According to Jeff Stenback, PT, OCS, PTs who treat musicians are usually faced with these challenges.

"Musicians aren't running for the 50-yard line or shooting a basketball, but there is definitely an athletic component to playing an instrument," said Stenback, assistant director at Orthopedic Rehabilitation Specialists, Miami. "You have to treat musicians like athletes, because if [patients] have long practice hours and have one performance after another, you're basically dealing with the same problem-flexibility and the ability to make those muscles perform over a period of time without fatigue."

Musician Injuries Even when dedicated musicians are up to the task of long hours performing, however, the upper extremities may not be as cooperative, and repetitive stress injuries (RSIs) and cumulative trauma disorders (CTDs) are common among this population. Stenback said that in most cases, a sudden change in practice habits, coupled with overuse, is the culprit.

"I tend to see more students than professionals, and usually it's students who are changing their repertoire-either they've changed instructors, they're working on new music, taking up another instrument or they've just come back from a hiatus and they're now practicing with a vengeance without properly warming up," he explained. "When musicians go from practicing just a few hours a day to seven or more hours a day, it doesn't take long for symptoms to occur." Combine that level of practice with general schoolwork on a computer or other activities that involve the upper extremities, and RSIs and CTDs will usually follow.

Although these problems are most often centered around the upper extremities, the PT pointed out that musicians may experience referred pain in the neck, shoulder and back, and even in the lower extremities if they play the drums or another instrument that demands use of the legs. "In some patients who play wind instruments, such as a flute or clarinet, we'll even see problems in the facial muscles related to their embouchure-related to the position and use of the facial muscles in order to blow through the instrument effectively," he added.

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As any PT knows, however, recognizing patients' symptoms is usually much easier than pinpointing the mechanism of their impairments, and for this reason, Stenback stressed the need for thorough history-taking during the evaluation. "The patient's history is probably the most important part, because what you learn from the patient will oftentimes direct the rest of your evaluation and treatment," he said. "Athletes and dancers tend to be very body-aware, but musicians on the whole are not, so it may take a bit more questioning about their practice habits." For example, Stenback said he'll ask patients about the instruments they play, how often they practice, and if there's been any recent change in their repertoire, such as an increase in practice time or a change in instructor. Other questions related to the onset of symptoms (i.e. when the symptoms began, when they are aggravated, etc.) are also helpful.

After taking a patient history, therapists should conduct some basic objective tests to measure the extent of the injury. For example, Stenback measures his patients' strength on a standardized five point scale (a grading of 5 is considered normal; anything less indicates diminished strength) and uses the American Academy of Orthopedic Surgeon's normative grading system for range of motion in specific joints. PTs who treat this population usually also perform sensory testing, palpation of the involved structures, and an assessment of patients' ability to perform their activities of daily living (which should include observation or discussion of reptetitive tasks, positions in which these tasks are undertaken and cover areas such as breathing and breath control).

At this point in the evaluation, PTs should have a good understanding of the cause and extent of their patient's injury, but in order to confirm those findings therapists should also observe patients while they play their instrument. Particularly when treating patients who play multiple or rare instruments, observation can be a critical part of the evaluation. "Some of my patients are interested in folk instruments such as the concertina or Irish bagpipe, so there are times when I won't know the [performance] demands until I watch them play," Stenback said. "But when I can watch patients' play in the clinic, I'll usually see the problem right away." Videotaping patients from different angles while they perform also offers patients a chance to critique their own form.

Treatment and Home Management After conducting a thorough evaluation, including objective and subjective assessments as well as observation, PTs who treat musicians typically move on to treating acute symptoms in the clinic. To this end, Stenback said he usually favors more active manual therapy over passive modalities. "Modalities such as e-stim, hot and cold packs and ultrasound are fine in their place, but I tend not to use them much," he explained. Instead, the PT focuses on manual therapy, including ongoing palpation assessments, soft tissue mobilization and work on trigger points.

The PT also stressed the need for a home exercise program, initiated from day one of treatment, that includes ROM activities, as well as progression into light strengthening (Stenback cautioned against heavy weightlifting for this population) and endurance activities. Although a home exercise program should be tailored to the patient's individual needs, the key is to gradually progress the program as treatment continues. A home exercise program will help get patients actively involved in their rehab, and offer them a way to manage symptoms after discharge.

While ergonomics of the individual instrument plays a relatively small role in the treatment of musicians, Stenback added that he may also consider adjustments to instruments that are not a good "fit" for his patients. "There is an optimal way to perform, but that doesn't necessarily mean that all people will fit the same instrument. For example, some instruments, such as the bassoon or tuba, require a certain musician 'type,'" he noted. "In these cases, we may make adjustments such as the type of chin rest or shoulder rest height, to get the patient a little more ergonomically aligned with the instrument they're playing."

Long-term Support As a final point, Stenback stressed the need for therapists to offer musicians advice and support after discharge. Much like athletes, there is a psychological component to musicians' injuries in that these patients may be experiencing chronic pain and are concerned about their ability to get back to practice. Therapists can help alleviate these concerns by fully explaining the mechanism of the injury, empowering patients with self-management techniques, and making themselves available for consultation at a latter date.

"Because playing an instrument is so important to these patients, there is considerable concern when [symptoms] prevent them from practicing, and student musicians in particular may be very worried about having problems at such an early stage in their careers," he said, "so you need to give them support. We're here to see that patients get back to their level of function, but that doesn't mean we won't speak to them after discharge. I get calls from former patients who have questions or need advice on a regular basis, and it's a great joy to see them back doing what they love to do."