Actsafe Performing Arts Safety Table of contents Primers Introduction...... 4 This book is one in a series of Performing Arts Safety MSI symptoms...... 5 Primers that also includes: MSIs common to musicians...... 8 Prevention...... 18 • The Performing Arts Safety Primer Treatment...... 27 • Dancers and MSI When to seek medical assistance...... 30 Additional information...... 31

Actsafe would like to thank Dr. Robert Cannon and Dan Robin- son, PhD. CCPE RK for their contributions towards this Primer.

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First printing, December 2010. Printed in Canada.

3 Introduction MSI symptoms

A Musculoskeletal injury (MSI) is any injury or If you develop an MSI, you may experience disorder of the muscles, bones, joints, tendons, symptoms that interfere with your ability to ligaments, nerves, blood vessels, or related soft perform at the level you are accustomed to, tissues. This includes a strain, sprain, or inflam- including: mation that is caused or aggravated by activity. • Musicians (including vocalists) are prone to • weakness MSI that is caused or aggravated by practice, • numbness rehearsal, or performance. Playing a musical • tingling instrument may be second only to computer use • stiffness (reduced range of motion) in terms of population exposure to MSI. Some • loss of muscular control studies have shown that approximately half of professional musicians and music students Some musicians assume that their painful condi- experience significant MSI symptoms. tion is normal and find ways to mask the effects of the developing injury. This is partly due to a There are many things you can do to help pre- performance culture in which there is a long- vent and treat MSI. An MSI can be painful and standing philosophy that “the show must go on,” can interfere with both your professional and and partly due to a common concern among personal life, so it’s important to use prevention professional musicians of being labelled as a strategies. If you already have an MSI, there musician with an injury. are treatment options that will help you stop the injury from getting worse and speed up the heal- There is also a predominant medical perspective ing process. that MSI is neither life-threatening nor medically serious. However, an MSI can be artistically and professionally limiting, or even career-ending,

4 5 with devastating effects on your physical, emo- Level 4 tional, and financial well-being. If you experience Pain occurs as soon as you attempt to pain that may indicate MSI, take steps to deal participate in class, practice, rehearsal, or with the problem. performance, and is too severe to continue. Many aspects of daily life are affected. Below are the five levels of MSI signs and symp- toms in performers. If you are at Level 1 or 2, Level 5 modify your activities to prevent further progres- Pain is continuous during all activities of daily sion of symptoms. If you are at Level 3 or higher, life, and you are unable to participate in class, seek professional assistance. practice, rehearsal, or performance.

Level 1 Pain occurs after class, practice, rehearsal, or performance, but you are able to perform normally.

Level 2 Pain occurs during class, practice, rehearsal, or performance, but you are not restricted in performing.

Level 3 Pain occurs during class, practice, rehearsal, or performance, and begins to affect some aspects of daily life. You must alter technique or reduce the duration of activity.

6 7 MSIs common to musicians Tendon and muscle disorders Tendon and muscle disorders that affect mu- Jaw and head Shoulder sicians include tendinitis and tenosynovitis, • Temporomandibular • Shoulder impingement joint (TMJ) dysfunction syndrome strains, and focal dystonia.

Tendinitis and tenosynovitis Back and neck Tendons are rope-like structures made of strong, • • Back and smooth fibres that do not stretch. During move- ment, tendons normally slide within a lubricated Hand and arm • Cubital tunnel tendon sheath. Excessive tension in the tendon syndrome or the friction of repeated movements can result • in irritation of the tendon (tendinitis) or sheath • Carpal tunnel (tenosynovitis). Awkward postures that stretch or syndrome • De Quervain’s bend tendons around joints increase tension and syndrome friction, contributing to the risk of MSIs such as • Arthritis tendinitis. • Lateral dystonia • Lateral epicondylitis (tennis elbow) Strains • Medial epicondylitis (golfer’s elbow) A strain is a stretch or tear of muscle fibres or connecting tissues such as tendons or fascia. Chronic strains result from prolonged overuse of muscles. Acute strains result from traumatic injuries to muscles.

Excessive tension or impacts can eventually tear tendon fibres much like a rope can become frayed. Tendon strains usually result in the formation of scar tissue. Repeatedly strained 8 9 tendons can become thickened, bumpy, and Focal dystonia typically affects the: irregular. Prolonged irritation of the tendon • hands and fingers of string and keyboard sheath can cause the lining of the sheath to players thicken and constrict, making it difficult for the • feet of drummers tendon to slide in the sheath. • vocal chords of vocalists • embouchure of brass players Focal dystonia Focal dystonia is a muscle malfunction at a spe- You may experience referred symptoms in other cific location, which may result in: parts of your body when cramping or spasm oc- curs in the neck or back muscles. • cramping • involuntary flexing or straightening of a joint Tendon and muscle disorders in • a sense of fatigue specific body parts • loss of coordination Each musical instrument has particular physical Focal dystonia may or may not be painful, but and postural demands that place stresses on the it will interfere with your ability to play an instru- body. Knowing the parts of your body that are ment. more prone to injury may help you prevent MSI.

Muscle cramping is not necessarily focal dysto- Hand, wrist and forearm injuries nia. Cramping or stiffness may occur as a result of the fatigue induced by a particularly long or Description of symptoms: Muscle strains oc- difficult practice session, rehearsal, or perform- cur in the small hand muscles that control lateral ance. However, focal dystonia is a condition finger movement and finger spread, as well as in which muscle dysfunction can occur in the those that flex the finger at the large metacarpal absence of fatigue. joint.

Common with keyboards and guitar. 10 11 Description of symptoms: De Quervain’s Common in instruments that require complex syndrome is pain in the tendons at the base of postures with rotation of the forearm, bending the thumb and on the thumb side of the forearm. of the wrist, and independent finger movement, It becomes painful to move the thumb away from including keyboards, percussion, clarinet, oboe, the hand or engage in activities that require a harp, and trombone. firm grip or twisting motion. Description of symptoms: Rotator cuff tend- Common with clarinet, oboe, flute, keyboards initis is irritation of the shoulder tendons. Pain and percussion. usually occurs in the top or front part of the shoulder, or on the outer part of the upper arm. Description of symptoms: Irritation occurs in the muscles and tendons in the forearm that flex Common with instruments that require the arm and extend the wrist. to be in a raised position with the elbow pointing outward or forward, including violin, viola, cello, Common in instruments that require awkward double bass, and bassoon. postures, force, and fine coordinated movement of the hands and fingers, including strings, oboe, Back and neck French horn, and flute. Description of symptoms: Low . Elbows and shoulders Common with musicians sitting in restricted pos- Description of symptoms: Epicondylitis is el- tures for long periods. bow soreness where the forearm muscles attach to the bone on the elbow’s outer edge (lateral Description of symptoms: Upper back and epicondylitis) or inner edge (medial epicondyli- neck pain. tis). It may also cause forearm or wrist pain. Common with instruments that require specific playing postures and force, particularly of the 12 13 head and upper arms, to support the instrument, sensory nerves. This tends to happen at specific including violin, viola, flute, harp, saxophone, locations: where the nerve crosses a joint or keyboard, double bass, and bassoon. where it travels through areas that are restricted in size by surrounding tissues. Aggravation Head and face of tendons or muscles that share space with nerves can result in local swelling that com- Description of symptoms: Muscle strains oc- presses the nerves. cur in the muscle that controls the shape of the mouth and lips (orbicularis oris). Common nerve compression or entrapment injuries. Common with vocalists and horn players. Description of symptoms: Disorders occur in the temporomandibular joint (TMJ), where the What is it? jaw joins the skull in front of the ears. Pain may • Irritation of tendons causes swelling within seem to be a headache or involve the face and the carpal tunnel and compression of the neck, and is usually related to either excessive at the wrist. muscle tension (for example, teeth clenching) or • Thought to be related to activities that to degradation of the joint itself. require repetitive or sustained wrist flexion, particularly with a lot of finger movement. Common with instruments that require careful and sustained jaw positioning, such as the violin, What are the symptoms? viola, saxophone, clarinet and French Horn. • Numbness, tingling, or pain in the thumb, index, and middle fingers. Nerve compression or entrapment Who does it usually affect? Nerve compression or entrapment results when • violin and viola players (left hand) there is pressure on or irritation of motor or 14 15 • guitar players (left hand) - particularly if index, and middle fingers. playing in the 12th or 13th position for too • Numbness, tingling, pain, or loss of coor- long. dination in the fourth (ring) and fifth (little) fingers, and pain at the elbow. Cubital Tunnel Syndrome Who does it usually affect? What is it? • violin and viola players (left hand) • Compression or entrapment of the ulnar • guitar players (left hand) nerve at the inside groove of the elbow. • flute players (left and right) • keyboard players (left and right) What are the symptoms? • Numbness, tingling, pain, or loss of coor- Sciatica dination in the fourth (ring) and fifth (little) fingers, and pain at the elbow. What is it? • Irritation or compression of the Who does it usually affect? as it leaves the spine in the low back and • violin and viola players (left hand) travels down into the leg. • guitar players (left hand) What are the symptoms? Thoracic Outlet Syndrome • Pain in the legs and buttocks.

What is it? Who does it usually affect? • Compression of the group of nerves • musicians who sit for prolonged periods, travelling toward the arm between the particularly if bent slightly forward or rotated first rib and collarbone. to the side. • musicians who sit on a chair or bench that is What are the symptoms? too high or has a square edge on the front of • Numbness, tingling, or pain in the thumb, the seat pan. 16 17 Prevention Reduce or eliminate your consumption of nicotine, alcohol, coffee, and drugs. They can You can help prevent MSI by using these six predispose you to MSI (for example, by reducing strategies: blood flow to your extremities or interfering with normal nerve function). 1. Maintain your personal health and well- being. Develop good practice habits 2. Develop good practice habits. Good practice habits are an excellent way to 3. Select appropriate practice locations. help prevent MSI. Risk factors most associ- 4. Select appropriate instruments and ated with MSI are lack of warm-up and lack of furniture. adequate breaks during practice sessions. 5. Carry and set up equipment safely. 6. Maintain body awareness. Warm up gently A warm-up helps stimulate blood flow and physi- Maintain your personal health and cally warms the muscles and joints you will use well-being while playing. Your physical warm-up should The first level of prevention is maintaining your involve gentle, smooth motions for several personal health and well-being in all aspects minutes. Your musical warm-up at the beginning of daily life. To prevent MSI and recover more of a practice session, rehearsal, or performance quickly from physically demanding practices, should start with long, slow notes to warm your rehearsals, or performances, follow these guide- muscles and encourage blood flow to the areas lines: that will be demanding it.

• Eat a healthy, well-balanced diet. Stretch properly • Drink plenty of water. Before stretching, slowly move each part of • Exercise regularly. your body through its comfortable range of • Get plenty of good quality sleep. motion. This begins the process of lubricating • Manage stress using healthy strategies. the joints and preparing your body for activity. 18 19 Next, perform light aerobic activity (for exam- Build variety into practice sessions ple, walking, jogging, or skipping) for approxi- Work with a variety of music or exercises during mately 5 minutes to raise your body tempera- practice to help prevent some of the repetition ture and enhance blood flow to the muscles. that may occur from practising a single phrase Stretch smoothly and gently (don’t bounce). repeatedly. Build in time to work with simpler Hold static stretches for 30–60 seconds. pieces to provide a partial rest. Try using imag- ing and visualization techniques to reduce the Take regular rest breaks physical playing time required to master a piece Rest breaks help relieve the stress of long prac- of music. tice sessions, rehearsal, or performance and al- low your muscles to become increasingly strong. Increase duration and intensity gradually Rest breaks may also help your mind. Research One of the most commonly reported risk factors indicates that learning may be more effective is a sudden increase in the duration and inten- when practice occurs in brief periods alternating sity of practice sessions. This typically occurs with short rest breaks. during preparation for a performance, during preparation of a new and difficult piece of music, The suggested ratio of practice to rest varies. or when returning from a holiday. Gradually Here are some suggestions: increase the duration and difficulty of practice • 5 minutes of rest for every 25 minutes of so your body can adapt to the changing de- playing mand. • 10 minutes of rest for every 50 minutes of playing Select appropriate practice locations • 10–15 minutes of rest for every 30 minutes Environmental factors such as cold or poor light- of playing ing can increase your risk of MSI. Cold environ- ments reduce blood flow to the fingers and arms, If necessary, spread practice time throughout the interfere with adequate lubrication of tendons day in order to get enough rest. and joints, and can slow nerve conduction in the

20 21 extremities. Lighting levels influence your ability require more effort to play well. Pianos with ex- to read music, which may affect your playing cessive dead space at the tops of the keys will posture and result in eye strain. require more force to get enough volume.

Select a practice environment that is properly Furniture heated and well lit. Where this is not possible, Set chairs or stools at a height that allows your wear adequate clothing and warm your hands feet to sit flat on the ground with your knees at before playing. Use portable task lamps or a 90° angle. If the chair is too tall, use a footrest battery-powered clip lights to illuminate sheet (even something as simple as a phone book) to music in poorly lit environments. support your feet. If the chair is too short, add a cushion to the seat, or place wooden blocks Select appropriate instruments and under the chair feet. furniture Taking an ergonomic approach to your selection Adjust music stands so the top of the sheet of instruments and furniture can help you elimi- music is at or just below eye level. If the music nate many MSI risk factors. stand must be substantially lower than eye level, make an effort to look at the sheet music by Instruments lowering your eyes rather than tilting your head. Select an instrument that fits you well. Be cau- Place the music stand directly in front of you to tious anytime you change instruments or play minimize neck rotation. a new instrument of the same type (including a better-quality instrument). Use specialized devices to help achieve proper posture or force. A high chin rest can help you Avoid playing poorly designed or poorly main- position a violin or viola without tilting your head tained instruments. For example, wind instru- excessively or elevating your shoulder. Har- ments with leaky valves or pads and string nesses can help support the weight of heavier instruments with bridges that are too high will instruments such as drums or tubas.

22 23 Carry and set up equipment safely

Lifting and carrying heavy equipment can put the upper extremities and back at risk and contribute to fatigue or aggravate existing conditions.

Lift equipment safely Pay attention to safe lifting technique and plan your lift from start to finish. Avoid high-risk behaviours such as twisting your back or rapid lifting. Take the time to do the job right.

When planning a lift, ensure that you:

• know how heavy the load is • have a stable base with your feet shoulder width apart Use safe lifting techniques to help prevent • are positioned to face the item you MSI in your upper extremities and back. are lifting • have a solid grip on the item When moving heavy equipment, ensure that you • have a clear route to your have enough people to help. Ask for assistance, destination especially if you have an existing injury. Where possible, use a lifting assist such as a dolly or hand truck, or pack equipment in wheeled con- tainers. Allow enough time for set-up to prevent rushing around while carrying equipment and to allow for adequate rest and recovery before playing. 24 25 Select appropriate containers Treatment When transporting your equipment, select containers that are not excessively heavy and The first level of injury management is recog- that have well-constructed, padded handles nizing early warning , and and wheels (as appropriate). Try to avoid large, administering simple self-help techniques such heavy loads in containers that will need to be as the RICE treatment protocol. The second lifted. It is better to make two trips with a smaller level is recognizing signs and symptoms that are load than one trip with a heavy load. persistent or unusual and seeking professional medical assistance. Maintain body awareness Early warning signs and symptoms Body posture while playing influences the risk Learn to recognize MSI signs and symptoms. of MSI. Posture includes not only your back and Early warning signs and symptoms include: neck, but also the positioning of your shoulders, arms, hands, and legs, as well as the force that • discomfort, pain, tingling, or numbness while you use to play your instrument. playing • weakness in your hands or difficulty with fine Practise a body awareness or movement control of your fingers discipline to help create the awareness that is • stiffness or limited range of motion required to ensure good posture while playing. • postural changes (for example, shoulders Training in disciplines such as the Alexander elevated or rounded forward) Technique, Feldenkrais Method, Pilates Method, • local swelling or redness yoga, or Tai Chi helps increase awareness and tends to enhance physical fitness. If you notice discomfort or pain while playing your instrument, take a break until the symptom subsides. Avoid playing through the pain. In most cases it will only get worse if you continue to play. 26 27 RICE treatment protocol Do not use alternative methods of icing (creams, balms, or rubs) because they only cool the first Use the RICE treatment protocol (rest, ice, layers of skin and not deeper into the injured compression, and elevation) during the immedi- area. Never use ice to numb an area so you can ate stages of injury to help reduce the amount keep performing through pain. This only masks of damage to your body. The RICE protocol the symptoms and you may make the injury helps decrease swelling, discomfort, and muscle worse. spasm as well as prevent further injury. Compression Although the RICE treatment protocol will help Wrap the injury in a tensor bandage, using a manage your injury, seek guidance from a criss-cross method. Get directions for appropri- health-care professional to manage persistent or ate wrapping techniques from a health-care worsening symptoms. professional. Compression and ice often can be combined by wrapping the ice in the tensor Rest bandage. Rest the injured area to avoid further aggrava- tion. Elevation Elevate the injured area above the level of the Ice heart to help move fluid away from the injury. Apply ice or cold packs to the injured area for 15–20 minutes to help reduce swelling and man- age pain. Never place ice directly on your skin as this can result in frostbite. Place crushed or cubed ice in a wetted towel and then place the towel on the affected area. If ice is not available, a pack of frozen vegetables works just as well.

28 29 When to seek medical Additional information assistance All of the documents listed below are available If symptoms continue to occur each time you at no cost from our website (www.actsafe.ca) or play, continue to get worse, or are unusual for in hardcopy from our office. For further details, you, seek medical assistance. If symptoms con- contact us at [email protected]. tinue to persist after you have stopped practis- ing, or if they appear at times other than when Pain is Optional For Office Workers you are playing your instrument (for example, Actsafe produced comic book discussing MSI during sleep), seek immediate help from a symptoms and prevention common to office health-care professional who is experienced in workers. Great information for anyone who treating musicians’ injuries. works on a computer.

Performing Arts Safety Bulletins Safety guidelines for the performing arts indus- try in British Columbia focusing on a variety of health and safety topics.

Performing Arts Safety Primer A 36 page booklet that contains concise and relevant information and guidelines that relate to issues that all artists, managers, and crafts people may encounter. Answers basic health and safety questions that may come up in day to day production and rehearsal.

30 31 Performing Arts Safety Primer: Dancers and MSI Includes information on symptoms, prevention and treatment for MSIs common to dancers.

To see our full library of health and safety infor- mation and materials, please visit our website at www.actsafe.ca.

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