EDITORIALS
795
PERFORMING ARTS MEDICINE
Classification of problems Essentially problems affecting the performing artists can be classified into three main groups. 1. Those which are directly occupational. These are usually due to bad posture, poor technique and excessive muscle tension. Excessive muscle tension in turn is usually associated with performance anxiety. 2. Those which are predominantly psychological due to emotional stress, worry and fatigue. Stage fright and depression come into this category. Obviously the fear of being replaced by a younger colleague 'who is not sick' is constantly there. The ensuing anxiety invariably compounds any problem. 3. Those not related causally to the occupation but highly relevant in preventing the artist from following his or her profession. These would include painful shoulders, elbows and backache commonly seen in any rheumatological clinic. Incidence of problems In one of the largest recent surveys [1] dealing with professional musicians (ICSOM), 76% of players claimed to suffer from a complaint severe enough to compromise playing. A recent (unpublished) survey carried out by the Association of British Orchestras revealed that some 15% of professional orchestral players are off work longer than 1 month every year because of an occupationally relevant medical problem. Other surveys reveal similar figures [2]. Performance anxiety A survey carried out in Britain and on the continent in 1984 [3] revealed that 88% of British professional symphony orchestra players occasionally suffer from stage fright compared to 34% on the continent. In a quarter of those admitting to the problem, it was not an uncommon experience. In a handful of players the problem of stage fright was so bad that it made their lives a nightmare. In terms of therapy for performance anxiety there is
no doubt that the judicious use of Beta blockers has revolutionized the approach [4, 5]. They are best and most successfully used in conjunction with counselling and behavioural techniques. The possibility of a severe underlying depression should always be remembered in the chronic stage fright sufferer and treated appropriately. Occupational disorders According to Hunter Fry [6] some 50% of musicians suffer from pain in a shoulder or in an upper limb. In these patients there are no physical signs, they are often labelled as repetitive strain injury or RSI but the term regional pain syndrome is much to be preferred. There is seldom any evidence of injury and repetitive movements are unlikely to be the cause at least in musicians [7]. There is some evidence that increased tension in the involved muscles may be the causative factor [8]. Postural problems need to be corrected by Alexander teachers, technical problems by skilled teachers of the instrument and emotional and stress related problems need to be ironed out by trained counsellors or psychologists. Beta blockers may have a role here as mentioned earlier, especially if the emotional stress results in increased muscle tension. Anti-depressants should be used if there is an element of depression. It can be seen from this that for such patients a multidisciplinary approach is essential. Currently there is anxiety about hearing loss not only among pop musicians [9] but also in opera orchestras [10] who have to perform in a confined space. Singers can all too easily develop voice strain problems and/or vocal nodules which make them unemployable. It is impossible here to cover all the problems of the performing artist such as entrapment neuropathies and focal muscle dystonias, for recent reviews see those of Lambert [2] and Lockwood [11]. Co-ordinating performing arts medicine throughout Britain Fortunately efforts are now being made to tackle the problems of performing artists on a national basis. Some years ago the British Performing Arts Medicine Trust was formed with the aims of building a credible clinical and academic base for the discipline. The aim is to improve the health of those engaged in the performing arts by ensuring that everyone has swift and free access to doctors who are themselves specially trained in performing arts medicine and who understand the pressures on the performer. Some problems lie within the realm of specially trained general practitioners but a swift referral network is essential so that intervention by the hospital specialist can take place when appropriate. If the subject is going to develop along the right lines as a serious discipline, a supervisory role by relevant consultants and specialists is essential.
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
MOST performing artists have no health problems. They are usually happy and active and stay so provided their technique is good and their mind and body remains relaxed. However, performing artists are just like sportsmen in that they are prone to occupational stresses and injuries which are specific to their profession. They are also liable to the usual 'run of the mill' health problems to which everyone is prone. Unlike most of us, however, if these problems are not recognized and tackled quickly, the resultant inability to work even for quite short periods may lead to the loss of a career. No one in the performing arts professions enjoys security of tenure. One is only as good as one's last performance.
796
BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 12
Training of honorary advisers The training of these honorary advisers needs to be a continuous process to ensure that the latest techniques appropriate to performing arts medicine are known. National conferences, intensive seminars and clinics are being arranged. Ten meetings have already taken place and at least two training videos have been made. Performing arts clinics Specialist performing arts clinics are essential in their own right [12] but they are now doubly necessary to give support to the developing General Practitioner networks. Clinics already exist in Edinburgh, London and Leeds and in 12 other regional centres consultants with appropriate experience in performing arts medicine have been identified. Research and disease prevention The work of the advisers and the clinics will soon
give us an accurate data base from which to operate. For the first time we will have an idea of the exact type and frequency of problems throughout the country. It is also the intention to find better ways of treating and preventing some of these occupational illnesses. Collecting data centrally will enable sufficient experience to be amassed speedily so that the most efficacious therapy can be made to all. I. M. JAMES and C. B. WYNN PARRY
The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG
REFERENCES
1. Fishbein M, Middlestadt SE, Ottati V, Strauss S, Ellis A. Medical problems among ICSOM musicians: an overview of a national survey. Med Prob Per)Art 1988;3:l-8. 2. Lambert CM. Hand and upper limb problems of instrumental musicians. Br J Rheumatol 1992;31:265-71. 3. James IM. Most players admit to stress symptoms. Classical Music 1984;262:7. 4. James IM, Griffith D, Pearson R et al. Effect of oxprenolol on stage fright in musicians. Lancet 1977;ii:952-4. 5. James I. Practical aspects of the use of Beta blockers in anxiety states. Situational anxiety. Postgrad Med J 1984;60:(Suppl 2)19-24. 6. Fry J, Hunter. Incidence of overuse syndrome in the symphony orchestra. Med Prob Perf Art 1986;l:l-5. 7. Brooks PM. Repetition strain injury. Lancet 1987;ii:738. 8. Moulton B, Spence SH. Site specific muscle hyperreactivity in musicians with occupational upper limb pain. Behav Res Ther 30:375-86. 9. Speaks C. Nelson D, Ward WD. Hearing loss in rock and roll musicians. J Occup Med 1970;12:216-19. 10. Karlsson K, Lunqvist PG, Olaussen T. The hearing loss of symphony orchestra musicians Scan Audio 1983; 12:257-64. 11. Lockwood AH. Medical problems of musicians. N Engl J Med 1989,320:221-7. 12. Wynn Parry CB. Performing arts clinics at the London 6.4-11. ISSTIP.
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
The work of the medical profession sometimes has to be interlinked with other disciplines. The success of treatment often means involvement of music teachers, teachers of the Alexander method, trained counsellors as well as more conventional paramedical disciplines such as physiotherapy. Appointment of honorary medical advisers To speed up identification of serious problems requiring consultant intervention and to ensure that simpler problems are quickly and efficiently dealt with by primary care doctors a number of initiatives have been launched. The most succesful of these to date has been the Association of Medical Advisers to British Orchestras scheme. Some 30 primary care doctors have been appointed as honorary medical advisers to the major British orchestras. In the not too distant future, honorary medical attachments will be made to other arts organizations such as opera companies, theatres and most important of all to training establishments. Some, but by no means all, training colleges and academies already have their own doctor, these doctors should be skilled in performing arts medicine. This approach enjoys the enthusiastic support not only of the main music and acting charities but also of the performers themselves and of their unions.
795
PERFORMING ARTS MEDICINE
Classification of problems Essentially problems affecting the performing artists can be classified into three main groups. 1. Those which are directly occupational. These are usually due to bad posture, poor technique and excessive muscle tension. Excessive muscle tension in turn is usually associated with performance anxiety. 2. Those which are predominantly psychological due to emotional stress, worry and fatigue. Stage fright and depression come into this category. Obviously the fear of being replaced by a younger colleague 'who is not sick' is constantly there. The ensuing anxiety invariably compounds any problem. 3. Those not related causally to the occupation but highly relevant in preventing the artist from following his or her profession. These would include painful shoulders, elbows and backache commonly seen in any rheumatological clinic. Incidence of problems In one of the largest recent surveys [1] dealing with professional musicians (ICSOM), 76% of players claimed to suffer from a complaint severe enough to compromise playing. A recent (unpublished) survey carried out by the Association of British Orchestras revealed that some 15% of professional orchestral players are off work longer than 1 month every year because of an occupationally relevant medical problem. Other surveys reveal similar figures [2]. Performance anxiety A survey carried out in Britain and on the continent in 1984 [3] revealed that 88% of British professional symphony orchestra players occasionally suffer from stage fright compared to 34% on the continent. In a quarter of those admitting to the problem, it was not an uncommon experience. In a handful of players the problem of stage fright was so bad that it made their lives a nightmare. In terms of therapy for performance anxiety there is
no doubt that the judicious use of Beta blockers has revolutionized the approach [4, 5]. They are best and most successfully used in conjunction with counselling and behavioural techniques. The possibility of a severe underlying depression should always be remembered in the chronic stage fright sufferer and treated appropriately. Occupational disorders According to Hunter Fry [6] some 50% of musicians suffer from pain in a shoulder or in an upper limb. In these patients there are no physical signs, they are often labelled as repetitive strain injury or RSI but the term regional pain syndrome is much to be preferred. There is seldom any evidence of injury and repetitive movements are unlikely to be the cause at least in musicians [7]. There is some evidence that increased tension in the involved muscles may be the causative factor [8]. Postural problems need to be corrected by Alexander teachers, technical problems by skilled teachers of the instrument and emotional and stress related problems need to be ironed out by trained counsellors or psychologists. Beta blockers may have a role here as mentioned earlier, especially if the emotional stress results in increased muscle tension. Anti-depressants should be used if there is an element of depression. It can be seen from this that for such patients a multidisciplinary approach is essential. Currently there is anxiety about hearing loss not only among pop musicians [9] but also in opera orchestras [10] who have to perform in a confined space. Singers can all too easily develop voice strain problems and/or vocal nodules which make them unemployable. It is impossible here to cover all the problems of the performing artist such as entrapment neuropathies and focal muscle dystonias, for recent reviews see those of Lambert [2] and Lockwood [11]. Co-ordinating performing arts medicine throughout Britain Fortunately efforts are now being made to tackle the problems of performing artists on a national basis. Some years ago the British Performing Arts Medicine Trust was formed with the aims of building a credible clinical and academic base for the discipline. The aim is to improve the health of those engaged in the performing arts by ensuring that everyone has swift and free access to doctors who are themselves specially trained in performing arts medicine and who understand the pressures on the performer. Some problems lie within the realm of specially trained general practitioners but a swift referral network is essential so that intervention by the hospital specialist can take place when appropriate. If the subject is going to develop along the right lines as a serious discipline, a supervisory role by relevant consultants and specialists is essential.
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
MOST performing artists have no health problems. They are usually happy and active and stay so provided their technique is good and their mind and body remains relaxed. However, performing artists are just like sportsmen in that they are prone to occupational stresses and injuries which are specific to their profession. They are also liable to the usual 'run of the mill' health problems to which everyone is prone. Unlike most of us, however, if these problems are not recognized and tackled quickly, the resultant inability to work even for quite short periods may lead to the loss of a career. No one in the performing arts professions enjoys security of tenure. One is only as good as one's last performance.
796
BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 12
Training of honorary advisers The training of these honorary advisers needs to be a continuous process to ensure that the latest techniques appropriate to performing arts medicine are known. National conferences, intensive seminars and clinics are being arranged. Ten meetings have already taken place and at least two training videos have been made. Performing arts clinics Specialist performing arts clinics are essential in their own right [12] but they are now doubly necessary to give support to the developing General Practitioner networks. Clinics already exist in Edinburgh, London and Leeds and in 12 other regional centres consultants with appropriate experience in performing arts medicine have been identified. Research and disease prevention The work of the advisers and the clinics will soon
give us an accurate data base from which to operate. For the first time we will have an idea of the exact type and frequency of problems throughout the country. It is also the intention to find better ways of treating and preventing some of these occupational illnesses. Collecting data centrally will enable sufficient experience to be amassed speedily so that the most efficacious therapy can be made to all. I. M. JAMES and C. B. WYNN PARRY
The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG
REFERENCES
1. Fishbein M, Middlestadt SE, Ottati V, Strauss S, Ellis A. Medical problems among ICSOM musicians: an overview of a national survey. Med Prob Per)Art 1988;3:l-8. 2. Lambert CM. Hand and upper limb problems of instrumental musicians. Br J Rheumatol 1992;31:265-71. 3. James IM. Most players admit to stress symptoms. Classical Music 1984;262:7. 4. James IM, Griffith D, Pearson R et al. Effect of oxprenolol on stage fright in musicians. Lancet 1977;ii:952-4. 5. James I. Practical aspects of the use of Beta blockers in anxiety states. Situational anxiety. Postgrad Med J 1984;60:(Suppl 2)19-24. 6. Fry J, Hunter. Incidence of overuse syndrome in the symphony orchestra. Med Prob Perf Art 1986;l:l-5. 7. Brooks PM. Repetition strain injury. Lancet 1987;ii:738. 8. Moulton B, Spence SH. Site specific muscle hyperreactivity in musicians with occupational upper limb pain. Behav Res Ther 30:375-86. 9. Speaks C. Nelson D, Ward WD. Hearing loss in rock and roll musicians. J Occup Med 1970;12:216-19. 10. Karlsson K, Lunqvist PG, Olaussen T. The hearing loss of symphony orchestra musicians Scan Audio 1983; 12:257-64. 11. Lockwood AH. Medical problems of musicians. N Engl J Med 1989,320:221-7. 12. Wynn Parry CB. Performing arts clinics at the London 6.4-11. ISSTIP.
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
The work of the medical profession sometimes has to be interlinked with other disciplines. The success of treatment often means involvement of music teachers, teachers of the Alexander method, trained counsellors as well as more conventional paramedical disciplines such as physiotherapy. Appointment of honorary medical advisers To speed up identification of serious problems requiring consultant intervention and to ensure that simpler problems are quickly and efficiently dealt with by primary care doctors a number of initiatives have been launched. The most succesful of these to date has been the Association of Medical Advisers to British Orchestras scheme. Some 30 primary care doctors have been appointed as honorary medical advisers to the major British orchestras. In the not too distant future, honorary medical attachments will be made to other arts organizations such as opera companies, theatres and most important of all to training establishments. Some, but by no means all, training colleges and academies already have their own doctor, these doctors should be skilled in performing arts medicine. This approach enjoys the enthusiastic support not only of the main music and acting charities but also of the performers themselves and of their unions.
