Kava Published Web Version

7/28/2019 Kava Published Web Version

1/30

Article

MusicPerformance

Research

Copyright2010

RoyalNorthernCollegeofMusic

Vol3(1)SpecialIssueMusicandHealth:130

ISSN17559219

Trunkenduranceexerciseandtheeffecton

instrumentalperformance:

apreliminary

study

comparingPilatesexerciseandatrunkandproximal

upperextremityenduranceexerciseprogram

KristieS.Kava,CathyA.Larson,ChristineH.StillerandSaraF.Maher

OaklandUniversity,MichiganandDetroitMedicalCenter

ABSTRACT: Instrumental musicians are at risk for upper extremity performance related

musculoskeletal

disorders

(PRMD).

Increased

trunk

muscle

endurance

and

neuromuscular

controlmayallowthemusicianmoreeffectivemanagementoftheupperextremitywork

load. Thepurposeofthispreliminarystudywastoinvestigateandcomparetheefficacyof

twotherapeuticexerciseapproachesdirectedtowardincreasingtrunkandproximalupper

extremitymuscleenduranceandneuromuscularcontrol,andtodetermineifthesechanges

affect instrumental performance. This study was an interrupted timeseries, twogroup,

preposttest experimental design. Participants included 14 universitylevel instrumental

musicianswhowereassignedeither toaPilatesmatexerciseprogram,oraconventional

trunkenduranceexerciseprogram. Trunkenduranceandsevenselectedaspectsofinstru

mentalplayingweremeasuredat thebeginningof thestudy,after thesixweekbaseline

(nointervention)period,andafterthetwoconcurrentsixweekexerciseinterventions. Fol

lowing both interventions, there was a significant increase in trunk extensor and lateral

muscle endurance. The participants reported a significant decrease in pain, fatigue, and

perceivedlevelofexertionwhileplayinganinstrument. Therewasnosignificantdifference

intrunkendurancewhencomparingthetwoexercisegroups;therefore,thePilatesmethod

wasequallyaseffectiveastheconventionaltrunkandproximalupperextremityendurance

exerciseprogram. Musicianeducationandwellnessprogramsshouldincludeexercisepro

grams that improve trunk muscular endurance and neuromuscular kinesthetic control,

thereby allowing the musician to improve the physical aspects of their performance and

achievetheirhighestlevelofmusicality.

KEYWORDS:Musician injuries,musicianwellness,therapeuticexercise, instrumentalists

exercise

1


2/30

Article

Therateofoccurrenceofmusculoskeletalinjuriesformusiciansrangesfrom39percentto

87percent,whichissimilartoworkrelatedmusculoskeletalinjuriesinthegeneralpopula

tion(Wu,2007;Zaza,1998). Morespecifically,76percentofthe4,025membersoftheIn

ternationalConferenceofSymphonyandOperaMusicians(ICSOM)reportedhavingatleast

one injury severeenough toaffectperformance (Fishbein,Middlestadt,Ottati,Strauss,&

Ellis,1988). Forprofessionalmusicians,evenaminormusculoskeletalinjury,whichmaynot

bedisablingtothegeneralpopulation,maysignificantlyaffecttheirabilitytoperform. The

musculoskeletal injuries incurredbymusicians inthecourseoftheirworkaredescribedas

PerformanceRelatedMusculoskeletalDisorders(PRMD)andaredefinedbyZaza(1998)as

neuromuscular disorders that develop from playing an instrument, rather than problems

thatmay interferewithplaying. Even ifPRMDdonotpreventthemusician fromplaying,

theymayaffectthemusicality(definedbyFink,2002,asabalanceofesotericandpractical)

ofhisorherplaying(ListerSink,2002). IdentifyingandaddressingPRMDarethereforees

sentialforthemusician.

Thenecessity

for

successful

prevention

and

treatment

of

musculoskeletal

problems

in

musicianshas led togreaterawarenessofPRMDamongmusicians,musiceducators,and

healthcareprovidersandtothedevelopmentofperformingartsmedicine. Thishasgrowna

greatdealoverthelastthreedecades. Oneofitsprimarygoalsiseducationforthepreven

tionandtreatmentofPRMD(Storm,2006).

Withinperformingartsmedicine, identifyingandmanagingboth thephysicalandpsy

chologicalstressencounteredbytheartistisdescribedasanimportantcomponentinmain

tainingthewellnessofthemusician. Wheninvestigatingthephysicalrequirementsandef

fectsofmusicalperformancethereareseveralfactorstoconsider. Themusicianmustoften

achievehighspeedcontrolofrepetitivecomplexupperextremitymovementpatternswhich

canlead

to

muscular

fatigue

(de

Lisle,

Speedy,

Thompson,

&

Maurice,

2006).

Some

instru

mentsalso requirestatic,awkwardpositioningof thejointsandmusclesof thespineand

upper extremities, which may add to muscular fatigue (Quarrier, 1997). In occupational

medicine research, undesirable functional changes have been found to occur in skeletal

muscleduringsustainedexertion,resultingindecreasedprecisemotorcontrolandskeletal

muscleoveruse injuriesincludingtendonitis,muscularpain,entrapmentneuropathies,and

focaldystonia(Bejjani,Kaye,&Beham,1996;Brandfonbrener,2006;Chaffin,1973;Hansen

&Reed,2006;Lederman,2003;Lederman,2006;LieNemeth,2006;Quarrier,1997;Zaza,

Charles,&Muszynski,1998). Theserequirementsofupperextremityspeed,coordination,

control,andmuscularendurance,alongwithstressfulposturalpositionsmaintainedforlong

timeperiods,

place

the

musician

at

an

increased

risk

for

PRMD.

RiskofPRMDisalsoincreasedbythepsychologicalstressthemusicianmayexperience

asaresultofgeneralanxiety,performanceanxiety(stagefright),anddepression(Steptoe,

2001). Heorshemayexperiencediscomfortwhileplayingresultingfromincreasedphysio

logicalarousal leading to increasedmuscular tension thatcancause injuries to theupper

extremity musculature. Musicians may experience these significant psychological and

physicalstresseswithoutrealizingtheirextentandtheeffectontheirhealth,andthenega

tiveimpactontheirmusicality.

Giventhedemandsencounteredduringperformance,themusicianmightbenefitfrom

atrunkstabilizationexerciseprogramthatwouldassistinefficientmanagementoftheup

perextremity

workload.

This

program

would

include

trunk

muscle

endurance

and

neuro

2


3/30

Article

muscularcontroltrainingastheyfacilitatetrunkstabilization. Panjabi(1992)definesstabili

zationasthecoordinationofspinalmusclecontrol,allowingthe individualtomaintainthe

neutralspinalpositiondynamicallywhileperformingactivitiesofdaily living. Accordingto

Hodges (2004) it is necessary for management of the upper extremity workload and is

achievedbycontractingthestabilizingtrunkmusclespriortomovingthearm. Suchcontrol

ofthetrunkmusculatureiscriticalfortheefficienttransferofenergyfromthetorsotothe

smallerextremitiesduringmanyactivities. It involvesmuscleandkinesthetic lumbopelvic

controlwherebytheribcageandpelvisremainconnectedduringtorsionalactivitiesofthe

trunk. In addition, scapular stabilization is a necessary component of trunk control and

whenpresent,mayassist indecreasing theworkload transferred to theupperextremities

during functional activities such as instrument playing (Tse, McManus, & Masters, 2005).

Therefore, trunkmuscularenduranceexerciseandposturalkinesthetictrainingare impor

tantcomponents inaprogramforpreventionandmanagementofPRMD(Ackermann,Ad

ams,&Marshall,2002;Hodges,2004;Palac&Grimshaw,2006).

Eventhough

exercise

is

considered

an

important

component

in

injury

prevention

and

rehabilitationforPRMD,thereareveryfewresearchstudiesexaminingtheeffectivenessof

exercise programs for musicians with randomized controlled trials. In a review article,

ShaferCrane (2006)described theuseof trunkandshoulderstabilizationexercises in the

treatmentofrepetitivestrainupperextremity injuries inthemusician. Thesewere found

effective in increasingtrunkmuscleenduranceandposturalkinestheticawareness. Inan

otherreview itwasreportedthatmanyofthemusculoskeletalpainandposturaldisorders

inmusicianscouldbepreventedbyaregularconditioningandcomprehensiveposturalpro

gram (Dommerholt,Norris,&Shaheen,1997). Thisprogram includedexercisestorestore

trunkandpelvic stability,motioncontrol, flexibility,musclebalance, strength,endurance,

andefficient

breathing

patterns.

Inasingleparticipantcasestudy,PalacandGrimshaw(2006)detailedacasehistoryin

volvinga femaleviolinistwith leftupperextremitypainonpalpationover the lateraland

dorsal forearm, insertion of the levator scapulae,and theupper trapezius. Thispatients

treatment plan included diaphragmatic breathing exercises, trunk strengthening, endur

ance,andkinesthetictraining,flexibilityexercisesforthecervicalspineandupperextremi

ties,andmanualtherapy. Thepatientrespondedwithdecreasedpainand increasedfunc

tionalabilityandremainedpainfreethroughthreeyearsofpostinterventionfollowup. In

PalacandGrimshawsopinion,themostimportantaspectoftreatmentforthisviolinistwas

her acquisition of the kinesthetic awareness of posture and position that allowed her to

continueas

aperformer

(Palac

&

Grimshaw,

2006).

Ackermannetal. (2002)comparedstrengthversusendurancetraining,specifically,for

the undergraduate music major. Nineteen undergraduate music majors participated in a

studyusingatestretestcontroldesign. Theywereassignedeithertoastrengthoranen

durancetraininggroupexerciseregimen,meetingtwotimesweeklyforsixweeks. Theex

ercisetrainingineachgroupwasdirectedatthetrunkandproximalupperextremitymuscu

lature. Endurance trainingwas found tobemoreeffectiveas theenduranceparticipants

reportedasignificantdecrease inperceivedlevelofexertionduringplaying. Basedonthis

literaturereview,increasingtrunkmuscleenduranceandneuromuscularcontrolisindicated

inthepreventionandtreatmentofPRMD(Brandfonbrener,1998).

3


4/30

Article

Having evaluated the physical demands placed on the musician and determined the

mosteffectivetreatmentprogramsforPRMD,wenowconsiderPilatesexerciseasaninter

ventiontomeettheneedsofthemusician. Pilatesexercisetraining,basedontheteachings

ofJosephPilates(18801967),claimstoincreasetrunkmuscleendurance,strength,flexibil

ityandneuromuscularcontrol. Itsgoalistoimprovegeneralbodyflexibilityandhealthby

emphasizing core (truncal) strength, endurance, posture, and coordination of breathing

withmovement. Itwasoriginallyusedalmostexclusivelybyathletesanddancers,buthas

recentlybecomemorecommoninrehabilitationandfitnessprograms. Morethanfivemil

lionpeoplepractisePilates intheUSA(Chang,2000). Theexercisescanbeadaptedeither

toprovidegentleenduranceandstrengthtrainingforrehabilitation,ortochallengeskilled

athleteswithavigorousworkout(Segal,Hein,&Basford,2004). InStottPilates,usedinthe

presentstudy,theoriginalprogramhasbeenmodified(Merrithew,2001)soastoincorpo

ratemorepreparatoryexercises, improvesafetyandpermitthemaintenanceofaneutral

spineposition.

Pilatestraining,

often

referred

to

as

core

strengthening,

focuses

on

extensor,

flexor,

lateral trunkandscapularmusculature. Thegoalof increasing trunkmusclestrengthand

endurance without straining peripheraljoints is achieved through coordinating breathing

withmovement;stabilizationofthescapula,pelvis,andribcageregions;andneutralhead

andcervicalspineplacement. Pilates instructorsprovide tactilecuesandverbal feedback

withvisualizationtomaximizemovementaccuracyandsafetyduringexercise. Pilatesexer

cises initiallyuseaminimal levelofforceonthetrunkmusculature. Asthe individualpro

gressesanddevelopsimprovedtrunkstrength,endurance,andkinestheticposturalcontrol,

the level of force placed on the musculature increases so as to retrain proprioceptive

mechanismswhilefosteringmoreefficientmovementpatterns(Segaletal.,2004).

Researchbased

evidence

to

validate

the

claims

of

Pilates

practitioners

is

just

beginning

to appear in the literature. Fortyseven participants attending aPilates matclass once a

weekforsixmonths,wereassessedforcompositeflexibility,bodycomposition,andselfas

sessmentofhealth, includingposture. Theparticipantsdemonstrated improvedflexibility,

but no changes in body composition or assessment of health and posture (Segal et al.,

2004). IncomparisonofPilatestrainingwithandwithoutequipment(anoblongshapedex

ercise ring) to exercise using conventional weightlifting equipment, Pilates training was

showntobemoreeffectiveformuscularendurancewhileweightliftingwasmoreeffective

formuscularstrength (Petrofsky,Morris,Bonacci,Hanson,Jorritsma,&Hill,2005). Aran

domized control trial study investigated the efficacy of Pilatesbased therapeutic exercise

treatmentas

compared

to

standard

care

(physician

consultation

without

any

specific

exer

ciseintervention)ofchroniclowbackpainandfunctionaldisability. ThePilatesmethodwas

statisticallysignificantlymoreeffectiveindecreasingchronicnonspecificlowbackpainand

functionaldisability(Rydeard,Leger,&Smith,2006).

Thus, existing research investigating Pilates exercise has shown that this method in

creasestrunkmuscleenduranceanddecreasespain. Inordertomanageupperextremity

workloads,itisnecessarytoachieveneuromuscularcontrolofthescapula,pelvisandspine.

Thisrequirestrunkmuscularendurancetomaintainstablepositionsduringfunctionalactivi

ties. AnexerciseprogramaimedatpreventionandmanagementofPRMDmay includePi

latesexerciseasanadditionalexercisemethodfortheinstrumentalmusician.

4


5/30

Article

Thepurposesof thisstudywere to:1) investigate theeffectivenessofenduranceand

neuromuscularcontrolexerciseprogramsdirectedat improving trunkandproximalupper

extremitymuscleenduranceandlumbopelviccontrol;2)determineifchangesintrunkmus

cle endurance and lumbopelvic control affect instrumental performance; 3) compare the

effectiveness of two typesof enduranceandneuromuscularcontrol exerciseprograms:a

Pilatesmatprogramandaconventionaltrunkandproximalupperextremityenduranceex

erciseprogram.

METHOD

Participants

Fourteen instrumentalmusicians(fivemen,ninewomen)withameanageof20.932.84

years(range

=18

29

years)

enrolled

in

auniversity

music

program

volunteered

to

take

part

inthisstudy. Theparticipantsplayedthefollowinginstruments:flute(n=5),trumpet(n=

2),oboe(n=1),clarinet(n=1),trombone(n=2),basstrombone(n=1),harp(n=1),and

percussion(n=1). Theywererecruitedusingpurposivesamplingandsamplingofconven

iencethroughtheuniversitybandprogram,followingapprovaloftheprojectfromtheInsti

tutional Review Board of the sponsoring university. Written notices were displayed and

verbal announcementswere made requestingvolunteers for this study. Eachparticipant

readandsignedaninformedconsentformdetailingthepurpose,procedure,possiblerisks,

andtimecommitmentinvolvedwithparticipationinthestudy. Atthetimeofthisstudy,the

participantswerenot involved inanyotherregularexerciseprogramandhadnopriorex

perience

of

Pilates

exercise.

Also,

at

the

onset

of

the

study,

13

of

the

14

participants

de

scribedpain in theupperback,neck,orupperextremitieswhen theyplayed their instru

ment. Anyindividualswithadiagnosedmedicalconditionsuchascervicaldiscdiseasewith

painradiatingintotheupperextremity,neurologicalsymptoms,upperextremitytendonitis,

upperextremitynerveentrapment,anyconditionexacerbatedwithexercise,oranycondi

tioninwhichexercisewascontraindicated,wereexcludedfromthestudy.

Studydesignandprocedures

Thisstudyutilizedaninterruptedtimeseries,twogroup,preposttestexperimentaldesign

(Figure1). Theresearchprojectlasted13weeksandwasconductedwithinonesemesterto

controlattrition

of

the

participants

due

to

schedule

changes.

Three

data

collection

sessions

wereconducted:1)initial;2)pretest(aftersixweekswithoutintervention);3)posttest(af

tersixweeksofexercise). Ineachdatacollectionsessionaquestionnairewasadministered

and trunk muscleendurance and lumbopelvic control measures were collected. Random

assignmentoftheparticipantswasattempted,butduetorequiredweeklyschoolrehearsal

forsomeoftheparticipants,theassignmentwasbasedonconvenience. Afterassignment

tooneofthetwoexercisegroups,theparticipantscompletedeithersixweeksofPilatesex

ercisesorconventionaltrunkandproximalupperextremityenduranceexercises. Afterthe

exercise intervention,athirdandfinaldatacollectionsessiontookplace. Fortheconven

ience of the participants, the exercise classes were conducted during the evening in the

5


6/30

Article

physicaltherapydepartmentofthesponsoringuniversity. Equipmentused includedexer

ciseballs,mats,lightweights(13pounds),Therabandandexerciserings.

X1

PilatesMatProgram

PretestInitialtest Posttest

X2

UpperExtremity

&TrunkEndurance

Program

Baselineperiod

without

exercise6week

exercise

period

FIGURE1. Interruptedtimeseries,twogroup,pretestposttestexperimentaldesign.

Trunkmuscleenduranceandlumbopelviccontrolmeasurement

Trunkmuscleenduranceandlumbopelviccontroloutcomemeasuredatawerecollectedby

a licensed physical therapist blinded to the group assignment. Three trials of endurance

(measured inseconds)wererecordedforthetrunk flexors,extensors,andbilateral lateral

trunkmusculature(Figures2,3and4). Themuscleendurancetestingwasperformed ina

rotatingorder

of

muscle

groups,

allowing

athree

minute

rest

period

between

each

muscle

group,thenrepeatingtheprotocolthreetimes. Lumbopelviccontrolwastestedoncedur

ingeachsessionasdescribedbyMcGill(2006)(Figure5).

FIGURE2.Trunkflexorendurancetest. Theparticipantassumesasupinepositionwith90

degrees of flexion at the hip and kneejoints. The cervical spine and upper trunk are

flexedasfaraspossiblewhilemaintaininganeutralpelvisposition. Endurance ismeas

uredinsecondsandthetestisterminatedwhentheparticipantmovesoutoftheoriginal

position(Ito,

Shirado,

Suzuki,

Takahashi,

Kaneda,

&

Strax,

1996).

6


7/30

Article

FIGURE

3.

Trunk

extensor

endurance

test.

The

participant

assumes

a

prone

position

while

liftingthesternumoffthefloorandmaintainingthethoracicspineandpelvisinaneutral

position. Asmallpillowisplacedundertheabdomenandtheparticipantmaintainsslight

cervicalflexion. Endurance ismeasured insecondsandthetest isterminatedwhenthe

participantmovesoutoftheoriginalposition(Itoetal.,1996).

FIGURE4.Lateraltrunkendurancetest. Theparticipantassumesafullsidebridgeposi

tionwiththe legsextendedandthetopfootplaced infrontofthe lowerfoot. Thepar

ticipantsupportsthetrunkononeelbowandtheirfeetwhileliftingtheirhipsoffthefloor

tocreateastraightlineovertheirentirebodylength. Theuninvolvedarmisheldacross

thechestwiththehandplacedontheoppositeshoulder. Enduranceismeasuredinsec

ondsandthetest isterminatedwhentheparticipantmovesoutoftheoriginalposition

(McGill,2006).

7


8/30

Article

A B C

D

FIGURE5.Lumbopelviccontroltest. Theparticipantassumesthefullpushupposition(A

andD). Thetrunk isheld inplankpositionwiththepelvisandribs level. Ayardstick is

placedperpendiculartothespineoverthepelvisattheL5 level,parallelwiththefloor.

Theparticipantliftsonehandandplacesitovertheother. Lumbopelviccontrolistested

bilaterallyandispresentwhenthepelvisremainslevelandtheyardstickremainsparallel

withthefloor(B). Lumbopelviccontrolisnotpresentwhenelevationofthepelvisoccurs

and

the

yardstick

does

not

remain

parallel

with

the

floor

when

the

hand

is

moved

(C)

(McGill,2006).

Questionnaire

Thequestionnairecomprisedsevenitemsconcerningthepresence,frequencyandintensity

ofpain,fatigue,musculartension,perceivedlevelofexertion,andperceived levelofmusi

calityduringinstrumentalperformance(AppendixA). Painexperiencedbytheparticipants

while playing was considered a symptom associated with performancerelated muscu

loskeletaldisorder

(PRMD)

as

defined

by

Zaza

et

al.

(1998).

Though

this

questionnaire

was

8


9/30

Article

notpiloted,thisdefinitionofPRMDhasbeenfoundtobereliablewhenusedbymusicians

(Ackermannetal.,2002;Zaza&Farewell,1997). Participantswere instructedtomarkre

sponsesusingvisualanalogscales(VAS)consistingofa10cmlineforeachitembelowwhich

descriptors were provided representing the full range of possible responses (Yoshimura,

Paul,Aerts,&Chesky,2006).

Four additional narrative questions administered at posttest addressed perceived

changes in functional activities, response to the experience of undertaking the exercise

class,anditseffectonpersonalwellnessgoals(AppendixB).

Evaluationsessions

Initial (Week 1): Trunk muscular endurance and lumbopelvic control data were collected

(Figures 15). The questionnaire was administered to the participants. The participants

thencontinuedwiththeirnormalactivitiesforsixweekswithnointervention.

Pretest

(Week

7):

The

same

physical

therapist

collected

identical

outcome

measure

mentdataforeachparticipant,asintheinitialsession(Figures15). Next,the14individuals

wereassignedtoeitherthePilatesexercisegroup(X1)(n=7;sevenwomen,nomen)orthe

conventionalproximalupperextremityandtrunkenduranceexercisegroup(X2)(n=7;two

women,fivemen). Arequiredweeklyflutechoirrehearsalwasscheduledduringthesame

time theconventionalenduranceexerciseclasshadalreadybeenscheduled. Asa result,

theseflutestudentshadtobeassignedtothePilatesclass. Mostfluteplayersinthechoir

werewomenandthereforethePilatesclassparticipantswerewomen.

Posttest(Week13): For13participants,thesamephysicaltherapistcollectedthesame

outcomemeasurementdataas inthe initialandpretestdatacollectionsessions,whilere

mainingblinded

to

group

assignment.

One

participant

was

tested

by

adifferent

examiner

duetoaschedulingconflict. Duringthis lastdatacollectionsession,theparticipantscom

pletedfouradditionalnarrativequestionsontheselfreportquestionnaire(AppendixB).

Testretestreliabilityofthetrunkendurancemeasures

Inpreviousstudiestrunkflexorendurancetestretestreliability(r)wasfoundtobegoodto

excellent (Portney & Watkins, 2000)

with

a correlation for healthy men of 0.95 and for

healthywomenof0.89(Itoetal.,1996). Inanadditionalstudy,trunkflexorendurancetest

retestreliabilitywasexcellent;the intraclasscorrelationcoefficient(ICC)was0.95withp


10/30

Article

Descriptionofexerciseintervention

Bothexerciseinterventionprogramsusedtrunkmuscleendurancetrainingeitherthrougha

Pilatesmatexerciseclassoraconventionaltrunkandproximalupperextremityendurance

exerciseclass.

The

Pilates

exercise

routine

included

agreater

emphasis

on

kinesthetic

pos

turalawarenessand intentionalbreathingwithmovement. Bothexercisegroupsmet for

two onehour sessions each week for six weeks and were taught by a licensed physical

therapistalsotrainedasaStottPilatesinstructor. ThePilatesparticipantslearnedselected

exercisesfromtheStottPilatesMatProgram(Merrithew,2001;AppendixC,Part1). These

werechosenbecausetheyarereportedtoincreasemuscularendurance,flexibility,andkin

estheticawareness. Inthisclass,allexercisesweredirectedbytheinstructorusingdemon

stration,visualandtactilecues,andverbalfeedback. Eachclassbeganwithaselectedpor

tionoftheentireprogram,thougheachtrunkmusclegroupwasaddressedineverysession.

Progression through theexerciseswasdeterminedbythedevelopingenduranceandneu

romuscularcontrol

abilities

of

the

participants.

As

the

participants

became

able

to

perform

theexerciseseffectively,moreadvancedexerciseswereaddedtotheclass. Theclasspar

ticipantsmovedthroughtheexercisesasagroup.

Theconventionalendurancetrainingclassincludedexercisesfortheproximalupperex

tremityandtrunkmusculature(AppendixC,Part2). Theseproximalexerciseswerechosen

becauseenduranceofthescapularandtrunkmusclesisnecessarytosupporttheworkload

ofthedistalupperextremitymusculature(Ackermannetal.,2002;Dommerholt,1997). The

exercisesusedweightsandinvolvedsinglemovementsoftendirectedtoonespecificmuscle

group with less emphasis on neuromuscular control than Pilates exercises. The weights

rangedfromonetothreepoundsandtherepetitionsrangedfrom15to20sincelightresis

tance

and

higher

repetitions

are

most

effective

in

endurance

training

(American

College

Of

Sports Medicine, 1998). Participants recorded the weight they used and the number of

repetitionstheyperformedforeachexercise. Iftheyreportedanypainperforminganexer

cisewithaweight,theamountofweightwasdecreasedortheweightwaseliminatedalto

gether. Initiallythe instructordirectedalltheexercisesforthegroup. Astheparticipants

becamefamiliarwiththeexercises,theycompletedthem independentlywithinthegroup,

although the instructor continued directing some of the exercises and moved about the

roomtomakecorrectionsasneeded.

StatisticalAnalysis

Statisticalanalysis

was

performed

using

SPSS

software

version

13.0.

Analyses

of

variance

andttestswereusedtoanalysescoresrepresentingtrunkmuscleenduranceandtheseven

selfreportquestionswhile frequency ofoccurrencewas used toanalyse the lumbopelvic

controldata. Thedatacollectedfromthefournarrativequestionsadministeredduringthe

posttestdatacollectionsessionwereevaluatedusingcontentanalysis(Portney&Watkins,

2000).

10


11/30

Article

RESULTS

Attendance

The

attendance

rate

was

84%

for

the

Pilates

exercise

class

and

95%

for

the

endurance

train

ingexerciseclass. Themainreasonsfornonattendancewereillnessorschoolrequiredper

formanceorrehearsal.

Trunkmuscleendurancemeasures

Althoughthetwoexercisegroups(Pilatesandconventionaltrunkenduranceexercise)were

small,preliminaryonewayanalysesofvariancewereconductedtoruleoutdifferencesbe

tween the two groups at initial testing and pretesting (at the end of the baseline, no

interventionperiod),andthentotestfordifferencesattributabletotypeofexerciseatpost

testing (after the intervention). These revealed a significant difference between the two

groupsat

initial

testing

for

the

left

lateral

trunk

muscles

(F

[1,

12]

=6.76,

p

=.023),

and

a

nearsignificantdifferencefortherightlateraltrunkmuscles(F[1,12]=6.76,p=.054),such

that the Pilatesgroup hadgreater endurance. There were also significant differences be

tweenthetwogroupsatpretesting,againfortheleftlateraltrunkmuscles(F[1,12]=6.83,

p= .023),andanearsignificantdifference for the right lateral trunkmuscles (F [1,12] =

4.34,p= .059),suchthatthePilatesgrouphadgreaterendurance. Therewerenosignifi

cantdifferencesbetween the twogroupsatposttesting. Meansandstandarddeviations

forbothgroupsateachtimeoftestingareshowninTable1.

TABLE1. Trunkmuscleendurancemeasuredinseconds

Mean(SD)

Initial

Mean(SD)

Pretest

(beforeexerciseintervention)

Mean(SD)

Posttest

(afterexerciseintervention)

Muscle

Group

Endurance

n=7

Pilates

n=7

Endurance

n=7

Pilates

n=7

Endurance

n=7

Pilates

n=7

Flexors 71.6 (25.0) 80.0(29.0) 68.2(22.9) 74.2(30.6) 76.4(21.9) 105.6(66.4)

Extensors 106.3(73.8) 135.5(70.4) 81.3(26.1) 121.6(79.5) 124.3(63.9) 127.3(51.4)

Rightlateral 29.6(7.5) 45.2(23.9) 28.0(9.7) 44.8(18.1) 40.2(13.0) 53.4(16.7)

Leftlateral 26.7(4.3) 46.0(19.4) 26.7(6.0) 44.8(19.5) 41.4(17.1) 52.4(19.4)

Changescoreswerecalculatedbysubtractingeachparticipantsscoresatinitialtesting

fromthoseatpretesting,andatpretestingfromthoseatposttesting. ANOVArevealedno

effectofexercisetypeonchangescoresfollowingthebaselineperiodor intervention. For

thisreason,theparticipantswereconsideredasonegroup(N=14),andpairedsamplest

tests were undertaken to investigate the effect of endurance exercise, regardless of

whetherthisconsistedofPilatesorconventionaltrunkenduranceexercises.

11


12/30

Article

12

Therewerenosignificantdifferencesbetweenparticipantsscoresat initialtestingand

pretesting. There were, however, significant differences between their scores at pre

testingandposttestingforextensors(F[1,12]=2.34,p=.036),rightlateral(F[1,12]=3,p

= .001) and left lateral trunkmuscles (F [1,12] =3.1,p= .008) such thatendurancewas

showntohave increasedattheendoftheexercise interventionperiod. Therewasalsoa

trendtowards increasedenduranceforflexors(F[1,12]=1.87,p=.084). These increases

areillustratedinFigure6.

One participant demonstrated lumbopelvic control at baseline and pretest. Five partici

pants including three inthePilatesandtwo in theconventionalendurancegroupdemon

stratedlumbopelviccontrolatposttest.

As shown inTable2, therewasa statistically significantdifferencebetween selfreported

intensityofpainatthe initialtestandpretestsessionsreportedbyall14participants,but

nootherchangeduringthebaselineperiod. Bycontrast,followingtheintervention(regard

lessofexercisetype),participantsreportedthattheycouldplaytheirinstrumentsforlonger

periodsoftimebeforebeginningtoexperiencemusclefatigueandpain. Theyalsoreported

lessfrequencyandintensityofpainaswellaslowerperceivedlevelsofexertion. Thediffer

encesbetweentheirratingsatpre andposttestwerestatisticallysignificant. However,the

differencesbetweentheratingsofthetwoexercisegroupsatposttestwerenotsignificant.

TheseareillustratedinFigures7and8.

Questionnaire

Lumbopelviccontrolfrequencyofoccurrence

FIGURE6.

Effects

of

exercise

on

trunk

muscle

endurance.


13/30

TABLE2.Questionnaireselfreportdataresults

Question Difference

between

pre

test

and

ini

tialtest(baselineperiod):paired

samplesttestvalues(df=13)

Difference

between

post

test

apre test(intervention): paire

samplesttestvalues(df=13

1. Iexperiencemusclefatigueafterplayingmy

instrumentforthefollowinglengthoftime:

(minutes)

0.09,NS 3.38,p=0.005

2. Myperceivedlevelofexertionafterplaying

myinstrument45minuteswithoutrest(how

tiredyoufeelingeneral)is:(scale=0100)

0.68,NS 2.25,p=0.043

3. Iexperiencepainwhileplayingmyinstru

mentwhenIhavebeenperformingforthefol

lowinglength

to

time:

(minutes)

0.81,NS 2.86,p=0.013

4. Mylevelofmusicality(beingabletoenjoy

theprocessofmakingmusicandnotonlybe

concernedwiththeoutcome)whileplayingmy

instrumentis:(scale=0100)

0.84,NS 2.00,NS

5. Iexperiencemusculartensionwhileplaying

myinstrumentafter:(minutes)1.06,NS 1.57,NS

6. TheintensityofpainthatIexperiencewhile

playingmyinstrumentis:(scale=0100)2.39,p=0.033 3.26,p=0.006

7.The

frequency

of

pain

that

Iexperience

whileplayingmyinstrumentis:(scale=0100)0.70,NS 3.02,p=0.01

13


14/30

FIGURE7.Playingtimebeforeonsetoffatigue(Q1)andpain(Q3).

0

10

20

30

40

50

60

70

80

Question2 Ques ti on6 Question7

ran

kin

g

Pretest

Posttest

FIGURE8.Perceivedlevelsofexertionat45minutesofplaying(Q2),intensityof

pain(Q6)andfrequencyofpain(Q7)duringplaying.

14


15/30

Article

Participantsrespondedasfollowstothenarrativequestionsadministeredatposttest:

Doyounoticeanychangewithplayingyour instrument?Someexamplesmightbe: isthere

anychangeinpainlevel,breathingpatternorbreathcontrolwhileplayingyourinstrument,

changingendurance

while

playing

your

instrument,

or

more

neutral

posture

while

playing

yourinstrument?

BreathcontrolFourparticipants intheenduranceexercisegroupand fiveparticipantsinthePilatesgroupreportedimprovedbreathcontrol. OnePilatesparticipant

alsodescribed improvedtoneproductionandqualityand improvedvolumecontrol

whileanotherstatedmybreathsupportwhileplayinghasimprovedvastlyandIam

betterabletotakeagoodbreath.

PainThreeparticipantsintheenduranceexercisegroupandthreeparticipantsinthePilatesgroupreporteddecreasedfrequencyand intensityofpainwhileplaying,

oftheseonestatedittakeslongertoexperiencepainduringbandrehearsals.

PostureSixparticipantsintheenduranceexercisegroupandsixparticipantsinthePilates group reported improved posture. Several participants in both groups de

scribed theirpostureasimprovedgreatly,withoneendurancegroupparticipant

statingIfeelstraighterwithamoreneutralposture.

PlayingenduranceTwoparticipantsintheenduranceexercisegroupandfourparticipants inthePilatesgroupreported increasedenduranceduringplaying;ofthese

one reported I can play my instrument for longer periods without getting tired

whileanotherstatedMyshouldersdontgetsotiredasquickly.

Muscle

tension

Two

participants

in

the

endurance

exercise

group

and

three

partici

pantsinthePilatesgroupreporteddecreasedmusculartensionoftheshouldersand

more relaxation. One Pilates participant reported less tension in my shoulders

whileanenduranceparticipantstatedIfeelmorerelaxed.

Isthereanythingdifferentinyourfunctionalactivitiesofdailyliving(i.e.sittingatthecom

puter,posture,otheractivities,sportsactivitiesorotherexamplesyoucangive)?

Changesinactivitiesofdailyliving(ADL)Mostparticipants(12of14)reportedimprovedposture in the followingADL: walking,sitting,driving,using thecomputer,

running,

and

playing

hockey.

One

endurance

participant

described

an

increased

abil

ity toselfcorrectpostureandaPilatesparticipant reported improvedpostureevi

dent to a nonparticipating person. Participants from both groups described de

creasedpainwhiledrivingandduringsittingactivities,better trunkcontroland in

creasedstrengthandenduranceinallADL. OneenduranceparticipantreportedADL

beingmorerelaxedandnatural,andoccurringwithlesseffort.

15


16/30

Article

Howwouldyoudescribethisclassexperienceintermsoftheclassexercisesandmotivation

forfuturegoalsregardingwellness?

Response to class experience All participants reported that the class motivatedthem

to

continue

an

exercise

program

after

the

end

of

the

exercise

intervention.

Several participants requested to continue the exercise class after the end of the

project. OneparticipantreportedIjustfeellikeabettermusician.

All14participantsdescribedacombinationofat leastthreeormorebenefitsafterthe

exerciseprogram.

DISCUSSION

Thepurposesofthisstudywerethreefold,to:1)investigatetheeffectivenessofendurance

and

neuromuscular

control

exercise

programs

in

improving

trunk

muscle

endurance

and

lumbopelvic control for the trunk and proximal upper extremity muscles; 2) determine if

changes in trunkmuscleenduranceand lumbopelviccontrolaffect instrumentalperform

ance;3)comparetheeffectivenessoftwotypesofenduranceandneuromuscularexercise

programs: a Pilates mat program and a more conventional trunk and proximal upper ex

tremityenduranceexerciseprogram. Themainfindingofthisstudywasthatbothtypesof

enduranceexercisewereeffective in increasingtrunkmuscleendurance,the frequencyof

lumbopelviccontrol,andenhancingseveralaspectsofinstrumentalperformance.

TheresultsofthisstudysupportthepreviouslymentionedreviewsofLederman(2003)

andDommerholtetal. (1997)

whoreportedthattrunkenduranceexercisedirectedat in

creasingenduranceandstabilitywaseffectiveinthepreventionandrehabilitationofPRMD

inmusicians. Ithasbeenreportedthattrunkmuscleenduranceandlumbopelviccontrolare

necessaryfortrunkstabilization,whichallowsformoreefficientmanagementofupperex

tremityworkloads(Hodges,2004;Leetun, Ireland,Willson,Ballantyne,&Davis,2004;Van,

Hides,&Richardson,2006). Thisisespeciallyimportantforthemusicianwhenrapid,highly

coordinated,repetitiveupperextremitymovementsareexecutedduring instrumentalper

formance. After the exercise intervention, effectivemanagement of theupperextremity

workloadmayhavebeenmorepresentintheparticipantsastheyreporteddecreasedpres

ence,frequencyandintensityofpain,fatigueandperceivedlevelofexertionduringplaying.

Atthebeginningofthebaselineperiodofthisstudy,13ofthe14participantsreported

upperback,midscapular,anddistalupperextremitypainduringinstrumentalperformance.

Themusicians

did

consider

themselves

to

be

healthy,

but

were

experiencing

muscular

pain

intheupperextremitiesanduppertrunkduringplaying. Thequestionnairewasdesignedto

evaluatetheaspectsofpain (presence, frequency, intensity)thatwould indicate improve

mentorworseningofsymptoms,aspainisconsideredasymptomofPRMD. Aftertheexer

ciseintervention,bothtypesofenduranceexercisegroupsreportedasignificantdecreasein

presence,frequency,and intensityofpainwhileplayingtheir instrument. Theparticipants

alsoreported improvedposture,regardlessofexercisegroup,andthiscancontributetoa

decrease in musculoskeletal pain as less stress is placed on muscular structures in the

shoulderandupperbackregion.

16


17/30

Article

Inseveralpreviouslymentionedreviewsandstudies,trunkmuscleenduranceexercise

and neuromuscular control training were effective in reducing pain (Dommerholt et al.,

1997;Lederman,2003;Ortiz,Olson,&Libby,2006;Palac&Grimshaw,2006;Rydeardetal.,

2006). Forthemusician,itisbeneficialtohavesupportfortheupperextremitieswithtrunk

stabilizationandmuscularendurancetodecreasethestressorphysicaldemandsontheup

perextremitiesduring instrumentalperformance. In thecurrentstudy,nearlyhalfof the

participants reporteddecreasedpresenceofpainduring instrumentalperformancewhich

supports thehypothesis thatendurance traininghasapositiveeffectonperformance,al

lowingthemusiciantofocusonthetaskofmakingmusicwithoutthedistractionofphysical

discomfort.

Inadditiontodecreasingpain,thisstudy foundthattrunkenduranceexercisetraining

(bothexercisegroups)decreased fatigueandtheperceived levelofexertionwhileplaying

an instrument. Thesefindingsare inagreementwithAckermannetal. (2002)who found

thatendurancetrainingwasmoreeffectivethanstrengthtraininginsignificantlydecreasing

theperceived

level

of

exertion

while

playing

an

instrument.

After

the

exercise

intervention

in the current study, nearly half of the participants reported increased endurance while

playingtheirinstrument. Thesefindingssupportthehypothesisthattrunkenduranceexer

cisepositivelyaffectsperformanceandmayallowthemusiciantoplaya longerrepertoire

withlessfatigue.

Posture, breath control, muscle tension, and playing endurance were reported to be

improvedafterboth typesofexercise intervention. Eachof theseattributes iscrucial for

themusicianandeach is interrelatedasachange inoneattributecanhavean impacton

another. Amajorityofparticipants reported improvedposturewhenplaying their instru

ment as well as when performing other activities. This improved posture likely resulted

fromgreater

muscle

endurance

and

kinesthetic

body

awareness.

Improved

posture

allows

themusicianmoreefficientergonomicuseofthetrunkandupperextremities,therebycon

tributingtothereportsofdecreasedpainandfatigueandimprovedplayingenduranceand

breathcontrol. Inaddition,amajorityoftheparticipantsreportedimprovedbreathcontrol

aftertheexerciseintervention. Breathcontrolisessentialtothewindinstrumentalistasitis

the basis of sound production, control, and tone quality. The intentional breathing with

movementandneuromuscularcontroltrainingperformedintheexerciseclassesmayhave

improvedtheparticipantsbreathcontrolabilities. Muscletensionwasalsoreportedtobe

decreased,whichagain likelywasdueto improvedposture,breathcontrolanddecreased

pain. Finally,theimprovedposture,breathcontrolanddecreasedmuscletensionreported

bythe

participants

likely

contributed

to

the

increased

playing

endurance

due

to

more

effi

cient use of trunk and improved breath control. These findings further support the hy

pothesisthattrunkendurancetrainingpositivelyaffectsinstrumentalperformance.

Attheendofthebaselineperiod,participantsreportedasignificantincreaseinpainin

tensityduringplaying,whichmayhaveresultedfromaconfoundingschedulingoccurrence.

Theparticipantshadabreakfromschoolrequiredperformancesduringthelasttwoweeks

ofthesix weekbaselineperiod,butdidcontinuewithpracticeschedulesandperformances

outsideofschool. Thenattheendofthetwoweekbreakandtheconcurrentendofthesix

weekbaselineperiodtheparticipantsreturnedtoschoolwithafullplayingscheduleofre

quiredschoolperformances. Theincreaseinplayingtimewasnotgradualformanyofthe

participantsand

the

second

data

collection

session

was

administered

at

the

end

of

the

re

17


18/30

Article

turnweek. Oneofthemost important injurypreventionguidelines formusicians is to in

creasepracticeorperformanceplayingtimegradually. Thesefactorsmayhaveaccounted

for the reported increasedpain intensityduringplayingdescribedwithin thebaselinepe

riod.

There were no statistically significant differences between the two exercise groups

trunkenduranceorlumbopelviccontrolaftertheexerciseintervention. Severalfactorsmay

havecontributedtothis,withoneimportantfactorbeingthedeconditionedphysicalstatus

oftheparticipantsatthestartofthisproject. Theyhadconsiderably lessmeantrunken

durance thanahealthycomparableadultpopulation (Itoetal.,1996). Mean trunk flexor

endurancevaluesforthecurrentparticipantswere44% lowerthanthoseofacomparable

adult population, while themean trunk extensor endurance values were 47% lower than

thoseofacomparableadultpopulation. Inaddition,themeanageofthecurrentpartici

pantswas20.9yearsascomparedto45.0years inthecomparableadultpopulation. The

participants intheenduranceclassweremoredeconditionedthanthePilatesparticipants

asdetermined

by

trunk

muscle

endurance

values.

Also,

the

endurance

group

exercise

pro

gramwaseasiertoteachandperformasthemovementsrequiredlessneuromuscularcon

trol. Therefore, the endurance participants might have demonstrated trunk endurance

change more rapidly as they started with less trunk endurance and the Pilates exercises

were more complicated to learn and perform because of the greater emphasis on trunk

neuromuscularcontrol. A longerexercise interventionmighthaveresulted inagreater in

creaseinmeantrunkendurancevaluesforPilatesparticipants.

Implicationsandrecommendations

Thispreliminary

study

has

demonstrated

beneficial

effects

of

two

types

of

endurance

exer

cise on aspectsof musical performance. As the participants trunkmuscle endurance in

creased,theyreporteddecreasedfatigueandthepresence,intensityandfrequencyofpain

whileplaying. Inaddition,posture,breathcontrol,muscletension,andplayingendurance

allwerereportedtoimprove. Suchimprovementsmayhelpmusiciansbettermanagepain,

fatigue,muscle tensionand stress,allof which can impedeplaying. Thiscanbring them

closertoaninjuryfreestateofwellness,whichisessentialforartiststoachievetheirhigh

estlevelsofmusicality(Figure10).

Performancerelated muscular disorders, and the necessity for their prevention and

management,havebecomemorewidely recognizedbyboth themedicalcommunityand

musiceducators.

The

methods

used

in

prevention

and

management

of

these

disorders

are

aimedatmanagingposture,breathcontrol,muscle tension,andplayingendurance. Fur

thermore,theyaimtoremoveimpedimentstomusicalplaying,suchaspain,fatigue,stress

andineffectivemanagementofmuscularworkload(Figure10).

Iffurtherstudiesfindbeneficialeffectsoftrunkenduranceexerciseformusicians,three

strategies for enhancing wellness can be recommended: 1) developing effective exercise

programsforthepreventionandmanagementofPRMD,2)educatinghealthcareproviders

working with musicians to identify and treat PRMD effectively, and 3) encouraging musi

ciansandmusiceducatorstosupporttheirstudents inthepursuitofhealthfulactivitiesto

lessentheoccurrenceofPRMDthroughouttheircareers. Thegoalofsuchwellnesseduca

tionis

to

increase

the

number

of

musicians

who

are

motivated

toward

amore

healthful

life

18


19/30

Article

stylebymakingthemawareoftherisksassociatedwithperforming,andthereforeinabet

terpositiontopreventoratleastmanageperformancerelatedinjuriesanddisorders.

Prevention/Management PRMD

EducationandTherapeuticMethods:

WellnessInjuryprevention

Selfcare

Exercise

ImpedimentstoMusicality

PainInjury

Fatigue

Stress

Workload

MusiciansAttributes

Posture

Breath

Control

MuscleTension

PlayingEndurance

InjuryFreeMusician

Wellness

Musicality

FIGURE10.Themultifactorialaspectsandimplicationsofwellnessandmusicalityforthe

musician.

Limitations

Asaresultofthedifficulties inherent inschedulingstudents,thesamplesizewassmall, it

was impossibletoachievetrulyrandomassignmenttoeachexercisegroup,andthedura

tionofthestudyandthereforetheinterventionperiodcouldbenolongerthanasingle

semester.

Futureresearch

Sincethiswasonlyapreliminarystudy,randomizedcontrolledtrialswithlargersamplesizes

areneededtoassesstheeffectivenessandbenefitsoftrunkmuscleenduranceandneuro

muscularcontrolexercisefor instrumentalmusicians. Infutureexercise interventionstud

ies,the lengthoftheexercise interventionshouldbe increasedtoallowparticipantsmore

timetogainincreasedkinestheticawareness. Itwouldbebettertoundertakelongitudinal

studies to determine the most effective educational and therapeutic methods for injury

preventionandtreatmenttomanagemusiciansinjuries. Suchstudiescouldbeundertaken

withinsecondary

level

university

music

programs,

so

as

to

avoid

scheduling

difficulties

and

19


20/30

Article

increasegroup size. Thephysical status of incominguniversitymusic students shouldbe

assessed before they embark on a rigorous program of study, in order to address their

needsattheoutset. Itwouldbeusefultodevelopanobjectivemeasurementofbreathcon

trol for future research into theeffectsofexercise. Finally,a reliableandvalidquestion

naireforuseinresearchandtreatmentshouldbedesignedspecificallyforinstrumentalper

formers.

CONCLUSION

Theresultsofthispreliminarystudysupportthehypothesisthattrunkenduranceandneu

romuscular control exercise programs would improve trunk endurance and lumbopelvic

control in instrumental musicians, potentially effecting positive changes during perform

ance. Whilethereisnoevidencethatoneprogramwasmoreeffectivethantheother,itis

clearthat

exercise

of

this

nature

is

beneficial.

Trunk

endurance

and

neuromuscular

control

exercisesarebeneficialfor instrumentalmusiciansandshouldbepartofanessentialwell

nessprogram includedwithinthecurriculumforallmusiceducationandperformancestu

dents.

ACKNOWLEDGMENTS:IwouldliketothankDr.CathyLarsonandthemembersofmycom

mitteefortheirgreateffort inassistingwiththisresearchproject. Iwouldalso liketoex

pressmydeepestgratitudeandappreciationtoDianeArnold,BethBurkel,LindaErickson,

Marilyn Graham and Susan Harrington for their many volunteerhours thatmade this re

searchproject

possible.

REFERENCES

Ackermann,B.,Adams,R.,&Marshall,E.(2002).Strengthorendurancetrainingforunder

graduatemusicmajorsatauniversity?MedicalProblemsofPerformingArtists,17(1),

3341.

American College of Sports Medicine. (1998). Position stand: The recommended quantity

andqualityofexercisefordevelopingandmaintainingcardiorespiratoryandmuscular

fitness,and

flexibility

in

healthy

adults.

Medicine

&

Science

in

Sports

&

Exercise,

30,

975991.

Bejjani, F.J., Kaye, G.M., & Beham, M. (1996). Musculoskeletal and neuromuscular condi

tions of instrumental musicians.Archives of PhysicalMedicine&Rehabilitation, 77,

406413.

Brandfonbrener,A.(1998).Theetiologiesofmedicalproblemsinperformingartists. InR.T.

Sataloff,A.Brandfonbrener,&R.J.Lederman(Eds.),Performingartsmedicine2nd

edi

tion.(pp.1945).SanDiego,CA:Singular.

Brandfonbrener,A. (2006).Special issues in themedicalassessmentofmusicians.Physical

MedicineandRehabilitationClinicsofNorthAmerica,17,747753.

20


21/30

Article

Chaffin,D.(1973).Localizedmusclefatiguedefinitionandmeasurement.JournalofOccu

pationalMedicine,15,346354.

Chang,Y.(2000).Graceunderpressure.Tenyearsago,5,000peopledidtheexerciseroutine

calledPilates.Thenumberis5millioninAmericaalone.Butwhatisit,exactly?News

week,135,7273.

deLisle,R.,Speedy,D.,Thompson,J.,&Maurice,D.(2006).Effectsofpianismretrainingin

threepianistswithfocaldystonia.MedicalProblemsofPerformingArtists,21(3),105

111.

Dommerholt, J.,Norris,R.,&Shaheen,M. (1997).Therapeuticmanagementof the instru

mentalmusician.OrthopedicPhysicalTherapyClinicsofNorthAmerica,6,185206.

Fink,S.(2002).Musicality.InK.Kropff(Ed.),Asymposiumforpianistsandteachers:Strate

giestodevelopthemindandbodyforoptimalperformance(pp.97106).Dayton,OH:

HeritageMusicPress.

Fishbein, M., Middlestadt, S.E., Ottati, V., Strauss, S., & Ellis A. (1988). Medical problems

amongISCOM

musicians:

Overview

of

anational

survey.

Medical

Problems

of

Perform

ingArtists,3,18.

Hansen,P.,&Reed,K.(2006).Commonmusculoskeletalproblemsinperformingarts.Physi

calMedicineandRehabilitationClinicsofNorthAmerica,17,789801.

Hodges,P. (2004).Lumbopelvicstability:A functionalmodelofthebiomechanicsandmo

tion control. In C. Richardson, P. Hodges & J. Hides (Eds.), Therapeutic exercisefor

lumbopelvicstabilization(pp.1328).London:ChurchillLivingstonPublisher.

Ito,T.,Shirado,O.,Suzuki,H.,Takahashi,M.,Kaneda,K.,&Strax,T. (1996).Lumbar trunk

muscleendurancetesting:Aninexpensivealternativetoamachineforevaluation.Ar

chivesofPhysicalMedicine&Rehabilitation,77,7579.

Lederman,R.

(2003).

Neuromuscular

and

musculoskeletal

problems

in

instrumental

musi

cians.MuscleNerve,27,549561.

Lederman, R. (2006). Focal peripheral neuropathies in instrumental musicians. Physical

MedicineandRehabilitationClinicsofNorthAmerica,17,761779.

Leetun,D.,Ireland,M.,Willson,J.,Ballantyne,B.,&Davis,I.(2004).Corestabilitymeasures

as risk factors for lowerextremity injury inathletes.Medicine&Science inSports&

Exercise,36(6),926934.

LieNemeth, T. (2006). Focal dystonia in musicians. PhysicalMedicine and Rehabilitation

ClinicsofNorthAmerica,17,781787.

ListerSink,B.(2002).Keeping itsimple:Fundamentalsofahealthfulpianotechnique.InK.

Kropff(Ed.),

A

symposium

for

pianists

and

teachers:

Strategies

to

develop

the

mind

andbodyforoptimalperformance(pp.189215).Dayton,OH:HeritageMusicPress.

McGill, S. (2006). Evaluating and qualifying the athlete/client. In S. McGill (Ed.),Ultimate

backfitnessandperformance(pp.147161).Waterloo,Ontario,Canada:WabunoPub

lishers.

Merrithew,L.C. (2001).StottPilatescomprehensivematworkmanual.Toronto:Merrithew

Corp.

Ortiz,A.,Olson,S.,&Libby,C.(2006).Corestabilityofthefemaleathlete:Areview.Journal

ofWomensHealthPhysicalTherapy,30(92),1117.

21


22/30

Article

Palac, J.A.,&Grimshaw,D.N. (2006).Musiceducationandperformingartsmedicine:The

stateofthealliance.PhysicalMedicineandRehabilitationClinicsofNorthAmerica,17,

877891.

Panjabi,M.M.(1992).Thestabilizingsystemofthespine,part I:Function,dysfunction,ad

aptationandenhancement.JournalofSpinalDisorders&Techniques,5,383389.

Petrofsky,J.S.,Morris,A.,Bonacci,J.,Hanson,A.,Jorritsma,R.,&Hill,J.(2005).Muscleuse

duringexercise:AcomparisonofconventionalweightequipmenttoPilateswithand

withoutaresistivedevice.JournalofAppliedResearch,5,160173.

Portney,L.G.&Watkins,M.P.(2000).Foundationsofclinicalresearch:Applicationstoprac

tice.Norwalk.CT:AppletonandLange.

Quarrier, N.F. (1997). The biomechanical examination of a musician with a performance

relatedinjury.OrthopedicPhysicalTherapyClinicsofNorthAmerica,6(2),145158.

Rydeard,R.,Leger,A.,&Smith,D.(2006).Pilatesbasedtherapeuticexercises:Effectson

participantswithnonspecificchronic lowbackpainand functionaldisabilityaran

domizedcontrolled

trial.

Journal

of

Orthopaedic

&

Sports

Physical

Therapy,

36(7),

472

484.

Segal,N.,Hein,J.,&Basford,J.(2004).TheeffectsofPilatestrainingonflexibilityandbody

composition:Anobservationalstudy.ArchivesofPhysicalMedicine&Rehabilitation,

85,19771981.

ShaferCrane,G.A.(2006).Repetitivestressandstraininjuries:Preventativeexerciseforthe

musician.PhysicalMedicineandRehabilitationClinicsofNorthAmerica,17,827842.

Steptoe,A.(2001).Negativeemotions inmusicmaking:Theproblemofperformanceanxi

ety. InP.N. Juslin& J.A.Sloboda (Eds.),Musicandemotion theoryand research (pp.

291307).Oxford,NY:OxfordUniversityPress.

Storm,S.

(2006).

Preface.

Physical

Medicine

and

Rehabilitation

Clinics

of

North

America,

17,

xiiixv.

Tse,M.,McManus,A.,&Masters,R. (2005).Developmentandvalidationofacoreendur

ance interventionprogram:Implicationsforperformance incollegeagerowers.Jour

nalofStrength&ConditioningResearch,19(3),547552.

Van,K.,Hides,J.,&Richardson,C. (2006).Theuseofrealtimeultrasound imaging forbio

feedbackof lumbarmultifidusmusclecontraction inhealthyparticipants.Journalof

Orthopedic&SportsPhysicalTherapy,36(12),920925.

Wu,S.J.(2007).Occupationalriskfactorsformusculoskeletaldisorders inmusicians:Asys

tematicreview.MedicalProblemsofPerformingArtists,22(2),4351.

Yoshimura,E.,

Paul,

P.,

Aerts,

C.,

&

Chesky,

K.

(2006).

Risk

factors

for

piano

related

pain

amongcollegestudents.MedicalProblemsofPerformingArtists,21,118125.

Zaza,C.(1998).Playingrelatedmusculoskeletaldisordersinmusicians:Asystematicreview

of incidence and prevalence. Canadian Medical Association Journal, 158(8), 1019

1027.

Zaza,C.,Charles,C.,&Muszynski,A.(1998).Themeaningofplayingrelatedmusculoskele

taldisorderstoclassicalmusicians.SocialScience&Medicine,47,20131023.

Zaza, C., & Farewell, VT. (1997). Musicians playingrelated musculoskeletal disorders: An

examinationofriskfactors.AmericanJournalofIndustrialMedicine,32,292300.

22


23/30

Article

KRISTIES.KAVA,P.T.,D.Sc.P.T.,OMPT isaphysicaltherapistandcertifiedPilatesinstructor

andownerofOaklandPhysicalTherapy,aprivatepractice inNovi,Michigan. Herclinical

background and expertise combines orthopedic manual therapy and therapeutic exercise

includingbodyawareness training in the treatmentofmusicians injuries. Shecompleted

herdoctoralworkatOaklandUniversity inRochester,Michiganand iscurrentlyamember

oftheWellnessTeamwithin theMichiganStateUniversitySchoolofMusic. Shehaspre

sentedbothnationallyandinternationallyregardingmusicianswellnessandenduranceex

ercisetraining. [[email protected]]

CATHYLARSONPT,PHDistheCenterforSpinalCordInjuryRecoveryResearchCoordinator

andSeniorPhysicalTherapistattheRehabilitationInstituteofMichiganintheDetroitMedi

cal Center. Her primary areas of research include investigatingthe relationship between

dosageofintensephysicaltherapyandoutcomesforindividualswithspinalcordinjury,with

theplantoexpandherresearcheffortstoincludestrokerecovery.Dr.Larsonisalsoactively

involvedin

direct

patient

care

and

teaches

avariety

of

courses

in

the

physical

therapy

cur

riculumsatOaklandUniversityandWayneStateUniversity.[[email protected]]

CHRISTINE STILLER, P.T., PH.D. is a special instructor at Oakland University in Rochester,

Michigan.SheholdsaPh.D.inEducationalPsychologyandherclinicalbackgroundis inpe

diatrics. [[email protected]]

SARA MAHER, P.T., D.SC.P.T., OMPT, is currently a full time faculty member at Oakland

University and a physical therapist practicing at Detroit Diesel in Redford, Michigan. Her

clinicalpractice

is

primarily

orthopedics

and

her

research

interests

include

ergonomics

and

occupationalsafety.[[email protected]]

23
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]


24/30

Article

APPENDICES

AppendixA:Questionnaire

MusicianSurvey:SelfReportData

Name:_________________________

1. Iexperiencemusclefatigueafterplayingmyinstrumentforthefollowinglengthoftime:

._______._______._______._______._______.________.

0min 30min 1hr. 1.5hr. 2hr. 2.5hr. 3hr.

Locationofmusclefatigue:__________________________________

2. Myperceivedlevelofexertionafterplayingmyinstrument45minuteswithoutrest(howtiredyoufeelin

general)is:

_______________________________________________

VeryLow VeryHigh

3. IexperiencepainwhileplayingmyinstrumentwhenIhavebeenperformingforthefollowinglengthof

time:

._______._______._______._______._______.________.


4. Mylevelofmusicality(beingabletoenjoytheprocessofmakingmusicandnotonlybeconcernedwiththe

outcome)whileplayingmyinstrumentis:

_______________________________________________

VeryLow VeryHigh

5. Iexperiencemusculartensionwhileplayingmyinstrumentafter:

._______._______._______._______._______.________.


6. TheintensityofpainthatIexperiencewhileplayingmyinstrumentis:

_______________________________________________

VeryLow VeryHigh

7. ThefrequencyofpainthatIexperiencewhileplayingmyinstrumentis:

____________________________________________________________

0 25 50 75 100

Never Rarely Sometimes Often EverytimeIplay

24


25/30

Article

AppendixB:AdditionalquestionsinquestionnaireadministeredinTestSession3.

QuestionNo.1. Doyounoticeanychangewithplayingyour instrument?Someexamples

might be: is there any change in pain level, breathing pattern or breathcontrolwhileplayingyour instrument,changingendurancewhileplaying

yourinstrument,ormoreneutralposturewhileplayingyourinstrument?

QuestionNo.2. Is thereanythingdifferent inyour functionalactivitiesofdaily living (i.e.

sittingatthecomputer,posture,otheractivities,sportsactivitiesorother

examplesyoucangive)?

QuestionNo.3. Howwouldyoudescribe thisclassexperience in termsof thedailyclass

exercisesandintermsofmotivationforfuturegoalsregardingwellness?

QuestionNo.4. Doyouhaveanyothercomments?

25


26/30

Article

AppendixC:Part1.StottPilatesMatClassExercises(Merrithew,2001).

Figure1.Abdominalprep

Lie on back, legs bent, arms toward ceiling.

Exhale, pressing arms down to sides, curling

up head and upper torso. Inhale, return to

startposition.

Figure2.Hundred

Lie on back, legs bent, arms toward ceiling. Ex

hale, pressing arms down to sides, curling up

headanduppertorso.Hold.Pumparmsinsmall

fluttermovements.

Figure3. Rollup

Lie on back, legs straight, arms overhead. Ex

hale,bringingarmsforwardcurlingupfromtop

of spine. Inhale as begin roll back, exhale as

slowlycompletingrollbackdown.

Figure4.Onelegcircle

Lie on back, leg extended on mat, other leg

straight up. Inhale, circling leg across body and

exhaleasyoufinish circlingdownandaroundto

beginning. Maintainstillpelvis.

Figure5.Rollinglikeaball

Sit with knees to chest. Inhale, roll back to

shoulders.Exhale,rollbacktoseat.

Figure6.Singlelegstretch

Lieonback,onelegkneetochestwiththeother

leg at 45 degrees. Exhale, curling up head and

uppertorso.Holdingtorsopositionexchangeleg

positions.

Figure7.Singlelegstretchwithobliques

Lie on back, legs bent to chest, hands behind

head.Exhale,liftingheadanduppertorso. Twist

torso and elbow to opposite knee, extending

other leg to 45. Inhale, twisting to other side,

changinglegs.

Figure8.Doublelegstretch

Lieonback,handholdingkneestochest.Exhale,

curlingupheadanduppertorsotoknees. Hold

curl, inhale and extend arms and legs toward

ceiling. Exhale,bringinglegsandarmsbackin.

26


27/30

Article

Figure9.Spinestretchforward

Situpstraight,bentlegsopenslightlywiderthan

hips, feet flexed, hands behind on mat. Inhale.

Exhale,roundingtorsoover. Inhale,sittingup.

Figure10.Saw

Situpstraight,legsopenslightlywiderthanhips.

Extendarmstoside. Exhale,roundingspineover

leg,reachoppositehandtowardoutsideoffoot,

otherarmback,palmup.

Figure11.Breaststrokeprep

Lie on stomach, elbows bent, lower rib remain

ing on mat. Inhale, raising upper torso, coming

up to forearms. Exhale, slowly lowering torso

backtostartposition.

Figure12.Swandiveprep

Lieonstomach,elbowsbent. Inhale, raisingup

pertorso,cominguptopalms. Exhale,lowering

torsobacktostartposition.

Figure13.Heelsqueeze

Lieonstomach,legsapart.Supportingabdomen,

bendkneesandgentlysqueezeheelstogether.

Figure14.Obliquerollback

Sitstraight, legsbentwith feeton themat. Ex

hale, slowly rounding back halfway. Reach arm

behind.Inhale,returning.

Figure15.Spinetwist

Situpstraight,legspressedtogether,feetflexed.

Reacharmsouttosides,palmsforward. Exhale,

twisting twice to one side. Inhale, returning.

Keeparmsstraight,legspressedtogether.

Figure16.Sidekicks

Lieonside,backstraightinlinewithedgeofmat,

legshinged30degrees infrontoftorso.Lifttop

legtohipheight.Bringtoplegforwardandthen

backwithoutmovingtorso.

27
http://photosmart.hpphoto.com/FilmStripHome.aspx?JobID=26189bc8-5d20-4dc6-a38a-f80af6a9121d&SKU=HP&Index=0


28/30

Article

Figure17.Sidelegseries

Lie on side, back straight in line with edge of

mat, legs straight. Lift top leg to hip height,

slowlyreturndowntostartposition.

Figure18.Teaser

Lieonback,legson45degreediagonal. Exhale,

curling up to V position, keeping legs in place.

Inhale, holding V position, exhale slowly rolling

backtostartposition.

Figure19.Seal

Balanceonseat,holdinglegs. Clapfeettogether

three times. Inhale, rolling back to shoulder.

Pauseslightly toclap feet together three times.

Exhale,rollbacktostart.

Figure20.Pushups

Inhale, lowering to pushup position, elbows

nexttoribs.Exhale,pushinguptoarmsstraight.

Repeat 3 times. Arms straight, inhale, walking

handsback to feet.Hangover in forwardbend.

Exhale, rolling spine up to stand. Inhale. Re

versesequenceintopushupposition.

28


29/30

Article

AppendixC:Part2.Trunkandproximalupperextremityenduranceexerciseclass(Acker

mannetal.,2002).

Figure1.Bicepscurl

Standingwitharmsstraightbysides,rais

ing weights to shoulders by bending el

bowsonly.

Figure2.Reversefly

ProneoverSwissball,armsat90of

abduction with elbows bent to 90

and arms internally rotated so that

forearms are perpendicular to the

floor.

Shoulderblades

slide

closer

togethertoraiseelbows.

Figure3.

Lateral

raise

Standing,armsstraightbysides,weights

raisedto90ofshoulderabduction.

Figure4.

Triceps

extension

Prone over ball with arms at 90

shoulder abduction and forearms

perpendicular to the floor. Extend

elbows.

Figure5.Shoulderforward

Standingwithweightsinhandsandarms

straightbysides. Weightsraisedforward

toendofrangeofforwardflexion,keep

ingelbowsextended.

Figure6.Bentoverrow

Standing,bendingforwardfromhips

with lumbar spine neutral and one

knee bent up onto chair to support

position. Place one hand on mat.

Hangotherarm,withweight,toward

floor. Raise weight vertically to side

ofthebody.

29


30/30

Article

Figure7.Backextension

Prone over ball, gradually extending

spine from neck through to lower back

while holding weights up against sternal

notch.

Figure8.Shoulderextension

Proneoverballwitharmshangingto

ground with thumbs facing forward

(arms in external rotation). Holding

weights inhandsbringingarmsback

toward body and into full shoulder

extension while internally rotating

arms.

Figure9.Oppositeshoulderandhipex

tension

Proneoverball,raisingonearmandthe

opposite leg simultaneously with arms

andkneesstraight.

Figure10.Situps

Lyingsupine,armscrossedwithhand

on opposite shoulder. Contract ab

dominalsandcurlupfromthehead,

keeping pelvis in neutral position.

Hold

and

then

lower

to

start

position.

Figure11.Sideplankposition

Sidebridge position with the legs ex

tended or knees bent. Support on bent

elbow with other arm across chest and

handonoppositeshoulder. Hipsliftedtoform plank position from shoulder to

kneeorfoot.

Figure12.Pushups

On hands and knees with hips ex

tended or hands and toes with hips

extended, trunk in plank position.

Maintainplankposition;bendelbowsand lower body towards floor, then

returntostartposition.

REFERENCES:APPENDIXC

Ackermann,B.,Adams,R.,&Marshall,E.(2002).Strengthorendurancetrainingforunder

graduatemusicmajorsatauniversity?MedicalProblemsforPerformingArtists,17(1)

3341.

Merrithew,L.C.(2001).StottPilatesComprehensiveMatworkManual.

Documents

Kava Published Web Version