Health Problems of Performing Artists

“It is difficult to think of any activities that make greater demands on the nervous system than the performing arts. Virtually all forms of music, dance, and the dramatic arts require an extraordinary level of sensorimotor control, precision, speed, endurance, and in some cases strength. The qualities of artistic sensitivity, interpretation, and creativity must be combined with the above largely executive functions under the most stressful circumstances – performance before an audience including one’s peers and critics.” Richard J. Lederman. “Neurological problems of performing artists.” IN Textbook of Performing Arts Medicine. RT Sataloff, A Brandfonbrener, R Lederman, eds. Raven Press, NY, 1991.

As is true of all humans, health problems occur in musicians and dancers, but performance artists that force different parts of their bodies to go through strenuous repetitive training have certain problems unique to their professions. Other problems common to us all, which may seem no more than minor inconveniences to most people, can be major afflictions to performing artists, sometimes even career-ending.

Brief History

The first known description of occupational overuse is believed to have been penned in 1713 by Bernardino Ramazini in a book entitled Diseases of Tradesmen. His description included the following: “rupture of the groin…distentions of the head, palpations [sic] of the temples, pulsations of the brain, inflations or swellings of the eyes and tingling in the ears…ruptures of the vessels of the breast…fatigue of the lungs.”

Well-known physicians of the 19th century treated authors for writer’s cramp, a term used even then, and noticed that pianists and other instrumentalists seemed to have similar afflictions. Sir William Osler defined muscle disorders affecting various occupations as follows: “The continuous and excessive use of the muscles in performing a certain movement may be followed by an irregular, involuntary spasm or cramp, which may completely check the performance of the action.” Smith Ely Jelliffe said: “…the chief factor beyond all others is the frequent and continuous use of certain muscular movements in an occupation beyond the natural capacity of the individual to stand the strain”, thus recognizing that individuals differ in the degree of likelihood to develop problems.

The terminology has varied over the years. Terms used have included craft palsy, occupational overstrain, fatigue disease, overuse, musician’s cramp, violinist’s cramp, pianist’s cramp, etc. Also used were occupational neurosis or exhaustion neurosis, but in the 19th century the term neurosis meant a neurological problem rather than a psychological problem as the term is used today. Personal favorite: “professional impotence” a term used by Guillaume-Benjamin Duchenne in 1861

In 1932 Kurt Singer wrote Diseases of the Musical Profession : a Systematic Presentation of their Causes, Symptoms and Methods of Treatment. He suggested reduction in practice time (!) for nervousness. He wrote about all types of performers and noted many ailments, such as laryngitis, dental and vision problems. He equated “enlargement of the lungs” of wind players with emphysema. Later studies, however, have not shown an increase of emphysema in wind players.

In 1934 the International Labour Office of Occupation and Health’s Encyclopedia of Hygiene, Pathology and Social Welfare devoted two chapters to musicians.

During the 1980s interest in performing artists’ problems increased dramatically. Realization of performing artist problems came to public notice with the publication of the New York Times article “When a Pianist’s Fingers Fail to Obey”, written by Dancer/freelancer Jennifer Dunning, where she described Gary Graffman’s and Leon Fleischer’s injuries. In 1983 Hunter J.H. Fry, Australian physician, founded the Performing Arts Medicine Society, a section of Australian Medical Association. He also devised various methods to try to reduce mechanical strain. The first issue of Medical Problems of Performing Artists appeared in 1986. The American Occupational Medical Association established an Arts Medicine Section in 1987. In 1989 the Performing Arts Medicine Association was formed. Also in 1989, the Association of Medical Advisors to British Orchestras was established. The latter organization invited physicians to become specially trained in problems of performing artists.

Overview of Health Problems

Performing artists have problems in the following areas: dermatitis, nerve compression syndromes, occupational cramps, intraoral pressure problems (trumpets, trombones, tubas, oboes), cardiac abnormalities, vision and hearing problems, and miscellaneous ailments.

In 1963 ICSOM ( International Conference of Symphony and Opera Musicians) began publishing a journal, Senza Sordino This journal, focuses on articles of interest to musicians, from time to time about health problems.

In 1978 a study by the National Institute for Occupational Safety and Health (NIOSH) appeared in Senza Sordino. It ranked the stress level of occupations, with musicians recorded at an unenviable 5 th of 130 occupations. And in 1988 ICSOM published the results of a study in Senza Sordino. This 1986 study showed that 82% of performing artists have had medical problems at some point in their careers. Of these, 76% said the problem(s) severely affected performance. 78% of string players reported suffering from painful musculoskeletal problems.

Stage performance carries certain risks: outdoor performance problems such as insect stings, excessive cold and heat and lack of reverberation feedback for singers; falling stage scenery; visual difficulties due to special effects like fog and poor lighting, poor acoustics; and actually falling off stage. For a blackly humorous version of the latter, visit http://www.gofish.com/cnvVideoPlayer.html?gfid=17-1001066

Psychological problems

Performance and preparation therefor can be very stressful. Recording studios are a stressful environment due to the need for maintaining absolute silence apart from the music being recorded (pages must be turned in silence, no extraneous movements, etc.)

All performing artists are subject to performance anxiety. Disabling stagefright is reported by 24.7% of musicians experiencing psychological problems. They worry about problems with concentration, memory lapses, tremors (string players), breathing problems (singers and horn players), gastrointestinal problems, decreased salivation (singers and horn players), and palm sweating. In the 1970s propranolol began to be prescribed to counteract performance anxiety. But one of its actions is reduced heart rate, a problem for dancers. It also can cause dry mouth, as can anxiolytics and antidepressants. Phenothiazines (antipsychotics) are contraindicated because of the side effects of dry mouth, dizziness, movement problems with lips, and tremors.

39% of musicians report psychological problems. In addition to stagefright, 16.6% suffer from depression; sleep disturbances plague 14.2%; 13.2% experience acute anxiety. However, on a standard test, Symptom Checklist 90, musicians were recorded at lower percentages than the general population in the 9 categories measured, among them obsessive-compulsive disorder, depression, anxiety, and paranoia.

Mid-life problems experienced by performing artists are similar to those in the general population, but exacerbated by stardom achieved by some artists, as self-esteem may depend on receiving continued acclaim. Other artists can be disturbed by not having achieved hoped-for recognition. Fears of being overtaken by younger artists contribute. Burnout is a problem. Musculoskeletal and nervous system problems may force early retirement.

Vision and Hearing

Some vision problems are peculiar to musicians. Stage lights create a lot of glare. Bifocals may need different adjustments, with longer focal lengths needed by pianists and conductors, as well as possibly a larger near vision segment. Macular degeneration and neovascularization due to diabetes need to be treated with laser photocoagulation if possible. This is especially critical for horn players, as the act of blowing increases intraocular pressure, or dancers or stage singers who move around a lot.

Hearing problems are obviously critical for musicians, who need to reliably hear frequencies above that required by other people. Cochlear dysfunction can make reliable matching of pitches for singers and string players impossible. A study was done of 40 – 60 year old musicians who had been performing 15 to 25 years, playing an average of five hours per day. They showed hearing losses at 8000 and 10000 Hz. Hearing loss is not found in musicians with fewer than 10 years performing experience, but in 42% of those performing more than 20 years.

Concerns, well-placed, about hearing of rock musicians and listeners, have been reflected in the popular press. Rock bands can exceed 110 decibels in performance. But symphony orchestras, which can reach 90 decibels, are still loud enough to cause hearing loss, especially to musicians seated beside drums, trumpets, or bassoons.

Musculoskeletal and Nervous System

Musculoskeletal and nervous system problems include overuse, hypermobility, osteoarthritis, fibrositis, nerve entrapment, Thoracic Outlet Syndrome, and motor dysfunction. 62% of musicians suffer from these, usually in upper extremities for musicians and lower extremities for dancers. The size and weight of instruments can present problems for smaller performers. The average age of performers seeking treatment is 32, ranging from 10 – 80.

Focal dystonias (nerve problems in specific muscle areas) usually manifest due to one of more of the following situations: difficult passages being repeatedly rehearsed; an abrupt increase in rehearsal or practice time to prepare for a performance or audition; playing on a new instrument; beginning study with a new teacher; or a change in technique.

Sports injuries contribute to problems, as do outside jobs involving repetitive motions, or significant time spent doing word processing or other keyboarding on a computer.

Hyperextensible or hypermobile joints can be an advantage in playing, but excess laxity can lead to poor muscle control, greater likelihood of injuries, and an increase of arthritic conditions in later life. More than 20% of musicians have hypermobile joints, compared with 8% of the general population. Osteoarthritis appears in joints of 25% of performers by age 30, although not usually apparent to the performers under 35 years of age, with 40% being symptomatic by age 80. Neck discomfort afflicts 25% of musicians, especially violinists/violists.

For musculoskeletal/nervous problems, the best treatment is usually complete rest for a time period. If not possible due to career demands, resting periods in sessions are helpful. Good technique is essential. Other treatments include non-steroidal anti-inflammatory agents such as acetaminophen, splints, ice, exercise, adaptive devices such as shoulder straps, relaxation training, local injections of steroids, or surgery.

Longevity

Conductors in a 1980 study were reported to live longer than the normal population, probably due to the aerobic nature of their work. Our personal speculation is that empowerment due to control of an orchestra contributes to conductors’ longevity. Conductors’ career longevity is also greatest, followed by strings and keyboardists, then vocalists, with woodwind and brass players last among musicians, due to the huge demands placed on breathing capacity. And dancers have the shortest length of performing careers.

Does music increase the listener’s longevity? Much has been written as far as music’s effects on the developing fetus. As to the effects of music to listener’s longevity, there are no current statistics; however, the following gem provides a theory that listening to music may provide a balanced appreciation throughout life:

Mischa Elman, violinist, reportedly said at the end of his career: “You know, the critics never change; I’m still getting the same notices I used to get as a child. They tell me I play very well for my age.”