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Introduction

The School of Music at SIU, as required by the National Association of Schools of Music is obligated to inform students and faculty of health and safety issues, hazards, and procedures inherent in practice, performance, teaching and listening both in general and as applicable to their specific specializations. This includes but is not limited to information regarding hearing, vocal and musculoskeletal health, injury prevention, and the use, proper handling and operation of potentially dangerous materials, equipment and technology.

Individuals are personally responsible for avoiding risk and preventing injuries to themselves before, during, and after study or employment in the SIU School of Music. The policies, protocols, and operational procedures developed by the School of Music do not alter or cancel any individual’s personal responsibility to make responsible personal decisions. They serve only to better educate and inform the students and faculty of the School of Music.

The information provided here is for information purposes only and is not a substitute for medical advice or treatment by a licensed professional, nor is it a substitute for each individual’s responsibility to cultivate his or her own healthy habits on a daily basis.

What ALL Musicians Should Know and Do

The School of Music wishes to thank Dr. Kathleen Campbell, PhD, Professor and Director of Audiology Research, Southern Illinois University School of Medicine.

Hearing

Hearing health is essential to your lifelong success as a musician.
• Your hearing can be permanently damaged by loud sounds, including music. This is called Noise-Induced Hearing Loss (NIHL). Such danger is constant.
• Noise-induced hearing loss is generally preventable. You must avoid overexposure to loud sounds, especially for long periods of time.
• The closer you are to the source of a loud sound, the greater the risk of damage to your hearing mechanisms.
• Sounds over 85 dB (your typical vacuum cleaner) in intensity pose the greatest risk to your hearing.
• Risk of hearing loss is based on a combination of sound or loudness intensity and duration.
• Recommended maximum daily exposure times (NIOSH) to sounds at or above 85 dB are as follows:

- 85 dB (vacuum cleaner, MP3 player at 1/3 volume) – 8 hours
- 90 dB (blender, hair dryer) – 2 hours
- 94 dB (MP3 player at ½ volume) – 1 hour
- 100 dB (MP3 player at full volume, lawnmower – 15 minutes
- 110 dB (rock concert, power tools) – 2 minutes
- 120 dB (jet planes at take-off) – without ear protection. Sound damage is almost immediate

• Certain behaviors (controlling volume levels in practice and rehearsal, avoiding noisy environments, turning down the volume) reduce your risk of hearing loss.
• The use of earplugs and earmuffs helps to protect your hearing health.
• Day-to-day decisions can impact your hearing health, both now and in the future. Since sound exposure occurs in and out of school, you also need to learn more and take care of your own hearing health on a daily, even hourly basis.
• It is important to follow basic hearing health guidelines, and to stay informed about hearing loss issues.
• If you are concerned about your personal hearing health, talk with a medical professional. If you are concerned about your hearing health in relationship to your program of study, consult the appropriate faculty member at SIU.

A long-term problem associated with being a musician is hearing loss. Loud sound can actually damage the organ in your ear that is responsible for you to hear. The National Institute of Occupational Safety and Health devised two excellent guides to understand if you are being exposed to an unsafe level of noise. If you have to raise your voice to be heard by another person, then you are being exposed to a potentially hazardous amount of noise. Also, after engaging in activity, if your ears are ringing at the end of the day or at night, you were probably exposed to a hazardous level of noise. The best way to prevent long-term hearing loss is to modify the acoustic environment and reduce the amount of exposure. At times this is not possible and as a last resort, earplugs may be needed. It is our recommendation that you discuss this with your instructors or a hearing professional. There are now several types of high fidelity earplugs designed specifically for musicians. (Dr. James Daniels, M.D., SIU School of Medicine)

Dr. Kathleen Campbell, PhD, Professor and Director of Audiology Research at the Southern Illinois University School of Medicine recommends the resources of the National Hearing Conservation Association for further information regarding hearing preservations. Please see the website at: www.hearingconservation.org

This information is provided by the National Association of Schools of Music (NASM) and the Performing Arts Medicine Association (PAMA). For more information, consult the other NASM-PAMA hearing health documents located on the NASM website at: http://nasm.arts-accredit.org/index.jsp?page=NASM-PAMA_Hearing_Health

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.

Introduction

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

Pay Attention

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.

Ergonomics

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.

Prevention

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.

About the Authors

Dr. James Daniels is a Professor of Family and Community Medicine and Orthopedic Surgery. He is Board Certified in Preventive Medicine with a subspecialty in Occupational Medicine, Family Medicine, and Sports Medicine. He has an MPH from the Medical College in Wisconsin with emphasis on human ergonomics. He is the Director of SIU Primary Care Sports Medicine Fellowship in Quincy, Illinois.

Dr. May Kim is an Assistant Professor of Family and Community Medicine at the Quincy Program. She has a special interest in treating performing artists for medical conditions.

Dr. James Daniels and Dr. May Kim can be contacted for non-urgent medical problems at jdaniels@siumed.edu or mkim@siumed.edu or by phone at 217-224-9484. If you are experiencing an urgent medical problem, please see your family healthcare provider or a healthcare provider at the Student Health Center.

Resources

Hansen PA and Reed K. “Common musculoskeletal problems in the performing artist.” Physical Medicine and Rehabilitation Clinics of North America. 2006;(17)780-801.

Bejjani FJ, Kaye GM and Benham M. “Musculoskeletal and Neuromuscular conditions of instrumental musicians.” Archives of Physical Medicine and Rehabilitation. 1996;77(4)406-413.

Hoppman RA and Patrone NA. “A review of musculoskeletal problems in instrumental musicians.”Seminars in Arthritis and Rheumatism. 2989;19(2):117-126.

The Perils of Being a Musician. http://www.zzounds.com/edu--musiciandangers. Accessed 7/23/2013.

Wellness. http://www.musiciansway.com/wellness.shtml. Accessed 7/23.2013.

What Singers Should Do

The School of Music wishes to thank Dr. Diane Coloton, D.M.A., Senior Lecturer in Voice, Southern Illinois University, Carbondale.

1. Get enough sleep.
Lack of sleep wears you out physically, dulls mental function and compromises your immune system. Getting enough sleep is the best weapon against illness.

2. Stay hydrated.
Drink plenty of water throughout the day, especially on the day before and the day of a performance. This is hydrating at the cellular level, not just wetting your mouth! Drinking lots before and during performances generally washes away saliva, making you feel even thirstier.

Dr. C Tip: Hide a Lifesaver or two in your folder, pocket, or “opera locker” and, when not singing, sneak it into you mouth if really dry. Avoid throat drops with Benzocaine and menthol. Both have numbing effects and do not promote hydration. Simple, hard sugar candy is best.

Dr. C Tip: Cranberry juice is very drying. Avoid it when you’re singing.

3. Stay healthy, stay in shape
Maintain a strong immune system and avoid stress by eating a healthy diet, getting enough sleep, and balancing work and play. Singing is physically demanding, so promote strength and endurance in your workouts.

4. If you get a sore throat as a result of a cold or flu, you can make yourself more comfortable by drinking plenty of fluids, gargling with warm salt water (1 tsp. of salt for each 8 oz. of water), placing a warm cloth on swollen glands, and sucking on lozenges that have Camphor or Benzocaine -- desirable to deaden throat pain. Ibuprofen and acetaminophen can reduce fever. A cool mist humidifier in your room can help loosen secretions . . . all this on the advice of your parents and doctors, of course.

5. Practice correctly.
Pace yourself so you don’t sing for long periods of time. “Practicing” involves much more than singing, so learn a phrase or two at a time, notes and rhythm, diction, etc. Don’t strain your voice by guessing at or reaching for notes you’re unsure of. If you don’t know the pitch of high leap for sure, play it first on the piano. Don’t scream your best.

6. Don’t overuse and misuse your voice.
Don’t sing too loudly or softly for your comfort.
Don’t sing for too long at a time.
Don’t sing things that are harmful for your young, developing voice.
Don’t try to talk over noise in loud restaurants.
Don’t yell at sports events.
Don’t cough or clear your throat unnecessarily.
Don’t smoke. Cigarettes are lethal, and smoke dries the vocal folds.
Don’t abuse alcohol. Aside from obvious dangers, alcohol is also very drying.

7. Don’t forget that everything you do affects your voice!
Your voice is your instrument, so treat it with respect.

What Instrumentalists Should Do

The School of Music wishes to thank the Associated Board of the Royal Schools of Music and the Canadian Network for Health in the Arts for the following information:
1. Evaluate your technique. Reduce force, keep joints in the middle of their range of motion, use large muscle groups when possible, and avoid fixed, tense positions.
2. Always warm up. As an athlete would not begin a vigorous physical activity without warming up, a musician must warm up carefully before practice or performance.
3. Take breaks to stretch and relax. Take short breaks every few minutes and longer breaks each hour. Two or more shorter rehearsals each day are more productive than marathon single sessions. Even in performance, find those opportunities to relax a hand, arm, or embouchure to restore circulation.
4. Pace yourself. No pain, no gain is a potentially catastrophic philosophy for a musician. Know when enough is enough, and learn to say 'no' to certain performances or lengths of performing that might result in injury.
5. Check out your instrument. Does your instrument place undue stress on your body? Is your instrument set up optimally for you to relieve pressure on hands, joints, etc.? Is there a strap, carrier, or stand available to relieve the stress?
6. Evaluate other activities. Pains and injuries affecting your music making could be caused by other activities in your daily life. Computer use is notorious for causing afflictions including carpal tunnel syndrome and tendinitis.
7. Pay attention to your body. Pain is the mechanism by which your body tells you that something is wrong. Listen to your body; if it hurts, stop what you are doing.
8. Get medical attention. Do not delay in seeing a doctor. A physician may prescribe a minor adjustment or, in worst-case scenarios, stipulate not performing for a period of time. As drastic as this may sound, a few months of rest is better than suffering a permanent, career ending injury. Likewise, the demands placed on singers' voices are immense. Hardly a month goes by where a top singer is not forced to interrupt a tour, take a break, or undergo a medical procedure due to problems with their voice. Medical professionals are making the case that the demands put on one's voice when singing one to three hours is as intense as those made on an Olympic marathon runner's body. Additional factors such as nutrition, smoking, drug use, noisy environments, and proper voice training (or the lack of it) all play a role in a singer's ability to perform at her/his best.
9. Be clean. Wash your hands before and after to practicing. Do not share intruments and mouthpieces. Regularly clean mouthpieces, flute head joints, bocals, and saxophone necks. Talk with your applied teacher about the best ways to keep your instrument clean

If you are feeling ill, USE the health services provided for you by the University.
Student Health Services at Southern Illinois University (shs.siu.edu) provides primary care for routine, acute and chronic illnesses. The SHC offers prescription and allergy injections, immunizations, health education, in house laboratory services, confidential HIV testing, reproductive consultation including contraception, specialty consultation referral, treatment and screening for STDs, and women’s and men’s health care. SHC also provides wellness education and seminars. The Student Medical Insurance Plan (SMIP) provides health insurance coverage that complements the on-campus primary care services, covering off-campus services such as emergency room, hospitalizations, surgery, ambulance and specialty care. Students are automatically enrolled in SMIP as a condition of SIU Carbondale enrollment, registration and the assessment of the Student Medical Insurance Fee.

Resources:
National Association of Schools of Music (NASM) http://nasm.arts-accredit.org/
Performing Arts Medicine Association (PAMA) http://www.artsmed.org/index.html
PAMA Bibliography (search tool) http://www.artsmed.org/bibliography.html
Southern Illinois University School of Music