Performing Arts Medicine: Current Trends in Treating the String

Musician

Eric N. Bengtson, MA, LAT, ATC, PES, CPTCoordinator of Performing Arts Medicine

Outline• Introduction• Medical Needs• Performing Arts Medicine Overview• Injuries– Anatomy

• Recommendations• Performing Arts Medicine at App State

Demographics

• The audience

• The presenter

Introduction

• String oriented presentation

• The human body is consistent

“Most music-related injuries are the result of soft tissue overuse stemming from long hours of practice, poor

physical conditioning, and stressful postural positioning”

Quarrier NF. Performing Arts Medicine: The Musical Athlete. J Orthop Sports Phys Ther 17:90-95, 1993

Performing Artist and Traditional Athlete

• Strength• Flexibility• Endurance• Coordination• Talent / Ability• Physical skills determine

level of success• Begin training at a young

age

• Competitive field• Psychological endurance• High stress in striving for

perfection• Economic success is

dependent on level of skill

• Prone to activity-oriented, overuse injuries

Quarrier NF. Performing Arts Medicine: The Musical Athlete. J Orthop Sports Phys Ther 17:90-95, 1993

Elbaum L: Musculoskeletal problems of instrumental musicians. J Orthop Sports Phys Ther 8:285-287, 1986

Fatigue

Adaptive Patterns

Pain / Injury Poor Technique

Quarrier NF. Performing Arts Medicine: The Musical Athlete. J Orthop Sports Phys Ther 17:90-95, 1993

Pain is a symptom, not a diagnosis.

Not Seeking Medical Care

• Lack of knowledgeable medical professionals• “no pain-no gain” principle• The belief that performance related pain is

inevitable or will resolve itself• Consciously or unconsciously ignoring pain• Fear of temporary loss of income or

employment• Treatment itself may threaten their ability to

performBrandfonbrener A: Performing arts medicine: an evolving specialty. Music Educators J 77:37-41, 1991

Lowest Success Rate:1. General Practitioner (6%)2. Neurologist (13%)3. Orthopedist (20%)

Highest Success Rate:1. Surgery (94%)2. Rest – stop playing (84%)3. Physical Therapy (82%)

Fishbein M, Middlestadt SE, Ottati V, Strauss S, Ellis A: Medical problems among ICSOM musicians: Overview of a national survey. Med Probl Performing Artists 3:1-8, 1988

Psychological Influence of Injury

• Performing artists have been shown to be more attached to their craft than athletes are to their sport. – Being removed from their craft while injured can

negatively alter psychology

• Self-reported an increased physical health status but decreased mental health status compared to the general population

Bengtson E. The Correlation Between Time Loss Due to Injury and Perceived Health Status in Female Collegiate Dance Students. Unpublished.

Voltmer E, Zander M, Fischer JE, Kudielka BM, Richter B, Spahn C. Physical and Mental Health of Different Types of Orchestra Musicians Compared to Other Professions. Med Probl Perform Art 2012; 27(1):9-14.

Performing Arts Medicine• Emerged ~40 years ago from physicians and

therapists not understanding the strains and stresses placed on the performer’s body

• Early research focused on musicians– Dance research followed

Harman SE. Odyssey: the history of performing arts medicine. Md Med J. 42(3):251-3; 1993

• Performing Arts Medical Association– Founded in 1989– www.artsmed.org

• International Association of Dance Medicine & Science– Founded in 1990– www.iadms.org

Performing Arts Medicine• At Appalachian State University: – College of Health Sciences– Department of Theatre & Dance– Athletics Department– Hayes School of Music

• Staff with performing arts medicine education– Program implementation– Research

Supplementary Fitness

• General training principles• Fatigue• Muscular strength and endurance• Flexibility• Cardiovascular fitness

Supplementary Fitness

This is not simply a way for the artist to get in shape

Studies suggest that it is not adequate to train performers without proper physiologic preparation

Laws H. Fit to Dance 2: Report of the Second National Inquiry into Dancers’ Health and Injury in the UK. London: Dance UK, 2005.

Wyon M, Redding E, Abt G, Head A, Sharp C. Development, reliability and validity of a multi-stage dance specific aerobic fitness test (DAFT). J Dance Med Sci. 2003; 7(3):80-4.

Krasnow DH, Chatfield SJ. Dance science and the technique class. Impulse. 1996;4:162-72.

General Training Principles• “SAID” principle– Specific– Adaptations to– Imposed– Demands

• The body must be challenged above a minimum threshold for improvement to occur– For example, if the demands of dance class are similar day

to day there will be insufficient overload for desired improvement

Fatigue

• Supplemental exercise when done correctly has the ability to slow fatigue– Except after exercise

• Fatigue leads to more errors when playing

Drinkwater EJ, Klopper CJ. Quantifying the physical demands of a musical performance and their effects on performance quality. Med Probl Perform Art 2010;25:66-71

Strength & Muscular Endurance• Optimal strength training program should be specific to the

desired outcome.

• Muscular Strength– 70-100% of maximum strength– Low number of repetitions and sets– 5-6 minute rest between sets

• Muscular Endurance– 60-70% of maximum strength– High number of repetitions and sets– 2-4 minute rest between sets

Clark MA, Lucett SC, Corn RJ. National Academy of Sports Medicine: Essentials of Personal Fitness Training. Baltimore: Lippincott Williams & Wilkins, 2008. Print.

In a 2007 study, performers were asked to complete one year of supplemental exercise in addition to their classes. Compared to their classmates the subjects experienced:– Reduced fatigue– Increased energy levels– Increased capacity in their dance classes to sustain

technique and jumping ability

Rafferty S, Redding E, Irvine S, Quin E. The effects of a one-year dance-specific fitness training program on undergraduate modern dance students: an experimental study. Abstract. J Dance Med Sci. 2007; 11(1):16.

A 2012 study demonstrated that two one-hour circuit training sessions per week for six weeks is enough to increase (as compared to a control group)– muscular power by 11%– muscular endurance by 22%– aerobic fitness by 11%– aesthetics (in the dancer) by 12%

Angioi M, Metsios G, Twitchett EA, Koutedakis Y, Wyon M. Effects of Supplemental Training on Fitness and Aesthetic Competence Parameters in Contemporary Dance: A Randomised Controlled Trial. Med Probl Perform Art 2012; 27(1):3-8.

Flexibility• Important element of physical fitness. Is used for:– Correcting muscle imbalances– Increasing range of motion– Decreasing excessive tension of muscles– Relieving joint stress– Improving musculotendinous junction extensibility– Maintaining normal functional length of muscles– Improving optimum neuromuscular efficiency– Improving function– Preventing injury

Alter MJ. Science of Flexibility, 2nd ed. Champaign, IL: Human Kinetics, 1996.

Chaitow L. Muscle Energy Techniques. New York: Chruchill Livingstone, 1997.

Koutedakis Y, Sharp NCC. The Fit and Healthy Dancer. Chichester: Wiley, 1999

Flexibility

Cardiovascular Conditioning

• Cardiac demands during performances is far above what would be expected from a supposedly sedentary activity

• Rehearsals: 74-124 beats per minute (bpm)

• Concerts: 123-152 bpm• Soloist: 140-164 bpm

Inesta C, Terrados H, Garcia D, Perez JA: Heart rate in professional musicians. J Occup Med Toxicol 2008;3:16.

Cardiovascular ConditioningAerobic Exercise– Uses oxygen– Rehearsal only elicits an improvement in aerobic

capacity in a very unfit group of people• too intermittent in nature

• A rise in heart rate to 70-90% of maximum heart rate will stress the aerobic system

• 20-40 minutes, 2-3 times a weekKoutedakis Y, Sharp NCC. The Fit and Healthy Dancer. Chichester: Wiley, 1999