Performing Arts Medicine is a branch of occupational medicine that formally addresses the medical concerns of those who play musical instruments, sing or dance.1 It covers the overall health, prevention and management of injuries related to artists of all types as they practice their craft.
Dance medicine and science investigates the causes of dance injuries, promotes their care, prevention and safe post-rehabilitation return to dance, and explores the ‘how’ of dance movement. Some specific concerns include the biomechanical, physiological, and neuromotor aspects of dance, nutrition, psychological issues, and the body therapies and somatics area.2
Music medicine and the physiology of music-making has its roots in a 1713 treatise by Bernardino Ramazzini called “Diseases of Tradesmen”, regarded to be the first summary of occupational diseases of musicians. This was followed in the 1800s by articles describing injuries in keyboard and violin players, and musician’s cramp (focal dystonia).3 Modern history has seen an increased awareness of overuse injuries and other musculoskeletal problems affecting performance.
Non-musculoskeletal issues in performing arts medicine include nutrition (including the female athlete triad), hearing loss, vocal health, dental issues, respiratory disorders, performance anxiety and other psychosocial issues, HIV/AIDS, and substance abuse.
Musculoskeletal and neurologic conditions affecting performing artists can result from acute injury, such as an ankle sprain after landing from a jump. They may be chronic from overuse, as in tendinopathy from poor technique or ergonomics while holding a musical instrument. Other conditions like focal dystonia develop over time without clear etiology.
Epidemiology, including risk factors and prevention
The lifetime prevalence of injury among professional ballet dancers has been reported to be as high as 95%. Modern dancers and younger ballet students suffer injury rates from 40-80%. Not surprisingly, the foot and ankle make up 30-65% of all reported injuries.4 Risk factors include age (injuries are more severe with advanced age), gender (no overall difference between men and women, however women suffer more foot/ankle injuries while men suffer more shoulder/back injuries), strength, flexibility, pedagogy, skill (novice dancers carry higher risk than elite dancers), costumes, shoes, dance surfaces, theater environment, and rehearsal and performance schedules.4,5
A large survey6 of 2,212 orchestra members revealed that 82% had a medical problem at some point in their careers, while 76% had experienced a problem severe enough to affect their performance ability. Risk factors include gender (females at higher risk, associated with hand size and higher rates of joint laxity); type of instrument (highest risk in string and keyboard instruments) and weight of instrument; required posture, repetitious finger work, and longer practice times; general health/conditioning (consider flexibility, strength, endurance, and nutrition); repertoire, technique, and change in playing time or teacher.7 Prevention begins with education, proper training, ergonomic adaptations and if necessary, medical intervention.
Performing Arts Medicine has some overlap with Sports Medicine, as athletes and performing artists have common challenges such as practicing or playing everyday, playing through pain, competing or performing in challenging environments, having the pressure to succeed and the risk for career-threatening injuries. Travel and jet lag, nutrition, hydration, overuse injuries and performance anxiety can also affect both populations.8 However, there are issues unique to performing artists. Dancers need to be athletic while executing steps gracefully. Musicians are considered “small muscle athletes” due to extensive use of hands and fingers.
Dancers can suffer from overuse syndromes, particularly in the lower extremities. Jumping may force up to twelve times the body weight onto the pelvis, legs, and feet; even with proper posture and alignment, they are still at risk for injury.5 Common ankle and foot pathologies include anterior or posterior ankle impingement syndrome, subtalar subluxation, tendinopathies, sesamoiditis, stress fractures (most commonly the second metatarsal). Other conditions include patellofemoral syndrome, meniscal tears, ligamentous injuries of the knee, iliotibial band syndrome, femoroacetabular impingement, greater trochanteric pain syndrome, disc herniation, radiculopathy, spondylolysis, spondylolisthesis, and sacroiliac joint dysfunction.5
Overuse syndromes of the upper limbs are common among musicians.9 Repetitive action causes fatigue, which leads to recruitment and substitution of other muscles, resulting in increased tension and resistance. Ultimately tissues are stressed beyond their physiological limits, resulting in pain, weakness, and loss of control. Other musculoskeletal problems include sprains and strains, osteoarthritis, joint hypermobility syndrome, and peripheral nerve injuries. Lederman identified ten peripheral nerve disorders, the three most common of which include thoracic outlet syndrome, ulnar neuropathy, and carpal tunnel syndrome.10 Focal dystonia (musician’s cramp) is described as an involuntary movement when performing a specific task. It typically manifests as involuntary flexion of the 4th and/or 5th digits of the hand, more commonly on the right. Increased stress, anxiety, and poor sleep are associated with focal dystonia. Proposed etiologies include excess motor excitability, poor cortical sensory processing, and dysfunctional mediation from the basal ganglia.11
2. Essentials of Assessment
History taking should be specific to the needs and demands of a performance artist. and may extend beyond what may be appropriate for the average neuromusculoskeletal patient. Aside from inquiring about actions that aggravate the symptoms and their impact on common functional tasks like driving, lifting or holding objects, performance-specific questions are also necessary.
Dancers should be asked about level of experience (i.e., age started, total years dancing), styles of dance, movements that aggravate or relieve symptoms, practice and performance schedule, most frequent corrections from teacher, types of shoes, costumes, props, performance surface/environment, and any recent changes to dance regimen, partners, or choreographers.
For musicians, it is important to know what instrument(s) they play; about acquisition of a new instrument or associated equipment like a neck strap, bow or carrying case; a new teacher; duration of studying the instrument; primary musical genre; total playing time prior to the injury – including individual practice, rehearsals, lessons, and performances; future playing demands; recent increases in practice time or intensity; presence of warm-up period prior to playing; scheduled breaks during practice, and duration of breaks. One must also ask which playing techniques (chords or scales, for example) aggravate symptoms, and whether symptoms have resulted in the patient stopping or cutting back from playing.
As with all patients, one must perform a thorough investigation of the musculoskeletal and neurological systems. Pay special attention to abnormalities or asymmetries in resting and dynamic posture, spinal and pelvic alignment, joint ranges of motion, muscle imbalances in tension, bulk, or flexibility, poor firing patterns like scapular dyskinesis, etc.. Assess for increased laxity in conditions such as hip dysplasia or shoulder instability.
Clinical functional assessment: mobility, self care, cognition/behavior/affective state
The artist should be observed performing his or her craft in real time. Dancers should perform common steps and positions, especially those which aggravate symptoms. Musicians should bring their instruments in to the evaluation when possible. An ergonomic assessment of the musician-instrument interface (holding or supporting and playing the instrument) while seated or standing is necessary,. It is helpful if the musician is observed playing different musical passages. A video assessment can also be useful, since some symptoms and physical examination findings occur with fatigue or repetitive movements.
Appropriate laboratory studies will depend on the suspected condition but are not typically necessary. Work-up may include a complete blood count, basic metabolic panel, thyroid function tests, creatine kinase and hormonal levels. Genetic testing may be indicated if considering joint hypermobility syndrome or other genetically predisposed condition like a neuromuscular disorder.
Similar to laboratory studies, necessary imaging will also depend on the suspected condition. This may include X-rays, ultrasound, and magnetic resonance imaging (MRI). MRI can detect soft-tissue injuries and is more sensitive than X-rays for detecting compression or insufficiency fractures but is more costly and less real-time than ultrasound.
Supplemental assessment tools
Nerve conduction and electromyographic (EMG) studies can be helpful for radiculopathies and peripheral nerve injuries. Motion and video analysis may be useful for clinicians but also patients as a form of biofeedback.
Footwear, costumes, set design, overly rigid and non-level stage surfaces may increase the risk of injury for dancers. Musicians risk injury when working in cramped quarters, and/or use non-adjustable furniture and music stands, because these can alter postures and restrict movement. For all performers, lighting, temperature, noise levels and air quality (when performing outdoors) are possible risk factors for injury.
Social role and support system
Psychosocial stressors, depression or anxiety, disordered eating, sleep, personality, coping and the absence of a support system are associated with the risk of injury in dancers.5,12 Among musicians, long hours at work, work content, high job demands, low control/influence, and the lack of social support have been linked to musculoskeletal pain.13 Performers may be reluctant to seek medical help due to insurance issues such as workers compensation and limited private coverage.
Many performing artists are reluctant to seek medical help, since they may be perceived as being unreliable, weak, or having inferior talent. They also fear “losing their gig” if they admit to injury. They are more likely to seek advice from their teachers14, try home or alternative treatments and may delay seeking medical care. Performers may perceive pain as a normal consequence of practicing their art,15 (i.e., “no pain, no gain”) and may play or dance through the pain. Adhering to a rehabilitation program, especially limiting activity , may be difficult.
3. Rehabilitation Management and Treatments
Generally, treatment involves relative rest, adjustments in technique and ergonomics, modifications of the performer-instrument interface, relaxation and body awareness (for example, Alexander technique or Feldenkrais method), physical and/or occupational therapy, use of splints, adaptive devices, modalities, analgesic or anti-inflammatory medications, local injections, or surgery.16
Coordination of care
Treating a performer involves a multifaceted approach, and depending on the diagnosis may require referrals to physical and occupational therapists, athletic trainers, otolaryngologists, audiologists, geneticists, nutrtitionists, endocrinologists and mental health professionals.
Patient and family education
Patient education centers on reducing injury risk. Educating dance and music instructors is also important, since they are often the first of sources of advice for performers. Methods to reduce injury include using proper technique and practice habits, doing strength training and general conditioning exercises,17 having adequate hydration, nutrition, rest and sleep, doing a warm-up and cool-down routine, and limiting practice to 45-50 minutes at a time, coupled with a 10-15 minute break. For musicians, achieving ergonomically correct posture and musician-instrument interface also prevents injury.
4. Cutting Edge/Emerging and Unique Concepts and Practice
Performing Arts Medicine benefits from the use of technological advances in motion analysis such as videography, force plates and surface EMG, in both clinical and research settings. The evolving field of regenerative medicine may also provide additional treatment options.
5. Gaps in the Evidence-Based Knowledge
Standardized clinical guidelines for management of injuries in performing artists still do not exist, mainly due to the relative lack of evidence-based and laboratory research compared to Sports Medicine. The dynamics of human artistic performance are complex, and trying to isolate single variables that can be studied scientifically is difficult.18 Quantitative and qualitative research and increased collaboration amongst performing artists, clinicians, educators, and researchers is helping to develop effective, targeted, and relevant health promotion and performance optimization strategies for performing artists worldwide.19
- “Performing arts medicine.” Segen’s Medical Dictionary. 2011. Farlex, Inc. https://medical-dictionary.thefreedictionary.com/performing+arts+medicine. Accessed November 5, 2017
- Harkness Center for Dance Injuries. https://med.nyu.edu/hjd/harkness/students/dance-medicine-science-career. Accessed November 3, 2017
- Harman SE. The Evolution of Performing Arts Medicine. In: Sataloff RT, Brandfonbrener AG, Lederman RJ (eds.). Performing Arts Medicine, 3rd ed. Narberth, PA: Science and Medicine, Inc.; 2010: 1-24.
- Shybut GT. Foot and Ankle Injuries in Dancers. In: Sataloff RT, Brandfonbrener AG, Lederman RJ (eds.). Performing Arts Medicine, 3rd ed. Narberth, PA: Science & Medicine, Inc.; 2010: 271.
- Liederbach, M. Epidemiology of Dance Injuries: Biophysical considerations in the Management of Dancer Health. Dance Medicine: Strategies for the Prevention and Care of Injuries to Dancers. Orthopedic Section, APA, Inc. 2008.
- Fishbein M, Middlestadt SE. Medical problems among ICSOM musicians: overview of a national survey. Med Probl Perform Art 1988; 3:1-8.
- Brandfonbrener AG. Etiologies of Medical Problems in Performing Artists. In: Sataloff RT, Brandfonbrener AG, Lederman RJ (eds.). Performing Arts Medicine, 3rd ed. Narberth, PA: Science & Medicine, Inc.; 2010: 29.
- Dick RW, Berning JR, Dawson W, Ginsburg RD, Miller C, Shybut GT. Athletes and the arts–the role of sports medicine in the performing arts. Curr Sports Med Rep. 2013;12(6):397-403.
- Fry HJH. Overuse syndrome in musicians: prevention and management. Lancet. 1986 Sept 27; 2(8509):728-31.
- Lederman RJ. Neuromuscular and musculoskeletal problems in instrumental musicians. Muscle & Nerve. 2003:25(5); 549-561.
- Newmark J. and Hochber, FH. Isolated painless manual incoordination in 57 musicians. J Neurol Neurosurg Psychiatry. 1987 Mar; 50(3): 291-295.
- Mainwaring LM, Finney C. Psychological Risk Factors and Outcomes of Dance Injury: A Systematic Review. J Dance Med Sci. 2017;21(3):87-96.
- Jacukowicz A. Psychosocial work aspects, stress and musculoskeletal pain among musicians. A systematic review in search of correlates and predictors of playing-related pain. Work. 2016;54(3):657-68.
- Air ME, Grierson MJ, Davenport KL, Krabak BJ. Dissecting the doctor-dancer relationship: health care decision making among American collegiate dancers. PM&R. 2014;6(3):241-9.
- Bruno S, Lorusso A, Caputo F, Pranzo S, L’abbate N. [Musculoskeletal disorders in piano students of a conservatory]. G Ital Med Lav Ergon. 2006;28(1):25-9.
- Hoppmann RA. Musculoskeletal Problems of Instrumental Musicians. In: Sataloff RT, Brandfonbrener AG, Lederman RJ (eds.). Performing Arts Medicine, 3rd ed. Narberth, PA: Science & Medicine, Inc.; 2010: 207-227.
- Nygaard andersen L, Mann S, Juul-kristensen B, Søgaard K. Comparing the Impact of Specific Strength Training vs General Fitness Training on Professional Symphony Orchestra Musicians: A Feasibility Study. Med Probl Perform Art. 2017;32(2):94-100.
- Manchester RA. Research in performing arts medicine. Med Probl Perform Art. 2015;30(1):66-7.
- Ackermann BJ. The Sickness of stigmas. Med Probl Perform Art. 2017;32(3):183-184.
Jennifer Yang, MD
Nothing to Disclose
Dustin Leek, MD
Nothing to Disclose