Physical Therapy, Physical Training
PLAYING WITH NO PAIN AND TO THE HIGHEST LEVEL: THE CASE OF MUSICIANS

Musicians as athletes

I affirm this with the conviction of someone who knows these two universes well: musicians are high-performance athletes, but they do not treat themselves as such. Professional musical performance and high-performance sports require very similar levels of commitment, as well as physical and mental demands. The time, commitment and consistency required to achieve a high level of performance playing an instrument or performing a specific sport skill have much more in common than one might initially think. Some differences will lie in the fact that, in general, neuromuscular recruitment associated with playing an instrument has a greater focus on fine motor skills (i.e. short movements of greater precision and performed mainly with the limbs extremities) and less at the level of gross motor skills (i.e. larger movements involving larger muscle groups) that we normally associate with sports movements. However, it should be clarified that both large muscle groups play an important role, particularly at a postural level, in instrumental performance, and the smaller muscles associated with fine motor skills also play a fundamental role in most sports movements.

For example, if we establish a parallel between playing the violin and performing a given sport specific skill in tennis, we find that, although at different levels, a balance of fine and gross motor control is necessary for better performance in both activities. When we play the violin, we want to maintain a high and controlled posture so that holding the violin with the non-dominant arm and handling the bow with the dominant arm allows the fine work of the hands and fingers to occur as efficiently as possible. Now, if the musculature involved in the stabilization of the trunk and in the elevation of the arms is weak, fatigue sets in more quickly resulting in postural loss, in an execution carried out with greater muscle tension and consequently in a worse performance. In the case of the serve in tennis, due to the high demand for motor coordination and strength involving all the large muscle groups of the lower and upper body, there is also a need for high levels of fine motor skills coordination regarding wrist, hand and finger movements, in order to implement a given spin effect and the desired direction to the ball.

In fact, both musical and sports performance involve neuromuscular recruitment to produce movement and work that requires precision, speed, endurance and strength. In addition, and particularly at a professional level, playing an instrument and playing a sport are activities that require long hours of repetitive movements that, combined with poor physical conditioning, can lead to a variety of clinical conditions. It is unthinkable that a highly competitive athlete does not follow a training program targeting the development of his/her physical qualities which should be complementary to the practice of his/her sport. It is easy to recognize that a good physical fitness level will ensure greater resilience and longevity in sports. The same applies to musical performance. Musicians are high-performance athletes and should prepare themselves as such! Living and playing with pain is not inevitable, it is an option.

The prevalence of pain and injury in musicians

As the years go by and the hours playing their instrument accumulate, it is almost inevitable that professional musicians develop musculoskeletal and/or neuromuscular problems of varying severity at some point in their career. More so if they do nothing about their physical preparation. Review studies on the prevalence of injuries in professional musicians point out that 76% of musicians suffer or have suffered from physical problems that prevent them from performing at their usual level and 84% had injuries that interfered negatively with their musical practice1. Some musicians will develop tendinopathies and low back pain of varying intensity, which they will be able to manage with chronic intake of anti-inflammatory medications or simply by playing less frequently and/or just by enduring pain and discomfort. Others will develop more serious overuse injury syndromes that will become chronic and compromise not only quality of musical performance, but also quality of life, forcing them to periods of musical inactivity. Additionally, others will suffer from even more serious forms of injury that may result in abandoning their career as an instrumentalist musician.

In general, the most frequent injuries affecting musicians manifest themselves through pain and/or dysfunction, especially on the joints, tendons, ligaments and nerves of the upper limb, head, neck and spine. For example, in orchestral instrumentalists, injuries of musculoskeletal and/or neuromuscular origin are more common and affect about 64% musicians, of which 20% consist of peripheral nervous problems and about 8% of cases of focal dystonia2. It makes sense, considering that these are the most stressed areas of the body during instrumental practice. An exception would be the cases of focal dystonia, which, although it may be accompanied by pain and musculoskeletal injury, the root cause of the dysfunction observed at the peripheral level is actually central, that is, the dysfunctional neuronal circuits are at the upper levels of the central nervous system such as the cerebral cortex. Thus, the most frequent injuries in instrumentalist musicians can be summarized as follows3:

  • Musculoskeletal injuries – epicondylitis, tendinopathies (tendinosis, tendinitis, tenosynovitis), bursitis, arthritis, arthrosis, osteoarthritis, contractures, injuries to the temporomandibular joint;
  • Nerve trapping and inflammation – carpal tunnel syndrome, thoracic outlet syndrome, radial tunnel syndrome, ulnar nerve compression syndrome, ulnar tunnel syndrome, cervical and lumbar radiculopathies;
  • Hypermobility;
  • Focal dystonia;
  • Hearing loss.

The onset of injuries in musicians is due to an array of factors that naturally interact. Several authors have identified the following factors facilitating and/or causing the development of injuries in musicians1:

  • Physiological and biological factors such as gender and age. Women seem to be more likely to develop peripheral musculoskeletal and nerve injuries compared to men, and individuals who engage in high volume instrumental practice at an early age, at 4-5 years of age, are also more likely to develop injuries later in life4,5. In the case of focal dystonia, there is a clear higher prevalence in males (over 90%) and in women with menstrual disorders, which suggests that hormonal factors may be predisposing to the development of this disorder6.

 

  • Type of instrument. The characteristics of the instrument (size, shape and weight) and the time of practice imply different levels of physical demand, in which fatigue onset and an execution based on too much physical effort can lead to the development of injuries7. For example, the position needed to play the clarinet implies that the entire weight of the instrument is supported on the right thumb, and at the same time it requires a large amount of short and fast movements of the fingers of both hands8. Another example particularly special to me is the double bass. A bulky instrument with an air column of considerable inertia, which requires not only considerable grip strength to press on the strings, but also considerable whole body physical effort (which, can of course, be optimized with efficient technique) to move this column of air and make the instrument vibrate and produce sound. Anyone who has tried playing the double bass for a few minutes realizes the physical demands that playing this instrument encompasses.

 

  • Instrumental technique. A poor instrumental technique, with non-optimized positions, based on physical effort rather than on movement efficiency, associated with long hours of practice without rest, will naturally predispose the player to pain and injury, especially in the wrists, hands, neck and shoulders9 .

 

  • Specific technical demands. The technical demands of a particular musical piece that often requires high-speed and high-intensity execution, with fatiguing repetition of movements or maintenance of extreme hand positions for a long period of time. All of this creates high levels of mechanical stress and may cause injury10,11.

 

  • Body asymmetry. In the same way that an athlete of a one-side dominant sport will try to compensate for these asymmetries by working out both sides of the body, a musician is in a similar situation, because playing an instrument implies asymmetrical work in very unnatural positions for long periods of time, which will favor the occurrence of various muscular imbalances12.

 

  • Poor physical fitness. Good levels of strength and general physical conditioning are essential to maintain a good position to play an instrument for long periods of time. Most of these positions are very unnatural. Being in good physical fitness will allow to resist the onset of fatigue, recover more quickly between rehearsals or practice sessions, and in fact, it will allow to tolerate more hours of practice avoiding technique and performance deterioration7. Muscle imbalances and weakness resulting from long hours of sitting in certain positions and high volume repetition of short movements must be prevented through exercise programs aiming to strengthen the body globally, and at the same time to compensate for muscle imbalances induced by instrumental practice13.

 

  • Other lifestyle factors. We know that lifestyle factors such as smoking or smoke exposure, alcohol consumption, sleep deprivation, malnutrition, poor hydration and obesity have very damaging effects at a systemic level on our body. Regarding neuromuscular injuries, we know that all these forms of toxicity weaken the body’s connective tissue (cartilage, tendons, ligaments, membranes), muscles and nerve conduction, predisposing to the development of localized inflammatory processes as well as chronic injuries. For example, did you know that obesity is highly predisposing to development of carpal tunnel syndrome?14 Or that smoking is strongly associated with development of injuries and dysfunctions in the shoulder?15

Preventing and resolving injuries in musicians

Any elite athlete empirically knows something that has long been supported by science. That the most effective way to prevent (and also treat) overuse or overload injuries due to high volume sports practice is to ensure good levels of physical fitness combined with good recovery habits, adequate rest and nutrition. Regarding physical fitness, it is unthinkable for an elite athlete, not to follow a regular physical training program. An athlete knows that this will have negative consequences both on sports performance and on the susceptibility for developing injuries. The athlete knows that the weaker his/her musculoskeletal system is, the greater the vulnerability to injury. The question is, and if we consider that professional musicians are required to engage on activities requiring high physical and mental performance for long hours of daily practice, shouldn’t musicians treat themselves as high-performance athletes? I am certain that they should.

In fact, a 2019 systematic review investigating the topic of physical training for professional orchestra musicians1 indicates that following a structured physical training program of varying durations (from a few weeks to several months) has generally resulted in significant improvements in musical performance and in reducing (and even eliminating) chronic pain1.

To keep playing at the highest level for a long time, musicians would greatly benefit if they treated themselves as high-performance athletes and ensure that they maintain good physical shape combined with good habits of recovery, rest and nutrition. And to be clear, when I talk about staying in good physical shape, I don’t mean playing sports. In fact, playing sports as a mean to improve one’s physical fitness is not ideal and can even be harmful. More activity with asymmetric characteristics would be added on top of another, also asymmetric, which is playing a musical instrument. In general, all sports are constituted by specialized movements, and for that reason, also asymmetrical. So, except for purely recreational reasons (which can also be positive at a mental and stress release level), the practice of a sport as a strategy to improve physical fitness is not ideal and should not be the first choice particularly by musicians (I discuss this very topic in this article: Why musicians should not play sports).

General physical fitness is improved through the process of training our physical qualities. This should entail an assessment of the initial status in order to identify specific limitations and outline a specific intervention strategy. One should always start at the base and progress from there, just like the process of learning to play a musical instrument. Here, attention to detail is key. A well-designed training program implies the management of training variables specific to the profile and objectives of the athlete or, in this case, the musician. A correct selection of exercises is crucial, as well as close monitoring of their implementation regarding form of execution, training load and progression over time. As I mentioned, it is not very different from the process of learning to play a musical instrument!

For a musician, playing the instrument is the top priority. It can be obsessive, I know. But playing better in the long run does not necessarily mean playing more hours, but rather investing in taking care of the ‘’machine’’ that is our body. I reiterate once more that playing with pain or discomfort is an option and not an inevitability. Take care of your body and treat it well, because you will need it in the long run!

Train well to play well!

Nuno Correia

References:

  1. Gallego, C., Ros, C., Ruíz, L., Martín, J. (2019). The physical training for musicians. Systematic review. Sportis Sci J, 5 (3), 532-561.
  2. Lederman, R. J. (2003). Neuromuscular and musculoskeletal problems in instrumental musicians. Muscle & Nerve, 27(5), 549–561.
  3. Betancor Almeida, I. (2011). Hábitos de actividad física en músicos de orquestas sinfónicas profesionales: un análisis empírico de ámbito internaciona Tesis Doctoral. Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria.
  4. Fishbein, M., Middlestadt, S., Ottati, V., Straus, S., y Ellis, A. (1988). Medical problems among ICSOM musicians: Overview of a national survey. Medical Problems of Performing Artists, 3(1), 1–8.
  5. Viaño, J. J. (2004). Estudio de la relación entre la apariciación de lesiones musculoesqueléticas en músicos instrumentistas y hábitos de actividad física y vida diaria. En III Congreso De La Asociación Española de Ciencias Del Deporte. Valencia: Universidad de A Coruña.
  6. Rosset-Llobet, J., Candia, V., Fàbregas, S., Ray, W., & Pascual-Leone, A. (2007). Secondary motor disturbances in 101 patients with musician’s dystonia. Journal of neurology, neurosurgery, and psychiatry, 78(9), 949–953.
  7. Sardá, E. (2003). En forma: ejercicios para músicos. Barcelona: Paidos.
  8. Thrasher, M., y Chesky, K. (1998). Medical problems of clarinetists: Results from the U.N.T. musician health survey. The Clarinet, 25(4), 24–27.
  9. Wynn, C. B. (2004). Managing the physical demands of musical performance. En Williamon A. (Ed.), Musical excellence: Strategies and techniques to enhance performance (pp. 41–60). Londres: Oxford University Press.
  10. Bejjani, F. J., Kaye, G. M., y Benham, M. (1996). Musculoskeletal and neuromuscular conditions of instrumental musicians. Archives of Physical Medicine and Rehabilitation, 77(4), 406–413.
  11. Mark, T., Gary, R., y Miles, T. (2003). What every pianist needs to know about the body: a manual for players of keyboard instruments: piano, organ, digital keyboard, harpsichord, clavichord. GIA Publications. Martín.
  12. Ackermann, B., Adams, R., y Marshall, E. (2002). Strength of endurance training for undergraduate music majors at a university? Medical Problems of Performing Artists, 17(1), 33– 41.
  13. Frabretti, C., y Gomide, M. F. (2010). A saúde dos músicos: dor na prática profissional de músicos de orquestra no ABCD paulista. Revista Brasileira de Saúde Ocupacional, 35(121), 33– 40.
  14. Shiri R, Pourmemari MH, Falah-Hassani K, Viikari-Juntura E. The effect of excess body mass on the risk of carpal tunnel syndrome: a meta-analysis of 58 studies. Obes Rev. 2015;16(12):1094-1104.
  15. Bishop, Julie Y. et al. (2015). Smoking Predisposes to Rotator Cuff Pathology and Shoulder Dysfunction: A Systematic Review. Arthroscopy, Volume 31, Issue 8, 1598 – 1605.