Health Problems of Musicians

Singers

“Physician interest and involvement in the voice dates back at least to the time of Hippocrates in the fifth century B.C. His Corpus Hippocraticum provides some of the earliest medical speculation on the workings of the voice, recognizing the importance of the lungs, trachea, lips, and tone in phonation. Aristotle noted the role of the voice in emotional expression. Claudius Galen, who practiced from 131 to 201 A.D., is hailed as the founder of laryngology and voice science…Major advancement...[came with] the Renaissance with the writings of Leonardo da Vinci…Advances [also] occurred in the East, particularly in the ninth century, when Rhazes the Experienced in Baghdad described disorders of the voice and recommended respiratory and voice training.” From “The Evolution as Seen Through Literature”. Harman, Susan E. IN Textbook of Performing Arts Medicine. New York, Raven Press, 1991.

In modern times, Manuel Garcia, an opera singer born in 1805, became a teacher because he developed problems through poor technique and excess singing. He used a dental mirror as a way to indirectly view the larynx and vocal cords, a method still used today. High-tech examination methods are now available to otolaryngologists, including strobovideolaryngoscopy and electromyography.

Sound quality of the voice comes from the larynx, tongue, lips, palate, pharynx, nasal cavity, and the locations and positioning of these vis-à-vis one another. Minor changes in any of these organs or their positions can affect quality of the singing voice. Consider the hypernasal speech from a cleft palate or hyponasal speech with greatly enlarged adenoids (Julia Child).

Singers’ voices, being a part of the body rather than a separate instrument, are vulnerable to almost all possible changes in the body. Of course, throat, mouth, nasal, neck, and lung problems have the greatest effect.

Singing teachers are a mixed bag, some great, and some who can ruin a career, with most fair to middlin’. Changing teachers, even if from a mediocre to a much superior teacher, can temporarily cause problems as the singer learns new ways. Young and beginning singers can be tempted to sing roles beyond their training and vocal maturity; most Wagner operas and some Verdi roles require sustained breath control and maximal volume production, and the somewhat looser vocal mechanism that comes with maturity and training.

Singers vary in the amount of muscle tension in the larynx, jaw, and other structures. Too little tension results in lack of control of the tone, but paradoxically, too much tension can also interfere with control. The ideal is to have good breath support using the abdominal and intercostal muscles, with the jaw loose, and throat and larynx only as tense as is required to produce a given pitch. In addition, as the pitch rises, the vocal cords must shorten to produce the pitch, and the opening in the surrounding tissues becomes smaller. Amateur singers will correspondingly tighten their throat muscles and general and a number of years of training are often necessary to overcome this tendency.

The type of singing also affects muscle tension. Classical singers have lower muscle tension scores than is true of other types of singers. Within classical music this also varies with the type of singing. Choral singers are the most relaxed, followed by art songs and operas, the last requiring singing over an orchestra and other factors mentioned in the next two paragraphs. Singing jazz or pop results in more muscular tension, musical theater more yet, then bluegrass/country/western, and the highest muscular tension is recorded in rock and gospel singers.

Stage singing presents various challenges. Concert and operatic singers preparing for performance often are learning new music and rehearsing extra hours. Operatic costumes can be heavy, and stage blocking can require the singer to sing from awkward body positions. Leg and back injuries can interfere with mobility, as well as throwing off a singer’s preferred stance when singing, which results in throat tension and breath control problems.

There is also the “Lombard effect”, in which a singer accustomed to singing a cappella or with piano accompaniment, upon singing with an orchestra, ratchets up the volume to achieve the same vocal feedback to his/her ears. Pop singers are especially vulnerable to this problem. Monitor speakers which direct the sound back to the stage can help. “ Las Vegas voice” is a term coined to mean singing in dry conditions, with overamped bands, and sidestream cigarette smoke.

Needless to say, smoking is extremely damaging to oral, lung, and throat mucosa, and is entirely contraindicated for singers. To the extent possible, sidestream smoke should be also avoided. Smoking marijuana, which is unfiltered, is particularly toxic to the larynx and vocal folds. However, Dr. Robert Thayer, author of the chapter “Care of the Professional Voice”, in Medical Problems of Performing Artists, referenced above, advises that if singers refuse to give up marijuana smoking, they at least use a water pipe!

Singers who conduct can strain their voices by singing along with different parts and demonstrating the correct note sequences or correct technique, often in varied registers according to the part they are demonstrating. Teaching from a keyboard with constant turning of the head and neck to see students, can be wearing. Singers also need to remember to carry good singing techniques over to speaking. Many Americans speak at a lower pitch than is optimum for their voice, and with a tight jaw. Especially when preparing for performances, or in less than optimal health, “Don’t say a single word for which you are not being paid” is advisable, as well as avoiding phone use. Cheerleading and/or yelling at games are absolutely verboten!

Singers have been prescribed various drugs to ease performance anxiety. Propranolol and other beta-adrenergic blockers have been used but they dry the throat. Tranquilizers can produce confusion and memory difficulties, and antidepressants can also produce dry mouths and throats. Diuretics are also problematic for this reason. Singers should avoid aspirin products if possible as they can cause submucal hemorrhages in the vocal folds.

Alcohol in small amounts, say one glass of wine on a performance day, may actually be helpful, but alcohol addiction will ruin a career due to well-known adverse effects. Cocaine is particularly problematic for singers with its drying effects. Any substance which impairs clarity of thought will adversely affect performance.

Singers are subject to the inevitable changes with aging such as weakening of the vocal folds and surrounding musculature, or arthritis in surrounding supporting structures. Neurological problems which cause tremor will also affect vocal control. Hearing loss makes matching of pitches difficult. Hormone changes affect both sexes, as does hypo- or hyperthyroidism. and in women the phenomenon known as “laryngopathia premenstrualis”. Birth control pills may affect vocal tone. Estrogen-alone pills are contraindicated and estrogen-progesterone combinations are best. They should not be used to postpone periods before performances. Androgen should never be prescribed for singers. During the later stages of pregnancy breath control is problematic, and vocal quality may be affected. (This writer’s mezzo-soprano mother, who had four children, reported that she actually gained a high note per child!)

Temporomandibular joint dysfunction (TMJ) problems can cause headaches, and affect production of a free, relaxed tone, and singers are prone to this because they will hyperextend their jaws either downward or forward. Jaws can actually lock in place. A rock star was capable of opening his jaw to 77 mm; his jaw would lock open in performances, at which point he would turn his back on the audience and the percussionist would place his jaw back in the correct position.

Singers need to be careful about diet and exercise. Being fit is necessary for the best breath control. Eating a heavy meal immediately pre-performance will make good breath support difficult. Weight control is important as obesity interferes with breathing, and the diabetes which can accompany obesity will often produce dry mouth and reduce the energy needed for stage performance. If weight loss is needed it should be gradual as sudden losses affect vocal quality. Milk products make the throat temporarily phlegmy, and spicy foods and coffee can contribute to gastroesophageal reflux which irritates the vocal folds and surrounding tissues. Singers should avoid eating for several hours before retiring to bed. Singers with asthma and other allergies need to be treated as uncontrolled allergies really affect breathing, and are easily exacerbated by dusty stages and dressing rooms. Mold can be present on inadequately cleaned costumes and in areas with damp climates.

Upper respiratory tract infections are problematic for all musicians but particularly so for singers. Infections concentrated in the nasal and sinus areas will affect tone somewhat but otherwise do not interfere with singing per se, but chest infections make good breath control difficult, and throat infections and laryngitis directly affect the singer’s instrument. Heavy singing at such times can result in lesions to the cords or even paralysis. Ability to sing loudly, hoarseness, changes in timbre, and breaking into different registers are all likely. (The writer has had personal experience when during a severe bout of laryngitis, she attempted to sing a note, the result being two separate pitches, neither euphonious, and neither the pitch she intended to produce.)

Treatment with broad-spectrum antibiotics or penicillin and its relatives, does not normally cause problems, unless the singer is allergic. Corticosteroids can be used for severe health problems when performances are imminent, but should be prescribed sparingly and carefully. Singing with severe infections, or singing too loudly over prolonged periods, or with poor technique such as excessive throat tension, can result in the singer’s most dreaded malady: “nodes” or nodules on the vocal folds. Throat or vocal fold hemorrhage is possible in singing with infections or massive oversinging. Rest is the only remedy for hemorrhages, and the best remedy for infections and nodules, but the latter may require surgery. Surgery can be successful but must be very carefully done, and singers need topflight instruction in good vocal technique both before and after the surgery. Also, other surgeries such as tonsillectomy and thyroidectomy need extreme care. Intubation causes trauma to the soft tissues in the throat and will adversely performance for some weeks afterward. 

Famous singers who have had problems

Julie Andrews performed while “singing over a cold” a few years ago, with the result of nodule formation. She had surgery in 1998, but it was unsuccessful, reducing a four-octave range to that sung by a choral alto. She is still not singing.

Maria Callas had an operatic career spanning from 1941 to the mid-1960s. She developed vocal problems in the late 1950s, which her accompanist Robert Sutherland said were due to her overworking her voice. She did manage, however, to reprise Tosca in the 1960s, probably her signature role and her first role at La Scala in 1941.

Jose Carrera has survived lymphoblastic (lymphocytic) leukemia, of which the first symptom was persistent bleeding and infection in his gums. This was discovered in 1987; he spent four months in a Barcelona hospital, and then several months more in Seattle where he received a bone marrow transplant. The latter was successful; he made a triumphant return in 1988, and continues his career to this day.

Enrico Caruso had several health problems. A notable incident took place on December 11, 1920, in which he suffered bleeding, either from the throat or the lungs, while on stage singing in “L’Elisir d’Amore”. His health deteriorated after that and his final performance was two weeks later on December 24, 1920.

Beverly Sills is very highly regarded as one of America’s divas. She retired in 1980 at age 50, saying that she “wanted to go out on a high note”. She was a coloratura, the lightest soprano voice. During the 1970s she decided to go beyond the usual coloratura repertoire, and tackled heavier roles such as Violetta in Verdi’s “La Traviata”. Consequently she developed a “wobble”, with thin an undependable high notes.

String Players

“There is…little relationship between the physical activities of the right and left arms and hands of string players. The fingers of the left hand are in relatively constant movement, flexing and extending, abducting and adducting, while the fingers of the right hand are in continuous flexion but are relatively stationary in guiding the bow’s traversal of the strings. The arms do not move through the same planes, at the same speeds, or require equal amounts of tension and motion.” Alice G. Brandfonbrener, “Epidemiology of medical problems”. IN Textbook of performing arts medicine. Robert T. Sataloff, Alice G. Brandfonbrener, Richard J. Lederman, eds. New York, Raven Press, 1991. p.46.

65% - 70% of string players report having musculoskeletal problems; this is the highest percentage of all orchestral players.

Bass violin players experience the most back problems of orchestra players. All parts of the back are affected, upper, middle, and especially the lower back. Musicians of all heights are affected but in different ways. Compression of the left sciatic nerve is also a likely problem because many bass players sit on stools to play, with right legs extended for balance and left legs crooked on the stool rungs, to support the instrument. Exercise is helpful to prevent or treat this problem. End pins can also be adjusted to the height of the player. However, changes in end pins, and in chin rests for violinists and violists, can lead to problems.

For violinists/violists, shoulders, arms, and necks are the problem areas. With left shoulders, problems develop due to maintaining a static position and supporting the instrument. Right shoulder problems come from the somewhat unnatural position the arm must assume, and from pushing the bow back and forth.

Tendinitis of the rotator cuff can occur, due to long hours of playing or excessive tension in movements. Nerve impingement or entrapment problems can also arise. Sometimes inherent structure of the shoulder causes problems. “Droopy shoulders” (long sloping shoulders and a long slender neck) make playing difficult due to the angle which the chin and shoulders must assume to stabilize the violin or viola; this problem is especially likely in females.

The method of bow grip can cause problems in all string players. Cellists and bassists may suffer pain or numbness in the tip of the right thumb.

Electric bass guitar players have an even greater likelihood of problems. Plucking versus bowing is more difficult on fingers, and the thicker strings of bass guitars are more difficult to pluck than those on lead guitars. Size and weight of instrument are problematic, even with shoulder straps.

Classical guitarists actually present with more problems than pop or rock guitarists. Much more complex passages need to be plucked, and classical players do not generally use neck straps. They play sitting, with the left foot elevated on a small stool to support the guitar; this position creates a downward and forward slope of shoulders.

All guitarists use hyperflexion of wrists, and flexion of left fingers across strings, causing tension problems. The size of the players versus their instruments may cause difficulties.

Nerve entrapments or focal dystonias may become apparent. Players will initially notice tingling, heaviness, coldness, tightness, or lack of flexibility in fingers or hands. If no changes are made, pain and loss of response and control can ensue. If these problems are ignored, the result may be thoracic outlet syndrome or nerve root compression in the neck. Carpal, median, cubital, and ulnar nerves are all subject to entrapment problems.

Surgery is often successful, but conservative measures such as different chin rests, playing positions, or techniques, and massage with pressure point therapy may help, with use of ice packs and non-steroidal antiinflammatory drugs. Biofeedback has also been successfully tried. And rest, partial or complete for a period, is essential. Some players use special splints.

“Trigger finger”, or difficulty extending fingers from a flexed position is possible. Ganglions (cystic structures) can arise in wrist areas. They can be painful, and if large enough can interfere with wrist, hand or finger movements. Joint changes from osteoarthritis are also painful and can interfere in playing rapid passages or holding sustained positions.

Finger dystonias can make even tremolos and good vibrato for violins/violas difficult or impossible, and can impair fast plucking for guitarists. Guitarists may al have problems with flexion of the third finger. Diseases such as multiple sclerosis or Parkinson’s can lead to early career termination.

“Fiddler’s chin” or ‘fiddler’s neck” can cause acne or scarring on the chin, or contact dermatitis if the player is allergic to substances such as terpentine or ebony in the chin rest. “Cellist’s chest” (or “cellist’s scrotum”) or “guitar nipple” can result from contact with woods, varnishes, or terpentine in the instrument. All string players can develop an allergy to particular resins in the instrument or bow.

String players also develop calluses on the left fingers, and in guitar players, on the right fingers as well from plucking. Calluses can become thick and overgrown, catching upon strings, causing cracking and infection. Some people never form calluses and have pain always with picking. Artificial substances such as Nu Skin® may be used as substitutes.

String players suffer hearing loss. Players in rock bands develop hearing loss due to high decibel levels in performances. Violinists/violists will lose hearing especially in the left ear as that ear is closest to the strings on the instrument.

Horn Players

Problems experienced by horn (brass and woodwind) players which affect their careers fall into the following categories: visual, cardiothoracic, musculoskeletal, teeth and jaw, and probably most important, lip and embouchure problems.

Visual

Players who put in many hours daily of practice or performers, especially with those instruments requiring high intraoral pressure such as oboes, will suffer subtle losses in visual fields over a long career.

Cardiothoracic

A persistent myth holds that the wind pressure needed to produce good tone has led to emphysema, but even as early as 1874 this was disproven in a study by WH Stone. However, uncontrolled asthma can certainly make horn playing difficult or impossible, and emphysema would end a career.

French horn players have been reported to experience cardiac arrhythmias because of abrupt changes in cerebral and systemic vessels when playing. Hernias and hemorrhoids in horn players have been anecdotally reported. Laryngoceles (laryngeal mucosa herniated through the thyrohyoid membrane) can occur in wind players. Pneumothorax or air leaking from the lungs into the chest cavity, causing collapse of the lungs, presumably from heavy pressure generated by playing, has been reported. Oboists can induce aValsalva maneuver, temporarily halting the heartbeat, with possible loss of consciousness or syncope.

Smoking is obviously contraindicated due to deterioration of pulmonary function and reduction of resistance to infection.

Musculoskeletal

35% of brass players report severe musculoskeletal problems in the upper torso, shoulders, and neck in ICSOM survey. This is especially likely to occur in young men “macho” players who like to show off instruments and technique. Shoulder problems occur in all horn players. Tendinitis and nerve compressions, especially the ulnar nerve, but also the carpal and cubital nerves, are common.

All woodwind players are subject to repetitive use injuries in fingers. Some wind players’ hands will involuntarily lift off the instrument while playing slow scales. Trills can be a particular problem. Arthritic changes with aging will also make playing difficult. Continuing to play after onset of symptoms can result in carpal tunnel syndrome or disabling wrist tendinitis.

Clarinetists and oboists have more right hand problems, especially in thumbs which support the load of the instruments by hooking under a ½ inch-wide supporting ledge on the back of instrument. Short thumbs and fingers lead to placing the load on the thumb tip rather than on the intraphalangeal joint. Clarinets have also become heavier: in the 19 th century they weighed about. 300g, but to achieve more range, clarity, and brightness of tone, they were enlarged and now weigh about 830g.

Flute and piccolo players have more trouble with left fingers, hands, wrists, arms, shoulders, and necks, due to the abnormal hyperextended position of the left wrist. Problems are exacerbated by unusually short arms or fingers, or poor technique.

Straps have been suggested for the clarinet to relieve pressure on the right thumb. In 1988 Richard Norris, M.D., invented a “flute rest” for problems with the left index finger, and also an “angle-headed flute”, called the “Swan Neck Flute”, which reduced neck problems resulting from tilting the head to play. For more information about this, and for illustrations of four different versions of this flute, visit http://www.flutelab.com/swan/swanintroduction.htm

Other than possible alterations of instruments, the best remedy is prolonged rest until symptoms abate. Also, “sensory motor retuning” (a form of biofeedback) has been tried with some success.

Teeth and jaw problems

Although there is debate in the musical community about the possible effects of orthodontia on playing, playing horns, especially sustained practice of six or more house daily, does create back pressure upon teeth, up to 500g (100g pressure is sufficient to begin to move teeth).

Lack of posterior teeth or poor-fitting dentures for wind players with consequent pressure sores, contribute to playing problems. If dentures are needed, the best dentures are osseointegrated implants, used with soft acrylic denture aids. If dental surgery is necessary, great care must be taken so as not to harm embouchure, for all types of horn players. Woodwind players should avoid playing for at least two weeks after tooth extraction. Also, wind players are advised to have teeth casts made in case of injury.

Horn players also suffer from TMJ (temporomandibular joint dysfunction) problems. Wind players rest instruments on their jaws, possibly contributing to TMJ problems.

Bruxism or teeth grinding can make TMJ problems worse and can alter occlusion (teeth placement and bite), which can in turn affect ease or difficulty of playing).

Fun factoid to know: different patterns of muscular force required for each wind and brass instrument. Teeth placement and jaw structures can play an important role as to which instrument a person can most successfully play. For example, clarinetists benefit from a narrow upper dental arch and a high palate. Oboists and bassoonists do better with a somewhat protruding lower jaw.

Embouchure and lip problems

Embouchure comes from French and means ‘mouthpiece’. In musical terms, it also means the way a horn player must position the lips, teeth, and jaws to achieve the best tone on the particular instrument. A good embouchure is absolutely essential to horn playing.

Brass instruments must be able to use both lips to form a good seal. Neurological problems caused by pressure of the mouthpiece or intraoral pressures can lead to involuntary upward pulling at lateral corners of the mouth, tremors of the lips, or “puckering out” of both lips, all of which destroy the air seal or make it difficult to form. Good embouchure necessitates in producing up to 130 mm Hg intraoral pressure without leakage, as opposed to at most 6 mm Hg in normal speaking. Rupture of the orbicularis oris muscle, a muscular ring in the lips responsible for forming the embouchure, can end a career, although surgery has been successful.

Other lip problems horn players suffer include: sores from crooked or jagged teeth, problems from traumatic injuries, and allergies.

Lip shields are advisable for crooked or jagged teeth. 36% of horn players report lip discomfort from sharp teeth; 81% of single-reed and 77% of double-reed players report such problems. Traditionally musicians have used tape, cigarette paper, or pieces of rubber glove as lip seals, with mixed success. The best are clear vinyl plastic shields, custom-made, obtained from dental laboratories

Leakage of saliva leads to a form of acne on the lips. Leakage and/or allergies also lead to maladies described by such colorful terms as “clarinetist’s cheilitis” or “flautist’s chin”, both contact dermatitis inflammations due to allergies. Allergic reactions occur to exotic woods used for reeds by wind players, or to nickel or occasionally other metals used in mouthpieces of brass instruments. The latter problem can usually be resolved by gold or silver plating of the mouthpiece.

Sharing mouthpieces also contribute to transmissible diseases such as herpes labialis, the common cold, hepatitis, and other bacterial or spirochetal infections. Fungal spores can lurk in bagpipes but there are no known cases of transmission between individuals using the same bagpipe.

Health Problems derived from Harp Playing

A tomb painting of the ancient Amarnian ruler Pa-Aton-Em-Heb (1350 BC, Eighteenth Dynasty) appears to indicate that harpists are susceptible to occupational illnesses. The harpist in question has slightly closed eyes with swollen eyelids, and he seems to stare into space; his shoulders are round and his face emaciated. His temple is heightened and hollowed by a broken line joining the end of the eyebrow with the corner of the eye. These clues suggest the harpist depicted was a victim of temporal arthritis associated with polymyalgia rheumatica.

In 1988, a group of prominent researchers conducted a study on musicians’ health in which they surveyed 4,025 symphony orchestra members. This group constituted a representative sample of 47 major orchestras in the United States. Two of the researchers, M. Fishbein and S. E. Middlestadt, divided their results among instruments, including the harp. Of all harpists, 55% perceived significant occupational stress, and 93% of harp soloists experienced some form of stress. These are the highest figures for all instruments. The findings led to the conclusion that, in general, but especially in harpists, there is a strong correlation between job stress and the incidence of mental and physical problems among symphony musicians,.

Some of the problems posed by the modern pedal harp can be said to be: First and foremost, the size, shape and weight of the harp combined with the predominance of females among professional harpists poses logistical transportation problems. Also, the necessity to frequently tune the large number of strings in the harp causes problems of the right wrist and hand. These are problems before the artist even starts to play! Once the playing starts, although the instrument is tipped back into its playing position, the intent is to have it balanced without actually resting any weight against the right shoulder. Occasionally this balance is not achieved, creating a number of subsequent muscular problems, primarily with the right shoulder and upper arm. The arm stretches required, and the simultaneous use of both hands and feet can present particular overuse or fatigue problems.

Erzsébet Gaál in a questionnaire distributed to harpists in 1997 confirms that besides moving the harp, problem areas for harpists are the back, the shoulder, and the neck. The responses to the questionnaire also revealed that almost half of the harpists who replied, ranging in age from 31 to 40 and who had played the harp for a span of 11 to 20 years, felt that they had reached the zenith in their harp playing and were on a decline because of physical and mental disturbances. One harpist said, “I have noticed that as I am getting older, my body needs more warm-up and stretching in order to play harp pain-free. It would be valuable to learn these habits in school, so that when you really need it, you already have established good work habits and can avoid injury.”