Chapter 1: The Reality of Problems
Fire consumes the Christmas tree—at least in the imagination of the six-year-old boy playing
with his red truck. He pretends to be a heroic fireman rescuing his family. Two months later, with eyes
glued to the television screen, this boy‘s little sister jumps up and down as their country‘s Olympian
figure skater perfectly executes a jump combination. Plopping to the floor in exhaustion after jumping in
excitement, the little girl‘s thoughts drift to her birthday gift. She hopes for a pair of ice skates. Six
months later, in the family‘s backyard, the older brother swings his bat imitating the Major League
Baseball player who recently broke the home-run record. This same summer night, riding home from a
cousin‘s college recital, the ten-year-old sister blankly stares at the minivan window as she mentally
reconstructs the recital stage and begins humming her favorite theme from a Brahms‘ violin sonata.
Children dream of doing and becoming different things when they grow up. When children
imagine themselves becoming a fireman, ice skater, or baseball player, they do not imagine the potential
hazards that accompany these aspirations—hazards such as getting burned in a fire, getting a torn ankle
tendon from attempting an ice jump, or getting a concussion from a wild pitch. As children grow up,
even if they never personally experience an injury, they realize the potential dangers of burns, tears, and
concussions involved in pursuing their dream vocation. But something that escapes many people‘s
awareness is that even the young girl‘s dream of playing violin includes physical health risks.
Tracing the History of Musicians’ Playing-Related Problems
Playing-related problems of instrumental musicians have been noted throughout history. In the
anthology Performing Arts Medicine,1 Susan Harman unfolds the growing awareness of and attention
given to musicians‘ injuries in the chapter ―The Evolution of Performing Arts Medicine.‖ Harman is no
stranger to music medicine literature since she is the Coordinator of the Music Medicine Clearinghouse at
the Baltimore Library for Medical and Chirurgical (chirurgeon is archaic for surgeon) Faculty.2 While
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bibliographies on music medicine are continually accumulating within various personal and institutional
websites, the Clearinghouse is a brick and mortar construction housing bibliographic references.3 Like
Harman, the other authors included in this anthology have had specialized training and personal
experience in their given topic.4
More importantly, the anthology‘s editors are well equipped to be filtering information on
performing arts medicine. The first of the three editors is Robert Sataloff, who specializes in
otolaryngology. For this field, he is professor at Thomas Jefferson University, an adjunct professor at
University of Pennsylvania and Georgetown University, and chairman of graduate work at Allegheny
University Hospitals. Sataloff is also a faculty member at the Academy of Vocal Arts and the Curtis
Institute of Music. Lastly, he is chairman for the American Institute for Voice and Ear Research and for
the Voice Foundation‘s Board of Directors.5 The anthology‘s second editor Alice Brandfonbrener is the
original editor of the journal Medical Problems of Performing Artists, assistant clinical professor of
medicine at Northwestern University Medical School beginning in 1983, and the director of the medical
program for performing artists at the Rehabilitation Institute of Chicago beginning in 1998.6 The final
editor Richard Lederman is director within the Department of Neurology at the Cleveland Clinic
Foundation‘s Medical Center for Performing Artists.7
Concerning the history of performing arts medicine, Harman‘s research indicates that as early as
1713 at least one physician recognized musicians‘ ailments as its own category of occupational diseases;
Bernardino Ramazzini authored the treatise Diseases of Tradesmen. 8 Harman quotes parts of
Ramazzini‘s explanation of musicians‘ occupational ailments as ―rupture of the groin . . . distentions [sic]
of the head, palpitations of the temples, pulsations of the brain, inflammations or swellings of the eyes
and tingling in the ears.‖9 While these descriptions may not be perfectly diagnostic, this eighteenth
century document demonstrates that musicians‘ experiencing occupational discomfort is not a new
phenomenon. Tracing thoughts on musicians‘ playing-related difficulties after Ramazzini and through
much of the 1800s is difficult because the literature on this subject is lacking. From the few documents
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available, Harman gathers that doctors did speculate and experiment on current circulating hypotheses for
sufferings particular to the instrumentalist. 10 Harman recognizes that many of these hypotheses (such as
wind instruments attributing to the lung disease emphysema) were ―unsubstantiated beliefs.‖ 11 While this
period of history did not contribute to forming effective treatments or finding cures, the interest
surrounding musicians testifies that they experienced physical occupational discomfort.
In the next period (the late nineteenth century), the medical attention given to musicians was
focused on problems in the hand—most rampant among pianists. These mild to major hand cramps
caused pain and loss of dexterity similar to writer‘s cramp.12 Much speculation and different schools-ofthought ensued on proper piano technique. For example, pedagogues debated whether the ―modern
piano‖ (developed between 1825 and 1900 and with a much heavier touch than its ancestors) should be
played with the same finger approach as the harpsichord was played. 13
Nineteen thirty-two witnessed Dr. Kurt Singer‘s German book being translated into English.
Harman dubs this book Diseases of the Musical Profession: A Systematic Presentation of Their Causes,
Symptoms and Methods of Treatment as ―the first book devoted to the subject‖ of musicians‘ medical
problems.14 Around this same year, musicians and occupational discomfort were addressed on an even
broader level. The International Labour Office in Geneva, Switzerland included two articles on musicians
in their 1930-1934 encyclopedia Occupation and Health: Encyclopedia of Hygiene, Pathology and Social
Welfare.15
The next stage of interest came in the 1960s. Researchers and musicians wanted to gain
understanding ―in the physiology of music making.‖16 People began to study and publish findings on
things such as the workings of the respiration system in wind playing, potential hearing loss from rock
and roll or orchestra concerts, and physical aspects for playing stringed instruments.17 Even those in the
medical field began to call attention to musicians‘ needs by printing studies and writing editorials in
medical journals.18
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One seed sown at a Neurology Conference in Vienna would at first appearance seem to have had
no bearing on the development of performing arts medicine. The theme of this 1972 conference involved
music, but not physiology; it was music and neurology. Two men at the conference were inspired to
coauthor a book Music and the Brain: Studies in the Neurology of Music. Harman explains its relevance,
―While this was not a book on music medicine . . . The fact that the book was published at all and was
widely quoted lent credibility to the notion of a developing subspecialty.‖19
Up until 1981, articles on music-making and health had been published in journals specific to
either musicians or physicians. In 1981, musicians‘ sufferings hit a general public news source. The
New York Times told the story of two pianists Leon Fleisher and Gary Graffman who were both seeking
help for debilitating hand problems.20 This story not only raised general awareness but also personalized
the problem by placing two well-known solo performers‘ names under the looming cloud of performance
injury. It also revealed the need for more research since Graffman‘s and Fleisher‘s problems were
remaining unanswered.21 Oddly enough, while the article forecasted bad news, it also seems to have
comforted readers who were injured musicians themselves. The article did not provide solutions to
musicians‘ problems, but it did reveal to every reader, from the local neighborhood musician to the music
conservatory teacher, that his sufferings were not part of his vain imaginations and may even be worthy of
medical attention. As a result, many more musicians began seeking medical help.22 During this same
period, musicians and medicine gained additional attention from journalists debating musicians‘ use of
drugs (specifically those known as beta blockers) to suppress performance anxiety.23
The idea of musicians and the need for medical attention continued to gain momentum. The
1980s witnessed music organizations such as the National Flute Association devoting conference sessions
to physiological health.24 Even entire conferences converged on the topic of music and medicine. For
example, the first conference of Medical Problems of Musicians was in 1983 (and has run every year
since).25 Also, the Biology of Music Making conference, ―the International Society for the Study of
Tension in Performance conferences, the International Society for Music in Medicine conferences, [and]
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the Playing Hurt series‖ were all conferences initiated in this decade to decrease the number of suffering
musicians.26 Besides conferences supplying sporadic advice, musicians started creating clinics in highly
performance-populated areas to help injured musicians find practical, local help year round.27
Also in the 80s, two music unions, the International Conference of Symphony and Opera
Musicians (ICSOM) and the American Federation of Musicians (AFM), began to increase the amount of
attention they devoted to physical performance health both in meetings, advertisements, and
publications.28 In 1993, ICSOM even collected one author‘s articles into a book, making the information
more easily available to musicians since the information was now in one publication rather than multiple
journal issues; the book is the well-known and well-used The Musician’s Survival Manual: A Guide to
Preventing and Treating Injuries in Instrumentalists by Richard Norris, MD.29
Besides current organizations, such as the music unions (like ICSOM) and individual
instrumental associations (like the National Flute Association), giving some attention to the physiology of
music making, people began forming new organizations to devote all their attention to performing arts
medicine. In1983 in Australia, the Performing Arts Medicine Society was spear-headed by the
―physician-[musician]‖ Hunter J. H. Fry.30 On another continent in the following year, Dr. Ian James set
out to ―advance knowledge in the field and ensure that competent care [would be] available to all
performing artists in Britain‖ by establishing the British Performing Arts Medicine Trust.31 The
International Arts Medicine Association (IAMA) formed in 1985. And the ―first professional medical
organization in the field . . . providing quality medical care for performers‖ was begun in 1989 and is
known as the Performing Arts Medicine Association (PAMA). Performing arts medicine, as PAMA
explains, encompasses the needs of musicians, dancers, and actors.32 These organizations are only
samplings of the music medicine organizations that have emerged within the past eighteen years; before
1983, having medical organizations dedicated to the performing arts was unknown.
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Another contribution to developing music medicine is the Music Medicine Clearinghouse
(mentioned above in the introduction of Harman) established in 1988 at the Baltimore Library of the
Medical and Chirurgical Faculty. Harman says that its sole purpose is ―gathering, organizing, and
disseminating information to health professionals, musicians, and researchers.‖33 By 1998, the
Clearinghouse already contained ―over one thousand books and journal articles from the medical, music,
and popular press.‖34
Many of the organizations mentioned above have started journals to further develop performing
arts medicine. The forefather of these journals is PAMA‘s the Medical Problems of Performing Artists
(MPPA). Begun in 1986, it has published many studies on musicians‘ medical problems creating a
―forum for . . . physicians, musicians, allied health professional, and alternative therapists.‖35 According
to the Medical Problems of Performing Artists‘ website from March 4, 2011, MPPA is now the official
journal of the Dutch Performing Arts Medicine Association and the Australian Society for Performing
Arts Healthcare besides PAMA.36 One other example of these journals is the International Journal of
Arts Medicine. This world-wide perspective for arts medicine, provided by IAMA and the International
Society for Music in Medicine, appeared in 1991.37
From eighteenth century ink pens to twentieth century scientific journals, the cry for medical
attention kept mounting. The day arrived when performing arts medicine was publically recognized as its
own field. Harman says, ―In 1989, MPPA editor Alice Brandfonbrener could report ‗the presence of Arts
Medicine as a medical discipline is an accepted reality today.‘‖38 Now, musicians‘ physical needs are
known beyond the music population; they are recognized as meriting their own medical research.
If one were to take a few moments on Google, he would quickly discover that research and
interest continues since 1989. For example, today (specifically February 21, 2011), searching
―Musicians‘ Playing-Related Problems‖ in Google Scholar (but without the quotations marks around the
phrase) yields three hundred two results. Similarly, searching ―Instrumental Musicians' Playing-Related
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Problems,‖ one would see two hundred eighteen entries. Entering the first and second phrases
respectively into the regular Google search engine produces 5,230,000 results and 1,010,000 results.
Purely for the purpose of comparison, taking other phrases in Google scholar (using the following search
options: ―articles and patents‖ rather than ―legal opinions and journals,‖ ―any time,‖ and ―include
citations‖) and Google yields the following results:
PHRASE
GOOGLE SCHOLAR
GOOGLE
Musicians‘ Playing-Related
Problems
Instrumental Musicians' PlayingRelated Problems
Firemen‘s Occupational Injuries
342 results
5,230,000 results
218 results
1,010,000 results
2,550 results
11,500 results
Splinting a Broken Arm
12,300 results
7,030 results
Muffins and Healthy Eating
16,700 results
664,000 results
*Note: for every single ―results‖ number, Google said ―about‖ before the number.
While research has been done and continues to progress, the development of this field has, in
many respects, only just begun. Brandfonbrener explains the active role each musician should play in
discovering ways to help musicians prevent and recover from their sufferings: ―If [musicians] sit back and
do not take active roles in shaping the specialty, [they] will have only [themselves] to blame when it then
fails to achieve its full potential.‖39
Problems Experientially
Why is so much time invested in researching musicians‘ performance-related health? According
to the economic principles of supply and demand, resources are not usually spent to discover, assemble,
and distribute new information on a topic unless a demand for the information is present.40 People in the
music occupation are seeking information on health and wellness (creating the economic demand) since
they are suffering physically. In 1974, Janet Horvath, the then college student who majored in cello, took
three months off from playing due to chronic arm pain—pain severe enough that she could not even eat
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with silverware normally.41 In 2004, the Chicago Symphony‘s principle oboist Alex Klein resigned due to
his left hand malfunctioning.42 Horvath says, ―Pieces he had played as a child were suddenly and
inexplicably difficult for him.‖43 One day his fingers no longer responded to his brain‘s messages; Klein
encountered the debilitating and mysterious injury focal dystonia.44 These two musician‘s injury stories
and many others are recounted by Horvath herself in her book Playing (Less) Hurt. While Horvath‘s
injury in college disabled her for several months, it did not unravel her life or even her music career. She
reworked her technique eliminating all unnecessary tension so that she not only finished her degree, but
also played and plays well enough to be a member of the Minnesota Orchestra.45 In this orchestra she is
the associate principal cello, retaining this chair now for thirty years.46 Originally studying musicians‘
injuries to recover from her own, Horvath continued educating herself so that she now helps other
musicians recover from or prevent their own injuries.47 Her knowledge from years of research and
experience are encapsulated in the outstanding resource for all musicians—Playing (Less) Hurt.
Hearing stories such as Horvath and Klein are disturbing and uncomfortable. Creating music
whether as a career or hobby seems so distant from danger; it does not include chemical reactions, unsure
footing, or moving objects such as those around firemen, ice skaters and baseball players. Could it really
involve injury? Maybe the stories mentioned above are only surreal or represent the minority of
musicians‘ experiences. On the contrary, sadly, these stories only hint at the extent of playing-related
health problems among instrumental musicians—whether these musicians are orchestra players, teachers,
non-classical musicians, university students, or even children.
Three surveys from 1986 demonstrate the prevalence of playing-related problems among
orchestral musicians. First, ICSOM surveyed all of its forty-eight member orchestras on health and
performance. 48 The results of this survey were first revealed in 1987 in ICSOMs own publication Senza
Sordino and were reprinted, by permission, in 1988 in MPPA.49 MPPA indicates that the primary authors
of this ICSOM survey were Martin Fishbein, Ph.D., and Susan Middlestadt, Ph.D., who ―specialize in
research methodology‖ at the University of Illinois.50 Out of the 2,212 orchestral musicians participating
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in the study,51 eighty-two percent experienced medical problems—seventy-six percent indicating that one
of their medical problems was severe enough to impact their performing ability.52 Second, the Australian
plastic surgeon53 and musician54 Hunter J. H. Fry (mentioned above as a founder of a medicine
organization) questioned musicians from eight different orchestras in Australia, America, and England.55
His results were printed in MPPA in 1986; sixty-four percent of these 485 musicians reported
experiencing pain (ranging from one to five on a five-point pain scale) from overuse injuries.56 Third, in
June 2009, the current editor of MPPA Ralph Manchester57 wrote the editorial ―Looking at Musicians‘
Health through the ‗Ages,‘‖ which overviews many surveys on musicians and their health from the 80s,
when surveys on this subject started being conducted, through 2009.58 Besides mentioning the above two
surveys, another orchestral study he referenced was Caldron et al.‘s 1986 survey results.59 This study
documented that fifty-nine percent of 378 United States‘ orchestral musicians experienced pain.60
Health problems and pain interrupt more than orchestral musicians‘ lives as revealed in several
more articles published in MPPA. In the September 2009 issue, Cecilia Wahlström Edling, a physical
therapist in the Department of Paramedicine at Sweden‘s Brommageriatriken AB, and Fjellman-Wiklund,
a senior lecturer in the Department of Community Medicine and Rehabilitation at Sweden‘s Umeå
University, published their findings on music teachers.61 From a Swedish music school, seventy-seven
percent of forty-seven music teachers had had musculoskeletal problems (musculoskeletal will be
discussed later) within the past year.62
In the non-classical region, MPPA published a study on folk music students attending the
Montana Fiddle Camp in 2005.63 The study was conducted through the University of Rochester‘s School
of Medicine and Dentistry by Taylor Buckley, a medical student, and Ralph Manchester (the current
editor of MPPA), Director of University Health Service. 64 This professor and student reported that the
bluegrass musicians who participated in the study ranged from ten to eighty-nine years of age and played
one of the following as their primary instrument: fiddle, guitar, piano, mandolin, bass, banjo, or
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bagpipes.65 From the survey, almost sixty-five percent of the seventy-one adults and thirty-five percent of
the forty minors had experienced playing-related pain.66
At the college level, the majority of students have agile muscles and bodies that have not been
ravaged by deterioration simply due to the normal aging process; yet, studies on tertiary students reveal a
prevalence of playing-related problems even among young musicians. In December 2008, MPPA
published the results of Brandfonbrener‘s study on music college students.67 At Northwestern University
in 2004, 2005, 2006, and 2007, Brandfonbrener questioned each class of incoming freshman.68 Seventynine percent of 325 incoming freshman from ‘04-‘07 reported that they had already experienced pain
from playing.69
Looking at two different high school studies verifies the indications of the above freshman study.
Manchester‘s afore mentioned editorial cites two secondary studies conducted by Fry in the 80s.
Surveying ninety-eight high school Australian music students, Manchester said that Fry‘s study revealed
fifty-six percent of the students had had ―performance-related pain on at least one occasion.‖70 In 1989,
Fry published the results of a study on 169 high school students in Great Britain with seventy-one percent
reporting pain related to their instrument.71
Another study examining children from primary and secondary schools displays similar findings.
MPPA printed the article summarizing Sonia Ranelli‘s research study with Drs. Leon Straker, Director of
Research, and Anne Smith, Research Fellow in the School of Physiotherapy, from Curtin University of
Technology in Australia.72 Besides lecturing at this university, Ranelli was working on her doctorate at
the time of this 2008 publication. These three surveyed 731 Australian instrumental music students
ranging from seven to seventeen years old in 2003.73 Sixty-seven percent of the 731 children admitted to
having had playing related musculoskeletal symptoms.74 Symptoms were defined as ―mild aches and
pains experienced during and following playing, which may or may not affect performance.‖75 Of the
731 children, thirty percent experienced playing-related musculoskeletal disorders.76 Disorders defined as
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―pain, weakness, lack of control, numbness, tingling, or other symptoms that interfered with the ability to
play the instrument as usual.‖77
While these surveys provide a strong testimony of musicians experiencing health problems in
performance, these surveys are also imperfect tools for analysis in two ways. First, the observer should
recognize that these surveys did not use the same questions or terminology; therefore their studies yield
different results and consequently lead to different interpretations. (Though, researchers will often render
different interpretations even given the same results.) As Manchester notes, this unconformity in
questionnaires and terminology poses problems for ―drawing conclusions.‖78 Second, surveys depend
upon willing participants. Paula Brusky, a doctoral student in 2009 at the University of Sydney in
Australia, surveyed bassoon players.79 In MPPA‘s 2009 publication of her analysis, she mentions the
possibility ―that musicians who have injuries are more inclined to take part in PRMD [playing-related
musculoskeletal disorders] research‖ since they long to find answers to their problems.80 Having injured
musicians as the most willing participants for these studies ―may account for the [high] injury statistics.‖81
Still, no person truly knows if the musicians who have opted not to participate in studies have or have not
experienced playing-related health problems.
All the studies referenced above bear grave implications on the prevalence of musicians‘ physical
pains. While no study is perfect, the surveys‘ results yield strong evidence that the majority of musicians
encounter physical playing-related medical problems. Truly, every musician was not surveyed, but the
combination of these studies accurately represents the entire population of musicians because the studies
targeted a variety of musicians from different ages and backgrounds. From each of the surveys, the
results agree: medical problems related to performing an instrument are not a rare circumstance. The
research cited here is only a sampling of the body of research testifying to the same conclusion—
musicians are physically suffering.
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Chapter 2: Symptoms and Causes of Playing-related Problems
As the statistical numbers indicate, instrumental musicians are experiencing playing-related
health problems (PRHP). The reason for identifying any problem is to find its solution. The solution for
musicians‘ PRHP is relief, but relief is much easier written than realized. To find relief, musicians must
do the following: watch for any development of a problem; uncover its cause; identify a treatment; and,
apply the treatment.*
Watching for the Symptoms
Musicians should be aware of their bodies to know if they are functioning properly. Quoting
Horvath, ―The earlier the symptoms are recognized and treated, the sooner and more completely recovery
can ensue.‖ 82 In order to easily identify the body‘s warning signs before severe damage occurs, Horvath
lists the top ten musculoskeletal symptoms a musician should become familiar with.
10 Danger Signals83
1. Pain and/or burning sensation
2. Fatigue or Heaviness
3. Weakness
4. Impaired Dexterity
5. Tingling, Numbness
6. Clumsiness
7. Stiffness
8. Involuntary movement
9. Impaired circulation
10. Difficulty with normal daily activities
*
These steps were inspired by Mr. Cory Smith‘s (Associate Professor of Violin at the University of Akron)
comment that practicing a musical instrument is like the field of medicine. In the field of medicine, people must 1.
Watch for a problem, 2. Go to the doctor for a diagnosis of the problem, 3. Identify treatment through the help of a
physician, and 4. Take the treatment. Likewise, for efficient practicing, musicians should 1. Listen for the problem,
2. Identify the cause, 3. Find the solution, and 4. Apply the solution (Personal communication in an Independent
Study meeting with Mr. Smith in September 2010).
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Severity of a Problem
For each PRHP, no two experienced problems, even if they have the same diagnosis and cause,
will be identical. Each problem will mature in varying degrees and reach different levels of severity. The
severity of a problem depends upon the musician‘s reaction to the problem. Noticing symptoms does not
equate to addressing the cause of the symptoms. If one is oblivious to or denies early signs, the problem
continues. One‘s actions may even expedite its growth. Or if a musician uses the symptoms to identify
the cause and treat the problem, he can stifle its growth, prevent further development, or completely
eradicate it.84
Pain: a Measuring Tool of Severity
While pain is only one of many musculoskeletal symptoms, it is the most experienced symptom, 85
one of the earliest symptoms to herald a problem, and one of the symptoms that increases as the problem
increases. Even though performers may wish that pain were not a symptom, it is actually very helpful.
As Ranelli et al. explains, mild pain signals a ―threat of injury to tissues‖ and is easily detected by the
body. 86 Therefore, many researchers use pain as the indicator of a problem‘s existence; studies, such as
the ones referenced at the beginning of this paper, report the prevalence of PRHP as a percentage of
musicians playing in pain. Researchers also use pain to determine the severity of a problem. The
following three researchers‘ methods will illustrate. Ranelli et al. distinguishes between mild and major
musculoskeletal problems by assessing mild or major pain; they say that playing-related musculoskeletal
symptoms are ―mild aches and pains experienced during and following playing, which may or may not
affect performance,‖ while playing-related musculoskeletal disorders are ―pain, weakness, lack of control,
numbness, tingling, or other symptoms that interfered with the ability to play the instrument.‖87
Fry conceived the following grading scale to assess severity of overuse injuries.
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Grading of Severity of Injury88
Grade 1: Pain in one site on playing. This must be consistent rather than occasionally, and pain ceases
when the musician stops playing.
Grade 2: Pain in multiple sites on playing. Physical signs of tissue tenderness minimal. May have
transient weakness or loss of control. No interference with other uses of the hand.
Grade 3: Pain in multiple sites. Pain persists away from the instrument, some involvement in other uses
of the hand that now cause pain. May have weakness, loss of control, loss of muscular response or
dexterity.
Grade 4: As for Grade 3. All common uses of the hand cause pain—housework, driving, writing, turning
faucets or door knobs, hair grooming, dressing, washing or drying, but these uses are possible as long as
the pain is tolerated.
Grade5: As for Grade 4 with loss of capacity to use the hand because of disabling pain.
Inspired by Fry‘s grading scale for overuse injuries, Richard Hoppmann, MD, (Chief of Medical
Service at Dorn Veterans Hospital, a professor of Medicine and Vice Chairman in the Department of
Medicine at the University of South Carolina‘s School of Medicine)89 presents the following
measurements of pain, to access severity of any musculoskeletal injury, in his article ―Musculoskeletal
Problems in the Instrumentalist Musician.‖
Grade Description90
1
Pain while playing or for a short period after playing
2
Pain that persists for a longer period (hours) after playing
3
Pain that progresses while playing and requires the practice session to be shortened but resolves
between sessions
4
Pain that progresses while playing and does not totally resolve between sessions
5
Continuous pain that markedly reduces or prevents playing
These measurements of severity are simply tools to decipher how advanced a musculoskeletal
PRHP is. Having a balanced perspective on pain and its implications is important. This discussion of
pain, its prevalence, and the importance for musicians to be wary of any minute manifestation of pain is
critical; yet, musicians need to remember what Brandfonbrener highlights: ―Pain is a symptom, not a
Mallinak 15
diagnosis. It . . . is a marker for many diverse kinds of diagnoses,‖91 and Horvath says, ―not all pain
means injury. Prolonged, persisting or chronic pain means that something is wrong.‖92
What are these problems?
While all musicians can experience performance-related health problems, the encountered
problems may be quite different between instrumental and non-instrumental musicians. The scope of this
paper will address only instrumental musicians‘ problems, which may occasionally overlap with those
problems found among vocalists. The phrase ―playing-related health problems‖ † (PRHP) encompasses
two types of problems—occupational and non-occupational. In his book Fit as a Fiddle: the Musician’s
Guide to Playing Healthy, Dr. William Dawson (a bassoon player, music teacher, an associate professor
at Feinberg School of Medicine, president of the Performing Arts Medicine Association, and previous
hand surgeon),93 presents these two terms94 for categorizing PRHP. Musicians‘ occupational problems
are initiated by playing habits—therefore, playing the instrument (the occupation) is the primary cause.
Non-occupational problems are initiated by circumstances independent of the instrument but are
aggravated by playing the instrument—therefore, the occupation is a secondary cause. For this discussion
on musicians‘ PRHP, ―problems‖ will be understood to mean physical health problems. (Performing arts
medicine does encompass psychological besides physiological aspects of playing an instrument.)95
†
Different authors use different phrases to describe musicians‘ sufferings. Presently, there is no established phrase.
The phrase ―playing-related health problems‖ was inspired by Ranelli et al. Ranelli‘s article ―Prevalence in
Children‖ only discusses musicians‘ musculoskeletal problems and thus uses this phrase ―playing-related
musculoskeletal problems‖ (p. 178). Other authors use other phrases. In Fit as a Fiddle, Dawson discusses
musicians‘ ―problems‖ specifically related to physical pain in the musculoskeletal system (p.1-4). In the chapter
―Epidemiology and Risk Factors‖ from the anthology Medical Problems of the Instrumentalist Musician,
Brandfonbrener uses the phrases, ―musicians‘ injuries,‖ ―musicians‘ health problems‖ (p. 171), ―performancerelated medical problems‖ (p. 173) and other similar combinations. This paper uses the phrase, ―playing-related
health problems,‖ since it captures the focus of this paper. Musicians have physical health difficulties more than
during actual performance; therefore, ―playing-related‖ instead of ―performance-related.‖ Plus, this paper is about
instrumental musicians who ―play‖ their instruments. Musicians encounter more than injuries; they may suffer due
to disease. Hence, the phrase includes ―problems.‖ The phrases ―playing-related health problems‖ and ―playingrelated medical problems‖ are interchangeable. This author simply prefers the phrase using ―health‖ instead of
―medicine‖ because ―health‖ is more easily used in conversation. For example, in a sentence, one can say, ―The
musician‘s playing-related health . . .‖ but cannot say, ―The musician‘s playing-related medicine . . .‖
Mallinak 16
Creating Music Involves the Physical
Even though music often transports its listeners to realms beyond the physical, the creation of
music depends upon the physical. While the most expensive Stradivarius violins and Steinway pianos are
fine instruments, they cannot produce any sound until they become a tool in the hands of a living human
being. In his book The Biology of Musical Performance and Performance-Related Injury, Alan Watson,
author and professor in music biology,96 says, ―More than any other part of the body, it is the movements
of the arm and the hand that are used to create music. Just as much as [one‘s] instrument, these are the
tools of [the musician‘s] trade.‖97 Playing an instrument demands the musician to execute many intricate,
repetitive, and fast physical tasks. Horvath sheds light on the physical repetitious demands of
instrumental playing by citing Barbara Paull, an ―orthopedic physiotherapist,‖98 and Christine Harrison‘s,
a Canadian violinist,99 book The Athletic Musician:
Ravel‘s Bolero brings the house down every time it‘s played. The snare drum player always receives
an ovation, well deserved. In the fourteen-minute work, the snare drum player repeats a 24-note
pattern nonstop from beginning to end. The piece is 430 measures. That‘s 5,144 arm strokes. What
a feat! Add to that the control necessary to start almost inaudibly at pianissimo and ever-so-gradually
increase in volume over fourteen minutes to the piece‘s rousing fortissimo conclusion. It requires
intense concentration and physical control to play unwaveringly steady in rhythm from start to finish.
Adams‘s Harmonielehre contains an awesome amount of repetition. The first 94 bars of Part III have
approximately 976 repeated eighth notes for the flute and piccolo and for the piano, harp and clarinet
as well. (They at least have a few measures of rest.) This during a mere fraction of the work!100
Since making music relies on physical mobility, dexterity, flexibility, strength, and endurance, it is no
wonder that musicians could and do experience physical difficulties.
Why Have a Non-occupational Category?
Before discussing the general causes of problems, the non-occupational category must be
explained. After all, since playing the instrument is the occupation, one would logically conclude that all
PRHP would be occupational. Additionally, if PRHP were permitted to encompass some non-
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occupational problems, one might wonder what is to prevent all ailments from being labeled playingrelated.
While instigated away from the instrument, some non-occupational problems become playingrelated ones when they (a) prevent the musician from playing, (b) make playing difficult, or (c) become
worse when the instrument is played. In instance (a), a broken collar bone may prevent a flutist from
playing for a season. (b) A swollen finger may present challenges in executing proper flute technique.
(c) A musician‘s approach to his instrument after a non-occupational injury may inflame the problem. For
example, when muscles are not used, they weaken (atrophy)101 or become stiff.102 After a season of rest
to allow a broken bone to heal, muscles need time to adjust to their original time and intensity of playing
(original meaning accustomed amount before the period of rest).103 Returning to one‘s instrument with
inadequate rest after a traumatic injury, lack of transition, or lack of therapy may exacerbate a problem
that originated away from the instrument.104
In short, the reasons for a non-occupational category are that all contributing causes must be
addressed in order to obliterate a problem,105 and that some non-occupational problems can be a
contributing cause.106 Christopher Wynn Parry (who works in London‘s Devonshire Hospital in the Hand
Clinic)107 discusses in his article, ―Clinical Approaches,‖ why a thorough analysis is important to help
suffering musicians.108 This article is included in the anthology, Medical Problems of the Instrumentalist
Musician, co-edited by the Past President at Paris‘s Institut de la Main, Raoul Tubiana, and an American
―Consultant in Hand Sugery [and] Professor of Orthopedic Surgery,‖ Peter Amadio.109 Parry pens,
―Clearly musicians are heir to all the orthopaedic and rheumatic disorders that affect the normal
population, but it is essential to establish to what extent these conditions have been brought on or are
aggravated by playing or whether they are entirely incidental. In either event it is necessary to take a full
performing history.‖110
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Multiple and Interconnecting Causes: Complexity
Determining causality is necessary to treat a problem effectively. Unfortunately, pinpointing the
cause is no easy task. What makes causal identification difficult is that problems may arise from not
simply one cause, but interplaying causes. Identifying the root cause or all contributing causes of a
problem can be very challenging if not impossible since every musician‘s daily routine is unique. Each
musician has many contributing factors to his everyday life. As Brandfonbrener explains in ―The
Etiologies of Medical Problems in the Performing Artist,‖ ―The etiologies of most of the medical
problems of musicians are multiple risk factors operating synergistically, rather than a single factor
responsible alone for a given injury. The importance of recognizing this lies in the fact that all of the
etiological factors must be considered, diagnostically and therapeutically, in order for there to be accurate
assessment and appropriate treatment of an injury.‖111 These risk factors include the instrument itself,
technique, age, gender, repertoire, teachers, 112 environment, posture,113 body size, 114 muscle flexibility,115
practice time and intensity,116 colleagues, conductors,117 and activities away from the instrument—
whether they be cleaning the house, typing at the computer, riding in a car, or playing a game of baseball.
118
Even though identifying the causes of PRHP is difficult because every musician‘s life is unique,
identifying all contributing causes is critical. Attempts to relieve suffering without addressing its cause
(or causes) would be like a gardener picking off the leaves of a weed. The leafless weed may be
unnoticeable for a time but will only grow back since its roots are still alive.
Causes of Occupational and Non-Occupational
The causes of occupational and non-occupational problems are bodily deterioration through
injury and disease. The distinction between injuries and diseases is the place of origin. Injuries originate
from outside the human body while diseases attack the body internally at the cellular level. MerriamWebster's Medical Dictionary defines injury as ―hurt, damage, or loss sustained‖119 and disease as ―an
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impairment of the normal state of the living animal or plant body or one of its parts that interrupts or
modifies the performance of the vital functions, is typically manifested by distinguishing signs and
symptoms, and is a response to environmental factors (as malnutrition, industrial hazards, or climate), to
specific infective agents (as worms, bacteria, or viruses), to inherent defects of the organism (as genetic
anomalies), or to combinations of these factors.‖120 Injuries and diseases may deteriorate any human
body system. While The Merck Manual of Medical Information designates more than two systems of the
human body (for example, several systems are the respiratory, nervous, and cardiovascular),121 musicians‘
injuries and diseases will be distinguished as musculoskeletal or non-musculoskeletal. Musculoskeletal
means of the muscle and skeletal system. The Merck Manual of Medical information explains, ―The
skeleton, muscles, tendons, ligaments, and other components of joints form the musculoskeletal
system.‖122 The musculoskeletal system earns its own PRHP subcategory, while all other systems are
lumped into one, because, as Dawson mentions, the majority of PRHP are within the musculoskeletal
system.123
Playing Related Health Problems: Bodily Deterioration by Cause
OCCUPATIONAL
1. Overuse Injuries
NON-OCCUPATIONAL
1. Overuse Injuries
A. Musculoskeletal
A. Musculoskeletal
B. Non-musculoskeletal
B. Non-musculoskeletal
2. Misuse Injuries: Musculoskeletal
2. Misuse Injuries: Musculoskeletal
3. Traumatic Injuries: Musculoskeletal
4. Disease: Musculoskeletal
A. Genetic
B. Foreign Invader
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I. Overuse
As noted above, overuse may be initiated at or away from the instrument. This dual role explains
why overuse is one of the most commonly experienced124 and researched125 causes of PRHP. An overuse
injury is exactly what the word means; Dawson explains, ―Overuse implies that the involved area of the
body is being used correctly but to an abnormal degree.‖126 Any part of the body that is overused can be
damaged, but for the musician, the musculoskeletal system and the ears are the most prone. Overuse
injuries may develop from a person exhausting his physical capability during one event or, as Watson
discusses, in an accumulation of constant use over days or years.127 To avoid repetition, both
occupational and non-occupational overuses are discussed together.
A. Overuse in the Musculoskeletal System
In the musculoskeletal system, Horvath explains, ―overuse is the term applied when any tissue,
bone, joints or soft tissue such as muscle, ligaments or tendons are stressed beyond their anatomical or
physiological limit.‖128 Musculoskeletal overuse has many synonymous phrases. Dawson mentions
―cumulative trauma disorder, overuse syndrome, repetitive strain injury,‖ and other phrases, as all
referring to the same condition. 129 Watson even cleverly suggests another pseudonym, ―delayed
treatment syndrome,‖130 since overuse problems often mature when a person ignores his body‘s early and
mild symptoms. Signs of overuse may be minor, severe, or any condition between depending on the kind
and amount of treatment the musician employs as soon as he notices the symptoms. Overuse symptoms
(may) include the following: pain, swelling, heat, stiffness, tightness, lack of flexibility, loss of
coordination, a locking or catching finger, muscle fatigue, muscle spasms,131 weakness, involuntary
movement, and impaired circulation.132 If overuse damages nerves, which is rare, numbness or tingling
may develop.133 Overuse is most common in the arms and hands. As Watson says, ―More than any other
part of the body, it is the movements of the arm and the hand that are used to create music.‖134
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Conditions that trigger overuse injuries are physical exhaustion from excessive use. Excessive
use may result from excessive repetition and/or force due to an increase in time and intensity of work, or
due to genetic make-up.135 Excessive use may also result from sustaining a given posture for too long. If
a musician works past his body‘s physical limit, he is overusing it—even if he has proper form. Dawson
expounds, ―Muscles that must contract frequently or forcibly for a prolonged period have a chance neither
to rest and replenish the chemicals needed for further contraction nor to get rid of the lactic acid and other
waste products of their metabolism.‖136 Just as a boy will not experience pain walking to his friend‘s
house several blocks away, neither will a musician experience trouble practicing for an hour when he
knows his instrument‘s technique. Yet, just as the boy may experience flattened feet and a sore back after
touring Washington D.C. for eight hours—even though he knows how to walk properly, so too, the
technically sound musician may experience overuse pain if he uses the same muscles and tendons for
hours without adequate breaks for his body to recuperate.
1. Sudden Increase in Time and Intensity
A sudden occupational increase of physical activity—playing the instrument—is probably the
biggest culprit of musicians‘ overuse injuries. 137 To clarify, increasing playing time and intensity is not
what causes a problem, but how the increase is approached. If one does not prepare the body physically
for the increase, then an injury is likely to develop. A sudden increase in time set aside for practice does
not automatically provide a sudden increase in one‘s physical endurance. Abrupt changes in playing time
or intensity are big temptations for musicians. When musicians change schools, teachers, start a new
instrument, start new and difficult repertoire, obtain a new job, prepare for auditions, recitals,
competitions, or return from vacation,138 they face situations that ask for more than what is an already
familiar or mastered zone of playing. While, increasing endurance is intrinsic to increasing musical and
technical capability, endurance is gained little by little—conditioning the body by going ever so slightly
past the already mastered level until the next level is obtained and then, continuing this cycle of growth.
Going from beginner to virtuoso is possible, but not in one bound. Dawson says, ―It takes a certain
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amount of time and personal practice to properly and comfortably achieve new motions, forces, and
patterns of musical technique; without a gradual training and conditioning process, physical difficulties
are likely to ensue.‖139
Non-occupational increases in time and intensity of physical activities can lead to overuse as
well. Non-occupational overuse injuries are PRHP when the damaged musculoskeletal area is one
necessary for instrumental activities. 140 If a musician begins a painting project, cleaning business, or job
that requires hours of computer typing, the hands may be overworked and injured during any one of these
tasks. Or the hands may experience cumulative overuse; neither a single playing nor non-playing activity
exhausts the hands, but rather the combination of two or more activities exceeds the body‘s limit. All day
long the hands are used in repetitive motions whether in changing the direction of the paint brush,
scrubbing a kitchen sink, typing at the keypad, or pressing ivory piano keys.
2. Genetics
The second condition that triggers musculoskeletal overuse injuries from excessive repetition is
actually tied to genetics. For example, being double-jointed in the hand can cause PRHP. Hypermobile
joints are not strong enough to keep a proper frame; when a finger joint with lax ligaments depresses a
piano key, the joint will collapse. Dawson explains the ramifications, ―To compensate for this
[collapsing], the performer must use the finger flexor muscles more vigorously and in different patterns.
If this compensation is not performed in a careful and organized way, the abnormal patterns of use may
lead to muscle strains.‖141 Muscles that would not have been worked much or at all have to compensate
for the week muscles and thus are overworked.
Body size is another genetic factor that may lead to an overuse injury. Hands that are too small
to play a given instrument comfortably may pose a problem. Certain passages may be more difficult to
execute for the small hand than for the ideally sized hand. Since the passage is more difficult for the
smaller hand, the person with small hands would need to practice this passage more than the person with
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ideally sized hands.142 Also, hands that are not strong will have to practice more in order to build the
necessary strength for playing. If this time spent to increase muscle strength is not carefully accumulated,
overuse injuries may develop. Interestingly, researchers have noticed that more women than men
experience overuse injuries, and Dawson suggests that the higher rate of injuries in women than men
might be due to smaller hand size.143 Body proportions, besides the hands, such as the neck, wrist, arm,
or lung, can pose susceptibility to an occupational overuse injury.144 Clearly, the musician‘s genetic
make-up is not under his control, but how he reacts to his genetic conditions (tissue flexibility and body
size) can encourage or prohibit the development of overuse injuries.
3. Posture
Lastly, holding a proper posture for too long can create musculoskeletal fatigue. Posture is
important in the life of the musician since (a) posture is part of every person‘s experience and (b) posture
at the instrument influences execution of technique. Horvath explains the essentials of good posture
according to the Alexander Technique and Yoga; good posture is within the body‘s natural alignment,
meaning that the spine is lengthened (―maintaining a natural curve or lordosis‖ rather than collapsing or
becoming as straight as a wood board) and the head is in a ―neutral‖ position on top of the spine.145
Horvath says that in a proper sitting posture, the ―center of gravity should be forward and [the] body[‘s]
weight should be on [the] sitting bones and [the] feet.‖146 Working with a good posture, the body
―should be balanced and relaxed . . . not have to strain to maintain it,‖ and ―feel fluid.‖147
Yet, even if proper posture is maintained, pain will develop if the postural muscles sustain the
same position without adequate rest.148 Proper postures for proper amounts of time equate to proper use.
Horvath explains that muscle activity is either dynamic or static (postural).149 When muscles are engaged
dynamically, they are constantly varying their amount of tension and relaxation.150 On the other hand,
muscles that support a given position, sustain the frame through constant tension.151 Blood flow is
influenced by the amount of muscle tension. Compared to blood flow when the body is resting, dynamic
use enhances flow while static use restricts it.152 Blood supplies the muscles with oxygen and removes
Mallinak 24
metabolic waste. Horvath explains that when ―blood does not readily flow through the muscle,‖ such as
during static use, ―[o]xygen is not replenished and waste is not removed.‖153 Whether muscles are used
dynamically or statically, the muscles become fatigued if overworked, but the slower the blood flow, the
faster the onset of muscle fatigue occurs, and the longer the muscles take to recover from fatigue.154
Horvath says that static loading can result in pain and ―damage to joints, tendons and ligaments . . . [and]
is therefore associated with higher risk for arthritis, muscle spasms and inflammation.‖155 Overusing
postural muscles by keeping them stationary for too long may lead to damage from fatigue. 156
B. Non-Musculoskeletal Overuse: Damage to the Ear
While overuse syndrome, and other such titles, refers to the musculoskeletal system, overuse in
non-musculoskeletal systems also result in damage. Overuse of one particular non-musculoskeletal
organ, the ear, can reap devastating consequences to the musician. Musicians rely on this organ to create
their art. It receives musical language, and instructs through identification of pitch, rhythm, phrasing,
articulation, balance, pulse, color, and dynamics.157
As Dawson articulates, ―[Overuse] is characterized by excessive physical use (force, duration, or
repetition).‖ 158 While this definition applies to musculoskeletal overuse, it still informs the definition of
overuse to the ear. As Horvath says, ―Like overuse syndromes, hearing loss problems tend to be
cumulative. Unlike overuse injuries, hearing loss is permanent.‖159 ‡ Hearing loss may be hereditary or
acquired and, no matter which of these two types, either may be experienced at any age. 160 Nonhereditary
hearing loss may result from disease, ototoxic drugs, trauma, and noise.161 Hearing may be ―adversely
affect[ed]‖ by ―high blood pressure, alcohol consumption, smoking, and aging,‖162 but much hearing loss
among musicians is actually from excessive sound. 163 Noise-induced hearing loss (NIHL) results when
the ear is exposed to too much sound in one instance, over a window of time that does not provide
adequate rest to the ear, or from repeated abuse that the ear becomes too weak to recuperate.164 When
‡
Unless otherwise cited within the text, Horvath is the one being quoted throughout the section on ear damage.
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sound waves enter the ear, they bend the ear‘s hair cells which transmit ―electrical impulses through the
auditory nerve to the brain.‖ After bending from a sound wave, the hair cells bounce back to place unless
the force of a single sound wave or of repeated sound waves causes the hair cells to ―lose their
resilience.‖165
Sound is measured in decibels (dB) with softest audible sounds = 0dB and conversation sounds =
60dB.166 An ear can only handle a certain amount of dB a day. The ―daily dose‖ for the ear is eight hours
of 85 dB.167 As the dB increases, noise exposure time must be reduced. A simple increase of 3 dB cuts
the ―maximum exposure time . . . in half.‖ 168 Therefore, while one could listen to 85 dB for eight hours
in a day, one should be around 88 dB for only four hours a day.169 Continuing the reduction time for
every increase by three dB, constant sound at 103 dB is dangerous to the ear after only seven and a half
minutes.170 Immediate hearing loss can occur at 141 dB, and the eardrum rupture at 150 dB.171 Besides
time and sound level, Horvath includes two other factors to hearing loss.
Hearing Loss and Injury = Exposure time + Noise level + Peak level + Proximity to the sound172
Decibel levels and numbers do not mean much unless one knows how many decibels certain
actions are. While the following chart is by no means exhaustive, it provides helpful insight. Horvath
credits the information of this chart to ―US News & World Report, April 1999, Robert Thayer Sataloff,
M.D., Otolaryngologist, [and] International Musician, May 1998, Dec. 2000; Michael Chasin, M.Sc.,
Aud © www.hearnet.com.‖173
Activity
Decibel Level
Watch Your Ears
Hearing Threshold
Whispering
Conversation
Normal piano practice
0
30
60
60-70
Discomfort Begins
Vacuum cleaner
Telephone ring
Chamber music in small
auditorium
75-80
75-80
75-80
Maximum Exposure Time
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Hearing loss may begin
Hair dryer, lawn mower,
motorcycle, busy street
Piano fortissimo
Violin fortissimo
Major sporting event
French horn
85
84-103
82-92
95
90-106
85 dB – 8 hours
88 dB – 4 hours
91 dB – 1 hour
Damage occurs with regular sustained exposure
CD player-volume at ½
Subway train
Oboe
Trombone, trumpet
Flute
French horn
Timpani, bass drum
Piccolo
94
95
90-94
85-114
85-111
90-106
106
95- 112
94 dB – 1 hour
100 dB – 15 minutes
Pain begins! Danger!
Symphonic music peak
Orchestra pits
Amplifier rock 4-6 feet
Ambulance, jackhammer
120-137
120
120
125
Immediate danger! Any exposure risky!
Jet plane takeoff
Rock music peak
Gunshot
135-140
150
140-165
Death of hearing tissue!! 180
Horvath cites Allison Wright Reid‘s study A Sound Ear (which was printed in 2001 and 2008 by
the Association of British Orchestras)174 to note that, decibel level aside, certain noises are actually riskier
than others. The human body does not function efficiently under stress.175 If a person does not enjoy a
certain noise, he will naturally tense his body, thus reducing his body‘s ―repair mechanisms.‖ 176
Therefore, this study ―indicates that pleasant harmonies and classical music are less harmful than
noise.‖177
II. Misuse
Injuries of misuse are similar to overuse because their musculoskeletal symptoms are the same,
but misuse is a distinct category of PRHP because the source of its symptoms are different. Rather than
developing from a correct action that was simply executed too many times, misuse injuries develop from
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an incorrect playing technique, incorrect posture, or an incorrect playing environment.178 Dawson
explains, ―Overuse implies that the involved area of the body is being used correctly but to an abnormal
degree . . . By contrast, misuse usually is caused by an incorrect activity, such as using poor or improper
physical techniques or mechanics to perform any task, or by ‗mismatch‘ between the individual and the
instrument (for instance, a small-framed person trying to play a full-sized viola).‖179
Interestingly, besides manifesting themselves through the same symptoms and developing into
the same injuries (such as tendinitis and carpal tunnel, covered in the next chapter), overuse and misuse
habits viciously interplay with each other.180 For example, a pianist may work on an octave passage using
proper, symptom-free technique. He works on the passage so long that the necessary muscles to execute
the proper technique become too tired to continue, yet he continues, therefore requiring other muscles to
compensate. This compensation leads to misuse from an incorrect technique. Or if the pianist starts
playing the octave passage with incorrect technique—misuse, this passage will not come easily.
Therefore, he may practice this passage excessively—overuse—as he tries to figure out the proper
technique.
A. Technique
Misuse injuries from poor playing techniques are occupational problems. While no musician has
an identical physical construction to another musician, and therefore each musician‘s approach to his
instrument is unique, technical approaches to instruments are still correct or incorrect. Correct technique
is executing various playing styles, timbres, and dynamics without physical injury. The last phrase is
important; one could know how to execute each technique but apply the techniques at the wrong times
and still end up injuring himself.181
Improper technique results in excessive muscle tension. Having no tension during playing is
impossible since executing any physical endeavor, even raising a finger, requires muscle tension. Watson
says, ―When developing good technique, the ultimate aim should be to eliminate any unnecessary
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muscular activity from playing.‖182 Unnecessary muscle tension results in two ways. First, when people
are learning a new physical coordination tasks, including playing an instrument or a single musical
passage, they often engage more muscles than needed.183 Therefore, certain muscles are unnecessarily
tensed. Second, these unnecessarily tensed muscles cause the necessary muscles to become more tense
than they should be; the muscles needed to execute the action must now ―overcome the opposing muscles
to [move in the correct direction].‖184 Besides tightening to counteract the extra tension in surrounding
muscles, Watson explains that muscles will tense in anticipation of being used; therefore, if a performer is
uncomfortable with a passage, extra muscles contract in preparation for playing in case the performer
makes a mistake.185 Proper technique necessitates the minimum amount of muscle tension and gives the
muscles time for recovery by relaxing them even while simultaneously working a different set of muscles.
Professionals can relax some muscles while working others. This perfected routine of tension and
relaxation is what makes difficult tasks appear natural to the professional. To quote Watson, ―Great
players make playing look easy because they have found ways to make playing easy on themselves.‖186
B. Posture
Misuse injuries from an incorrect posture may be occupational, non-occupational, or a
combination of the two. A person may initially employ a bad posture (misuse from the start) or may use
a good posture to the point of fatigue and then resort to a bad posture (overuse leading to misuse). Bad
postures break the natural alignment of the body and create more static loading upon the body than good
postures do.187 The natural alignment may be broken in various ways. Horvath lists the most common
ones that musicians should be wary of.
Risky Postures188
In Necks: tilting, rotating, or cocking heads forward or down.
In Torsos: bending, twisting, or leaning forward or backward.
In Wrists: deviating, lifting, or dropping wrists or hands.
In Shoulders: lifting, twisting, or rolling shoulders forwards.
In Thumbs: squeezing, gripping, pinching, or angling thumbs.
In Legs and Feet: sitting immobile or standing still for extended periods of time.
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C. Environment
The third area of misuse injuries regards musicians‘ environment. The American Heritage®
Stedman's Medical Dictionary defines ergonomics as ―The applied science of equipment design, as for the
workplace, intended to maximize productivity by reducing operator fatigue and discomfort.‖189
Misapplication of a musicians‘ working environment includes temperature (whether in a practice room,
studio, hall, or under a gazebo), lighting, the instrument itself, and any playing equipment.
1. Temperature
External temperature can affect any human‘s internal temperature. Temperature does affect the
flexibility of muscles and their ease of movement.190 Horvath again references Paull and Harrison‘s book,
The Athletic Musician, to highlight harmful conditions for the musician. In their book, the authors discuss
the similarities between industrial workers‘ soft tissue injuries and musicians‘ injuries. 191 Temperature is
one risk element to injury onset: ―Working in cold condition, where [industrial] workers actually feel cold
while they work, increases their susceptibility to injury.‖192 Even if musicians are comfortably dressed in
the house, in their car, or for conditions outside, the temperature at the playing location may be different
and may even change as the rehearsal or performance progresses. Also, the instrument itself may react to
different temperatures and levels of humidity193 which in turn will manifest unfamiliar character traits that
demand the performer to adapt.
2. Lighting
In ―Applied Ergonomics,‖ Richard N. Norris, MD, (a doctor at the Arts Medicine Program at
Pioneer Spine and Sports Medicine Physicians)194 mentions that poor lighting encourages the performer to
assume an improper, crouching posture simply to see his music. 195 Poor posture alone is unhealthy for
the body, but this crouching posture may even inhibit proper playing technique.
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3. Instrument
Instruments themselves can contribute to a misuse injury if the instrument increases static load on
the performer leading to fatigue and poor posture. Instruments create static load when the instrumentalist
must extend his limb(s) away from his body, support the instrument, and/or assume an asymmetric
posture to play the instrument. Maintaining any posture creates static load on the body.196 Hovath
mentions that raising the weight of one‘s own arm and sustaining that position increases static load on the
body.197 If supporting the weight of one‘s own arm creates extra muscle tension then supporting the
weight of any object increases static load as well.198 Carelessly lifting the weight of an instrument and its
protective case during transportation can cause injury, especially in the back.199 For those
instrumentalists who support their instrument in part or in full when playing, their muscles have to work
harder than normal to sustain this foreign weight.200 Musicians do accumulate muscle strength, thus
building endurance, to bear this extra weight, but Watson mentions that this accumulation of strength can
even cause a problem if instrumentalists‘ muscles are conditioned unevenly.201 For example, Watson
describes brass players who, in holding their instruments with arms extended in front of their bodies,
develop muscle imbalance which leads to a pinched shoulder tendon.202
Instruments do create a static load; therefore, considering appropriate instrument size for each
player is important, especially for children who are constantly growing. 203 Every individual has a unique
body size and proportions;204 therefore, an instrument that is ideal in weight and proportions for one
player can be totally unsuited to the next. Some individuals may be more susceptible to injury from
playing a particular instrument than others would be.205
Even when musicians are careful to maintain as neutral a posture as possible, some or their
instruments require them to assume an asymmetric posture. Watson lists several of these instrumentalists
as ―string players, guitarists, brass players, and flutists.‖206 Asymmetry causes excessive static muscle
loading and muscle imbalance.207
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4. Equipment
When considering the instrument itself, one must also consider the equipment that musicians use
while playing their instrument.208 Playing equipment, in Horvath‘s words, exists to ―improve playing
comfort and reduce fatigue.‖209 Since each person‘s body is uniquely built,210 his use of equipment
should be unique as well. When Horvath wrote the following, she was referring to a specific accessory
for saxophones, but it is the goal for all playing equipment: ―[Oleg Saxophone] Enhancers allow the
musician to personalize the instrument according to his or her unique physical traits and specific technical
requirements.‖211 Mis(or non)application of necessary playing equipment can increase or even cause
musculoskeletal pain, muscle imbalance, poor posture, and skin irritation.
For instrumentalists who sit while playing, the chair is a very important tool. In order to allow
the natural curve of the spine (good posture), Watson explains that the instrumentalists knees should be
slightly lower than his hips.212 Thus the seat of the chair should slope down toward the front or at least be
level to allow the performer to sit on the edge of his chair.213 Chair height will need to be adjusted
according to the player‘s leg length. Chairs should provide lumbar (lower back)214 support, be cushioned,
and stable.215
Straps and floor pegs are vital for instrumentalists who bear the instrument‘s weight. These tools
are designed to, in Dawson‘s words, ―minimize strain of supporting a heavy instrument.‖216 The use of
straps is expanding; Horvath mentions straps that go around the neck, shoulders, torso, and even under the
seat.217 Without straps to distribute the weight of the instrument, a clarinetist, for example, must bear
eight hundred grams with his right thumb.218 Floor pegs are useful to more instrumentalists than the
cellist. Endpins or props have been used for the English horn, contra-bassoon, tuba219 bassoon, and bass
clarinet.220
Stabilization for the hand such as hand braces for trumpeters and thumb guides for flutists can
also relieve excessive tension.221
Mallinak 32
To protect the skin, Horvath says that fluid finger sleeves can ―reduce finger chaffing from
holding instruments.‖ For string players, proper shoulder and chin rest sizes can relieve excessive
pressure on their neck.222 While these rests may help prevent pain, they can also cause sores or callouses
if either rest is not the correct size.223
Besides skin irritation, chin and shoulder rests are particularly important to violinists and violists
for proper posture. While these players must play in an asymmetric posture, the asymmetry should be
from asymmetric arm extension, not an asymmetric spine. These instrumentalists should play their
instruments while keeping the head, neck224 and shoulders as neutral as possible.225 Horvath says,
―Alignment of the spine is of the utmost importance. Just as [people] need to make sure that [they] get
the proper sized clothes and shoes, violinists and violists need to make sure the fit of the chin rest is
correct.‖226
Chin and Shoulder rests help to maintain proper head, neck, and shoulder alignment when
the width of the violin is smaller than the space between the player‘s chin and shoulder. Horvath
elaborates, ―Most full-sized violins range from an inch to an inch-and-a-half-deep. Most adult necks span
three to five inches between their collarbone and chin. This space must be filled in. The violin, the chin
rest, and the shoulder rest must be adjusted so that the left shoulder is not raised or the head and chin are
not lowered and bearing down to hold the instrument. Obviously, long-necked players need to build up
the area more.‖227
Clearly, no one-size-fits-all method in instruments and their playing equipment will work. Every
instrumentalist‘s use of playing equipment should look different from one another if their application is
truly suited to their personal body construction.
III. Trauma
While trauma may involve emotional aspects, in this discussion, trauma refers to The American
Heritage® Stedman's Medical Dictionary, ―A serious bodily injury or shock, as from violence or an
accident.‖228 PRHP traumatic injuries are wounds from a moving or stationary object. For example, if
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one is playing baseball and misses a catch, the ball may hit him, resulting in a jammed finger or fractured
bone. Even if one is not around speeding objects, he may still receive a physical shock injury if his body
speeds into a stationary object. Even though concrete does not fly, it still may break one‘s bone if he falls
onto it. Symptoms of traumatic injuries vary depending on the injury received, but many of them will
include the common musculoskeletal reactions to an injury such as pain, swelling (and heat), tenderness,
discoloration, loss of mobility and dexterity.229
To demonstrate the reality that many instrumentalists‘ injuries are actually from traumatic
experiences due to non-music related activities, Dr. William Dawson (a bassoon player, music teacher, an
associate professor at Feinberg School of Medicine, president of the Performing Arts Medicine
Association, and former hand surgeon)230 expounds, ―Rarely do musical performances or related activities
cause injury directly; much more frequently the trauma is due to sports or other nonmusical pursuits. My
clinical data on medical problems affecting nearly fourteen hundred instrumentalists over a fifteen-year
period [1984-1996]231 reveals that injury or trauma was the principal cause of difficulties affecting their
hands and upper extremities.‖232 Dawson explains that forty percent of the hand injuries in the fourteen
hundred musician patients were from playing sports, and ―two-thirds of these involved a ball of some
type.‖233 After sports, falling on or receiving impact to the hand were the next largest culprits for
Dawson‘s data on hand injuries, followed by car, house, and work accidents.234
IV. Disease: Degeneration
Musicians have often been compared to athletes;235 both exercise to develop muscles and build
strength, accumulating endurance to execute specific physical actions during performance. Of course, the
difference between musicians and athletes is that they condition totally different muscles. Though
similar, Pierre Dana, DCD, DSO (from France)236 noted, in his essay ―Orofacial Problems,‖ an interesting
difference between athletes and musicians; athletes retire from public performing long before musicians
do.237 Athletes retire early due to their aging bodies no longer being able to sustain the extensive physical
Mallinak 34
demands of their profession. While musicians may not retire early like athletes do, their bodies age like
everyone else‘s.
Furthermore, just like any other human being, musicians‘ bodies deteriorate from diseases both
inherited or from a foreign invader. Whether the body is being worn away through the natural aging
process or a foreign disease is accelerating the degenerative process, the symptoms of body deterioration
are the same. Two examples of bodily breakdown from disease are arthritis and fibromyalgia. Arthritis is
manifested in the joints. Horvath says that tendinitis or bursitis may cause the pain and ―inflammation of
ligaments, tendons or bursae.‖238 According to Dawson, arthritic joints lose mobility because of joint
stiffness and deformity.239 Fibromyalgia is a rheumatic disease but does not affect the joints.240 Horvath
says it is ―the most common cause of general musculoskeletal pain;‖ the muscle, tendon and ligament
pain is often chronic and may ―[involve] aching, stiffness and fatigue.‖241
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Chapter 3: Diagnoses of Problems and Their Implications
In review, the steps for finding relief from a PRHP are watching for symptoms, uncovering the
cause(s) of the symptoms, identifying a treatment, and applying the treatment. The previous chapter
covered steps one and two. While this chapter cannot discuss every possible treatment since each PRHP
has unique contributing causes, it will cover the most commonly experienced or most severe PRHP and
their respective treatments.
Hearing Damage: Non-musculoskeletal
The biggest non-musculoskeletal problem for musicians is hearing loss—biggest in terms of most
damaging to performing ability and most likely to occur due to the performing environment. Like any
other human being, musicians may be born with or develop hearing loss of any variety, but, musicians are
exposed to loud sounds more than other people are since the very fruit of their labors is sound.
According to Robert Thayer Sataloff, (introduced earlier as an editor of the Performing Arts Medicine
anthology), and Joseph Sataloff, professor of otolaryngology at Thomas Jefferson University,242 in their
article ―Hearing Loss in Musicians,‖ ―The musical performance environment poses not only critical
hearing demands but also noise hazards.‖243 Occupational hearing loss is no small occurrence; Horvath
says, ―More people are afflicted with hearing loss than all other occupational injuries combined.‖244
Symptoms: Horvath provides another chart of hearing damage indicators. Her sources were
material on www.hearnet.com, interviews with Stephen Mitchell, M.D., and Marshall Chasin, M.Sc, Aud
©, Musicians‘ Clinics of Canada, and the second (revised) publication of A Sound Ear by Reid.245
Signs of Trouble
1. Normal sounds seem loud, even painful. Undue sensitivity to certain timbres or frequencies, even
if they are not loud.
2. Loud sounds become unbearable.
3. A single tone sounds as a different pitch in each ear or multiple pitches sound in one ear.
4. Any ringing in the ears. This can be a mild ringing or humming, which can last a few seconds or
can be loud and persistent to the point of interfering with hearing. This condition is known as
tinnitus.
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5.
6.
7.
8.
Inability to hear words clearly.
A tendency to speak loudly.
A frequent impulse to turn up volume on TVs, sound systems, telephones and the like.
Any confusion in discerning consonants during conversation—p‘s, t‘s, th‘s, b‘s, d‘s—and in
music, an inability to discern subtle shadings, colors or overtones in the music.
9. Ear, neck, or jaw pain, or frequent ear ―popping.‖
10. Difficulty distinguishing sound or conversation when there is ambient or background noise, or
difficulty hearing which direction a sound is coming from.
Sataloff and Sataloff summarize general symptoms of damage to the ear as hearing loss,
―distortion of sound quality, . . . loudness . . . and pitch,‖ and hearing noises within the ears.246 Hearing
loss is permanent247 except for one instance—―temporary threshold shifts‖248 (TTS). Under TTS,
symptoms of ear pressure, ringing, and hearing loss surface but then dissipate after resting the ears for
eighteen hours.249 If the TTS signals are unheeded and risky sound exposure is not eliminated,
cumulative occurrences of TTS will end in permanent damage as well.250
Hearing loss is typically in both ears. For the musician though, it often occurs in only one ear or
is more severe in one ear than the other due to a musician‘s position on stage or his own instrument. This
is the proximity factor Horvath included in her hearing loss equation (mentioned in chapter 2). For
example, violins and piccolos direct the sound on one side of the instrumentalist‘s head.251
Granted, a musician who experiences hearing loss may still produce music as long as he has a
highly developed inner ear such as Beethoven did, but the artist‘s task is far more difficult with one of his
greatest artistic tools eliminated. Further, every aspect of a musician‘s life would be penetrated by this
injury. Referencing ―Kris Chesky, Ph. D., in his article ‗Preventing Music Induced Hearing Loss‘ in the
January 2008 Music Educator Journal,‘‖ Horvath says that hearing loss ―causes communication
difficulties, problems with academic and cognitive performance, and social isolation.‖252
Cause: NIHL is caused by overuse.253 As Sataloff and Sataloff state, ―Amount of hearing loss is
related to the intensity of the noise, duration and intermittency of exposure, total exposure time over
months and years, and other factors.‖254 Sounds from the instrument itself, from neighboring instruments,
Mallinak 37
from the amplification system, or the poor acoustics of the room, may all contribute to hearing
impairment. 255 Brandfonbrener explains, ―The risk of hearing loss in musicians is directly related to the
repertoire they play, the loudness of the music that they play, and the distance they sit from other
musicians.‖256 Some instruments naturally produce greater dB than others,257 and some instruments direct
sound to one side of the head instead of evenly dissipating the sound thus posing greater risk, to the
player‘s own ear and his near neighbor‘s, than other instruments do.258 Yet regarding cumulative overuse,
such as damage from exceeding one‘s ―daily dose,‖259 every musician is at risk. Horvath says, ―[One]
would expect woodwind, brass, and percussion to be loud. But one‘s own instrument contributes the
greatest noise exposure.‖260 Musicians who perform with electric enhancement of sound are at an
increased risk for more severe damage.261 Electronic magnification can produce louder sounds than
instruments are naturally acoustically capable to do; Horvath‘s chart provided in chapter 2 shows that the
loudest symphonic music peak is 137 dB while the loudest rock music peak is 150 dB.262
Musicians need to be protective of their ears at all times, which means during practice,
performance, and everyday activity. Excessive noise can be a non-occupational occurrence too; ipod
earbuds,263 lawn mowers, drills, motorcycles and guns, can cause permanent hearing loss. 264
Treatment: Usually, treatments can only prevent further damage§ or mitigate the already
permanent damage. Ear plugs (prevent further damage), hearing aids, and counseling (to help the patient
readjust)265 are all helpful treatments, but none of them are able to restore what hearing was lost. In rare
instances of sensorineural hearing loss (which is damage to the inner ear rather than the auditory
nerve),266 Sataloff and Sataloff say, ―Some spontaneous remissions and improved hearing [have occurred]
with therapy.‖267 Even so, they continue, ―Most cases of sensorineural hearing loss produced by aging,
hereditary factors, and noise cannot be cured.‖268
§
Horvath tells the story of a man, Dr. Wen Chen, Ph.D. and previous professor of physiology, who experienced
severe tinnitus on page 130-131 of Playing (less) Hurt. He recovered his hearing almost completely after two years
of testing his hypothesis that he could ―re-charge‖ his hearing neurons by giving them adequate rest and proper
nutrition.
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For most PRHP, noticing early symptoms and immediately treating them can prevent permanent
damage—but not for the problem of hearing loss. Besides TTS, when symptoms of hearing loss surface,
permanent hearing loss has already occurred.269 The best possible ―treatment‖ is the proactive kind—
prevention. Therefore one must assess the risks to hearing loss and take appropriate action to protect the
ears from becoming damaged.270 If the excessive decibel levels are a result of electronic magnification,
the sound system could be adjusted so that it does not produce levels that are damaging to the ear. If the
loudness is from an acoustic instrument, then the performer and the performer‘s ensemble neighbors
should employ ear plugs. Brandfonbrener says, ―Presumably musicians who deny or are ignorant
concerning this increased risk [of hearing loss] and neglect to appropriately protect themselves are more
likely to suffer irreversible, incapacitating loss.‖271
To determine if one is at risk for hearing damage without waiting for sings of damage to surface,
he can estimate his daily dose of dB by, Horvath explains, ―download[ing] an Excel macro from the
British Health & Safety Executive website www. Hse.gov.uk/noise/calculator.‖272 Horvath explains
another way to determine if ears are being overly exposed (she found this test through www.hearnet.com).
On the way to any event that contains noise, one should set his car radio to the lowest volume that he can
still hear what is being verbalized on the news broadcast. Immediately after the event, he should turn the
radio back on to that predetermined radio volume. If he can no longer decipher what is being said on the
radio, then he knows that his ears were overused.273
Instruments that pose greatest risk: Classical musicians that play woodwind, brass, or
percussion are at a particular risk due to the instruments‘ peak dB levels.274 Any instrument that projects
sound to one side of the performer‘s head, such as the violin, viola, piccolo and flute, puts the ear on that
side of the head at a particular risk to damage.275 Musicians who sit directly in front or next to any of the
instruments already mentioned are in danger of ear overuse. 276 Any musician that plays with electronic
equipment, such as those in a rock and roll band, is at a greater risk than other musicians.277 Yet no
matter what instrument is played, all musicians need to be wary; total noise exposure from lower dB
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levels than the instruments or conditions mentioned can accumulate to exceed the ears daily sound
limit.278
Tendinitis: Musculoskeletal
Many of musicians‘ problems result from their tendons and tendon sheaths becoming inflamed.
Tendons are the tissues that connect bone to muscle.279 They are covered by a sheath and coated with
synovial fluid so that the tendon easily slides back and forth within its sheath. If the tendon is
overworked, it will swell. Tendons are more easily aggravated when their sheaths become smaller due to
confined spaces within a bent joint. Specific diagnoses of tendon problems are tendinitis and
tenosynovitis. Dawson explains that tendinitis is an ―inflammatory condition of a tendon.‖280
Tenosynovitis is ―an inflammation of the gliding (synovial) coverings of a tendon.‖281 Two specific types
of tenosynovitis are De Quervain’s tenosynovitis and trigger finger. The first of these is inflammation
within the wrist by the thumb, and the second is a swollen tendon unit ―catching‖ instead of gliding
between its sheath‘s points at the wrist into the palm.282
Symptoms: Tendons convey symptoms at the site of injury. When a tendon is injured, it
thickens or becomes inflamed. This thickening restricts its movement within the tendon sheath. If a
tendon is near the skin, the swelling may be visible. If an injured tendon is being used or is resting but
touched, it may create a ―crackling or bubbling sensation‖ called crepitus. The third and biggest
symptom of tendinitis or injury to the tendon unit is pain. Different patients experience different levels of
pain depending on the severity of the injury. The tendon may hurt when touched, when being used to
execute an action, when being stretched, or even when in complete rest. A patient may feel pain in only
one of these instances or in any combination of them.283
Causes: Excessive repetition (overuse), excessive force (misuse), or an inflammatory disease (such
as rheumatoid arthritis) all trigger tendinitis or tenosynovitis. Besides swelling when overused or
misused, the rate of swelling may be accelerated if the tendons are forced to work under restricted
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conditions, such as a bent joint. Sheaths become narrower as joints form more and more acute angles.
This narrowing constricts the tendons‘ mobility. Due to the joints‘ role in maximizing or minimizing the
tendons‘ space, many tendon problems are found around the joints especially in the hand, wrist, forearm,
elbow,284 and shoulder.285 Dawson says that inflammation is most prominent in ―restricted areas of the
body, including both the back and front of the wrist where the tendons are held closely to the underlying
bones during movement.‖286 Overuse or misuse of tendons may be occupational, non-occupational or an
accumulation of the two.287 The total number of times a tendon is required to work and the amount of
muscle force it is required to work under are, again quoting Dawson, ―the primary [causes] of musicrelated inflammation.‖288
Treatment: Since instrumentalists‘ tendon pain is often a result of overuse, resting the irritated
tendon area allows the inflammation to decrease. One should also evaluate his habits at the instrument
and away from it. If misuse is a cause of pain, then improvement to the tendon requires one to form new
habits that will not irritate the tendon.289
Ironically, each person becomes so accustomed to his habits that even if they are unnatural, he
does not recognize them as unnatural or harmful because his brain has reregistered them as feeling natural
since they have become his normal habits. Therefore, having another eye assess a situation can be helpful
to identify unnatural, irritating movements.290 Indeed, even more helpful than asking any person to watch
one‘s habits is having unfamiliar, trained eyes assess the situation.291 People specifically trained in
musculoskeletal disorders can diagnosis the problem and prescribe treatment for recovery. When misuse
is a cause, therapists are a great asset to facilitate relearning healthy body movements. They can also help
by providing a splint to restrict movement prohibiting the injured area from being overly engaged.
Quoting Dawson, therapists may also prescribe exercises to ―strengthen and retain other muscle groups
that may minimize the excessive demands on inflamed tissues.‖292
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Sometimes people take medications to mitigate the swelling and pain. Dawson says, ―The choice
of medication, its dose, the method of administration, and the duration of use must be determined on an
individual basis by the treating physician, based on the nature and severity of the problem.‖293
Medications should be employed warily and only when prescribed by a doctor familiar with performing
arts medicine. Medications are a superficial treatment since they only address the tendons‘ symptoms.
For example, if a musician is experiencing tendinitis due to excessive movement of the wrist in a flexed
position and takes medication to decrease the swelling, the swelling may diminish; but if he continues to
play with an incorrect wrist technique, then the symptoms may become worse. Due to the medication, the
symptom is apparently no longer present. While suppressing symptoms seems helpful, it is not if the
suppression permits the musician to continue on his path of misuse. Therefore, medications are probably
most helpful in treating inflammatory diseases. For inflammatory diseases, symptoms arise apart from
any misuse or overuse; for instance, swelling may occur even though the patient did not do anything
wrong. If an inflammatory disease is the cause of the tendon problem then doctors specializing in the
particular inflammatory disease should be sought. Rheumatologists, for example, can help in cases of
rheumatoid arthritis.294
In severe cases, when lifestyle changes or therapy do not improve the tendon‘s swelling, then
surgery may be an option in order to prevent the tendon from rupturing. These surgeries either widen the
opening that the tendon glides through or remove some of the damaged and inflamed tendon fibers.295
Musicians must realize that the success of all these forms of treatment depends upon an accurate
diagnosis. As Dawson says, ―Simply put, effective treatment involves controlling not only the
inflammation but also its underlying cause.‖296 For example, if one wears a splint to decrease the
inflammation, but the tendon irritation was caused by misuse, then the problem will reoccur as soon as
activity is begun (unless, of course, the person identifies and forsakes the misuse). Or if one takes
medication to decrease the swelling and block the pain from registering but does not modify his excessive
Mallinak 42
forceful actions, the pain and swelling will remain and may be in danger of increasing since the warning
signs that usually keep people from continuing a harmful action are being suppressed.
Instruments that pose greatest risk: While all instrumentalists are at risk of developing tendon
pain, players most susceptible to developing tendinitis or tenosynovitis are those whose instruments allow
and repertoire demands repetitive intricate finger work. Instrumentalists are at a greater risk if the rapid
finger movement is forceful.297 Also, since neither piano nor strings require air-flow for their sound
production, pianists and string musicians can skip taking breaks from playing and thus over practice more
easily than wind instrumentalists can.
Nerve Compression: Musculoskeletal
Nerve compression is a nerve being pinched by other anatomical structures. Nerves are more
likely to get compressed (or entrapped) when they run close to other anatomical structures, particularly at
the joints. For musicians, Dawson explains** that nerve compression problems usually surface ―in the
neck and upper extremities.‖298 Carpal tunnel syndrome is the most common nerve compression. This
compression is of the median nerve (which travels down the arm into the base of the hand) at the wrist.299
Other areas that cause grief are compression of the ulnar nerve or neck nerves. The ulnar runs in the
forearm like the median nerve, but instead of running in the middle of the forearm, it is on the pinky side
of the arm. One type of nerve compression in the neck is called thoracic outlet syndrome.300
Symptoms: When nerves are pinched, they cannot relay messages properly. When nerves ―that
transmit information from the peripheral parts of the body to the brain (sensory nerves)‖ are pinched, then
tingling or complete numbness results. When nerves ―that supply impulses to muscles (motor nerves)‖
are pinched, then the limbs become weak or clumsy.301 Atrophy, ―muscle [becoming] smaller and
weaker,‖ may occur under continuous compression.302 Also, pain may accompany both of these
disorders.303 Interestingly, unlike symptoms of tendon problems, nerve symptoms may surface in areas
**
Unless otherwise cited within the text, Dawson is the one being quoted throughout the section on Nerve
Compression.
Mallinak 43
other than the area being compressed. ―Steady pressure on a nerve . . . can cause tingling and pain in the
area of the body supplied by that nerve—and this area often may be located far away from the actual site
of compression.‖304
Causes: Nerve compression may result from activity at or away from the instrument.305 Some
compression problems result from overuse and misuse—especially when a joint is in a flexed position. In
the case of non-occupational problems, working with a flexed wrist whether it is work done while typing
at the computer306 or while scrubbing walls may cause excessive nerve pressure. Also, swollen tendons
from overuse can exert pressure on neighboring nerves.307 On the occupational side, Dawson gives the
example of a violinist playing with the left elbow continuously bent.308 If the ulnar nerve comes out of its
―groove‖ at the elbow when the elbow is bent, then the fingers may become numb or clumsy. 309 Dawson
also discusses occupational misuse from playing with high wrists; ―Constant use of the wrist in a highly
flexed position can cause excessive pressure on the median nerve.‖310 These high wrist positions may be
seen in electric bass, bassoon, or piano players. ―[Carpal tunnel syndrome] can be caused by any activity
that produces repetitive forced flexion of the wrist toward the palm.‖311 Musicians should note the
recurring causal themes of a.) excessive repetition (overuse) and b.) excessive force (misuse) as
contributing factors to many problems. Simple joint flexion is a key character in the development of
carpal tunnel syndrome: ―For some people, musicians included, merely holding one‘s wrist flexed for a
few moments may precipitate these symptoms [of nerve compression].‖312
The non-occupational disease of rheumatoid arthritis may cause carpal tunnel syndrome when it
inflames the tendons surrounding the median nerve.313 Causes for nerve compression in the neck may be
herniated discs, bone spurs from arthritis, or poor posture (misuse).314 Nerve compression in the neck
from poor neck or shoulder posture is called thoracic outlet syndrome.315 Ulnar nerve compression is a
result of constant pressure on the palm (such as pressure from a bicycle handle)316 or to the elbow (which
creates weakness and numbness in the fingers called cubital tunnel syndrome317).
Mallinak 44
Treatment: Identifying and treating any problem is important and musicians should not ignore
nerve compression symptoms ―because procrastination in seeking treatment may lead to permanent nerve
and muscle damage.‖318 Ways to treat pinched nerves depends on the source of the pressure. If the
compression is from repetition, one should limit that area‘s use. If a bent joint irritates the nerve, then the
joint needs to stay in a neutral position more often. To help keep a joint in a neutral position or to prevent
overuse, splints may be employed. As in the case of thoracic outlet syndrome where poor posture causes
pressure on the nerves, then one could do specific exercises to strengthen the weak postural muscles.319
Since use of any area naturally creates pressure, rest from activity is often the best treatment.
Horvath instructs those injured to ―avoid any activity that might stress the injured area, including
computer use, knitting, playing your instrument, using weights of any kind, gardening, carpentry, painting
and wallpapering, or heavy lifting.‖320
Like with tendinitis treatments, doctors may prescribe medications to mitigate pain and swelling
(of tissues that are compressing the nerve). Or in rare instances, if treatments rend no improvement,
doctors may recommend surgery.321 Therapists can be a great asset to musicians. For example, ―a
patient‘s arm or wrist that has been held in a splint for a prolonged period may benefit from specific
exercises designed to restore lost motion, strength, and flexibility.‖322
Instruments posing the greatest risk: Any instrument that requires a constant flexed joint to
maintain the playing posture puts the instrumentalist in a danger of developing a nerve compression
disorder. Piano and strings players should be particularly wary of carpal tunnel syndrome since,
according to Watson‘s research, they have historically developed it more than other instrumentalists.323
Mallinak 45
Focal Dystonia: Musculoskeletal
While focal dystonia is, as Horvath†† puts it, a ―relatively rare‖ occupational disorder,324 for those
that incur it, it is life altering. Onset of focal dystonia redefines one performing career. This
―occupational cramp‖ is ―a neurological disorder in which the brain, for unknown reasons, sends
erroneous messages through the nerves and causes loss of coordination and motor control.‖325 For being
physically painless, focal dystonia wreaks much havoc. It causes muscles in a particular area to contract
involuntarily only under specific circumstances. For unknown reasons, the involuntary muscle cramping
happens when the muscles are placed on the instrument in order to play.326
Symptoms: For the oboist Alex Klein of the Chicago Symphony, ―One day his left hand just
didn‘t work properly. Pieces he had played as a child were suddenly and inexplicably difficult for
him.‖327 One day the muscles responded normally, and the next day the muscles would not respond to the
oboist‘s intentions. Horvath copied the following list by Steven Frucht, a doctor at the ―Clolumbia
Presbyterian Medical Center Movement Disorders Clinic,‖ on focal dystonia symptoms.328
1. The first signs are small lapses in the usually instinctive ability to perform on your instrument. They
may show up in technical passages, usually not problematic, that become resistant. With brass players,
they often start in one register.
2. Over the course of months, the performance problems become progressively worse.
3. Neither increasing practice nor taking time off helps.
4. There is usually no pain associated with dystonia.
5. Pianists usually are affected in the right hand, and the spasms cause the fingers to contract and curl
under when attempting to play. String players . . .left . . . guitarists in either hand. Woodwind palyers are
in great jeopardy, as they can develop dystonia in their embouchure or hands. Brass players are usually
afflicted in the corners of the mouth and jaw.
6. Playing your instrument triggers the muscle spasms. The spasms are not present when at rest.
7. Dystonia is task-specific to playing your instrument and does not usually spread to other activities.
††
All quotations for the focal dystonia section are from Horvath.
Mallinak 46
8. Massage therapy, acupuncture and other methods of muscle function theraphy do not usually provide
relief, since dystonia is a neurological disorder.
While dystonia usually causes muscles to contract undesirably only when in the context of
playing the instrument, at least one publicized sufferer experienced otherwise. For Glen Estrin, ―a highly
accomplished horn player,‖ his clenching jaw became so severe that eating and talking became
difficult.329
Causes: Currently, the cause of focal dystonia remains elusive.330 Several different culprits have
been suggested and considered. While none of the following have been proven positive, they are still
suspects having not been disproven as a cause: sudden playing-time increase (overuse), excessive
repetition (overuse), traumatic injury, changes in brain representation to certain muscles, intense playing
(misuse or overuse), a change in teacher or technique or instrument, or nerve entrapment (overuse or
misuse).331 ―Although their causes are unknown, occupational cramps occur when people are ar the limit
of their musculoskeletal abilities.‖332 Some interesting but unexplainable data regarding dystonia cases
are that most patients are professional musicians, the age of onset is around thirty-five years, and that men
get it three times more often the women do.333
Treatment: Getting an accurate diagnosis by seeing ―an expert neurologist‖ is helpful in order to
begin treatment. 334 While no treatment is known to eliminate this disorder and success in minimizing its
affects varies,335 diagnosis is still worthwhile. First, without it, one may waste time and energy
attempting ―treatments‖ that have already been found to be ineffective for focal dystonia, and second, in
knowing what one is fighting, he can join the ranks of focal dystonia fighters to glean and share
insights—not to mention increase morale. Estrin (the horn player with a clenched jaw) founded
―Musicians with Dystonia‖ to help and encourage fellow sufferers.336 Once again, musicians should
never ignore symptoms; early diagnosis is always worthwhile. While no musician or even non-musician
Mallinak 47
enjoys admitting that they have a problem, the earlier a problem is identified, the less time it (including
dystonia) will have to mature.
While focal dystonia may very well end some people‘s careers, diagnosis of this disorder does not
necessitate laying down the music profession. Some musicians treat dystonia using a medication, such as
botulinium toxin injections or artane.337 Musicians have returned to their instruments using this
medicated approach, such as the pianist Leon Fleisher using botulinium,338 but Horvath says, ―by far the
most successful approaches to this disorder seem to be retraining and instrument modification.‖339 At this
point, simply preventing focal dystonia from developing into its more severe stages is considered
successful treatment since no cure is known.340 Another successful treatment is to work around the
disease‘s domain, creating and forming new habits that are not controlled by the disease. For example,
some horn players with focal dystonia are still able to play since they retrained their lips to work with a
modified mouthpiece. Admittedly, they are unable to perform as they could before the dystonia, but
unlike other dystonia cases, they still play their instrument.341
For the pianist Michael Houstoun, focal dystonia did end his performing career—at least for a
time. With the help of practitioners and teachers, after five years of research, study, experimenting, and
patience, Houstoun performed at the piano once again. He was able to play again having forged ―new
neurological pathways and mastering new patterns.‖342 Another story of perseverance is Joanna Falk‘s.
Even though she has focal dystonia in her left ring finger since 1991, she has been the principal flute in
the Norrkoping Symphony Orchestra of Sweden. Similar to Houstoun, Falk has conditioned new
neurological pathways and physiological execution of technique. Unlike Houstoun, this new technique is
for playing on a modified instrument.343 If active performance is not a possibility, musicians with
dystonia have found creative ways to maintain music careers.344 The oboist Klein records music, plays
chamber music, teaches and conducts.345
Mallinak 48
Instruments posing the greatest risk: Since the cause is unknown, no particular instrument
poses any greater risk than the others.
Back, Neck, Shoulder Pain: Musculoskeletal
Problems in the back, neck, and shoulders, while seeming too broad a category to assist in
understanding PRHP, are actually very important for musicians to study. Multiple studies found that pain
in these areas are some of the most common locations of suffering among instrumentalists. For example,
according to Fishbein and Middlestadt‘s ICSOM survey of 2,212 orchestral musicians (referenced in
chapter 1), the majority of severe (―severity defined in terms of the effect of the problem on the
musician‘s performance‖) 346 musculoskeletal pain was in the back, neck, and shoulder respectively.347
Problem Location
Back
Neck
Shoulder
Lower
Upper
Middle
Right
Left
Right
Left
Percent reporting out of 2,212 instrumentalists
as a problem
as a severe problem
44%
24%
32%
17%
22%
10%
21%
13%
22%
12%
20%
13%
20%
11%
Edling and Fjellman-Wiklund‘s survey of forty-seven music teachers from Sweden (also
referenced in chapter 1) agree with the ICSOM findings: ―Work-related musculoskeletal disorders among
musicians seem to be most frequent in the neck, shoulders, upper extremities, and lower back.‖348
Though not the last study to agree, one more example demonstrating the prevalence of the back, neck and
shoulder problems is Ian James‘ international survey of 1639 orchestral musicians.349 From the anthology
Medical Problems of the Instrumentalist Musician, James reports in his chapter, ―Survey of Orchestras,‖
―The distribution of the pain was mainly in the neck and back.‖ The second greatest was the right
shoulder mentioned by thirty-eight percent of the subjects and then the left shoulder at thirty-six
percent.350
Mallinak 49
I.
Static Loading in the Back and Neck
Stiff, tense muscles maintain a muscular static load. Muscles bearing this load quickly become
fatigued. If not relieved in a timely manner and the necessary blood supplied, tendons, ligaments, spinal
discs, and nerves can be damaged. 351
Symptoms: Fatigue is the first signal that the muscles need to be relaxed. If the stiff position is
maintained, pain quickly begins.352 Symptoms of fatigue and pain occur wherever the muscle is being
overloaded. If the muscle is by a disc, the disc may become painful.353 The tense muscles may compress
neighboring nerves resulting in tingling and numbness.354 As mentioned in the nerve compression
section, compression symptoms can occur in places other than the location of the pinched nerve. For
example, numb fingers my result from static loading in the neck and shoulders.355 Other symptoms can
be headaches and eyestrain.356
Causes: Overuse and misuse can result in back, neck or disc injury. If the same position is held
for too long, fatigue ensues and injury may result from the limited blood flow.357 Besides longevity,
frequency of use without sufficient recuperation can cause problems. For example, the outer layer of a
spinal disc is in danger of cracking not only from sustained incorrect static use, but also from repetitive
dynamic use, such as bending multiple times.358 Instruments that are supported or held when played
expedite the rate of fatigue since they add to the static loading of the muscles.359
Many problems surface form postural misuse. Poor postures may occur during daily activity,
while playing the instrument, or even in only holding the instrument. Horvath‘s list of risky postures
(provided in last chapter) all break the body‘s natural alignment thus increasing static loading and
accelerating muscle fatigue.360 Horvath elaborates on the static load that these ―risky postures‖ create.361
One example she discusses is the neck. Tilting the head seems like an innocent act but can actually cause
some significant muscular stress. According to Horvath, the head weighs fifteen pounds.362 Tilting the
Mallinak 50
head breaks the body‘s natural neutral alignment.363 The tilt requires the neck muscles to keep the fifteenpound head lifted, thus placing static load in the neck.364
Poor postures specific to activities with the instrument are leaning forward and/or crouching over
the instrument. While leaning is a great temptation to, Horvath mentions, ―cellists, flutists, guitarists,
bass players, bassoonists and many others,‖ it is an unnecessary and harmful position to maintain.365
Leaning ―requires sustained muscle tension and static loading in [the] back muscles;‖ leaning also thrusts
the shoulders forward, making any arm movements ―more difficult.‖366
Distributing static load asymmetrically can cause muscle imbalances which damage the joints and
nerves.367 Some instruments, such as the flute, necessitate their players to torque their body by tilting or
twisting the head. 368 Musicians may even begin to inhabit an asymmetric playing posture away from their
instrument if their muscles are continually worked unevenly.369
Besides poor static posture, injury can occur from poor active posture. Lifting heavy objects,
which may include transporting one‘s instrument, can quickly cause damage to the muscles or cracks in
some discs if the instrumentalist uses an incorrect lifting posture.370 Under extreme posture positions,
discs may not crack but cause nerve pain by compressing nearby spinal nerves.371
Treatments: Unfortunately, one cannot simply try to eliminate static loading in his body
because every posture except for lying down requires static load somewhere in the body. 372 Therefore,
one must seek to minimize the static load and bring timely relief to the muscles bearing the load.
Resting the muscles is crucial. Musicians should change their position as much as possible to
alter which muscles are being statically loaded. Horvath recommends ―alternat[ing] between sitting and
standing‖ and wiggling legs are arms periodically while sitting.373 Watson suggests taking a brief break
every thirty-five to forty-five minutes of practice.374
Mallinak 51
To relieve accumulated tension and enhance blood flow, Horvath also encourages stretching.375
For instrumentalists who sustain a tilt or torque, stretching in the opposite direction should become a
habit. Flutists who play with their head tilted to the right should lean their head to left when not playing.
As Horvath says, a musician should do ―motions opposite to the ones [they] do constantly at [their]
instruments.‖376
Playing equipment should be a dear friend to instrumentalists. Chin rests can diminish
asymmetry for violinists.377 Wheels on cases can relieve back strain for cellists.378 Eye-level music
stands can discourage instrumentalists‘ from tilting their head.379 The possibilities are endless, and each
musician should experiment with various sizes and heights to discover what tools and positions enable
him to play most fluidly.380
Horvath instructs the musician to ―be vigilant about posture at all times, even away from [the]
instrument.‖381 Musicians already regularly condition their playing muscles, but good posture
necessitates strong postural muscles. Brandfonbrener mentions that musicians may be prone to carry
themselves with poor posture if they do not take the time to condition the important postural bearing
muscles.
The maintenance of ‗good‘ posture is important for efficient and effective functioning in many
activities, including musical ones. The posture requisite for playing many instruments is
unnatural, and often uncomfortable and asymmetric. Adequate development of postural muscles
comes only with appropriate exercising. Because many musicians are sedentary there is a
tendency for muscle groups essential for good posture to be poorly conditioned, tending to place
undue stress on secondary muscle groups and leading to reduced endurance. 382
Exercising important postural muscles can help prevent injury. For example, engaging the
abdominal muscles protects the back while lifting things.383
Some muscles may become so imbalanced and poor postures so regular that the instrumentalist
may not realize he inhabits a risky posture,384 and some injuries may actually become worse from
inappropriate stretching attempts.385 Therefore, having trained eyes examine one‘s posture habits is very
Mallinak 52
helpful. Trained professionals such as occupational therapists or Alexander Technique teachers (teachers
of proper body alignment)386 can help identify unhealthy habits and instill healthy ones.387
Musicians should see a doctor if their problems are more than a slight and sporadic soreness.
Chronic pain, numbness and disc problems can all be serious injuries that need medical assistance.388
Instruments posing the greatest risk: Instruments that require the performer to assume an
asymmetric posture place an instrumentalist in danger of back and neck problems. Even the postures that
maintain a symmetric back, but require sustained arm extension, put extra stress on the muscles.389
Instruments that must be held by the performer pose a risk since the musician‘s muscles must maintain a
given amount of tension to bear this foreign weight. 390 Large, heavy instruments also create more muscle
strain during transportation. 391
II.
Shoulder
A shoulder problem that plagues musicians first and foremost is tendinitis. The other problems
are bursitis (like tendinitis, an inflammatory problem), impingement of the bursa, rotator cuff tear, and
frozen shoulder. Shoulder problems alone comprise about one third of instrumentalists‘ playing-related
doctor‘s visits.392
Symptoms: While a shoulder problem causes pain in the shoulder, it may also create pain in the
neck, arm, or hand.393 Weakness and restricted motion, even to the point of no longer being able to raise
it, are symptoms besides pain.394
Causes: Sometimes shoulder pain is caused by neck extension, a leaning torso, extended arms,
or raised shoulders.395 The raised-shoulder habit may occur when a person is under stress.396 As
discussed earlier, tendinitis is inflammation of the tendon. Similarly, bursitis is inflammation but of the
bursa which, Horvath explains, ―are fluid-filled sacs that cushion movement . . . and smooth motion.‖397
The shoulder blade may encroach upon by the bursa creating an impingement. Tendinitis, bursitis, and
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impingement, all are varying results from using an arm multiple times while it is elevated (overuse and/or
misuse). Bursitis may also be caused by demanding the muscles to work while cold.398
Rotator cuff symptoms of pain, weakness, and lack of mobility, indicate overuse, re-injury of an
old shoulder injury, or deterioration.399 The rotator cuff muscles and tendons ―help hold the humerus
bone in the shoulder socket and provide stability and strength.‖400 If greatly strained, tearing of the
tendons or muscles may actually occur.401
Frozen shoulder is exactly what its title implies. Immobilization of the shoulder results in loss of
arm mobility from swelling or ―band‖ adhesions to the joint. 402 This explanation appears to be circular;
immobilization leads to loss of mobility (or immobilization). The original immobilization might be
voluntary in situations such as a broken arm. Then loss of mobility due to immobilization becomes an
involuntary restriction. The shoulder becomes stuck in the resting position since the muscles became
weak, swollen, or tense during the period of rest. Another case of frozen shoulder may result even if one
does not chose to keep his arm stationary for a season. For example, the shoulder may become frozen in a
position due to an illness or a stroke that prevents its movement.403
Treatments: Sufferers of these shoulder problems should see a therapist for exercises to increase
shoulder mobility.404 For severe injuries, performing arts doctors may recommend surgery, but this route
is rarely necessary.405
Instruments posing the greatest risk: Many pianists have shoulder injuries. Those instruments
that necessitate regular mobility of a raised arm (such as violinists or percussionists who playing timpani,
mallets, bells or a drum set) are at the greatest risk for shoulder problems.406
Arthritis: Musculoskeletal
Even though arthritic problems among musicians are non-occupational problems, instrumentalists
who have arthritis definitely feel the ramifications of this joint disease when holding and playing their
Mallinak 54
instrument. While people may associate arthritis with deterioration in the aging process, arthritis from
degeneration (osteoarthritis) is only one kind. The arthritic disease is rheumatoid arthritis.407
Symptoms: Arthritic joints experience stiffness, an aching pain, and loss of mobility.408 Those
joints that are commonly afflicted by osteoarthritis are the fingers, hands, and spine. Arthritis may also be
accompanied by deformity of the joint as the joints obtain bone spurs or the joints‘ bones erode (allowing
the digits to angle in an unnatural manner).409 Symptoms in the spine can present challenges to the
instrumentalists causing discomfort in sitting and in glancing toward the conductor or fellow chamber
musicians. Symptoms may even occur within the spinal nerve if arthritic spurs develop on the spine. If
nerves in the spine are being compressed, then numbness and weakness will be experienced in the area
that that nerve supplies. 410
While osteoarthritis does not include inflammation, rheumatoid arthritis does.411 Rheumatiod
arthritis is, as Horvath puts, ―an autoimmune disease‖ that may develop rapidly.412 While osteoarthritis
afflicts the cartilage in the joints, rhematiod arthritis spreads to more than just the joints, destroying
connective tissue.413 It creates pain from all the swelling, redness and heat. Stiffness only occurs if joints
are immobile. If used, joints actually become more flexible than usual from the excess amounts of
synovial fluid.414
Causes: Arthritis may result from an old overuse injury.415 Osteoarthritis is ―known as ‗wear
and tear‘ arthritis,‖ says Dawson.416 The deterioration of the cartilage between the bones occurs from
joint use as people age. Onset may be sooner or later depending on the amount of wear on the joints.
Joints wear out faster if they are forced to function under excessive weight or if they have been injured
repeatedly.417 Actually, Horvath states that a previous joint injury from ―overuse can lead to arthritis.‖418
Muscles are less mobile if constricted. Since muscles are sometimes tensed unnecessarily due to stress,
stress may play a role in the development of osteoarthritis.419 Causes of rheumatoid arthritis remain
mysterious.420 For some reason, women experience it three more times than men. 421 It typically afflicts
Mallinak 55
thirty five to fifty-year-olds.422 A person‘s genetics influence his experience of arthritis whether it be
osteoarthritis or rheumatoid.423
Treatments: As with any other problem, accurate diagnosis is crucial for treatments to work.424
Therefore, seeking specialized doctors, especially those familiar with musicians‘ injuries is helpful
whenever a problem is encountered.
Various treatments for arthritis are taking medications to decrease the inflammation, getting a
splint to rest the inflamed joint, exercising (to strengthen the joint in order to slow down its degeneration),
and surgery. No treatment should be attempted without seeking the advice of a medical professional.425
Horvath says, ―Proper treatment can help to decrease the rate of damage to cartilage by carefully
monitoring activity to avoid further . . . wear and tear to the joints.‖426 Exercising to have a healthy
posture will put less static postural load on the joints and encourage mobility in the joints.427
Since rheumatoid arthritis progresses rapidly, one should seek professional help immediately.
The sooner the inflammation can be addressed, the better; minimizing the inflammation can ―prevent
damage to the joint.‖428 This disease is no gentle stranger, but rather a blatant invader. Treatments can be
helpful and playing one‘s instrument is still possible.429
Instruments posing the greatest risk: No instrumental playing causes arthritis, but since
playing an instrument may lead to overuse430 and overuse may contribute to arthritic joints,431 then
instruments that require repetitive actions (especially if the actions are forceful) may contribute to
arthritis.
Face and Mouth Problems: Musculoskeletal
Just as problems in the hand cause difficulty to the instrumentalist, so too facial problems can
limit or even prohibit musical production. Dawson says, ―The facial structures are as crucial to the
production of music as are the fingers, and any alterations that result from aging, illness, or injury may
Mallinak 56
have a serious effect on the wind player‘s embouchure and sound production.‖432 Musicians who breathe
into their instruments to produce sound do so by forming an embouchure. In ―Temporomandibular Joint
Disorders, Facial Pain, and Dental Problems of the Performing Artist,‖ James Howard, DDS (Chief in the
Temporomandibular Joint Clinic in the Children‘s Hospital and Medical Center and Clinical Associate
Professor in the Department of Orthodontics at the University of Washington)433 explains, ―The word
embouchure is French in origin and means ‗opening into;‘‖ therefore, it is the ―manner or method of
applying the lips and tongue to the mouthpiece of a wind instrument to produce a tone.‖434
I.
Face: Bell’s Palsy
Bell‘s Palsy is another name for idiopathic facial paralysis—idiopathic meaning that the disease‘s
cause is unknown. Only one half of the face is affected from this cranial nerve malfunction. 435
Symptoms: Bell‘s Palsy usually begins with pain behind one ear. This one-sided pain is
followed by paralysis. For just one side of the face, the patient‘s skin will sag and will not be able to
form facial expressions. One eyelid will not be able to blink, and the lips will not seal properly.
Occasionally, numbness develops.436
Cause: While the cause is unknown, in ―Neurological Problems of Performing Artists,‖
Lederman, MD, Ph.D. (introduced in chapter 1 as an editor of the anthology Performing Arts Medicine)
says, ―Recent evidence suggests a causative role for herpes simplex virus.‖437
Treatment: The most necessary step when experiencing this temporary paralysis is to place eye
drops in the eye that is not being coated and protected by the eyelid. If the eye becomes dry, it may
become scarred in the cornea. Some treat Bell‘s Palsy using corticosteroids, but this action is
―controversial.‖ The pain and loss of facial response usually fades away on its own. Still, one should
keep a doctor updated. A relationship with a medical professional will allow for prompt action if
paralysis lingers or increases, therefore indicating another disorder.438 While Bell‘s Palsy paralysis is
Mallinak 57
temporary, lasting for several weeks or months, some patients never fully return to their original muscular
facial capabilities.439
Instruments posing the greatest risk: Since the cause is unknown, no particular instrument
poses any greater risk than the others.
II.
Mouth: Teeth and TMJ
While the lips and tongue may be the only physiological facial elements that must come in
contact with the instrument‘s mouthpiece to create music, the action and position of the TMJ and teeth
also determine each instrumentalist‘s embouchure. 440
The Importance of the Teeth
While wind instrumentalists experience continual physical pressure (the instrument‘s
mouthpiece) and nonphysical pressure (the instrumentalist‘s own air) to their mouth, enough data has not
been collected to prove or disprove that these pressures contribute to dental deformity
(malocclusion441).442 Even so, both Howard and Dawson recommend that wind instrumentalists obtain a
mold of their teeth. Even if movement or loss of the teeth is not caused occupationally, shifting and
losing teeth are likely to occur from aging or accidents. From Howard, ―It behooves all professional wind
musicians to have dental models taken as a permanent record in case of accidental injury to the front teeth
so that a dentist could accurately restore the desired tooth contours.‖443 Actually, Dawson recommends a
mold not only for the teeth but also for the jaw for any instrumentalists, such as violinists, whose face is
in contact with their instrument;444 ―Plaster models of the upper and lower teeth and jaws, preferably
made early in the performer‘s adult life, can be used later as a guide for reconstructing or revising tooth
and jaw alignment and shape to prior playing contours but not to the so-called ―ideal‖ or ―normal‖
condition,‖ since every person‘s jaw is unique and might not be well served by a text-book
replacement.445
Mallinak 58
Since keeping one‘s original teeth is much easier than having to replace them (whether or not one
has a mold), Dawson stresses the advantage of maintaining one‘s teeth in order to deter dental
malocclusion. Besides the daily brushing and flossing, maintaining includes seeing the dentist who can
actually identify a disease before the patient will sense its damaging effects on his teeth or gums.
―Appropriate treatment of these problems in their early stages is generally more effective, less timeconsuming and expensive, and requires less musical adaptation by the player.‖446
Temporomandibular Joint Disorder
The TMJs are the joints, on either side of the face, that connect the jawbone (the mandible) to a
skull bone.447 Any temporomandibular joint disorders (TMD) greatly affect violin, viola, and wind
instrumentalists.448 Howard explains,‡‡ ―The signature of TMD is pain provoked by jaw function.‖449
Symptoms: Sufferers of TMD often have pain. This pain may be in the face, ears, neck, or
manifest itself as an overall headache.450 In a study, out of 396 people experiencing TMD, ninety-seven
percent sought professional help due to pain. The other three percent sought help due to other symptoms.
While these symptoms may not motivate one to employ treatment as quickly as pain does, they still cause
irritation and discomfort. The other TMD symptoms are a locking jaw, fatiguing jaw muscles,
diminishing range of motion (ROM) in the jaw, and recurring noises in the joint. These noises may be a
clicking or grating. Often the grating is from osteoarthritis.451 One can discern whether or not his jaw has
normal motion range by employing the ―3-finger test;‖ if a person is able to insert three of his fingers
stacked vertically into his mouth, then his jaw range is normal.452 Failure of this test may signal a
TMD.453
The popping and clicking noises of the jaw indicates misplacement of the joint disk. The joint
disc lies between the temporal skull bone and the jaw bone. When the mouth is closed, the disc lies a
little too far forward. Then when the mouth is opened, the disc pops back into place.454
‡‡
Unless otherwise cited within the text, Howard is the one being quoted throughout the section on TMDs.
Mallinak 59
TMD may develop very rapidly or may progress to a point and remain consistently in that stage.
For example, ―Some patients will remain indefinitely in an early, non-painful stage of clicking. Others
will have short duration in an early stage with rapid transition into a more dysfunctional and painful stage,
including catching and locking.‖455
Cause: According to The Merck Manual of Medical Information, TMD is generally caused by ―a
combination of muscle tension and anatomic problems within the joint.‖456 Interestingly, more women
encounter TMD than men in a 1.8 to 1 ratio. 457 Researchers believe that more women experience TMD
than men because of stress. Stress triggers TMDs. Now, in that women have TMD more than men does
not necessarily indicate that women are under more stress than men. Rather, the physiological
consequences of stress on women manifests themselves through head and neck pain while, in men,
consequences of stress affect their cardiovascular system.458 Another reason that stress is believed to
cause TMD is that 76.8% of 3428 TMD sufferers were between the ages of fifteen and forty-four years
old—which encompass many years of high pressure from school, becoming independent, maintaining a
job, and establishing and supporting a family.459
As already mentioned, TMD pain may result from musculoskeletal pain in the head and neck.
Poor posture, whether or not as a reaction to stress, causes head and neck pain460 since it creates extra
muscular tension. Another cause of TMD, especially for muscle fatigue in the jaws, is from dental
malocclusion; the jaw may be tired from muscle pressure from crowded teeth or loss of needed teeth.461
Or, jaw muscles may hurt if a person has a habit of grinding his teeth, called bruxism. 462
TMD may result from direct pressure from a foreign object. This excessive pressure may
accumulate from holding the instrument (such as a viola) or from a traumatic injury. Direct impact to the
jaw or to another area, such as the neck, that then places more pressure on the jaw, may occur from a
single traumatic blow.463 A few examples of trauma would be tripping and falling, getting hit by a ball, or
being in a car accident.464
Mallinak 60
Oddly enough, habits of nail biting or biting one‘s tongue, lips, or objects such as a writing
utensil causes strain on the TMJ.465 Since TMD occurs from muscle tension,466 any unnecessary tensing
of the jaw muscles can contribute to a TMD.
Several non-occupational hobbies, such as swimming and snorkeling, that include motion of the
mandible or pressure on it can initiate or irritate an already existing TMD.467
Occupational ―aggravation‖ of TMD occurs in wind instrumentalists if they ―protrude the
mandible‖ to form their embouchure (such as flutists or brass players) or simply press their instrument
against the already injured TMJ. 468 For violin and viola players, their occupation can actually be the
source of a TMD. First, the pressure from the instrument against the jaw can cause pain in the jaw or
face. Second, supporting the weight of the instrument between the shoulder and chin causes disorders,
especially in violists due to the instrument‘s weight.469
Lastly, diseases such as osteoarthritis and rheumatoid arthritis may contribute to TMDs.470
Treatment: First and foremost, musicians must get an accurate diagnosis in order for any
treatment to be effective. TMDs can usually be addressed by modifying one‘s habits or surroundings. To
relieve TMD, one should minimize the amount of TMJ muscle tension. For example, if teeth grinding is
a problem, plastic teeth guards could be worn. While eating is a necessity, eating hard, crunchy foods is
not. Certain bite plates can even be helpful for brass players to put in the mouth while playing in order to
minimize jaw pressure. A musician should be aware of how he holds and uses his jaw whether playing or
not playing his instrument. If at any time, he is exerting extra pressure or creating extra tension, he
should modify his instrumental technique and habits. To identify unnecessary jaw tension, Horvath says,
―When [a person‘s] mouth is relaxed, [his] teeth shouldn‘t be touching. [He should] Remember this: Lips
together—teeth apart.‖471
Mallinak 61
String players can seek the best possible combination of a shoulder rest and chin rest to minimize
the instruments pressure and weight. Certain wind players, such as the clarinet and saxophone, can
employ neck straps to distribute the weight of the instrument upon their body.472
Habitual adjustments to the actions that caused TMD will often eliminate the disorder. Besides
altering one‘s normal habits, Horvath says that a person might encourage relaxation by doing ―jaw
exercises, massage, acupuncture, biofeedback, [and] stress management.‖473
Instruments posing the greatest risk: Violas and violins pose the greatest risk for TMDs in
musicians since playing these instruments may actually trigger a TMD. 474 Wind instruments in general
also place players in danger of irritating and making TMDs worse due to the facial tension and possible
pressure from forming the embouchure and resting the instrument against the face. 475
Implications
Noticing symptoms, analyzing causes, and accessing appropriate treatments are all important
steps to find relief from PRHP, but cannot actually remove a problem. Just as a patient must swallow his
prescription medication for the medication to take effect, a musician must apply his treatment. No step is
sufficient in isolation from the others. Musicians can take heart. As previously injured musicians testify,
relief can become a reality.476 It just does not happen by accident. Musicians can heal from injury and
minimize the effects of disease.
If recovery from playing in pain is attainable, even more, prevention of pain should be feasible.
Whether or not musicians have experienced PRHP, all musicians should educate themselves about PRHP
in order to prevent any or other playing problems from occurring. Prevention is possible, but it takes
intentionality.477 The same principles necessary to maintain healthy playing after injury are the same to
withhold an injury. Playing an instrument need not equate to incurring PRHP. Musicians‘ bodies are a
tool, and musicians must be sensitive to the body‘s capabilities and limitations. Music making can and
should be PRHP free.
Mallinak 62
Endnotes
Chapter 1
1
Sataloff, Brandfonbrener, and Lederman, eds. Performing Arts Medicine. 2d ed.
Ibid., xiii.
3
Harman, ―Evolution of Performing Arts Medicine,‖ 3, 12.
4
Sataloff, and Brandfonbrener, Lederman, eds. Performing Arts Medicine. 2d ed., xiii-xv.
5
Ibid., title page.
6
National Library of Medicine, ―Biography-Alice Brandfonbrener,‖ Local Legends: Celebrating America‘s Local
Women Physicians, National Library of Medicine,
http://www.nlm.nih.gov/locallegends/Biographies/Brandfonbrener_Alice.html (accessed February 24, 2011).
7
Sataloff, Brandfonbrener, and Lederman, eds. Performing Arts Medicine. 2d ed. title page.
8
Harman, ―Evolution of Performing Arts Medicine,‖ 1.
9
Ibid.
10
Ibid.
11
Ibid.
12
Ibid., 1-2.
13
Ibid., 2.
14
Ibid.
15
Ibid., 3.
16
Ibid., 5.
17
Ibid.
18
Ibid., 5-6.
19
Ibid., 6.
20
Ibid.
21
Ibid.
22
Ibid.
23
Ibid., 6-7.
24
Ibid., 7.
25
Ibid.
26
Ibid.
27
Ibid., 8.
28
Ibid., 8-9.
29
Ibid.
30
Ibid., 8.
31
Ibid., 10.
32
Performing Arts Medical Association, ―Who is PAMA,‖ Performing Arts Medical Association,
http://www.artsmed.org/about.html, (accessed on March 24, 2011).
33
Harman, ―Evolution of Performing Arts Medicine,‖ 11.
34
Ibid.
35
Ibid., 9.
36
Science and Medicine, Inc., Medical Problems of Performing Artist, http://www.sciandmed.com/mppa/ (accessed
March 4, 2011).
37
Harman, ―Evolution of Performing Arts Medicine,‖ 10.
38
Ibid., 11.
39
Ibid.
40
BasicEconomics.info, ―Supply and Demand,‖ Basic Economics. http://www.basiceconomics.info/supply-anddemand.php, (accessed March 4, 2011).
41
Horvath, ―Playing (less) Hurt,‖ 3-4.
42
Ibid., 72, 74.
43
Ibid., 74.
44
Ibid.
45
Ibid., 4-5.
46
Ibid., 5.
2
Mallinak 63
47
Ibid., 4-5.
Fishbein and Middlestadt et al., ―Medical Problems among ICSOM Musicians,‖ 1.
49
Ibid., 1.
50
Ibid.
51
Ibid., 2.
52
Ibid., 5.
53
Fry, ―Incidence of Overuse Syndrome,‖ 51.
54
Harman, ―Evolution of Performing Arts Medicine,‖ 8.
55
Fry, ―Incidence of Overuse Syndrome,‖ 51.
56
Ibid., 51-52.
57
Science and Medicine, Inc., Medical Problems of Performing Artist, http://www.sciandmed.com/mppa/ (accessed
March 4, 2011).
58
Manchester, ―Looking at Musicians‘ Health through the ‗Ages,‘‖ 55, 57.
59
Ibid., 56.
60
Ibid.
61
Edling and Fjellman-Wiklund, ―Musculoskeletal Disorders and Asymmetric Playing Postures in the Upper
Extremity and Back in Music Teachers‖ (hereafter cited as ―Musculoskeletal Disorders in Music Teachers‖) 113.
62
Ibid., 113, 115.
63
Buckley and Manchester, ―Overuse Injuries in Non-Classical Recreational Instrumentalists,‖ 80.
64
Ibid.
65
Ibid., 81.
66
Ibid., 83.
67
Brandfronbrener, ―History of Playing-related Pain in 330 University Freshman Music Students,‖ (hereafter cited
as ―History of Pain in University Freshman‖), 30-36.
68
Ibid., 31.
69
Ibid., 31-32. Note: Even though the title of the article says 330 students, only 325 students gave an answer on the
question about past playing-related pain.
70
Manchester, ―Looking at Musicians‘ Health through the ‗Ages,‘‖ 55.
71
Ibid.,
72
Ranelli et al., ―Prevalence of Playing-related Musculoskeletal Symptoms and Disorders in Children Learning
Instrumental Music,‖ (hereafter cited ―Prevalence in Children‖), 178.
73
Ibid., 180.
74
Ibid., 181.
75
Ibid., 178.
76
Ibid., 181.
77
Ibid., 178.
78
Manchester, ―Looking at Musicians‘ Health through the ‗Ages,‘‖ 55.
79
Brusky, ―High Prevalence of Playing-related Musculoskeletal Disorders in Bassoon Players,‖ (hereafter cited
―Bassoon Players‖) 81.
80
Ibid., 85.
81
Ibid.
48
Chapter 2
82
Horvath, Playing (less) Hurt, 28..
Ibid., 29.
84
Ibid., 28.
85
Hoppman, ―Musculoskeletal Problems in Instrumental Musicians,‖ 209.
86
Ranelli et al., ―Prevalence in Children,‖ 178.
87
Ibid.
88
Fry, ―Incidence of Overuse Syndrome,‖ 51.
89
Sataloff, Brandfonbrener, and Lederman, eds. Performing Arts Medicine. 2d ed., xiii.
90
Hoppmann, ―Musculoskeletal Problems in Instrumental Musicians,‖ 209.
83
Mallinak 64
91
Brandfronbrener, ―History of Pain in University Freshman,‖ 35.
Horvath, Playing (less) Hurt, 24.
93
Dawson, Fit as a Fiddle, Back Cover.
94
Ibid., 3.
95
The two following sources both have chapters covering psychological besides physiological problems: Sataloff,
Brandfonbrener, and Lederman, eds., Performing Arts Medicine, and Tubiana and Amadio,eds., Medical Problems
of the Instrumental Musician.
96
Watson, Biology Musical Performance, backcover.
97
Ibid., 42.
98
Horvath, Playing (less) Hurt, 9.
99
Rowman and Littlefield Publishing Group, ―The Athletic Musician,‖ The Scarecrow Press, Inc.,
http://www.scarecrowpress.com/Catalog/SingleBook.shtml?command=Search&db=^DB/CATALOG.db&eqSKUda
ta=0810833565 (accessed March 7, 2011).
100
Horvath, Playing (less) Hurt, 10.
101
Dawson, Fit as a Fiddle, 110, 143.
102
Ibid., 91, and Horvath, Playing (less) Hurt, 155.
103
Horvath, Playing (less) Hurt, 151.
104
Dawson, Fit as a Fiddle, 109.
105
Parry, ―Clinical Approaches.‖ 203.
106
Dawson, Fit as a Fiddle, 3.
107
Tubiana and Amadio, eds., Medical Problems of the Instrumentalist Musician, x.
108
Parry, ―Clinical Approaches.‖ 203-205.
109
Tubiana and Amadio, eds., Medical Problems of the Instrumentalist Musician, title page.
110
Parry, ―Clinical Approaches.‖ 203.
111
Brandfonbrener, ―The Etiologies of Medical Problems in Performing Artists,‖ 22.
112
Brandfonbrener, ―Epidemiology and Risk Factors,‖ 171.
113
Brandfonbrener, ―The Etiologies of Medical Problems in Performing Artists,‖ 24, 27.
114
Horvath, Playing (less) Hurt, 23.
115
Dawson, Fit as a Fiddle, 37.
116
Ibid., 34.
117
James, ―Survey of Orchestras,‖ 196.
118
Dawson, Fit as a Fiddle, 86-87.
119
Dictionary.com. ―Injury.‖ Merriam-Webster‘s Medical Dictionary. Merriam-Webster, Inc.
http://dictionary.reference.com/browse/injury, (accessed March 8, 2011).
120
Dictionary.com. ―Disease.‖ Merriam-Webster‘s Medical Dictionary. Merriam-Webster, Inc.
http://dictionary.reference.com/browse/injury, (accessed March 8, 2011).
121
Berkow et al. eds., The Merck Manual of Medical Information (hereafter cited Merck Manual), 5.
122
Ibid., 214.
123
Dawson, Fit as a Fiddle, 4.
124
Watson, Biology Musical Performance, 74.
125
Many surveys, papers and chapters of books, even contained in this paper‘s bibliography, are written on overuse
problems among musicians.
126
Dawson, Fit as a Fiddle, 33.
127
Watson, Biology Musical Performance, 74.
128
Horvath, Playing (less) Hurt, 11.
129
Dawson, Fit as a Fiddle, 32.
130
Watson, Biology Musical Performance, 74.
131
Dawson, Fit as a Fiddle, 38-39.
132
Horvath, Playing (less) Hurt, 29.
133
Dawson, Fit as a Fiddle, 40.
134
Watson, Biology Musical Performance, 42.
135
Dawson, Fit as a Fiddle, 33-34.
136
Ibid., 33.
137
Ibid., 35.
138
Ibid.
92
Mallinak 65
139
Ibid.
Ibid.
141
Ibid., 38.
142
Horvath, Playing (less) Hurt, 165.
143
Dawson, Fit as a Fiddle, 36.
144
Horvath, Playing (less) Hurt, 23.
145
Ibid., 35.
146
Ibid.
147
Ibid.
148
Ibid., 33.
149
Ibid.
150
Ibid.
151
Ibid.
152
Ibid.
153
Ibid.
154
Ibid.
155
Ibid., 37.
156
Ibid., 33.
157
Ibid., 125.
158
Dawson, Fit as a Fiddle, 32.
159
Horvath, Playing (less) Hurt, 123.
160
Sataloff and Sataloff, ―Hearing Loss in Musicians,‖ 85.
161
Ibid., 89.
162
Horvath, Playing (less) Hurt, 128.
163
Ibid., 126.
164
Ibid., 125.
165
Ibid.
166
Ibid., 124.
167
Ibid.
168
Ibid.
169
Ibid., 126.
170
Ibid.
171
Ibid., 124.
172
Ibid., 126.
173
Ibid., 128.
174
Ibid., 124.
175
Ibid., 127.
176
Ibid.
177
Ibid.
178
Dawson, Fit as a Fiddle, 33.
179
Ibid.
180
Ibid.
181
Personal communication in an Independent Study meeting with Mr. Cory Smith (Professor of Violin at the
University of Akron) in September 2010.
182
Watson, Biology Musical Performance, 89.
183
Dawson, Fit as a Fiddle, 25.
184
Watson, Biology Musical Performance, 91.
185
Ibid., 91.
186
Watson, Biology Musical Performance, 29.
187
Horvath, Playing (less) Hurt, 34.
188
Ibid., 37.
189
Dictionary.com. ―Ergonomics.‖ The American Heritage® Stedman's Medical Dictionary. Houghton Mifflin
Company. http://dictionary.reference.com/browse/ergonomics (accessed March 12, 2011).
190
Watson, Biology Musical Performance, 86.
191
Horvath, Playing (less) Hurt, 9.
140
Mallinak 66
192
Ibid., 10.
Brandfonbrener, ―The Etiologies of Medical Problems in Performing Artists,‖ 24.
194
Tubiana and Amadio, eds., Medical Problems of the Instrumentalist Musician, ix.
195
Norris, ―Applied Ergonomics,‖ 596.
196
Horvath, Playing (less) Hurt, 33.
197
Ibid.
198
Ibid.,, 160, and Watson, Biology Musical Performance, 93.
199
Watson, Biology Musical Performance, 29.
200
Norris, ―Applied Ergonomics,‖ 596, and Watson, Biology Musical Performance, 33.
201
Watson, Biology Musical Performance, 33-34.
202
Ibid., 33.
203
Dawson, Fit as a Fiddle, 36.
204
Watson, Biology Musical Performance, 37, 91.
205
Horvath, Playing (less) Hurt, 23.
206
Watson, Biology Musical Performance, 31.
207
Horvath, Playing (less) Hurt, 34, 37.
208
Norris, ―Applied Ergonomics,‖ 595.
209
Horvath, Playing (less) Hurt, 158.
210
Watson, Biology Musical Performance, 37, 91.
211
Horvath, Playing (less) Hurt, 157-158.
212
Watson, Biology Musical Performance, 38.
213
Ibid.
214
Ibid., 18.
215
Ibid., 38.
216
Dawson, Fit as a Fiddle, 133.
217
Horvath, Playing (less) Hurt, 157.
218
Ibid.
219
Ibid.
220
Dawson, Fit as a Fiddle, 133.
221
Horvath, Playing (less) Hurt, 158.
222
Ibid., 159.
223
Ibid.
224
Ibid.
225
Ibid., 160.
226
Ibid., 159.
227
Ibid.
228
Dictionary.com. ―Trauma.‖ The American Heritage® Stedman's Medical Dictionary. Houghton Mifflin
Company. http://dictionary.reference.com/browse/trauma (accessed March 18, 2011).
229
Horvath, Playing (less) Hurt, 29.
230
Dawson, Fit as a Fiddle, Back Cover.
231
Ibid., 85.
232
Ibid., 5-6.
233
Ibid., 86.
234
Ibid., 87.
235
Watson, Biology Musical Performance, 74.
236
Tubiana and Amadio, eds., Medical Problems of the Instrumentalist Musician, ix.
237
Dana, ―Orofacial Problems,‖ 467.
238
Horvath, Playing (less) Hurt, 80.
239
Dawson, Fit as a Fiddle, 72-73.
240
Horvath, Playing (less) Hurt, 77.
241
Ibid., 77.
193
Chapter 3
Mallinak 67
242
Sataloff, Brandfonbrener, and Lederman, eds. Performing Arts Medicine. 2d ed., xiv.
Ibid., 90.
244
Horvath, Playing (less) Hurt, 124.
245
Ibid., 124, 127.
246
Sataloff and Sataloff, ―Hearing Loss in Musicians,‖ 89.
247
Horvath, Playing (less) Hurt, 123.
248
Sataloff and Sataloff, ―Hearing Loss in Musicians,‖ 86, 92.
249
Horvath, Playing (less) Hurt, 127.
250
Ibid.
251
Ibid., 125.
252
Ibid., 123.
253
Ibid., 125.
254
Sataloff and Sataloff, ―Hearing Loss in Musicians,‖ 91.
255
Ibid.
256
Brandfonbrener, ―The Etiologies of Medical Problems in Performing Artists,‖ 41.
257
Horvath, Playing (less) Hurt, 124.
258
Ibid., 124-125.
259
Ibid., 123-124.
260
Ibid., 124.
261
Brandfonbrener, ―The Etiologies of Medical Problems in Performing Artists,‖ 41.
262
Horvath, Playing (less) Hurt, 128.
263
Ibid., 134.
264
Sataloff and Sataloff, ―Hearing Loss in Musicians,‖ 91.
265
Ibid., 96.
266
Ibid., 88.
267
Ibid., 89.
268
Ibid., 96.
269
Horvath, Playing (less) Hurt, 123, 127.
270
Sataloff and Sataloff, ―Hearing Loss in Musicians,‖ 97.
271
Brandfonbrener, ―The Etiologies of Medical Problems in Performing Artists,‖ 41.
272
Horvath, Playing (less) Hurt, 127-128.
273
Ibid., 127.
274
Ibid., 124.
275
Ibid., 125.
276
Brandfonbrener, ―The Etiologies of Medical Problems in Performing Artists,‖ 41, and Sataloff and Sataloff,
―Hearing Loss in Musicians,‖ 91.
277
Sataloff and Sataloff, ―Hearing Loss in Musicians,‖ 92.
278
Horvath, Playing (less) Hurt, 124, 134.
279
Watson, Biology Musical Performance, 2.
280
Dawson, Fit as a Fiddle, 50.
281
Ibid.
282
Ibid.
283
Ibid., 51-52
284
Ibid., 49.
285
Watson, Biology Musical Performance, 42.
286
Dawson, Fit as a Fiddle, 50.
287
Ibid., 51.
288
Ibid., 53.
289
Ibid., 52.
290
Horvath, Playing (less) Hurt, 34.
291
Dawson, Fit as a Fiddle, 109.
292
Ibid., 53.
293
Ibid., 52.
294
Ibid.
243
Mallinak 68
295
Ibid., 53.
Ibid., 52.
297
Watson, Biology Musical Performance, 75.
298
Dawson, Fit as a Fiddle, 56.
299
Ibid., 57.
300
Ibid., 58-59.
301
Ibid., 55-56.
302
Ibid., 56.
303
Ibid., 57.
304
Ibid., 56.
305
Ibid.
306
Ibid., 63.
307
Ibid., 64.
308
Ibid., 59, 62.
309
Ibid., 62.
310
Ibid.
311
Ibid., 58.
312
Ibid.
313
Ibid., 64.
314
Ibid., 58-59.
315
Ibid.
316
Ibid., 58.
317
Ibid., 59.
318
Ibid., 64.
319
Ibid., 65.
320
Horvath, Playing (less) Hurt, 64.
321
Dawson, Fit as a Fiddle, 66-67.
322
Ibid., 68.
323
Watson, Biology Musical Performance, 85.
324
Horvath, Playing (less) Hurt, 72.
325
Ibid.
326
Ibid.
327
Ibid., 74.
328
Ibid., 73.
329
Ibid., 74.
330
Ibid., 72.
331
Ibid., 73.
332
Ibid., 72.
333
Ibid., 73.
334
Ibid.
335
Ibid.
336
Ibid., 74.
337
Ibid., 73.
338
Ibid., 75.
339
Ibid., 77.
340
Ibid., 73.
341
Ibid., 77.
342
Ibid., 76.
343
Ibid., 74-75.
344
Ibid., 74.
345
Ibid.
346
Fishbein et al., ―Medical Problems among ICSOM Musicians,‖ 2.
347
Ibid., 5.
348
Edling and Fjellman-Wiklund, ―Musculoskeletal Disorders in Music Teachers‖ (abbreviated title) 113.
349
James, ―Survey of Orchestras,‖ 195.
296
Mallinak 69
350
Ibid., 197.
Horvath, Playing (less) Hurt, 33.
352
Ibid.
353
Ibid., 35.
354
Ibid., 34.
355
Ibid., 34.
356
Ibid.
357
Ibid., 33.
358
Ibid., 36.
359
Ibid., 160, and Watson, Biology Musical Performance, 93.
360
Horvath, Playing (less) Hurt, 33, 35, 37.
361
Ibid., 34-37.
362
Ibid., 34.
363
Ibid., 34, 35.
364
Ibid., 34.
365
Ibid.
366
Ibid.
367
Ibid.
368
Ibid.
369
Ibid., 23.
370
Ibid., 36.
371
Ibid.
372
Ibid., 33.
373
Ibid., 35.
374
Watson, Biology Musical Performance, 86.
375
Horvath, Playing (less) Hurt, 34.
376
Ibid.
377
Ibid., 159.
378
Watson, Biology Musical Performance, 92.
379
Horvath, Playing (less) Hurt, 35.
380
Ibid., 34.
381
Ibid.
382
Brandfonbrener, ―Epidemiology and Risk Factors,‖ 178.
383
Horvath, Playing (less) Hurt, 36.
384
Ibid., 34.
385
Ibid., 36.
386
Dawson, Fit as a Fiddle, 100.
387
Horvath, Playing (less) Hurt, 36.
388
Ibid., 34.
389
Ibid.
390
Ibid., 160, and Watson, Biology Musical Performance, 93.
391
Watson, Biology Musical Performance, 29.
392
Horvath, Playing (less) Hurt, 41.
393
Ibid.
394
Ibid., 43.
395
Ibid., 34.
396
Ibid., 36.
397
Ibid., 42.
398
Ibid., 42-43.
399
Ibid., 42.
400
Ibid.
401
Ibid., 43.
402
Ibid.
403
Ibid.
404
Ibid.
351
Mallinak 70
405
Ibid., 42.
Ibid., 45.
407
Ibid., 80.
408
Dawson, Fit as a Fiddle, 72.
409
Ibid., 73.
410
Ibid., 74.
411
Horvath, Playing (less) Hurt, 80.
412
Ibid.
413
Ibid.
414
Ibid., 81.
415
Ibid., 80.
416
Dawson, Fit as a Fiddle, 72.
417
Horvath, Playing (less) Hurt, 80.
418
Ibid.
419
Ibid.
420
Ibid., 81.
421
Ibid.
422
Ibid.
423
Ibid., 80.
424
Ibid., 82.
425
Dawson, Fit as a Fiddle, 75.
426
Horvath, Playing (less) Hurt, 80.
427
Ibid.
428
Ibid., 81.
429
Ibid.
430
Dawson, Fit as a Fiddle, 35.
431
Horvath, Playing (less) Hurt, 80.
432
Dawson, Fit as a Fiddle, 137.
433
Sataloff, Brandfonbrener, and Lederman, eds. Performing Arts Medicine. 2d ed., xiii.
434
Howard, ―TMD, Facial Pain, and Dental Problems of the Performing Artist,‖ 114.
435
Lederman, ―Neurological Problems of Performing Artists,‖ 55.
436
Ibid.
437
Ibid.
438
Ibid.
439
Ibid.
440
Howard, ―TMD, Facial Pain, and Dental Problems of the Performing Artist,‖ 120-121.
441
Ibid., 117.
442
Ibid., 122-123.
443
Ibid., 123.
444
Dawson, Fit as a Fiddle, 138.
445
Ibid., 137-138.
446
Ibid., 137.
447
Berkow et al. eds., Merck Manual, 470.
448
Howard, ―TMD, Facial Pain, and Dental Problems of the Performing Artist,‖ 99.
449
Ibid., 111.
450
Ibid., 99.
451
Ibid., 104.
452
Ibid., 105.
453
Ibid.
454
Berkow et al. eds., Merck Manual, 471-472.
455
Howard, ―TMD, Facial Pain, and Dental Problems of the Performing Artist,‖ 104.
456
Berkow et al. eds., Merck Manual, 470.
457
Howard, ―TMD, Facial Pain, and Dental Problems of the Performing Artist,‖ 104.
458
Ibid.
459
Ibid., 100-101, 104.
406
Mallinak 71
460
Ibid., 106.
Ibid., 111.
462
Ibid., 108.
463
Ibid., 106.
464
Ibid., 110.
465
Ibid., 107-108.
466
Berkow et al. eds., Merck Manual, 470.
467
Howard, ―TMD, Facial Pain, and Dental Problems of the Performing Artist,‖ 109.
468
Ibid.
469
Ibid. 110.
470
Ibid. 105, 111.
471
Horvath, Playing (less) Hurt, 79.
472
Ibid.
473
Ibid.
474
Howard, ―TMD, Facial Pain, and Dental Problems of the Performing Artist,‖ 110.
475
Ibid. 109.
476
Horvath, Playing (less) Hurt, 4 (only one story of many Horvath shares in the book).
477
Many if not all the sources on performing arts medicine discuss the importance of prevention. Two specific
examples, in Horvath‘s Playing (less) Hurt, the entire book testifies that prevention is possible (Horvath‘s subtitle is
―An Injury Prevention Guide for Musicians‖), and Dawson‘s Fit as a Fiddle, pages 132-140 are specifically devoted
to ―Prevention.‖
461