By Saskia Constantinou  

A closer look at ailments affecting musicians

Musicians are not generally thought of as athletes but rather as artists. However, their profession has its perils and medical conditions which vary in severity from incidental occurrences to such serious maladies which may disable them from practising and performing. 

As this is a phenomenon which has affected musicians with whom I have worked, it has led to a deep personal interest in the subject and research to identify whether the training and preparation of musicians, and particularly orchestral musicians is sufficient to counteract the effects of these physical and mental maladies.  

This is not a matter which has recently come to light. The study of performing arts medicine can be traced back to the Italian physician Bernardino Ramazzini who, in the early 1700’s summarised the occupational diseases of musicians. More recently, and with further awareness of medical conditions linked to musicians, there are specialised clinics and a scientific journal Medical Problems of Performing Arts devoted to the subject.  

The maladies can be divided into two sections – those physical, referring to musculoskeletal, neurological and dermatological as well as mental, which is commonly referred to as PSS – Performance Stress Syndrome, and a subject for an article in two weeks time.  

Orchestral musicians are highly trained artists who have devoted years of practice and personal sacrifice towards their career. Many musicians even relocate specifically to join their orchestra of choice, subject of course to numerous rounds of auditions.  So, musicians who dedicate their lives to playing in orchestras do so first and foremost because they love their art form and their desire to produce performances of the highest quality.

It is a most exhilarating experience to hear a large, modern symphony orchestra performing exciting repertoire with all the variety of colour and sounds. So, in this pleasure, one of the last things we might think about is the physical volume level of what is going on, and the fact that it might be harmful to the very people who are generating the sound – the musicians themselves.  It is naturally a very serious matter and seems unimaginable that the hearing of musicians, imperative for success in their profession, might be at risk.  

There has been extensive research on the subject with Miriam Daum revealing shocking statistics “In a study at Sweden’s Concert Hall in Gothenberg, 59 out of 139 orchestral musicians (42%) had hearing losses greater than that expected for their ages.”Exposure to excessive sound levels causes damage in two ways – mechanical and sensorineural loss, the latter caused by repeated exposure to excessive noise levels, the one of most concern to musicians.

Daum explained that the noise levels caused “physiological and psychological problems including increased heart rate, blood pressure, nervousness, tension and anger” to name a few.  Doctors Steven Liu and Gregory Hayden agree that positioning in the orchestra has an impact on hearing loss with studies showing that violinists have great hearing deficits in the left ear which receives more ‘noise’ than the right. Most orchestras now raise the brass and percussion players to a higher level to lessen the sound pressure levels reaching the ears of the musicians seated in front of them.  

The orchestral violinist is an integral part of the entire team.  Violinists and violists in particular are susceptible to dermatological disorders – especially where they hold the violin. It presses against the neck below the jaw, and causes a skin irritation commonly called “fiddler’s neck”. This scaling can form cysts, scarring and pustules which are cosmetically not attractive but have also lead to concerns of malignancy. Viola players, by virtue of the size of their instrument are more prone to the problem.

Some players are even allergic to their chin rest which sometimes produces a localised eczema on the side of the chin and cheek. Boxtree wood is recommended as an alternative as it is not known to contain allergens. 

Cellists are not affected on their necks but on their chest in the area of the sternum where the instrument presses and on their knees – known as “cello knee”.  

One of the most common syndromes though, is overuse. Symptoms most frequently reported are pain in the upper limbs, shoulders or back with a tingling and weakness. Violinists and violists because of the placement of the instrument, also suffer from TMJ – (temporomandibular joint syndrome) which produces pain and clicking when the jaw moves. This in turn causes chronic headaches and an “awareness” of the jaw on waking. In more extreme cases, there is a limited opening of the mandible and an increased rightward deviation. In layman’s terms, these musicians would find biting into an apple impossible! 

The concert is the culmination of much hard work attained by hours of daily practice. In the case of string players, they endure daily intensive use of their upper extremities which are frequently placed in bizarre positions. The training is rigorous, and without many hours of intensive work each day, little is achieved. So, this leaves them predisposed to maladies such as tendonitis, nerve entrapment, tunnel carpal syndrome and focal dystonia. 

Focal dystonia is a syndrome characterised by involuntary, prolonged muscle contractions and can affect any part of the body. In violinists, it can affect either hand and is considered a more common problem than is often realised. In a recent survey conducted by Jabusch in 2006 of focal dystonia patients, 17% were tutti players, 17% teachers and 15% were students. The condition is difficult to treat and at present, there is no single cure.  

In high contrast to the degree of interest in the training of sports athletes, little has been done to care for the musicians’ physical and mental needs. Musicians are to blame too – they are not as careful as they should be – if we look locally, one wonders in the Cyprus Symphony Orchestra, how many members arrive early to work in order to do warm-up exercises and prepare for the forthcoming three hour rehearsal?  

In lieu of trying to reduce injuries within the orchestra, nine major orchestras in the United States implemented daily warm up exercises away from the instrument. However, the musicians didn’t comply with the programme citing lack of time, not being paid for exercising and believing that they didn’t require exercise. This was despite an educational program showing them that  exercises could prevent injuries.  

Implementer of the programme, Dr Alice Brandfonbrener concluded that “education must start earlier, before musicians are set in their routine and before injuries can begin to develop.” 

This was also the hypothesis of Lisa Britsch, a Masters student who investigated performance related problems of young musicians. “Poor overall physical conditioning was a contributory factor for musculoskeletal problems…a survey of conservatory students showed that those who took a course designed to prevent health problems found that they benefited from the instruction.” Britsch also emphasised the importance of teachers finding the problems early enough to prevent injury.  

So, the next time you sit comfortably in the audience, enjoying a relaxing evening of music, spare a thought of what the musicians have gone through, to give you this pleasure.