  The fact that I can’t find an article detailing Lewis’s methodology doesn’t mean that she didn’t publish through a peer review process, it just means I didn’t find it.  However, it would be nice if Lewis would be more forthcoming about her methodology on her web site or in her books.  As Dr. David M. Steinharn noted in his review of Lewis’s book for the journal Medical Problems of Performing Artists, much of the information Lewis bases her treatment around appears to be conducted anecdotally.  Regardless of how many anecdotes you collect, 5000 anecdotes are are no better than 1 anecdote.  The plural of anecdote is not evidence.

Assuming that Lewis does take confirmation bias into account when diagnosing and offering treatment for brass players with embouchure issues, my next criticism has to do with her term, “embouchure overuse syndrome.”  It implies a medical condition, which if true should probably be diagnosed and treated by a medical professional.  Lewis writes of this condition:

For the purpose of discussion here, embouchure overuse syndrome refers to any chronic embouchure-related playing problems which last for more than two weeks and includes any or all of the following:  lip pain, chronic lip swelling or bruising, numb, rubbery, or cardboard lips, recurring pressure-point abrasions, air-induced abrasions, lack of endurance, unfocused sound, lack of playing control, and chronic high-range problems.

Broken Embouchures, page 3

It seems here that Lewis has simply listed the majority of embouchure problems, put them under the umbrella of embouchure overuse syndrome, and then claimed that the majority of these problems are caused from overplaying.  Do players sometimes suffer from some of the above problems as a result of demanding playing?  Absolutely.  But are 99% of the above problems caused by overplaying?  Probably not.  Many of the above problems can be caused by excessive mouthpiece pressure, twisting the lips up with the mouthpiece, playing with an embouchure type that doesn’t suit the musician’s anatomy or other problems with embouchure form, lack of sufficient air support, misuse of the tongue, and many other mechanical issues. These problems may be exacerbated by fatigue, but the root cause may not simply be playing too much.  My criticism here is that this definition is much too broad and the term “overuse” implies a particular sort of treatment program that may disguise, but not actually correct, the real issue.

My last criticism about Lewis’s resources is that they completely ignore any discussion of how brass embouchures actually function when working properly and how to make corrections in a player’s embouchure form when it deviates from these successful patterns.  She seems to be on the right track, in that she acknowledges that every embouchure is different, but Lewis appears to be ignorant of the fundamental principles of air stream direction, the embouchure motion, and how a player’s anatomy can make their embouchure function differently from another player’s.  Any diagnosis of embouchure problems needs to address these issues before offering a treatment program. Anyone claiming expertise in brass embouchures should be at least familiar with the brass embouchure types, at the very least to eliminate these issues before diagnosing and treating serious embouchure troubles.

As with other essays here where I criticize other methods or authors, my point here isn’t to discourage people who may benefit from Lewis’s resources, but to encourage a more open and honest collaborative effort with the field as a whole.  As I mentioned already, there is a lot in Lewis’s resources that can be helpful, it’s just incomplete.  As the basic brass embouchure types are easily verified, someone with a good understanding of embouchure form and function may be able to make effective use of Lewis’s exercises and advice, provided the situation is appropriate.  It’s probably not useful for the 99% Lewis cites, but shouldn’t be dismissed out of hand.  When trying to treat your own embouchure troubles, a little healthy skepticism and critical thinking can save you time and effort.

Lyle Sanford

Hi, Dave – Wish more folks understood that, “The plural of anecdote is not evidence.” When I became interested in music therapy back in the 70’s, read whatever I could find, and so much of it was testimonial, wishful thinking and anecdotal. I think all of it was well intentioned, but in the end clouded the subject more than clarified it.

The other thing that just knocks me out, and that I had no idea of until I took up the horn, is so how unsettled the whole embouchure issue is. My assumption had been that after centuries of the instruments being played, this sort of stuff would have coalesced into a general agreement of how to play a brass instrument. And for the horn on top of all that, what exactly the instrument is isn’t settled with singles, doubles, triples, decants, differing wraps and an astonishing array of mouthpiece choices. The world of brass is far more complex than I’d ever guessed.

Dave

Hi, Lyle. Your comment hits on some (perhaps obvious) pet peeves of mine. I might just get worked up enough to reply with a separate post on those issues, when I have a bit more time.

John Ericson

Very interesting post. While I am sure there are specifics on which we may disagree, the big picture you get at is on the money, there is a lot out there that could and should be questioned about conventional understandings of the embouchure, tonguing, mouthpiece pressure, placement, etc. I appreciate also the link to the review by Dr. David M. Steinharn, he raises some additional very valid points in relation to the Lewis book.

Relating both to your article above and also to the comment by Lyle, a horn teacher I know that teaches at a fairly large music school uses a famous text on the horn in their horn pedagogy class, but taught from the angle that practically everything in the book is wrong! They use it only as a point to start discussion, and I used this general approach in my pedagogy class this year with the same book. Especially on the horn there are multiple pedagogical approaches with really too much of it ultimately based on anecdotal evidence. It will be interesting to follow your continued thoughts on the topics raised here.

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