After listening and observation, education and therapeutic exercises specific to musicians are needed to treat them well.
By Marianne Roos, M.Sc., Pht, Cand. PhD
As described in the previous blog, musicians typically receive no education on injury prevention and management or general health throughout their musical training (1). In addition, their workplace culture is made up of a number of beliefs and habits that do the opposite of promoting health! (e.g. a no pain no gain approach to practicing, avoiding healthcare professionals, alienation of colleagues who perform physical therapy exercises at work) (2).
For this reason, education becomes especially important in this population. Discussing mechanical stress quantificationand questioning their practice habits in detail is essential. Ask them when they practice (morning, afternoon, evening, night?), whether they start with physical warm-ups (they should!), which warm-ups they do (many musicians are hyper lax (3) and/or practice unnecessary static stretching), the volume at which they practice (playing loudly is more physically taxing and not always necessary), and, importantly, how often and for how long they take breaks.
Feel free to suggest changes to their practice schedules in order to improve load management. They also require much guidance on rest and relative rest after injury, as well as on gradual return to work and practice after periods of rest.
They especially need help learning to listen to their bodies and to understand the signals the body is sending to them. Many have played with pain for so long that they have great struggles respecting their own limits.
Starting with basic pain education is essential – what is pain and what does it mean? What are the different types of pain? When is it too much?
Musicians also tend to be intense and try to over-achieve at what they do – they’re used to spending hours a day evaluating their own playing and striving to be better, so they often automatically apply this to all their activities! Generally speaking, they are the type of clients that will exaggerate the physical therapy exercises we give them – performing too many repetitions with too much tension.
They often believe that if their muscles aren’t burning or they aren’t exhausted, they’re doing something wrong (I see this all the time!). So how do they respond? They push as hard as they can until the burn/discomfort is there! It’s important for us to be very clear about physical therapy exercise parameters and how to respond to body signals.
Speaking of listening to their bodies: musicians are known to conceal their injuries altogether or to wait as long as possible before consulting (2,3). As rehabilitation professionals, we know that this greatly increases the risk of longer-term problems or chronicity. Therefore, recognizing problems early on, managing them correctly, and knowing when to consult for them are highly relevant subjects of discussion.
Other important topics for education include nutrition, hydration, general fitness, and physical activity (because they’re small-muscle athletes!)(3).
In this section, I’m going to talk about therapeutic exercises for musicians, which is a broad population! When considering musicians, the first thing we think of is that they all play different instruments, and surely each instrument group needs different exercises! Well, yes and no.
A major part of my doctorate is offering a catered exercise program to orchestral musicians, including strings, winds, brass, and percussion, so I have put a lot of thought and research into the question of catering physical therapy exercises for different instruments types.
Looking in the scientific literature, the effect of many different exercise approaches on musicians’ physical well-being has been explored (including pilates, strength training, endurance training, general fitness training, Cesar & Mesendieck, postural training, and body mapping, among others)(4–9).
The musical populations, research methodology, and results are highly variable, but there is a trend suggesting the effectiveness of postural therapeutic exercises that takes musicians’ work demands into consideration, ie. that progress from basic postural activation to functional musical movements (more on this below).
As for the different instruments, on further reflection, one realizes that there are many similarities to the physical needs of different instrumentalists: they all need an adequate trunk, neck, and scapular control, stability, and endurance in order to support the weight of the instrument while performing intricate movements for sustained periods of time. Let’s break it down:
The majority of musicians’ injuries are related to fatigue and overuse, so they need to learn to use their energy optimally and make sure they have adequate endurance. Key considerations:
Musicians spend their lives developing unbelievable motor control of specific movements. Their job is to spend thousands of hours perfecting special motor patterns – they are masters! However, having gesture-specific motor control can have its limits, especially as musicians age.
By adding control and stability to the trunk and larger joints, musicians can learn to better support the movements they’ve mastered, and benefit from energy transfers from the trunk and large joints to the extremities, thus decreasing fatigue and protecting structures in the latter areas.
The momentum they develop through expressive movement (eg. back-and-forth or up-and-down movements of the trunk as they play, like head-banging but less violent) is excellent for this – by getting more of the body involved in their instrument-specific movements, the energy demands on the extremities are decreased; in the same way that golfers and pitchers need their lower extremities to provide momentum and energy transfers that significantly increase torque and velocity, thereby preventing injury of the upper extremities, musicians benefit from relying more on their trunks and large joints.
And for that, they require adequate trunk and large joint control which can be largely achieved through motor control and postural physical therapy exercises.
Although musicians’ upper extremities can be involved in dynamic movements, beyond those muscle groups, it’s their postural muscles that play the most important role. In order to limit over-exertion leading to poor motor control and increased risk of injury, these postural muscles need enough strength and endurance for the task at hand – again suggesting the importance of postural exercise in this population.
Musicians need to be fit! Maybe not as fit as athletes, but fit to play! Studies have demonstrated significant increases in heart rate, respiratory rate, and perceived exertion as well as muscular fatigue during musical practice and performance (10).
Therefore, general fitness, as well as adequate hydration and nutrition, are central to their capacity to perform optimally. If they’re not active, I recommend trying to help them identify physical activities that they may enjoy and be able to integrate into their routine (summer and winter!).
Musicians play either seated (cello, piano, harp) or standing (percussion), or both (guitar, winds, brass, upper strings, etc.). In the orchestra, musicians are usually seated, but upper strings (violin and viola) may play standing for certain pieces, and most instruments play standing for important solos.
Therefore, most musicians need to have the postural strength and endurance to hold a weight in their arms (usually an instrument, but don’t forget the pile of printed music that singers hold out high in front of them so that their eyes are never far from the conductor and audience!) and perform repeated difficult movements for long periods of time in both sitting and standing.
Their postural control, therefore, needs to be adequate in both positions, and in the lower extremities. For this reason, the therapeutic exercises program that I’ve been offering to orchestras as part of my doctorate includes a series of physical therapy exercises for the hips (as well as the neck, shoulders, abdominals, and back), so that musicians develop adequate hip external rotator and abductor activation and general lower extremity control and endurance to support standing postures.
It’s important not to mistake postural exercise (exercises for the postural muscles) for postural training (“correction” of posture). As mentioned in the precedent blog when I wrote about observation, we need to avoid making assumptions about optimal postures for musicians, instead of taking the approach of activating postural muscle groups to optimize the playing technique that they have mastered.
In practice, here’s what I recommend (very briefly!) (5,11): musicians need a daily dynamic physical warm-up routine to perform every day before their first practice routine or rehearsal; after warm-ups, start by teaching basic postural activation of the trunk, neck, and shoulders; from there, therapeutic exercises should progress by combining postural activation of different body regions at the same time, moving towards functional movements, with resistance and asymmetrical postures that resemble the weight of the instrument in their arms.
They often need help to learn to breathe while they’re moving, and also to relax certain parts of the body while others are active. The final step is to transfer what they and their bodies have learned from the exercises to playing their instruments (it’s a mental challenge!).
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