Preventing Musculoskeletal
Injury (MSI) for Musicians
and Dancers
A Resource Guide
Preventing Musculoskeletal Injury
(MSI) for Musicians and Dancers
A Resource Guide
June 6, 2002
Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 1
About SHAPE
SHAPE (Safety and Health in Arts Producti...
Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 2
Acknowledgments
Thanks to the members of SHAPE’s Spec...
Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 3
Contents
About this resource guide......................
Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 4
Joint injuries: Arthritis ..............................
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About this resource guide
Performers such as musician...
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Who should read this resource guide
If you participat...
Part 1
Background
Background
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What is musculoskeletal injury (MSI)?
Musc...
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• nerve degeneration
• bone degeneration o...
Background
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Pain
Pain is a unique experience for each...
Background
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Risk factors
Medical and scientific resea...
Background
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In general, the strongest relationship be...
Background
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General prevention and treatment
Preventi...
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References
Bernard, B., and L. Fine, eds....
Part 2
Musicians and musculoskeletal
injury (MSI)
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Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers

SHAPE (Safety and Health in Arts Production and Entertainment) is an industry association dedicated to promoting health and safety in film and television production, theatre, dance, music, and other performing arts industries in British Columbia. Get more info at http://www.acoustiguard.com/products/soundproofing-floors/freedom-step-subfloor-panels.html
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Transcripts - Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers

  • 1. Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers A Resource Guide
  • 2. Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers A Resource Guide June 6, 2002
  • 3. Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 1 About SHAPE SHAPE (Safety and Health in Arts Production and Entertainment) is an industry association dedicated to promoting health and safety in film and television production, theatre, dance, music, and other performing arts industries in British Columbia. SHAPE provides information, education, and other services that help make arts production and entertainment workplaces healthier and safer. For more information, contact: SHAPE (Safety and Health in Arts Production and Entertainment) Suite 280–1385 West 8th Avenue Vancouver, BC V6H 3V9 Phone: 604 733-4682 in the Lower Mainland 1 888 229-1455 toll-free Fax: 604 733-4692 E-mail: info@shape.bc.ca Web site: www.shape.bc.ca © 2002 Safety and Health in Arts Production and Entertainment (SHAPE). All rights reserved. SHAPE encourages the copying, reproduction, and distribution of this document to promote health and safety in the workplace, provided that SHAPE is acknowledged. However, no part of this publication may be copied, reproduced, or distributed for profit or other commercial enterprise, nor may any part be incorporated into any other publication, without written permission of SHAPE. National Library of Canada Cataloguing in Publication Data Robinson, Dan. Preventing musculoskeletal injury (MSI) for musicians and dancers : a resource guide Writers: Dan Robinson, Joanna Zander and B.C. Research. Cf. Acknowledgments. Includes bibliographical references: p. ISBN 0-7726-4801-8 1. Musculoskeletal system - Wounds and injuries - Prevention. 2. Entertainers - Wounds and injuries - Prevention. 3. Musicians - Wounds and injuries - Prevention. 4. Dancing injuries - Prevention. I. Zander, Joanna. II. Safety and Health in Arts Production and Entertainment (Organization). III. B.C. Research. III. Title. RD97.8.A77R62 2002 617.4'704452 C2002-960144-4
  • 4. Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 2 Acknowledgments Thanks to the members of SHAPE’s Special Committee on Musculoskeletal Injury for helping develop and review this resource guide and to the organizations they represent: • Burt Harris, Pacific Music Industry Association • Day Helesic, Canadian Alliance of Dance Artists, BC Chapter • Jennifer Mascall, The Dance Centre • Gene Ramsbottom, Vancouver Musicians’ Association, Local 145, American Federation of Musicians of the United States and Canada Thanks also to: • Dan Robinson, Joanna Zander, and BC Research (researching and writing) • Rob Jackes, Linda Kinney, and Robyn Carrigan of SHAPE (coordinating and reviewing) • Kevin Sallows (coordinating and editing) • David Harrington of the Lynn Valley Orthopaedic and Sports Physiotherapy Centre (reviewing) • Workers’ Compensation Board (WCB) of British Columbia (reviewing) Thanks to the WCB for their permission to use source material from WCB health and safety publications, including the lifting illustration on page 29.
  • 5. Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 3 Contents About this resource guide................................................................................................... 5 Who should read this resource guide ................................................................................. 6 Part 1: Background What is musculoskeletal injury (MSI)?.............................................................................. 8 Risk factors....................................................................................................................... 11 General prevention and treatment .................................................................................... 13 References........................................................................................................................ 14 Part 2: Musicians and musculoskeletal injury (MSI) Overview.......................................................................................................................... 16 Tendon and muscle disorders (tendinitis, tenosynovitis, focal dystonia, muscle strain) ................................................. 19 Nerve compression or entrapment (carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, sciatica).. 22 Preventing musculoskeletal injury for musicians............................................................. 24 Treating musculoskeletal injury for musicians ................................................................ 31 References........................................................................................................................ 33 Part 3: Dancers and musculoskeletal injury (MSI) Overview.......................................................................................................................... 36 Preventing musculoskeletal injury for dancers ................................................................ 40 Treating musculoskeletal injury for dancers .................................................................... 43 Nutrition........................................................................................................................... 46 Bone injuries .................................................................................................................... 48 References........................................................................................................................ 50 Part 4: Musculoskeletal injuries (MSIs) prevalent in performers Overview.......................................................................................................................... 56 Jaw and head injuries: Temporomandibular joint (TMJ) dysfunction............................. 59 Shoulder injuries (rotator cuff injuries)............................................................................ 61 Shoulder injuries: Rotator cuff tears ................................................................................ 62 Shoulder injuries: Shoulder impingement syndrome ....................................................... 64 Hand and arm injuries: Carpal tunnel syndrome.............................................................. 66 Hand and arm injuries: Cubital tunnel syndrome............................................................. 69 Hand and arm injuries: Thoracic outlet syndrome ........................................................... 71 Hand and arm injuries: De Quervain’s syndrome............................................................ 73 Hand and arm injuries: Lateral epicondylitis (tennis elbow) ........................................... 75 Hand and arm injuries: Medial epicondylitis (golfer’s elbow) ........................................ 77 Hand and arm injuries: Focal dystonia............................................................................. 79
  • 6. Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 4 Joint injuries: Arthritis ..................................................................................................... 81 Hip injuries: Snapping hip syndrome (tight iliotibial band)............................................. 83 Knee injuries .................................................................................................................... 86 Knee injuries: Patellofemoral pain................................................................................... 88 Knee injuries: Knee sprains and strains ........................................................................... 90 Knee injuries: Meniscus tears .......................................................................................... 92 Back and neck injuries ..................................................................................................... 94 Back and neck injuries: Spondylolysis............................................................................. 96 Back and neck injuries: Back and neck pain.................................................................... 98 Lower leg and ankle injuries.......................................................................................... 100 Lower leg and ankle injuries: Shin splints, stress fractures, and stress reactions .......... 103 Lower leg and ankle injuries: Ankle sprains.................................................................. 106 Lower leg and ankle injuries: Posterior impingement syndrome (dancer’s heel).......... 109 Lower leg and ankle injuries: Anterior impingement syndrome.................................... 111 Lower leg and ankle injuries: Achilles tendinitis........................................................... 113 Lower leg and ankle injuries: Subtalar subluxation....................................................... 115 Foot and toe injuries....................................................................................................... 117 Foot and toe injuries: Stress fractures of the second metatarsal..................................... 118 Foot and toe injuries: Fractures of the fifth metatarsal (dancer’s fracture).................... 121 Foot and toe injuries: Cuboid subluxation ..................................................................... 123 Foot and toe injuries: Flexor hallucis longus tendinitis ................................................. 125 Foot and toe injuries: Blisters ........................................................................................ 128 Foot and toe injuries: Bunions ....................................................................................... 130 Foot and toe injuries: Toenail injuries............................................................................ 131 Index............................................................................................................................... 132
  • 7. Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 5 About this resource guide Performers such as musicians and dancers are at risk of occupational health problems that can significantly interfere with their ability to perform. If not recognized and properly treated, many of these health problems can limit, interrupt, or even end an individual’s performing career. This resource guide provides information and resources for the prevention of musculoskeletal injury (MSI) in performers. Other terms used to describe MSI include: • overuse problems • repetitive strain injury • cumulative trauma disorder • work-related musculoskeletal disorder • activity-related soft tissue disorder Generally, this guide will use the term musculoskeletal injury or MSI to describe an injury or disorder of the muscles, bones, joints, tendons, ligaments, nerves, blood vessels, or related soft tissues that may be caused or aggravated by activities related to performing, rehearsing, practising, or taking classes in music or dance. Performers can and should prepare themselves for a long and healthy career by learning to recognize: • early signs and symptoms of MSI • occupational factors that cause or aggravate MSI • practical strategies to reduce the risk and impact of MSI This resource guide has four parts. Part 1, Background, defines musculoskeletal injury and provides basic information on pain, risk factors, and general prevention and treatment. Parts 2 and 3 will be easier to understand if you read Part 1 first. Part 2, Musicians and Musculoskeletal Injury (MSI), discusses common symptoms and types of injuries; tendon and muscle disorders; nerve compression or entrapment; and strategies for preventing and treating MSI. Part 3, Dancers and Musculoskeletal Injury (MSI), discusses common symptoms and types of injuries; strategies for preventing and treating MSI; nutrition; and bone injuries. Part 4, Musculoskeletal Injuries (MSIs) Prevalent in Performers, summarizes MSIs that occur in musicians and dancers. These MSI summaries provide a brief description of the injury as well as information on signs and symptoms; the causes of the injury; and treatment and prevention strategies. These summaries are not intended to replace the services of trained medical practitioners. Performers who recognize their own experience within an injury summary are strongly urged to seek a professional medical opinion.
  • 8. Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 6 Who should read this resource guide If you participate in any aspect of the performing arts industry, this resource guide may help you prevent MSI in performers. A holistic approach to injury prevention includes consideration of personal, administrative, technical, and artistic issues, and recognizes that risk of injury can be significantly influenced by various factors (for example, parents, training at an early age, and facility and equipment design). Figure 1 provides a non-exhaustive overview of participants in the performing arts industry who may have influence on the risk of MSI in performers. If your occupation is included or if your involvement in the performing arts industry has any influence on the experience of performers, this resource guide may be useful to you. You are encouraged to look for ways in which your involvement may prevent MSI in performers. Performers Musicians, vocalists, dancers Music instructor School board, trustee, or staff Parent Special FX coordinator Props builder Sound engineer Stage crew member Technical director Union/ association Producer Maintenance staff Agent/ manager Facility manager Videographer Artistic director Composer/ arranger Choreographer Conductor Dance instructor Architect Interior designer Equipment designer Purchaser Physical plant engineer Costumer Director Playwright Society board member Company manager Early development Venue design TechnicalAdministrative Artistic Orchestrator/ copyist Stage manager Piano tuner Regulatory body Funding agency Figure 1 A non-exhaustive overview of participants in the performing arts industry who have varying degrees of influence on the risk of MSI in performers
  • 9. Part 1 Background
  • 10. Background Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 8 What is musculoskeletal injury (MSI)? Musculoskeletal injury (MSI) is any injury or disorder of the muscles, bones, joints, tendons, ligaments, nerves, blood vessels, or related soft tissues. This includes a strain, sprain, or inflammation that is caused or aggravated by activity. Daily activities place demands on the body that may contribute to the development or occurrence of MSI. Most performers spend a large part of each day on practice, rehearsal, or performance. The physical, professional, and artistic demands of these activities can be stressful on the body and may eventually result in MSI-related signs or symptoms. Signs and symptoms Signs that may indicate MSI include: • swelling • redness • difficulty moving a particular joint Symptoms that may indicate MSI include: • numbness • tingling • pain These signs and symptoms may appear suddenly or they may develop gradually over a period of months or years. Signs and symptoms may or may not occur during the activity that is causing or aggravating the condition. Some conditions result in signs and symptoms that occur after the activity and may even occur during sleep. Health professionals classify the severity of signs and symptoms using a graded scale that represents the progression of a typical overuse injury. This scale, adapted for performers, is illustrated in Figure 2, page 9. The severity of an injury and the need to establish a treatment plan increase as an individual progresses from Level I to Level V. Health effects Early signs or symptoms are indicators of various health effects that may develop if the signs or symptoms are allowed to progress. The specific health effects that are likely to develop depend on the specific activities. MSI-related health effects include: • strains • sprains • disc herniation • tendinitis • tenosynovitis • bursitis • nerve compression
  • 11. Background Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 9 • nerve degeneration • bone degeneration or malformation Early recognition of signs and symptoms and appropriate responses are critical in minimizing the severity of health effects and maintaining an individual’s ability to practise, rehearse, and perform. Pain occurs after class, practice, rehearsal, or performance, but the individual is able to perform normally. Pain occurs during class, practice, rehearsal, or performance, but the individual is not restricted in performing. Pain occurs during class, practice, rehearsal, or performance, and begins to affect some aspects of daily life. The individual must alter technique or reduce the duration of activity. Pain occurs as soon as the individual attempts to participate in class, practice, rehearsal, or performance, and is too severe to continue. Many aspects of daily life are affected. Pain is continuous during all activities of daily life, and the individual is unable to participate in class, practice, rehearsal, or performance. Level I Level V Level IV Level III Level II Figure 2 Progression of MSI signs and symptoms in performers. Where are you on this scale? If you are at Level I or II, modify your activities to prevent further progression of symptoms. If you are at Level III or higher, seek professional assistance.
  • 12. Background Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 10 Pain Pain is a unique experience for each individual. The pain threshold of performers tends to be very high, partly because pain is a common experience in this physically demanding industry. Performers normalize pain and are less likely to fear it than the average person. Yet pain is a defence mechanism that is intended to protect and preserve our bodies. If you experience pain, it is important to pay attention to: • when the pain occurs • how long it lasts • how it influences your ability to perform • how it influences your other daily activities Knowing where you are on the signs and symptoms scale (see Figure 2, page 9) may help you distinguish between pain that is due to intense or unaccustomed physical activity and pain that indicates a progressing injury.
  • 13. Background Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 11 Risk factors Medical and scientific research has identified several risk factors that are widely believed to increase the likelihood of MSI (for more information, see “References,” page 14). Understanding these risk factors and looking for practical ways to minimize their influences are important for maintaining your health and desired activity levels, as well as for preventing the frustrating and potentially career-ending effects of MSI. Risk factors include environmental aspects, physical demands of activities, and personal characteristics. Figure 3 illustrates the primary risk factors associated with these three categories. Risk factors Physical demands Awkward postures Forceful exertion Repetition Long-duration activities (inadequate rest) Contact stress (sharp edges) Vibration Personal characteristics Age and gender Physical fitness (strength, flexibility, endurance) Nutrition Posture Addictive substances (tobacco, alcohol, narcotics) Psychological stress Diseases or health conditions (pregnancy, diabetes, osteoporosis) Musculoskeletal injury Environmental aspects Temperature Confined space Layout of space Equipment Layout or configuration of equipment Surfaces (floors) Lighting Figure 3 A non-exhaustive list of MSI risk factors
  • 14. Background Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 12 In general, the strongest relationship between risk factors and incidence of MSI is associated with extreme levels of any single risk factor or the occurrence of multiple risk factors simultaneously. For performers, the greatest risk of MSI is associated with situations that involve: • a change in technique or instrument • intense preparation for performance • preparation of a new and difficult piece • prolonged performance without adequate rest These situations are common for performers, but they could lead to a worst-case scenario. Over time, repetitive and sustained postures may result in stress to tendons, muscles, and nerves. Psychological stress and poor diet — which often accompany a challenging schedule, pressure to perfect, and performance anxiety — may also contribute to the negative effects of physical demands on performers.
  • 15. Background Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 13 General prevention and treatment Prevention MSI prevention is based on two levels of approach: (1) Control the risk factors and (2) Recognize and respond to early signs and symptoms. Controlling risk factors Controlling risk factors requires an awareness that they exist and the creative use of strategies to reduce their effects. In the performing arts, as in other occupations, control strategies are based on a combination of the following philosophies: • Balance physical and psychological demands with the characteristics of the individual (know your personal limits). • Maintain a high level of well-being, health, fitness, and nutrition. Recognizing and responding to early signs and symptoms Early recognition of signs and symptoms allows performers to: • seek professional medical assistance • get referrals to appropriate specialists • take preventive action before pain starts to affect their daily lives (Figure 2, Levels I and II, page 9) Unfortunately, it is more common for performers to work through pain until they can no longer perform. At later stages of injury (Levels III–V), the likelihood of full recovery diminishes, and the treatment process is more complex and disruptive to daily life. Treatment Medical management of signs and symptoms is best performed by medical practitioners who are sensitive to the professional and artistic demands placed upon performers. Musicians and dancers should seek the services of known medical professionals who have demonstrated an understanding of the performing arts. Performers commonly combine complementary approaches with traditional medical management of MSI. There are many complementary approaches spanning a range of philosophies and practices, including: • body-awareness training (for example, the Alexander Technique, Feldenkrais Method, Pilates Method, yoga, and Tai Chi) • acupuncture • massage therapy • herbal medicine While anecdotal evidence supports the effectiveness of complementary approaches, it is recommended that they be implemented in conjunction with the approach of traditional western medicine. For a list of health-care professionals who have experience treating MSI for musicians and dancers, contact SHAPE.
  • 16. Background Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 14 References Bernard, B., and L. Fine, eds. 1997. Musculoskeletal disorders and workplace factors: A critical review of epidemiological evidence for work-related musculoskeletal disorders of the neck, upper extremity and low back. Publication No. DHHS (NIOSH). Cincinatti: U.S. Department of Health and Human Services, National Institute for Occupational Safety and Health: 97–141. Chong, J., M. Lynden, D. Harvey, and M. Peebles. 1989. Occupational health problems of musicians. Canadian Family Physician 35:2341–2348. National Institute of Health. 1998. Acupuncture — National Institute of Health consensus conference. Journal of the American Medical Association 280 (17): 1518–1524. Paull, B., and C. Harrison. 1997. The athletic musician: A guide to playing without pain. Lanham, Md.: The Scarecrow Press, Inc. Zaza, C. 1998. Play it safe: A health resource manual for musicians and health professionals. London, Ont.: Canadian Network for Health in the Arts.
  • 17. Part 2 Musicians and musculoskeletal injury (MSI)
  • 18. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 16 Overview Musicians are prone to musculoskeletal injury (MSI) that is caused or aggravated by playing their instruments. Playing a musical instrument may be second only to computer use in terms of population exposure to a risk factor for MSI (Morse et al. 2000). Some studies have shown that approximately half of professional musicians and music students (including vocalists) experience significant symptoms (Chong et al. 1989; Fry 1986a; Norris 1993; Zaza 1998a). Although MSI is common across the entire industry, the risk of MSI is apparently greater for women than men and greater for string players and keyboardists than other musicians (Zaza and Farewell 1997). The difference in risk between genders may be due to anatomical and hormonal differences between women and men. The increased risk for string players and keyboardists is most likely due to the specific postural requirements of playing these instruments. Symptoms Common MSI symptoms for musicians include pain, weakness, stiffness (reduced range of motion), numbness, tingling, or loss of muscular control that interferes with the musician’s ability to perform at the level they are accustomed to (Zaza, Charles, and Muszynski 1998; Kella 1997). A number of musicians assume that their painful condition is normal and find ways to mask the effects of the developing injury (Fry 1986a; Sternbach 1993). This is partly due to a performance culture in which there is a long-standing philosophy that “the show must go on,” and partly due to a common concern among professional musicians of being labelled as a musician with an injury (Sternbach 1993; Zaza, Charles, and Muszynski 1998). Unfortunately, many musicians, including those whose professional careers are well established, lack the financial resources necessary to subsidize preventive or early treatment. There is also a predominant medical perspective that MSI is neither life-threatening nor medically serious, despite the musician’s perspective that an MSI (and some recommended treatments) can be artistically and professionally limiting, or even career- ending, with devastating effects on the musician’s physical, emotional, and financial well-being (Zaza, Charles, and Muszynski 1998). The music and medical communities require heightened awareness to significantly reduce the incidence of MSI in musicians. “Music, by its very nature, consists of moving tones — in many cases, moving extremely rapidly and for prolonged periods. The repetitive physical motions and forces required to play such music may at times exceed the body’s capabilities and thus become the source of physical problems.” ~ W. J. Dawson, 1997 “All patients complained of pain upon playing.... In half of these patients these symptoms resulted in loss of speed, volume or control. Rapid passages requiring arpeggios, octaves or trills were often affected.” ~ J. Newmark and F. H. Hochberg, 1987
  • 19. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 17 Types of MSI Common MSIs that musicians experience are related to: • tendon inflammation (tendinitis or tenosynovitis) • muscle cramping (focal dystonia) • muscle strain • compression or entrapment of nerves that affect the hands, arms, neck, back, or face A general description of each of these types of MSI is provided in “Tendon and Muscle Disorders” (page 19) and “Nerve Compression or Entrapment” (page 22). Each musical instrument is associated with a unique set of injuries that are related to the physical and postural demands of playing that instrument. Table 1, page 18, provides a summary of common MSIs associated with playing specific instruments. Understanding basic anatomy and the nature of common MSIs can greatly improve a musician’s understanding of risk factors and preventive strategies. Part 4, Musculoskeletal Injuries (MSIs) Prevalent in Performers, provides summaries of many of the MSIs listed in Table 1, including information on the causes of the injury; signs and symptoms; and treatment and prevention strategies. “Our data imply that particular repetitive movements associated with musical instruments predispose players to inflame characteristic areas of the upper limbs.” ~ J. Newmark and F. H. Hochberg, 1987
  • 20. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 18 Table 1 Musculoskeletal injuries associated with specific instruments Violin/viola Neck pain Thoracic outlet syndrome (left) Carpal tunnel syndrome (left) Cubital tunnel syndrome (left) Flexor carpi ulnaris tendinitis (left) Rotator cuff tendinitis (right) Extensor carpi radialis tendinitis (right) Temporomandibular joint dysfunction Guitar Triceps tendinitis (right) Focal dystonia of index and middle fingers and thumb (right) Thoracic outlet syndrome (left) Carpal tunnel syndrome (left) Flexor carpi ulnaris tendinitis (left) Strain of dorsal interosseous (left) Cello/string bass Neck pain Ulnar nerve entrapment (left) Flexor carpi ulnaris tendinitis (left) Rotator cuff tendinitis (right) Extensor carpi radialis tendinitis (right) Harp Neck pain Flexor and extensor tenosynovitis of thumbs Extensor carpi radialis tendinitis (left) Medial epicondylitis (left) Flexor hallucis longus tenosynovitis of big toe (right) Vocals Vocal cord strain Facial and neck muscle strain Focal dystonia of vocal cord muscles Saxophone Back and neck pain Extensor carpi radialis tendinitis (right and left) Temporomandibular joint dysfunction Clarinet Carpometacarpal joint strain (right) Carpal tunnel syndrome De Quervain’s syndrome (right) Lateral epicondylitis (right and left) Temporomandibular joint dysfunction Bassoon Back and neck pain Temporomandibular joint dysfunction Dental problems Strain of teres major and pectoralis major (right) De Quervain’s syndrome Oboe Extensor carpi radialis tendinitis (right) Lateral epicondylitis (right) Ulnar nerve entrapment (right) Posterior interosseous nerve entrapment (right) Back and neck pain De Quervain’s syndrome Flute Thoracic outlet syndrome (left and right) Ulnar nerve entrapment (left) Extensor carpi radialis tendinitis (left) Back and neck pain De Quervain’s syndrome (left and right) Focal dystonia of ring and little fingers (left) Trombone Focal dystonia of lip Lateral epicondylitis (right) Strain of orbicularis oris Trumpet Maxillofacial and lip trauma Pharyngeal dilatation Bagpipes Focal dystonia of ring and middle fingers (right) French horn Temporomandibular joint dysfunction Strain of extensor carpi radialis (right) Strain of dorsal wrist ligament (right) Strain of orbicularis oris Tuba Strain of orbicularis oris Percussion Lateral and medial epicondylitis Flexor carpi ulnaris tendinitis Extensor carpi radialis tendinitis De Quervain’s syndrome Carpal tunnel syndrome Achilles tendinitis Keyboards (piano/organ/accordion) Thoracic outlet syndrome Medial and lateral epicondylitis Tendinitis of wrist flexors and extensors Carpal tunnel syndrome De Quervain’s syndrome Dorsal wrist ganglion Focal dystonia of thumb, finger, hand, and foot muscles Note: This table is based on reports by Chong et al. (1989), Fry (1986a and 1986b), and Norris (1993). This is not an exhaustive list of all MSIs or instruments. If you are aware of any other common MSIs, please contact SHAPE (see page 1 for contact information).
  • 21. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 19 Tendon and muscle disorders (tendinitis, tenosynovitis, focal dystonia, muscle strain) The human body moves and generates force based on tension produced by muscles and transferred to bones by tendons, which attach muscle to bone. Tendinitis and tenosynovitis Tendons are rope-like structures made of strong, smooth fibres that do not stretch. During movement, tendons normally slide within a lubricated tendon sheath. Irritation of the tendon (tendinitis) or sheath (tenosynovitis) results from excessive tension in the tendon or the friction of repeated movements. Tension and friction in tendons increase when awkward postures stretch or bend tendons around joints, contributing to the risk of MSIs such as tendinitis. Excessive tension or impacts can eventually tear tendon fibres much like a rope can become frayed. This type of MSI is called a strain and usually results in the formation of scar tissue. Repeatedly strained tendons can become thickened, bumpy, and irregular. Prolonged irritation of the tendon sheath can cause the lining of the sheath to thicken and constrict, making it difficult for the tendon to slide in the sheath. Focal dystonia Focal dystonia is a malfunction of the muscle at a specific location, which may result in: • cramping • involuntary flexing or straightening of a joint • a sense of fatigue • loss of coordination Focal dystonia may or may not be painful, but it will interfere with the musician’s ability to play an instrument. Muscle cramping is not necessarily focal dystonia. While cramping or stiffness can occur as a result of the fatigue induced by a particularly long or difficult practice session, rehearsal, or performance, focal dystonia is a condition in which muscle dysfunction can occur in the absence of fatigue. Focal dystonia typically affects the: • hands and fingers of string and keyboard players • feet of drummers • vocal chords of vocalists • embouchure of brass players (Sternbach 1994) The musician may experience referred symptoms in other parts of the body when cramping or spasm occurs in the neck or back muscles. For example, cramping in the neck muscles may result in pain behind the ears or above the eyes that resembles a headache. Several tendons and muscles are particularly at risk of injury for musicians.
  • 22. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 20 Hand, wrist, and forearm Keyboard and guitar players are susceptible to straining the small hand muscles that control lateral finger movement and finger spread (interosseous), as well as those that flex the finger at the large metacarpal joint (lumbricales). These strains are largely due to playing loud repeated octaves or chords that require difficult finger positioning (Chong et al. 1989). Clarinet, oboe, flute, keyboard, and drum playing have been associated with De Quervain’s syndrome (Zaza 1998a and 1998b; Chong et al. 1989). De Quervain’s syndrome is characterized by pain in the tendons at the base of the thumb (extensor pollicis brevis and extensor pollicis longus) and on the thumb side of the forearm. It becomes painful to move the thumb away from the hand or to engage in activities that require a firm grip or twisting motion. In keyboard players, De Quervain’s syndrome has been associated with performing a “thumb under” ascension of the keyboard (Chong et al. 1989). In clarinet and flute players, the thumb extensors are continuously involved in supporting the instrument. Drumming can involve extreme flexion and lateral motion of the wrist (ulnar and radial deviation) with rapid deceleration at the moment of impact, which repetitively stresses the extensor tendons. The muscles and tendons in the forearm that flex the wrist (move the palm of the hand toward the forearm) and extend the wrist (move the palm of the hand away from the forearm) are commonly irritated because of the demands of posture, force, and fine coordinated movement that playing some instruments requires of the hands and fingers. String players tend to injure the wrist flexors of the left wrist (flexor carpi ulnaris) and the extensors of the right wrist (extensor carpi radialis). This is due to the flexed wrist posture the musician maintains while applying pressure to strings with the left hand and the extension of the wrist while controlling the bow. The small rapid bow movements required for sustained tremolo place high demand on both the flexor and extensor muscles (Chong et al. 1989). Maintaining wrist flexion or extension while making rapid, forceful, or precise finger movements places a great deal of stress on the long tendons that cross the wrist. Certain wind instruments (oboe, French horn, and flute) require sustained wrist extension to hold the instrument while allowing the fingers to curl into position for fingering. Elbow and shoulder Elbow soreness can result where the forearm muscles attach to the bone on the elbow’s outer edge (lateral epicondyle) or on its inner edge (medial epicondyle). These are the anchor points for tendons of several muscles, including flexor carpi ulnaris on the inner elbow and extensor carpi radialis on the outer elbow. Inflammation of these tendons is called epicondylitis and can result in pain at the elbow, forearm, or wrist. Lateral epicondylitis (tennis elbow) is aggravated by activities that involve extending the wrist, straightening the fingers, or rotating the forearm so the palm faces up. Medial epicondylitis (golfer’s elbow) is aggravated by activities that involve flexing the wrist, bending the fingers, or rotating the forearm so the palm faces down. Musicians are most “With rates of playing reaching 30–40 notes per second, the intrinsic muscles of the hands become at risk for strain; indeed, this diagnosis is one of the most common performance-related problems seen in all instrumentalists.” “Rapid finger movements also can lead to tendon difficulties.” ~ W. J. Dawson, 1997
  • 23. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 21 likely to develop epicondylitis when playing instruments that require complex postures with rotation of the forearm, bending of the wrist, and independent finger movement. Musicians who play keyboard, percussion, clarinet, harp, oboe, or trombone have been reported to be at risk of lateral or medial epicondylitis (Fry 1986b; Chong et al. 1989). The shoulder tendons are at risk of injury for musicians who need to keep their arm in a raised position with the elbow pointing outward or forward. Irritation of the shoulder tendons is often referred to as rotator cuff tendinitis. The rotator cuff comprises the tendons of several muscles (teres major, infraspinatus, supraspinatus, and subscapularis), which help stabilize the arm at the shoulder joint and control rotation of the arm within the shoulder joint. Pain is usually experienced on the top or front part of the shoulder, or on the outer part of the upper arm, and may occur at night. Playing violin, viola, cello, string bass, or bassoon has been associated with rotator cuff tendinitis (Chong et al. 1989; Zaza 1998a and 1998b). Back and neck Low back pain is common among musicians, largely as a result of prolonged sitting in a restricted posture (Fry 1986a; Chong et al. 1989). The seated posture flattens the lumbar curve in the spine, increasing pressure in the intervertebral discs and placing the posterior ligaments and small muscles of the back into tension. Bulging or herniation of the intervertebral discs or local swelling because of strain of the small muscles and ligaments can result in muscle spasms and nerve compression. Upper back and neck pain are more common in certain musicians because of specific playing postures required to support an instrument or the force required to play the instrument. Upper back and neck pain are usually related to postures of the head and upper arms, which are supported and stabilized by muscle activity in the upper back and neck. The static head position required to hold a violin or viola can lead to neck and face pain. Head posture adopted to play an instrument often involves turning the head to one side (for example, flute or harp), or tilting the head downward (for example, saxophone or keyboard). Larger, heavier instruments (for example, double bass or bassoon) that require strength to support or play are associated with back and neck pain. While this is likely due to the physical demands of playing these instruments, methods of transporting and carrying heavier instruments are also a consideration. Head and face Vocalists and horn players are susceptible to straining the muscle that controls the shape of the mouth and lips (orbicularis oris). Wind musicians often suffer disorders of the temporomandibular joint (TMJ), which is where the jaw joins the skull in front of the ears. TMJ pain can seem to be a headache or can involve the face and neck, and is usually related to either excessive muscle tension (for example, teeth clenching) or to degradation of the joint itself. TMJ disorders develop for various reasons and are often related to psychological stress or teeth alignment. Instruments that require careful and sustained jaw positioning (violin, viola, saxophone, clarinet, and French horn) present the greatest risk of TMJ disorders.
  • 24. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 22 Nerve compression or entrapment (carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, sciatica) Peripheral nerves travel from cranial nerves in the brain or spinal cord to the outer regions of the body. Motor nerves send signals to muscles. Sensory nerves transmit information such as pain, temperature, position, and pressure from receptors in the skin, muscles, and joints to the brain and spine. The proper functioning of both motor and sensory nerves is required for coordinated movement. Nerve compression or entrapment results when there is pressure on or irritation of the nerve. This tends to happen at specific locations, where the nerve crosses a joint or where it travels through areas that are restricted in size by surrounding tissues. Aggravation of tendons or muscles that share space with nerves can result in local swelling that compresses the nerves. Several nerve compression disorders are common for musicians, including carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, and sciatica. Carpal tunnel syndrome Carpal tunnel syndrome is compression of the median nerve at the wrist, resulting in numbness, tingling, or pain in the thumb, index, and middle fingers. The carpal tunnel is a narrow passage in the wrist that is formed by the bones on the back of the wrist (carpals) and a band of ligament on the inside of the wrist (flexor retinaculum). Several nerves, major blood vessels, and tendons run through the carpal tunnel to the hand. Swelling within the carpal tunnel can result from irritation of tendons, which causes pressure on the median nerve. This is thought to be related to activities that require repetitive or sustained wrist flexion, particularly with a lot of finger movement. The left hand of violinists, violists, and guitar players is commonly affected by carpal tunnel syndrome, particularly if playing in the 12th or 13th position for too long (Sternbach 1991). Cubital tunnel syndrome Cubital tunnel syndrome is compression or entrapment of the ulnar nerve at the inside groove of the elbow, resulting in numbness, tingling, pain, or loss of coordination in the fourth (ring) and fifth (little) fingers, and pain at the elbow. Postures that require flexion at the elbow and wrist with rotation of the palm upward (supination) — for example, the left hand while playing violin, viola, or guitar — present a risk of cubital tunnel syndrome (Chong et al. 1989). Thoracic outlet syndrome Thoracic outlet syndrome is compression of the brachial plexus (a group of nerves travelling toward the arm) between the first rib and collarbone, which can produce symptoms similar to carpal tunnel syndrome or cubital tunnel syndrome. Postures that result in the shoulders being rounded forward or elevated, sustained use of the pectoral muscles, and breath-holding or irregular breathing patterns all present a risk for thoracic
  • 25. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 23 outlet syndrome. Violin and viola players are susceptible to thoracic outlet syndrome on the left side because of the posture required to secure the instrument between the chin and shoulder. Flute players are susceptible on both sides because of a static playing posture that involves flexing the shoulders forward, reaching the left arm across the midline of the body, and controlling the breathing. Posture while playing keyboard often involves rounded shoulders with the arms in a forward position, the head tilted forward, and irregular breathing patterns. Sciatica Sciatica involves pain in the legs and buttocks caused by irritation or compression of the sciatic nerve as it leaves the spine in the low back and travels down into the leg. Similar compression of nerves as they leave the spine can occur at any level, including the neck, with symptoms often reported in other regions of the body innervated by the compressed nerve. Musicians who are required to sit for prolonged periods, particularly if bent slightly forward or rotated to the side, are susceptible to low back pain and sciatica. The sciatic nerve can also be compressed in the back of the leg and irritated by prolonged sitting on a chair or bench that is too high or has a square edge on the front of the seat pan.
  • 26. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 24 Preventing musculoskeletal injury for musicians MSI prevention for musicians must be based on an understanding of the risk factors within the context of the musician’s perspective, but it must also consider other participants in the performing arts industry (see Figure 1, page 6). Ideally, injury prevention strategies involve an active awareness of risk to the musician by all participants in the industry. Occupational risk factors Occupational risk factors for MSI include: • awkward (non-neutral) postures • repetitive motions • force • vibration • long duration of exposure to risk factors For musicians, risk factors that have the greatest demonstrated association with MSI are lack of warm-up and lack of adequate breaks during practice sessions (Zaza and Farewell 1997). Developing and adhering to a warm-up routine is important. Rest breaks should leave the musician feeling refreshed. Longer rest breaks may require another warm-up period to prepare the body to play the instrument again. Prevention strategies Musicians usually spend the most amount of time playing their instruments and have the most control over their situation during practice sessions, particularly during home practice. Rehearsals and performances are often governed by the demands of the conductor, bandleader, show schedule, venue, or designated duration of sets. Therefore, behavioural prevention strategies usually focus on practice habits. Many of these strategies can also be implemented, in part, during rehearsals and performances. Prevention strategies must not compromise the instrument, the music, or the musician’s health. The nature of music is such that repetitive and sustained awkward postures are often required to hold and play the instruments. However, musicians can have some influence over many risk factors, for example, by adjusting practice schedules, varying the difficulty of music, and using good playing technique. Prevention strategies that may influence the primary risk factors for MSI include the following: • Maintain personal health and well-being. • Select appropriate practice locations. • Develop good practice habits. • Select appropriate instruments and furniture. “The upper extremity problems of hand, wrist, forearm, and elbow are frequently related not to the actual performance of the instrument, but to the process of reed preparation.... Some woodwind players are constantly working at a reed desk, with head forward, shoulders rounded, arms and hands engaged in repetitive motions and applying pressure, to maintain a continuous supply of high- quality reeds.” ~ J. Kella, 1992
  • 27. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 25 • Carry and set up equipment safely. • Maintain body awareness. The following prevention suggestions have some supporting evidence in the scientific literature, either for musicians or in occupations where there are similar types of injuries. Maintain personal health and well-being The first level of prevention is maintaining personal health and well-being in all aspects of daily living. Considering nutrition, hydration, physical activity, sleep quality, and stress management helps ensure that some of the intrinsic risk factors are managed. Managing these aspects of wellness helps ensure that the body is strong, fit, well nourished, and well rested. This helps prevent MSI and allows for more rapid recovery from physically demanding practices, rehearsals, or performances. Smoking, alcohol consumption, coffee consumption, and the use of drugs can predispose an individual to MSI by negatively influencing physiological and psychological functioning (for example, reducing blood flow to the extremities, interfering with normal nerve function, or altering judgment and decision-making abilities). These are issues that compromise wellness in the absence of other physical or psychological stressors. In the physically and psychologically demanding environment of a musician, this reduces resilience and the ability to cope with other stressors. Select appropriate practice locations Environmental factors such as cold or poor lighting can increase risk of MSI. Cold environments reduce blood flow to the fingers and arms, interfere with adequate lubrication of tendons and joints, and can slow nerve conduction in the extremities. Lighting levels influence a musician’s ability to read music, which may affect playing posture and can result in eye strain. Selecting a practice environment that is properly heated and well lit is the ideal prevention strategy. Where this is not possible, wearing adequate clothing and warming the hands prior to playing is important for controlling the negative influence of cold on the functioning of the hands and fingers. Gloves or fingerless gloves may help keep the hands warm, but keeping the entire body warm is important for maintaining adequate blood flow to the extremities, which is considerably reduced when the body becomes cool. In a poorly lit environment, the use of portable task lamps or battery-powered clip lights to illuminate sheet music can help. Develop good practice habits Practice habits that contribute to the risk of MSI include: • lack of warm-up • inadequate rest • overly strenuous repetition of demanding musical phrases • sudden changes in practice routine (Zaza and Farewell 1997; Paull and Harrison 1997; Kella 1997)
  • 28. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 26 Warming up A warm-up is intended to stimulate blood flow and physically warm the muscles and joints the musician will use while playing. A warm-up should involve gentle, smooth motions for several minutes. A musical warm-up at the beginning of a practice session, rehearsal, or performance should include long, slow notes to warm the muscles and encourage blood flow to the areas that will be demanding it during practice, rehearsal, or performance. The use of stretching exercises to prevent MSI is controversial. Although widely considered beneficial, stretching and the use of whole-body exercise to warm up have not been demonstrated to produce benefits for musicians. Before undertaking a new stretching program, musicians should become familiar with good stretching technique. Musicians who experience pain or other symptoms should seek medical advice regarding appropriate exercises. Stretching properly Good stretching technique involves a proper warm-up and slow, controlled stretching of specific muscles. Warm-up should consist of two stages: joint rotation and aerobic warm- up. 1. Joint rotation. Slowly move each part of your body through its comfortable range of motion. (Remember, this is the warm-up, not the stretch. Don’t push your range of motion.) This begins the process of lubricating the joints and preparing your body for activity. 2. Aerobic warm-up. Perform light aerobic activity for approximately five minutes to raise your body temperature and enhance blood flow to the muscles. The aerobic warm-up may involve a rapid walk, slow jog, or even skipping. The key to safe stretching is a smooth, gentle, and steady elongation of the muscles (static stretching) without bouncing. Bouncing or ballistic stretching causes the muscles of the stretching limb to contract instead of elongate, which increases the potential for injury. Hold static stretches for 30–60 seconds. Taking rest breaks Practising, rehearsing, or performing for long periods or practising new material may expose a musician to excessive physical stress. Rest breaks help mitigate this stress. Any type of physical training, including music rehearsal or practice, is based on the overload principle. To see an improvement in performance, the body must work harder than it is accustomed to working. This principle works well as long as the muscles get adequate rest. Without rest, muscles become fatigued and can no longer do the same amount of work. The physical stress of playing then shifts from the muscles to other soft tissue such as tendons and ligaments. Most soft tissue injuries occur when the muscles are fatigued. With adequate rest between practice or rehearsal sessions and within performances, muscles become increasingly strong and able to do more work. Adequate rest breaks
  • 29. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 27 allow musicians to feel refreshed and ready to continue performing near their physical limitations without progressively increasing their level of pain, discomfort, or fatigue. Scheduling regular breaks into practice sessions provides a rest not only for load-bearing muscles and tendons, but also for the mind. This is expected to allow physical recovery of tissues that are under stress while playing and may also enhance learning. There is evidence that learning occurs more effectively if practice is performed in brief periods of time with short rest breaks, compared with long concentrated periods of practice (Zaza 1994). The suggested ratio of practice to rest varies. Here are some suggestions: • 5 minutes of rest for every 25 minutes of playing • 10 minutes of rest for every 50 minutes of playing • 10–15 minutes of rest for every 30 minutes of playing (Zaza 1994; Kella 1997; Norris 1993) More frequent rest breaks may be warranted if the musician is learning a particularly demanding repertoire. This may also involve spreading practice time throughout the day in order to allow adequate rest (Kella 1997). Professional organizations prescribe regular breaks during rehearsals and performances as well. Avoiding repetition Planning to work with a variety of music or exercises during a practice session can help prevent some of the repetition that may occur from practising a single phrase over and over again. Building in time to work with simpler pieces can provide a partial rest to minimize fatigue, particularly when learning physically difficult phrases. It has been suggested that the use of imaging and visualization techniques can reduce the physical playing time required to master a piece of music (Lieberman 1989). Imagining that you are playing the music, note by note, movement by movement, can assist in the cognitive aspects of learning new music and enhance the speed at which motor learning takes place. This strategy reduces the reliance on physical practice time and may reduce the physical risk of injury. Increasing duration and intensity One of the most commonly reported risk factors is a sudden increase in the duration and intensity of practice sessions (Zaza and Farewell 1997; Kella 1997; Norris 1993; Chong et al. 1989). This typically occurs during preparation for a performance, during preparation of a new and difficult piece of music, or when returning from a prolonged break or holiday. Gradual increases to the duration and difficulty of practice are better than abrupt increases in practice intensity and duration (Zaza 1994). The gradual change in activity allows the body to adapt to the changing demand and can allow musicians to become aware of their limits if they pay close attention to signs and symptoms.
  • 30. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 28 Select appropriate instruments and furniture Selecting instruments Changing instruments or playing a new instrument of the same type (including a better- quality instrument than the one previously played) presents a situation in which there is a sudden change in physical demands and an increase in the risk of MSI. Playing poorly maintained or poorly designed instruments can require greater effort or force than playing similar, well-maintained instruments. For example, wind instruments with leaky valves or pads and string instruments with bridges that are too high will require greater effort to play well. Pianos with excessive dead space at the tops of the keys will require more force to obtain volume. Selecting quality instruments and maintaining their proper working condition will assist in preventing MSI (Norris 1993). Selecting an instrument that fits the musician will help the musician adopt a reasonable playing posture without making concessions to adapt for excessive reaches or awkward hand and finger postures. Selecting and adjusting furniture Selecting or adjusting furniture — including chairs, music stands, or gadgets to support the instrument — can have a profound influence on playing posture. Set chairs or stools at a height that allows the musician’s feet to sit flat on the ground with the knees at a 90° angle. If the chair is an inappropriate height and is not adjustable, there are many possible solutions, including the following: • If the chair is too tall, use a footrest (even something as simple as a phone book) to support the musician’s feet. • If the chair is too short, add a cushion to the seat, stack two chairs, or place wooden blocks under the chair feet. (Paull and Harrison 1997) Adjust music stands so the top of the sheet music is at or just below eye level. If the music stand must be substantially lower than eye level, the musician should make an effort to look at the sheet music by lowering the eyes rather than tilting the head. Place the music stand directly in front of the musician to minimize neck rotation. Various gadgets are available to help achieve the posture or force required to play different instruments. A high chin rest can assist in positioning violins or violas without tilting the head excessively or elevating the shoulder. Harnesses can help support the weight of heavier instruments such as drums or tubas. Carry and set up equipment safely Musicians often have a significant amount of equipment to carry and set up before a practice session, rehearsal, or performance. This activity presents a risk of injury to the upper extremities and back and can contribute to fatigue or aggravation of existing conditions. Several strategies can be implemented to reduce the risk associated with carrying and setting up equipment.
  • 31. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 29 Lifting safely As with all lifting tasks, pay attention to safe lifting technique and plan your lift from start to finish. Avoid high-risk behaviours such as twisting your back or rapid lifting. When planning a lift, ensure that you: • know how heavy the load is • have a stable base with your feet shoulder width apart • are positioned to face the item you are lifting • have a solid grip on the item • have a clear route to your destination Take the time to do the job right. Lifting injuries tend to happen more often when there is pressure to get the job done quickly. Using appropriate containers When transporting your equipment, select containers that are not excessively heavy and that have well-constructed, padded handles and wheels (as appropriate). Try to avoid large, heavy loads in containers that will need to be lifted. It is better to make two trips with a smaller load than one trip with a heavy load. When moving heavy equipment, ensure that you have enough people to assist. Ask for assistance. Where possible, use a lifting assist such as a dolly or hand truck, or package equipment in wheeled containers. Allow enough time for set-up to prevent rushing around while carrying equipment and to allow for adequate rest and recovery before playing your instrument. If you have an existing injury in your upper extremities or back, look for ways to avoid carrying equipment altogether. Ask other band members, stage hands, or crew members who are not injured to carry your equipment or perform aspects of set-up that may aggravate your injury. Trading duties may allow you to help during set-up while minimizing the effect on your injury. If you must carry equipment, allow extra time for set-up so you can pace your activity and have time to recover from the work of set-up before playing your instrument. Maintain body awareness Body posture while playing influences the risk of MSI. Poor body mechanics result in awkward postures during both static and dynamic aspects of playing, increasing stress on tissues. Body posture includes not only the back and neck, but also the positioning of the shoulders, arms, hands, and legs, as well as the force that is applied to play the instrument. Excessive force while playing can contribute to the stress on tissues. Some musicians have a tendency to use greater force than is necessary when playing forte or when the
  • 32. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 30 instrument is poorly fit to them. Overplaying is common for string players (left hand), drummers, and horn players (Norris 1993). Practising body awareness or movement disciplines Practising one of several body awareness or movement disciplines can help create the awareness that is required to ensure good posture while playing. Training in alignment and awareness disciplines such as the Alexander Technique, Feldenkrais Method, Pilates Method, yoga, or Tai Chi in addition to playing an instrument increases awareness of playing posture and tends to enhance physical fitness. In any of these approaches, the goal is to gain a better sense of posture, movement, and status of the body. This allows the musician to make appropriate choices regarding playing posture, is expected to improve fluidity of movement, and assists the musician in learning to understand the difference between normal fatigue-related discomfort and pain that indicates excessive tissue stress or injury. Many musicians have learned to play with pain and view this as a normal experience. Learning to recognize the signs and symptoms that indicate the development of MSI at an early stage is absolutely critical if steps are to be taken to prevent it from progressing. Recognition of familiar aches and pains allows the musician to combat these early signs with simple self-help techniques. Knowing when and where to go for medical help if these symptoms do not subside can prevent an ache from becoming a disruptive or even career-ending disease.
  • 33. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 31 Treating musculoskeletal injury for musicians Musicians’ injuries can be managed at two levels. The first level is recognition of early signs and symptoms, and administration of simple self-help techniques. Ideally, musicians should learn to identify early signs and symptoms and practise self-help techniques at an early age. The second level is recognizing signs and symptoms that are persistent or unusual and seeking professional medical assistance (Kella 1997). Warning signs and symptoms Learn to recognize MSI signs and symptoms. Early warning signs and symptoms include: • discomfort, pain, tingling, or numbness while playing • weakness in the hands or difficulty with fine control of the fingers • stiffness or limited range of motion • postural changes (for example, shoulders elevated or rounded forward) • local swelling or redness If you notice discomfort or pain while playing your instrument, take a break until the symptom subsides. Avoid playing through the pain. In most cases it will only get worse if you continue to play. RICE treatment protocol (rest, ice, compression, and elevation) The RICE treatment protocol (rest, ice, compression, and elevation) is applied during the immediate stages of injury to help reduce the amount of damage to the body. This protocol will help manage the injury; however, guidance from a health-care professional should be sought to manage persistent or worsening symptoms. The immediate benefits of following the RICE protocol are that it: • decreases swelling • decreases discomfort • decreases muscle spasm • prevents further injury Rest The concept of rest in this treatment protocol is a relative term. The objective of rest is to stop the exposure of the injured area to activities that aggravate the injury. Ice Applying ice or cold packs helps reduce swelling and manage pain by decreasing blood flow to the injured area and numbing pain sensation. Apply ice to the injured area for 15–20 minutes. Never place ice directly on the skin as this can result in frostbite. Place crushed or cubed ice in a wetted towel and then place the towel on the affected area. If ice is not available, a pack of frozen vegetables works just as well. Alternative methods of icing (creams, balms, or rubs) are not recommended because they only cool the first
  • 34. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 32 layers of skin and not deeper into the injured area. Never use ice to numb an area so a musician can keep performing through pain. This is dangerous because it masks the symptoms and has the potential to make the injury worse. Compression Apply external compression to the injured area by wrapping the injury in a tensor bandage. Apply the wrapping in a criss-cross method — get directions for appropriate wrapping techniques from a health-care professional. Compression reduces the swelling of the injured body part by forcing fluid away from the injured tissue. Compression and ice often can be used together by wrapping the ice in the tensor bandage. Elevation Elevation allows gravity to help move the fluid away from the injured site. Elevate the injured area above the level of the heart. Preventive measures If you experience early signs and symptoms of MSI, try the following preventive measures: • Identify aspects of your set-up, practice habits, or playing posture that may be contributing to the sign or symptom. Take appropriate actions to improve any shortcomings you may notice. • Increase the amount of rest and decrease the duration of continuous playing time until you can play without symptoms. This may mean allocating more practice hours in your day to obtain the same amount of playing time. • Be extra-conscious of performing a gradual, smooth warm-up at the beginning of your practice, rehearsal, or performance sessions. • Be aware of which passages contribute to the signs and symptoms, and reduce your intensity and level of repetition while practising those passages. Perform long, slow notes or simpler passages immediately following the complex passages to allow some additional recovery time within the practice session. Alternate physical practice with mental practice (visualization or imagery) to balance the physical demand with adequate rest, while maintaining a focus on mastery of the passage. When to seek medical assistance If symptoms continue to occur each time you play, continue to get worse, or are unusual for you, seek medical assistance. If symptoms continue to persist after you have stopped practising, or if they appear at times other than when you are playing your instrument (for example, during sleep), seek immediate help from a health-care professional who is experienced in treating musicians’ injuries. Refer to Figure 2, Progression of MSI Signs and Symptoms in Performers, page 9. You may want to seek assistance at any level along this scale. However, it is recommended that you seek immediate help from a health-care professional if you reach Level III or beyond. For a list of health-care professionals who have experience treating MSI for musicians, contact SHAPE.
  • 35. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 33 References Chen, R., and M. Hallet. 1998. Focal dystonia and repetitive motion disorders. Clinical Orthopedics 351:102–106. Chong, J., M. Lynden, D. Harvey, and M. Peebles. 1989. Occupational health problems of musicians. Canadian Family Physician 35:2341–2348. Dawson, W. J. 1997. Common problems of wind instrumentalists. Medical Problems of Performing Artists Journal 12 (4): 109. Floyd, R., and C. Thompson. 1994. Manual of structural kinesiology. Toronto: Mosby- Year Book Inc. Fry, H. 1986a. Incidence of overuse syndrome in the symphony orchestra. Medical Problems of Performing Artists (June): 51–55. ———. 1986b. Overuse syndrome of the upper limb in musicians. The Medical Journal of Australia 144:182–185. Kella, J. 1992. Occupational problems of wind players. The International Musician (November): 2. ———. 1997. A musician’s guide to preventing occupational injuries. Allegro (July/August): 11. Lieberman, J. 1989. You are your instrument: Muscular challenges in practice and performance. Strings (November/December): 48–50. Marxhausen, P. Musicians and injuries. www.engr.unl.edu/eeshop/music.html (May 31, 2002). Morse, T., J. Ro, et al. 2000. A pilot population study of musculoskeletal disorders in musicians. Medical Problems of Performing Artists Journal 15 (2): 85. Musician’s Health www.musicianshealth.com (May 31, 2002). Newmark, J., and F. H. Hochberg. 1987. “Doctor, it hurts when I play”: Painful disorders among instrumental musicians. Medical Problems of Performing Artists Journal 2 (3): 94–96. Norris, R. 1993. The musician’s survival manual: A guide to preventing and treating injuries in instrumentalists. St. Louis: MMB Music Inc. Noteboom, T., R. Cruver, J. Keller, B. Kellogg, and A. Nitz. 1994. Tennis elbow: A review. Journal of Orthopaedic Sports Physical Therapy 6:358–366. Paull, B., and C. Harrison. 1997. The athletic musician: A guide to playing without pain. Lanham, Md.: The Scarecrow Press, Inc. Pujol, J., J. Roset-Llobet, D. Rosines-Cubells, J. Deus, B. Narberhaus, J. Valls-Sole, A. Capdevila, and A. Pasual-Leone. 2000. Brain cortical activation during guitar-induced hand dystonia studied by functional MRI. Neuroimage 12 (3): 257–67. Reid, D. 1992. Sports injury assessment and rehabilitation. New York: Churchill Livingstone.
  • 36. Part 2: Musicians and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 34 Renstrom P. 1994. Clinical practice of sports injury prevention and care. London: Blackwell Scientific Publications. Silverstein, B. 1987. Occupational factors and carpal tunnel syndrome. American Journal of Industrial Medicine 11:343–358. Sternbach, D. 1991. Carpal tunnel syndrome: What to know about it, what to do about it. International Musician (July): 8–9. ———. 1993. Addressing stress-related illness in professional musicians. Maryland Medical Journal 42 (3): 283–288. ———. 1994. Current information on occupational cramps/focal dystonia. International Musician (January): 14–15. Zaza, C. 1993. Prevention of musicians’ playing-related health problems: Rationale and recommendations for action. Medical Problems of Performing Artists 8:117–121. ———. 1994. Research-based prevention for musicians. Medical Problems of Performing Artists 9:3–6. ———. 1998a. Playing-related musculoskeletal disorders in musicians: A systematic review of incidence and prevalence. Canadian Medical Association Journal 158 (8): 1019–1025. ———. 1998b. Play it safe: A health resource manual for musicians and health professionals. London, Ont.: Canadian Network for Health in the Arts. Zaza, C., C. Charles, and A. Muszynski. 1998. The meaning of playing-related musculoskeletal disorders to classical musicians. Social Science and Medicine 47 (2): 2013–2023. Zaza, C., and V. Farewell. 1997. Musicians’ playing-related musculoskeletal disorders: An examination of risk factors. America Journal of Industrial Medicine 32:292–300.
  • 37. Part 3 Dancers and musculoskeletal injury (MSI)
  • 38. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 36 Overview Musculoskeletal injury (MSI) is the most frequently reported medical problem among classical and modern dancers. The majority (60–80%) of dancers have reported at least one injury that has affected their dancing or kept them from dancing (Bowling 1989; Hamilton et al. 1992; Milan 1994; Guierre 2000), and approximately half of dancers report at least one chronic injury (Bowling 1989). Note: This part includes lists of selected references at the end of each section as well as a full reference list at the end of the part (page 50). Long-term and chronic injuries In 1989, Bowling surveyed the injury incidence in 141 professional ballet and modern dancers in the United Kingdom, including representation from the Royal Ballet, London Contemporary Dance Theatre, Sadler’s Wells Royal Ballet, Diversions Dance Company, English Dance Theatre, and many smaller dance companies. The majority of dancers surveyed had experienced multiple injuries and injuries that were either recurring or not resolving (chronic). Many dancers report long-term and chronic injuries because minor injuries go unreported and untreated for long periods. By the time these dancers finally report an injury or seek treatment, the damage has intensified to a level that requires major rehabilitation. Many dancers report self-treating injuries rather than seeking systematic professional medical treatment. Dancers self-treat and delay medical intervention for various reasons. They are often required to juggle a demanding schedule and lack the financial resources necessary to subsidize preventive or early treatments. In a 1992 study, Hamilton et al. found that the personality traits that characterize people with a high pain threshold also distinguish most of the injured dancers. As a result of a high pain tolerance, a dancer may delay medical intervention (Hamilton et al. 1992; Tajet-Foxell and Rose 1995). Delayed-onset muscle soreness versus injury Through their careers, dancers learn to recognize the difference between the delayed- onset muscle soreness that normally accompanies a physically demanding workout and the pain or symptoms that indicate injury. Delayed-onset muscle soreness is muscle stiffness that may develop 24 to 36 hours after intense or unaccustomed physical activity. Delayed-onset muscle soreness is a normal part of a physically challenging training program. It does not usually limit further activity and subsides within a few days. Muscle, tendon, or ligament injuries typically have a more rapid and localized onset of pain and require much longer (weeks or months) for full recovery. Because dancers commonly experience delayed-onset muscle soreness, there is a danger that they may not recognize pain caused by injury as such. Therefore, dancers are at risk of further aggravating injuries by continuing to train or rehearse in the same way. Factors contributing to injury The high incidence of injury in dancers has been attributed to: • excessive dance training at an early age (before puberty)
  • 39. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 37 • extensive and intense rehearsal • the physical characteristics of footwear • dancing on pointe • the dietary habits common to dancers (Reid 1988) The effects of excessive and intense rehearsal are compounded by: • overtired or overworked dancers • inadequate warm-up • unstable or unsuitable flooring • cold environments (Bowling 1989) Faulty technique has been implicated as a major problem and contributor to injury (Maran 1997; Guierre 2000). Injuries because of faulty technique tend to recur even when rest and rehabilitation are successful in treatment of the initial injury. Each time a dancer resumes dancing with incorrect technique, the dancer may be reinjured. This scenario illustrates the importance of long-term dance training that includes a focus on correcting faulty technique. The combination of high physical, mental, and environmental demands is thought to contribute to the high incidence of injury in dance (Smith, Ptacek, and Patterson 2000). The mental demands of dance can manifest as both physical stress (for example, muscle tightness or hyperventilation) and mental anxiety. Both of these factors are known contributors to injury (Smith, Ptacek, and Patterson 2000; Hamilton et al. 1992). Treating stress disorders in dancers has been shown to reduce the incidence of injury (Maran 1997). The dancer’s stress level may also be influenced by interpersonal conflicts among individuals in the dance environment. Rest and proprioception Rest after injury, particularly lower limb injury, plays an important role in maintaining or restoring proprioception. Proprioception relies on sense organs in the joints to provide awareness of the joint’s position, which is critical for posture, balance, and coordinated movements. Proprioception is important for dancers who are trying to coordinate difficult choreography and to balance in difficult positions. Postural stability requires adequate proprioception from the ankle joint. Proprioception is decreased for several weeks in dancers who have sprained their ankle, but will gradually improve as the injury heals. Dancers with ankle injuries have decreased postural stability and are more likely to suffer reinjury if they return to dancing before regaining full proprioception (Leanderson et al. 1996). Types of MSI The most common dance MSIs are strains, sprains, and bone disorders affecting the back or lower extremities (Bowling 1989; Kadel, Teitz, and Kronmal 1992; Khan et al. 1995). The majority of dance injuries are to the hip, knee, ankle, and foot. The lower limb is particularly vulnerable to injury for dancers because of the stress and strain that dance requires of this area (Milan 1994; Khan et al. 1995). The high incidence of lower
  • 40. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 38 extremity injury has been attributed to forcing turnout and dancing on pointe in classical ballet dancers (Khan et al. 1995). Approximately two-thirds of dance injuries are overuse and misuse injuries to the soft tissue (Bowling 1989; Milan 1994). Although soft tissue injuries are generally associated with full recovery within six to eight weeks, this is not typically the case for dancers, whose injuries often become chronic (47–60% of injuries) (Bowling 1989; Milan 1994). Chronic injuries are most likely to affect the back, neck, and lower extremities of dancers (see Table 2). Table 2 Body parts affected by chronic injuries in dancers Body part injured Percentage of chronically injured dancers Back or neck 29 Ankle 20 Knee 17 Thigh or leg 16 Hip, groin, or rib 6 Foot or toes 6 Upper extremities 6 (Adapted from Bowling 1989) The majority of soft tissue dance injuries occur at performances or rehearsals (see Table 3). This suggests that the environmental, psychological, and physical factors affecting the dancer during performance or rehearsal increase the risk and incidence of injury. Dancers are more likely to push their physical limits during performance or rehearsal. Dancers may also experience high levels of physical and mental anxiety that result in tight muscles. Inadequate warm-up contributes to an increased risk of injury. Environmental factors that may affect dancers are the types of floors and temperatures in theatres. Table 3 Location of injury occurrence Location Percentage of dancer injuries Performance 32 Rehearsal 28 Class 16 Slow onset — multiple locations 7 Unknown 17 (Adapted from Bowling 1989)
  • 41. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 39 References Bowling, A. 1989. Injuries to dancers: Prevalence, treatment and perceptions of causes. British Medical Journal 298 (6675): 731–734. Guierre, A. Ballet dancers’ injuries: A review of literature. www.home.worldnet.fr/~aguierre/ (October 1, 2000). Hamilton, W., L. Hamilton, P. Marshall, and M. Molnar. 1992. A profile of the musculoskeletal characteristics of elite dancers. American Journal of Sports Medicine 20:267–273. Kadel, N., C. Teitz, and R. Kronmal. 1992. Stress fractures in ballet dancers. American Journal of Sports Medicine 20 (4): 445–449. Khan K., J. Brown, S. Way, N. Vass, K. Crichton, R. Alexander, A. Baxter, M. Butler, and J. Wark. 1995. Overuse injuries in classical ballet. Sports Medicine 19 (5): 341– 57. Leanderson, J., E. Eriksson, C. Nilsson, and A. Wykman. 1996. Proprioception in classical ballet dancers. American Journal of Sports Medicine 24 (3): 370–373. Maran, A. 1997. Performing arts medicine. Royal College of Surgeons of Edinburgh. Milan, K. 1994. Injury in ballet: A review of relevant topics for the physical therapist. Journal of Orthopaedic Sports Physical Therapy 19 (2): 121–129. O’Malley, M., W. Hamilton, J. Munyak, and J. DeFranco. 1996. Stress fractures at the base of the second metatarsal in ballet dancers. Foot and Ankle International 16 (3): 89–146. Smith, R., J. T. Ptacek, and E. Patterson. 2000. Moderator effects of cognitive and somatic trait anxiety on the relation between life stress and physical injuries. Anxiety, Stress and Coping 13:269–288. Tajet-Foxell, B., and F. Rose. 1995. Pain and pain tolerance in professional ballet dancers. British Journal of Sports Medicine 29 (1): 31–34. Whitting, W., and R. Zermick. 1998. Biomechanics of musculoskeletal injury. Windsor, Ont.: Human Kinetics Publishing.
  • 42. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 40 Preventing musculoskeletal injury for dancers When preventing and treating dance MSIs, it is important to understand the mechanism of injury, the multifactorial causes of injury, and the professional and artistic demands on dancers. This section provides general suggestions and considerations to help prevent MSIs in dancers. Dance on sprung floors According to Newton’s third law, for every action there is an equal and opposite reaction. When jumping and completing high-impact manoeuvres, a dancer exerts a force on the floor and the floor exerts an equal force on the dancer. These forces have a large impact on the dancer’s feet and joints. A sprung floor absorbs some of the force, decreasing the acute impact on the body. Dance in warmer studios Cold environments are associated with decreased blood flow to the extremities. When blood flow is decreased, the affected body parts are more prone to injury. Warm up before dancing Warming up accomplishes three important changes in the body that help reduce the risk of injury: 1. Exercise increases the temperature of the muscle and connective tissue. This is associated with a decreased risk of soft tissue injury. 2. Exercise provides the stimulus and time needed for the cardiovascular system to adjust blood flow from the body’s core to the active muscles, where the need for oxygen increases in response to the exercise. 3. Exercise stimulates joint lubrication and prepares the joints for full range of movement. An adequate warm-up should accomplish each of these three goals. Remain aware of dancers’ limitations When teachers and choreographers are aware of dancers’ physical and mental limitations and requirements, dancers are not likely to feel pressure (whether real or interpreted) to push themselves beyond their capabilities. Dancers who are fatigued and pushing themselves beyond their physical capacity are more likely to adopt sloppy technique or make unsafe movements, increasing their risk of injury. Rest between workouts Any type of fitness training, including dancing, is based on the overload principle. To see an improvement in fitness, the body must work harder than it is accustomed to working. This principle works well as long as the muscles get adequate rest between workouts. Without rest, muscles become fatigued and can no longer do the same amount of work. The stress of the work (i.e., dance) then shifts from the muscles to other soft tissue such as tendons and ligaments. Most soft tissue injuries occur when the muscles are fatigued.
  • 43. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 41 With adequate rest between workouts, muscles become increasingly strong and able to sustain more force, and thus do more work. Adequate rest breaks between workouts allow dancers to feel refreshed and ready to continue working near their physical limitations without progressively increasing their level of pain, discomfort, or fatigue. Without adequate rest between workouts, cumulative fatigue reduces muscle strength and endurance, and the level of pain or discomfort associated with activity progresses. Maintain communication Communication between dancers and artistic directors, teachers, and choreographers is important to maintain dancers’ health. Brief conversations in class or rehearsal can help monitor dancers’ physical and mental status. Early identification of problems can help reduce the likelihood of injury. Open communication provides both an opportunity and permission to identify signs and symptoms of developing soft tissue injuries before they become problematic. In addition, showing a genuine interest in dancers’ well-being can have a positive effect on their level of stress and state of mind. A dancer’s status can provide valuable information regarding the balance between the intensity of the workout and the adequacy of rest and recovery. Rest when injured Immediate management of acute MSIs is important. Care administered within the first 72 hours of an acute injury is critical to the injury’s outcome. The RICE treatment protocol (rest, ice, compression, and elevation) is an effective measure in dealing with an acute soft tissue injury (see page 44). Knowing the difference between delayed-onset muscle soreness and pain due to injury is important for determining when to rest an injury and when to continue physical activity. Delayed-onset muscle soreness peaks 24 to 36 hours after intense or unaccustomed activity. It is a normal response to such activity and subsides within a few days. Most dancers will recognize this soreness as muscle stiffness that is common during training. No restriction of activity is required for recovery from delayed-onset muscle soreness, and the individual may benefit from active use of the sore muscles. Pain due to more serious soft tissue injury usually has a more rapid or acute onset and more localized symptoms, and is recognized as having different characteristics from the usual muscle soreness. Most soft tissue injuries require rest in the form of modified activity to allow the damaged tissue to heal. Modified activity may range from reduced intensity of activities that stress the damaged tissue to complete removal of all activity that affects the injured region. Guidance is best provided on a case-by-case basis by a medical professional who is familiar with sports or occupational injuries and the dance industry. Get proper nutrition Maintaining the body in a strong, resilient state requires enough balanced nourishment to support the caloric and metabolic demands of high-level physical activity and to develop a strong structural foundation in the musculoskeletal system. Bone density and muscle mass depend on an adequate supply of nutrients to support constant tissue remodelling. For more information, see “Nutrition,” page 46.
  • 44. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 42 Avoid strain when carrying equipment For most dancers, carrying equipment, clothing, costumes, and other items is a reality that can place a significant amount of stress on the neck, shoulders, arms, and hands. Minimize the effects of carrying by selecting appropriate containers for your gear. Ideally, containers should be lightweight, with padded handles or shoulder straps. Avoid carrying gear in bags with narrow straps or handles because these increase the effects of contact stress. Where possible, use wheeled carts or bags (such as overnight travel suitcases) with handles that allow you to pull them while in a full standing posture.
  • 45. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 43 Treating musculoskeletal injury for dancers Dancers’ injuries can be managed at two levels. The first level is recognition of early signs and symptoms, and administration of simple self-help techniques. Ideally, dancers should learn to identify early signs and symptoms and use self-help techniques at an early age. The second level is recognizing signs and symptoms that are persistent or unusual and seeking professional medical assistance. The RICE treatment protocol (rest, ice, compression, and elevation) helps control the initial stages of an injury during the first few days. Injury that persists or becomes worse and begins to influence the dancer’s ability to continue dancing is initially addressed by conservative treatment methods. Conservative treatment methods are non-surgical interventions that may include the use of: • medication • activity modification • physical therapies • splints • orthotics • taping • ultrasound • acupuncture When conservative treatment methods are ineffective or the initial injury is particularly severe, more aggressive (surgical) approaches may be warranted. Warning signs and symptoms Learn to recognize MSI signs and symptoms. Early warning signs and symptoms include: • discomfort, pain, tingling, or numbness while dancing • weakness or difficulty with fine control of movement • stiffness or limited range of motion • postural changes (for example, shoulders elevated or rounded forward) • local swelling or redness If you notice discomfort or pain while dancing and circumstances allow it, take a break until the symptom subsides. Preventive measures If you experience early signs and symptoms of MSI, try the following preventive measures: • Identify aspects of your training habits or dance technique that may be contributing to the sign or symptom. Take appropriate actions to improve any shortcomings you may notice.
  • 46. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 44 • Increase the amount of rest and decrease the duration of continuous dance time until you can dance without symptoms. This may mean allocating more rehearsal hours in the day to obtain the same amount of dance time. • Be extra-conscious of performing a thorough warm-up at the beginning of your rehearsal or performance sessions. • Be aware of which movements contribute to the signs and symptoms, and reduce your intensity and level of repetition while rehearsing those movements. Alternate physical rehearsal with mental rehearsal (visualization or imagery) to balance the physical demand with adequate rest, while maintaining a focus on performance. RICE treatment protocol (rest, ice, compression, and elevation) The RICE treatment protocol (rest, ice, compression, and elevation) is applied during the immediate stages of injury to help reduce the amount of damage to the body. This protocol will help manage the injury; however, guidance from a health-care professional should be sought to manage persistent or worsening symptoms. The immediate benefits of following the RICE protocol are that it: • decreases swelling • decreases discomfort • decreases muscle spasm • prevents further injury Rest The concept of rest in this treatment protocol is a relative term. The objective of rest is to stop the exposure of the injured area to activities that aggravate the injury. The dancer can continue with a normal workout routine, but should avoid the actions that result in discomfort or stress to the injured tissue. Ice Applying ice or cold packs helps reduce swelling and manage pain by decreasing blood flow to the injured area and numbing pain sensation. Apply ice to the injured area for 15–20 minutes. Never place ice directly on the skin as this can result in frostbite. Place crushed or cubed ice in a wetted towel and then place the towel on the affected area. If ice is not available, a pack of frozen vegetables works just as well. Alternative methods of icing (creams, balms, or rubs) are not recommended because they only cool the first layers of skin and not deeper into the injured area. Never use ice to numb an area so a dancer can keep performing through pain. This is dangerous because it masks the symptoms and has the potential to make the injury worse. Compression Apply external compression to the injured area by wrapping the injury in a tensor bandage. Apply the wrapping in a criss-cross method — get directions for appropriate wrapping techniques from a health-care professional. Compression reduces the swelling of the injured body part by forcing fluid away from the injured tissue. Compression and ice often can be used together by wrapping the ice in the tensor bandage.
  • 47. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 45 Elevation Elevation allows gravity to help move the fluid away from the injured site. Elevate the injured area above the level of the heart. When to seek medical assistance If symptoms continue to occur each time you dance, continue to get worse, or are unusual for you, seek medical assistance. If symptoms continue to persist after you have stopped dancing or if they appear at times other than when you are dancing (for example, during sleep), seek immediate help from a health-care professional who is experienced in treating dancers’ injuries. Refer to Figure 2, Progression of MSI Signs and Symptoms in Performers, page 9. You may want to seek assistance at any level along this scale. However, it is recommended that you seek immediate help from a health-care professional if you reach Level III or beyond. Conservative medical treatments Conservative medical treatments are non-surgical methods of addressing a condition. The majority of dancers’ injuries will respond well to an aggressive but conservative medical treatment program that is based on a team approach to case management. Several treatment modalities must be coordinated to deal with the injury thoroughly and to prevent recurrence, including: • accurate diagnosis • correction of dance technique (if necessary) • manual therapies to promote joint and soft tissue healing • nutrition advice • a strength and fitness program (such as the Pilates Method) to maintain fitness levels and rehabilitate injured tissues while the dancer is unable to dance (Khan et al. 1995) Involving sports-medicine specialists in the treatment program has been shown to result in a high success rate (Bowling 1989). Dance injuries that do not respond to conservative treatment and require surgical intervention are likely to benefit from dance-specific rehabilitation that includes a focus on maintaining and re-establishing joint mobility, flexibility, and strength. References Bowling, A. 1989. Injuries to dancers: Prevalence, treatment and perceptions of causes. British Medical Journal 298 (6675): 731–734. Khan K., J. Brown, S. Way, N. Vass, K. Crichton, R. Alexander, A. Baxter, M. Butler, and J. Wark. 1995. Overuse injuries in classical ballet. Sports Medicine 19 (5): 341– 57. For a list of health-care professionals who have experience treating MSI for dancers, contact SHAPE.
  • 48. Part 3: Dancers and musculoskeletal injury (MSI) Preventing Musculoskeletal Injury (MSI) for Musicians and Dancers 46 Nutrition Nutrition influences the body’s ability to respond to the stress of physical activity, injuries, and micro-traumas. Dancers who do not have adequate nutritional intake have a higher incidence of injury (Maran 1997). Maintaining adequate hydration is also vital to avoiding injury. Dehydration occurs when the amount of water in the body decreases below normal levels. When the body is dehydrated, the level of electrolytes (sugars and salts) becomes unbalanced, and the risk of MSI and heat injury increases. Eating disorders Dancers as a group have been identified with a high incidence of eating disorders (Disordered Eating and Eating Disorders Web site, November 2, 2000). Eating disorders affect males and females. In this resource guide, the term eating disorder refers to maintenance of a diet lower than 70% of the recommended daily allowance (RDA) and to the disorders anorexia nervosa and bulimia nervosa. Eating disorders are psychological disorders that have serious physical complications. Anorexia nervosa is characterized by abnormally low body weight. Anorexics achieve their low body weight by severely restricting the intake of food and possibly purging even small amounts of food. Bulimia nervosa is characterized by the ingestion of large quantities of food in short periods (binges), followed by attempts to purge the food. Purging is accomplished by vomiting, using laxatives, or engaging in intense physical exercise. Eating disorders have been implicated in the high percentage of dancers who suffer from injury, osteoporosis, and fertility problems (Maran 1997). Dancers who are suffering from an eating disorder should seek professional help as soon as possible. Body mass index (BMI) The effects of poor nutrition have been shown to significantly increase the risk of injury in dancers (Benson et al. 1989). Dancers with a lower than normal body mass index (BMI) are more likely to become injured. BMI represents the relationship between weight and height (weight in kilograms divided by height in metres squared). BMI is a loose predictor of nutritional status. An acceptable BMI ranges between 20 and 25, with 18 to 20 defined as mild starvation, and below 16 indicating severe starvation. In 1989, Benson et al. showed that dancers with BMIs below 19 spent more days off with injury than dancers with BMIs above 19. Menstrual dysfunction Low BMI and eating disorders are also implicated in menstrual dysfunction. Menstrual dysfunction is another risk factor for MSI (Benson et al. 1989). Menstrual dysfunction refers to either delayed menarche (initiation of menstruation at puberty) or amenorrhea (cessation of menstruation). Dancers with lower than normal BMIs are more likely to suffer from delayed menarche or amenorrhea.

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