Considerations for Treating the Musician
Nicholas Quarrier, PT, MHS, OCS, Jeffrey T. Stenback, PT, OCS

A survey of 4025 members of the International Conference of Symphony and Opera Musicians (ICSOM) found that of 2122 respondents, 76% reported having had at least one medical problem severe enough to affect performance.’ A survey of 117 professional music teachers reported that 90% of the respondents had taught students with music-related injuries. 2  The teachers believed the injuries were caused by improper playing technique, poor posture, rapid repetitive movements, poor physical condition, and emotional stress.2 As minor pain complaints are expected while playing a musical instrument, persistent musculoskeletal problems should not be expected. Persistent pain requires seeking both medical and instructional advice. The music teacher should be made aware of the pain or discomfort, and if changes in technique, practice time, or repertoire do not result in relief, further consultation with someone in the field of arts medicine may be needed.3

Most music-related injuries are classified as some variety of overuse injury which often is accompanied by acute tendinitis, myositis, or a nerve impingement.  The evaluation and examination of these injuries requires knowledge of the instrument played and the physical and emotional demands placed upon the musician. The acute treatment of these injuries is often straightforward and involves reduction of the inflammation and protection of the involved area. The care of the musician becomes more complicated with injuries that are more chronic in nature. In these cases, the examination and intervention can be more involved. It must be stated that if a musician earns his living by making music and is injured, simply instructing the individual to stop playing and to rest the injured body part probably won’t work. When offered this suggestion, the musician more than likely will discontinue working with that health care provider and search for another. Just as in a more sports-related patient, it is important that the affected activity is maintained at a high level of function and removing the patient entirely from their craft (unless unavoidable) can be the source of further problems later on. Therefore the psychological implications involved in treating a musician are critical and must be included in treatment considerations.
Efficient care of the injured musician requires a comprehensive understanding of the factors that predispose an individual to an injury. It is conjectured that music-related injuries occur due to a combination of 3 factors: sustained muscle contraction, abnormal joint positioning, and emotional stress leading to abnormal sympathetic nervous system discharge.

SUSTAINED MUSCLE CONTRACTION
Musicians frequently hold much of their tension in the shoulder girdle musculature and may abnormally elevate or depress the shoulders. Myotrac EMG examination of the upper trapezius muscles often confirms the sustained muscle contractions in the proximal muscle groups. This increased muscle tension seems to be pervasive in all instrumentalists, including singers. Persistent elevation/depression may lead to reduced blood circulatory flow into the upper extremities. But, as rapid repetitive movement occurs in the fingers and wrists, the demand for oxygen-rich blood increases. As a result, the sustained muscle contractions in the shoulders may lead to distal ischemic conditions. If ignored and the activity continues, inflammatory agents are produced and tissue irritation may pursue (tendinitis, etc.).

Perhaps contributing to these sustained muscle contractions, many musicians also have proximal muscle weakness throughout the shoulder girdle and upper back which means that stability issues will be prevalent. Aberrant postural changes often include scapular elevation, forward head posturing with suboccipital muscle shortening and rounding of the shoulders with scapular protraction. Accessory muscles that are not meant to substitute for larger postural muscle groups are called into play and frequently are not up to the task. Continued use of these inefficient patterns causes the musician’s shoulders to elevate higher and round forward so that the scapulae protract further and the humeral heads are positioned anteriorly. Without a change in this positioning, the pectoral muscles shorten over time, midthoracic muscles become less and less antagonistic, and a more rounded back posture is assumed.

Sustained over-activity in the sternocleidomastoids, rib elevators, and levator scapular muscles lead to an abnormally elevated rib cage and affect inspiratory volume, thus reducing the use of more efficient diaphragmatic breathing. Fatigue is a natural consequence of this aberrant upper quarter postural control. The musician may notice tightness in their jaw muscles, occasional headaches and tension that creeps quickly into their upper back and shoulder - noticing that they “have to play harder,” and expend more effort to get the same result musically. As a result, these abnormally tightened muscles rapidly reach an isehemic response - effectively heightening fatigue and causing further deterioration in playing abilities.
Musicians require good proximal stability to maintain playing postures proximally while their coordination and skill work is done distally. This stability allows for freedom of movement throughout the remainder of the extremity. Obviously regular practice with proper technique is a good foundation for endurance work for a piece like Mahler, for instance. But our patients are better served by incorporating postural awareness exercises (ie, chin retraction with various degrees of cervical rotation or scapular retraction combining different degrees of shoulder abduction/ external rotation) that target problem areas and progressive endurance-related activities (eg, UBE at 30° and 60° per second [watch wrist/hand positioning!], repetitive and progressive weighted ball throws [1-5#],  and gymnastic ball activities) outside of their musical experience. . .thus effectively cross-training their postural muscles and allowing the muscles they most frequently use to experience different patterns of movement.

ABNORMAL  JOINT POSITION
Musculoskeletal units surrounding joints work most efficiently when the joint is held in the neutral position. This is most easily proven by attempting to make a tight fist in both a neutral and flexed wrist position. A much stronger fist is obtained in the neutral position versus the flexed position. When the joints are positioned in any extreme range of motion for an extended period of time and rapid finger activity occurs, muscle and tendons will fatigue sooner than if rapid activity occurs in a more neutral position. Over time, fatigue leads to pain, chemical irritation, and possible inflammation. The most common abnormal joint positions seen in musicians are wrist ulnar deviation, wrist flexion, finger abduction, and forward head posture. Ulnar deviation has been mostly reported in keyboard players,8 but is, in our experience, evident with many of the other instruments as well. Musicians must repetitively reposition fingers, wrists, forearms, elbows, and shoulders in rapid succession, occasionally repeating the same patterns over and over and other times changing direction or combinations of joint movements in widely varying amplitudes. The stresses inherent in abnormal positioning that we all associate with poor postural habits are magnified in musicians when requirements of skill and coordination are superimposed. Much of the skill and coordination involved in making music occurs distally, which is probably why these particular abnormal joint positions are so prevalent. Newer movement patterns that are difficult due to repertoire played, lack of familiarity with required fingering patterns or portions of a passage, time spent practicing, current technique or teaching style, and even the size of the performer themselves can result in the assumption of these awkward postures.
Incorporation of a well-designed stretching program, postural awareness program, and ergonomic assessment that targets problem areas can offer the musician a means of self-management and incorporate a level of joint protection to hopefully avoid future reoccurrence (eg, neural stretches for the UE, pectoral, scalene, and levator scapular muscle stretching). Several musicians have even reported onset of symptoms after having changed their bowing style or the bow itself (different bows might be used in some string players that better suit the type of piece being performed, eg, Mozart versus Beethoven). While some changes are most certainly the result of technique itself and are better addressed by the musician’s music instructor or someone well-versed in specifics of technique, the effects of these changes posturally are best addressed by the physical therapist.
Acclimation to changes (whether they are postural/positional or technique-related) take time and the musician should allow for a period of transition when making a change or learning a new movement pattern so that they are more acutely aware of the effects of that change. Unfortunately, sheer repetition is often employed by musicians in order to increase proficiency with difficult fingering, for example, but it can push already irritated tissues into an inflamed state (eg, a percussionist practicing a snare drum roll for 15 minute intervals—even though the actual requirement of the piece may be a matter of seconds at a time; a pianist practicing a difficult passage “until she gets it right”). Segmenting their practice time with frequent breaks, breaking up difficult fingering passages or blocking the passage into smaller and more easily learned patterns and being aware not to over practice a new movement pattern are important. Obviously, superimposing problems in technique only serves to exacerbate already strained tissues and the forces generated in the involved limb can be quite large when the repetitive nature of the activity is considered.9
In addition, other considerations might include, but are not limited to, positioning of the instrumentalist in order to view the conductor or music score, uncomfortable/inappropriate seating, environmental factors (ie, extremes of temperature, smoky or theatrically fogged venues) and cramped rehearsal/performance spaces only complicating the situation. Related activities that are outside of instrumental practice, such as time spent in composition, use of a computer keyboard, writing postures, sleep posturing, and recent weight-training may have contributory influences on the musician’s symptoms.

EMOTIONAL STRESS
Proximal muscles become tense with sympathetic nervous system activation (fight or flight response) and become relatively relaxed with parasympathetic nervous system activation. High levels of emotional tension pervade in a music conservatory, school of music, or professional music organization. 10 A simple confirmation of this abnormal sympathetic nervous system activation may be noted using the Heartmath Freezeframer computer analysis system. This system evaluates the individual’s heart rate and mathematically converts the signals to demonstrate ANS activation. Many musicians tested show erratic and ineffective breathing patterns, typically seen in upper chest breathers. This response is readily graphically displayed and shows high levels of sympathetic tone. Performance anxiety including fear of failure, stage fright, peer pressure, losing an orchestral seat, jury/recital performance, and poor performance all add to abnormal nervous tension experienced by many musicians.3, 11
Performance anxiety causes many to complain of chronic cold hands/feet and rapid irregular breathing.3, 12  This increased muscle tension merely adds to the detriment of prolonged sustained muscle contractions.
Many musicians are already aware that they either have a tendency to play with or without tension, as many music teachers are addressing this aspect. The musician will frequently comment on having been told that they play with increased tension and need to relax more. The musician, however, is not always as aware of how to effectively deal with a buildup of tension or how to recognize early warning signs that musculoskeletal tightness is imminent. Obviously, active intervention on the part of the musician to effectively avoid an abnormal/excessive stress response is more effective and takes considerably less time than managing a stressful response after it has taken hold. Proper instruction in diaphragmatic breathing techniques or exercises to help improve inspiratory volume as well as relaxation techniques are useful here, in addition to teaching an appropriate home stretching program to target affected areas (eg, lateral rib cage stretching, thoracic circles in sitting/standing to improve mobility). Improved diaphragmatic breathing often shows more parasympathetic activation on the Freezeframer. This unit can effectively be used for biofeedback training. There are a host of various techniques available that can teach relaxation. It is important to pair the correct technique with the learning style of the performer (eg, Jacobsen’s contract vs. relax techniques are more concrete and tend to work well with more auditory learners vs. visual imagery techniques that are more effective with visual learners). But there are plenty of other inherent stressors present for the musician, such as an upcoming audition, for example, where a lot is riding on their ability to perform well. The more important the audition is perceived, the more intensely the individual practices - usually to an excess, prior to the event. The accompanying emotional stress appears physiologically as a cascade of increased sympathetic activity (ie, dryness of the mouth, cold/clammy hands, light headedness, tingling sensations in the extremities, palpitations, tension in the face/jaw and extremities, increase in pulse and respiration) often accompanied by a loss of coordination and an increase in incidence of mistakes.

Psychologically, any negative internal self-talk also is damaging and, if present, the musician may benefit from appropriate intervention by a trained health care professional. Very high expectations of the individual to perform well can aggravate any existing tension. A young double bass player noted that he was experiencing cramping in his fingers and hands that would increase as he pushed through his practice or rehearsal. He had just been told that an important audition was coming up in a city to which he wanted to move back and in which his fiancee was now living. “I really wanted the audition to go well. Everything would be so much easier if I could move back to [that city] . . . my fiancee wouldn’t have to move once we get married.” He began excessive practice for several weeks prior to the audition and ultimately had to cancel the audition only a couple of hours prior because his symptoms had worsened enough to cause him to be unable to play. Either way, it is ultimately the individual’s performance that is affected if symptoms are ignored.
Peer pressure remains an issue in groups where hierarchy and seniority rule. Upcoming auditions for a first chair position or prime placement in an orchestra are frequent sources of this stress. “I know that even though some of my fellow musicians want the best for me, I also feel that others are secretly happy that I might do poorly at an audition. . .even though they may wish me well to my face.” The competitive nature of hierarchies present in the music world
certainly do not appear to be on their way out and musicians will need to be prepared for such stresses as part of their basic training.

CONCLUSION
We have discussed several aspects of injury predisposition in the musician, as well as a few treatment considerations. As physical therapists, recognition of specific movements involved in a dysfunctional state are part of our daily activities. It is not that much different for the population discussed here, with the caveat that it is important to understand the unique factors affecting the instrumentalist. Our abilities as physical therapists in recognizing and treating specific biomechanical dysfunction creates a unique opportunity to influence this patient population. In these authors’ experience, the typical injured musician reports more distal extremity pain, abnormal upper back, or shoulder girdle tension, and has been dealing with their symptoms for at least several weeks if not months before seeking treatment. Often, the musician has a very limited idea that what we do can help. There is a definite need for education in this still-emerging area of rehabilitation. We have a chance to share in their pursuit of creating a superior musical experience and hopefully avoiding the pitfalls of a musculoskeletal injury along the way.

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Nicholas Quarrieiç MHS, P1 OCS, c/o
Ithaca College, Department of P1
Ithaca, NY Jeffrey T Stenback, P1 OC
Orthopedic Rehabilitation Specialists,