1. STUDENTS Basic Information on Neuromuscular and Vocal Health

2. Sources of This Information on Hearing Health National Association of Schools of Music (NASM)— provides contextual issues in music programs regarding neuromuscular and vocal health Performing Arts Medicine Association (PAMA)— provides information of a medical nature

3. Disclaimers for Information in This Presentation Information provided is generic and advisory. Information is oriented toward musicians and lay persons. Information does not substitute for professional judgments of medical or other experts. Information is not to be considered medical advice. Current information does not supersede present and future empirical research. Information does not serve as basis for NASM accreditation functions. Information does not endorse accompanying reference materials.

4. Responsibility for Neuromuscular and Vocal Health Health and safety depend in large part on personal decisions of informed individuals. This information does not relieve individuals of personal responsibility for avoiding risk and preventing injuries to self before, during, and after study or employment at any institution. This information does not relieve the individual of personal responsibility for appropriate, prudent, and safe behaviors or actions.

5. Responsibility for Neuromuscular and Vocal Health This information does not shift responsibility or liability for consequences of inappropriate, imprudent, and/or unsafe behaviors in any instance or over time to any institution, to NASM, or to PAMA. Neuromuscular and vocal health are important for everyone, but especially for musicians.

6. Neuromuscular and Vocal Health: Basic Issues Neuromusculoskeletal System (NMS)—nervous system, muscular system, and skeletal system  These support the body’s physical structure and enable movement  These include the body’s position in space  These include the relationship of the skeletal system to corresponding muscles and tissues  Terms like “alignment” and “posture” involve spinal positioning, weight distribution, muscular support, and balance  Important for musicians and their neuromuscular and vocal health

7. Neuromusculoskeletal and Vocal Health “Neuromusculoskeletal” encompasses not only overt physical movements (e.g., pressing keys, strumming strings), but also small internal movements (e.g., to produce breath or modify vocal sounds). Neuromusculoskeletal health includes vocal health.

8. Neuromusculoskeletal and Vocal Health Vocal health is important to all musicians because the voice is used in speaking and singing in professional roles (e.g., conductors, coaches, teachers, recording engineers, researchers, and therapists). Good health and healthy behaviors are important to all musicians, regardless of their instruments and/or areas of specialization.

9. Sources of Neuromusculoskeletal/Vocal Disorders Genetic factors Infections Trauma or injury Behaviors—either in isolation or repeated over time

10. Music, The Musician, and Neuromusculoskeletal Health Musical performance = physical activity involving large and small movements—those we can see and those inside the body. Musical performance—involves conscious positioning of the body into specified playing and/or singing postures, which may be unnatural at first.

11. Music, The Musician, and Neuromusculoskeletal Health Practice routines are physically demanding and time-intensive, with few “days off” for the serious musician at an advanced level. Some musicians may develop NMS conditions, complications, or disorders related to their musical activities.

12. Music, The Musician, and Neuromusculoskeletal Health Personal decisions about practice and performance are important in the individual’s NMS health and fitness. Musicians are responsible for their art form and for supporting the well-being of all musicians. It’s important to have a positive relationship between musical performance and NMS health.

13. The Neuromusculoskeletal System (NMS) Musculoskeletal system—includes muscles, tendons, ligaments, bones, joints, and associated tissues that move the body, allow for speech, and help the body maintain its form. The term, “neuromusculoskeletal” adds the nervous system, which coordinates voluntary and involuntary actions by transmitting signals to different parts of the body. Nervous system contains:  Central nervous system (CNS)—brain and spinal cord  Peripheral nervous system (PNS)—nerves that allow the CNS to communicate with the rest of the body

14. Vocal Anatomy: Contains Four Component Systems “Generator”—breath provided by the lungs  Main muscle involved is the diaphragm, a dome-shaped muscle extending along the bottom of the rib cage  Diaphragm is assisted by various muscles in the abdomen, ribs, chest, and back “Vibrator”—larynx, commonly called the “voice box”  Vocal folds (or vocal cords) = 2 infoldings of mucous membranes  When breath regulated by the generator passes along the vocal folds, they vibrate creating sound

15. Vocal Anatomy: Contains Four Component Systems “Resonator”—cavity above the larynx responsible for giving the voice its tonal quality.  Includes vocal tract, much of the pharynx (the throat), the oral cavity, and the nasal passages “Articulator”—tongue, lips, cheeks, teeth, and palate  Helps to shape sounds into recognizable words and specific vocalizations NOTE: These four components work together to produce human speech and singing.

16. Disorders of Neuromusculoskeletal System: Temporary or Permanent Causes  Genetic or related to pre- existing medical condition  Related to trauma or injury  Related to specific behaviors which are subject to modification/change Common symptoms  Pain  Stiffness  Aching  Throbbing  Cramping  Muscle weakness

17. Disorders of Neuromusculoskeletal System Temporary Disorders may respond to  Rest  Behavior modification  Medical interventions

18. Causes of Behavior-Related Neuromusculoskeletal Disorders Overuse--any practice or activity in which anatomically normal structures are used in a so- called normal manner, but to a degree that exceeds their biological limits  Produces physical changes that can cause symptoms or complaints  Degree of excessive activity needed to produce symptoms/damage varies from person to person and seems to be related to a person’s individual anatomy and physiology

19. Causes of Behavior-Related Neuromusculoskeletal Disorders Misuse—a practice in which anatomically normal structures are used in an abnormal manner and/or to an excessive degree, sufficient to produce specific symptoms. Places certain bodily structures under stress Abuse—occurs when an activity is performed not only excessively (overuse) or improperly (misuse), but also in a conscious, willful manner, often producing deleterious physical effects  Common instrumental example = “playing through the pain”  Vocal example = repeated instances of singing too loudly or singing out of range  Also includes use of dangerous substances

20. Causes of Behavior-Related Neuromusculoskeletal Disorders Genetic factors—most common one influencing behavior-related NMS disorders = hypermobility  Also known as “joint hyperlaxity” or “double-jointed”  May predispose a person to muscle pain syndromes and/or tendinitis (inflammation of tendons—tough bands of fibrous connective tissue that connect muscle to bone)

21. Causes of Behavior-Related Neuromusculoskeletal Disorders Hypermobile joints have greater than normal range of motion  People with these tend to use more muscle tension when completing movements or tasks involving the hypermobile joint  Excess tension allows for better control, but can increase risk of damaging or straining muscles  Individuals with this condition are generally advised to monitor and actively reduce the tension carried in muscles and sometimes to do specific strengthening exercises and use external methods of joint support, such as splints or tape

22. Facts and Conclusions Facts  NMS health is essential for musicians.  Many behavior-related NMS disorders are preventable. Conclusions  Musicians have basic NMS health responsibilities.  Healthy NMS behaviors are a critically important addition to the musician’s portfolio of essential disciplines.

23. Facts and Conclusions Constant attention is necessary because NMS damage sometimes occurs gradually over time. Severe or advanced symptoms of certain NMS disorders may be career-ending for a musician. Even if initial problems are not debilitating, they can cause career activity to become increasingly difficult and finally impossible.

24. Meaning of Facts and Conclusions Musicians necessarily engage in repeated NMS behaviors and hold particular postures when they rehearse and perform. Such behaviors and postures do NOT equal automatic risk of one or more NMS disorders. Many factors are involved in determining inherent risk. Managing NMS health starts with understanding basic facts and avoiding the most obvious problematic behaviors, postures, and situations.

25. Meaning of Facts and Conclusions A behavior is risky when it involves overuse, misuse, or abuse of certain bodily components. A behavior is risky when it fails to recognize and adapt to an individual’s physical limitations, genetic or otherwise. Thoughtful judgment about what to do and what not to do for yourself and others involves gaining in- depth knowledge and applying it with sophisticated understanding. A number of variables interact at the same time. These are unique to specific settings and situations.

26. Variables Influencing a Musician’s Risk of NMS Disorders Intrinsic Factors—non-modifiable  Gender—more problems in female than male instrumentalists  Related to smaller average size of the female hand and fingers  Related to smaller bulk and cross-sectional dimensions of female muscles  Females have higher vocal ranges than males  Anatomy—factors like height, hand size, lung capacity, and joint hypermobility may affect the way students play certain instruments as well as the choice of repertoire  Singers—factors = lung capacity, vocal range, tessitura, timbre  Affect assignment of voice parts and songs singers are expected and selected to sing  Since anatomy cannot be changed, technique and an approach to playing and singing music must take anatomy into account

27. Variables Influencing a Musician’s Risk of NMS Disorders Intrinsic Factors—modifiable  Alignment—poor posture can increase risk of injury  Involves good balance and body positioning  Quality of movement—micro and macro movements affect the quality of sound  High levels of body awareness are needed to avoid bound, stiff, or limited movements that can lead to injury  Stress and psychological health—injuries/pain more likely if musician is under stress and/or depressed  NMS problems can lead to depression  Psychological health is important for overall physical health  Motivation and effort—improving muscle strength and endurance require motivation and consistent effort  Exercise and conditioning are important  Musicians may seek guidance from physical therapists, somatic educators, vocal coaches, and other healthcare specialists

28. Variables Influencing a Musician’s Risk of NMS Disorders Extrinsic Factors—non-modifiable  Assigned musical repertoire—certain musical pieces pose particular physical and vocal challenges  Venue—once selected, the setting for performance/rehearsal can make injury more or less likely  Acoustics, temperature, lighting, and seating affect performance  Instrument—though some instruments can be modified somewhat, some characteristics cannot be changed  Frequency of injury is higher for instruments that require many repetitions of finger action and for instruments that must be held in difficult postures  Large instruments may involve more problems Wider stretches for keys, strings, and valves Greater muscle tension and increased use of the smaller and weaker hand muscles More difficult to play quickly because of great size and complexity of keywork and valve travel or greater space between strings and fingerboard

29. Variables Influencing a Musician’s Risk of NMS Disorders Extrinsic Factors—modifiable  Time spent playing or singing—the single most important risk that can be managed by musicians is TIME (i.e., practicing; frequency and nature of rest breaks during practice sessions; how quickly one increases practice time when major performances are approaching; how one approaches more technically demanding passages)  Non-music related activities that can involve overuse or misuse  Fitness and conditioning activities, such as sports participation, especially if overdone or done incorrectly  Excessive use of certain electronic devices, such as computers, tablets, cell phones, and gaming systems  Loud social events and those in which cigarette smoke or alcohol are involved pose serious risk to vocal health  Some forms of outside employment may involve excessive or improper use of the NMS system

30. NMS Issues Affecting the Body Muscle Pain—principal cause is sore muscles  May be related to overuse, misuse, abuse, postural factors, tension, technical problems, or poor conditioning  When muscles get fatigued and are placed under further stress, microscopic damage and disruption of muscle fibers can occur (called “muscle strain”)  Muscle contraction involves specific chemicals When in short supply, optimal efficiency is lost Muscle contraction produces lactic acid; if this accumulates, it decreases the muscle’s ability to continue efficient contractions  Muscle strain and incorrect muscle contractions can lead to pain  Playing-related NMS disorders at all ages are more commonly seen in shoulders, neck, hands/fingers/wrists, and lower back  Specific locations may be related to specific instruments

31. NMS Issues Affecting the Body Neuropathies—a general medical term meaning “diseases or malfunctions of the nerves.” Classified according to types or location of affected nerves. Focal neuropathy—restricted to one nerve or group of nerves or to a particular area of the body.  Symptoms may appear suddenly and include pain, sensory disturbances (e.g., numbness, tingling, “pins and needles,” burning, itching) and weakness  May occur at site of nerve compression or entrapment in extremities  Entrapment = compression on the nerve as it passes through a narrowed channel bound by bone, fibrous bands, bulky muscles, or enlarged arteries

32. Three Most Common Entrapment Neuropathies Carpal Tunnel Syndrome—median nerve (runs from forearm into palm of hand) becomes pressed or squeezed at wrist  Carpal tunnel—a narrow, rigid passageway of ligament and bones at the base of the hand containing the median nerve and several tendons  When tendons are irritated or strained, they may swell and narrow the tunnel compressing the nerve and causing pain, weakness, or numbness in the hand and wrist that radiates up the arm

33. Three Most Common Entrapment Neuropathies Ulnar Neuropathy—ulnar nerve (runs from neck along the inside edge of the arm and into the hand on the side of the pinky finger) becomes inflamed due to compression of the nerve  Symptoms include tingling, numbness, weakness, and pain, primarily along the elbow, the underside of the forearm, and along the wrist or inside edge of the hand  Often linked to repetitive wrist or elbow movements—e.g., sustained elbow flexion among players of bowed instruments can contribute to this condition in some cases

34. Three Most Common Entrapment Neuropathies Thoracic Outlet Syndrome–a group of disorders that occur when the blood vessels or nerves in the thoracic outlet (the space between the collarbone and the first rib) become compressed  Most often the result of poor posture  Can be caused by constant muscle tension in the neck and shoulder areas  Symptoms include pain in the neck and shoulder areas and numbness in the fingers

35. NMS Issues Affecting the Body Dystonia—disorder of sustained muscular contractions, producing unwanted movements or abnormal postures  Focal dystonia—affects a particular area of the body  More prevalent in men (genetic or hormonal factors may be involved)  Repetitive movements, especially those that are painful, seem to trigger it  In musicians, symptoms usually appear in upper limb for keyboard, string, percussion, and woodwind players or in embouchure in brass and some woodwind players  Right hand of keyboard players and left hand of string players most commonly affected

36. NMS Issues Affecting the Voice Phonatory Instability  Phonation—process by which air pressure generated by the lungs is converted into audible vibrations  “Voicing” occurs when air from the lungs passes along the vocal folds at the base of the larynx causing them to vibrate  Production of a tonal, pleasant voice with smooth changes in loudness and pitch depends upon the symmetrical shape and movement of the vocal folds  Phonatory instability occurs when there is asymmetrical or irregular motion of the vocal folds that is superimposed on the vocal fold vibration–often manifests itself as an unsteadiness, hoarseness, or roughness of voice (long or short-term possible)  Short term causes include fatigue, certain medications, drug use, and anxiety—to eliminate these, the causative agent must be removed  Over-the-counter medications, antidepressants, and highly caffeinated drinks can cause vocal tremors—a form of phonatory instability

37. NMS Issues Affecting the Voice Vocal Strain—overuse of the voice (singing or speaking) can produce this  Singers must exercise caution when singing at the extremes of the vocal range  Misuse can also occur  Examples = attempting repertoire beyond vocal maturity/development and improperly learning and practicing certain vocal styles  Prolonged overuse can lead to development of vocal nodules (i.e., soft, swollen spots on the focal folds)  As abuse continues, nodules become callous-like growths  Require specialized and prolonged treatment and rehabilitation  Can have grave consequences for singers

38. Basic Protection for All Musicians Avoid situations that put your NMS health at risk. Refrain from behaviors that compromise your NMS health. Warm up before practice and performance to mobilize muscles and joints and increase blood flow to body parts being used in performance Lubricate the vocal folds. Drink water.

39. Basic Protection for All Musicians Take breaks from practice and rehearsal whenever possible (rule of thumb—5 minutes of rest per half hour). Avoid excessive practice time and stress. Set daily practice limits and vary repertoire during practice sessions.

40. Basic Protection for All Musicians Avoid excessive repetition of difficult repertoire, especially if progress is slow. Avoid repertoire that is beyond your technical or physical reach. Refrain from sudden increases in practice times; slightly REDUCE practice time before juries, recitals, etc. to allow mind and body adequate energy for performance.

41. Basic Protection for All Musicians Ensure proper body alignment and technique.  Be mindful of balance and weight distribution  Ensure adequate freedom of movement and support during practice and performance  Use external support mechanisms, such as shoulder rests, neck straps, and flute crutches, when necessary Maintain good “mental hygiene.”  Get adequate sleep, good nutrition, exercise, time with friends and family  Manage stress; make time for relaxation  Refrain from hazardous activities or recreational drug use  Seek help of mental health professionals, if needed

42. Vocal Protection Drink plenty of water—vocal folds need lubrication.  Drink 8 glasses a day Avoid and/or limit caffeinated and alcoholic beverages. Do not smoke; avoid secondhand smoke. Be aware that some medications, such as allergy pills, may dry out your vocal tissues.  Stay well hydrated if you use them  Check with your doctor if you have questions

43. Vocal Protection Avoid dry air environments, and consider using a humidifier at night. Avoid yelling or raising your voice unnecessarily. Avoid throat clearing and voiced coughing. Use vocal amplification systems when available and appropriate. Rest your voice, especially if you are sick. Give yourself time to recover.

44. Marching Music—A Special Consideration Marching requires:  Playing an instrument while also moving along a street or across an athletic field, often rapidly with irregular movement patterns  High levels of physical conditioning, strength, and endurance  Good general health and physical fitness  Great physical demands on neck, torso, lower back, and legs from carrying heavy instruments

45. Marching Music—A Special Consideration Marching activity-related physical disorders include:  Sprained ankles  Toe contusions  Knee strains  Sunburn and dehydration (esp. in summer heat)

46. Marching Music—A Special Consideration Marching requires:  Physical warm-up  Times of rest and rehydration  Appropriate sun protection  Appropriate ear protection, if needed

47. Basic Things Musicians Need to Know and Do Understand and share with others risk inherent in excessive and improper NMS use while playing and singing music, including the risk of prolonged or permanent damage Recognize that playing and singing music in inappropriate ways or for extended time can cause playing and singing-related NMS disorders

48. Basic Things Musicians Need to Know and Do Monitor practice time and intensity, choice of repertoire, and playing/singing techniques to prevent development of playing- and singing-related disorders Apply health knowledge to specific musical context– practice, performance, production, education, competition, and listening