To You and Your Students’ Good Health: Q & A Column 2022

Compliments of the CMS Committee on Musicians’ Health 

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The Musicians’ Health Committee, comprised of medical professionals and music faculty, all strong advocates for musicians’ health, is happy to bring you a Q & A column for this month's CMS Newsletter. If you like this idea, please send us your musicians’ health-related questions which we will direct to our committee members, or other professionals with whom we have contact, to be answered in future newsletters. Linda Cockey and, Heather Malyuk Committee Co-Chairs.

 

Q:“When should a musician start seeing a Physical Therapist and how do you find a provider?”
Answered by Janice Ying, PT, DPT: April, 2022.

Dr. Janice Ying is the founder of Opus Physical Therapy and Performance in Los Angeles, CA - a physical therapy practice specializing in rehabilitation and wellness for performing artists. She currently serves as the Wellness Professor at the Colburn School - Conservatory of Music and is an Adjunct Clinical Instructor at the University of Southern California - Division of Physical Therapy and Biokinesiology.

Experiencing an injury that affects your ability to play is not only stressful, but can have long-lasting consequences if not properly addressed.  A large percentage of playing-related injuries among musicians stem from overuse, rather than due to a sudden traumatic onset, like in sports injuries.  Physical Therapists are the experts when it comes to human movement and can help you develop strategies not only to overcome injuries, but to prevent them in the first place.  

Here are some things to consider when deciding whether or not to seek care from a Physical Therapist:

  • Identify what factor(s) may be contributing to your symptoms.  Was there a recent change in your playing load or practice schedule? Learning a new technique? Picked up a new hobby?  Identifying and potentially modifying some of these things may help resolve your symptoms.  You may want to work with your teacher or professor in the early phases to find a solution.
  • How long do the symptoms last?  How quickly symptoms come on and/or take to resolve after you’ve stopped the painful activity may be a good indicator whether to seek help or not.  
  • What type of symptoms are you experiencing?  If you feel numbness, tingling and/or weakness, it is recommended that you seek care sooner rather than later.  
  • How long have you been feeling these symptoms?  When it comes to injury care, sooner is always better than later.  

Generally, I would suggest trying to make modifications on your own and if there is no improvement or even a worsening of your symptoms, wait no longer than 2 weeks before reaching out for help.  That is, unless you are experiencing very concerning symptoms such as weakness, excruciating or persistent pain, then seek help as soon as possible.  Many states in the US now have direct access for physical therapists, which allows patients to go directly to a PT without a physician’s referral.  This can often cut down on wait time to receive care.  Every state law is different, so be sure to ask your PT if there are any limitations or restrictions if choosing to go this route.

Here are some things to consider when choosing a Physical Therapist:

  • Find a therapist who understands the physical and cultural demands of instrument playing - or one who will take time to do so.  There are a number of physical therapists across the country who have specialized in treating instrumental musicians.  Below are two directories to help find a performing arts medicine specialist in your area.  If you do not live in an area that is easy to access one of these specialists, take time to find someone that will listen to you and put in the effort to truly understand your goals and develop an individualized plan to help you get there.  
  • Performing Arts Medicine Association (PAMA)Directory:  https://pama.memberclicks.net/referral-directory
  • American Physical Therapy Association (APTA) Directory (Under ‘Practice Focus’ choose Performing Arts Physical Therapy):  https://aptaapps.apta.org/APTAPTDirectory/FindAPTDirectory.aspx
  • Ask your friends and colleagues about their recommendations. Trying to sort through the pool of healthcare professionals on your own often can feel like throwing a dart blindfolded.  Ask your colleagues about their experiences to help narrow the field.  However, always keep in mind that what worked for one person may not always be the right fit for you.
  • What is their training background and experience?  Physical therapy is a diverse field with many different approaches.  Find someone whose treatment approach is in line with your own preferences.
  • If playing related, bring your instrument (if applicable) and have them watch you play.  While your therapist may not know how to play your instrument (bonus points if they do), they should have the skills to analyze the task and look at your playing from a biomechanical perspective to see if there are any positions or movements that may be contributing to your symptoms.
  • Assemble your healthcare team BEFORE there is a problem.  Being proactive and establishing a relationship with your healthcare providers prior to there being a problem is always recommended.

Q:“What have athletes known for years that musicians are just beginning to apply to their practice and performances?”
Answered by Randall Dick: February, 2022.

 

Randall Dick, M.S., FACSM, is a member of the American College of Sports Medicine. He has worked for 20 years with the National Collegiate Athletic Association, managing its sports medicine and injury prevention programs. He has authored more than 50 peer-reviewed publications and served on the US Lacrosse Sports Science Committee and as a consultant for Major League Baseball injury surveillance. He began developing the Athletes and the Arts initiative after a conversation with the New Orleans-based Preservation Hall Jazz Band Randall leads this organization, an initiative that works to integrate sports medicine principles and wellness into the performing arts field. Since 2008 he has worked with de-identified healthcare data at Eli Lilly and Company and IBM Watson Health.

A: Like athletes, performing artists:

  • Practice and/or perform almost every day
  • Often play through pain and need pain management
  • Compete or are in challenging environments
  • Experience little or no “off season’’
  • Sometimes face extreme competition
  • Risk the temptation of substance abuse
  • Face significant risk of career-threatening injury

Issues facing both performing artists and sport athletes include:

  • Travel / jet lag
  • Nutrition / hydration
  • Overuse
  • Optimize performance
  • Mental health

Sport athletes have access to nutritional information to help them understand what and when to eat, as well as medical support for injury prevention, management, and rehab. In addition, they have access to film reviews (with the help of athletic trainers and coaches) so they can work on modifying posture, mechanics, pitch, Moreover, they have a sport psychologist to help them get out of a slump. Sadly, the performing artist (musicians, dancers, and actors) has many of the same needs but with little to no access to these same resources.

The Target Audience

Athletes benefit from a system that educates not only themselves but also medical professionals, coaches, trainers, and even parents about how to optimize health and performance. 

Performing artists would greatly benefit from the following:

  • Having teachers who can provide them with the names of appropriate medical professionals, should a student need to establish a health care relationship.
  • If possible, should an injury occur, perform for a health care professional, so they understand one’s craft
  • Document a week of typical activities (it would be beneficial if students would provide this information to a physician, therapist or other medical professional if needed)
  • Testing and education for musicians on music-induced hearing disorders as teachers should educate students about hearing preservation

Educators /Instructors in the performing arts should consider the following:

Medical Professionals seeing performing artists need to consider the following:

  • Know you are seeing a performing artist and understand the volume and intensity of the activity
  • Consider an annual pre-participation exam targeted to the specific activities of the performer
  • Use a team-approach whenever possible—medical professionals, teachers, therapist(s)

Lessons Learned from sport’s research that can be applied to performing artists

Practice and Performance:

  • The NUMBER of practice hours may hurt rather than help at some point – less is more
  • Consider FOCUSED practice segments with different goals in each session
  • Quantify the VOLUME and INTENSITY of performing arts activity(this should become standard practice of all performers using a simple tool for tracking performance hours for an appropriate session broken out by HIGH, MODERATE or LOW intensity)
  • Large ACUTE increases in time spent physically practicing increases the risk of injury. If the AMOUNT or INTENSITY of practice must increase, do it gradually and include adequate breaks

Recovery / Cross-training:

  • Emphasize the importance of both mental and physical rest and recovery
  • Employ alternative mental and physical activities that contribute to performance but use alternative muscle groups or mental focus—mental practice away from the instrument can strengthen skills

Mental Health:

Youths in today’s culture are driven to train early and extensively. Early specialization and extensive training creates well-documented risks of over-use injury, burnout, stress, and less enjoyment in youth sports and in the performing arts as well.  The importance of a coach or an instructor in establishing a safe and healthy environment is key for both sport athletes and performing artists.

A 2021 collaborative article published by the International Olympic Committee emphasizes the importance of attending to mental as well as physical health. See: Gouttebarge V, Bindra A, Blauwet C, et al, International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes’ mental health, British Journal of Sports Medicine, 2021;55:30-37 at: https://bjsm.bmj.com/content/bjsports/55/1/30.full.pdf

The System

Sport organizations such as the National Federation of State High School Association, the National Collegiate Athletic Association (NCAA) and various other governing bodies develop standards, guidelines and rules around practice and competition to enhance health and safety. For example, the NCAA has various guidelines shared with all institutions in a Sports Medicine Handbook and restricts formal practice of a sport to 20 hours a week.

Such oversite management would greatly benefit performing artists as well and provide them with accepted guidelines upon which to base practice, performance, and general participation.  A few examples are emerging, including The National Association of Schools of Music (NASM) Health and Safety Standard for all NASM accredited schools that reads in part: “It is the obligation of the institution that all students in music programs be fully apprised of health and safety issues, hazards, and procedures inherent in practice, performance, teaching and listening.” And “Music program policies, protocols, and operations must reflect attention to injury prevention and to the relationships among musicians’ health;” Specific methods for addressing these issues are the prerogative of the institution.”  See NASM Handbook 2020-21: - F.; 2.d.p. 67-68: https://nasm.arts-accredit.org/about/current-notices/current-notice-nasm-handbook-2020-21-published/  and NASM Advisories – NASM-PAMA: https://nasm.arts-accredit.org/publications/publications-a-z/ 

Measuring optimal performance and incorporating researched concepts

Compared to sports, optimal performance in the performing arts environment is currently somewhat subjective. This area could benefit from repeatable quantifiable measures around performance so one can accurately measure how performance changes after an intervention.  For example, in sports, practice limits are imposed for safety by NCAA, Little leagues and USA football while there is not really any formal limits or guidelines imposed as a standard protocol in the performing arts with regard to length and intensity of rehearsals.  If such measures were established, it would open the door to a variety of alternative training options (such as track athletes doing pool workouts) that could then be evaluated to see if they achieve a desired result and would possibly reduce overuse and/or injury on specific body areas.

Final thoughts and summary

Sport athletes benefit from established research and targeted education to themselves and the medical personnel and coaches who work with them.  Many of these findings are applicable to performing artists and would help to optimize their health and performance as practicing artists.  In addition, further research should be conducted in this population to better understand their unique characteristics and needs.

As jazz musician Jon Batiste, a classically trained graduate of Julliard (both bachelors and master’s degrees) and Ambassador for Athletes and the Arts stated:

“The conservatory environment is very different.  I went to Julliard six years and never in any of my lessons was there any instruction about nutrition or any sort of quantifiable method to determine the pros and cons of playing long hours.   If I missed a note, I was just told to do it again, to practice more”.

“…Music is healing and if you want to heal other people, you’ve got to heal yourself first. The healthier we are as musicians and the arts community in general, the better the world will be.”

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