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13 Articles in Volume 18, Issue #7
A Commentary on Medical Cannabis
Are Abuse-Deterrent Opioids Appropriate for Your Pain Patient?
Behind the AHRQ Report
Challenges Facing Abuse-Deterrent Formulations
Demystifying Opioid Abuse-Deterrent Technologies
Editorial: Our Clinical Pain Neighborhood
Independent Pain Practice: A Case Example
Inside Performing Arts Medicine
Letters to the Editor: ACT Therapy; Compounded Topicals
Nerve Growth Factor and Targeting Chronic Pain
Pain Control for Athletes: What Works?
Quality Training: One Center’s Experience with Pain Assessment
The Importance of Developing Professional Relationships in Pain Practice

Inside Performing Arts Medicine

A history of and treatment approaches for managing the unique MSK problems experienced by musicians.
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What is Performing Arts Medicine?

Performing Arts Medicine (PAM) focuses on the care and treatment of specific problems affecting performing artists, including musicians, dancers, singers, and actors. Although PAM may be considered a branch of occupational medicine, many performing arts practitioners do not have an occupational medicine background and represent a wide variety of medical specialties.1,2 PAM is, rather, more analogous to sports medicine as it involves treating small and large muscles and other soft tissue structures. For example, dancers often experience muscle overuse injuries that can lead to tendinitis or muscle strain in large muscles; while musicians may develop bursitis or tendinitis when smaller muscles are required for repetitive fine motor control (special attention will be placed on the instrumental musician for purposes of this review). PAM clinicians work closely with a variety of medical specialists, such as those in physical medicine and rehabilitation, neurology, hand/orthopedic surgery, rheumatology, and otolaryngology, to provide performing artists with comprehensive care.

Performing Arts Medicine evolved as a medical specialty in the 1980s based on the work of Australian orthopedist Hunter Fry, MD, as well as the research of Richard Lederman, MD, and Alice Brandfonbrener, MD, in the United States. From their early studies, it was discovered that many performing artists were suffering from a variety of medical problems related to their field.3 Initially, PAM literature was limited, consisting mainly of materials published by the Performing Arts Medicine Association (PAMA), among them the Textbook of Performing Arts Medicine and the Journal of Medical Problems of Performing Artists. While there were only about 100 English-language articles published during the 1970s, more than 400 PAM articles were published in the 1980s.3 One researcher identified 1,366 performing arts papers from 1997 to 2001, and in the next five years, 1,438 music medicine articles were released.4 The steadfast increase in publications has led to a growing interest in PAM, but perhaps more pertinent, has been the rise of documented performance-related injuries and their related studies.5-13

Categorizing Common Medical Problems Among Performing Artists

Medical problems facing performing artists can be divided into two categories: performance-related (or caused) problems and performance-affecting problems. Each category may be subdivided into musculoskeletal (MSK) problems and non-musculoskeletal (non-MSK) problems (see sidebar, “Performance-Related MSK/Non-MSK Problems”).

Muscle overuse syndromes commonly occur in musicians as certain tissues are engaged repetitively. The biomechanical stresses from these repetitive tasks may result in micro-tears that lead to disruptions of normal collagen repair cycles, disorganization of the collagen matrix, and the development of cumulative cellular damage due to a failed healing pattern with zones of hyper- and hypoplasia.14,19 Factors leading to overuse may include genetics, performance technique, practice habits, duration and intensity of play, and conditioning of the musician.15

Non-MSK performance-related problems may include performance anxiety or “stage fright” that can have a severely negative impact on a performer’s ability to perform. Studies have shown that 17% of professional symphony members had severe stage fright, where as upward of 50% are at least somewhat negatively impacted.6 Since stage fright symptoms include severe nervousness, shakiness, increased heart rate, and perspiration, beta-blockers such as propranolol 10 mg have been useful in helping to control symptoms. Approximately 27% of musicians with stage fright use beta-blockers.6

In addition, certain chronic pain conditions, which are not exclusively performance-related, may still be performance-affecting. These include MSK conditions such as osteoarthritis, headaches, autoimmune disorders with joint or muscle problems, and neuropathies. Non-MSK performance-affecting problems may include asthma, allergies, sinusitis, loss of vision, depression, Parkinson’s Disease, and so forth.

Assessing Performance-Related Musculoskeletal Problems

Overuse injuries are the most common injury in the performance-related MSK category, with incidence higher in women than men (1.7:1), often due to the smaller anatomy of the upper extremities which require greater stretch to play musical instruments, such as the piano.15 Injury location is most common in the areas of greatest repetitive motion, namely the hands, forearms, elbows, and shoulders.

Instrument-specific injuries are also common. For instance, among violin and viola string players, the left hand is often fingering the instrument and, therefore, is in constant motion, while the bowing right arm is more prone to shoulder or elbow overuse. Similar usage of both upper extremities is common among guitar and mandolin players. The static load of the instrument itself becomes significant in brass instruments, so supportive harnesses are of value. In piano playing, both hands are in constant motion, and the wrists are often in an abducted/adducted position, potentially adding strain. Large octave stretches across the keyboard can injure smaller muscles of the hands. While woodwind instruments place hands and forearms in a more anatomically neutral position, instruments such as the clarinet or flute put undue force on the right thumb or left first index finger, respectively.

Common Physical Examination Findings

Last updated on: October 4, 2018
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