To You and Your Students’ Good Health: Q & A Column

A: “This is the time of year when students are already stressed as many are preparing for juries and/or recitals.” Consider including:

• “Safe stress” playing environments to try out repertoire - see Dr. Noa Kageyama on Effective Practice
  
  
• Quick recording segments as “trial runs” - seeJ. Mishra/B. Fast iPractice: Technology in the 21^st Century Music Practice Room (2019)
  
  
• Goal setting or planning worksheets or journals to help manage time and tasks effectively – see Gerald Klickstein’s 321 Goals
  
  
• Basic stress management techniques (breathing, relaxation, stretching, guided mindfulness activities, imagery) practiced regularly during lessons, ensemble rehearsals, or performance classes –see Don’t Sweat It: Your Guide to Managing Stress  and Vanessa Cornett’s book on The Mindful Musician: Mental Skills for Peak Performance (2019)
  
  
• Advocate the need for adequate sleep—check out Blog post by Lois Svardon Sleep, Stress and Performance
  
  
• Encourage healthy, positive habits of thought, to minimize the self-critical “inner judges” – check out Dr. Julie Nagel’s Blog Thinking about Thinking
  
  
• Encourage healthy eating habits and proper hydration—check out Choose My Plate

Finally, remember that it is normal to experience stress and anxiety related to exams, juries, recitals—anything in which a performance will be evaluated by an expert. Think of these as learning experiences that will make the next performance better.

A: “Whether you’re trekking across town to perform in an under-heated cathedral, marching outside with the band, leading The National Anthem for a football game, or joining in festive caroling, this is the time of year when musicians are coping with less than ideal weather conditions.” 

• Stay indoors and warm as much as possible before performing.
• Warm up the entire body to prepare tissues for stretching
  • Breath through the nose and mouth in a hot shower or simply run warm water over hands and face. 
  • Increase the temperature of bodily tissues, including core temperature. Get heart rate up and blood circulating with gentle repetitive sports cardiovascular work - see “A Mindfulness Warm-Up for Musicians” athletesandthearts.com
  • Increase blood temperature and flow to muscle, tendon, ligaments, connective tissues – check out https://is-warmup-a-waste-of-time.weebly.com/four-physiological-changes-that-occur-in-the-body-during-a-warm-up-and-why.html
• When tissues are warmed up, stretching exercises should begin
  • Purpose: to increase suppleness and mobility of playing muscles, not strength
  • Start more slowly than usual, especially if practice room is cool; stop or modify if pain/problems arise – see Dawson WJ: Fit as a Fiddle: The Musician’s Guide to Playing Healthy, 2008, Reston, VA: Rowman & Littledfield. See also https://www.musicnotes.com/now/tips/10-essential-stretching-exercises-for-musicians/
• Warm up your instrument
  • Critically important, especially for wooden instruments (e.g., oboe)
  • May take up to 30 minutes for large wind instrument to regain pitch
  • Blow air steadily and gently through instrument.  
  • Swab before playing to remove water vapor which has condensed inside during warmup 
• Trap the body’s warmth. Exposed skin = heat loss. Avoid a shivery sound and optimize performance capabilities by dressing beautifully and strategically for the cold. 
  • Can you incorporate a stylish, colorful hat with a small wool cap underneath? 
  • Layer shape-enhancing Spanx® with three pairs of tights or nylons…or even long black Smartwools®.  
  • Consider ditching the idea of the perfect suit or slinky dress and invest instead in a gorgeous long wool or velvety coat with a plush scarf, chic hat, and sleek, perhaps fingerless, gloves or a [fake] fur collar around your neck and wrists. 
  • Lastly, sporting well-trimmed facial hair and wearing long hair down will only add comfort to an outside performance. 
• Singers, keep your voice warm. The voice box, or larynx, is lined with ultra-sensitive tissue that triggers a cough when it senses anything foreign to its natural environment; this includes cold air! 
  • Breath through your nose. While not ideal for singing, nose breathing is a good crutch when singing outside as it warms, filters and moistens inhaled air before it reaches your vocal box. 
  • After warming up your voice, humming and replying “mmmhmmm” can help keep the cold out and the voice warmed. 
  • Help maintain warmth by sipping a warm, non-caffeinated and non-phlegm-inducing drink such as weak broth or water with honey and a little lemon.
• Singers, keep your vocal folds hydrated. Outside air in winter tends to be dry - as does the inside air once the central heat is turned on. A dehydrated voice loses flexibility, elasticity for high pitches, and stamina. 
  • Drink sufficient water consistently month-to-month prior to the performance to reach optimal hydration levels inside your voice’s many layers. 
  • Inhaling air with at least 35-45% humidity will help you maintain your voice’s slick outer layer. Keep a regularly sanitized vaporizer or humidifier running at night in your bedroom, and tote a personal steamer. – see Gates, Rachael, et.al. The Owner's Manual to the Voice. (Oxford, 2013), pp. 37-38, 49
  • Trigger your mouth and throat to secrete saliva by adding a little lemon to your water and temporarily trap the beneficial moisture via a little honey, aloe vera, pectin or glycerin. Some singers stick a tiny piece of a lozenge under the tongue or in the cheek to keep the juices flowing (e.g. Grether’s Pastilles, Luden’s® Throat Drops). – see Gates, Rachael, et.al. The Owner's Manual to the Voice. (Oxford, 2013), p. 53

A: “The production of sound (the act of being a musician) typically starts with the ability to hear. The auditory system, one of our most delicate and intricate senses, connects musicians to the world around them, and it is a delicate and intricate system. Interested readers can view this video for a more detailed look into the anatomy and physiology of auditory transduction. The ear can be thought of as a part of the musician’s instrument and, as such, should be cared for regularly!”

All musicians should know the following 5 aspects of hearing loss prevention:

1. Have your hearing tested by an audiologist. Above all, this is the best thing you can do for your hearing. This will not only be the window into your invisible instrument (your hearing) but alert you to any changes in your hearing that you might not notice. Fortunately, and unfortunately, musicians can “ear train” to discrete changes in hearing over time which can render those changes unnoticeable until they become severe. Beyond that, an annual hearing test is your way to:
   • Verify that your hearing protection is working
   • Provide a regularly updated baseline to which any sudden changes in hearing can be compared
   • Give you an opportunity to have an audiologist look in your ears and remove any occlusive earwax
     
     
2. Know when your hearing is at risk. Hearing loss occurs when sound is too loud (amplitude), for too long (duration). Fortunately, there are some guidelines that help predict when we are at risk for hearing loss (these do not predict our risk for music-induced hearing disorders such as tinnitus or ringing in the ears). Generally, when sound is lowered by 3 decibels (dB), you can double your exposure time. Steps for knowing when to pop in earplugs:
   1. Download the NIOSH SLM app on your iPhone. This is the only sound level meter app validated to be accurate.
   2. Measure the sound levels during rehearsal and if you can, performance. Refer to this chart to know if you are at risk for hearing loss due to loud sound (click and scroll down to “Average Sound Exposure Levels Needed to Reach the Maximum Allowable Daily Dose of 100%”).
   3. Choose an earplug that reduces the sound to a level that will not cause hearing loss. For example, if you measure sound levels of 100 dB and your rehearsal is 2 hours long, an earplug with 9 dB of attenuation will be sufficient. If your rehearsal is 4 hours long, you may want to consider an earplug that reduces sound by 15 dB.
      
      
3. Find earplugs that work for you. Most musicians begin with over-the-counter, universal fit earplugs and are often unhappy with the results. Most earplugs you can purchase off- the- shelf, do not provide the sound quality a musician requires. Technically, musicians can “ear train” to any form of hearing protection given enough time and effort, but most musicians are simply not able to take the time to ear train get used to foam earplugs. Additionally, some over-the-counter hearing protection actually blocks MORE sound than needed. More effective earplug options for musicians are:
   • Universal-fit: Etymotic ER20s
   • Custom-fit: Made by multiple companies
   • Active hearing protection: Etymotic MusicPro, ASI Audio 3DME
     
     
   Earplug choice should always begin with a full hearing evaluation and consultation with an audiologist and appropriate expectations of hearing protection. No earplug will sound exactly like your open ear canal, but with practice, your ears will become “bilingual” and you will be able to communicate musically both without and with the earplugs.
   
   
4. Be a wise consumer of marketing. There are heaps of companies claiming to sell “musician” earplugs, however just labeling a product “musician” or “high fidelity” does not mean they actually are. One tip is to look at the company’s published specifications for their earplugs. Did they include a frequency response curve? If so, a rule of thumb is to choose an earplug that has a flat frequency response. In other words, the earplug that shows the flattest line across the frequency response graph. Some companies publish an NRR (Noise Reduction Rating) which shows the estimated attenuation the hearing protection achieves if fit and worn properly. However, there are no two ears alike on earth, so a wise consumer will be aware that the NRR is not necessarily a real-world estimation.
   
   
5. When earplugs are not enough. Wearing a true, high fidelity, musician earplug is still a compromise on sound quality. If you find that earplugs are not working for you, even after considerable ear training efforts, consider an in-ear monitor system or a self-tunable earplug. This can be especially helpful for vocalists and reed and wind instrument players. For more information on hearing loss prevention strategies and types of hearing protection, contact Dr. Heather Malyuk ([email protected]) or Dr. Laura Sinnott ([email protected]).

A: With the COVID-19 pandemic and its consequences in daily life, there is a shift towards virtual platforms as well as shortages in jobs. Many jobs currently available to students involve even more physical and repetitive activities that can particularly stress musicians’ bodies. Therefore, ergonomics and efficient practice techniques is particularly important during this difficult time.

All students should keep the following 6 aspects in mind as a working musician: 

1. What to assess in job demands? 

• What are the additional loads on the upper body and upper limbs? High injury risk associated with:
  • High forces (lifting, lowering, carrying, pulling, pushing of heavy items)
  • Repetition (repetitive movements with/ without force)
  • Awkward positions
• Are there opportunities for sufficient rest breaks? 
  • Seated tasks → frequent breaks (work/rest=25min/5min) → significant reduction in discomfort in lower back, neck/shoulders and forearms/wrists (DOI: 10.1539/joh.14-0209-OA). 
  • Standing work → work/rest=45min/15min → reduced effects of postural loading on lower back and legs (DOI: 10.1080/001401398186009). 
  • Micro-pauses → 10-15 second pauses/10-15 min work → decreased post-work pain intensity, increase engagement and perceived performance (doi:10.1097/SLA.0000000000001665, DOI:10.1037/apl0000308). 
  • Allow 60-90 minute down time in upper limb usage between summer job and practicing.

2. Practice good ergonomics in computer work: It involves sustained static postures and repetition. 

• Set up an ergonomically friendly work station. (https://www.osha.gov/SLTC/etools/computerworkstations/).
• Use a laptop dock (or a box) to elevate the screen (needs USB keyboard) for long durations of computer work. 
• “Screen break” apps → remind breaks/micro-pauses. 
• Use of virtual conferencing platforms (e.g. virtual camp counselor) → use of voice and listening. Protect voice and hearing in addition to physical health (https://www.claviercompanion.com/webinar-replays).

3. Manage forces in shopper and delivery jobs: There is an increase in shopper and grocery/food delivery job postings. 

• Shoppers: 
  • Text messaging with customers → head-forward, bent elbows and repetitive thumb use → risk for neck pain, ulnar nerve irritation (peripheral nerve that passes behind the “funny-bone”) and small muscle strain of thumbs. Remain in aligned posture.
  • Lift, carry and lower grocery bags into cars + to customers’ door. Divide into manageable weights. 
• Shoppers + delivery workers:
  • Drive (usually short distances) → Keep vehicle well maintained.

4. Choose traditional summer jobs carefully: As the stepwise opening of businesses are planned for the summer by many states, traditional summer jobs for students will likely be available. 

• Outdoor jobs: 
  • Landscaper, farm hand, plant nursery helper, golf caddy, sign holder: Lifting, carrying, lowering, pulling and pushing of heavy items. Find out job requirements and rest schedules before deciding to apply.
• Food service jobs: Server, busser and ice cream scooper jobs carry high risks for injury.
  • Servers/bussers: Carry heavy trays (often overhead) with wrist and fingers in end-range extension → upper limbs exposed to forces in awkward positions and ulnar nerve under stretch. Hosting may be less strenuous. 
  • Ice cream scooping: Requires “twisting” wrist against resistance → wrist and forearm exposed to forces in awkward positions. 
• Care giver jobs:
  • Nanny for small children: Lifting, carrying and lowering → thumbs and wrists exposed to repetitive high forces → risk for inflammation of some of the long tendons of the thumbs (De Quervain’s tenosynovitis; nicknamed “mommy thumb” when seen in mothers with small children; has significant consequences for musicians). Occasional baby-sitting of infants/toddlers (rather than daily), or baby-sitting of older children who do not need to be carried may be less risky.
• Housekeeping cleaning jobs: Cited among the high risk occupations by OSHA (https://www.osha.gov/SLTC/ergonomics/)
  • Carrying, pulling/pushing of heavy items (vacuum cleaners or buckets/supplies), twisting (cleaning cloths) and scrubbing → high forces in awkward hand/wrist positions → risk for overuse disorders such as tennis elbow, golfer’s elbow or carpal tunnel syndrome.
• Retail jobs: Some with high risk.
  • Cashiers: repetitive movements
  • Stocking shelves: repetitive lifting, carrying, and lowering of items of a variety of weights and sizes 

5. Keep fit: 

• Regular exercise is necessary to keep the body functioning at its best to endure the demands of both practice and a summer job:
  • Cardiovascular fitness → maintain physical activity, delay fatigue.
  • Conditioning → adequate strength and flexibility → increase musculoskeletal capacity above the requirements of the job at hand → reduce injury risk.

6. Keep practicing: Students’ practice duration and intensity tend to decrease over the summer break → return to school in fall → sudden increase in practice time → injury spike in September (Manchester RA, 1988)

• Minimize de-training: maintain a daily practice schedule of at least 2 hours. 
• Complete any summer job about 2-3 weeks before returning to school and begin gradually increasing practice time (no more than 10% increase per week).

Contact Dr. Serap Bastepe-Gray ([email protected]) or Amanda Greene ([email protected]).

A: Unless you are a health care professional, HIPAA does not apply. However, if you are a faculty or staff member at a K-12 school or an institution of higher education, FERPA might apply. In general, FERPA regulations allow school officials to inform a family member when a student is exhibiting behavior that raises concerns about the student’s safety. 

1. It’s best to consult with experts if you need to get answers to questions about FERPA. See https://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html
   
   
2. Assuming you are a music teacher without formal training in mental health care, you’ll want to help your student while observing appropriate boundaries. In your role as a teacher, it’s best not to ask specific questions about why your student is upset – that’s better left to a mental health professional who has the training and expertise to elicit the appropriate information in a supportive way. If the student wants to talk about a specific concern or event, that’s okay, but try to keep that part of the discussion brief.
   
   
3. If the distraught student doesn’t want to say much, it’s perfectly okay to acknowledge that the student appears to be upset and to ask how you can help. If the response is “No, I’m okay”, a simple statement that you’re available for a future conversation may be all that’s necessary. However, if you have any concern about the student’s safety or risk for self-harm, you may need to consider getting help. In a school setting, a counselor or school psychologist may be available to consult with you. If the student is a minor, contacting the parent or guardian might be the next step. In extreme circumstances, your only option might be to call 911.
   
   
4. If the student wants to talk, your main role will be that of the active listener. Active listening is a combination of remaining non-judgmental while the student talks, reflecting back what the student has said and providing empathy. Specific examples are provided in the link below.
   https://med.dartmouth-hitchcock.org/documents/supporting-emotional-distress.pdf
   
   
5. After listening to what the student wants to say, the next step is to come up with a plan. If you can, offer the student something that is comforting, such as a tissue for tears or a comfortable place to sit. It may be worthwhile asking the student what they would like to do. As long as what the student wants to do is not dangerous, that can give them a sense of ownership and   responsibility in being able to solve the problem they’re facing. If the student’s suggestion doesn’t include getting professional help, it’s appropriate to bring that up as an option, even if it’s framed as “someone to talk to”. 
   
   
6. To wrap things up, try to get the student to agree to some type of follow-up plan. If you have another lesson scheduled in a week or two, ask the student to commit to taking some particular action by then. If you feel the need to be in touch with the student sooner, ask for permission to do so by phone, text message or email.

Contact Ralph Manchester, MD at: [email protected]

A: The decision to engage in group singing during the Covid-19 pandemic, an international, national, and local health emergency, is personal. Large-scale vaccination will be the only way to allow singing to resume in pre-pandemic format. Existing scientific knowledge, ongoing scientific studies, and resources from singing/performing arts, health, and government organizations mentioned below offer recommendations for possible mitigations and precautions, as you assess your risk and make decisions about singing at this time.

• COVID-19 MODE OF TRANSMISSION: 
  • Covid-19 is a novel Coronavirus infection primarily spread through the air via infected droplets/aerosols and by contact with infected particles. Link-TIME article Aug 25 
  • SINGERS ARE AEROSOL SUPER-SPREADERS AND AT HIGH RISK WITHOUT PRECAUTIONS. Before Summer 2020, aerosol scientists inferred from existing data on coughing/ sneezing/loud talking that singers are super spreaders because they emit a high volume of droplets/aerosols.
• GUIDELINES/RESOURCES FOR SINGERS FROM PERFORMING ARTS ORGANIZATIONS
  • In early May, National Assoc of Teachers of Singing/American Choral Directors Association/ Barbershop Harmony Association/Chorus America began a series of webinar discussions with medical and scientific experts and developed resources to manage Covid-19 for singers. Link-NATS Resources, Link-ACDA Resources
  • Performing Arts Medicine Association and many other organizations created guidelines for teachers, singers, instrumentalists, and dancer/athletes. Link-PAMA Guidelines. 
  • One should also refer to the guidelines from CDC Link and local health officials regarding Covid-19 risk and management of the disease.
• UNPRECEDENTED COALITION OF ARTS ORGANIZATIONS FUND AEROSOL TRANSMISSION STUDY: 
  • In June, the National Federation of State High Schools (NFHS) Link-NFHS Covid19 Resources and College Band Directors National Association (CBDNA) led a coalition of 85+ international arts organizations, including CMS, to support a six-month study of aerosol transmission by wind instrumentalists, classical and CCM singers, actors dancers/athletes, child singers, and senior singers at Univ. of Colorado-Boulder and Univ. of Maryland.
  • PRELIMINARY RESULTS STRONGLY SUGGEST SINGERS ARE SUPER SPREADERS.
  • Other similar studies are underway at Colorado State Univ. and other locations. 
• CU-BOULDER/UMD STUDY TAKEAWAYS: (These are from preliminary results, not yet peer-reviewed, but offered to aid faculty/students/administrators in planning for the start of school in Fall 2020.) 
  Preliminary Report #1-July 13-Summary Update Link; Slides with results: Link
  Preliminary Report #2-August 6-Summary Update: Link; Slides with results: Link
  • MASKS: 
    • EVERYONE needs to wear masks at all times-students, faculty, staff. 
    • Fit matters! No gaps, nose covered, tight around the edges, pleated surgical (not N95) or 3-layer cloth mask preferred. 
    • Bandannas, tube/single-layer masks, or face shields not recommended.
  • DISTANCE: 
    • Keep a 6-foot distance surrounding each performer, 2 arm lengths apart. 
    • Applies indoors and outdoors.
  • TIME: 30-minute rehearsal maximum in one space. 
    • A longer time risks a dangerous concentration of infectious particles. 
    • Try to limit amount of full-out singing. Sing softer to work on technical issues.
    • Avoid moving in the space during rehearsal. Stop singing 5 minutes before rehearsal ends to allow aerosols to disperse.
  • LOCATION: 
    • Outdoor sessions preferred: using a tent with no sides is ok; a tent with sides has no ventilation and is worse than indoors.
    • Move location every 30 minutes, with a 3-5 minute break to reduce aerosols.
    • Indoor sessions: consult building technology team. 
    • HEPA filter and enhancement of HVAC air exchange cleansing recommended. 
    • Determine Air Change Rate per Hour (ACH) for your room. Let the room stand empty for 1 complete air exchange between class sessions (3 exchanges is best); i.e. 1 exchange=20 minutes, 3 exchanges=60 minutes.
  • HYGIENE: 
    • Control entrance to/exit from the room. 
    • Limit numbers in the room and in equipment/folder storage areas to allow 6-foot social distancing. 
    • Avoid sharing items such as books, folders, sheet music. 
    • Use frequent handwashing and make 60%-alcohol hand sanitizer available in multiple places.
  • REHEARSAL TECHNIQUES: 
    • Place performers in straight lines (not curved in to face center). 
    • Conductor should consider using amplification and ALL should avoid loud talking. 
    • Plan 3-5 minute non-singing breaks to reduce aerosols.
• COVID-19 SYMPTOMS IN SINGERS/POSSIBLE AFTER-EFFECTS/REHABILITATION:
  • Symptoms vary from person to person. Severe shortness of breath and coughing lasting for weeks common. 
  • Allow time for a very slow return to singing, rebuild the voice only as you are able. 
  • Consider working with a Singing Voice Specialist or Voice Teacher to recover.
  • In-depth symptoms for singers and potential singer-specific after-effects: Link.  Singer/Dancers Cardiac After-Effects: Link. 
• ASSESS YOUR RISK TOLERANCE: 
  • Risk Assessment/Estimator Tools may help clarify your willingness to engage in group singing based on your physical health, safety concerns, and your mental health concerns of limiting the role of singing as an expression of artistry and personal/professional enjoyment. Link

1. Discuss the problem with your teacher first, and do it early – don’t wait until your problem is severe or an important playing date is approaching.
2. Be honest, candid, complete, and forthright about symptoms and how they affect playing.
3. State to your teacher and medical professional how you have tried to treat this on your own.
   1. Music-related “treatment”– modification of setup, practice, technique.
   2. Other modalities – physical and/or pharmaceutical.

1. Become aware that something is troubling your student; listen and observe.
2. Ask student about the problem and try to determine if it is music-related. If so, try to find the cause – use observation, questioning. Then develop playing-related strategies to deal with it. If these are not working -> recommend professional help. If not, find out how it affects playing. 
3. Can your student still play without damage or increased symptoms? 
   1. If so, resume slowly and carefully; stop if symptoms reappear.
   2. If not -> recommend professional help

1. Recognize your patient is a musician and wants to keep playing; music is their life.
2. Learn how symptoms affect the requirements for playing.
3. Try to make a provisional diagnosis.
4. Use history and physical exam; additional evaluations as indicated.
5. When possible, observe student playing their instrument – look for:
   1. Signs of discomfort or pain
   2. Improper postures
   3. Use of excessive force when playing
6. Plan a course of treatment – conservative whenever possible. This may involve both  musical and medical types.
7. Try to preserve some playing opportunities.
8. Follow up to determine efficacy of treatment; modify if necessary.