To view this article in PDF form, click here.

A review of the unique injuries sustained by musicians

Musculoskeletal injuries in musicians range from common repetitive stress injuries to unusual, sometimes career-ending disorders. Here’s how to help the patient return to making music.

Michelle Heinan, EdD, MS, PA-C

Michelle Heinan is the PA program director at Lincoln Memorial University/DeBusk College of Osteopathic Medicine, Harrogate, Tennessee. She also is a musician who plays several instruments. She has indicated no relationships to disclose relating to the content of this article.

“… in addition to being an art, playing a musical instrument is a sport in the sense that musicians often begin younger than athletes, training in the expert use of muscles from childhood to adulthood.” —David Rivinus, violin maker¹

Musicians, like athletes, require physical conditioning and preparation to perform at their best, and like athletes, they can develop physical problems as a result of their practice. Throughout the centuries, performing artists generally have kept physical problems and injuries to themselves. Musicians were, and still are, told to “play through the pain.” Although health care providers do not have a good understanding of the physical and psychological injuries that can occur, musicians still need, and seek, quality treatment. PAs should be familiar with injuries in musicians, whether they care for professional musicians or not. Professional musicians are not the only persons afflicted; children and adults who are active in music may be seen in family practice, urgent care, orthopedic, or neurology clinics.

Medical problems that can afflict musicians include contact dermatitis, hearing loss, pneumothorax, increased intraocular pressure, gastroesophageal reflux disease, performance anxiety, focal dystonia, and various musculoskeletal disorders. The simplest injuries can take a musician “out of the game” long enough to result in psychological problems, another area that may need to be addressed. This article focuses on the musculoskeletal disorders that may develop in musicians, including repetitive strain injuries (RSIs); carpal tunnel syndrome (CTS); back pain; and focal dystonia of the hands, forearms, and mouth.

In some cases, an injury can end a career or have a severe negative economic impact because the musician must rest the injured extremity or area. In a national survey of orchestral musicians, 76% of respondents had to take time off from performing because they developed a serious injury during their career.² Some small studies have found that 50% of treated musicians were unable to return to their career at all.³ PAs caring for members of this unique patient population should understand their patient’s passion for music, aspirations and fears related to being a performer, and stresses being dealt with both in and out of the performance hall.

INJURY PREVALENCE

According to the Bureau of Labor Statistics, approximately 264,000 musicians were employed in the United States in 2006.⁴ Given that musculoskeletal injuries are reported by 50% to 76% of professional musicians, the problem is substantial.⁴ Schuele and Lederman identified 8.5 episodes of injuries per 100 university music performance majors.⁵ In a University of Texas study, the prevalence of musculoskeletal injuries among players of brass instruments—the French horn, trombone, trumpet, or tuba—was 61%.⁶ Trombone players had the highest rate of injury, and female trombonists, in particular, sustained injuries involving mainly the left upper extremity and upper back.⁶ Female musicians may be more susceptible to musculoskeletal injuries than male musicians.⁷ In a study conducted by the International Conference of Symphony and Opera Musicians, 70% of the women and 52% of the men had a performance-related musculoskeletal problem. Women may sustain musculoskeletal performance-related injuries more often because they have smaller anatomy and less muscle mass.⁸ Additional studies are needed to determine why women musicians experience more injuries than men.

Asymmetry of the musculature can develop from the demands of the instrument, posture, and practice time. One example is the stronger deltoid, bicep, tricep, and pectoral muscles that string instrument players develop from holding the instrument away from the body and from the movement used to play the instrument. The infraspinatus and teres minor muscles are not utilized as extensively on the left side, resulting in muscular asymmetry. The stress that can be placed on musicians’ bodies is illustrated by a violinist playing one of Handel’s Messiah movements; the violinist bows 740 times in 2 minutes.² In another example, the snare drummer performing Ravel’s Bolero continuously repeats a 24-note pattern for the entire 14-minute piece, performing a total of 5,144 arm strokes.²

Musicians who experience pain may adjust their technique to accommodate the pain, which can cause an injury in another area.² The literature on injuries in musicians is rather limited, making it more important for PAs to be aware of the specific risk factors for this group of patients (see Table 1). The extent of exposure to these risks should be documented in the patient’s history.

COMMON SYMPTOMS

The predominant feature of an RSI is pain at the affected site. Cramping, weakness, and stiffness are also associated symptoms. Performing arts medical providers categorize musical instrument playing-related pain with the following scale: grade 1, pain occurs only when playing; grade 2, pain occurs when playing and for a short period afterward; grade 3, pain occurs when playing and for hours or days afterward; grade 4, pain is constant; and grade 5, pain is incapacitating and severely limits all activities.⁸

The location of the pain depends on the instrument played. Flute players may develop problems with the right shoulder because the playing position requires the shoulder to be externally rotated and abducted. Clarinet and oboe players complain of pain in the webbed area between the thumb and index finger caused by supporting the instrument. The dexterity needed to manipulate the strings can cause string instrumentalists to experience pain in the left upper extremity. Trombone players use the left upper extremity to hold the instrument in place to maintain the embouchure, or the lip formation to the mouthpiece of the instrument. French horn players place the right hand in the bell of the instrument and use the left upper extremity for compressive features of the embouchure and to apply pressure to the valves. Tuba and trumpet players utilize the right hand to manipulate the valves and to compress the mouthpiece against the embouchure. Tuba players support the instrument in their left arm and on their left leg.⁶

The most common nerve-entrapment disorder that affects musicians is CTS.⁹ The disorder can manifest as pain, discomfort, and paresthesias. Pain may occur in the affected extremity at night and can radiate. If the symptoms are ignored, motor-control problems or even muscle atrophy can result. CTS is prevalent in string instrumentalists because the use of poor wrist position when playing may not have been corrected (see Figure 1).⁵

Neck and back pain is another problem that can be caused by poor posture, both standing and sitting; poor seating arrangements, in order to properly see the conductor; or poor instrument lifting techniques. Pain can be located in the cervical, thoracic, or lumbar regions, or in all regions of the spine. This problem can affect any musician.

A common musculoskeletal problem is focal dystonia, defined as a syndrome of sustained muscle contractions, frequently causing twisting and repetitive movement or abnormal posture.¹⁰ Focal dystonia can manifest as pain and/or discomfort in the affected upper extremity without any sensory deficits. Musicians note a loss of control in the extremity or embouchure, causing them to change their technique. Focal dystonia affects keyboard, string, and woodwind players more than players of other instruments.⁹ Musicians with focal dystonia experience abnormal involuntary movements that may cause the fingers to flex at the interphalangeal joints; some have reported difficulty with writing, brushing their teeth, or using a spoon. Documented cases of drummers’ dystonia include a sustained involuntary movement or posture, a tremor or twisting in the affected limb, stiffness and tightness, and a decrease in rhythmic control.¹¹ Brass and woodwind players have developed lip injuries that prevent the musician, for instance a trumpet player, from being able to hold the high notes, from maintaining the correct embouchure for good tone quality, or from playing the instrument at all. Musicians who experience focal dystonia related to the embouchure can have difficulty talking, eating, or kissing.³ Patients experience symptoms such as cheek and lip tremors, tongue protrusions, and involuntary jaw closures. Another name for this condition is Satchmo’s syndrome. Louis Armstrong suffered from it in 1935, and it caused him to stop playing for a year.

HISTORY AND PHYSICAL EXAMINATION

When taking a musician’s history, the PA should begin by obtaining a standard medical history that includes illnesses, operations, medications, allergies, substance use/abuse, and trauma. Next, the focus is on the injury itself (see Table 2). Finally, questions should focus on the patient being a musician (see Table 3).⁹ A review of systems specific to the complaint should be conducted. In addition, the musician should be evaluated for related conditions, such as an underlying depression, which may develop from coping with any resultant limitations or pain.⁹

Before examining the affected area, the PA should observe a demonstration of the positioning of the hands/fingers on the instrument, angulation of the joints, degree of movement when the instrument is played, and weight bearing. These points are important for string, keyboard, brass, and woodwind players because they are more susceptible to injury. Posture with and without the instrument in position for playing also is important because musicians may be sitting or standing in an abnormal position for long periods of time. Observe the patient for fasciculations, tics, or any involuntary movements.

Physical examination of the affected area should be performed, including checking the skin color and looking for any signs of atrophy, asymmetry, deformity, swelling, or lesions. The pulses, skin temperature, peripheral sensation, motor coordination, flexibility, ligamentous laxity, and crepitus should be evaluated. The injured area(s) need to be palpated for tenderness; the patient should perform range of motion exercises with the affected extremity or spine.

Additional diagnostic tests and examinations included in the physical examination are specific to the area affected by the injury. The Cozens test determines elbow strength. A positive result is diagnostic of epicondylitis. Several tests are used to diagnose disorders of the forearm and wrist including Tinel’s test, Phalen’s test, Finkelstein’s test, and the Allen test. The hands should be examined for nodules, flexibility, snuffbox tenderness, and triggering. Neurologic examination includes all the deep tendon reflexes, strength, position sense, coordination (hands, fingers, arm, point to point movements, rapid alternating movements), sensitivity to light touch, sharp/dull sensations in the extremities, and 2-point discrimination.^9,12 Examination of the head, neck, and throat includes an inspection of the mouth and neck, including the dentition, oral musculatures, gums, jaw excursion, and a neurologic examination as it relates to focal dystonia of the mouth.¹² Electromyography and nerve conduction studies should be performed as necessary for the musculoskeletal disorders including focal dystonia. Radiographs, MRI, or CT should be ordered depending on symptoms.

BASIC AND SPECIFIC TREATMENTS

Rest is the usual treatment. Depending on the severity of the injury, a period of 2 to 7 days is recommended. Practitioners of performing arts suggest limiting the rest period to prevent muscle atrophy. In addition, ice should be applied during the acute phase of the injury; placing the extremity in a splint or an elastic bandage (Ace wrap) provides compression, as well as allows for rest of the extremity; and elevating the extremity helps reduce swelling. Range of motion, strengthening exercises, and physical therapy modalities are also recommended. Some musicians may become depressed while coping with their injury and rehabilitation; therefore, appropriate treatment for depression may be needed.⁹

NSAIDs are recommended for any inflammatory process; otherwise, acetaminophen is used for pain. Muscle relaxers can be prescribed for muscle tightness or cramping. Narcotics are rarely used. Corticosteroid injections are used as treatment before considering surgery. Relaxation techniques such as the Alexander technique and Feldenkris method have been beneficial to musicians. These techniques emphasize self-awareness of body position, muscle tension, and efficiency of movement.⁹ A musician should return to playing the instrument gradually after an injury and preferably under the supervision of an occupational or physical therapist.⁵

Carpal tunnel syndrome is treated conservatively in most musicians. Physical therapy, splinting the extremity at night, analgesics, and rest are prescribed. Sometimes changing the position of the extremity in relation to the instrument is effective during recovery. Surgery may be indicated if the patient does not respond to conservative treatment.

Focal dystonia treatment is symptomatic. Nerve conduction studies and EMG may be helpful. If nerve entrapment is involved, surgery for decompression can be performed. Anticholinergic medications alone or in conjunction with botulinum toxin injections have been successful in some cases. Some musicians have used splints to immobilize the affected fingers while playing. Musicians with embouchure dystonia have tried changing the configuration, placement, and size of the mouthpiece. Therapy also consists of buzzing exercises, or making a low droning or vibrating sound into the mouthpiece of the instrument. Other treatment methods include abstinence from playing, physical and musical exercises, biofeedback, psychotherapy, and body awareness techniques. If the current music instructor is not teaching proper technique and injury prevention, the musician should consider working with a new instructor.³

PREVENTION

Instrument modification may be beneficial depending on the problem. Ergonomically correct instruments are made to adjust to the person playing the instrument. In some cases, these instruments were developed for people who suffered a stroke or some other injury that prevents them from playing an instrument in the traditional manner. Musicians who play large instruments should be educated in proper lifting techniques. Chairs for practices and performances should be supportive. A foam wedge that tilts forward is helpful in maintaining proper posture and in alleviating pain.⁹ Proper position of the musician’s chair in order to see the conductor is also necessary. PAs and other health care providers, as well as music teachers, should educate musicians about the warning signs of an evolving injury that requires medical attention.

Sometimes the type of repertoire can result in injury; repetitive passages such as arpeggios, notes played rapidly and in a sequential order from low to high or high to low, or trills, rapid alternations between two tones, are stressful on musicians’ extremities. Trills are performed by moving one finger rapidly or bowing rapidly. Education on proper playing technique is essential to avoid injury. Warm up and cool down exercises, such as physical stretches and playing scales and slow pieces before and after practices and performances, also need to be emphasized. If the conductor does not perform warm up exercises, musicians should do so on their own. Another preventive measure is to take adequate breaks and limit the length of rehearsal times.¹³ If a musician has not played the instrument for a long period of time, he or she should return to playing gradually. This gradual return includes progressively increasing the length of practice times, frequency of practices, and intensity of playing.⁵

CONCLUSION

Information about injuries in musicians and the most effective way to treat these injuries is limited in the literature. Some of the studies were conducted in the 1970s, 1980s, or in European countries. Books that explain what can cause an injury and when to seek medical treatment are available for musicians. However, further research is needed in the United States so the health care community can provide the high quality of care to musicians that will enable them to continue pursuing their passion for music. JAAPA

REFERENCES

	1.	Young E. Professional musicians accepting ergonomic instruments. Orthopedics Today. 2004;24(6):90.
	2.	US Department of Labor. Musician, singers, and related workers. http://www.bls.gov/oco/ocos095.htm. Modified December 18, 2007. Accessed March 21, 2008.
	3.	Horvath J. Playing (less) Hurt: An Injury Prevention Guide for Musicians. Kearney, NE: Jane Horvath; 2002.
	4.	Schuele SU, Lederman RJ. Occupational disorders in instrumental musicians. Med Probl Perform Art. 2004;19(3):123-127.
	5.	Schuele S, Lederman RJ. Focal dystonia in woodwind instrumentalists: long-term outcome. Med Probl Perform Art. 2003;18(1):15-20.
	6.	Chesky K, Devroop K, Ford J. Medical problems of brass instrumentalists: prevalence rates for trumpet, trombone, French horn, and low brass. Med Probl Perform Art. 2002;17(2):93-98.
	7.	Davis J, Mangion S. Predictors of pain and other musculoskeletal symptoms among professional instrumental musicians: elucidating specific effects. Med Probl Perform Art. 2002;17(4):155-168.
	8.	Shoup D. Survey of performance-related problems among high school and junior high school musicians. Med Probl Perform Art. 1995;10(3):100-105.
	9.	Hoppman RA. Instrumental musicians‘ hazards. Occup Med. 2001;16(4):619-631.
	10.	Crnivec R. Assessment of health risks in musicians of the Slovene Philharmonic Orchestra, Ljubljana, Slovenia. Med Probl Perform Art. 2004;19(3):140-145.
	11.	Lederman RJ. Drummers’ dystonia. Med Probl Perform Art. 2004;19(2):70-74.
	12.	Meinke WB. A proposed standardized medical history and physical form for musicians. Med Probl Perform Art. 1995;10(4):137-139.
	13.	Fjellman-Wiklund A, Brulin C, Sundelin G. Physical and psychosocial work-related risk factors associated with neck-shoulder discomfort in male and female music teachers. Med Probl Perform Art. 2003;17(4):33-41.