STUDENTS Basic Information on Neuromuscular and Vocal Health

STUDENTS

Basic Information on Neuromuscular and Vocal

Health

Sources of This Information on Hearing Health

National Association of Schools of Music (NASM)—provides contextual issues in music programs regarding neuromuscular and vocal health

Performing Arts Medicine Association (PAMA)—provides information of a medical nature

Disclaimers for Information in This Presentation

Information provided is generic and advisory.Information is oriented toward musicians and lay

persons.Information does not substitute for professional

judgments of medical or other experts.Information is not to be considered medical advice.Current information does not supersede present and

future empirical research.Information does not serve as basis for NASM

accreditation functions.Information does not endorse accompanying

reference materials.

Responsibility for Neuromuscular and Vocal Health

Health and safety depend in large part on personal decisions of informed individuals.

This information does not relieve individuals of personal responsibility for avoiding risk and preventing injuries to self before, during, and after study or employment at any institution.

This information does not relieve the individual of personal responsibility for appropriate, prudent, and safe behaviors or actions.

Responsibility for Neuromuscular and Vocal Health

This information does not shift responsibility or liability for consequences of inappropriate, imprudent, and/or unsafe behaviors in any instance or over time to any institution, to NASM, or to PAMA.

Neuromuscular and vocal health are important for everyone, but especially for musicians.

Neuromuscular and Vocal Health: Basic Issues

Neuromusculoskeletal System (NMS)—nervous system, muscular system, and skeletal system These support the body’s physical structure and enable

movement These include the body’s position in space These include the relationship of the skeletal system to

corresponding muscles and tissues Terms like “alignment” and “posture” involve spinal

positioning, weight distribution, muscular support, and balance

Important for musicians and their neuromuscular and vocal health

Neuromusculoskeletal and Vocal Health

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

Neuromusculoskeletal health includes vocal health.

Neuromusculoskeletal and Vocal Health

Vocal health is important to all musicians because the voice is used in speaking and singing in professional roles (e.g., conductors, coaches, teachers, recording engineers, researchers, and therapists).

Good health and healthy behaviors are important to all musicians, regardless of their instruments and/or areas of specialization.

Sources of Neuromusculoskeletal/Vocal Disorders

Genetic factorsInfectionsTrauma or injuryBehaviors—either in isolation or repeated

over time

Music, The Musician, and Neuromusculoskeletal Health

Musical performance = physical activity involving large and small movements—those we can see and those inside the body.

Musical performance—involves conscious positioning of the body into specified playing and/or singing postures, which may be unnatural at first.


Practice routines are physically demanding and time-intensive, with few “days off” for the serious musician at an advanced level.

Some musicians may develop NMS conditions, complications, or disorders related to their musical activities.


Personal decisions about practice and performance are important in the individual’s NMS health and fitness.

Musicians are responsible for their art form and for supporting the well-being of all musicians.

It’s important to have a positive relationship between musical performance and NMS health.

The Neuromusculoskeletal System (NMS)

Musculoskeletal system—includes muscles, tendons, ligaments, bones, joints, and associated tissues that move the body, allow for speech, and help the body maintain its form.

The term, “neuromusculoskeletal” adds the nervous system, which coordinates voluntary and involuntary actions by transmitting signals to different parts of the body.

Nervous system contains: Central nervous system (CNS)—brain and spinal cord Peripheral nervous system (PNS)—nerves that allow the

CNS to communicate with the rest of the body

Vocal Anatomy: Contains Four Component Systems

“Generator”—breath provided by the lungs Main muscle involved is the diaphragm, a dome-

shaped muscle extending along the bottom of the rib cage

Diaphragm is assisted by various muscles in the abdomen, ribs, chest, and back

“Vibrator”—larynx, commonly called the “voice box” Vocal folds (or vocal cords) = 2 infoldings of mucous

membranes When breath regulated by the generator passes along

the vocal folds, they vibrate creating sound

Vocal Anatomy: Contains Four Component Systems

“Resonator”—cavity above the larynx responsible for giving the voice its tonal quality. Includes vocal tract, much of the pharynx (the throat),

the oral cavity, and the nasal passages“Articulator”—tongue, lips, cheeks, teeth, and

palate Helps to shape sounds into recognizable words and

specific vocalizationsNOTE: These four components work together

to produce human speech and singing.

Disorders of Neuromusculoskeletal System:Temporary or Permanent

Causes Genetic or related to

pre-existing medical condition

Related to trauma or injury

Related to specific behaviors which are subject to modification/change

Common symptoms Pain Stiffness Aching Throbbing Cramping Muscle weakness

Disorders of Neuromusculoskeletal System

Temporary Disorders may respond to Rest Behavior modification Medical interventions

Causes of Behavior-Related Neuromusculoskeletal Disorders

Overuse--any practice or activity in which anatomically normal structures are used in a so-called normal manner, but to a degree that exceeds their biological limits Produces physical changes that can cause symptoms

or complaints Degree of excessive activity needed to produce

symptoms/damage varies from person to person and seems to be related to a person’s individual anatomy and physiology


Misuse—a practice in which anatomically normal structures are used in an abnormal manner and/or to an excessive degree, sufficient to produce specific symptoms. Places certain bodily structures under stress

Abuse—occurs when an activity is performed not only excessively (overuse) or improperly (misuse), but also in a conscious, willful manner, often producing deleterious physical effects Common instrumental example = “playing through the pain” Vocal example = repeated instances of singing too loudly or

singing out of range Also includes use of dangerous substances


Genetic factors—most common one influencing behavior-related NMS disorders = hypermobility Also known as “joint hyperlaxity” or “double-jointed” May predispose a person to muscle pain syndromes

and/or tendinitis (inflammation of tendons—tough bands of fibrous connective tissue that connect muscle to bone)


Hypermobile joints have greater than normal range of motion People with these tend to use more muscle tension

when completing movements or tasks involving the hypermobile joint

Excess tension allows for better control, but can increase risk of damaging or straining muscles

Individuals with this condition are generally advised to monitor and actively reduce the tension carried in muscles and sometimes to do specific strengthening exercises and use external methods of joint support, such as splints or tape

Facts and Conclusions

Facts NMS health is

essential for musicians.

Many behavior-related NMS disorders are preventable.

Conclusions Musicians have basic

NMS health responsibilities.

Healthy NMS behaviors are a critically important addition to the musician’s portfolio of essential disciplines.

Facts and Conclusions

Constant attention is necessary because NMS damage sometimes occurs gradually over time.

Severe or advanced symptoms of certain NMS disorders may be career-ending for a musician.

Even if initial problems are not debilitating, they can cause career activity to become increasingly difficult and finally impossible.

Meaning of Facts and Conclusions

Musicians necessarily engage in repeated NMS behaviors and hold particular postures when they rehearse and perform.

Such behaviors and postures do NOT equal automatic risk of one or more NMS disorders.

Many factors are involved in determining inherent risk.

Managing NMS health starts with understanding basic facts and avoiding the most obvious problematic behaviors, postures, and situations.

Meaning of Facts and Conclusions

A behavior is risky when it involves overuse, misuse, or abuse of certain bodily components.

A behavior is risky when it fails to recognize and adapt to an individual’s physical limitations, genetic or otherwise.

Thoughtful judgment about what to do and what not to do for yourself and others involves gaining in-depth knowledge and applying it with sophisticated understanding.

A number of variables interact at the same time. These are unique to specific settings and situations.

Variables Influencing a Musician’s Risk of NMS Disorders

Intrinsic Factors—non-modifiable Gender—more problems in female than male instrumentalists

Related to smaller average size of the female hand and fingers Related to smaller bulk and cross-sectional dimensions of female

muscles Females have higher vocal ranges than males

Anatomy—factors like height, hand size, lung capacity, and joint hypermobility may affect the way students play certain instruments as well as the choice of repertoire Singers—factors = lung capacity, vocal range, tessitura, timbre Affect assignment of voice parts and songs singers are expected

and selected to sing Since anatomy cannot be changed, technique and an approach

to playing and singing music must take anatomy into account


Intrinsic Factors—modifiable Alignment—poor posture can increase risk of injury

Involves good balance and body positioning Quality of movement—micro and macro movements affect the

quality of sound High levels of body awareness are needed to avoid bound, stiff, or

limited movements that can lead to injury Stress and psychological health—injuries/pain more likely if

musician is under stress and/or depressed NMS problems can lead to depression Psychological health is important for overall physical health

Motivation and effort—improving muscle strength and endurance require motivation and consistent effort Exercise and conditioning are important Musicians may seek guidance from physical therapists, somatic

educators, vocal coaches, and other healthcare specialists


Extrinsic Factors—non-modifiable Assigned musical repertoire—certain musical pieces pose particular

physical and vocal challenges Venue—once selected, the setting for performance/rehearsal can make

injury more or less likely Acoustics, temperature, lighting, and seating affect performance

Instrument—though some instruments can be modified somewhat, some characteristics cannot be changed Frequency of injury is higher for instruments that require many repetitions

of finger action and for instruments that must be held in difficult postures Large instruments may involve more problems

Wider stretches for keys, strings, and valves Greater muscle tension and increased use of the smaller and weaker

hand muscles More difficult to play quickly because of great size and complexity of

keywork and valve travel or greater space between strings and fingerboard


Extrinsic Factors—modifiable Time spent playing or singing—the single most important risk

that can be managed by musicians is TIME (i.e., practicing; frequency and nature of rest breaks during practice sessions; how quickly one increases practice time when major performances are approaching; how one approaches more technically demanding passages)

Non-music related activities that can involve overuse or misuse Fitness and conditioning activities, such as sports participation,

especially if overdone or done incorrectly Excessive use of certain electronic devices, such as computers,

tablets, cell phones, and gaming systems Loud social events and those in which cigarette smoke or alcohol are

involved pose serious risk to vocal health Some forms of outside employment may involve excessive or

improper use of the NMS system

NMS Issues Affecting the Body

Muscle Pain—principal cause is sore muscles May be related to overuse, misuse, abuse, postural factors,

tension, technical problems, or poor conditioning When muscles get fatigued and are placed under further

stress, microscopic damage and disruption of muscle fibers can occur (called “muscle strain”) Muscle contraction involves specific chemicals

When in short supply, optimal efficiency is lost Muscle contraction produces lactic acid; if this accumulates, it

decreases the muscle’s ability to continue efficient contractions Muscle strain and incorrect muscle contractions can lead to

pain Playing-related NMS disorders at all ages are more commonly

seen in shoulders, neck, hands/fingers/wrists, and lower back Specific locations may be related to specific instruments


Neuropathies—a general medical term meaning “diseases or malfunctions of the nerves.”

Classified according to types or location of affected nerves.

Focal neuropathy—restricted to one nerve or group of nerves or to a particular area of the body. Symptoms may appear suddenly and include pain, sensory

disturbances (e.g., numbness, tingling, “pins and needles,” burning, itching) and weakness

May occur at site of nerve compression or entrapment in extremities

Entrapment = compression on the nerve as it passes through a narrowed channel bound by bone, fibrous bands, bulky muscles, or enlarged arteries

Three Most Common Entrapment Neuropathies

Carpal Tunnel Syndrome—median nerve (runs from forearm into palm of hand) becomes pressed or squeezed at wrist Carpal tunnel—a narrow, rigid passageway of

ligament and bones at the base of the hand containing the median nerve and several tendons

When tendons are irritated or strained, they may swell and narrow the tunnel compressing the nerve and causing pain, weakness, or numbness in the hand and wrist that radiates up the arm


Ulnar Neuropathy—ulnar nerve (runs from neck along the inside edge of the arm and into the hand on the side of the pinky finger) becomes inflamed due to compression of the nerve Symptoms include tingling, numbness, weakness, and

pain, primarily along the elbow, the underside of the forearm, and along the wrist or inside edge of the hand

Often linked to repetitive wrist or elbow movements—e.g., sustained elbow flexion among players of bowed instruments can contribute to this condition in some cases


Thoracic Outlet Syndrome–a group of disorders that occur when the blood vessels or nerves in the thoracic outlet (the space between the collarbone and the first rib) become compressed Most often the result of poor posture Can be caused by constant muscle tension in the neck

and shoulder areas Symptoms include pain in the neck and shoulder areas

and numbness in the fingers


Dystonia—disorder of sustained muscular contractions, producing unwanted movements or abnormal postures Focal dystonia—affects a particular area of the body More prevalent in men (genetic or hormonal factors may

be involved) Repetitive movements, especially those that are painful,

seem to trigger it In musicians, symptoms usually appear in upper limb for

keyboard, string, percussion, and woodwind players or in embouchure in brass and some woodwind players Right hand of keyboard players and left hand of string players

most commonly affected

NMS Issues Affecting the Voice

Phonatory Instability Phonation—process by which air pressure generated by the lungs is

converted into audible vibrations “Voicing” occurs when air from the lungs passes along the vocal

folds at the base of the larynx causing them to vibrate Production of a tonal, pleasant voice with smooth changes in

loudness and pitch depends upon the symmetrical shape and movement of the vocal folds

Phonatory instability occurs when there is asymmetrical or irregular motion of the vocal folds that is superimposed on the vocal fold vibration–often manifests itself as an unsteadiness, hoarseness, or roughness of voice (long or short-term possible) Short term causes include fatigue, certain medications, drug use, and

anxiety—to eliminate these, the causative agent must be removed Over-the-counter medications, antidepressants, and highly caffeinated

drinks can cause vocal tremors—a form of phonatory instability

NMS Issues Affecting the Voice

Vocal Strain—overuse of the voice (singing or speaking) can produce this Singers must exercise caution when singing at the

extremes of the vocal range Misuse can also occur

Examples = attempting repertoire beyond vocal maturity/development and improperly learning and practicing certain vocal styles

Prolonged overuse can lead to development of vocal nodules (i.e., soft, swollen spots on the focal folds) As abuse continues, nodules become callous-like growths Require specialized and prolonged treatment and

rehabilitation Can have grave consequences for singers

Basic Protection for All Musicians

Avoid situations that put your NMS health at risk.

Refrain from behaviors that compromise your NMS health.

Warm up before practice and performance to mobilize muscles and joints and increase blood flow to body parts being used in performance

Lubricate the vocal folds. Drink water.


Take breaks from practice and rehearsal whenever possible (rule of thumb—5 minutes of rest per half hour).

Avoid excessive practice time and stress.Set daily practice limits and vary repertoire

during practice sessions.


Avoid excessive repetition of difficult repertoire, especially if progress is slow.

Avoid repertoire that is beyond your technical or physical reach.

Refrain from sudden increases in practice times; slightly REDUCE practice time before juries, recitals, etc. to allow mind and body adequate energy for performance.


Ensure proper body alignment and technique. Be mindful of balance and weight distribution Ensure adequate freedom of movement and support

during practice and performance Use external support mechanisms, such as shoulder rests,

neck straps, and flute crutches, when necessaryMaintain good “mental hygiene.”

Get adequate sleep, good nutrition, exercise, time with friends and family

Manage stress; make time for relaxation Refrain from hazardous activities or recreational drug use Seek help of mental health professionals, if needed

Vocal Protection

Drink plenty of water—vocal folds need lubrication. Drink 8 glasses a day

Avoid and/or limit caffeinated and alcoholic beverages.

Do not smoke; avoid secondhand smoke.Be aware that some medications, such as

allergy pills, may dry out your vocal tissues. Stay well hydrated if you use them Check with your doctor if you have questions

Vocal Protection

Avoid dry air environments, and consider using a humidifier at night.

Avoid yelling or raising your voice unnecessarily.

Avoid throat clearing and voiced coughing.Use vocal amplification systems when

available and appropriate.Rest your voice, especially if you are sick.

Give yourself time to recover.

Marching Music—A Special Consideration

Marching requires: Playing an instrument while also moving along a

street or across an athletic field, often rapidly with irregular movement patterns

High levels of physical conditioning, strength, and endurance

Good general health and physical fitness Great physical demands on neck, torso, lower back,

and legs from carrying heavy instruments


Marching activity-related physical disorders include: Sprained ankles Toe contusions Knee strains Sunburn and dehydration (esp. in summer heat)


Marching requires: Physical warm-up Times of rest and rehydration Appropriate sun protection Appropriate ear protection, if needed

Basic Things Musicians Need to Know and Do

Understand and share with others risk inherent in excessive and improper NMS use while playing and singing music, including the risk of prolonged or permanent damage

Recognize that playing and singing music in inappropriate ways or for extended time can cause playing and singing-related NMS disorders

Basic Things Musicians Need to Know and Do

Monitor practice time and intensity, choice of repertoire, and playing/singing techniques to prevent development of playing- and singing-related disorders

Apply health knowledge to specific musical context– practice, performance, production, education, competition, and listening

Documents

STUDENTS Basic Information on Neuromuscular and Vocal Health