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Journal of Occupational Science Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rocc20 Injured Professional Musicians and the Complex Relationship between Occupation and Health Christine Guptill PhD, OT Reg. (Ont.) a b a Music Performance Studies, The University of Western Ontario b McMaster University, Canada Available online: 08 May 2012

To cite this article: Christine Guptill PhD, OT Reg. (Ont.) (2012): Injured Professional Musicians and the Complex Relationship between Occupation and Health, Journal of Occupational Science, DOI:10.1080/14427591.2012.670901 To link to this article: http://dx.doi.org/10.1080/14427591.2012.670901

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Christine Guptill This mixed format (research and discussion) article addresses the relationship between occupation and health. The conceptual discussion is deepened by including findings from a phenomenological study of the lived experience of professional musicians with playing-related injuries. Participants described decreased awareness of time and of their bodies when they were healthy, particularly when experiencing flow. Participants described flow as detrimental to their health, and used strategies to disrupt flow in order to continue in their chosen occupation. This choice can be seen as unhealthy, particularly in cases where the musician has been advised to decrease or stop playing for health reasons. However, occupational science theories favour individual choice in occupations. This apparent contradiction can be resolved if the definition of health is broad and includes justice and freedom to choose.

Keywords: Occupation, Health, Flow, Occupational justice, Musicians

Occupational science asserts that the American Occupational Therapy occupation is an innate need Journal. (Wilcock, 1993) and that as human beings we are, by nature, occupa- The concept of ‘flow’ was first tional beings (Yerxa, 1998). It has introduced in this journal in 1993 also been argued that engaging in by Yerxa and colleagues, as a means j Christine Guptill, PhD, OT Reg. (Ont.), Assistant occupation improves health. Indeed, of understanding the relation- Professor, Music Performance occupational science as a discipline, ship between occupation and Studies, The University of and occupational therapy as a prac- health. Proposed by psychologist Western Ontario; Post tice, were founded on this concept Csikszentmihalyi (1975, 1993), Doctoral Fellow, McMaster University, Canada (Jackson, Carlson, Mandel, Zemke, flow has been defined as ‘‘a sub- & Clark, 1998; Law, Steinwender, jective, psychological state that oc- Downloaded by [University of Western Ontario] at 07:58 08 May 2012 j Correspondence to: & Leclerc, 1998; Molineux, 2004; curs when people become so Christine_Guptill@alumni. Wilcock, 1998, 2005; Yerxa, 1998). immersed in an occupation that uwo.ca The founders of occupational science they forget everything except felt that demonstrating the impor- what they are doing’’ (Wright, 2004, 2012 The Journal of – tance of occupation for well-being p. 66). Flow experiences are Occupational Science Incorporated would justify the profession of occu- characterized by clear goals the pational therapy (Clark et al., 1991). person wants to achieve; a high Journal of Occupational Science This is most powerfully illustrated by degree of concentration; loss of the 2012, iFirst, pp 1Á13. a paper informally known as the feeling of self-consciousness, the ISSN 1442-7591 print/ ‘well-elderly study’ (Clark et al., merging of action and awareness; a ISSN 2158-1576 online http://dx.doi.org/10.1080/ 1997), as discussed by Jackson et al. distorted sense of time, one’s sub- 14427591.2012.670901 (1998) in a follow-up publication in jective experience of time is altered;

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direct, unambiguous and immediate feedback; a and Persson’s paper highlighted the potentially balance between ability level and challenge (the destructive effects of flow experiences, noting that activity is neither too easy nor too difficult); a they ‘‘could become too energy demanding and sense of personal control over the situation or even addictive, possibly leading to overload’’ (69). activity; the activity is intrinsically rewarding, so there is effortlessness of action; and becoming Playing a musical instrument is not generally absorbed in the activity (Wright, 2004). All of viewed by society as a ‘risky’ occupation. Never- these characteristics do not need to be present in theless, the risk for professional and aspiring order for flow to be experienced. Those most professional musicians of sustaining a playing- relevant to participants in the study reported related injury (PRI) is significant. Conservative here were the level of concentration, losing estimates indicate that the prevalence of PRI is consciousness of self, an altered sense of time, between 39 and 47%, similar to supermarket feedback, intrinsic reward and being absorbed in checkers and assembly line workers (Zaza, 1998). the occupation. The largest study in North America to date reported that 76% of professional musicians had In the occupational science literature, flow was current physical problems that interfered with introduced to support the notion that pleasure their playing (Fishbein, Middlestadt, Ottati, and happiness are powerful evolutionary forces, Straus, & Ellis, 1988). thereby supporting the premise that occupation is a basic human need (Yerxa, 1993). More recently, Musculoskeletal injuries comprise the majority of Wright (2004) described that within occupational injuries typically experienced by musicians, and science ‘‘flow can be viewed as a phenomenon include tendonitis, epicondylitis, and arthritic that can help us to understand how occupations changes (Brandfonbrener, 2003). Upper extremity may help people attain the highest level of well- and back injuries are most common, and occur being’’ (p. 73). As demonstrated by this state- more frequently in violin, viola and piano players ment, the occupational science literature has (Zaza, 1998). These injuries are reported more associated flow with a positive, desired state frequently in women (Zaza, 1998), although related to health and well-being. However, as this may represent likeliness to seek treatment Wright acknowledged, negative potential impacts rather than a higher frequency of injury have been alluded to, and a few studies have (Brandfonbrener, 2009). explored negative aspects of both occupation and flow. In particular, occupations that might cause Injuries in musicians can be difficult to diagnose, as harm (e.g. addiction) or are considered ‘risky’ they often present in the chronic phase, and pre- (e.g. participating in extreme sports) have been sentation can be atypical. Additional complicating explored (Golledge, 1998; Haines, Smith, & factors make the diagnosis, treatment and prognosis

Downloaded by [University of Western Ontario] at 07:58 08 May 2012 Baxter, 2010; Helbig & McKay, 2003; Lyng, of PRI challenging (Brandfonbrener, 2003). These 1990; Russell, 2008; Willig, 2008). A new per- include psychological factors, including a close spective on occupational risk as value-laden and connection between the occupation and the indivi- normalizing has been developed by Dennhardt dual’s identity and sense of self-worth, and high rates and Rudman (2012). of anxiety and depression inthis population (Chesky & Hipple, 1997; Fishbein et al., 1988; Langendo¨rfer, Jonsson and Persson (2006) also explored the Hodapp, Kreutz, & Bongard, 2006). Some clinicians negative consequences of flow, specifically men- have also noted a tendency for these patients to tioning a study by Ware and Kleiman (1992) who somatize (Brandfonbrener, 2003; Spahn, Ell, & examined flow experiences in information tech- Seidenglanz, 2000). nology, as the Internet evolved at the beginning of the 1990s. Some users of this new technology Risk factors for PRI in musicians include the use were found to have insufficient sleep. Jonsson of repetitive movements (Hagberg, Thiringer, &

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Brandstro¨m, 2005), awkward body positions research was influenced by van Manen’s (Brandfonbrener, 2000), and stress and anxiety phenomenology of practice, which he defined (Lockwood, 1989; Zaza & Farewell, 1997). An as ‘‘the employment of phenomenological meth- important temporal risk factor is a sudden od in applied or professional contexts such as increase in the amount of practice time, which clinical psychology, medicine, education or can occur when preparing for a performance, or pedagogy, nursing, counseling’’ (van Manen, when music students enter new or intensive 2002, 10). educational or training settings (Hoppman, 2001; Newmark & Lederman, 1987). Mitigating The methodology also draws from the philoso- factors include taking breaks and performing a phies of Martin Heidegger (1927/1962), Maurice physical warm-up (Lockwood, 1989), and Merleau-Ponty (1945/2002), and Hans-Georg teaching students more efficient practice Gadamer (1960/1989). Heidegger’s views on techniques (Fry, 1987). Finally, it has been hermeneutics and Gadamer’s dialogic views in- noted that musicians tend to have low fitness fluence this methodology, in that the researcher is levels compared to their peers (Brandfonbrener, an active participant in describing and interpret- 2003, 2009). ing the phenomenon. This work acknowledges the importance of the experiences of the partici- As can be seen, an epidemiologic understanding pants, but does not see them as experts who are of playing-related injuries has been established in an infallible source of knowledge about the the performing arts medical literature. However, phenomenon. Other sources of lived experience this understanding has thus far not included the were also consulted when interpreting the find- lived experience of musicians who sustain the ings (van Manen, 1997). These included my own injuries. I therefore conducted a phenomenologi- experience of the phenomenon, self-reflection cal study with the goal of understanding the and journaling, consulting other phenomenologi- lived experience of professional musicians with cal research, and novels, poetry, films, television playing-related injuries. Selected findings from programs, and song lyrics that shed light on the this study are presented here, to deepen the lived experience. discussion of the relationship between occupation Recruitment and Participants and health. This study consisted of in-depth interviews with 10 professional musicians who had self- Methodology identified as having experienced a playing- related injury. The number of participants is As an occupational therapist and semi- consistent with Thomas and Pollio’s(2002) professional musician, I was interested in under- recommendation of 6 to 12 participants, standing the lived experiences of professional Polkinghorne’s recommendation of 5 to 25

Downloaded by [University of Western Ontario] at 07:58 08 May 2012 musicians who have experienced playing-related participants (1989), and Creswell’s observation injuries. This question lends itself well to a that phenomenological studies involve ‘‘as many qualitative, phenomenological approach, which as 10 individuals’’ (2007, p. 131). Snowball ‘‘aims at gaining a deeper understanding of the sampling was used to recruit participants from nature or meaning of our everyday experiences’’ key informants known to me. Two in-depth (van Manen, 1997, p. 9). In healthcare, phenom- interviews were conducted with each partici- enology often answers questions about how pant, ranging from 1 to 2 hours in length. individuals experience particular health con- After initial data analysis, participants were cerns (Doherty & Scannell-Desch, 2008; invited to a focus group where preliminary Goldberg, 2008; Ingadottir & Halldorsdottir, findings were presented and discussed. Six 2008; Parsons-Suhl, Johnson, McCann, & participants attended the focus group. This Solberg, 2008; Russell, Thille, Hogg, & Lemelin, study was approved by the University of Western 2008; Toombs, 2001). The methodology for this Ontario’s Research Ethics Board.

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Analysis when you’re in a concert, or I just am in some other Analysis used the hermeneutic process initially place where I don’t feel them.’’ Elizabeth explained, outlined by Heidegger and developed by van ‘‘when I’m playing I kind of forget about the pain, I Manen (1997). The analysis was influenced by don’t notice the pain.’’ Simon also expressed the Heidegger’s concept of historicity, acknowledging absence of the body when he was not in pain: the individual contexts of the participants and the ‘‘Every once in awhile it will dawn on me that ‘hey, researcher. The analysis was also influenced by you know, my back’s doing okay.’ ’’ Merleau-Ponty’s concept of the lived-body, as playing a musical instrument is an inherently Jacqueline felt that this experience of losing touch embodied experience. Lastly, van Manen’s (1997) with her body had partly to do with the level of ‘existentials’ Á lived time, body, space and social difficulty of the work: ‘‘If something is really relations Á were used to develop questions for the difficult to do then I’m more likely to be so focused interviews and to frame the analysis of the data. on the music that I can’t focus as much on my body.’’ The analysis was also guided by the data itself, Mark related to this, stating that ‘‘I think I get into with themes emerging from the importance that those frozen positions [that cause pain] when I’m musicians placed on them as well as their practicing cause I get focused on one little [musical] resonance with my own experience, through issue.’’ dialogue during the focus groups, and in con- sultation with research sources. By contrast, participants also noted that they were more aware of their bodies when they were Rigour experiencing injuries, and that this intruded Quality in phenomenological research depends in upon their experience of music performance. part on the way in which the methods reflect the Simon explained: ‘‘You can’t focus on the artistic philosophical groundings of the methodology, demands or even the technical demands. It [pain] which have been described above. In addition to takes your mind away from tuning, ensemble, this, a reflexive journal was used to document music-making.’’ Barbara described a similar ex- decisions made about strategies for conducting perience. ‘‘It’s no fun being in pain when you’re the study and about thought processes during playing because you can’t totally focus on the music- data analysis (Cohen, Kahn, & Steeves, 2000). making, so that limits your enjoyment of the I also met with an experienced qualitative experience.’’ Robert also experienced a dampening researcher who was a member of my dissertation effect of injuries upon his experience of playing: committee, in order to determine whether the ‘‘It’s not as much fun. You don’t get the rush in the analysis was plausible (Cohen et al., 2000; van same way when you’re in the middle of playing and Manen, 1997). Early findings were checked for accuracy and plausibility both in the second it hurts.’’

Downloaded by [University of Western Ontario] at 07:58 08 May 2012 interviews and during the focus group. Finally, thick, rich descriptions are provided to assist the However, some of the participants felt that this reader in determining the accuracy of the descrip- interruption of the unconscious performance of tion of what it is like to be a professional musician music that can occur was necessary and impor- with an injury. tant in maintaining health and longevity as a performer. Mark explained:

Findings If you focus on the music, you forget about Receding nature of the body pain in your shoulder and you just injure Participants indicated that when they were yourself more. So the whole thing about involved in music-making, they were less aware getting away from that focus on music, and of their bodies. As Mark described, ‘‘I never am focusing on your body, the body that’s aware of pain in concerts...either they don’t happen creating the music is so important.

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Barbara also spoke about the importance of being slow time moves.’’ Barbara’s experience with aware of the body in order to maintain health. rehearsals continued: ‘‘When you’re in pain it’s [sighs] looking at the clock, ‘when am I gonna go I think you have to learn to have some home and get in the bath and soak my sore joints’ control. There can be excitement with con- and stuff. You are more aware of the time.’’ Robert trol... My joy is in finding a way to play also expressed his experience of time: that I’m not in pain, and that I can fully do what I need to do to make that music come When it hurts you feel like you’re there for a alive and I’m not regretting it the next day longer time. It doesn’t just fly by, you don’t because I’m suffering from it. get to the end of the show and say, ‘wow, where did that one go?’ you know. It’s like, Instrument as an extension of the body ‘oh man, I’m finally outta here.’ Lived space, in phenomenological terms, is not congruent with the vernacular concept of geo- For Sandra, the experience of time was impacted graphic space. Merleau-Ponty (1945/2002) de- by changes she made to her practice routine at scribed lived space as a ‘‘system of possible home, particularly increasing breaks and limiting actions, a virtual body with its phenomenal ‘place’ the time she practiced, in order to cope with her defined by its task and situation’’ (p. 291). In this injury. study, lived space was demonstrated primarily through the musicians’ relationship with their There have been days that felt like time was instruments. Elizabeth described her relationship really dragging on because I couldn’t get with her instrument as ‘‘wonderful, it’s like a part of anything done. ...If it takes me three and a my body. It’s like I’m talking.’’ Sandra stated, ‘‘I still half weeks to learn a piece of music then feel like it [her instrument] is part of my arm; but it that feels like... ‘God, is this ever going to used to be more natural [before she experienced end’ or ‘how many hours is it going to be in injuries]’’. According to the participants, this was between my hours of practicing sitting more likely to take place when they were around waiting to be able to get going on intensely focused on the music. this again?’ ... I used to sit down for three or four days and just practice all the time Receding nature of time until I could play whatever it is I had to As with the body, participants described that their play. This is way more dragged out. perception of the passage of time was influenced by their engagement in the music, as well as by More specifically, Sandra explained that she felt interference from their injuries. When they were she was ‘‘way, way, way, more alert’’ to the amount engaged, time passed very quickly, as described of time she spends in a practice session. She said,

Downloaded by [University of Western Ontario] at 07:58 08 May 2012 by Elizabeth: ‘‘When I’m playing the time just Á it’s ‘‘I sort of have my eye on the clock all the time about like 5 minutes, 2 hours later ... I get lost in it.’’ how long I have got and then I have to stop.’’ Barbara described her experience during rehear- sals: ‘‘You’re sitting there... enjoying the rehearsal Not all of the participants conceived of time in and playing, time goes by pretty quickly for the most terms of hours and minutes. Simon explained that part.’’ However, when participants became aware in performance, he often thinks in terms of the of their bodies through fatigue or discomfort, this number of pages left in the piece. Barbara also affected their experience of time. Jacqueline spoke about time in years, in relation to aging. explained that when she played in what she She explained: described as ‘the pain zone’, ‘‘it’s like it [time] stops almost, and I’ll be looking at the clock over and It makes you think about your age more, over again, and it will feel like an eternity has gone because you’re hurt. When you’re in pain, by and it’s been two minutes. It’s excruciating, how suddenly you think ‘well if I’m in pain now,

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what kind of pain am I gonna be in later, oh Other participants also described common musi- my God how long can I keep playing my cal practices as injurious, such a practicing for instrument? Am I gonna have to retire early, long periods of time, particularly without breaks; am I gonna make it to retirement? Am I intensive, long rehearsals; overplaying (including gonna be a cripple and a mess when I’m volume and physical effort); poor body awareness older?’ I think it does make you more aware. and attention to general health (e.g. getting You feel like time’s moving faster ... I think regular exercise, stretching); and touring, with you are more aware of time. its associated stress. This is illustrated by Giselle, speaking about a fellow musician: Barbara further explained that the passage of minutes when she experienced pain was slower, People are dropping like flies, you know. but the perception of the approach of age was And it’s just overplaying, because there is faster. just too much work. They treat you like a slave ... That’s what happened to her, the stress of the job ...she was there in all those Negative aspects of occupation and flow hard years of [conductor’s name] when it The participants in this study spoke about the [orchestra] was really a playing machine potential for engagement in musical performance, like Japan, China, Europe, recording galore, particularly during flow, aggravating or causing like they’d be in a recording session for five playing-related injuries. Jacqueline compared her days, they would be locked in that church, engagement in music as akin to addiction: and then they’d get on the plane a week after and they would do Paris and London and My partner at the time was saying, ‘It’s you know, she says to me ... ‘the stress was almost like an abusive relationship that you horrendous.’ ... I always said ‘I want to have with your instrument. You go to it, and have your job’ and she always said, ‘you you play it, and it hurts, and you walk don’t want my job’. away; but then you keep coming back to it all the time.’ ...I was just so in love with it, Several of the participants in this study viewed I didn’t want to give it up. It was so worth it the state of flow as a risk for injury, and took steps to me somehow, in a very strange way, to to avoid it in their personal practice. Strategies to continue to suffer through it. ... It’s sort of avoid flow included using an egg timer to break like a drug that you have to take in up practice time; taking frequent breaks; and moderation. avoiding playing pieces from start to finish, focusing instead on specific sections that required Mark described how his university practice- work. behaviours, which were common among his

Downloaded by [University of Western Ontario] at 07:58 08 May 2012 peers, were unhealthy: Occupational disruption, alienation and For me a big thing would be to go to the marginalization University and find an empty room, one of Occupational justice has been defined as ‘‘addres- those big halls... and sit on the stage at ten s[ing] what people do in their relationships and at night and start practicing, and just walk conditions for living’’ (Wilcock & Townsend, out of there in a complete daze at like two in 2000, p. 84). These same authors (2009) elabo- the morning and not have any idea what rated this definition with the following: time it was and... just totally idiotic. [laughs] Completely out of touch with Motivating this exploration is a utopian reality, you know? And what a mistake. vision of an occupationally just world ’Cause you can do so much more if you just governed to enable all individuals to set the timer, focus on one or two things. flourish in diverse ways by doing what

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they decide they can do that is most have social contacts outside of music to cultivate meaningful and useful to themselves and balance. to their families, communities, and na- tions. (p. 123) Musicians in this study also experienced occupa- tional marginalization, which ‘‘operates invisibly, Associated notions that contribute to or are a major force of injustice being normative stan- examples of occupational injustice have been dardization of expectations about how, when, and developed in the occupational science literature. where people ‘should’ participate’’ (Townsend & These include occupational disruption, which has Wilcock, 2004, p. 81). Jacqueline described her been defined as ‘‘deprivation from access to experience of social norms: ‘‘people are already, to occupation’’ (Whiteford, 1997, p. 126) within a some degree, raising their eyebrows and saying ‘how relatively short timeframe (as distinguished from could you be doing something so frivolous?’’’ For deprivation, which takes place over an extended Jacqueline, this led to a lack of understanding period of time). Musicians may experience occu- from her friends and family that she would leave a pational disruption if they are unable to engage in future career as a musician due to injuries. music performance for a period of time due to Elizabeth related her experience in seeking care pain or medical contraindication. from her family doctor: ‘‘I don’t think they do [take her occupation seriously]. He [her family doctor] Musicians who are unable to continue to play an has no idea how important that is to me.’’ Simon instrument, or at the level they previously expressed: ‘‘I’ve never worked an honest day in my enjoyed, may also experience occupational alie- life. Except 50 cents pulling weeds for a neighbour.’’ nation, defined as ‘‘absence of meaning or pur- These participants experienced marginalization, pose in the occupations of daily life’’ (Bryant, sometimes self-imposed, in regards to the value of Craik, & McKay, 2004, p. 283). Participants in their occupation. this study discussed this as a possibility in their interviews. Elizabeth said that it would be like Finally, musicians with injuries can experience ‘‘cutting off my whole way of communicating, occupational deprivation in the form of un-(or cutting off a whole ream of social relationships I’ve under)employment as a result of a disability. developed.’’ Jacqueline stated, ‘‘Life would be so Although few of the participants in this study empty without it [music]. I’d feel like everything had experienced occupational deprivation, they else was just kind of like a second-best.’’ Other were impacted by the threat of deprivation while participants, however, had less extreme visions of managing their injuries. Several were also under- what it would be like if they could no longer play. employed as a result of their injuries, in an Mark felt that he would eventually come to that attempt to maintain their playing abilities in time, and that ‘‘it would be really hard not to play,’’ specific areas. Robert, for example, had stopped performing certain repertoire that he found ex-

Downloaded by [University of Western Ontario] at 07:58 08 May 2012 but ‘‘it’s not going to freak me out.’’ Barbara expressed the tension between the love of music acerbated his elbow pain. Other participants and the challenges of being a musician. ‘‘It could reported declining particular paid engagements. be devastating in one sense ... or else it could be For Jacqueline, this was because the time com- also a relief to not be doing the things that have mitment required was too long for her pain comfort; for Nancy, because adding work to her taxed your body or your emotions.’’ The difference prior commitments would be too physically in these participants’ perceptions of what depri- demanding. vation and alienation might be like appeared to depend on the role music played in their lives. For example, Elizabeth saw music as key to her Social determinants of health identity and central to her social relations with Musicians in this study, like many musicians others. Mark, by contrast, had other areas of worldwide, experienced the negative impacts of interest in his life, and felt that it was important to social determinants of health. In the US, musi-

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cians’ median income during the period of 2003 in performing music, but that awareness to 2005 was $22,600 compared to the overall was increased when they experienced pain and labor force median of $30,100 (National Endow- injury. ment for the Arts, 2008). In Canada the discre- pancy is higher; the 2006 census found that the Jackson (1996) found that individuals who median earnings for musicians was $9,394, experience flow also experience distorted time, compared to the overall labor force earnings of and different experiences of the body. Where the $26,850 (Hill Strategies Research, 2009). Many phenomenological literature distinguishes be- musicians work for more than one employer and tween healthy and unhealthy bodies, studies on are engaged in freelance work (National Endow- athletes have noted that flow experiences can also ment for the Arts, 2008), and therefore may lack include a sensation of bodily well-being. This access to extended healthcare benefits. In addi- must be realistically contrasted with the pain that tion, many playing-related injuries are sustained is often experienced by elite athletes, and the during or before post-secondary education, and hyper-body awareness that is an essential compo- so musicians’ playing-related injuries may be nent of sports performance at that level. When excluded from coverage by extended healthcare engaged in performance, some of the participants or workers compensation insurance plans. As has in the current study felt that their instruments been demonstrated elsewhere, these social deter- became a part of their bodies, such that they need minants can have significant impact on the health only intend to play and it happened. This is also of individuals. However, the musicians in this consistent with flow theory, which proposes study chose to continue in their valued occupa- that people who are engaged in flow lose their tion, although some noted that there was not sense of self-consciousness, experience a much choice in continuing. Simon stated, ‘‘It’s merging of action and awareness, and perform more like a quiet desperation to recover from it effortlessly. [injury], because it’s your living, such as it is, I Flow in occupation and risk of injury mean what else are you gonna do?’’. Thus far, no This current study sheds light on the potentially evidence exists to demonstrate whether continu- negative health consequences of flow itself when ing to engage in a professional musical occupa- people engage in an occupation that is not tion has benefits to health, whether individual or considered inherently risky. As participants re- societal, over the long-term. lated, getting ‘lost’ in the music can result in injury, because the experience results in dissocia- Discussion tion from the body, which might otherwise provide cues such as pain that might encourage The receding nature of the ‘healthy, normal’ body musicians to stop playing. Similarly, dissociation has been demonstrated in other phenomenologi- from the experience of time can result in lengthy

Downloaded by [University of Western Ontario] at 07:58 08 May 2012 cal works. As Aho and Aho (2009) stated, ‘‘I do playing sessions without breaks, which has been not typically experience myself as ‘having’ or identified as a risk factor for playing-related possessing a body at all’’ (p. 18). This observation musculoskeletal injuries (Wu, 2007; Zaza & has also been noted by Toombs (1995, 2001) and Farewell, 1997). The participants in this study Leder (1990). Similarly, Toombs (1990) reported indicated that they took steps to avoid flow by that people who are in ill health experience time using an audible egg timer to alert themselves to a as moving more slowly. The invisibility of the scheduled break time, breaking up practice ses- instrument in musical performance has also been sions throughout the day, and paying attention to described in the phenomenology literature by their bodies during practice sessions. Schmickling (2006) and Behnke (1989). This study re-iterated these findings, with participants In the current study, Jacqueline expressed an noting that they were not aware of their bodies, addictive element to her own musical pursuits, instruments or the passage of time when engaged which was described by her partner at the time as

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an abusive relationship with her instrument. Occupational choice and health Jonsson and Persson’s work (2006) suggests that As described above, individuals’ choice of if musicians spend a significant amount of time occupations, and of how to engage in chosen performing music, their performance should occupations, can have an impact on their health. reflect a balance of challenging and relaxing Although some research has investigated occupa- repertoire. It also suggests that a balance of tions that might cause harm or are otherwise occupations that promote flow (such as music) ‘risky’, as previously described, to the author’s with other occupations that are challenging and knowledge no one has yet juxtaposed occupation that allow for relaxation is desirable for main- as a potential detriment to health. This study taining health. It is interesting to note that after indicates that there may be situations in which occupational choice may in fact be detrimental to experiencing playing-related injuries, Jacqueline aspects of health. For example, continuing to play chose to pursue another career and continue with the violin may aggravate a player’s shoulder music as a significant avocation. She spoke about bursitis and associated pain. There may, however, this as a balance that allows her to enjoy playing be benefits in other areas of health; this occupa- while devoting time to other interests, which tion might provide continued employment, seems to reflect the balance suggested by Jonsson social relations with colleagues, friends and and Persson. The relationship between musical spouse, and self-esteem. This complex relation- performance, the experience of flow, the receding ship, where a factor may be enabling in one nature of lived time and body, and the musicians’ health domain and disabling in another, can be expression of strategies to interrupt flow in order illustrated using the model of the WHO’s to preserve their health, are new and important International Classification of Functioning, findings in this study. Disability and Health (2001) (Figure 1).

In this model, the bi-directional arrows indicate Relationship between occupation and health that the health domains presented in the model This study has demonstrated that the relationship can influence each other. Factors that affect each between occupation and health is not a simple domain can either be enabling or disabling, and equation, where engaging in occupation im- yet the effect is not necessarily cumulative. It proves, or even maintains, health. For partici- follows that while a certain occupation may be pants in this study, the occupation of music- detrimental to health Á returning to the example making has not always contributed to health; these musicians perceived that their occupation had either caused injury or aggravated associated conditions such as osteoarthritis. In some cases, participants were advised by healthcare profes-

Downloaded by [University of Western Ontario] at 07:58 08 May 2012 sionals to quit playing for the good of their health. It might be argued that in order to continue playing, some of the participants made lifestyle changes that were of benefit to their health Á for example, Elizabeth resolved to lose weight and began taking supplements, and Nancy began regular physical activity. However, it is important to note that these choices were not made only for their benefit to health in general. In Elizabeth’s Figure 1: Interaction between Components of Health case, for example, choices were made that in the International Classification of Functioning, allowed her to extend her ability to play music, Disability and Health (WHO, 2001, p. 18). (Repro- which is central to her life. duced with permission)

JOURNAL OF OCCUPATIONAL SCIENCE, iFirst article, 2012 9 CHRISTINE GUPTILL

of shoulder bursitis Á at a body function and viewed through the lens of occupational justice structure level, this does not preclude it as including spirituality, self-determination and from improving health in the domain of partici- freedom of choice, it is possible that performing pation. Whether an occupation is beneficial or music, despite the cause or aggravation of injury, detrimental to health also depends on the per- can sometimes be seen as providing fulfillment in spective Á is it individual health, or societal other areas of health. Similarly, if the viewpoint is health? Does being engaged in occupations which person- or client-centred Áin this case, the view- benefit one’s social participation and contributes point of the musician Á the benefits may outweigh to societal health, override any detriment to the potential detriments. individual health? Clearly these are complex questions that challenge the assumption that occupation is beneficial to health. Conclusion

The WHO’s Ottawa Charter for Health Promotion The findings reported here demonstrate that the (1986) defined health as ‘‘a resource for everyday relationship between the occupations of musi- life, not the objective of living. Health is a positive cians and health is complex. While occupational concept emphasizing social and personal re- science has often presented occupation as neces- sources, as well as physical capacities’’. If one sary for, and beneficial to, health, this study accepts this definition, it is easier to understand suggests that this is not always the case. It seems how the relationship between occupation and reasonable to propose that occupation may re- health can be more complex than has been present a continuum of benefit, strongly influ- portrayed in the occupational therapy and science enced by the nature of the occupation and its literature. The Charter definition also highlights meaning for the individual who is thus engaged. the importance of overarching principles Further research is needed to extend understand- like individual choice and occupational justice, ings of the benefits and drawbacks of engaging in which provides a macroscopic view of health occupation to the health of human beings. as a societal value while at the same time Questions that remain to be answered include valuing the individual’s right to freedom of how occupational meaning and identity influence choice. the relationship between occupation and health; whether occupational justice favours individual A complex relationship choice of occupation over societal well-being; and Whereas the occupational science and therapy literature has previously portrayed occupation as whether differing cultural values and power necessary for, and beneficial to, health, this study relationships are adequately accounted for in adds to the body of literature that demonstrates conceptualizations of the relationship between that this portrayal is inaccurate or incomplete. occupation and health. Downloaded by [University of Western Ontario] at 07:58 08 May 2012 Musicians in this and other studies have a complex relationship with music and with their instru- Acknowledgements ments. While this occupation may be meaningful, pleasurable, and central to a musician’s identity, it This article is based on a presentation given to the may also cause physical injury. Being injured can Combined SSO:USA and CSOS conference: Re- cause deep emotional upset and impact musicians’ defining Boundaries and Bridges in Occupation, abilities to perform in other occupations that are in October 2010 in London, Ontario, Canada. meaningful to them (Guptill, 2011a, 2011b). The It reports selected findings from the author’s perception of the benefit of this occupation for doctoral dissertation. The research was funded health depends on the definition of health to by a doctoral fellowship from the Social Sciences which one subscribes, and the viewpoint from and Humanities Research Council of Canada. which one examines the benefit. If health is

10 JOURNAL OF OCCUPATIONAL SCIENCE, iFirst article, 2012 CHRISTINE GUPTILL

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JOURNAL OF OCCUPATIONAL SCIENCE, iFirst article, 2012 13 Work 40 (2011) 269–280 269 DOI 10.3233/WOR-2011-1230 IOS Press

The lived experience of working as a musician with an injury

Christine Guptill Assistant Professor, Don Wright Faculty of Music, the University of Western Ontario, London, Ontario, Canada Post-doctoral Fellow, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada Hand & Upper Limb Clinical Research Lab, St. Joseph’s Healthcare London, Ontario, Canada E-mail: Christine [email protected]

Received 1 May 2010 Accepted 26 November 2010

Abstract. Objective:Researchandclinicalexperiencehaveshownthatmusiciansareatriskofacquiringplaying-relatedinjuries. This paper explores findings from a qualitative research study examining the lived experience of professional instrumental musicians with playing-related injuries, which has thus far been missing from the performing arts health literature. Methodology:Thisstudyemployedaphenomenologicalmethodologyinfluenced by van Manen to examine the lived experiences of professional musicians with playing-related injuries. Participants and Methods:TenprofessionalmusiciansinOntario,Canadawereinterviewedabouttheirexperiencesasmusicians with playing-related injuries. Six of the participants later attended a focus group where preliminary findings were presented. Results:Thefindings demonstrate a need for education about risk and prevention of injuries that could be satisfied by healthcare professionals and music educators. Conclusions:Thepracticeandtrainingofhealthcareprofessionalsshouldincludethe“tactful”(vanManen)deliveryofcarefor this important and vulnerable population.

Keywords: Playing-related injury, work, phenomenology, performing arts, health

1. Introduction Risk factors contributing to these injuries include the repetitive nature of the necessary movements, the The daily occupation of professional instrumental long hours of practice needed to perform well, and the musicians involve many hours of practice, whether it awkward postures required to play certain instruments be individual studio time or practice in a group set- (such as the asymmetric, raised arms position of the ting such as an orchestra. The performing arts health violin) [4,5]. In addition to these physical factors,stress literature has demonstrated that musicians are at risk and anxiety have also been linked to playing-related of acquiring playing-related injuries, as described be- injuries [6]. However, little is understood about the low. The prevalence of these types of injuries is diffi- lived experience of musicians with injuries and how cult to determine due to a lack of high-quality studies. However, one reliable systematic review indicated that their work impacts this experience. the prevalence of injuries, excluding minor symptoms, This paper explores findings from a qualitative re- was between 39 and 47%, or in other words, similar search study examining the lived experience of injured to work-related musculoskeletal disorders in newspa- professional instrumental musicians. During the anal- per workers, supermarket checkers and assembly line ysis phase, the researcher identified three roles that de- food packers [1]. Some studies using a broader defini- scribed the lived experiences of the participants: mu- tion of playing-related injuries have reported lifetime sician, teacher and worker. This paper will explore the prevalence as high as 90% [2,3]. musicians’ role as workers and the relationship between

1051-9815/11/$27.50 2011 – IOS Press and the authors. All rights reserved 270 C. Guptill / The lived experience of working as a musician with an injury this role and their experiences with playing-related in- accessible language and wouldbewellunderstoodby juries. musicians. Defining the ‘professional’ musician is also chal- lenging. The number of hours musicians play per week 2. Methodology can vary. Some musicians who identify themselves as ‘professional’ might only perform as their primary The methodology used in this study was derived source of income for part of the year, and for some from the philosophy of hermeneutic phenomenology, their primary source of income might be employment influenced by the work on phenomenology of practice other than performing (e.g. teaching in an elementary developed by Max van Manen [7]. This philosophy school). It was determined that the best approach was acknowledges that both the researcher and the partic- again to allow musicians to self-identify, by requiring ipants are caught up in our experiences of the world identification as a ‘professional musician’ as a criterion and that this experience cannot be completely pushed to participate in the study. aside when examining a phenomenon. The method- The participants ranged in age from 28 to 59 years, ology used in this work drew from the philosophy of with most (8) in their 50s. They performedon a variety Merleau-Ponty [8], acknowledging that there is a phe- of instruments: four played the violin, two the cello, nomenon to be described, but that our only access to one harp, one flute, one percussion, and one trumpet. it is through our lived, embodied experience. Heideg- All of the participants did freelance musical work, and ger’s views on hermeneutics [9] and Gadamer’s dia- for three participants, this formed the majority of their logic views [10] also influenced this methodology in performance work. Four musicians performed regular- that the researcher is an activeparticipantindescribing ly as part of an orchestra, and one performed in an or- and interpreting the phenomenon. The methodology chestra part-time. All of the participants were teachers; five taught in formal school settings, four of those in acknowledges the importance of the experiences of the universities and one in a private elementary school. All participants, but does not see them as experts who are an had started music studies by age 10, with the youngest infallible source of knowledge about the phenomenon. beginning at age 4. Their injuries ranged from ten- donitis to difficulties with orofacial musculature, arthri- tis and bone spurs. Although nine of the participants 3. Methods had not had complete resolution of their symptoms, all continue to identify themselves as professional musi- 3.1. Participants cians and continue to play.

Ten adult, professional, classically-trained, English- 3.2. Recruitment speaking musicians in Ontario who had experienced physical playing-related injuries, either at the time of This study was approved by the University of West- the study or in the past, participated in this study. Clas- ern Ontario’s Office of Research Ethics. Purposeful, sically trained musicians were chosen in order to se- snowball sampling was used in this study, as well as lect participants with similar experiences, and due to criterion sampling, in that all participants must have the researcher’s ability to recruit key informants from met the criteria outlined above. Initially, email contact this population. The number of participants is consis- was established with six people in the musical com- tent with Creswell’s observation that phenomenolog- munity in Ontario, including conductors, faculty mem- ical studies involve “as many as 10 individuals” [11] bers at a local university, musicians, and arts managers. (p.131), Polkinghorne’s recommendation of 5 to 25 par- In addition, two orchestras gave permission for the re- ticipants [12], and Thomas and Pollio’s recommenda- searcher to speak to the musicians and leave a letter of tion of 6 to 12 participants [13]. information for interested parties. Playing-related injuries are difficult to define, and there is no gold standard for their diagnosis [14]. There- 3.3. Interviews fore, musicians who volunteered for the study were asked in the letter of information and during the inter- In-depth interviews were chosen as a method of col- views to self-identify as having experienced a ‘playing- lecting narratives of the lived experiences of profes- related physical injury’. It was felt that this term used sional musicians with injuries. Interviews are com- C. Guptill / The lived experience of working as a musician with an injury 271

– Please tell me about a specifictimewhenyouwereinjured. How did it happen? ∗ When did it happen? ∗ What happened when you became injured? ∗ What was it like to continue working? ∗ What was it like to continue teaching? ∗ What was it like at home? ∗ – What is it like to be an injured musician? How do you experience your body when you are injured? ∗ What does your body feel like? ∗ How do you experience time when you are injured? ∗ Is it faster, or slower? ∗ Do you feel that injury is related to age, experience? ∗ What are social relationships like when you are injured? ∗ What is it like at home? ∗ Can you describe the place you associate with being injured? ∗ Where do you experience injuries? ∗ Is there a place that is meaningful to you in relation to being injured? ∗ – Did you seek out any help for your injury? Who? ∗ When? ∗ Why? ∗ What help did you receive? ∗ What was the process of seeking and receiving help like? ∗ Fig. 1. Interview guide. monly used as a data collection strategy in hermeneu- searcher was able to obtain all the information needed tic phenomenological research [7,15–18]. Van Manen during the interview. described interviews as a means of collecting exam- The interviews consisted of main questions about the ples of lived experience, through which we can seek to experience of being an injured professional musician, understand the phenomenon in question. with probes used as needed. The interview guide is Interviews were recorded and transcribed verbatim, presented in Fig. 1. Demographic information was col- and names were replaced by pseudonyms. Identify- lected as it arose in the discussion at the first interview ing information – e.g., names of healthcare providers; (e.g. age the person began playing; current age; marital orchestras with whom the musicians’ perform – was status). If it was not discussed in the first interview, removed from the transcripts. Two interviews were further information was sought in the second interview. conducted with each participant with the exception of Using this information and through email collaboration the last two. Giselle had a health concern just prior to with the participants, biographical sketches were de- the first interview, and initially cancelled the interview, veloped for each participant to assist in contextualizing providing instead a written account of her experiences. the interview data. She later agreed to an interview. Since the researcher had already read the material from Giselle’s written 3.4. Focus group account, and since the researcher had completed inter- views with all other participants (seventeen in total), Drawing from Gadamer’s focus on the importance she was able to obtain all of the information needed of dialogue in accessing and interpreting the phe- during the interview. It was therefore felt that a second nomenon [10], a focus group was used after interviews interview was not required. Thomas was also only in- in order to engage the participants in a dialogue about terviewed only once. Again, this interview took place the preliminary findings. After interviews were com- after all other interviews had been completed, so the re- plete and initial analysis had begun, nine participants 272 C. Guptill / The lived experience of working as a musician with an injury were contacted by email about their availability to par- 3.6. Analysis ticipate in a focus group. The tenth participant had very different experiences than the rest. Although dif- Analysis in this study employed a hermeneutic pro- ferences are natural and important in focus groups, ex- cess of moving between the details and the broader concept of the whole until both can be seen simulta- perienced focus group researchers feel that there does neously. This was initially outlined by Heidegger and need to be a shared experience in order for partici- developed for research application by van Manen [7]. pants to engage in a discussion (David Morgan, per- This study was interested in not only a description of sonal communication; Marlene Cohen, personal com- this phenomenon, but also the meaning of the lived munication). One of the primary motifs that emerged experience, which is implicit in Heidegger’s work and from the interviews was a deep sense of frustration with more explicitly stated in van Manen [7]. The analysis the difficulties participants had encountered in getting was also influenced by Merleau-Ponty’s concept of the help in the healthcare system. However, this individual lived-body, since playing a musical instrument is an had received almost immediate treatment with which inherently embodied experience [8]. Finally, the anal- he was very satisfied. Since this frustration was cen- ysis was guided by the data itself, with themes emerg- tral to what other participants had experienced, it was ing from the importance that musicians placed on them felt that there would not be enough common ground as well as their resonance with the researcher, through dialogue during the focus groups, and in consultation with the other participants for a discussion. He was with research sources. therefore not asked to participate in the focus group. Focus groups have not been widely used in hermen- 3.7. Reflective journal eutic phenomenologicalwork. Marlene Cohen, a nurse researcher, employs focus groups and feels that “peo- Journaling is a way of ensuring rigor in hermeneu- ple [do not] have trouble sharing in a group made up of tic phenomenology, documenting the process of influ- people who share the experience” (personal communi- ence of the researcher and what is researched, and vice cation). Other researchers have also used these meth- versa [26]. Throughout the research process the re- searcher kept a journal, documenting the development ods in hermeneutic phenomenological research [19– of thoughts about phenomenology, musicians’ injuries, 24]. David Morgan advocates for their use to “‘give a and interpretations of the data. The journal included voice’to marginalizedgroups”,and in “appliedsettings relevant quotes about readings or thoughts about infor- where there is a difference in perspective between the mation from web searches conducted to better under- researchers and [the participants]” [25] (p.266). Since stand issues mentioned during interviews, the etymol- the voice of the musician has thus far been relatively ogy of certain words and expressions, and other ideas absent in the literature on musicians’ health, and be- that arose. ‘Field notes’ were also collected, includ- cause my perspective as a researcher and clinician is ing aspects of the physical environment in which the likely different than that of the professional musicians interviews or experiences took place, body language, in this study, focus groups were an appropriate method tone of voice, environmental distracters, and other per- for this work. tinent information. They also included observations made during interviews and recruitment efforts. For example, when subjects were recruited from a local or- 3.5. Other sources of lived experience chestra, the researcher remained afterwards to watch the rehearsal, and observations about the experience were recorded. Observations of the researcher’s own As recommended by van Manen, other sources of musical performance activities were also recorded. lived experience were used to interpret the findings [7]. These included the researcher’s own experience as a 3.8. Peer consultation part-time professional musician (akin to participant ob- The researcher met periodically with a member of servation), self-reflection and journaling, other phe- her thesis committee who had experience in qualitative nomenological research, and works of art that can shed methods. This member assisted in clarifying questions light on the experience and its meaning. In this study in the interview guide and in the interpretation of study novels, poetry, films, television programs, and song results. She also assisted in structuring the informa- lyrics were used to deepen the understanding of the tion that was presented to the participants for the focus lived experience. group session. C. Guptill / The lived experience of working as a musician with an injury 273

4. Findings this type of stress is counterproductive when trying to cope with an injury: “It’s more like a quiet desperation to recover from it [injury], because it’s your living, 4.1. The work of musicians such as it is, I mean what else are you gonna do?” Nancy noted that many musicians do not have access Participantsin this study discussed the work of being to extended healthcare and disability benefits. Those amusician.Someperformedasemployeesoforgani- participants who were associated with larger orchestras, zations, while others performed freelance in a variety however, did have access to sick leave,even if they were of settings including social events (e.g. weddings) and part-time members of the group. Simon also noted clubs. The participants also spoke about the pay, work- that “we’re not really talking about cut-throat business ing conditions and benefits to which they had access types and I know with our orchestra, when people have within the context of their experiences with injuries. used up their sick services, there’s still that sense of compassion.”

4.2. Employee versus freelance artist 4.4. Working conditions

Working conditions were discussed particularly in Two basic philosophies of the work of the musician relation to risk of injuries and balancing other commit- began to emerge during the interviews, and prompted ments. All the participants were also teachers, whether abriefdiscussionatthefocusgroupsession.Those in their own private studios, through a university or in musicians who played in orchestras spoke about the the grade school system. Mark indicated that orches- challenges of that type of work; while other musi- tras tend to perform three different programs per week cians, whose musical work did not consist of employer- during the season; with rehearsals, this could amount employee relationships but rather more freelance work, to nine two-and-a-half hour ‘services’ per week. Si- spoke less about the challenges of the work and more mon sometimes had difficulty fitting in the fourteen stu- about the intrinsic rewards of playing music. After the dents he taught at the university when heavier orchestra focus group session was over and the microphone was schedules were taking place. This schedule required turned off, a conversation took place which reflected musicians to acquire repertoire quickly and through ef- these differences between Simon and Elizabeth, whose ficient use of time so that, in Barbara’s words, “you experiences reflected the two extremes. Simon reflect- don’t have to spend your whole life practicing.” In ed that there was a time when he enjoyed playing and addition, Simon noted that too much personal practice the artistic involvement with music much more than he can detract from stamina for a concert. had found recently performing with an orchestra. Eliz- Although Robert’s performances with a pit orchestra abeth indicated that that enjoyment was a regular part (accompanying a live show) were much more frequent – of her own music performance. It appeared that the sometimes six performances per week – this was bal- freedom and control of freelance work allowed musi- anced by the seasonal nature of the work, which com- cians more choice in selecting the kinds of music they plemented his schedule as a university teacher. Jacque- played, venues in which they performed, and musicians line noted that some seasons were quite busy in free- with whom they worked. Those musicians with the lance work, such as Christmas, Easter and weddings most freedom also had more non-performance work in the summer. The financial reimbursement made it tempting for her to take on many commitments at a that provided their major source of income. Barbara time, or some social engagements of four hours or more reflected that despite the challenges of working in an (e.g. weddings, parties). However, she reflected that orchestra, she still found something each day for which those types of ‘gigs’ were a challenge mentally and to “thank God for making me a [instrument] player.” physically: “Everybody’s sitting there eating their din- ner, you know, clinking of plates and everything, and it goes on and on, and then by the end of it I feel pretty 4.3. Pay and benefits out of it.” Working conditions can be exacerbated by demand- The participants discussed the low pay associated ing tour schedules and conductors. Simon noted that with being a professional musician. Simon noted that he first experienced difficulties with his embouchure 274 C. Guptill / The lived experience of working as a musician with an injury whileon a ‘run-out’– an engagementthatrequirestrav- cial difficulties: “My orchestra was going under. I had el, but is close enough to not require an overnight stay. to do something, and I went into panic mode.” Through He associated that injury experience with being tired their experiences and the stories of other musicians from traveling. Giselle also illustrated the demands of in similar situations, these musicians demonstrated the orchestral life with anecdotes from a close friend who potential influence of employer financial stress on their performs with an internationally renowned orchestra well-being. with which Giselle also used to play: People are dropping like flies, you know. And it’s 4.5. Social status and community support just overplaying, because there is just too much work. They treat you like a slave... That’s what The participants also discussed the idea that per- happened to her, the stress of the job, and she kept forming music is not respected by the public, and per- saying, “I’m a machine, I’m a machine, I hate be- haps not seen as a ‘real’ job. Jacqueline stated, “Once ing a machine.” But she was there in all those hard you decide to go to university for music and do a per- years of [conductor’sname] when it [orchestra] was formance career, people are already raising their eye- really a playing machine like Japan, China, Europe, brows and saying ‘how could you be doing something recording galore, like they’d be in a recording ses- so frivolous?’ ” Simon’s comment reflected a similar sion for five days, they would be locked in that sentiment: “I haven’t worked an honest job in my life. church, and then they’d get on the plane a week after Except fifty cents pulling weeds for a neighbor.” Simon and they would do Paris and London and you know, also discussed at length the lack of support (financial she says to me... “the stress was horrendous.”... and audience attendance) in his community for the or- Ialwayssaid“Iwanttohaveyourjob”andshe chestra with which he performs. The issue of communi- always said, “you don’t want my job.” ty support for music in general was also discussed dur- Giselle also described the stress that conductors can ing the focus group session. Jacqueline, whose work is place on orchestra musicians: mostly freelance, did not agree that her community did not support live music. Elizabeth, whose work is sim- Ihadtodealwithavery,verycrazyconductor... ilar to Jacqueline’s, suggested that although the region and basically I had a breakdown there. It was very is not as supportive as it could be, the response from bad. Cause he played mind games and he knew the public varies according to the venue. Jacqueline who was vulnerable and he’d just put you down agreed that this might better reflect the warm response publicly and he would just make it so you can’t she received when performing. play anymore ... that is the first time I experienced abuse, the first time in my life. It was very, very powerful. 4.6. Lived social relations

Although Giselle’s experiences were unique with- 4.6.1. Social supports in this group, they speak to the potential for working Many participants spoke about their interactive roles conditions to impact negatively on the level of stress within their communities aseithersupportingorbeing experienced by musicians who are in situations – like supported by other musicians. Nancy described a shar- an orchestra – where a person in a position of pow- ing of information, stating that “different people have er, such as a conductor, can influence the environment different advice. We trade exercises and stuff.” Jacque- of the work, and the schedule of work is beyond the line described the circumstances she experienced: musician’s control. The financial situation of an employer can also pro- Iknowthatnotallmusiciansarecomfortabletalk- voke anxiety in musician-employees. Giselle explained ing about [injuries], but for me it was no big deal. the financial burden of stress and injuries in orchestras: IwashavingthisissueandIthought‘ifanybody “People are dropping, so they have to hire extras [addi- can provide suggestions at all, I’d be happy to hear tional musicians], and it costs a lot of money because them.’... It felt like everywhere I went people were these people [orchestra members who are off sick] are saying ‘yeah that happened to me too.’... For me paid, they’re on salary, plus they have to pay all the in talking with my musical peers about that, it was extra people that are subbing [substituting] for them.” asharedexperiencethatwecouldallreallyidentify Barbara described her reaction to her orchestra’s finan- with each other about. C. Guptill / The lived experience of working as a musician with an injury 275

Participants also spoke about the culture of silence There’s some people who I don’t want them to know that appears to surround musicians’ injuries. Mark that I’m hurting. I’m not gonna jeopardize what spoke about a sense of camaraderie amongst musicians somebody thinks of the way I might play and inter- who have been injured, but that some are more open pret it in light of ‘well he’s hurt,’ you know. There’s than others about their experiences. He himself has acertainsportsanalogythereIthink.Imeanyou’re been quite open about his injuries, although he admit- not gonna tell the coach you’re hurting or he’s not ted that this was not a choice. He described himself as gonna put me in. being ‘out of the closet’ because he was off work for an extended period and his colleagues therefore knew Giselle had a unique experience among the partici- something was wrong. In contrast, he spoke about a pants of feeling that she was stigmatized by her peers colleague who preferred to keep this information hid- because of her injuries. den. All my friends quit calling me. And I’d go and sit He just didn’t want to talk about it, he didn’t want in an orchestra rehearsal at [university] and I’d cry, people to know about it ...people talk in the chang- and people would just put their stuff in their case eroom and you’d hear that he’d had the operation and leave – it almost felt like I was contagious, you and stuff ... you don’t want to be going up to some- know? And I was writing letters to people, ‘please body in front of others until you really know how call me, please be my friend, please,’ and no. they feel about it [speaking to others about injury], These varied experiences of support (or lack of sup- cause a lot of people don’t want people to know. port) amongst the participants reflected the complexity Mark did have strong feelings about the potentially of the lived social relations involved in being a musician damaging effects of the culture of silence that he said with a playing-related injury. still persisted around the issue of musicians’ injuries: “Come on, let’s spread the wealth, I mean if people 4.6.2. Relations with colleagues have it out there, dammit I wanna know what they are Some participants in this study spoke about the so- [solutions], and let’s get over all this craziness about just cial aspect of music performance and its relationship to keeping it hidden.” Other participants were not as open the lived experience of being an injured musician. For with their experiences, and felt that health concerns example, Jacqueline described how common injuries were something they preferred to keep to themselves. were among her university peers: “It felt like every- Elizabeth stated: where I went people were saying ‘yeah that happened Idon’tthinktheyneedtoknow.AndIdon’twant to me too.’ ... For me in talkingwith my musicalpeers to be a whiner or seem like a loafer, a crutch or about that, it was a shared experience that we could something. And I don’t want them to think, ‘oh, all really identify with each other.” Mark spoke about she can’t do it, she’s got arthritis,’ or something. asenseofcamaraderieamongstmusicianswhohave ... It’s not a deep dark secret, but it’s like a mole been injured, but that some are more open than oth- or something. ers about their experiences. He himself has been quite In describing a mole, Elizabeth appeared to be re- open about his injuries, although he admitted that this ferring to something that would normally be hidden was not a choice. He describedhimselfas being‘out of (by clothing, for example), and only disclosed in very the closet’ because he was off work for an extended pe- private circumstances. riod and his colleagues therefore knew something was Some musicians were concerned about their per- wrong. In contrast, as described previously, he spoke ceived employability, should their injuries become pub- about colleagues who preferred to keep this informa- lic knowledge. Other participants indicated that some tion hidden. Thomas and Mark both noted that close of their peers shared this fear, even if they themselves relationships with colleagues could have its downside, were not concerned. Nancy explained that in terms of and Barbara in particular felt that this closeness could discussing injuries with colleagues, “some people do, at times be toxic in group situations. It should be not- you know, and some don’t, and I guess some people ed that all of the participants in this study performed are afraid to talk about it ‘cause they figure it might af- with other musicians some of the time, and for many of fect getting hired.” Robert explained that he discussed them, most of the time. Only certain instruments, such injuries with some of his colleagues, but was selective as piano, would typically perform regularly without about those to whom he discloses this information. accompaniment. 276 C. Guptill / The lived experience of working as a musician with an injury

The shared nature of this experience was also reflect- 5.1.1. Need for healthcare ed in the way the musicians approached care. Nancy Canadian census data from 2006 (the most recent and Robert had both sought treatment from healthcare available) indicate that the average income for musi- professionals who were recommended to them by col- cians was $14,439 (teachers in formal school and post- leagues. Nancy had taken her student to see a physio- secondary institutions were not included in these da- therapist that she herself had seen, and Giselle noted ta) [27]. Although the Canadian healthcare system is that her teacher took her to see a specialist that many often described as a public system, some services are local musicians had consulted. not covered. These include outpatient physical and occupational therapy, the majority of chiropractic ser- 4.6.3. Relations with teachers vices, and work-related injuries that pre-dated the per- Music teachers can have a strong influence not only son’s status as an employee (e.g. injuries acquired in on the technique used to play an instrument, but on the post-secondary training, or while the person was a free- student’s attitude towards and actions taken when in- lance musician). Because of their low pay and the jured. Jacqueline noted that her teacher’s instructions need for these types of services to treat work-related were important in determining her response to early injuries, musicians would benefitgreatlyfromaccess symptoms of injury. Her teacher had told her to prac- to extended healthcare and workers compensation ben- tice a certain number of hours per day, and although she efits. However, the census data indicated that 53% could not quite reach this goal and experienced signifi- of Canadian musicians were self-employed, and 42% cant pain, she still felt compelled to meet her teacher’s worked part-time [28]. Many members of professional expectations. Simon expressed discomfort during the orchestras in Canada are also not defined as ‘employ- focus group at the idea that his teacher might learn of his ees’, and therefore do not qualify for workers compen- difficulties with injuries. Interestingly, other musician sation (Francine Schutzman,President, Organization of participants countered his fear with the idea that his Canadian Symphony Musicians, personal communica- teacher might not only be sympathetic, but might have tion). The findings from this study, census information some ideas about how to help Simon. Finally, Giselle and working conditions indicate a need for healthcare described the response of her teacher when she became services for professional musicians in Canada. injured while at university. Her teacher inspired fear in most of her students, but reacted promptly to Giselle’s 5.1.2. Restricted participation injury by taking her to see a specialist who was able to The World Health Organization’s International Clas- help her continue playing. sification of Functioning, Disability and Health [34] The relationship with the teacher is an important described participation as “involvement in a life situ- aspect of lived social relations because it can influence ation” (p.10). Musicians with injuries, like other in- whether or not students experience injuries. This is jured workers, experience restricted participation. It further discussed below under “health promotion”. appears that through a variety of strategies, including adapting playing techniques and schedules, the nature of work accepted, changing equipment such as chairs, 5. Discussion and physical rehabilitation, the musicians in this study were able to continue to perform as professionals to a 5.1. Implications for healthcare level with which they were satisfied. Unlike the medi- cal advice that many musicians receive, “just stop play- Participants in this study indicated that they were ing and do something else” [35], it is important to re- frustrated by the lack of services that were readily avail- flect upon the fact that these musicians instead chose able to treat musicians. Thegapappearedtobecen- to implement adaptive strategies that allowed them to tered around knowledge of the nature of and treatment continue in their chosen occupation. for musicians’ health concerns; the work of musicians, Moreover, the musicians in this study chose strate- including physical demands of playing instruments as gies that intervene at the level of their own practice well as other work demands; and the importance of the time, and only minimally change their work of musi- occupation to the musician. In addition, low income cal performance. For example, union rules require a and limited access to healthcarecoveragecontributedto break to be taken every 90 minutes of rehearsal time in the perceived lack of services this group of participants athree-hourrehearsal,oranintermissionforaconcert expressed. over 90 minutes in length. Many of the participants in C. Guptill / The lived experience of working as a musician with an injury 277 this study indicated that they take breaks during their large ensembles, unions, educational institutions, and individual practice much more frequently, but none in- via the Internet. dicated these working conditions as a source of difficul- Participants indicated throughout the study that re- ty for them. This provides important insight into what liance on pain medication was undesirable, and that may be seen by musicians as limits to adaptations that complementary medicine, including supplements, di- can be made to their work environment, and may repre- etary and lifestyle changes, and exercise, were desir- sent a perception that is strongly socially ingrained and able forms of treatment for playing-related injuries. may or may not reflect the practicality of such changes. This suggests that the inclusion of complementary and Making changes to the occupation of music perfor- alternative approaches to care are important modes of mance may not be possible in all cases. However, some healthcare delivery for this group of musicians. In ad- musicians with playing-related injuries may prefer to dition, the limited time available for travel and return explore the possibility of changes to their occupation appointments, in addition to limited funds or access to as an alternative to decreasing or ceasing their playing- extended health benefits, suggest that local, economi- activities. cal treatment that encourages self-care is an appropriate approach for these participants. It also suggests that an Internet-based network of professionals organized by 5.1.3. Healthcare services for musicians region would be beneficial for professional musicians. Participants indicated that the healthcare profession- The perspectives of the participants in this study als they dealt with appeared to lack knowledge about were varied, and reflect the individuals who experi- the work involved in being a professional musician, and enced playing-related injuries. These individual differ- of treatment methods for musicians’ injuries. In or- ences demonstrate the importance of adopting a client- der to address some of these potential shortcomings, a centered approach to the care of musicians. A multi- multi-factored approach is advocated, including health- or inter-disciplinary approach is also advocated when care professional education, referrals to professionals working with musicians with injuries. Healthcare prac- who already possess skills in the treatment of musi- titioners also need to be cognizant of the potential im- cians, the establishment of associations to advocate for portance for musicians to maintain occupational bal- specialized skills, and publicationof research and treat- ance, which was highlighted by some of the participants ment approaches in peer-reviewed journals such as this in this study. This stands in stark contrast to what the special issue of WORK. author has observed in musical training as the encour- Most healthcare professionalcurriculalackspecif- agement to exclude other activities and pursuits in order ic training in playing-related injuries of performing to focus on attaining the highest level of achievement artists, including musicians. This means that many possible. professionals are unfamiliar with the specificpostures, Finally, musicians’ readiness to change is also impor- physical requirements, and nature of the work of pro- tant in achieving successful rehabilitation, since adap- fessional musicians. As in any occupational assess- tive strategies, equipment and lifestyle changes must ment, observing the occupation itself is key to under- be acceptable to the client or they will likely be aban- standing these factors. Asking musicians to bring their doned. Open communication and a deep understanding instrument to an assessment or evaluating the work re- of the musicians’ occupational context and personal in- quirements in the workplace itself (home studio or re- vestment in the occupation would be most helpful in hearsal hall) are both important tools for the treatment providing recommendations for change. of injured professional musicians. Specificservicesformusicianswithinjuriesare 5.1.4. Health promotion spread throughout Canada and are not widely adver- It is believed that providing young musicians and mu- tised, with a few exceptions, such as the Al & Malka sic teachers with informationaboutinjuryprevention Green Artists’ Health Centre in Toronto [36]. Musi- is key to the advancement of musicians’ health [37]. cians tend to rely on their colleagues and teachers for In addition, participants in this study indicated their treatment advice, and when they do seek treatment,they desires to ‘break the cycle’ of musicians’ injuries by generally consult these sources about where to seek providing information to their students and other young treatment. This would suggest that the provision of musicians about injury prevention and health promo- healthcare services to musicians should include com- tion strategies. To this end, the “Health Promotion munication with musicians and music teachers through in Schools of Music” initiative was established in the 278 C. Guptill / The lived experience of working as a musician with an injury

United States [38]. Such an organized movement for 5.2. Limitations health promotion in schools of music does not exist in Canada. However, it is hoped that further research Study limitations commonly addressed in qualitative and discussion between schools of music, healthcare work in the health sciences include issues like small professionals and researchers, information about injury sample size and the inability to generalize the results to prevention may be incorporated into the curricula in the broader population. Small samples are quite com- Canadian schools of music. This would raise aware- mon in qualitative research and in phenomenology in ness about the risk of injuries with students and educa- particular, because statistical representation of the pop- tors. It may also serve to encourage teaching, research ulation is not considered the goal of the work [7,12,13]. and treatment partnerships in the communities in which In phenomenology, detailed descriptions of the partic- the schools of music are located. ipants’ experiences are sought in order to shed light Training to become a musician can begin as early as on the nature of the phenomenon in question – in this the preschool years, depending on the curriculum [29, case, the lived experience of being an injured profes- 30]. By the time musicians become professionals sional musician. These detailed descriptions generally they have played for approximately 10,000 hours [31]. come from smaller samples, and as discussed previous- Visentin [32] noted that the musical community tends ly, the number of participants in this study is consistent to place music teachers on a pedestal and treat them with recommendations for studies using hermeneutic as infallible sources of information. In this current phenomenological methodologies. study, many of the participants noted that their teach- Regardless of the need for statistical representation, ers seemed to have lacked information about how to the gender distribution, age and the nature of the health prevent and what to do about playing-related injuries. concern in question are often provided for information Teachers may increase the risk of injury if they are in qualitative studies, in order to determine whether the not informed about injury prevention, do not recognize findings are relevant for the reader’s needs. At this the early signs of injury, or encourage students to adopt time, statistics regarding the nature of health concerns risky practice behaviours. However, teachers may also in Ontario musicians are not available. Although more decrease the risk of injury and improve the outcome of professional musicians in orchestras in Canada are men, injuries if they are sensitive to healthy practice habits the gender distribution amongst musicians in general and early warning signs, and if they are knowledgeable is approximately equal (Statistics Canada, 2009). In about local practitioners who can help in the event of this current study, there were six women and four men, injury. There is evidence that music teachers who re- ceive relevant training in music-specificphysiologydo which may represent a difference when compared to make changes in their teaching, and that these changes both Canadian musicians and orchestral musicians in subsequently benefittheirstudents[33]. Canada. The majority of the musicians in this study The findings from this study indicate that the work of were between ages 50 and 60, which is also differ- professional musicians, as in many occupations, con- ent than Canadian musicians as a group, which have sists of many factors that may influence health. Mu- amorevariedagedistribution.Lastly,itwasnoted sicians work in a variety of settings, both as employ- that all the participants taught, whether in their own ees and as freelance artists. All the participants in home studios or within the public or post-secondary this study were also teachers, whether formally through systems. Although no statistical information is avail- schools or universities, or informally in their own home able with which to compare this result, anecdotally this studios. Participants in this study described low pay is common amongst professional musicians in Canada. and lack of access to extended healthcare and workers The experience of the participants in this study may compensation benefits, which together contribute to a have been influenced by the different work that they lack of access to timely and affordable care. They also did. Different types of work, for e.g., whether they described stressful working conditions and a lack of performed primarily freelance or as employees, styles control over these conditions, both of which are asso- of music, e.g. jazz, world music, and classical reper- ciated with increased risk of occupational injury [39, toire, and the presence or absence of a non-performing 40]. A lack of recognition in society as providing an ‘day’ job might have influenced their experiences. In important service and a lack of community support al- addition, the different injuries experienced in this group so negatively impacted some of the participants in this might also have influenced their experiences as pro- study, although others found the support for their work fessional musicians. A musician who experiences a to be a positive aspect of their work. chronic injury related to playing,such as arthritis, might C. Guptill / The lived experience of working as a musician with an injury 279 have a different experience than a musician whose in- be filled by healthcare professionals and by music ed- jury is more acute, such as lack of embouchure control. ucators. Health promotion that includes collaboration Amorehomogenousgroupofparticipantsmayhave between these two groups, as has been advocated by provided different experiences and influenced the re- Chesky, Dawson and Manchester [36], would help to searcher’s interpretation ofthelivedexperience.How- change the culture of acceptance of injuries in music ever, it is partly through viewing contrasting experi- education and performance. The findings in this study ences that the researcher is able to understand the na- also demonstrated a need for specialized care for mu- ture of the phenomenon [7]. It is felt, therefore, that sicians with playing-related injuries, with accompany- the variations in the participants’ experiences were in ing health professional training and research to support fact helpful in this study. intervention strategies. Census data demonstrate that Canadian musicians 5.3. Relevance are vulnerable to health concerns not only as a result of the nature of their work, but also as a result of limited In this work, the experiences of the ten participants, income and corresponding limited access to healthcare six of whom participated in the focus group, do not ap- services. This may also reflect the circumstances of ply to every professional musician in Ontario, or even professional musicians in other nations. to those in the cities, towns, orchestras and ensembles represented by the participants. However, commensu- rate with the methodology, the insights gained from this 6. Conclusion deep exploration can be applied to sensitively devel- oping healthcare interventions, health promotion pro- At the end of this study, the playing-related injury grams, and music education that considers the value of one musician was completely resolved, two were and the possibilities of those individual experiences. much better, three were the same and four had expe- Drawing again from the methodology developed for rienced setbacks in their health, with one being hos- this study, it is this researcher’s position that the reader pitalized for a concern related to injuries. Clearly, is an active participant in developing an understand- playing-related injuries are long-term in nature, and ing of the lived-experience of musicians with playing- it is important that musicians develop individual cop- related injuries. In keeping with this view, readers ing strategies, which could include healthcare interven- shouldconsider the informationprovidedaboutthe par- tions, physical conditioning methods, prevention mea- ticipants as well as their specificcontextsoutlinedin sures, and workload and stress management. Interven- the findings, and decide if the research applies to their tion by healthcare practitioners can provide assistance area of interest or the individuals with whom they are with these coping strategies, if the view of health tak- working. en is broad and includes education of young musicians and teachers about the risk of injuries and prevention 5.4. Summary strategies. It will also prove to be effective only if healthcare professionals understand the nature of the The work of professional musicians varies in terms challenges experienced. It is hoped that studies such of time demands, financial compensation, availability as this become more prevalent and begin to influence of benefits, and stress in the workplace. Musicians in the practice and training of healthcare professionals to this study who worked for formal organizations such provide more “tactful” [41] care for this important and as orchestras had little control over these workplace vulnerable population. factors, while those in freelance work had greater con- trol. The trade-off, as in many areas of employment, includes the security of the work and the availability of References healthcare and disability benefits, which is particular- [1] C. Zaza, Prevalence and incidence of musicians’ playing- ly relevant for musicians with injuries. The musicians related musculoskeletal disorders: A systematic review, Cana- in this study indicated that greater control over their dian Medical Association Journal 158 (1998), 1019–1025. work contributed to their ability to avoid injuries, and [2] A.M. Abreu-Ramos´ and W.F. Micheo, Lifetime prevalence of to better manage injuries that did occur. upper-body musculoskeletal problems in a professional-level symphony orchestra: Age, gender, and instrument-specific The findings in this study demonstrate a need for ed- results, Medical Problems of Performing Artists 22(3) (2007), ucation about risk and prevention of injuries that could 97–104. 280 C. Guptill / The lived experience of working as a musician with an injury

[3] C. Guptill, C. Zaza and S. Paul, An occupational study of from Dissertations and Theses database. physical playing-related injuries in college music students, [23] J. Ranse and P. Arbon, Graduate nurses’ lived experience of Medical Problems of Performing Artists 15(2) (2000), 86–90. in-hospital resuscitation: A hermeneutic phenomenological [4] A.G. Brandfonbrener, Epidemiology and risk factors, in: Med- approach, Australian Critical Care 21(1) (2008), 38–47. ical Problems of the Instrumentalist Musician, R. Tubiana and [24] A. Schweitzer, Exploring narratives of relationship in intensive P.C. Amadio, eds, Martin Dunitz Ltd., London, UK, pp. 171– care nursing, Dissertation Abstract International 57(8) (1997), 194. 4979B (UMI No. AAT NN11361), Retrieved October 20, 2008 [5] M. Hagberg, G. Thiringer and L. Brandstrom,¨ Incidence of tin- from Dissertations and Theses database. nitus, impaired hearing and musculoskeletal disorders among [25] D. Morgan, Focus groups, Annual Review of Sociology 22 students enrolled in academic music education: A retrospec- (1996), 129–152. tive cohort study, International Archives of Occupational and [26] M.Z. Cohen, D.L. Kahn and R.H. Steeves, Hermeneutic phe- Environmental Health 78 (2005), 575–583. nomenological research: A practical guide for nurse re- [6] C. Zaza and V. Farewell, Musicians’ playing-related muscu- searchers,ThousandOaks,CA:SagePublications,2000. loskeletal disorders: An examination of risk factors, American [27] Statistics Canada, Retrieved May 13, 2009 from http://www. Journal of Industrial Medicine 32 (1997), 292–300. statcan.gc.ca, 2009. [7] M. van Manen, Researching lived experience: Human science [28] K. Hill and K. Capriotti, Astatisticalprofile of artists in for an action sensitive pedagogy,TheAlthousePress,London, Canada based on the 2006 census,retrievedDecember10, ON, 1997. 2009 from http://www.hillstrategies.com/docs/Artists Canada [8] M. Merleau-Ponty, Phenomenology of perception (C. Smith, 2006.pdf, 2009. Trans.), Routledge, London, UK, 2002 (original work pub- [29] Music for Young Children, MYC Programs, retrieved Novem- lished 1945). ber 19, 2009, from http://www.myc.com/Parents/MYC- [9] M. Heidegger, Being and time (J. Macquarrie and E. Robinson, Programs.htm, 2009. Trans.), Harper & Row, New York, NY, 1962 (original work [30] International Suzuki Association, The Suzuki Method TM, published 1927). retrieved November 19, 2009, from http://www.international [10] H.-G. Gadamer, Truth and method (J. Weinsheimer and suzuki.org/method.htm, 2005. D.Marshall, Trans.), Continuum, London, UK, 1989 (original [31] K.A. Ericsson, R.Th. Krampe and C. Tesch-Romer,¨ The role work published 1960). of deliberate practice in the acquisition of expert performance, [11] J. Creswell, Qualitative inquiry and research design: Choos- Psychological Review 100 (1993), 363–406. ing among five approaches,SagePublications,Thousand [32] P. Visentin, Prevention education through music instruction, Oaks, CA, 2007. Paper presented at joint Music Teachers National Association, [12] D.E. Polkinghorne, Phenomenological research methods, Canadian Federation of Music Teachers’ Associations, and in: Existential-phenomenological perspectives in psychology, The Royal Conservatory of Music conference, Toronto, ON R.S. Valle and S. Halling, eds, Plenum Press, New York, NY, (2007, May). 1989, pp. 41–60. [33] H. Hildebrandt and M. Nubling,¨ Providing further training in [13] S.P. Thomas and H.R. Pollio, Listening to patients: A phe- musicophysiology to instrumental teachers: Do their profes- nomenological approach to nursing research and practice, sional and preprofessional students derive any benefit? Medi- Springer Publishing Company, New York, NY, 2002. cal Problems of Performing Artists 19 (2004), 62–69. [14] C. Zaza, C. Charles and A. 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Manchester, Health pro- 54(2) (2006), 199–207. motion in schools of music: Initial recommendations for [18] A. Lindseth and A. Norberg, A phenomenological hermeneu- schools of music, Medical Problems of Performing Artists tical method for researching lived experience, Scandinavian 21(3) (2006), 142–144. Journal of Caring Sciences 18(2) (2004), 145–153. [38] J. Palac, Promoting musical health, enhancing musical perfor- [19] O. Alexis, V. Vydelingum and I. Robbins, Engaging with a mance: Wellness for music students, Music Educators Journal new reality: Experiences of overseas minority ethnic nurses 94(3) (2008), 18–22. in the NHS, Journal of Clinical Nursing 16(12) (2007), 2221– [39] S.J. Johnson, M. Batey and L. Holdsworth, Personality and 2228. health: The mediating role of trait emotional intelligence and [20] M. 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Injury Prevention: What Music Teachers Can Do Christine Guptill and Christine Zaza Music Educators Journal 2010; 96; 28 DOI: 10.1177/0027432110370736

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Downloaded from http://mej.sagepub.com at UNIV OF WESTERN ONTARIO on June 9, 2010 by Christine Guptill and Christine Zaza Injury Prevention What Music Teachers Can Do

he risk of injury in musicians has been dents was effective in improving several as- well established over the past twenty- pects of health and musicianship.5 Studies five years. Concerns about the risk of show that music teachers who learn about becoming injured have been increas- injury prevention do pass it along to their stu- T 6 ingly present in the music world. Research in dents. Many music teachers learn about injury performing arts medicine has demonstrated prevention through contact with other teach- that approximately 25 percent of music stu- ers and musicians, attendance at workshops, dents experience a playing-related injury.1 and through reading articles. Our goal is to Since musicians’ musculoskeletal injuries present evidence-based prevention strategies are associated with several factors related for music teachers that will assist in ultimately to practice habits, music teachers can and reducing these potentially career-threatening By learning about should play a vital role in injury prevention.2 injuries. In 2003, the National Association of Schools research-based of Music (NASM), the accrediting body for de- Injuries among Musicians gree-granting music institutions in the United methods of States, adopted the following statement for its Injuries to the upper extremity (hand, arm, 7 prevention, you handbook: “Institutions should assist students and shoulder) are common in musicians. to acquire knowledge from qualified profes- These include overuse problems, strains and can help your sionals and authoritative medical sources sprains, inflammatory conditions (e.g., ten- students avoid regarding the maintenance of professional donitis, tenosynovitis), nerve compression health and the prevention of performance in- problems (e.g., carpal tunnel syndrome), and playing-related juries.”3 Despite this statement, only a “hand- other neurological conditions, such as focal ful” of NASM-accredited institutions have de- dystonia. Instrumentalists also experience 8 injuries. voted resources to musicians’ health.4 Even symptoms in the back and neck, but these with these efforts, the basic question remains: have been less well described in the perform- What can music teachers do to prevent inju- ing arts medicine literature. Temperoman- ries? Although not widespread, prevention dibular joint disorder, which affects the joints education programs have been developed and between the jaw and skull, can be a concern implemented for music teachers and students for some, and others may experience skin dis- alike. For example, Claudia Spahn and her orders (e.g., violinists’ neck). Musicians can colleagues at the Freiburg Institute for Music also experience high levels of performance 9 Medicine demonstrated that their prevention anxiety and other mental health concerns. education course for conservatory music stu- Reported prevalence rates of playing-

Christine Guptill is an occupational therapist and holds a bachelor of music and a doctorate in rehabilitation sciences. She is an Copyright © 2010 MENC: The National oboist with the Concert Players Orchestra in London, Ontario, Canada. Christine Zaza holds a bachelor of music and a doctorate Association for Music Education in health studies. She currently teaches violin, piano, and theory in her music studio and is an instructor in the Department of DOI: 10.1177/0027432110370736 Psychology at Wilfrid Laurier University, Waterloo, Ontario. They can be contacted at [email protected] and http://mej.sagepub.com [email protected], respectively.

28 Music Educators Journal June 2010 Downloaded from http://mej.sagepub.com at UNIV OF WESTERN ONTARIO on June 9, 2010 related injuries in instrumental musicians ticing.19 The time intensity of a practice be advised against playing with cold vary from 26 to 93 percent. It is difficult session can also be changed by students hands in a cold room, for reasons of into- to know the true prevalence of these and their teachers. nation and instrument care as much as problems within the musician community Some risk factors are not modifiable. for injury prevention. For wind players, because processes for definitive diagno- These include gender (women seem to be deep-breathing exercises, focusing on ses have not been fully established, many more at risk than men), instrument played lowering the diaphragm without raising research papers use different definitions (string players and pianists have higher the shoulders, can assist in preparing the or fail to define playing-related injuries, rates of injury), age, and body mass index body for playing. Long tones in a com- and many studies are fraught with meth- (BMI) (older musicians and those with fortable range are advocated to prepare odological problems.10 In addition, there a higher BMI are at an increased risk the small muscles of the face and mouth. are vast differences in the frequencies of of injury).20 In addition, hypermobility Students can then move on to short certain types of injuries between different (double-jointedness) may be a risk factor, pieces of minimal technical requirement, common instrument groups (piano, upper although it is important to note that hyper- or moderately paced scales and arpeg- strings, guitar, flute, other woodwinds, mobility is more common in the musician gios. For pianists and string players, slow, and percussion).11 population than in the general popula- comfortable playing (e.g., scales, arpeg- tion. The relationship between hypermo- gios, or easy repertoire) is advocated dur- Risk Factors for Injuries bility and injuries remains unclear.21 ing warm-up. String players may wish to Many of the factors that contribute to use open strings where possible. Techni- An important risk factor for playing- playing-related injuries are related to play- cally demanding material or techniques, related injuries is the use of repetitive ing behaviors, and these behavioral fac- such as octaves for the pianists and dou- movements during extended hours of tors are modifiable. Students can be taught ble stops for string players, should be 12 practice. In particular, a rapid increase in good playing habits that may help prevent avoided. For all instrument types, teach- practice time seems to predispose musi- future injuries. Therefore, it is important ers should demonstrate an appropriate 13 cians to injury. This may occur when that teachers not only tell students what warm-up routine and advise students to preparing for an important audition or to practice, but show them how to prac- follow this routine during all their prac- performance or when beginning profes- tice. In the next section, we describe how tice sessions at home. sional music studies. Stress and anxiety music teachers can translate the research Stretching seem to be risk factors in acquiring inju- about suspected risk factors for playing- 14 ries. In addition, stress has been shown related injuries into good practice habits The scientific literature about stretching in 15 to affect performance. for students. musicians is inconclusive. Athletic trainers Awkward body positions mandated in the past have claimed that stretching by the shape and weight of the instru- Prevention Strategies improves performance and reduces inju- ment, the technical difficulty of the reper- ries in athletes; however, there is no con- toire, and playing unfamiliar instruments The following are modifiable risk factors clusive evidence that stretching prevents may also contribute to injuries.16 In addi- to consider for preventing playing-related injury in healthy individuals. It is safe to tion, the total number of years playing injuries: say that bouncing the limb during stretch- may be a risk factor for playing-related ing (called “ballistic” stretching) should sWarm-up injuries. For example, Yoshimura and her be avoided. There is some evidence that sBreaks colleagues found that an increased num- dynamic stretching (doing a movement sPosture, playing position ber of years playing the piano was a sig- that takes a joint near the end range of sTechnique nificant predictor of pain in pianists.17 motion) produces greater benefits for sRepetition Perhaps most importantly in terms high-speed movements,22 but this has not sPacing of the goals of this article, it has been been applied to musicians. There is also demonstrated that taking breaks during Warm-Up evidence that stretching may reduce the practice sessions and doing a physical sensations of stiffness and soreness when warm-up prior to playing may be related Many teachers advocate a musical warm- performing new activities.23 If stretching is to a decrease in playing-related injuries.18 up, which is important in preparing the done, then the safest way to approach it is It has also been shown that student tech- body and mind for performance. How- to go slowly and gently and to avoid any nique can be influenced by teaching ever, this can and should be combined stretching that causes pain. It is helpful students to be more efficient in their prac- with a physical warm-up. Students should to adopt postures that are different from

www.menc.org 29 those used in playing. For example, pia- preventing injuries.24 Students should be and visualize performing the piece at an nists can stand, lift the head and chin, and encouraged to incorporate two kinds of upcoming recital. A woodwind player who gently lean backward to extend the back. breaks into their practice routine: micro- was practicing standing could sit down They may also turn their palms upward breaks, and breaks away from playing. and sing her part as mental rehearsal. and extend their wrists and fingers. Keep A microbreak might consist of stopping Fingering parts while not playing is not a in mind that it is not how far you stretch for thirty seconds or counting rests when complete break, since the muscles of the a muscle that counts; it is how long you practicing a piece with accompaniment. fingers and posture of the hands, arms hold it. Many musicians can create prob- For wind instrumentalists, counting rests and body are still being used. lems by stretching too forcefully, because can greatly increase perceived stamina for they erroneously think that stretching a long recital and may not only prevent Playing Position more or stretching farther is better (e.g., injury, but may also improve students’ “If stretching three times is good, then self-confidence. All instrumentalists should be aware of stretching nine times is better.”). Longer breaks away from the instru- the natural curvatures of the spine, and ment should also be encouraged. Tubiana maintain these normal curves when sit- Breaks and Amadio write that “most music teach- ting or standing (see Figures 1 and 2). ers suggest a five-minute break after thirty Posture should not be static, and students We have found no specific research on minutes of practice.”25 However, clinical should be encouraged to move with the how long and how frequently musicians experience of the first author and research music and as required by the instrument should break. However, studies with in occupational health suggests that this (e.g., leaning the pelvis to the right to nonmusician workers have shown some will vary significantly with the instrument, reach higher notes on the piano). When indication that taking breaks is helpful in repertoire, and student familiarity with the possible, instruments sized to the body piece.26 This does not mean that students of the student should be chosen, rather need to leave the room and forget about than expecting a child to “grow into” the music. They should, however, change instrument. Last, keep in mind the rela- position and do an activity that does not tionship between the sheet music and the involve the muscles or postures that are student’s body posture. The height of the used for playing. For example, a pianist music may encourage poor posture if it could stand up, do some gentle stretches, is not level with the eyes (older students who use bifocals may need the music lower). Parents need to be included in the education of the specifics of playing posture for children, so that this can be monitored at home. This could be done through inclusion of information about playing position in a teacher’s introduc- tory letter, or in a course outline. Sitting When sitting to perform, musicians are often told to sit at the edge of their chair, and some tend to overextend the lower back in an effort to sit up straight. Sit- ting tall (shoulders down and back, chin not jutted out, not slouching) is impor- FIGURE 1 FIGURE 2 tant. However, in addition to the common The three natural curves of the Piano-playing position. Pianists slouching seen in many students, the first spine: (1) cervical, (2) thoracic, should maintain normal curves of author has also observed hyperextension (3) lumbar. spine when sitting at the piano. in the lower back of musicians who sit at the edge of their chairs. Both of these Note: Adapted from Adalbert I. Kapandji, Note: Adapted from Adalbert I. Kapandji, extremes can cause unnecessary ten- “Anatomy of the Spine,” in Raoul Tubiana “Anatomy of the Spine,” in Raoul Tubiana sion and pain in the lower and midback. and Peter C. Amadio, eds., Medical and Peter C. Amadio, eds., Medical Whether at the edge of the chair or not,

Problems of the Instrumentalist Musician Problems of the Instrumentalist Musician sitting posture should focus on maintain- (London: Martin Dunitz, 2000). (London: Martin Dunitz, 2000). ing the natural curves of the spine and

30 Music Educators Journal June 2010 Downloaded from http://mej.sagepub.com at UNIV OF WESTERN ONTARIO on June 9, 2010 ensuring that the feet are flat on the floor neutral joint postures are desirable for have better performances than those who (except in the case of pianists and harp- optimal functioning of the muscles and do not.31 ists, who need foot mobility for pedals). minimal injury. Wherever possible, teach- Guided imagery (imagining one- The student’s body weight should be ers should examine students for extreme self going through all the steps in a per- evenly distributed through the buttocks, postures and see if they can be corrected formance, right through to a successful legs, and feet. Students should learn to fit (e.g., bent wrists should be straight; head result) is an effective strategy for reducing themselves to their playing position and should not be tilted forward). Figures 3 performance anxiety and increasing con- to check for common problems (sitting through 5 illustrate some common pos- fidence.32 Guided imagery can therefore too close or too far from the piano). tural concerns and corrections that may be a powerful tool in students’ prepara- Chairs should be relatively flat, not be applied by teachers in lessons. tion for performances. highly curved surfaces, parallel to the floor or tilted forward no more than Repetition Pacing twenty degrees (not tilted backward), and preferably lightly padded. The seat depth While repetition is integral to performing As mentioned previously, it is important should stop one or two inches behind the music, it is also a risk factor for injuries. that students not crash-practice before bend of the knee. A solid back piece is However, there are ways to reduce repe- lessons, recitals, exams, and so on. The preferred, so that students can use the tition that can include practice techniques best strategy, as teachers know, is daily or backrest for support if needed. Pianists that may benefit the student in ways other almost daily practicing. Strategies such as should use adjustable benches, and teach- than simply injury prevention. keeping a practice chart or log can assist ers should adjust the height for students students with learning to practice. When Smart Practicing to demonstrate the appropriate position. an increase in practice time is needed, The height of the chair or bench should Smart practicing includes teaching stu- teachers can compare it to a crescendo allow the student to sit with hips, knees, dents not to start at bar 1 and play (not subito), and encourage students to and ankles bent at right angles (ninety through the piece, no matter what mis- gradually increase the time in increments degrees), or slightly higher for use of foot takes may be made, until the double bar. of ten to twenty minutes.33 pedals. Some health care practitioners Students should practice short chunks of Some busy students who are involved advocate a slightly forward-tilting posture music (e.g., a few bars, a phrase) when in several extracurricular activities find it in order to promote a natural curve in the learning a new piece. They can learn to impossible to find a thirty-minute block lumbar spine.27 In both cases, feet and be like detectives and try to find where of time to practice each day. Teachers can buttocks should be solidly planted to pro- problems arise in the music. (Is it finger- encourage these students to divide up vide stability for the moving upper body ing? Bowing? Uneven rhythm?) Problem their music “homework” into manageable parts. If necessary, a footrest can be used areas should be practiced slowly until small chunks of five or ten minutes (e.g., (e.g., phone book). It should be noted accurate, and only then should the tempo five minutes for scales here, ten minutes that the desirable characteristics of a chair be increased, without compromising on a piece there, etc.) are often not found in the folding chairs technique or sound. Muscle memory is commonly used in school auditoriums or involved in performing music, and it is classrooms. Schools should consider pur- important that the correct movements be Tension and Technique learned so that they can be relied on at chasing stacking (not folding) chairs with Many musicians are aware that undue ten- higher speeds. flat seats at two or three different heights sion can cause long-term pain and injury. to accommodate various and growing Cognitive Rehearsal and Imagery Although position is important in prevent- body sizes. Mental (cognitive) practicing (practic- ing undue tension, technique is also impor- Standing ing away from the instrument) can help tant. A student who is comfortable with scale patterns will approach scalic passages When standing to play, the most common reduce repetition, and can benefit the 28 with less tension and therefore reduce the postural error is to lock the knees back- learning process. Examples are learn- risk of injury in the long term. As teachers ward. This may cause slouching through ing the fingering of a scale on a table know, good technique also reduces the the mid- to upper back and shoulder top first, then going to the piano; listen- amount of repetition and time required areas. Encouraging students to unlock ing to recordings of the piece and study- to learn new repertoire. Teachers should their knees often corrects many postural ing the chord structure before playing it; work with students to develop technique difficulties, and can increase expression in and visualizing oneself practicing arpeg- at a pace that is achievable for the student the music if accompanied by gentle move- gios, scales, or a piece. Research shows and without overpracticing, while being ment. Feet should be placed about shoul- that visualizing a successful performance 29 alert to unnecessary tension. Regularly der width apart, with shoulders down and improves perceived self-efficacy, and scheduled breaks and micropauses can back, and the chin not jutted out. this in turn is likely to improve perfor- 30 assist students in returning to a relaxed, Ergonomic principles teach us that mance. We also know that people who first visualize themselves performing basic position for playing. Students should www.menc.org 31 Downloaded from http://mej.sagepub.com at UNIV OF WESTERN ONTARIO on June 9, 2010 FIGURE 3 FIGURE 4 FIGURE 5 Child at piano. Small child at the piano.

Child is seated too far away from the piano. Note the extended elbow and slight wrist extension. Woodwind player sitting at Child is seated too low due to his the edge of the chair and small stature. Note the elbows are demonstrating hyperextension too bent and the wrists are below the of the lower back. Her knees and keys. hips are not at right angles, and the music stand is too low.

Child is seated too close, and is compen- sating by bending over the piano at the neck. Note the elbows are too bent.

The adjustable bench was raised and a stool placed under the child’s feet. Note the elbows are now at right By moving to the back of the angles and the wrists are straight. chair and supporting the feet, the back is in better alignment and the hips and knees are now at right angles. The music stand was also raised.

Good position. The elbows are at right angles, and the wrists are straight. The child is able to sit straight and maintain Downloadednormal from http://mej.sagepub.com spine curves. at UNIV OF WESTERN ONTARIO on June 9, 2010 warm-up, long, slow tones in an easy hope that this article will help to increase Additional Resources for range are recommended for winds, and the awareness of the risk of injury within slow movements are recommended for the music education community and Healthy Playing players of all instruments. If stretching thereby promote wellness for generations is done, students can also stretch after a of musicians to come. s Dawson, William J., Fit as a Fiddle: The Musician’s Guide to Playing Healthy practice or performance session. (Lanham, MD: MENC/Rowman & NOTES If an Injury Occurs Littlefield Education, 2007). 1. Claudia Spahn, Sandra Strukely, and s Norris, Richard, The Musician’s Survival Andreas Lehmann, “Health Conditions, Music teachers do not need to become Attitudes toward Study, and Attitudes Manual: A Guide to Preventing and experts in performing arts medicine to toward Health at the Beginning of Treating Injuries in Instrumentalists provide sound advice to their students University Study: Music Students (Saint Louis, MO: MMB Music, 1993). to help prevent the all-too-common inju- in Comparison with other Student Populations,” Medical Problems of s Sataloff, Robert Thayer, Alice G. ries that many will face throughout their Performing Artists 19 (2004): 26–33. Brandfonbrener, and Richard J. careers. The strategies presented in this 2. Shinichi Furuya et al., “Prevalence Lederman, eds., Performing Arts article are simple to incorporate into les- and Causal Factors of Playing-related Medicine (San Diego, CA: Singular, sons or classroom instruction, and are Musculoskeletal Disorders of the Upper 1998). unlikely to do any harm. However, teach- Extremity and Trunk among Japanese Pianists and Piano Students,” Medical s Tubiana, Raoul, and Peter C. Amadio, ers may sometimes be approached by Problems of Performing Artists 21 eds., Medical Problems of the students in need of help with an injury. (2006): 112–17; Mats Hagberg, Instrumentalist Musician (London: Teachers should not diagnose their stu- Gunnar Thiringer, and Lars Brandström, Martin Dunitz, 2000). “Incidence of Tinnitus, Impaired Hearing dents’ injuries, but may find it helpful to and Musculoskeletal Disorders among s Williamon, Aaron, Musical Excellence: inform themselves about local services Students Enrolled in Academic Music Strategies and Techniques to Enhance and qualified healthcare practitioners that Education: A Retrospective Cohort Study,” Performance (Oxford, UK: Oxford can help students recover. International Archives of Occupational and Environmental Health 78 (2005): University Press, 2004). There are four basic symptoms of 575–83; Christine Zaza and Vernon s “The Musician’s Hand” (entire issue), playing-related injuries that should be Farewell, “Musicians’ Playing-related Hand Clinics 19 (2003), 211–360. investigated by a health care professional. Musculoskeletal Disorders: An Examination Pain should be avoided during playing at of Risk Factors,” American Journal of s Medical Problems of Performing Artists Industrial Medicine 32 (1997): 292–300. all costs. Although some pain may resolve journal, Science & Medicine, Inc. 3. National Association of Schools of Music, without complications, it is an indication “Facilities and Equipment, Health and s Performing Arts Medicine Association, that the player has pushed the body too Safety: Guidelines and Recommendations,” www.artsmed.org far, and changes need to be made. Numb- NASM Handbook 2007-2008 (Reston, VA: ness, tingling, or a sensation of “pins and Author, 2006), 54. needles” may be an indication of nerve 4. Judy Palac, “Promoting Musical Health, Enhancing Musical Performance: Wellness be encouraged to be aware of common involvement. Persistent lack of control of areas of tension, such as hiking the shoul- for Music Students,” Music Educators a finger, hand, or arm may signal a condi- Journal 94 (2008): 18–22. ders toward the neck or clenching the jaw, tion known as focal dystonia. The appear- 5. Claudia Spahn, Horst Hildebrandt, and and learn to focus on relaxing these areas ance of an unexplained bump might be Karin Seidenglanz, “Effectiveness of a whenever they are taking breaks or micro- related to a ganglion cyst (a benign out- Prophylactic Course to Prevent Playing- related Health Problems of Music pauses. This is particularly important when growth of the joint lining). All of these preparing for recitals and other potentially Students,” Medical Problems of Performing symptoms should be investigated and Artists 16 (2001): 24–31. stressful circumstances. Diligent attention professional treatment sought in order to 6. Margaret Redmond and Anne M. Tiernan, to these practices over time will pay off prevent the issue from becoming more “Knowledge and Practices of Piano when relaxation becomes an unconscious difficult to diagnose and treat. Teachers in Preventing Playing-related part of the student’s routine. Injuries in High School Students,” Medical Problems of Performing Artists 16 (2001): Teachers Are Instrumental 23–28; Zaza and Farewell, “Musicians’ Cool-Down Playing-related Musculoskeletal Disorders: This article has provided guidance for An Examination of Risk Factors.” Although no research can be found to music teachers on measures that can be 7. Christine A. Guptill, “An Occupational support the use of cool-down as a pre- Study of Physical Playing-related Injuries in taken to help prevent students from sus- College Music Students” (master’s thesis, ventive measure, given the athletic per- taining playing-related injuries. Teach- formance of playing a musical instrument, Western Michigan University, Kalamazoo, ers can be instrumental in instilling the 2000); William J. Dawson, “Upper- it seems prudent to recommend it. Both practice habits, postures, and techniques extremity Problems Caused by Playing Specific Instruments,” Medical Problems musical and physical cool-down activi- that can help to sustain students through ties are important. As recommended for of Performing Artists 17 (2002): 135–40. a lifetime of music enjoyment. We also 8. Deborah Barr et al., “Prevalence of Medical www.menc.org 33 Problems Associated with Playing the Great and Arm Pain in a Large Clinical Sample Manual: A Guide to Preventing and Highland Bagpipe: Survey Results and of Musicians,” Medical Problems of Treating Injuries in Instrumentalists (Saint Comparisons to Other Musicians,” Medical Performing Artists 17 (2002): 113–15. Louis, MO: MMB Music, 1993), 38–42; Problems of Performing Artists 20 (2005): 22. Thomas Little and Alun G. Williams, Barbara Paull and Christine Harrison, 163–67; Brownen J. Ackermann and Roger “Effects of Differential Stretching “Taking Care of Your Neck and Back,” in Adams, “Physical Characteristics and Pain Protocols During Warm-ups on High- The Athletic Musician: A Guide to Playing Patterns of Skilled Violinists,” Medical speed Motor Capacities in Professional Without Pain (Lanham, MD: Scarecrow Problems of Performing Artists 18 (2003): Soccer Players,” Journal of Strength and Press, 1997), 51–71. 65–71; John L. Rigg, Randy Marrinan, and Conditioning Research 20 (2006): 203– 28. Albert Bandura, Social Foundation of Mark A. Thomas, “Playing-related Injury in 7; Ian Shrier, “Does Stretching Improve Thought and Action: A Social Cognitive Guitarists Playing Popular Music,” Medical Performance? A Systematic and Critical Theory (Englewood Cliffs, NJ: Prentice Problems of Performing Artists 18 (2003): Review of the Literature,” Clinical Journal Hall, 1986), 62. 150–52. of Sport Medicine 14 (2004): 267–73. 29. Albert Bandura and Nancy E. Adams, 9. Johannes F. L. M. Van Kemenade, Maarten 23. Camilla L. Brockett, David L. Morgan, and “Analysis of Self-efficacy Theory of J. M. Van Son, and Nicolette C. A. Van Uwe Proske, “Warm-up Stretches Reduce Behavioral Change,” Cognitive Therapy Heesch, “Performance Anxiety among Sensations of Stiffness and Soreness and Research 1 (1977): 287–310. Professional Musicians in Symphonic after Eccentric Exercise,” Medicine 30. Adalbert I. Kapandji, “Anatomy of the Orchestras: A Self-report Study,” and Science in Sports and Exercise 37 Psychological Reports 77 (1995): 555–62. Spine,” in Raoul Tubiana and Peter C. (2005): 929–36. Amadio, eds., Medical Problems of the 10. Peter Bragge, Andrea Bialocerkowski, 24. Philip Tucker, “The Impact of Rest Instrumentalist Musician (London: Martin and Joan McMeeken, “A Systematic Breaks upon Accident Risk, Fatigue and Dunitz Ltd., 2000), 66. Review of Prevalence and Risk Factors Performance: A Review,” Work and Stress Associated with Playing-related 31. Ann Richardson, “Mental Practice: A 17 (2003): 123–37; Linda McLean et al., Review and Discussion, Part I,” Research Musculoskeletal Disorders in Pianists,” “Computer Terminal Work and the Benefit Occupational Medicine-Oxford 56 (2006): Quarterly 38 (1967): 95–107; Bandura, of Microbreaks,” Applied Ergonomics 32 Social Foundation of Thought and Action. 28–38; Christine Zaza, “Prevalence and (2001): 225–37; Robert A. Henning et Incidence of Musicians’ Playing-related al., “Microbreak Length, Performance, 32. Mary Jane Esplen and Ellen Hodnett, Musculoskeletal Disorders: A Systematic and Stress in a Data-entry Task,” “A Pilot Study Investigating Student Review,” Canadian Medical Association Ergonomics 32 (1989): 855–64. Musicians’ Experiences of Guided Imagery Journal 158 (1998): 1019–25. as a Technique to Manage Performance 25. Raoul Tubiana and Peter C. Amadio, eds., 11. Dawson, “Upper-extremity Problems.” Anxiety,” Medical Problems of Performing Medical Problems of the Instrumentalist Artists 14 (1999):127–32; Warren 12. Hagberg, Thiringer, and Brandström, Musician (London: Martin Dunitz, 2000), Brodsky, “Music Performance Anxiety “Incidence of Tinnitus.” 544. Reconceptualized: A Critique of Current 13. Richard A. Hoppman, “Instrumental 26. Tucker, “The Impact of Rest Breaks”; Research Practices and Findings,” Musicians’ Hazards,” Occupational Christine Zaza, “Research-based Medical Problems of Performing Artists Medicine 16 (2001): 619–31; Jonathan Prevention for Musicians,” Medical 11 (1996): 88–98. Newmark and Richard J. Lederman, Problems of Performing Artists 9 (1994): 33. Tubiana and Amadio, Medical Problems of “Practice Doesn’t Necessarily Make Perfect: 3–6. the Instrumentalist Musician, 544. Incidence of Overuse Syndromes in Amateur 27. Richard Norris, The Musician’s Survival Instrumentalists,” Medical Problems of Performing Artists 2 (1987): 142–44.

14. Zaza and Farewell, “Musicians’ Playing- ® related Musculoskeletal Disorders: An Examination of Risk Factors.” MUSIC ACE MAESTRO 15. Alan H. Lockwood, “Medical Problems Designed for Professional Music Educators of Musicians,” New England Journal of Medicine 320 (1989): 221–27. Combining all lessons from Music Ace® and Music Ace® 2, Music Ace® Maestro 16. Alice G. Brandfonbrener, “Epidemiology is a complete series of 48 engaging and Risk Factors,” in Medical Problems music lessons and games that teach of the Instrumentalist Musician, ed. Raoul ™ beginning music students of all ages the Tubiana and Peter C. Amadio, 171–94 basics of music theory, rhythm, pitch, (London: Martin Dunitz, 2000). note reading, listening, and the keyboard. 17. Ero Yoshimura et al., “Risk Factors Maestro Max for Piano-related Pain among College Music Ace® Maestro is designed for Students,” Medical Problems of Performing professional educators and is available New Data Management Tools Artists 21 (2006): 118–25. in a single user educator version, lab-packs and network versions supporting from five to 5,000 workstations. +
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34 Music Educators Journal June 2010