Ep 206: Managing musicians' musculoskeletal health, with Marianne Roos

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. Musicians and athletes might sometimes appear to exist in very different cultures. And yet the single minded focus, the thousands of

[00:00:29] hours of practice and the high training loads on their musculoskeletal systems mean that musicians and athletes probably have more in common than they have differences, at least from a musculoskeletal rehabilitation perspective. Today's guest is Marianne Roos, a former clarinetist and forever musician at heart who now practices as a physiotherapist. Marianne explains the physical and psychological demands of orchestra performance on the musician's body and shares the results of her PhD research in developing programs to reduce

[00:00:59] musculoskeletal injuries among orchestra musicians. Marianne Roos, welcome to JOSPT Insights. Thank you. Happy to be here, Claire. I'm very happy to have you on the podcast today, Marianne. We're often talking on JOSPT Insights about different approaches to supporting athletes' musculoskeletal health and the sorts of often quite heavy demands that sport places on the athlete's musculoskeletal system. Today we're doing a similar thing, only we're focused on a different group of people and a

[00:01:29] different population who also have very heavy demands and loads on their musculoskeletal system. Let's start by setting the scene with the orchestra. Which musicians make up an orchestra?

[00:01:43] So the musicians that typically make up an orchestra are strings, so violins. There are first violins and second violins, so there are more violins than there are other instruments. Then there are cellos and the violas, and those are slightly smaller groups. So maybe eight cellos, eight violas, for example, in comparison to 20 violins altogether.

[00:02:07] Then you have the winds. There are typically two of each instrument, or most of the instrumentation. So the orchestra size really varies depending on the piece of music that is played, so it can really grow. But in the core group of musicians usually have two clarinets, two bassoons, two flutes, two oboes, two trumpets, four horns, French horns, two to three trombones.

[00:02:30] And then you have your percussion, which includes a timpani and other percussive instruments, and sometimes other instruments such as the harp, which is also part of the percussion family. The double basses as well, which I forgot, along with the strings. Mostly strings, and then the brass and the winds are generally considered to be kind of solo, all solo instruments because they're all playing their own line.

[00:02:52] So the musculoskeletal demands on orchestra musicians are very high. One of the demands definitely is strength. First of all, they need to support the weight of the instrument. Studies have shown that there is a considerable loading of the spine already just from supporting the weight of the instrument.

[00:03:11] And they need to be, we often talk about the asymmetrical postures as well. So they need to be supporting the weight of the instrument and the weight of, say, their arms, their upper extremities up in the air in asymmetrical postures.

[00:03:24] And you need strength as well, for example, in the stringed instruments for the bowing. You know, we see musicians' arm flying back and forth with the bow in their hand, and it looks like their arm is flying. But in order to make a beautiful sound, there's quite a bit of friction between the bow and the string.

[00:03:41] And so you really actually need strength to be pushing that bow back and forth all of that time, and strengthen the fingers as you're pushing down the strings. And for the winds, you know, strengthen the fingers as well. So anyway, strength, endurance as well.

[00:03:55] Musicians need to play for a long time, often for longer than what they feel comfortable with. They need postural endurance, and studies have shown that it takes energy. You know, it's like a physical activity to play.

[00:04:08] It really, you know, they've shown that the METs are higher and, you know, greater cardiovascular output, et cetera, et cetera. So it really is a physical activity as they play.

[00:04:19] Yeah, and then there's the control. There's like motor control. So then you need really high functioning of the sensory motor neuromuscular systems working together. And that is so much of the elite musicians' work is training their sensory motor system and function.

[00:04:37] You know, they need to practice so much that in the end, everything is automated. So that when there's stress, when their hands start shaking, when they have shortness of breath for the winds and brass, when their hands are sweaty, that they can still perform those same movements, that they can still do the same performance.

[00:04:56] And also when they are tired, when fatigue comes in, that they can keep going.

[00:05:01] That's such a great summary. Thank you so much.

[00:05:04] And I'm intrigued because when a musician gets to the very elite level of the national orchestras, they've been training and progressing through the ranks for a really long time.

[00:05:15] Just as we think about a person playing at the elite level of sport has also been involved in their sport and training their body for a very long period of time.

[00:05:23] Can you give us a bit of a sense of that progression from a junior musician through the junior ranks to that very senior elite level in the orchestra?

[00:05:33] Yes. I mean, that's something that's really, really important to take into consideration when we think about musicians, because they do start very young and especially the elite orchestra players.

[00:05:43] I think often we don't realize to which extent there is very high level competition to get to that point.

[00:05:49] And they had to start really young and it's really competitive because they start so young and it really becomes a part of their identity of who they are.

[00:05:56] And that's also why when, if, and when they do get injured and their career is jeopardized by their pain, it's such a big deal because they've been working all these years and becomes part of their identity.

[00:06:08] Spring musicians will often start at three or four years of age, but depending on the instrument, so winds and brass, they can start later.

[00:06:17] Some eventually professional musicians will start only at age 14, but most of them will go through like a conservatory system where they are taking private lessons from a very young age and also starting with the other subjects such as oral training.

[00:06:31] Also when they're children, so before university level and then, you know, practicing hours a day from that young age, from childhood.

[00:06:40] There's so many parallels with the sporting world.

[00:06:43] I think you talked about the specialization of starting so young and having that very almost singular focus on the instrument you've chosen.

[00:06:52] The not taking breaks, the very focus on that reaching the elite level, the amount of training that's involved and the sacrifices and that sense of identity that my musicianship, my instrument is really all about who I am.

[00:07:08] And I think when you blend all of those things together, it's not surprising that when an injury occurs, I think we can all expect that they're going to have some injuries along the way.

[00:07:19] And when that happens, it's really difficult to deal with because all of a sudden maybe I can't play or maybe my body is not doing the things that I would like.

[00:07:29] Musicians have a much longer career than athletes do.

[00:07:33] Their professional careers can often be up to 50 years.

[00:07:38] And for you as a clinician, thinking about how do you tailor your approaches to helping people manage their musculoskeletal health is going to look different for someone who's in their teens and 20s than someone who's in their 50s, 60s and 70s.

[00:07:53] And I know that musicians, like when something happens and they'll be thinking, okay, thinking about the future.

[00:07:58] Like if this is now, what's it going to be like in 5, 10 years?

[00:08:03] I need to manage this amount right now.

[00:08:05] How much management is this going to take in a few more years?

[00:08:09] How long can I keep managing like this?

[00:08:11] While we're talking about load and training and culture, I guess, let's give a bit of a sense of the training loading that's going on to musicians' bodies.

[00:08:21] How many hours per week are they practicing?

[00:08:24] And then how often are they performing?

[00:08:26] That's also extremely variable.

[00:08:28] There's a lot more practicing happening when they're younger, when they are working on that development of those skills to win an audition.

[00:08:35] The way that musicians become professional orchestra musicians is they have to play an audition.

[00:08:41] It's very competitive.

[00:08:43] And so practicing for an audition, there are hours and hours of practicing is involved daily.

[00:08:49] And then once you get into the orchestra, as you have less experience, you are learning new music.

[00:08:57] So you're practicing more.

[00:08:58] But then eventually, once you've been there for a number of years, a lot of the same pieces come back again.

[00:09:03] You're playing the same pieces.

[00:09:04] So you can be practicing more.

[00:09:07] So it's really variable.

[00:09:08] Also varies from one instrument to the next because some instruments actually don't allow you to practice very much.

[00:09:14] For example, brass players that play with their mouths, the lips and the, we call it the embouchure, which is the setup with the lips and the musculature around the mouth.

[00:09:25] That's the embouchure.

[00:09:26] And the embouchure fatigues very quickly.

[00:09:28] And it's the same for certain wind players as well.

[00:09:31] And so that limits the number of hours of practicing.

[00:09:34] So it's really variable.

[00:09:35] But I'd say a conscientious musician who's been in the orchestra for a number of years will be practicing an hour and a half to two hours a day on non-rehearsal days.

[00:09:46] On rehearsal days, they are playing usually at least five hours in the orchestra already.

[00:09:51] So depending on the repertoire, it can be very fatigued.

[00:09:54] If it's loud, if it's fast, or if it's very static, that can also be fatiguing.

[00:10:02] So every single day, they have to kind of reevaluate.

[00:10:05] How much do I need to practice today?

[00:10:07] But how much can I practice today?

[00:10:09] And that's something that they actually, it's really difficult for them to evaluate.

[00:10:13] And as rehabilitation professionals, really so helpful when we can come in and help them with that.

[00:10:19] Also keeping in mind changes of repertoire.

[00:10:22] What's going on with, what do you notice with this kind of repertoire?

[00:10:24] What kind of repertoire are you playing right now?

[00:10:27] But for the number of performances, that also varies from one orchestra to the next, of course, and one week to the next.

[00:10:32] Their schedule is different every single week.

[00:10:34] These are all things that make it difficult to have like a strategy around management, right?

[00:10:39] It's just everything is different all the time.

[00:10:41] In one week, they can have between one.

[00:10:43] Usually there'll be one performance a week, at least.

[00:10:47] And but there can be five performances in one week.

[00:10:49] It's the variability that seems like it's the constant here and the loading.

[00:10:54] Let's transition that into talking specifically about the musculoskeletal health of orchestra musicians.

[00:11:01] And again, I think we're going to get into a, it depends on what type of instrument they're or which section of the orchestra they're in,

[00:11:08] because different demands are going to contribute to different musculoskeletal issues.

[00:11:13] So let's talk broadly, and then we can focus on the different sections of the orchestra.

[00:11:18] How frequently, typically, are orchestral musicians experiencing musculoskeletal pain and or injury?

[00:11:27] In the literature, when we talk about the musculoskeletal problems of orchestra musicians,

[00:11:32] we talk about playing-related musculoskeletal disorders,

[00:11:35] which are musculoskeletal problems that will actually have a negative impact on the person's playing capacity

[00:11:41] or the way that they perform normally, usually.

[00:11:44] And these are at a rate of up to 90%.

[00:11:49] Lifetime prevalence, over the course of their lifetime, up to 90% of musicians,

[00:11:54] orchestra musicians will experience such an injury.

[00:11:56] But studies have also shown point prevalence.

[00:11:59] So like at a given moment, up to about 50% of those injuries, between 37% and 50%.

[00:12:07] Exceedingly high, I would say.

[00:12:09] At any point in time, half of your orchestra is saying, I've got a problem.

[00:12:13] That is having an impact on my capacity to play.

[00:12:15] Yes.

[00:12:16] Exactly.

[00:12:16] And I imagine if you're the first violin, there are fewer people who can step into that role

[00:12:21] and do the first violin for you if you say, look, I'm really not able to play.

[00:12:27] Absolutely.

[00:12:27] Yeah.

[00:12:27] The solo chairs, they have that pressure.

[00:12:29] It might not be appropriate for the next person up to take that role.

[00:12:35] It's this combination of having a very specialist skill set that's very demanding on your body

[00:12:41] and not much backup.

[00:12:43] There's not much slack in the system to help you or to support you well if things are starting

[00:12:48] to go awry.

[00:12:49] I guess when you think of the demands, the fact that asymmetric posture repeated and over

[00:12:56] a long period of time, then that's going to get your brain to a place of, it's not surprising

[00:13:02] that tendinopathy and peripheral nerve entrapments are things that you're seeing much more frequently.

[00:13:07] We talked a little bit before about the culture of the orchestra.

[00:13:11] Let's zoom in on the culture in particular around preventing symptoms, musculoskeletal pain

[00:13:18] and injuries.

[00:13:20] Yeah.

[00:13:20] So as we talked about, the culture is really focused on excellence and high level performance

[00:13:26] and a lot less on injury prevention.

[00:13:29] There's not, classically there isn't a culture of injury prevention and that is such a big

[00:13:36] problem and why there are so many researchers now that are trying to go to the school level

[00:13:41] to go to younger musicians and trying to implement health education to make that part of the curriculum

[00:13:48] and part of what they're actually thinking about as they learn to play their instruments.

[00:13:52] Because classically, they're not taught to think about that at all.

[00:13:54] They're only taught to think about how well they're playing and they're taught to practice

[00:13:59] as much as possible to play as well as possible.

[00:14:02] And that's really, that is the culture.

[00:14:05] Practice as much as you can.

[00:14:06] Until you break.

[00:14:08] Until you break.

[00:14:09] Absolutely.

[00:14:10] As long as you play well.

[00:14:12] And so it's kind of crazy because you would think, we feel like we should be kind of past

[00:14:19] that now.

[00:14:20] A few years ago, we did focus groups, orchestra musicians here in town and spoke to them about

[00:14:25] implementation.

[00:14:26] Their perception on the implementation determinants.

[00:14:30] So the barriers and the facilitators to implementing health-related programs in their workplace.

[00:14:37] So either at the conservatory, university level or in orchestras.

[00:14:41] And this is where we talked a lot about the culture.

[00:14:45] And then I was, even knowing the culture myself, sort of hoped that we would hear something about

[00:14:50] the evolution kind of improvement in some of these, some of this mindset.

[00:14:55] But it was, it really felt like it was still these same concepts of like no pain, no gain.

[00:15:03] And pushing, pushing all the time as far as you can to breaking points and, and realizing later

[00:15:09] that you created your own problems pushing too far.

[00:15:13] It's within the individual, but it's also this pressure coming from the outside.

[00:15:16] Just knowing that there's constantly within an orchestra, you're, you're there, you've,

[00:15:21] you've won your job, but your colleagues are listening.

[00:15:24] People are judging you all the time.

[00:15:25] There are people in the audience that will write articles about you afterwards.

[00:15:28] It continues, that pressure continues in different forms.

[00:15:32] It's really, it's a really tough environment to grow up in and to then succeed in for a long

[00:15:38] period, a long career.

[00:15:40] What does an effective injury prevention program, a workplace, an orchestra workplace look like?

[00:15:46] It's not clear what is the most effective way to help musicians.

[00:15:52] But we, with our program, first of all, we did a pilot program when I was in my master's

[00:15:58] of physiotherapy.

[00:15:58] We did a pilot randomized control trial where we combined an exercise program with some health

[00:16:05] education, very minimal amount of health education, but still.

[00:16:08] The exercise program was a program that was developed in Australia by Clifton Chan and

[00:16:16] Tim Driscoll and Bronwyn Ackerman at the University of Sydney.

[00:16:20] We, I saw this program and I saw the studies that they had done.

[00:16:24] They hadn't done a randomized control trial to look at the effect of it, but they did look

[00:16:27] at the effect of it with two different groups of orchestra musicians.

[00:16:31] It looked really interesting, well-developed, and we, we, we trialed it here with our pilot

[00:16:37] randomized control trial.

[00:16:39] We did the same exercise program.

[00:16:40] And it's, it's a program that really focuses on, first of all, on a basic level, basic

[00:16:47] postural activation.

[00:16:48] So you start with activation of the transverse abdominus muscle and you need to master that

[00:16:54] exercise before starting any of the other exercises.

[00:16:57] There is a series of exercise for every region, well, the different regions of the bodies for,

[00:17:01] they have an, they call it the abdominals series and the back series.

[00:17:05] So a lot of work on the trunk, stability of the trunk, postural activation of the trunk,

[00:17:09] as well as of the hips.

[00:17:11] So you start with basic for each of those regions, basic postural activation, and then it increases

[00:17:17] in difficulty one step at a time.

[00:17:20] There are different levels and you, so you start at the basic level and you work your way up

[00:17:23] and you can go at different paces for different regions of the body.

[00:17:27] So in that way, it can be catered actually to different musicians where they're at, what

[00:17:34] their needs are, because you're going at different, different paces for the different body regions.

[00:17:40] Moving on to what's really interesting are then eventually the functional movements, which

[00:17:46] really mimic having the instrument in the arms and moving the trunk to make those musical

[00:17:53] movements that, those expressive movements that musicians want to make while they're playing,

[00:17:57] but still keeping that postural stability of those postural muscles activated, you know,

[00:18:02] all over.

[00:18:03] So the neck, the shoulders, you know, integrating that all together and having these, yeah,

[00:18:09] functional exercises.

[00:18:09] So it's, it's, it's a really interesting program in that way.

[00:18:13] Then from there, once those are mastered, the musician really, the next step is to imagine

[00:18:17] applying that to playing the instrument.

[00:18:21] And we found that it, that the, with our small sample size, it seemed like the program

[00:18:27] was effective in increasing, decreasing the pain intensity and interference of the pain.

[00:18:32] So on musicians playing capacity.

[00:18:34] And so we had these promising results.

[00:18:36] And from there, first we did the focus groups that I mentioned earlier in order to speak to

[00:18:41] the musicians who had participated in that trial about facilitators and obstacles to implementing

[00:18:48] a program such as that one.

[00:18:50] And, and they had a lot of, of suggestions for us, also practical suggestions on, on changes

[00:18:56] that we could make for the exercise program, as well as the education, as well as implementation

[00:19:01] factors, such as how can we make this work in, in musicians, crazy schedules.

[00:19:06] Can we make it more available on, or accessible for them?

[00:19:11] So we made those changes.

[00:19:13] And from there, we did the randomized control trial that was recently published in, in JOSPT,

[00:19:19] where we looked with a larger sample size.

[00:19:21] Okay.

[00:19:22] And, and, and these changes, changes that we made to the, both the exercise program and

[00:19:27] to the educational part of the program.

[00:19:29] We looked at what the impact was there in an intervention group that did the program compared

[00:19:34] to a group that did not do the program and to see what impact that had.

[00:19:38] And so the educational part, just to speak a little bit more about that, it talking a

[00:19:43] lot about load management.

[00:19:45] It's very complex, the, what musicians experience, because we've been talking a lot about the

[00:19:50] musculoskeletal system, but it's, of course, we're talking also about things like pressure

[00:19:55] and there's performance anxiety, psychosocial and judgment of the colleagues, competition,

[00:20:00] all of that.

[00:20:01] So a lot of psychosocial factors that are in there.

[00:20:04] So we really need to keep that in mind when we think about this population.

[00:20:08] And so we tried to have a kind of a global wellness also element to the, to the program.

[00:20:15] We had education also on nutrition and lifestyle based, you know, general physical activity

[00:20:23] levels.

[00:20:23] We did mindfulness, we did pain education.

[00:20:27] Also, just from my experiences speaking to musicians, I know there are a lot of false beliefs

[00:20:32] around health because they've gone through their whole training without health education,

[00:20:37] I mean, imagine.

[00:20:38] So there are a lot of specific topics to kind of talk to them about.

[00:20:44] Marianne, people can find a link to the published randomized controlled trial in the show notes

[00:20:49] of today's episode.

[00:20:50] What's your high level summary of the key results, the key messages you would like people

[00:20:55] to take away from the trial?

[00:20:57] There was an impact, a positive impact of the program on pain intensity.

[00:21:03] Can't be 100% sure because of wide confidence intervals, but they do suggest that.

[00:21:08] And I think with probably larger sample size, it may have been easier to see other effects.

[00:21:15] The data suggests that it would have been possible.

[00:21:17] It may be possible to see also effects on, on other variables such as the pain frequency

[00:21:26] and the pain interference.

[00:21:27] We did also find that the number of symptom locations was decreased in the intervention group.

[00:21:34] So it seems like the program can be effective in that way, but we, there are definitely more,

[00:21:39] more studies are, are necessary to really understand the, the impact.

[00:21:46] So perhaps, perhaps the, the program was effective for some, but not other musicians, which would

[00:21:51] not be surprising considering the heterogeneity of the population.

[00:21:54] Again, that, that variability, which we see all over, it does seem to be an effective, effective

[00:22:00] program.

[00:22:01] It's been so great having you explain some of the, the intricacies and the nuance of orchestra

[00:22:08] and the challenges faced by orchestral musicians.

[00:22:12] They're a wonderful group of people to work with, and it's been such a pleasure having you

[00:22:16] join me on JOSPT Insights today.

[00:22:18] So thank you very much.

[00:22:19] Thank you, Claire.

[00:22:20] It's been great to be here.

[00:22:26] Thanks for listening to this episode of JOSPT Insights.

[00:22:29] For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice,

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