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Persons choosing a musical career path are exposed to several unique factors that make them susceptible to possible development of upper extremity symptoms.  Performers are often required to assume unconventional positions (i.e., a violinist's left arm) and endure intensive use of their upper extremities on a daily basis.  The harmful effects of these factors are compounded by the fact that a musical career usually spans a lifetime, resulting in the possibility of 70-80 years of risk for development of symptoms.  It is important for musicians to implement safety measures for prevention of injuries and to recognize the signs and symptoms of possible upper extremity dysfunction.

Every musician should seek to understand the risk factors unique to their career and measures available to prevent injury or disabling upper extremity symptoms.  To effectively prevent injury and onset of symptoms in musicians, one must consider possible intrinsic (having to do with your body) and extrinsic (outside forces) contributing factors.

• Intrinsic factors that need to be assessed include age, nutrition, anatomic variations, flexibility, physical strength, size, joint laxity, gender, systemic disease, performance level and playing style.
• Several extrinsic factors can also place musicians at a higher risk for injury or symptoms.  These include:
  • an environment that is too hot, too cold, cramped or pressured
  • hobbies, an occupation, or sports activity that involves repetitive or sustained movement.
  • time and intensity of playing
  • size and shape of the instrument
  • quality of the instrument

Symptoms of upper extremity dysfunction can vary considerably from one musician to another.  In some cases, the symptoms will only be present during execution of certain techniques, when playing a specific instrument or after playing for extended periods of time.  As symptoms worsen, they will tend to be present more often and increase more easily.  Symptoms may include

• pain
• tenderness
• swelling
• popping
• snapping
• cramping
• lack of coordination
• tremor

The type of symptoms present will depend on the tissue involved and the severity and type of dysfunction.  Musicians, much like other well-trained athletes, are generally very perceptive of changes in their musculoskeletal system, especially if those changes interfere with their ability to play their instrument.

Identification of any signs or symptoms of dysfunction warrants further evaluation and implementation of treatment strategies.  These treatment strategies may include:

• rest
• orthotic supports
• medications
• specific exercises
• therapy
• education, and/or
• revision of playing techniques

In extreme cases, surgery may be beneficial.  Any specific treatment program should be individualized and directed by a trained medical professional.

Tips for Musculoskeletal Health

• Listen to your body: If you are experiencing extreme muscle fatigue, pain, muscle weakness or numbness address the issue now. These can be warning signs and if ignored you may damage your body to such an extent that you are forced to give up making music.  Nobody wants that.
  • There is nothing to be ashamed about many musicians have to address issues like this.
  • If any of these conditions are chronic (pain nearly all the time) or severe, consult your physician.
  • If you are referred to a specialist or physical therapist you may want to try and find one who works regularly with musicians. Ask music department faculty for names of local specialists who enjoy working with musicians.
  • Talk with your applied teacher about your pain/numbness/weakness and look for ways that you can improve your musical technique to help you.
  • Work with the department's Alexander Technique teacher to discover and lessen excessive tension, encourage relaxation, and improve your alignment/posture.  All these can help alleviate the pain and in conjunction with any medical intervention can help you heal and avoid further injury.
• If you experience occasional musculoskeletal discomfort or occasional pain associated with playing:
  • Talk with your applied teacher about this and look for ways that you can improve your musical technique to help you.
  • Take an Alexander Technique class to discover and reduce excessive tension, encourage relaxation, and improve your alignment/posture, or work privately with a local Alexander Technique teacher, and/or attend an Alexander Technique workshop.
    • American Society for the Alexander Technique of Alexander Technique teachers and workshops
    • Alexander Technique International of Alexander technique teachers and workshops.
• Relaxation is important
  • Take time to relax before you practice, rehearse, or perform. This can be as simple as doing some deep breathing, a little yoga or some "constructive rest".
  • Make relaxation a part of your daily regimen (especially when you are under stress). Tension is cumulative.  If you make relaxation activities part of your daily life, you will reduce the overall tension your body accumulates.  When you are feeling stressed, this is the most important time to keep to your relaxation activities as they will help you deal with the stress.
• Take frequent breaks.
  • During practice sessions make a point of getting up (if seated) stretching and walking around the room/along the corridor for a minute or two about every 20 minutes.
  • During rehearsals when you are not the focus of the rehearsal (i.e. the director is working with another section or you have a break/rest in your music, make a conscious effort to move, breathe, and let go of any tension you notice.
  • During performances be sure to start a piece with the best relaxed posture that you can. If you tense up during the piece, know that at any break in the music or at the end of the movement you have a choice to let go of the accumulated tension and to re-activate your relaxed posture.  Learning how to do this can also help you deal with issues of performance anxiety!
• Learn to practice efficiently.  Rather than putting in x number of hours, make your practice efficient and effective, thus reducing the hours you need to spend.  Talk with your applied teacher about strategies to make your practicing more focused.Observe how you use your body when you are not making music.  For example, if you are a pianist who experiences back pain when you play piano, you will want to look at your posture when you sit at a desk in the classroom, when you sit watching TV, when you sit at the computer in fact, all the times in the day you are sitting.  Improving all these will help you address the pain when you play piano.  Instrumentalists with wrist issues may need to look at how they use the computer keyboard as well as how they play their instrument.
  • Madeline Bruser, The Art of Practicing: A guide to making music from the heart. New York: Bell Tower, 1999.
• Vocalists:  Good, relaxed posture has a huge effect on your vocal use.  If you are experiencing excessive vocal fatigue, reduced range, or other issues; be sure to look at your posture and tension as possible causes.  Remember also that how you use your voice in your daily life (speaking) is directly related to how you use it when you sing, so be curious about how you might improve your speaking too.

Tips for a Healthy Voice

• Drink plenty of water.  Drink 6-8 glasses of water each day to keep your vocal folds lubricated.  Avoid beverages that can cause dehydration, such as: coffee, tea, caffeinated and alcoholic beverages.
• Take a vocal nap.  It is important to give your voice a break, whenever possible.  Just like other muscles the vocal cords can also become fatigued.  This can be worsened by yelling or talking in noisy areas.  If your voice feels tired, you should take a break.
• Reduce or decrease throat clearing and coughing.  Clearing your throat and coughing is similar to slamming the vocal cords together.  Excessive throat clearing and coughing can cause vocal cord injury and changes in voice quality.  This can result in an increased effort to produce voice.  Alternatives to throat clearing are: take a small sip of water, swallow, or gently clear the throat.
• Moderate voice use when sick.  It is especially important to decrease vocal use when you are sick, particularly when your voice sounds hoarse or feels tired.  Using your voice when irritated can only exacerbate the problem.
• Avoid smoking and smoky areas.  Smoking is damaging to the vocal folds.  It is well known that smoking leads to lung or throat cancer.  Primary and secondhand smoke irritates the vocal folds and causes edema on the vocal folds.  This will permanently change voice quality, nature, and voice producing capabilities.
• Vocal warm-ups and cool-downs.  Just as with exercise, your vocal folds need to warm-up and cool-down. It is important to add these aspects to your daily routine before and after singing or extended voice use (like teaching or preaching).  Voiced lip trills and glides are examples of exercises that will help to get your vocal folds ready to work efficiently, as well as cool-down from extended voice use.
• Coordinate your airflow.  Take the time to pause in between talking and take a good breath, instead of waiting until you almost run out of air.  Common voice quality - Glottal fry at the end of your sentence.
• Amplification system.  Consider using a microphone when you have the need to project your voice and decrease increased effort and strain.
• Physical activity.  Increase your physical activity to increase blood flow and oxygen to the muscles involved in voice use.  Physical activity will also increase coordination of muscles of breathing and phonation.
• Get adequate rest.  Overall adequate physical rest will make voice production easier.
• Listen to your voice.  Feeling vocally tired or sounding hoarse, or increased strain to produce your voice is not normal.  If you are experiencing any of these symptoms for extended periods of time, please consult an ENT or a Speech pathologist.

This 90-minute video shows a presentation given by Dr. Robert Sataloff at the 2008 National Conference of the National Association of Teachers of Singing. It provides a basic overview of essentials of anatomy and physiology that singing teachers should understand, as well as an overview of medical conditions that affect the voice, and basic concepts of evaluation and treatment.

Tips for Safety and Health

• Instruments - Both school owned and personal instruments are an easy way to catch or pass along a virus.  Individuals should make it a point not to perform on another individual's instruments.  If you must, use your own mouthpiece and insure you use your own reeds.
• Keep your instrument clean - Users of school owned or rented instruments are more susceptible to infection, especially if those instruments are not clean and maintained properly.  Make it a point to clean mouthpieces, flute head joints, bocals, and saxophone necks.  There are various cleaning solutions and brushes available for this purpose.
• Wash your hands - another solution to health care and safety is to remember to wash your hands before and after you use your instruments.

Resources

Use the following links and books below to help you stay informed:

• Conable, Barbara. What Every Musicians Needs to Know About the Body (GIA Publications, 2000)
• Klickstein, Gerald. The Musician's Way: A Guide to Practice, Performance, and Wellness (Oxford, 2009)
• Norris, Richard N. The Musician's Survival Manual (International Conference of Symphony and Opera Musicians, 1993)
• The National Association of Schools of Music (NASM) and the Performing Arts Medicine Association (PAMA) have developed a comprehensive set of jointly authored advisory documents on neuromusculoskeletal and vocal health for musicians. Information of a medical nature is provided by PAMA: information regarding contextual issues in music programs, by NASM. Visit this link () for more information on Neuromusculoskeletal Health and Vocal Health.
• Associated Board of the Royal Schools of Music (ABRSM), the world's leading authority on musical assessment, actively supporting and encouraging music learning for all
• Performing Arts Medicine Association (PAMA), an organization comprised of dedicated medical professionals, artists educators, and administrators with the common goal of improving the health care of the performing artist.
• Texas Voice Center, founded in 1989 for the diagnosis, treatment, and prevention of voice disorders.
• National Center for Voice and Speech (NCVS), conducts research, educates vocologists, and disseminates information about voice and speech.
• Vocal Health Center, University of Michigan Health System, recognized locally, regionally and nationally as a leading institution for the treatment and prevention of voice disorders. At the heart of the Center is a professional team comprised of experts from the University of Michigan Health System and U-M School of Music, encompassing the fields of Laryngology, Speech Pathology, and Vocal Arts. https://www.uofmhealth.org/conditions-treatments/ear-nose-throat/vocal-health-center
• A fabulous resource for books on all things related to music. This link takes you to the General Music section where you will find many books on performance health.
• Comprehensive listing of many useful links for performance health
• Exhaustive group of resources for repetitive strain injuries.