For Students in the School of Music to Help Prevent Injury
The School of Music wishes to thank Dr. James Daniels, M.D., Professor of Family and Community Medicine and Orthopedic Surgery and Dr. May Kim, M.D., Assistant Professor of Family and Community Medicine of the Southern Illinois University School of Medicine.
Welcome to the Southern Illinois University School of Music. You have worked very hard to get here and we want your experience to be as positive as possible. This short discussion is meant to be a resource for you about your health as a performing artist. A number of articles are referenced at the end of this discussion but the websites, www.musiciansway.com and www.zzounds.com/edu--musiciandangers, are particularly good resources to find more in-depth discussion about what we talk about below.
Health Problems in Performing Artists
Listed below are some common health problems that are encountered by performing artists:
1) Tendinopathy. This condition used to be referred to as tendonitis. A tendon is an anatomical structure that connects a muscle to a bone. At one point we thought that overuse of the tendon would cause inflammation. We now understand that this is not the case. Tendinopathy occurs with overload of the tendon and causes degeneration. This results in scarring, which changes the architecture of the tendon, and affects how the tendon functions. A tendinopathy can occur in two ways. The first is a discrete injury, such as a fall or a laceration. The other is repetitive activity which exceeds the tensile strength of the tendon causing scarring. Healthcare providers sometimes refer to tendinopathy as a sprain as opposed to a muscle injury (known as a strain, see discussion below). Pain from a tendon is usually described as a dull ache, and it is made worse with activity. It is relieved by rest. This type of discomfort usually lasts a number of weeks. Contrary to popular belief, non-steroidal anti-inflammatory drugs, also known as NSAIDS, provide pain relief but do not help these injuries to heal. We recommend treating these conditions with rest and application of ice for approximately 20 minutes intermittently. Over the counter medications such as ibuprofen or Tylenol can help with discomfort but should not be used for a regular or long-term basis without consulting a healthcare provider.
2) Muscle Pain. This condition is often referred to as a strain and occurs very commonly. As your technique and stamina improve, you may experience this type of discomfort. For muscles to increase in strength, they are first injured on a microscopic level and the healing process that your body undergoes causes the muscle to enlarge. A lot of the pain that musicians experience is not exactly from muscle damage, but from the connective tissue that surrounds the muscle. This is known as delayed onset muscle soreness or DOMS and usually occurs 48 hours after a strenuous activity. For this type of injury, we usually recommend modifying your practice schedule, consulting your professor about your technique and application of ice after practice. We usually recommend some type of warm-up before you start your practice. Patients may find that taking a warm shower in the morning will help alleviate some of these symptoms. Again, these symptoms should be self-limited. If they persist, see a healthcare provider at the Student Health Center or your own healthcare provider at home.
3) Nerve Entrapment. Nerves are long noodle-like structures that are tethered from the spinal cord into your muscles. Although these are not as common as a sprain or a strain as discussed above, when a nerve is injured, you may experience numbness or tingling in your extremities. If this happens occasionally and briefly, for example, stretching your elbow and hitting your ulnar nerve causing a tingling, often called, hitting your “funny bone,” there really is nothing to worry about. If these conditions happen frequently or last for prolonged periods of time, it is important that they be evaluated. Common nerves that are entrapped include the median nerve which can be entrapped on the palmar aspect of your wrist, referred to as carpal tunnel; or as described above, an injury to the ulnar nerve as it transverses the elbow referred to cubital tunnel syndrome. These conditions often require further evaluation to make sure that you do not have any other medical conditions that could be adding to this problem. Consulting with a therapist or an occupational therapist is often very helpful.
4) Focal Dystonia. Focal dystonia is a relatively rare condition in the general population but can have a particular harmful effect on an accomplished musician. Focal dystonia is a condition characterized by painless involuntary contractions that occur during a certain activity, such as performing or practicing. Approximately 1% of professional musicians develop focal dystonia and the effects can be debilitating. An example of famous musicians that have had this condition include Billy McLaughlin and Liona Boyd, who are guitarists, and pianists, Leon Fisher and Gary Graffman.
We really do not know the exact cause of focal dystonia but there are theories that explain it. Researchers think that there is a genetic predisposition and individual behaviors that can affect it. People who engage in skillful, repetitive activity across the span of years, such as musicians, are set up to develop this condition. Researchers have recognized that there are at least 13 genes or chromosomal locations that have been connected to this condition. We are uncertain who will develop this particular problem, so we recommend a number of preventive measures listed below:
a) Never push through fatigue or injury
b) Only increase performing or practice times in stages, no more than 10-20 percent per week. Let go of “perfectionism” and take the slow and steady course.
c) Acclimate gradually to any unfamiliar instrument.
d) Initiate technical changes in increments.
e) Curb new hand intensive or repetitive tasks.
f) Commit to healthy practice habits. Minimize stress intention. It is better to take short, frequent breaks than to engage in long practice sessions.
Other medical problems can mimic this condition so it is important that if you start to experience some of the symptoms described above that you get it checked out.
5) Chronic musculoskeletal conditions associated with being a musician. Over time, you may experience small “micro” injuries to the small joints of your hands and wrists. Each joint consists of two bones in contact. The joint has articular cartilage covering each bone and this is surrounded by a joint capsule or synovium. This articular cartilage has certain proteins in it that make it particularly slick. When the joint is overloaded, the body secretes synovial fluid into the joint capsule and you may experience some slight swelling of the joint. If the joint is overloaded over a period of time, the articular cartilage can start to thin out. This is replaced by another type of cartilage, referred to as fibrous cartilage that has a different set of proteins in it making it not as efficient as the articular cartilage. This can lead up to injury to the bone and ultimately to osteoarthritis. Everyone, eventually, develops some form of osteoarthritis depending upon what joints they use the most in their live. After a particular injury, such as a fracture or a life-long career using these joints, osteoarthritis may develop. This is why you should develop life-long habits now of using proper technique and a balanced practice schedule to help alleviate or slow down this problem.
Practical Tips to Help Prevent Health Problems in Performing Artists
Many of these injuries can be prevented or the time away from practice can be decreased by just paying attention. It is much better to nip these problems in the bud than to wait until they become overwhelming. One musician quoted in the Musician’s Way Blog, Janet Horvath, cellist, stated, “I continued to play with a sore arm with the rationalization that I could play through the pain and that the discomfort would just miraculously go away as I got into better shape as a cellist. But the pain did not go away, it got worse.” Here are a few ways to pay attention:
1) Watch out for overuse. As a musician, at your level, you probably play very efficiently, but do you do this relentlessly? Take regular mini or micro breaks throughout your practice time and limit the repetition. There may be times when this is not possible, but in general, healthcare professionals recommend that you increase activity no more than 10-20% per week.
2) Avoid misuse. It is important that you develop and practice a strong technique. Some of your instructors may use Alexander technique or Feldenkrais method. Whichever technique that you use, practice it on a regular basis. Key points to take away are to use the wrist in midranges of motion, then align and lengthen your spine to minimize tension.
3) Accidents. Aside from avoiding accidents in daily life, take care when you are hauling your instrument or dealing in stressful performance situations. Please allow yourself ample set up time before practice and concerts.
4) Be aware of your anatomy. We all differ somewhat in proportion and how an instrument matches our physique. For example, a musician with shorter fingers may need extensions placed on selected keys for their wind instruments or may prefer a petite-size guitar. You may have already made these types of adjustments but they are important to consider as your musical career continues.
5) Know yourself. There may be time when you are particularly stressed or ill. We commonly use the following recommendations called the Neck-Up/Neck-Down Rule. If you have symptoms above the neck and you are not running a fever, you probably need a small amount of rest and avoid spreading this to other people. This is all that is needed. If you have symptoms from the “neck down” such as cough, associated with fever, chills and body aches, you should probably consult with a healthcare provider. You may also have certain medical conditions that needs monitoring. For example, asthma during a stressful performance or fasting blood sugar if you are a diabetic and have been practicing for long periods of time.
Many musicians sit for hours each day practicing, studying and using computers. There are a few ergonomic principals that may be useful.
1. The first is balance “sitting on your bones.” While sitting, we would like you to balance on your ischial tuberosities. These are the firm boney prominences that you may feel underneath your buttocks. Try to get a feel for balancing on your ischial tuberosities. You can do this by sitting on the front edge of your chair with only your pelvis having contact with your seat. Place your feet flat on the floor and position your knees and hips apart the width of your shoulders. Position your hips higher than your knees. This helps you relax your lower back muscles. You can practice this by sitting on the chair and rocking back and forth to balance yourself.
2. Forward sloping cushions are ideal to achieve hip alignment.
3. Balance shoulders open heart. The shoulders are tricky to coordinate because they are one of our most mobile joints. Many instrumentalists tend to stiffen one or both of their shoulders when they bring their hands in to playing position. This can build up tension in the muscles and tendon and lead to injury. Experts recommend to start each practice or performance by placing your hands on your thighs and allow your shoulders to relax. When this happens, you will notice that your shoulders will lower and your shoulder blades will move closer together. We recommend that you take a number of cleansing breaths (deep breaths in both nostrils and out the mouth) to help you relax. This can be repeated as often as possible and is preferred over practicing over long periods of time and taking longer breaks.
4. Align and lengthen your spine. Avoid slumping forward or arching your back like a soldier at attention. Your spine has a couple of natural curves in it. Pretend that your pelvis is an anchor and that your spine is a string connecting it to a helium-filled balloon floating above. This allows your head to rise and your back to obtain a comfortable posture.
5. If you experience pain or odd sensations such as numbness and tingling, fatigue or inability to perform, we recommend a 3-step response STOP – REST – GET HELP
You can access all the resources available to you by discussing the problem with your instructor or healthcare provider. When you are evaluated by a healthcare provider, please explain to them that you are a musician and that you have some special needs as far as performing. Some healthcare providers do not understand that you are a highly skilled athlete! The use of a total healthcare team can often be of great benefit; physical therapists and occupational therapists are particularly in tune to evaluating patients with musculoskeletal conditions. When accessing a healthcare provider, it is probably a good idea to start with your family physician or one of the physicians at the Student Health Center. They can also put you in contact with a hearing specialist, orthopedic surgeons, or other specialists. Integrative medicine is taking a more prominent role in today’s world. The coordination of your care with acupuncturists, chiropractors, massage therapists, etc. can be very beneficial. It is important; however, that you maintain contact with your primary care healthcare provider and that they are the “captain” of the team. If not, conflicting advice can be given and you may run the risk of obtaining medical care that is not covered well by your medical insurance.
Some of these maladies can totally be prevented by taking a few simple steps.
1. Breathe – Move – Center. Depending upon your music medium, you should do a few things to warm up before you practice. This would include moving your arms and shoulders in circles or rolls, yoga or even tai chi movements. It is important that you develop something for you, as an individual, and try to do it before every practice and performance.
2. Set up goals. What am I going to do today? Am I going to do speed building exercises? Am I going to practice high velocity music? Am I going to focus more on my repertoire? Don’t try to do too much with each session.
3. Be mindful. As you unpack your instrument and set things up, start to focus in your artistic mindset – never blast through the steps in preparing. Affirm your passion for your art every day.
4. Begin moderately. Always start slowly and increase your tempo and speed as you go.
5. Mix it up. You might start with gentle improvisation one day and proceed to a variety of techniques or change your registry. If a particular technique feels odd, you might want to review and target a specific exercise.
6. Finish fast. If possible, try to conclude your warm up in 10-15 minutes so that you may nimble and focused. Extended drills can lead to exhaustion during rehearsals and performances.
7. Lastly, develop something called the “effort meter.” This is something that you can use to identify how you are doing on any particular day. Concentrate on an imaginary meter in your head that measures the effort that you are putting forth on a scale of 0 to 10. Zero represents inactivity and 10 represents maximum effort. During your course of practice or performance, this effort meter may change rapidly. The issue is to try to not stay in the “red zone,” (above 8) for prolonged periods of time. For example, if you are playing an instrument very intensely, you might practice and apply less pressure with your hands to free up your shoulders until the effort meter drops to a manageable position. This can also be used in another way. If you are having a particular bad day before practice, you may walk in with your meter high. It is a good idea to relax. Possibly talk to someone before starting your session.
This summary has been provided to you by SIU School of Medicine Department of Family and Community Medicine and Department of Orthopedic Surgery.