Performing arts medicine - Instrumentalist musicians Part I - General considerations

Abstract

Performing arts medicine is a relatively new specialty addressing the medical needs of dancers, musicians, ice skaters, and gymnasts. This paper focuses on the role of healthcare providers in the diagnosis and therapeutic management of instrumentalist musicians. Musicians are at high risk for developing painful musculoskeletal problems, including pain and overuse injuries, entrapment and peripheral neuropathies, and focal dystonias. Musicians' careers are threatened, when they are no longer able to play their instrument because of pain and dysfunction. To appreciate music-related injuries, it is important that clinicians are familiar with the context of musicians' injuries and disorders. This is the first paper in a series of three. This paper discusses the importance of taking an extended history. The typical history procedures need to be broadened when interviewing musicians, and should include instrument-specific questions, and questions regarding practice habits, education, repertoire, and employment. The second article addresses the physical examination, while the third article provides three case reports of musicians with hand problems, which serve to illustrate the points made in the first two articles. The articles are illustrated with several tables and photographs of musicians to assist the reader in assessing instrumentalist musicians and determining the most appropriate course of action.

Full text

PERFORMING ARTS MEDICINE
Performing arts medicine eInstrumentalist
musicians Part I eGeneral considerations
Jan Dommerholt, PT, DPT, MPS*
Bethesda Physiocare, Inc., Myopain Seminars, LLC, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD 20814-2440, USA
Received 24 November 2008; received in revised form 11 February 2009; accepted 12 February 2009
KEYWORDS
Musicians;
Performing arts
medicine;
History
Summary Performing arts medicine is a relatively new specialty addressing the medical
needs of dancers, musicians, ice skaters, and gymnasts. This paper focuses on the role of
healthcare providers in the diagnosis and therapeutic management of instrumentalist musi-
cians. Musicians are at high risk for developing painful musculoskeletal problems, including
pain and overuse injuries, entrapment and peripheral neuropathies, and focal dystonias.
Musicians’ careers are threatened, when they are no longer able to play their instrument
because of pain and dysfunction. To appreciate music-related injuries, it is important that
clinicians are familiar with the context of musicians’ injuries and disorders.
This is the first paper in a series of three. This paper discusses the importance of taking an
extended history. The typical history procedures need to be broadened when interviewing
musicians, and should include instrument-specific questions, and questions regarding practice
habits, education, repertoire, and employment. The second article addresses the physical
examination, while the third article provides three case reports of musicians with hand prob-
lems, which serve to illustrate the points made in the first two articles. The articles are illus-
trated with several tables and photographs of musicians to assist the reader in assessing
instrumentalist musicians and determining the most appropriate course of action.
ª2009 Elsevier Ltd. All rights reserved.
Introduction
The origin of the specialty of music medicine is generally
thought to date back to the late 1800s (Harman, 1998). For
example, in 1885 Forbes reported on the successful
practice of performing tenotomies of the accessory branch
of the extensor digitorum communis muscle in pianists
complaining of insufficient dexterity of their ring fingers
(Forbes, 1885). In 1887, Poore published the results of his
extensive research of occupational cramps of pianists
(Poore, 1887), followed by similar publications of violinists
(Wolff, 1890) and cornetists (Turner, 1893). Relative few
publications appeared in the medical and dental literature
throughout the next several decades (Ortmann, 1925, 1929;
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E-mail address: dommerholt@bethesdaphysiocare.com
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journal homepage: www.elsevier.com/jbmt
Journal of Bodywork & Movement Therapies (2009) 13, 311e319

Singer, 1932; Harman, 1998), until the first performing arts
medicine textbook was published in 1932 (Singer, 1932). It
was not until the 1977 publication of the textbook ‘Music
and the Brain: Studies in the Neurology of Music’, that the
creation of the new medical specialty of music medicine
became a reality (Crtichley and Henson, 1977; Harman,
1998). Although performing arts medicine could be
considered as a branch of occupational medicine, many
performing arts practitioners do not have an occupational
medicine background and represent a wide variety of
medical specialties (Bejjani et al., 1984a,b).
The growing interest in performing arts medicine is
reflected in the increasing number of medical confer-
ences and the establishment of special performing arts
societies around the world, including the Performing Arts
Medicine Society in Australia (1983), the British Per-
forming Arts Medicine Trust in the United Kingdom (1984),
the Performing Arts Medicine Association in the USA
(1989), and the Dutch Performing Arts Medicine Associa-
tion in the Netherlands (2005), among others (Harman,
1998). While there were only about 100 English-language
articles published during the 1970s, the 1980s saw the
publication of over 400 new articles (Harman, 1998).
Dawson identified 1366 performing arts papers during the
period 1997e2001 of which 972 (71.2%) were devoted to
music medicine (Dawson, 2003), while the next five-year
period featured as many as 1438 (70.8%) music medicine
articles out of a total of 8412 performing arts publica-
tions., including both music medicine and dance medicine
(Dawson, 2007).
Epidemiology
In the mid eighties, the International Conference of
Symphony and Opera Musicians [ICSOM] commissioned one
of the first large-scale epidemiologic studies. The study,
which was published in 1988, showed that 82% of 2212
musicians associated with 48 major symphony orchestras in
the United States had a medical problem with 76% of the
respondents claiming to have at least one medical problem
that interfered with their ability to play their instrument
(Fishbein et al., 1988). Many other epidemiologic studies
have since been completed in various countries, not only of
professional classical musicians (Fry, 1984, 1986a,b;
Middlestadt and Fishbein, 1988; Sakai, 2002; 
Crnivec, 2004;
Engquist et al., 2004; Heming, 2004; Kaneko et al., 2005;
Furuya et al., 2006; Abre
´u-Ramos and Micheo, 2007), but
also of conservatory and university students (Fry, 1987a,b;
Manchester, 1988; Manchester and Flieder, 1991; Pratt
et al., 1992; Zaza, 1992; Roach et al., 1994; Hagglund,
1996; Blackie et al., 1999; Guptill et al., 2000; Shields and
Dockrell, 2000; Pak and Chesky, 2001; Spahn et al., 2002;
Burkholder and Brandfonbrener, 2004; Yoshimura et al.,
2006; Kreutz et al., 2008), high school students (Lockwood,
1988; Shoup, 1995; Brown, 1997; Fry et al., 1998), and
several other select groups of musicians (Caldron et al.,
1986; Fry, 1986a,b, 1987a,b; Knishkowy and Lederman,
1986; Raeburn, 1987a,b; Dawson, 1990, 1999, 2001; New-
mark and Salmon, 1990; Harman, 1993; Potter and Jones,
1993; Bischof, 1994; Lederman, 1994; Roset-Llobet et al.,
2000; Spahn et al., 2001; Fjellman-Wiklund and
Chesky, 2006).
It is without question, that musicians are at high risk for
developing painful musculoskeletal problems ranging in
incidence from approximately 30% to almost 90% (Zaza,
1998). The medical issues musicians encounter can be
divided into three broad categories: musculoskeletal pain
and overuse injuries, entrapment and peripheral neuropa-
thies including carpal tunnel syndrome and cubital tunnel
syndrome, and focal dystonias (Brandfonbrener, 2000). In
a sample of 672 instrumentalists attending a performing
arts clinic, 71% were diagnosed with musculoskeletal
disorders (Lederman, 1994). Another retrospective report
of 100 patients with hand pain showed that inflammatory
conditions were the most common subgroup (Hochberg
et al., 1983). String players and pianists are most commonly
affected and female musicians are at greater risk than
males (Fishbein et al., 1988; Grieco et al., 1989; Zaza and
Farewell, 1997; Zetterberg et al., 1998; Pak and Chesky,
2001; Sakai, 2002; Furuya et al., 2006; Yoshimura et al.,
2006; Abre
´u-Ramos and Micheo, 2007). Bejjani et al. found
a 77.5% prevalence of upper extremity disorders among
violinists, violists, cellists, double bass players, pianists,
harpists, and guitarists (Bejjani et al., 1984a,b, 1996). In
a study of 40 musicians, Amadio and Russotti concluded
that the most common diagnosis was inflammatory tendon
disorders followed by nerve entrapment syndromes (Ama-
dio and Russoti, 1990). Psychologically, performance
anxiety is one of the more common issues (Havas, 1989;
Sternbach, 1993a,b). Anxiety and distress may be the result
of a high degree of perfectionism of musicians, but also of
musicians’ perception, that audiences expect flawless CD-
quality live performances (Sternbach, 1993a,b; Stoeber and
Eismann, 2007).
Broader context
Although the problems musicians encounter are rarely life
threatening, they commonly are career threatening and may
seriously impact on their ability to play their instruments
(Zaza et al., 1998). Performing arts medicine functions
within a very narrow margin. As Sataloff, Brandfonbrener,
and Lederman indicated, ‘the difference between 95%
recovery of an injured finger and 100% recovery may mean
the difference between a world-class performing career as
a violinist and obscurity’ (Sataloff et al., 1998).
In spite of the high risks associated with playing
a musical instrument, many musicians are willing to play
through pain even at a very young age (Hagglund and
Jacobs, 1996; Britsch, 2005; Park et al., 2007). The risks do
not stop musicians from pursuing their love of performing
and playing their instruments (Chen and Howard, 2004;
Park et al., 2007). Many musicians believe that pain is
inherent in the level of performance they try to achieve
(Amadio and Russoti, 1990), and sometimes musicians may
even feel they are responsible for their injuries and choose
to ignore the pain either consciously or subconsciously
(Quarrier, 1993). Injuries may be interpreted as an indica-
tion of inferior talent and overall failure as a performer
(Brandfonbrener, 2006). For others, financial limitations,
lack of health insurance, fear of loss of employment or
career advancement may contribute to their tendency to
play through pain (Dommerholt and Norris, 1997). While the
health of professional athletes gets much attention from
312 J. Dommerholt

sports management, fine arts management has not shown
the same degree of interest in the health of professional
musicians (Hoppmann and Patrone, 1989). Musicians as
a group tend to consult more with alternative practitioners
than with traditionally trained providers, often because of
a lack of trust of the medical establishment (Brandfonbr-
ener, 1998). A German study showed that as many as 68% of
professional musicians treated by physicians did not follow
their doctors’ recommendations (Molsberger et al., 1989).
Of all performing artists, musicians have experienced
the greatest difficulty in finding healthcare providers who
understand the specific demands of playing musical
instruments and the subtleties of their injuries (Brand-
fonbrener, 2006). Musicians’ injuries are commonly related
to practice, performances, and playing the instrument and
may not always be detectable with a standard physical
examination, which may subsequently lead to a dismissal of
the pain complaint, or to an incorrect diagnosis
(Winspur, 2003).
This article will address common mechanisms that may
lead to musculoskeletal injuries and dysfunction in musi-
cians. A discussion of focal dystonia will not be included,
but has been the focus of several recent publications
(Candia et al., 1999, 2002, 2005; Byl et al., 2003, 2006a,b;
Tubiana, 2003; Jabusch and Altenmuller, 2004; Ackermann
and Adams, 2005; Lie-Nemeth, 2006; Rosset-Llobet et al.,
2007). The possible contributions healthcare providers can
make to establish the correct diagnosis and the unique
aspects of the performing arts evaluation and intervention
will be highlighted with an emphasis on the history. Two
follow-up articles will review the examination procedures
and provide three case reports of musicians with specific
hand problems interfering with their ability to play their
respective instruments.
History
When musicians contact a healthcare provider, they must
be assured from the very first interaction, that the clinician
is thoroughly familiar with the specific demands of being
a musician (Wagner, 1995; Dommerholt and Norris, 1997;
Brandfonbrener, 2006). The clinician must know basic music
terminology, and understand the unique physical demands
and injury patterns of each musical instrument. For
example, pianists and other keyboard players often have
dysfunction of the wrist and finger extensors and intrinsic
hand muscles (Hochberg et al., 1983; Pak and Chesky,
2001), while violinists tend to have trouble with the neck
and shoulders, the left wrist and finger flexors, the
abductor digiti minimus, and dorsal interosseus muscles
(Bejjani et al., 1996; Berque and Gray, 2002; Ackermann
and Adams, 2003; Crnivec, 2004). Many healthcare
providers with an interest in musicians have a background
in the performing arts themselves as accomplished amateur
musicians, which is helpful in understanding the specific
risk factors (Brandfonbrener, 2006). Clinicians without
a music background will need to become familiar with the
context of musicians’ injuries and disorders (Wagner, 1995).
Musical performance requires a unique combination of
skills, including a highly integrated level of complex motor
tasks, artistic creativity, emotional expression, musical
interpretation, sensory motor control, dexterity, precision,
muscular endurance, speed, and stress management
(Wilson, 1989; Dommerholt, 2000).
The first step of the examination is the history, which in
addition to the general history, should include several
specific questions. Different authors have emphasized
slightly different aspects of the history (Meinke, 1995;
Newmark and Weinstein, 1995). It is imperative to deter-
mine whether musicians have experienced similar problems
before, and whether they have had other music-related
injuries, which could point the clinician to possible tech-
nical or performance problems, such as playing with
excessive tension, poor posture, repetitive overuse, or
performance anxiety (Brandfonbrener, 2006). Most ques-
tions can be divided into a few broad categories, including
instrument-specific questions, and questions regarding
practice habits, education, repertoire, and employment. It
is important to expand the general history as musicians’
injuries are rarely the result of a single incident, although
a sudden change in a musician’s routine frequently
becomes the apparent precipitating event (Brandfonbr-
ener, 2006). Not all questions pertain to all musicians.
Clinicians need to direct the history to gain as much
pertinent information as possible in an efficient manner.
Instrument-specific history
A change in instrument is a common cause of the onset of
pain, for example when a musician recently started playing
a new piano with a different action than the previous piano.
The term ‘‘action’’ refers to the force required to depress
the piano keys. Changing to a different type of instrument,
for example from guitar to piano may increase mechanical
stress and static loading on the musician’s musculoskeletal
system, especially of the arm, shoulder, and trunk
(Cameron and McCutcheon, 1992). Changing from a violin to
a larger viola requires increased shoulder abduction while
playing, which can cause significantly higher intramuscular
pressure of the supraspinatus muscle and result in impaired
circulation and chronic muscle damage (Jarvholm et al.,
1988, 1991; Larsson et al., 1988; Palmerud et al., 2000;
Svendsen et al., 2004). Other examples are switching from
lighter to heavier instruments, which require more muscle
strength and altered playing postures, such as from clarinet
to saxophone, from piccolo to flute, or from flute to alto
flute. Switching from one keyboard instrument to another,
such as from piano to organ or harpsichord, can also be
problematic due to having to learn new and different
playing techniques, repertoire, and performing skills. The
way a particular instrument is being played may vary based
on the genre of music. A double bass player in a symphony
orchestra typically will use a bow, while in a jazz ensemble
it is more common to pluck the strings. See Table 1 for
pertinent instrument-specific questions.
Practice-specific history
Clinicians must review musicians’ practice habits. Musicians
spend much more time practicing than performing and it is
likely that most musculoskeletal injuries are related to
practicing. Often, they practice difficult passages for
several hours without interruption, which not only
increases the risk of injury, but may also trigger the
Performing arts medicine eInstrumentalist musicians Part I eGeneral considerations 313

development of focal dystonia (Byl, 2006a,b). A sudden
increase in practice time to prepare for an audition, recital
or concert, has been correlated to the onset of pain and
dysfunction (Fry, 1986a,b, 1987a,b; Newmark and Leder-
man, 1987). Does the musician only practice the music with
the instrument or does the musician engage in other forms
of practice, such as shadow-playing, mental practice,
relaxation, or visualizations? Shadow-playing is a term
introduced by Menuhin and relates to going through the
physical motions of playing a piece without the instrument
(Menuhin, 1986). Mental practice may include reviewing the
musical score, or listening to recordings of the music.
Visualization exercises are designed to literally visualize
the musical score without looking and may include the
practice of writing down the musical score from memory.
See Table 2 for pertinent practice-specific questions.
Education-specific history
The importance of a good teacher cannot be over-
estimated. Usually parents do not select teachers based on
their awareness of risk reduction and injury prevention and
there is little assurance that good teachers are aware of
potential risk factors with regard to developing practice
habits, general attitude to being a performer, repertoire,
and teaching style. If teachers have not experienced any
playing-related injuries, they may not be as empathic
toward students who develop painful disorders (Brand-
fonbrener, 1998). Often injuries develop when students
switch teachers, and receive different instructions in
technique and alter their repertoire. Students who have
been trained through early childhood music education
programs, such as the popular Suzuki Talent Education
Method, may encounter more traditional teachers who do
not share the same philosophy and who are critical of
students’ technique and accomplishments (Dommerholt
and Norris, 1997). See Table 3 for pertinent education-
specific questions.
Repertoire-specific history
The repertoire of a particular musician is to a great extent
dependent on the type of music the performer usually
plays. A classical guitarist performing solo recitals will play
a very different repertoire than a guitarist in a punk band.
But even within a certain musical setting, there may be
significant repertoire considerations. For example, a clas-
sical pianist with hand pain may be able to play Mozart, but
have considerable pain when playing Liszt or Rachmaninoff.
For orchestral musicians, playing modern music to which
they cannot easily relate may be more stressful and even
cause measurable physiological changes in heart and
respiration rates (Furhmeister and Wiesenhu
¨tter, 1973).
While it is practically impossible to be familiar with the
repertoire of every instrument and genre of music, sensi-
tivity to the relevancy of repertoire is important to
communicate with musicians. See Table 4 for pertinent
repertoire-specific questions.
Employment-specific history
A musician’s employment status has a direct impact on the
potential risk factors and work conditions. Some work
conditions pose significantly greater risks of injury. Many
orchestra chairs are not suitable for musicians. Folding
chairs are common in many orchestras both during prac-
tices and performances (Shafer-Crane, 2006). Musicians,
who are confined to playing in an orchestra pit may have to
perform under poor lighting conditions or be exposed to
high sound levels (Axelsson and Lindgren, 1981; Westmore
Table 2 Practice-specific questions.
Pertinent practice-specific questions
Does the musician practice sitting or standing?
How long does the musician practice per practice session?
How many practice sessions are there in a typical day?
How many breaks are there in between practice sessions
and how long is each break?
Does the musician include warm-up and cool-down periods
with each practice session?
How are practice sessions structured?
Has there been a recent change in practice habits?
Did the musician recently attend a music camp or workshop
during which playing and practice times were increased
substantially?
Table 3 Education-specific questions.
Pertinent education-specific questions
At what age did the musician begin the study of music?
How many teachers has the musician had?
Does the teacher advocate a varied repertoire?
How does the teacher structure the lessons?
Has there been a recent change in teacher? If so, has there
been a change in technique or in repertoire?
Table 1 Instrument-specific questions.
Pertinent instrument-specific questions
Which instrument(s) does the musician play?
What is the primary instrument?
Did the musician make any recent adjustments or
modifications to the instrument?
Has there been a recent change in instrument?
Table 4 Repertoire-specific questions.
Pertinent repertoire-specific questions
What kind of music does the musician usually play, i.e.,
classical, rock, jazz, folk, etc.?
Is there an exacerbation of the symptoms when playing
certain pieces?
Has there been a recent change in repertoire, i.e., from
classical to modern?
Has there been a recent change in performance level?
314 J. Dommerholt

and Eversden, 1981; McBride et al., 1992; Schmidtke,
1995). The light intensity at the music stand should be
approximately 500 lux, but intensities as low as 35e140 lux
were measured in one older study of orchestra musicians
(Haider and Groll-Knapp, 1971; Brok, 1979). Mean sound
levels within a symphony orchestra have been recorded as
high as 92 dBA with peak intensities exceeding 110 dBA,
while in other ensembles, such as jazz and rock bands,
musicians frequently are exposed to even higher sound
levels (Rintelman and Borus, 1968; Speaks et al., 1970;
Laitinen et al., 2003). Jazz and rock musicians, music
teachers, and pannists (steelband musicians) are among
groups of musicians at high risk for unhealthy sound expo-
sures (Ka
¨ha¨ri et al., 2003; Behar et al., 2004; Juman et al.,
2004). Exposure to poor lighting and excessive sound levels
has been shown to negatively impacts musicians’ postures,
quality of movement, and stress levels, thereby increasing
their risk of musculoskeletal injury and pain (Norris and
Dommerholt, 1996). Fortunately, several recent studies
have measured acceptable sound levels in orchestras
(Ka
¨ha¨ri et al., 2001a,b, 2004; Lee et al., 2005), but there
are still incidences where sound levels are potentially
dangerous (Laitinen et al., 2003; Behar et al., 2006). The
Health Promotion in School of Music Project, an initiative of
the University of North Texas System and the U.S. Per-
forming Arts Medical Association, emphasized that a ‘‘high
priority strategy is needed for informing all music students
about the risks for noise-induced hearing loss (Fjellman-
Wiklund and Chesky, 2006).
Professional musicians and serious music students are
functioning in often stressful and very competitive envi-
ronments (Middlestadt and Fishbein, 1988; Sternbach,
1993a,b; O
¨nder et al., 2000; Parasuraman and Purohit,
2000). Professional musicians may be fearful of job loss or
lack of career advancement, while students may worry
about not being accepted in high-level youth orchestras,
summer camps or preparatory conservatory programs
(Sternbach, 1993a,b). In addition, many professional and
gifted adolescent musicians suffer from severe perfor-
mance anxiety, which can be accentuated by stressful work
environments (Havas, 1989; Wesner et al., 1990; Sternbach,
1993a,b; Kenny et al., 2004; Osborne and Kenny, 2005;
Fehm and Schmidt, 2006). In a worldwide study of 55
orchestras, 70% of musicians reported experiencing anxiety
during performances (Wynn Parry, 1998).
Furthermore, clinicians need to obtain information
about possible other jobs or assignments, hobbies, and
other physical activities as they may cause or contribute to
the musician’s injury. Some musicians may hold other jobs
requiring much computer work or other repetitive activity.
Relevant hobbies or activities may include gardening, arts
and crafts, or sports activities (Dawson, 1995; Hopmann,
1998). Non-musical related upper extremity trauma is
a common source of disability in musicians (Dawson, 1990;
Blum and Ahlers, 1995). See Table 5 for pertinent employ-
ment-specific questions.
Classification
Questions about specific music-related issues will help musi-
cians have confidence and trust in their doctor or therapist and
will immediately distinguish the performing arts medicine
provider from other healthcare providers. Before concluding
the history, clinicians should determine the impact of pain on
playing musical instruments to categorize the severity of
injury and dysfunction using the Functional Grading of
Severity of Injury scale (Table 6)(Fry3, 1986a,b).
The Functional Grading of Severity of Injury scale is used
not only to document a musician’s status at intake, but also
to measure progress of therapeutic interventions. The scale
has not been validated, but is frequently used by per-
forming arts medicine practitioners (Hopmann, 1998). It
should be noted that occasionally musicians may not be
able to play their instruments even with a grade 1 severity
of injury. Each injury can be potentially career ending.
Table 5 Employment-specific questions.
Pertinent employment-specific questions
What are the work conditions (i.e., seating/chair, lighting,
sound levels)?
What is the musician’s job history?
In what kind of ensemble(s) does the musician play, i.e.,
band, orchestra, etc.?
Is the musician employed, free-lance, or an independent
contractor?
Does the musician perform regularly or is the musician
primarily a teacher or student?
Is the musician a soloist, or a member of an orchestra or
band?
What is the musician’s job satisfaction?
Does the musician experience psychological or emotional
stress at the work place, including performance anxiety?
Has there been a recent change in employment status?
Does the musician hold any other jobs?
Which hobbies does the musician have?
Table 6 Functional Grading of Severity of Injury (from
Fry, 1986a,b).
Grade Description
1 Pain is limited to one site and brought on by
playing the instrument.
2 Pain occurs in two or more sites with a high
workload and possibly some loss of coordination.
Physical signs may be present; however, there is
no interference with other uses of the hand.
3 Pain persists away from the instrument. There is
early involvement of other uses of the hand with a
possible loss of coordination or strength. Physical
findings include persistent tenderness of the upper
limb structures. The musician has difficulty
maintaining a high workload.
4 Pain persists at rest, at night, or both. The
musician has pain with most uses of the hand,
including activities of daily living. A normal
workload is challenging.
5 The musician has no functional use of the hand.
The musical career stops or is seriously
threatened.
Performing arts medicine eInstrumentalist musicians Part I eGeneral considerations 315

Summary and conclusions
Musicians have much difficulty in locating healthcare
providers with a special interest in their specific medical
needs. This article aims to lay the foundation of a per-
forming arts medicine program. By expanding the standard
history procedures, clinicians will be able to better
understand the specific demands of playing musical
instruments and the subtleties of musicians’ injuries
(Brandfonbrener, 2006). In part II, the examination proce-
dures will be reviewed, while in part III the information will
be applied to the physical therapy management of three
musicians with hand pain.
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