An Intensive Continuing Education Course to Enhance Care of the Performing Arts Athlete: The "Essentials of Performing Arts Medicine".

High occupational injury rates have been reported in performing artists, yet the quality of preventive and clinical care remains highly variable. Through the Athletes and the Arts collaboration, The Performing Arts Medicine Association, and the American College of Sports Medicine identified that health care practitioners' existing expertise should be enhanced to address the complex psychophysical needs of performing artists. In response, a 2-d continuing education course, "The Essentials of Performing Arts Medicine" (EOPAM), was developed and has been delivered at least annually since 2016. This course has been well-received by 149 physicians and 240 allied health professionals to date (average ratings, ≥3.5/5 from 2018 to present), with course quality significantly improved by a transition to online delivery in 2020 (average ratings ≥4.5/5; P < 0.01). Accordingly, EOPAM demonstrates that a brief continuing education course can enhance health professionals' understanding of the unique needs and demands of performing artists, addressing a key barrier to improved care.

Assessing Performing Artists in Medical and Health Practice - The Dancers, Instrumentalists, Vocalists, and Actors Screening Protocol.

ABSTRACT: Training in the performing arts exposes individuals to often extreme physical and psychological demands, which are linked to high occupational injury rates. The intense demands of performing artists have been likened to those of sport athletes. However, distinct differences in these demands necessitate specialized approaches to the health care of performing artists. Through the Athletes and the Arts collaboration, the American College of Sports Medicine and Performing Arts Medicine Association identified that the creation of a specialized preparticipation screening tool for performing artists would likely enhance health care for performing artists significantly. Based on a thorough review of established assessments and an extensive consultation process with domain experts, a consensus best-practice screening tool was developed: the Dancer, Instrumentalist, Vocalist, Actor (DIVA) Preparticipation Screening. This screening tool is modeled on the athletic preparticipation examination (PPE) in its structure and 30-min target duration. However, DIVA diverges considerably from the PPE in its content to address the specific risks and needs of performing artists. In particular, screening questions and physical examination procedures focus strongly on musculoskeletal injuries and mental health conditions, in response to the preponderance and interactions of these conditions appearing in performing artists. The DIVA tool presented is intended as a "living tool," which can be modified in the future to include new effective assessment techniques as appropriate. Training in the DIVA preparticipation physical examination is included as a core component of the essentials of performing arts medicine continuing education course described in detail in a companion manuscript in this issue.

Validity and reliability of the Musicians' Health Literacy Questionnaire, MHL-Q19.

High prevalence of musicians' physical and mental performance-related health issues (PRHI) has been demonstrated over the last 30 years. To address this, health promotion strategies have been implemented at some post-secondary music institutions around the world, yet the high prevalence of PRHI has persisted. In 2018, an international group of researchers formed the Musicians' Health Literacy Consortium to determine how best to decrease PRHI, and to examine the relationship between PRHI and health literacy. An outcome of the Consortium was the development of a new health literacy tool for musicians, the MHL-Q19, which drew from the theoretical framework of the European health literacy suite of tools, HLS-EU. The aim of the current study was to evaluate the validity and reliability of the MHL-Q19. Participants completed a battery of questionnaires, including the HLS-EU-Q16 for the assessment of general health literacy; the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians (MPIIQM); the RAND-12 quality of life questionnaire; and the General Self-Efficacy scale (GSE). We hypothesized that the MHL-Q19 would have a weak correlation with the HLS-EU-Q16; moderate correlation with the physical component scale and weak correlation with the mental component scale of the RAND-12; moderate correlation with the GSE; and finally, moderate correlation with pain interference and weak correlation with pain intensity of the MPIIQM. A total of 549 post-secondary music students from six English-speaking countries completed the battery of questionnaires, and 328 of these participants provided valid responses to the MHL-Q19 alone 2 weeks later. The tool showed acceptable internal consistency and test-retest reliability. Three of our hypotheses were supported, although the strength of the correlations varied from what we had predicted. The fourth hypothesis was not supported; our findings indicate that lower health literacy scores were weakly related to higher MPIIQM pain intensity and interference scores. The results of this study support the notion that musicians' health literacy is a distinct construct that cannot be fully evaluated with existing health literacy tools. Given that this is a new instrument, the evidence presented is positive and promising. Further studies will be needed to refine the tool.

Interaction between hand span and different sizes of keyboards on EMG activity in pianists: An observational study.

The availability of keyboards with reduced key width has been recently promoted as an ergonomic aid for small-handed pianists to overcome any potential physical disadvantages that may restrict their piano repertoire. However, a lack of biomechanical data exists to support whether reduced piano key size is effective in achieving this outcome. This research investigates the effect of playing on three different key width size pianos (5.5-inch octave, 6.0-inch octave and conventional size with 6.5-inch octave) on hand, arm and shoulder muscle activity levels according to the hand size of the pianists. Results indicate that piano key size affects the muscle activity levels of selected muscles. Furthermore, this effect of different key sizes changed according to the players' hand spans. Small-handed pianists may benefit from using smaller-sized keyboards to reduce muscular exertion during performance. This investigation provides preliminary EMG data supporting the use of different size keyboards to improve the ergonomic fit according to the dimensions of individual pianists.

The development and use of an anatomy-based retraining program (MusAARP) to assess and treat focal hand dystonia in musicians-A pilot study.

BACKGROUND: Movement dysfunctions are commonly reported in musicians, and in extreme cases may result in a persisting loss of motor control. This condition, whereby motor control of the hand during previously highly trained movements on the instrument is lost, is termed focal hand dystonia. It is widely considered to be a consequence of prolonged repetitive daily practice, often in combination with exposure to a range of other risk factors. Current literature recommends retraining as a promising treatment intervention, although only scant scientific evidence exists on which components should be included in a retraining program, and how these may be best administered. METHODS: A progressive muscle activation and movement exercise program was devised by one of the authors applying a series of anatomy-based off-instrument movement tasks. This series of fine motor control exercises, was used to both assess and retrain focal hand dystonia in a population of musicians. The standardized approach aimed to provide a systematic method of retraining musically relevant muscular synergies that could later be applied to the instrument, while still allowing individual modifications. Retraining sessions were mostly run online as a consequence of the coronavirus pandemic, although some early sessions were also able to be undertaken face to face. Both qualitative and quantitative measures were used in this case series to evaluate program efficacy, due to the typical heterogeneity of the focal hand dystonia participants. This included: blinded external neurological evaluation of video footage using the Tubiana grading system, written subjective feedback, exercise progressions, and performance outcomes. RESULTS: Pilot testing of 4 patients indicated the utility of the program over approximately a 12- month time period. All subjects improved, 2 of whom have returned to pre-dystonia performance levels. These patients reported the importance of patience and persistence with daily exercise sessions in their recovery. CONCLUSION: Using off-instrument playing-relevant exercises to enhance fine motor control and muscle activation can be effective in retraining focal hand dystonia, regardless of additional treatments or level of performance. They should be regularly practiced and progressed in order for effects to be best progressed to instrumental applications. Further research may elucidate whether there are optimal outcomes with single or particular combinations of treatment approaches.

Implementation of health education interventions at Dutch music schools.

A randomized controlled trial was conducted comparing the effects of a biopsychosocial course (PRESTO-Play) vs. physical activity promotion (PRESTO-Fit) to reduce disability related to musculoskeletal disorders in music students. The current study provides an external validation and a formative and process evaluation, allowing for a better interpretation of results. First, a group of experts was asked to complete a structured evaluation of design and content of the trial. Second, quantitative and qualitative data were analysed from different stakeholders (students, therapists and conservatory staff) using questionnaires, logs, field notes and emails to evaluate fidelity, dose delivered, dose received, reach and context. Results are presented descriptively. Two authors independently identified key responses that were merged into themes. Although no difference in disability was found between interventions, closer evaluation revealed that participants in PRESTO-Play reported that they learned about prevention of physical complaints and were more satisfied with course contents compared with PRESTO-Fit. Study design and contents of the interventions were found to be valid, with an appropriate dose delivered. Feedback from students and logs suggested that behavioural change and psychosocial principles in PRESTO-Play might have not been implemented optimally. Only moderate fidelity in both groups and too little contrast between interventions could have influenced results. Low attendance rates and a presumed lack of generalization further decreased possible effectiveness. Context greatly influenced implementation. Implementing a future health course with closer collaboration with the institution could optimize accessibility and communication, encourage attendance and enhance motivation for behavioural change.

Ergonomics in violin and piano playing: A systematic review.

This systematic review aimed to evaluate whether muscle activity and playing-related musculoskeletal disorders are associated with musicians' anthropometrics and their instrument size or set-up during violin and piano performance. Studies were retrieved systematically from six databases on 1 April 2019 combined with hand searching results. The Appraisal tool for Cross-Sectional Studies (AXIS tool) was used to evaluate the methodological quality of the included papers. A total of twenty articles were identified. Most included studies focussed on either the adjustment of the shoulder rest in violinists, or the hand size in pianists. However, methodological quality was inconsistent. The electromyography data reported by the included studies were not appropriately processed and interpreted. Studies generally reported the use of a shoulder rest changes muscle activity and smaller hand size is correlated to increased playing-related musculoskeletal disorders incidence. However, no conclusions can be drawn due to heterogeneity and low quality of methodology in the available literature.

Health on the Move-Challenges in Work and Lifestyle Changes for Performing Artists.

This issue of MPPA raises awareness once more of the highly specific needs of performing artists, and the specialised kind of support or assessment that will be required to optimally manage their health care needs. As reported in this issue, Kawano et al. concluded that highly expressive task-specific movements are often a normal part of the technical requirements for a dance routine, and analysing whether dancers are safe to perform these manoeuvres requires a highly trained eye and experience. Not only that, but their beliefs on how such movements affect their risk of injury may be influenced by perspectives within the dance culture (Hendry et al.). To be able to assess dancers and their injury risk requires health professionals to have substantial experience, as general health assessment measures are unlikely to be adequate to meet their highly complex performance demands (Clarke et al.). Similar experience is required in understanding the complex demands of the wide spectrum of musical performance, acting, and other artistic pursuits, including understanding strategies to help performing artists manage their workloads. Problems are highlighted with the impact of fatigue on circus (Decker et al.) and dance activities (Jarvis et al.), with work and training loads playing a role in affecting movement patterns and health status. Further research may clarify other factors contributing to fatigue in performing artists, as many issues such as travel, diet, and mood will contribute to feelings of fatigue.

Diversity and Training in Performing Arts Medicine.

Medical Problems of Performing Artists has addressed the needs of clinicians for many decades, providing evidence and opinion pieces on performing artists' healthcare regarding a wide range of health issues that may either affect or cause problems when performing. Traditionally, two major challenges facing the best approaches to managing the health of performing artists has been (i) limited scientific research evidence supporting preventative approaches, specific assessments and treatment methods for the vast array of conditions seen, and (ii) a lack of training programs specifically targeting performing artists' healthcare. Not only are there many important differences between general healthcare and managing the health of performing artists, but there are variations between individuals performing on the same instrument, and a vast array of styles and genres of performing arts that create very different demands on performers. In relation to the first point, a previous lack of available scientific literature has hindered evidence-informed performing arts medicine practice; however, high-quality research has recently progressed rapidly. This edition of MPPA also highlights the incredible breadth of information emerging, recognising the complex and multiple health demands facing diverse performing arts domains.

Health Education Literacy and Accessibility for Musicians: A Global Approach. Report from the Worldwide Universities Network Project.

OBJECTIVE: To address the need for accessible health education and improved health literacy for musicians throughout their lifespan. METHODS: Formation of a multicultural, international, and interdisciplinary collaborative research team, funded by the Worldwide Universities Network. The goal is to design a multi-strand research program to develop flexible and accessible approaches to health education for musicians, thus improving their health literacy. RESULTS: Two team meetings took place in 2018. The first was held 11 to 15 April 2018 in Perth, Australia, and involved a review of existing literature and interventions on health education in music schools, intensive development of research topics, aims, and methodologies, and identification of potential funding sources to support future large-scale research programs. This resulted in the draft design of three research projects, finalized during a second meeting in Maastricht, the Netherlands, 27 to 31 August 2018. DISCUSSION: These intensive meetings identified the need for both cultural change in music education settings as well as improved health literacy in musicians across global geographical regions. A global project to address health literacy and health education accessibility for musicians has commenced.

Health literacy and health promotion challenges in performing arts medicine.

In recent years, the role of health literacy in determining appropriate attitudes and behaviours to health has received extensive attention. According to the World Health Organisation, health literacy refers to the ability of individuals to access, understand, and use information in ways which promote and maintain good health for themselves, their families, and their communities. It has been increasingly recognised that this information should be tailored to the specific needs of the community (e.g., performing artists) to empower them to take an active role in improving their own health outcomes. One concern recognised for well over a decade now has been the challenge for non-health-trained individuals to recognise what is reliable when searching through the highly variable sources of "health information" published on the internet.

Educating Australian musicians: are we playing it safe?

The effectiveness of health promotion through arts engagement, and the health benefits and social importance of music in particular, are becoming increasingly recognized. However, like sport, music-making is an athletic endeavour, one that often involves high physiological and psychological loadings on the bodies and minds of musicians. Research over the past 30 years has revealed alarming rates of injury among musicians, and has identified health risk factors associated with music performance faced by professional and student musicians. Australia lacks consistent provision of essential health education for musicians, and research shows an unacceptably high prevalence of performance-related health problems among musicians of all ages. This article advocates for effective health promotion to be embraced in the policies and practices of Australian music performance organizations and educational bodies. It argues that a cultural shift is required, recognizing that a settings-based approach to health literacy is as fundamentally important for musicians as it is for any other occupation or athletic activity. Embedding health education into the delivery of music education will not only help to prevent injury over the lifespan of Australian musicians, it will support and sustain their capacity to contribute towards societal wellbeing and public health outcomes.

Prioritising Performance--Where Does Health Fit In?

Elite performance encompasses a complex balancing act involving a series of professionals attempting to help an individual perform to the limit of their abilities, whilst simultaneously striving to further their capacity. Teachers and performance scientists are under pressure to try to push performers harder to be able to achieve success in competitions, performances and their career. Clinicians must strive to keep the physical and mental health of performers in as good shape as possible while they are balancing these often extreme physical and psychological training demands--'the show must go on.' Efforts to better understand mechanisms that may impact both performance capacity and risk to health are therefore highly important, and feature in research presented in the current issue.

Potential Relevance of Altered Muscle Activity and Fatigue in the Development of Performance-Related Musculoskeletal Injuries in High String Musicians.

BACKGROUND: Muscle fatigue seems to be a risk factor in the development of performance-related musculoskeletal disorders (PRMDs) in musicians, but it is unclear how muscle activity characteristics change between musicians with and without PRMDs over a prolonged playing period. PURPOSE: To investigate muscle activity patterns in muscles of the arms, shoulder, and back of high string musicians during prolonged performance. METHODS: Fifteen professional or university high string musicians were divided into PRMD and non-PRMD groups. All musicians played a chromatic scale, then an individual "heavy" piece for 1 hr, and finally the chromatic scale again. Surface electromyography (sEMG) data were recorded from 16 muscles of the arm, shoulder, and trunk on both sides of the body. Two parameters were analyzed: the percentage load in relation to the respective maximum force during the chromatic scale, and the low-frequency spectrum to determine the fatigue behavior of muscles during the 1-hr play. RESULTS: Changes in muscle activation patterns were observed at the beginning and end of the trial duration; however, these varied depending on whether musicians had PRMDs or no PRMDs. In addition, low-frequency spectrum changes were observed after 1 hr of playing in the PRMD musicians, consistent with signs of muscular fatigue. CONCLUSION: Differences in muscle activity appear between high string musicians with and without PRMDs as well as altered frequency spectrum shifts, suggesting possible differential muscle fatigue effects between the groups. The applied sEMG analysis proved a suitable tool for detailed analysis of muscle activation characteristics over prolonged playing periods for musicians with and without PRMDs.

Making health care worth it: increasing value and awareness in performing arts medicine.

In recent years, across all health care disciplines, the higher quality and volume of specific literature on health issues pertaining to performing artists are allowing ever more specialised and targeted evidence-informed interventions to be delivered. Whether performing artists recognise the new-found knowledge as well as the growth in training and domain-specific expertise of certain dedicated health professionals is unclear. Developing and maintaining good communication and the establishment of trust between performing artists, educators, and health professionals is crucial to facilitate better management of injuries in performing artists.

Effects of Aging on Musical Performance in Professional Orchestral Musicians.

BACKGROUND: The physical and psychological demands of playing a musical instrument are likely to be affected by age-related decline in function, including physical, cognitive, psychological, and organ-related changes. However, the complex neurophysiological demands of playing a musical instrument may delay many normal aging-related changes. AIM: This study compared professional classical musicians of different ages, using a range of physical and psychological measures, to discover how increasing age might affect work performance and to identify possible risk and protective factors for physical and psychological health as the musicians age. SUBJECTS: 377 professional orchestral musicians from eight Australian orchestras (70% response rate), ages 18 to 68 yrs (mean 42.1). Multiple standardized physical and psychological tools were used to evaluate the impact of age on a range of physical and mental health variables. RESULTS: Age was not statistically associated with frequency or severity of performance-related musculoskeletal disorders, ratings of perceived exertion, QuickDASH scores, use of beta-blockers, workplace satisfaction, and most psychological tests. Differences were observed on SPIN (social anxiety) scores, with lowest scores in the oldest age group (10.66 in 55+ yrs vs 17.83 in 18-30 yrs, p=0.016). Older musicians had higher BMIs and fewer practice sessions per day than younger musicians and also were more likely to consume alcohol on 5+ days/wk (44% vs 9%, p=0.003). CONCLUSION: Advancing age does not appear to exert undue negative impacts on physical and psychological health or performance capacity of professional orchestral musicians. However, dwindling numbers in the older age groups may suggest a "survivor" effect, whereby those who develop significant age-related decrements may cease professional performance at earlier ages. Longitudinal studies on the professional trajectories of professional orchestral musicians are needed to explore this question further.

Pain Across Artists' Lifespan.

Having a lifelong career as a professional performing artist carries both challenges and benefits across different body systems. Pushing one's body to the limits results in a higher risk of suffering from some kind of episode of overload, whether it be physical or psychological. Indeed, a sudden increase in playing load (overtraining) is linked with increased frequency and intensity of pain or performance-related musculoskeletal disorders in both dance and music student populations. In this issue, research highlights this across the lifespan and in different genres of performing arts, including Irish fiddlers.

EMG amplitude, fatigue threshold, and time to task failure: A meta-analysis.

OBJECTIVES: Electromyographic (EMG) fatigue threshold (EMGFT) is utilised as a correlate of critical power, torque, and force thresholds that establishes a theoretical exercise intensity-the power, torque, or force at which the rate of change of EMG amplitude (ΔEM¯G) is zero-below which neuromuscular fatigue is negligible and unpredictable. Recent studies demonstrating neuromuscular fatigue below critical thresholds raise questions about the construct validity of EMGFT. The purpose of this analysis is to evaluate the construct validity of EMGFT by aggregating ΔEM¯G and time to task failure (Tlim) data. DESIGN: Meta-analysis. METHODS: Database search of MEDLINE, SPORTDiscus, Web of Science, and Cochrane (inception - September 2016) conducted using terms relevant to EMG and muscle fatigue. Inclusion criteria were studies reporting agonist muscle EMG amplitude data during constant force voluntary isometric contractions taken to task failure. Linear and nonlinear regression models were used to relate ΔEM¯G and Tlim data extracted from included studies. RESULTS: Regression analyses included data from 837 healthy adults from 43 studies. Relationships between ΔEM¯G and Tlim were strong in both nonlinear (R2=0.65) and linear (R2=0.82) models. ΔEM¯G at EMGFT was significantly nonzero overall and in 3 of 5 cohorts in the nonlinear model (p<0.01) and in 2 of 5 cohorts in the linear model. CONCLUSIONS: EMGFT lacks face validity as currently calculated; models for more precise EMGFT calculation are proposed. A new framework for prediction of task failure using EMG amplitude data alone is presented. The ΔEM¯G vs. Tlim relationship remains consistent across sexes and force vs. position tasks.

The Sickness of Stigmas.

In modern medicine, approaches to healthcare no longer only encompass injury management, but increasingly focus on understanding the performance demands and health risk exposures faced by performing artists. Quantitative and qualitative scientific and health analyses by performing artists, clinicians, educators, and researchers are increasingly helping us to develop effective, targeted, and relevant health promotion and performance optimisation strategies worldwide. While such research increasingly identifies improved methods of preventing and managing potential psychological, audiological, or physical challenges faced by performing artists, we still need to work hard to address very important barriers to implementing appropriate health approaches. One of the challenges to better health management in performing arts populations relates to stigmatization.