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14 Articles in Volume 18, Issue #7
A 2018 Update: The Federal Pain Research Strategy
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 (Part 1).

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

A performer giving an example of his or her technique is often valuable during the physical exam and assessment. For the instrumentalist, physicians should observe the positioning of the neck, wrists, elbows, and shoulders, as well as the trunk and pelvis. The neck should be close to neutral position with normal thoracic and lumbar kyphotic and lordotic curvature. The trunk should be centered over the ischial tuberosities. The wrists and elbows should be as relaxed and neutral as possible without elevating or protracting the shoulders. Areas of increased tension may be observed or palpated during playing. Since instruments are typically played in front of the musician in an asymmetric body position where both arms perform separate tasks, the static load of the instrument creates a tendency to lean forward, causing muscular strain.

Forward posturing may lead to protracted scapulae, first rib elevation, pectoralis minor contraction, cervical and upper thoracic strain, and scalene muscle contraction, to name a few potential conditions. Common tender points in muscles may often be found in areas of strain, which would include the supraspinatus, levator scapula, upper trapezius, forearm extensors, and dorsal interossei.

Common postural and dynamic muscle groups are typically hypertonic (restricted) or inhibited (weak). Often due to the lack of physical conditioning in musicians, the rhomboids, lower trapezius, serratus anterior and forearm extensors are inhibited while the upper trapezius, levator scapulae, scalenes, latissimus dorsi, and forearm flexors are hypertonic.18 Physical examination of these muscles groups and somatic dysfunctions may help to focus appropriate treatment.

Treatment Approaches for the Performing Artist

Several studies have shown that upward of 70% of musicians suffer performance-related injuries at some point in their career.6-13 Traditional treatment—including physical or occupational therapy, medications such as diclofenac gel for localized inflammation, and surgery—may be beneficial. However, these modalities are sometimes insufficient to restore patients back to health due to the consistently high demands of their field.

A comprehensive treatment approach should consider all possible causes of the injury and require a rational and often multi-disciplined team (see sidebar, “Treating Performance-Related Musculoskeletal Problems”). Treatment should begin with prevention education, which may address behavior and lifestyle modifications, safe and sensible practice habits, proper nutrition, vitamins and supplements, and home exercise programs geared toward possible dysfunctions. To avoid muscle overuse, musicians should be advised to take frequent breaks approximately every 30 minutes for 5 minutes and to avoid, as much as possible, any muscular activity used to hold up heavy instruments by using a harness designed to carry the weight of the instrument. If there is concurrent pain, practicing and playing must be discontinued indefinitely until the pain has resolved.15 Muscle strengthening and flexibility exercises, such as yoga, tai chi, deep muscle massage, rolfing, or osteopathic manipulative treatment (OMT), may help to reduce the potential for injuries as well.

In fact, one of the most essential tools a physician can utilize in treating performing artists is OMT. This soft tissue, hands-on approach using modalities such as strain-counterstrain, muscle energy technique, and myofascial release may restore range of motion and improve healing.16-18 The authors’ approach to the performing artist involves all of the above modalities, noting that techniques that relieve tissue stress and tension such as strain-counterstrain and myofascial release seem the most efficacious, followed by stretching techniques such as muscle energy. Muscle strengthening exercises of the injured tissue are generally avoided until the patient is relatively pain free.

It is also important to regularly assess and treat performing artists when they have co-occurring performance-affecting MSK problems. For instance, muscle spasms in the upper back, from an acute trauma for instance, may lead to muscle strain in the neck and subsequent tendinitis in the forearm or hand. A single problem such as this may compound into several complications, propagating from one region of the body to another. A thorough osteopathic physical examination requires structural examination from head-to-toe with emphasis on the area of pain, but not neglecting contributory dysfunctions occurring elsewhere in the patient.


A thorough understanding of the performance artist’s demands, instrument-specific injuries, and physical examination findings is crucial to providing a comprehensive treatment plan. A complete evaluation involves spending adequate time with the performing artist to obtain the patient’s history, with a focus on the performer’s lifestyle, practice habits, exercise routine, nutrition, stress level, and contributory medical problems. PAM physicians must be prepared to adhere to the evening/weekend hours and tour schedules of performance artists, putting into place a multi-disciplined approach that utilizes one or more of the following modalities: pharmacotherapy, exercise, nutrition, supplements, stress reduction, surgery, OMT, chiropractic manipulation, physical or occupational therapy, massage, Alexander or Feldenkrais techniques, or alternative medicine approaches. Since an injury to a performing artist may be physically, emotionally, and financially devastating, these patients require a treatment plan designed to meet their unique needs, allowing them the best opportunity to recover and return to their art.


Part 2 of this article focuses on temporomandibular disorders in performance artists.

Last updated on: December 9, 2019
Continue Reading:
Temporomandibular Disorders in Performance Artists (Part 2)
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