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Playing healthy staying healthy: creating the resilient performer.

While performing arts medicine is a relatively new field compared to sports medicine, the medical problems of performing artists are alarmingly common and career threatening. The articles in this series have explored the issue from various points of view; however, this overview will take an artist psychophysiological and ergonomic perspective. Medical problems of performing artists require specialized clinical and educational interventions targeted at populations exposed to highly stressful activities and environments.

Since 1986, the Musicians' Clinics of Canada has treated more than 10,000 musicians with muscle fatigue, anxiety, depression, nerve entrapments and various stress-related medical conditions. The acronym MADNESS encompasses the spectra of observed medical phenomenon and creates the possibility for targeted treatment interventions.' In Canada, healthcare services are universal, accessible and portable across the provinces, except Quebec, allowing the performing artist to seek medical consultations and obtain treatment interventions for their occupational health problems. (2)

Recent epidemiological studies have shown 84 percent of professional symphony musicians have experienced an injury that affects their ability to perform during their lifetime and 50 percent at any given time are playing hurt. (3) The reasons for this and why interventions are medically necessary at the clinical and educational levels have been examined. Specific risk factors are:

* Long practice sessions

* Insufficient rest

* Excess muscle tension

* Poor posture

* Muscle fatigue

* Sudden increase in playing

* Repertoire scheduling

* Stress

* Lack of fitness

* Insufficient warm-up

The focus of the earlier versions of the Musicians' Clinics of Canada from 1990 to 1996 were ergonomic interventions, such as posture, tension, force, support, duration, repetition, technique, recovery, strength, fitness and size. These concepts are common in occupational and sports medicine; however, they do not on their own explain the extremely high injury rates and extent of impairment and disability of performing artists.

In 1996, the clinic expanded to include assessment of psychophysiology and explored techniques to reduce the effects of chronic stress following ABCDEFG paradigm:








Crucial to the understanding of the underlying mechanisms and opportunities for intervention is the awareness of the neurobiology of performance stress. Integrative medicine, an evidence-based approach supported by research, focuses on addressing the underlying problems of musicians that lead to injury rather than focusing solely on healing an injury itself. This approach includes considerations such as how the body reacts to stress hormones over time, impacts upon the central and autonomic nervous system, and inflammatory response in the body. A detailed exploration of these concepts are beyond the scope of this brief overview but can be explored further in the text by Bessel van der Kolk The Body Keeps the Score. (4) Development of an array of integrative mind-body interventions to restore function and optimal performance were developed to address this issue.

Surface electromyography (sEMG) measures electrical signals generated by neuromuscular recruitment of muscles with wireless sensors to assess fatigue, power spectrum and power output during musical performance. This allows the modification of ergonomic factors relating to excessive force, duration, repetition and technique.

Motion analysis examines postural alignment and dynamic movements during musical performance objectively measuring factors that may create excessive biomechanical loads on anatomical vulnerable structures.

Audio/video feedback is crucial during the process of synchronizing the musical performance to muscle and movement data recorded in real time and available for playback analysis.

Heart rate variability analysis before, during and after musical performance can examine the balance of the sympathetic and parasympathetic nervous system.

Neurobiofeedback analysis measures the frequency of brain waves from very low to high frequencies to tune the mind-body connection into the zone of calm focus.

Psychotherapy techniques such as Mindfulness Based Stress Reduction (MBSR), Cognitive Behavioral Therapy (CBT) and Psychodynamic Therapy (PT) form the building blocks to down regulate the effects of chronic stress related to performance and the artistic lifestyle.

Acupuncture techniques can deactivate trigger points which are created by excessive stimulation from the sympathetic nervous system and ergonomic biomechanical imbalances.

Medications can be prescribed to modify or regulate neurotransmitter and hormonal regulation problems created by chronic stress.

Specific psychophysiological and ergonomic parameters can be measured with state-of-the-art biofeedback technology to allow the performing artist and clinician to collaborate together in a problem solving methodology. By seeing and feeling how these objective measurements relate to performance health problems, awareness of risk factors such as alignment, breathing and coordination create possibilities for restoration of autonomic regulation and homeostasis. Lifestyle modifications related to diet, exercise, focus and goals are integral to reverse the effects of biological aging and increase multisystem resilience outcomes. In 2015, the creation of the Artists' Psychophysiology and Ergonomic Lab (APELab) will allow an N-of-1 strategy to evaluate performance-related health problems and interventions to increase resilience.

In 2009, the dean of the Glenn Gould School at the Royal Conservatory in Toronto made a request to create the "Performance Awareness" course, which is mandatory for all Performance Diploma and Artist Diploma students. Basic mechanisms of performance-related stress on health are covered in detail, followed by interactive demonstrations of techniques to measure and reduce specific risk factors related to performance related injury and illness. The application of targeted psychophysiological interventions are formulated and evaluated with objective outcomes for each student. Long-term outcomes of the course are being evaluated. Further educational collaboration with the National Youth Orchestra of Canada and Toronto Summer Music Festival is ongoing during the summer months to continue the effort of injury prevention on a national basis. University faculties of music are now starting similar courses to address this urgent need.

Other organizations interested in performing arts medicine began working with PAMA with an international initiative called PAMAForte!

* Promoting the highest quality of care to all performing artists and bringing to that care an appreciation of the special needs of performing artists.

* Developing educational programs designed to enhance the understanding and prevention of medical problems related to the performing arts.

* Promoting communication among all those involved in the health care and wellbeing of performing artists.

* Fostering research into the etiology, prevention, treatment and rehabilitation of medical problems of performing artists.

Progress thus far includes: international leadership and collaboration, social media development and sharing, development of more regional meetings, highlighting the annual symposium with the Aspen Music Festival and School, partnerships with the International Association of Dance Medicine and Science, American College of Sports Medicine, National Association of Schools of Music, Music Teachers National Association, National Athletic Trainers Association and others. This will culminate in the first International Congress in Performing Arts Medicine in New York City in 2016.

And most importantly, by music teachers creating a background of relatedness to empower teams and teamwork to produce powerful results and taking a stand for the health of every performing artist in the world, our collective goal will be realized, that is the resilient performer.


(1.) John Chong, Melody Lynden, David Harvey and Marie Peebles, Occupational Health Problems of Musicians, Canadian Family Physician. 1989 Nov; 35: 2341-2348.

(2.) Chong, Christine Zaza, and Frank Smith, Medical Problems of Performing Artists: 1991 Mar; 6(1): 8.

(3.) Bronwen Ackermann, Tim Driscoll, Dianna T. Kenny, Musculoskeletal pain and injury in professional orchestral musicians in Australia. Medical Problems of Performing Artists. 2012 Dec; 27(4):181-7.

(4.) Bessel van der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, 2014.

By Dr. John Chong

Dr. John Chong is medical director of the Musicians' Clinics of Canada. He teaches performance awareness at the Glenn Gould School and is the medical consultant for the National Youth Orchestra of Canada and president of the Performing Arts Medicine Association.
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Title Annotation:Musician Wellness Series
Author:Chong, John
Publication:American Music Teacher
Geographic Code:1CANA
Date:Jun 1, 2015
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