Hazardous Harmony

By Claudia Stahl

IF TREATING MUSICIANS is part of your clinical repertoire, here's some enlightening news you'll want to tune in to: Musculoskeletal injuries in musicians may be more closely linked to stress, gender and instrument type than to overuse.

In a study of 281 classical musicians and music students, stress was found to be one of the greatest contributors to playing-related musculoskeletal disorders (PRMDs), says Christine Zaza, PhD, postgraduate fellow with the Medical Research Council of Canada at McMaster University, Hamilton, Ontario, who conducted the study. Female musicians were twice as likely to be injured than men, as were string musicians, she says.

Dr. Zaza, who specializes in research of chronic pain management and performing arts medicine, says the gender findings are unparalleled in ergonomic studies because orchestra musicians, regardless of gender, perform identical job tasks and play identical music. The research did not reveal why women were at higher risk, but Dr. Zaza urges female musicians to take heed nonetheless with precautions, such as warming up before long sessions of playing.

An example of her own research, Dr. Zaza had to abandon her aspirations to be a classical musician when thoracic outlet syndrome precluded her ability to play the violin and piano. While her condition was not related to overuse, she resolved to discover how many other musicians were living with pain. "Now I focus on getting the information out there to people who need it," says Dr. Zaza, who founded the Canadian Network for Health in the Arts.

Doctors and therapists who treat musicians find that most problems are in the upper extremities--hands, arms, shoulders, back. Many of these injuries are also from improper body use more so than overuse, says Nicholas Quarrier, MHS, PT, OCS, director of the Ithaca College Physical Therapy Clinic, Ithaca, N.Y. "Plenty of people play eight hours a day and don't get hurt," he notes, "because they are using their bodies efficiently."

Quarrier assesses musicians' body mechanics as they play in the clinic and at an annual summer educational colloquium, The Health Performance Institute for Musicians. He has taught musicians to significantly reduce pain and injury by simply changing how they hold or play their instruments, and applying other ergonomic strategies, such as taking breaks during practice.

But some of these strategies break with tradition, and meet with considerable resistance in the music community. For instance, few orchestral leaders and music educators are open to musicians holding their instruments in a way that interrupts group uniformity. Many also resist ergonomically friendly instruments, even though many are said to sound just as good as standard instruments.

Musicians who face this dilemma can at least change their body mechanics during practice, says Quarrier. But changing body mechanics produces limited results when musicians don't control their stress levels. Quarrier, Dr. Zaza and other experts concur that the tremendously competitive world of classical music exacerbates injury. Limited openings in orchestras, for instance, leave these musicians fiercely guarding their chairs.

Even as early as grade school, some musicians learn that expressing pain to an orchestra leader means risking loss of status, even a job. "The professional, classical musicians...are most afraid to address and approach pain," says Lori Stotko, OTR, CHT, of the Performing Arts Medical Care Program at the Palo Alto Sports Injury Center in Palo Alto, Calif. "Some have been taught to play through the pain."

Such pain often strikes classical musicians when they overprepare for a recital, performance or competition. Keeping stress in check and keeping practice hours within reasonable limits may reduce injury. Stotko, a jazz musician, also recommends replacing some physical practice with a mental review of the music, or a video or audio review of themselves playing.

"This is especially [helpful] for musicians who are injured or have a limited amount of playing time before they start experiencing pain," says Stotko.

Musicians are also at risk for injury when they acquire new or different types of instruments with an unfamiliar tension and design, since these can stress the body. Piano players are especially vulnerable because they routinely move from instrument to instrument, accompanying performers. Adjusting stool height and maintaining proper body mechanics may reduce injury, experts say.

Changing musical repertoire is another risk factor. The pieces by Russian composer and pianist Sergey Rachmaninoff, for instance, are an athletic undertaking for even the most seasoned musicians (if you have any doubt, rent the movie "Shine").

Without precautions, this, along with other risk factors mentioned, can lead to carpal tunnel syndrome, dystonia, and TMD--merely a handful of overuse problems musicians can develop. Pain, swelling, tingling and numbness are the body's signals for help, experts say.

But musculoskeletal problems aren't always from playing. The majority of the injuries that John Lu, MD, treats are related to occupational injuries, especially back and neck computer-related problems. He is a classically trained pianist and physical medicine and rehabilitation specialist at the Palo Alto Medical Clinic and has helped many musicians play more safely by teaching them to adapt their work and performance routines.

Specifically, musicians should apply a sports-medicine approach to practice and performance, Dr. Lu recommends. Like athletes preparing for a sporting event, musicians who gradually warm, cool, condition and strengthen their muscles are less likely to be injured. These exercises should strengthen the whole body, not just the arms and hands, adds Dr. Zaza.

While being a musician and a clinician enhances his knowledge of how to treat these artists, this isn't necessary, especially for OTs, says Stotko, who fills this bill.

"OTs are [naturals] at this because of their training in task and activity analysis," she says.

And little by little, their message of injury prevention--along with other rehab clinicians--is trickling out to musicians. But is it reaching music educators?

Steven Mandel, MD, professor of neurology at Thomas Jefferson University in Philadelphia, who routinely treats school-age children for musculoskeletal injuries related to playing instruments, is not convinced it is. This is unfortunate, given that educators play an important role in preventing long-term damage.

"Coaches and teachers who understand the problem can help [young] musicians make appropriate modifications," says Dr. Mandel. "When microtrauma turns into major trauma, it becomes permanent at times, even after surgery."

This article originally appeared in Advance for Physical Therapy and Rehab Medicine, April 1, 1998.