Occupational Health and Well-Being: Hazards, Treatment Options, and Prevention Strategies for Music Therapists

Occupational Health and Well-Being: Hazards, Treatment Options, and Prevention Strategies for... Healthcare is the fastest growing sector in the U.S. economy, and healthcare workers face a wide range of job-related hazards, including injury, illness, violence, and work-related stress. Data suggest that occupational injury and illness in healthcare workers are among the highest of any industry (Centers for Disease Control and Prevention, 2014). Music therapists, like other healthcare professionals, are exposed to work-related stressors that can adversely impact both their physical and mental health. However, unlike other healthcare professionals, music therapists also face additional risks associated with the musical aspects of their career. Research suggests that up to 93% of professional musicians experience playing-related injuries during their career (Kok, Huisstede, Voorn, Schoones, & Nelissen, 2016) and that professional musicians are at risk for contracting hearing disorders (Schink, Kreutz, Busch, Pigeot, & Ahrens, 2014). The literature also suggests that musicians are at risk for various psychological disorders, including anxiety disorders (trait, performance, social) and depression (Kenny, Driscoll, & Ackermann, 2012). Widespread interest in musicians’ job-related hazards first emerged in the 1960s and 1970s (Gaál, 2001). Today there is a growing body of research related to the anatomical, physiological, and psychological components of musicians’ health and well-being. Data suggest that musicians, like athletes, face physical injuries and/or mental health issues significant enough to jeopardize their careers (Pierce, 2012). Consequently, university music programs and professional music and arts organizations like the National Association of Schools of Music (NASM), the International Society for Music Education, and the Performing Arts Medicine Association now provide information on musicians’ health, well-being, and safety (Clark, Williamon, & Redding, 2013). NASM, the organization that establishes standards for undergraduate and graduate degree programs, first began to address the need for inclusion of health and wellness information in academic programs in 2010 (Pierce, 2012). Current NASM policies state that higher education programs should provide or facilitate access to education, counseling, and professional care associated with the maintenance of physical and mental health (NASM, 2015; Pierce, 2012). Hazards Facing Musicians Musicians typically spend many hours per week in both performance and practice. Many musicians start playing at an early age, which means that even young professionals have been playing for years or decades. Some researchers even suggest that most professional musicians have played more than 10,000 hours by the age of 20 (Lee, Eich, Ioannou, & Altenumüller, 2015). This ongoing, long-term exposure increases the risk for playing-related disorders that result from overuse or cumulative trauma (Pierce, 2012; Raymond, Romeo, & Kumke, 2012). Playing-related disorders vary and are often associated with the instrument played; possibilities include (a) muscle/tendon injuries, (b) joint injuries, (c) nerve compression or entrapment disorders, and (d) central nervous system disorders (Kenny & Ackermann, 2015). These disorders, which can be broadly divided into neuromuscular or musculoskeletal disorders, are collectively known as neuromusculoskeletal disorders and involve injury to the muscles, nerves, tendons, joints, and cartilage. Neuromusculoskeletal disorders are caused, precipitated, or exacerbated by persistent exposure to repetition, force, vibration, or awkward posture (Lederman, 2003; NIOSH, 2012). Research has shown that the lifetime prevalence of musculoskeletal disorders in musicians ranges from 62 to 93% (Kok et al., 2016). Playing-related musculoskeletal disorders (PRMDs) can be painful and debilitating, and can limit or even prohibit work (Chong, Lynden, Harvey, & Peebles, 1989; Foxman & Burgel, 2006; Lee et al., 2015; Raymond et al., 2012; Wu, 2007). Hearing Loss Hearing loss has been studied in a wide range of musicians, from orchestral performers to rock musicians, and the importance of hearing protection has been widely documented (Ackermann, Kenny, O’Brien, & Driscoll, 2014; Auchter & Le Prell, 2014; Chesky & Henoch, 2000; Federman & Picou, 2009; Schink et al., 2014). High sound levels can negatively impact musicians, yet musicians often have little control over the environment (Halleland, Harris, Sornes, Murison, & Ursin, 2009; Raymond et al., 2012). Researchers have suggested that musicians are often unaware that prolonged exposure to sound levels over 85dB can cause permanent hearing loss. As a result, the need to promote hearing health has been stressed with recommended strategies including, but not limited to, reducing the amount of time exposed to hazardous sounds or giving the ears a rest after exposure (Chesky, 2008). Hearing protection is especially important given recent research that suggests musicians are almost four times as likely to experience hearing loss (Schink et al., 2014). Unfortunately, the data suggest that hearing protection use among musicians has been limited, and that most musicians do not use hearing protection until symptoms are already present (Olson, Gooding, Shikoh, & Graf, 2016). Psychological Concerns In addition to neuromusculoskeletal conditions and hearing loss, musicians may also be at risk for various psychological concerns. It has been suggested that the mental health needs of musicians are not well understood and often poorly managed; concerns range from substance use to mental health disorders like anxiety and depression (Kenny et al., 2012). Performance anxiety in particular has been noted for its potentially debilitating effects (Pierce, 2012; Zaza & Farewell, 1997), and Kenny and colleagues (2012) found a complex relationship between performance anxiety and depression in their study of orchestral musicians. Research has further suggested that a large percentage of musicians will experience mental and/or physical health issues significant enough to jeopardize their careers (Pierce, 2012). Access to Healthcare Regardless of the type of health concern, data suggest that musicians often attribute symptoms to (a) the impact of an excessive workload on tired muscles, (b) poor posture, (c) poor practice technique, and (d) lack of fitness. As a result, they may not seek professional care for existing or potential issues (Raymond et al., 2012; Williamon & Thompson, 2006). Furthermore, it has been reported that many musicians lack health coverage, leaving them underserved in primary care. This lack of appropriate care can result in untreated or undertreated conditions, social and psychological stress, the inability to play music, permanent disability, and/or the inability to earn an income (Foxman & Burgel, 2006). Risks Associated with Music Therapy Practice Music therapists, like other musicians, are at increased risk for playing-related disorders (PRMDs), hearing loss, and psychological concerns. Music therapists also face risks specifically associated with music therapy practice. Current AMTA Professional Competencies require individuals to establish functional skills in voice, piano, guitar, and percussion (AMTA, 2013). In a 1992 study of performance-related injuries in music therapists, Yovich found that three of these instruments (guitar, voice, and piano) were cited as both the most played and the most pain causing. Though Yovich’s data is over 20 years old, functional skills on voice, piano, and guitar, along with percussion skills, are still considered “very desirable” to “essential” by music therapists (Jenkins, 2013), highlighting their ongoing importance to music therapy practice. It is therefore important that music therapists are aware of risks associated with these instruments. The following information highlights some of the more common hazards linked to each instrument. Voice Vocal problems have been well documented in fields with high voice demands. In 2008 Boyle and Engen wrote about the lack of information on the impact of vocal use in music therapists. Though information within the field of music therapy is limited, data are available from other professional voice users like singers and teachers (Doherty, 2011). One commonly cited problem is vocal fatigue (Boyle & Engen, 2008). Breathiness, aphonia (voice loss), and pain have also been cited in the literature (Doherty, 2011). Causes of voice problems include (a) misuse or overuse, (b) inflammation, (c) infections, (d) vocal nodules, and (e) neurological diseases (NIDCD, 2014). Symptoms of possible voice problems include (a) hoarse or raspy voice, (b) diminished range, (c) sudden deepening of the voice, (d) raw, achy throat, (e) difficulty talking, and (f) repeated need to clear your throat (NIDCD, 2014). Music therapists must also be aware of other factors that contribute to vocal health. For example, noisy environments (Houtte, Claeys, Wuyts, & Van Lierde, 2011), poor acoustics (Doherty, 2011), and moving between large and small groups (Boyle & Engen, 2008) can impact vocal health. Long days of speaking and singing, voice-compromising postures, singing in keys that are beyond the therapist’s comfortable range, and lack of focus on good posture and breath support when simultaneously singing and accompanying oneself may all contribute to vocal health issues (Boyle & Engen, 2008). Strategies for preventing and/or treating vocal conditions can be found in Table 1. Table 1 Common Music Therapy Instruments, Associated Injuries, and Prevention Strategies Instrument  Conditions/Disorders  Symptoms  Strategies to prevent/combat injuries  Voicea  • Organic disorders: related to anatomy/physiology (e.g., nodule, infection) • Functional disorders: related to improper use  • Hoarseness • Voices tires easily • Difficulty singing/speaking softly • Difficulty projecting • Loss of singing range • Discomfort • Chronic throat dryness or soreness • Difficulty swallowing • Shaky voice • Monotone voice  • Warm up • Ensure adequate sleep, hydration, and nutrition • Conserve the voice when possible (i.e., using nonverbal or written communication) • Amplify the voice when needed  Pianob  • PRMDs caused by misuse • PRMDs caused by overuse  • Pain/aching in wrist, hands, and fingers  • Warm up/cool down • Stretch • Take breaks to reduce tension • Maintain appropriate sitting posture (normal curve of the back, adjusted bench, etc.) • Use cognitive rehearsal (e.g., play on a tabletop before playing on the piano)  Guitarc  • PRMDs caused by overuse  • Pain • Decreased functioning • Motor coordination problems  • Use neutral playing positions • Adjust playing position when sitting vs. standing • Warm up • Take breaks • Use of soft carrying cases to reduce load  Percussiond    Pain Problems in hand, elbow, shoulders, and back  • Use neutral posture and ensure postural alignment • Warm up; take breaks • Use stretching/strengthening exercises • Be conscious of posture when standing  Instrument  Conditions/Disorders  Symptoms  Strategies to prevent/combat injuries  Voicea  • Organic disorders: related to anatomy/physiology (e.g., nodule, infection) • Functional disorders: related to improper use  • Hoarseness • Voices tires easily • Difficulty singing/speaking softly • Difficulty projecting • Loss of singing range • Discomfort • Chronic throat dryness or soreness • Difficulty swallowing • Shaky voice • Monotone voice  • Warm up • Ensure adequate sleep, hydration, and nutrition • Conserve the voice when possible (i.e., using nonverbal or written communication) • Amplify the voice when needed  Pianob  • PRMDs caused by misuse • PRMDs caused by overuse  • Pain/aching in wrist, hands, and fingers  • Warm up/cool down • Stretch • Take breaks to reduce tension • Maintain appropriate sitting posture (normal curve of the back, adjusted bench, etc.) • Use cognitive rehearsal (e.g., play on a tabletop before playing on the piano)  Guitarc  • PRMDs caused by overuse  • Pain • Decreased functioning • Motor coordination problems  • Use neutral playing positions • Adjust playing position when sitting vs. standing • Warm up • Take breaks • Use of soft carrying cases to reduce load  Percussiond    Pain Problems in hand, elbow, shoulders, and back  • Use neutral posture and ensure postural alignment • Warm up; take breaks • Use stretching/strengthening exercises • Be conscious of posture when standing  aDoherty (2011). bAllsop & Ackland (2010); Guptill & Zaza (2010). cFjellman-Wiklund & Chesky (2006); Foxman & Burgel (2006); Marques et al. (2003). dBrandfonbrener (2009); Sandell et al. (2009). View Large Table 1 Common Music Therapy Instruments, Associated Injuries, and Prevention Strategies Instrument  Conditions/Disorders  Symptoms  Strategies to prevent/combat injuries  Voicea  • Organic disorders: related to anatomy/physiology (e.g., nodule, infection) • Functional disorders: related to improper use  • Hoarseness • Voices tires easily • Difficulty singing/speaking softly • Difficulty projecting • Loss of singing range • Discomfort • Chronic throat dryness or soreness • Difficulty swallowing • Shaky voice • Monotone voice  • Warm up • Ensure adequate sleep, hydration, and nutrition • Conserve the voice when possible (i.e., using nonverbal or written communication) • Amplify the voice when needed  Pianob  • PRMDs caused by misuse • PRMDs caused by overuse  • Pain/aching in wrist, hands, and fingers  • Warm up/cool down • Stretch • Take breaks to reduce tension • Maintain appropriate sitting posture (normal curve of the back, adjusted bench, etc.) • Use cognitive rehearsal (e.g., play on a tabletop before playing on the piano)  Guitarc  • PRMDs caused by overuse  • Pain • Decreased functioning • Motor coordination problems  • Use neutral playing positions • Adjust playing position when sitting vs. standing • Warm up • Take breaks • Use of soft carrying cases to reduce load  Percussiond    Pain Problems in hand, elbow, shoulders, and back  • Use neutral posture and ensure postural alignment • Warm up; take breaks • Use stretching/strengthening exercises • Be conscious of posture when standing  Instrument  Conditions/Disorders  Symptoms  Strategies to prevent/combat injuries  Voicea  • Organic disorders: related to anatomy/physiology (e.g., nodule, infection) • Functional disorders: related to improper use  • Hoarseness • Voices tires easily • Difficulty singing/speaking softly • Difficulty projecting • Loss of singing range • Discomfort • Chronic throat dryness or soreness • Difficulty swallowing • Shaky voice • Monotone voice  • Warm up • Ensure adequate sleep, hydration, and nutrition • Conserve the voice when possible (i.e., using nonverbal or written communication) • Amplify the voice when needed  Pianob  • PRMDs caused by misuse • PRMDs caused by overuse  • Pain/aching in wrist, hands, and fingers  • Warm up/cool down • Stretch • Take breaks to reduce tension • Maintain appropriate sitting posture (normal curve of the back, adjusted bench, etc.) • Use cognitive rehearsal (e.g., play on a tabletop before playing on the piano)  Guitarc  • PRMDs caused by overuse  • Pain • Decreased functioning • Motor coordination problems  • Use neutral playing positions • Adjust playing position when sitting vs. standing • Warm up • Take breaks • Use of soft carrying cases to reduce load  Percussiond    Pain Problems in hand, elbow, shoulders, and back  • Use neutral posture and ensure postural alignment • Warm up; take breaks • Use stretching/strengthening exercises • Be conscious of posture when standing  aDoherty (2011). bAllsop & Ackland (2010); Guptill & Zaza (2010). cFjellman-Wiklund & Chesky (2006); Foxman & Burgel (2006); Marques et al. (2003). dBrandfonbrener (2009); Sandell et al. (2009). View Large Piano Musculoskeletal disorders are more common in pianists than in any other type of instrument, perhaps due to the motor demands placed on the arm, hand, and fingers (Allsop & Ackland, 2010). Musculoskeletal disorders include conditions like tendonitis (inflammation/irritation of the tendons), arthritis, and ligament sprains. Pianists often complain of tenderness in the wrists and fingers, and playing-related disorders typically include inflammatory problems like tendonitis, nerve and motor injuries, compressions or entrapments (e.g., carpal tunnel syndrome), or degenerative joint problems related to continued trauma (Lai et al., 2015). Some studies have suggested that risks for piano-related injuries or conditions are greater if the pianist is older and has a smaller hand size. Risks have also been associated with gender (female) (Bragge, Bialocerkowski, & McMeeken, 2006), unstable joints, or less playing experience (Redman & Tiernan, 2001). Given the predominance of females in the field of music therapy, it is important that female music therapists are aware of the potential for increased risks. Music therapists should also note that right-sided symptoms have been found to be more common, and that specific piano techniques, like octaves, arpeggios, and wide extent passages, have also been connected with injuries. Awkward playing positions, arguably a common issue for music therapists, can also contribute to injury (Heinan, 2008; Redman & Tierman, 2001). However, neutral playing positions may increase optimal functioning and reduce the likelihood of injury (Guptill & Zaza, 2010). Other aspects that have been associated with piano injuries include typing, caffeine consumption, and poor habits. Poor habits connected with injury include (a) tension, (b) bad posture or body mechanics, (c) extended practice sessions, (d) lack of practice breaks, (e) poor technique, (f) playing multiple instruments, (g) sudden increases in practice time, and (h) difficult repertoire (Redman & Tiernan, 2001). Strategies to address piano-related conditions can be found in Table 1. Guitar Musculoskeletal problems in guitarists are usually associated with the upper extremities (left hand, wrist, and neck) and back (Fjellman-Wiklund & Chesky, 2006; Rigg, Marrinan, & Thomas, 2003). Studies have shown that guitarists, both classical and popular music performers, are at risk for neck and shoulder disorders, with left-side problems more common (Dawson, 2002; Fjellman-Wiklund, Brulin, & Sundelin, 2003). Pain complaints have also been well documented, and some researchers have suggested that awkward sitting postures may be a major cause of guitarists’ pain-related complaints (Dhriti, Agrawal, & Aju, 2003). Guitarists, like pianists, can face additional issues, including inflammation and nerve problems. They may even deal with guitar string dermatitis and finger fractures, as well as shortening of the distal phalangeal finger bones from mechanical stress (Fjellman-Wiklund & Chesky, 2006). Other non-musculoskeletal concerns associated with playing the guitar include (a) stress, (b) fatigue, (c) sleep problems, (d) depression, (e) anxiety, (f) stage fright, and (g) substance abuse (Chesky & Hipple, 1999; Raeburn, 2000). Stressful work environments have been connected with headache and eye strain in guitarists, and many of the above problems are the result of extreme postures, repetitive movements, and static muscle work (Bosi, 2016). Again, like playing the piano, females are also potentially at increased risk. Music therapists must be aware of differences in sitting and standing playing positions and strive for a neutral playing posture that balances static (fixed holding position) and dynamic loads (force during movement) (Foxman & Burgel, 2006). More information on guitarists’ risks can be found in Table 1. Percussion Perhaps more so than any other instrument, playing percussion instruments places great demand on the musculoskeletal system (Mishra, De, Gangopadhyay, & Chandra, 2013; Sandell, Frykman, Chesky, & Fjellman-Wiklund, 2009). The playing motion for most percussion instruments involves wrist volar flexion (bending wrist toward palm) and dorsiflexion (bending wrist toward back of hand), medial rotation of the elbow (toward the body), and internal rotation of the shoulder (toward the body). Because of these movement patterns, most injuries occur in the muscle origins of the elbows and the extensor muscles of the forearm and the hand muscles, as well as the ligaments of the wrist and at the base of the thumb. The repetitive striking motions used to play most percussion instruments can result in overuse and tissue injuries from the elbow down, and stress can increase the likelihood that muscular problems occur (Fry, 1984; Judkins, 1991; Lederman & Calabrese, 1986; Sandell et al., 2009). Given that many percussion instruments require individuals to stand while playing them, poor posture can also lead to back pain. Hard surfaces, especially those found in keyboard instruments, can also contribute to injuries. Music therapists should be aware of the physical demands placed on the performer when playing percussion instruments and take them into consideration when using them during music therapy practice. More information on percussion-related injuries can be found in Table 1. Risks Associated with Helping Music therapists may be at risk for a range of conditions associated with the therapeutic or helping aspects of their career. These conditions are precipitated by stressors like poor working conditions, exposure to client trauma, and work–life balance (Trondalen, 2016) and can lead to distress, dissatisfaction, psychosomatic illnesses, reduced quality of life, and diminished service provision (Ruotsalainen, Verbeek, Mariné, & Serra, 2015; Trondalen, 2016). Specific stressors identified by music therapists include difficult referrals, ongoing need for advocacy for music therapy, poor working conditions, lack of professional recognition, and relationships with interdisciplinary team members, among others (Clements-Cortes, 2006; Trondalen, 2016). If stressors are not adequately managed, they can lead to both physical (i.e., headaches or hypertension) and psychological symptoms (i.e., anxiety or irritability). One of the most common issues faced by helping professionals is burnout, a syndrome that includes physical exhaustion, emotional exhaustion, distress, decreased motivation, and reduced personal accomplishment (Chang, 2014; Ruotsalainen et al., 2015). Burnout has been cited as a concern for music therapists, much like others in helping professions or human service fields (Chang, 2014; Clements-Cortes, 2006, 2013; Fowler, 2006). Specific job characteristics like lack of support, limited control, and unfair decision-making processes have been cited as risk factors for burnout, and the onset of burnout has been found to be moderated by personality characteristics (Skodova & Lajciakova, 2013). Anxiety, in particular, has been found to be predictive of emotional exhaustion, a primary symptom of burnout (Chang, 2014; Vega, 2010). Some research has suggested that music therapists may have a proclivity toward anxiety as a personality trait (Vega, 2010); music therapists may therefore need to take special precautions to identify and address anxiety associated with work life. Additional conditions or stressors identified in the literature include compassion fatigue and compassion stress (Clements-Cortes, 2006; Trondalen, 2016), as well as high levels of stress on the job, physical exhaustion (Murillo, 2013), secondary traumatic stress (Swezey, 2013) and emotional exhaustion (Vega, 2010). Music therapists have further cited concerns about self-awareness, personal health, appropriate boundaries with psychiatric consumers, transference/countertransference, working as part of an interdisciplinary/multidisciplinary team, and time management (Silverman, 2014). Research has suggested that these issues may impact music therapists’ professional well-being (Swezey, 2013) and prompt individuals to consider leaving the profession (Murillo, 2013). Music Therapy–Specific Research Very little research has been conducted on playing-related injuries among music therapists. A search of the literature revealed only one study investigating music therapists’ experiences with playing-related injuries (Yovich, 1992). (A second study by Howard [2002] was also found; it included music therapists but did not focus on them.) Yovich (1992) surveyed 200 music therapists regarding the frequency of performance-related job injury and usage of medical care for such injuries. Results showed that 40 of 117 individuals who responded to the survey (34%) had experienced pain and/or injury at some point during their career. Females were injured more frequently than males, which is consistent with research among other musicians. Guitar was the most frequently cited instrument that caused pain and/or injury, followed by piano and voice, respectively. However, guitar pain was usually cited as minor, while the voice was associated with more severe injury. Specific areas of the body cited as locations for pain were fingers, hands, and wrists. Only 35% of the respondents who reported injuries sought medical care, which is again consistent with data reported for other types of musicians. Those who did not seek out medical care often attributed pain as just part of playing their instruments. Specific conditions cited in the study included carpal tunnel syndrome, cramps, upper back problems, or overuse syndrome (pain/loss of function in muscles/ligaments due to excessive use). Polyps were also cited. Anti-inflammatory medications were the most frequently prescribed drugs given to treat the conditions, and over-the-counter medications like ibuprofen were also used. Most therapists who participated in the study were able to recover without time off work, although voice rest was required for some therapists. Research related to conditions associated with the helping aspects of music therapy is somewhat limited, but burnout appears to be the most common condition studied. Studies have investigated burnout among students (Clements-Cortes, 2015), clinicians (Chang, 2014; Clements-Cortes, 2006, 2013; Murillo, 2013; Oppenheim, 1987), and music therapy educators (Oppenheim, 1987; Richardson-Delgado, 2006). Risks associated with burnout among music therapists have included (a) financial issues, (b) personal issues, (c) work overload, (d) isolation or lack of understanding from other professionals, (e) amount of training required to practice music therapy, (f) lack of benefits, and (g) lack of awareness (Chang, 2014; Clements-Cortes, 2013). Physical, psychological, and emotional symptoms have also been identified; they have included (a) insomnia, (b) injuries, (c) poor quality of life, (d) shame, and (e) loss of enjoyment of work and lack of motivation (Chang, 2014). Finally, the importance of self-care in preventing burnout has been recognized in the literature, as has been the need to educate students and professionals on the health risks associated with music therapy practice (Clements-Cortes, 2013; Trondalen, 2016). Preventing and Treating Injuries Patient health and well-being is an important factor in therapeutic decision-making. Music therapists regularly consider aspects like healthy sound levels (Standley, 2014) and the physical demands required to play instruments when choosing the most appropriate instrumentation and musical strategies for music therapy practice (Rafieyan & Ries, 2007). The information available on music therapists’ health and well-being, however, appears to suggest that the same consideration is not always afforded to music therapists themselves. Clements-Cortes (2006) interviewed music therapists about work stressors and was surprised to find that no therapist mentioned playing instruments and/or using their voice for substantial periods of time as occupational health stressors. Boyle and Engen (2008) were similarly concerned about the limited information regarding vocal health issues faced by music therapists. Yovich (1992) further cited concerns about music therapists and performance-related injuries, suggesting that music therapists were prime candidates for overuse syndrome. Given the risks associated with music therapy practice, more emphasis is needed on music therapists’ health and well-being. Prevention Preventing injuries starts with maintaining instruments in good working order. Size too should be considered a preventative measure; for example, lightweight, narrow-body guitars can reduce injury in musicians who are smaller in size (Foxman & Burgel, 2006). Evaluating and modifying instruments to ensure ergonomically correct playing position may also be beneficial, as can supportive chairs, proper lifting techniques, and proper chair playing position (Heinan, 2008). Proper techniques when transporting instruments are equally beneficial; straps that go over the head and across the chest can distribute instrument weight more evenly, and gig bags or backpack-style cases can reduce strain. Cases with wheels, rolling suitcases, and hand dollies (or carts, in the case of multiple instruments) can further reduce strain for very large and/or heavy instruments (Foxman & Burgel 2006; Music Therapy Round Table, 2011; Norris, 2011). Development of healthy performance/playing habits can also prevent injury (Guptill & Zaza, 2010), as can instrument-specific strength and endurance training. Stretching, along with maintaining overall good physical health, has even been cited as an effective means of prevention (Kenny & Ackermann, 2010). More information on specific prevention strategies can be found in Tables 1 and 2. Table 2 General Prevention Strategies Practice routine  Adjust to new instruments before significant playing.a Take frequent breaks and vary playing styles.a Increase practice sessions progressively across time.a Warm up and cool down.a Incorporate stretching and strengthening exercises.a If pain is present, modify your activities to prevent further progression of symptoms.d  Posture  Use a neutral playing position.a, b Use less force when possible.a Modify instrument position in relation to body with pads or cushions or specialized seating.a  Playing technique  Seek out technique modifications from other performers to reduce risks.a Consult teachers about health-promoting playing technique.c  Health-promoting behaviors  Avoid smoking.a Get adequate nutrition and sleep.a Participate in bodywork like Alexander Technique and Feldenkrais or meditation and/or mindfulness exercises.a  Practice routine  Adjust to new instruments before significant playing.a Take frequent breaks and vary playing styles.a Increase practice sessions progressively across time.a Warm up and cool down.a Incorporate stretching and strengthening exercises.a If pain is present, modify your activities to prevent further progression of symptoms.d  Posture  Use a neutral playing position.a, b Use less force when possible.a Modify instrument position in relation to body with pads or cushions or specialized seating.a  Playing technique  Seek out technique modifications from other performers to reduce risks.a Consult teachers about health-promoting playing technique.c  Health-promoting behaviors  Avoid smoking.a Get adequate nutrition and sleep.a Participate in bodywork like Alexander Technique and Feldenkrais or meditation and/or mindfulness exercises.a  aFoxman & Burgel (2006). bMitchell (n.d.). cRedman & Tiernan (2001). dSafety & Health in Arts Production and Entertainment (2003). View Large Table 2 General Prevention Strategies Practice routine  Adjust to new instruments before significant playing.a Take frequent breaks and vary playing styles.a Increase practice sessions progressively across time.a Warm up and cool down.a Incorporate stretching and strengthening exercises.a If pain is present, modify your activities to prevent further progression of symptoms.d  Posture  Use a neutral playing position.a, b Use less force when possible.a Modify instrument position in relation to body with pads or cushions or specialized seating.a  Playing technique  Seek out technique modifications from other performers to reduce risks.a Consult teachers about health-promoting playing technique.c  Health-promoting behaviors  Avoid smoking.a Get adequate nutrition and sleep.a Participate in bodywork like Alexander Technique and Feldenkrais or meditation and/or mindfulness exercises.a  Practice routine  Adjust to new instruments before significant playing.a Take frequent breaks and vary playing styles.a Increase practice sessions progressively across time.a Warm up and cool down.a Incorporate stretching and strengthening exercises.a If pain is present, modify your activities to prevent further progression of symptoms.d  Posture  Use a neutral playing position.a, b Use less force when possible.a Modify instrument position in relation to body with pads or cushions or specialized seating.a  Playing technique  Seek out technique modifications from other performers to reduce risks.a Consult teachers about health-promoting playing technique.c  Health-promoting behaviors  Avoid smoking.a Get adequate nutrition and sleep.a Participate in bodywork like Alexander Technique and Feldenkrais or meditation and/or mindfulness exercises.a  aFoxman & Burgel (2006). bMitchell (n.d.). cRedman & Tiernan (2001). dSafety & Health in Arts Production and Entertainment (2003). View Large In addition to the specific strategies listed above, a number of health-promoting behaviors can improve both physical and psychological health and promote wellness. Ensuring adequate sleep, participating in regular exercise, and practicing other aspects of self-care can improve health and prevent problems (Chong et al., 1989; Clements-Cortes, 2013; Foxman & Burgel, 2006; Trondalen, 2016). Self-care involves taking responsibility for your own health and well-being, and it can include prevention of illness or injury and/or managing or coping with symptoms. It may be implemented independently or in conjunction with a healthcare provider (Godfrey et al., 2011). Self-care is particularly important for helping professionals, and the importance of self-care for music therapists has been well recognized (American Music Therapy Association, 2015; Clements-Cortes, 2013). Effective self-care strategies address a range of issues, including workplace safety, ergonomics, hearing health, vocal health, and injury prevention, among others. Maintaining adequate work–life balance, using positive self-talk, meditation, relaxation techniques, and counseling, have all been suggested as ways to prevent occupational health problems (Chong et al., 1989; Clements-Cortes 2013; Trondalen, 2016). Music therapists themselves have highlighted the need to use career-sustaining strategies that span the psychological, physical, and spiritual domains; specific strategies suggested have included (a) humor, (b) healthy diet, (c) rest, (d) recreation/leisure time with loved ones, (e) exercise, (f) hobbies, (g) prayer, and (h) using music outside the workplace (Murillo, 2013; Salmon & Stewart, 2005; Swezey, 2013; Trondalen, 2016). Supervision has also been suggested as a professional self-care strategy, particularly as it relates to personal development and greater self-awareness (Gardstrom & Jackson, 2011; Kennelly, Daveson, & Baker, 2015; Murillo, 2013; Trondalen, 2016). Calls for (a) increased information, (b) access to health-related support services, (c) distribution of materials among schools of music, musicians’ unions, and other organizations that regularly employ or train musicians, and (d) screening programs can be found in the music literature (Clark et al., 2013; Foxman & Burgel, 2006; Trondalen, 2016; Williamon & Thompson, 2006). The need for self-care education among music therapists and music therapy students has also been identified, with incorporating self-care into the curriculum and offering self-care workshops suggested as possible strategies for promoting occupational health and well-being (Clements-Cortes, 2013). Music therapists must be educated about burnout and other conditions that can negatively impact their career satisfaction. More research is needed to better understand how to prevent—and treat—the occupational health hazards faced by music therapists. Treatment Early diagnosis and aggressive treatment of PRMDs is important not only to address presenting problems but also to prevent future issues (Foxman & Burgel, 2006). Careful attention should be paid to pain, tightness, or numbness, and it is important to remember that pain, in particular, is a signal of overuse (Rietveld, 2013). When symptoms like pain present, music therapists should consult a medical professional to rule out specific injuries (Foxman & Burgel, 2006; Rietveld, 2013). During the consultation, it is important to communicate how symptoms impact your ability to function as a music therapist. Other relevant information to discuss may include (a) changes in instruments, (b) hours of practice, (c) practice habits, (d) playing conditions, and (e) previous pain/injury (Heinan, 2008). Conservative treatment (nonoperative) is the typical approach for musicians’ injuries (Rietveld, 2013), and rest is considered a key component of treatment (Heinan, 2008; Lederman, 2003). Individuals should intersperse rest breaks into any practice regimen, avoid playing in pain, and split rehearsals into smaller segments instead of longer, more intense periods (Foxman & Burgel, 2006). “Mental practice” (Reitveld, 2013, p. 431) during physical rest is additionally suggested as an effective means to maintain musical capabilities while also allowing sufficient recovery time. Depending on the type of injury, other treatment approaches may include icing, splinting, and the use of non-steroidal anti-inflammatory medications or analgesics like ibuprofen to reduce pain, swelling, and/or inflammation (Chong et al., 1989; Foxman & Burgel 2006; Lederman, 2003; Rietveld, 2013). Somatic educational practices like the Feldenkrais method or the Alexander technique can facilitate postural and movement training (Williamon & Thompson, 2006), while other body-oriented techniques like biofeedback, massage, and altering playing positions or the instruments themselves may also be included in the treatment process. In more pronounced or resistant cases, injections, immobilization/stabilization, and physical or occupational rehabilitation may be required, although operative treatment is rare and is generally undertaken only after unsuccessful conservative treatment (Heinan, 2008; Lederman, 2003; Norris, 2011; Rietveld, 2013). Psychological needs must also be addressed, and music therapists may need to be taught not to ignore their own needs (Trondalen, 2016). Beta blockers may even be prescribed in cases of performance anxiety (Norris, 2011). Conclusion Music therapists are at risk for a number of health-related occupational hazards. Specific concerns range from playing-related neuromusculoskeletal conditions brought on by overuse or misuse to hearing loss and psychological conditions such as performance anxiety and burnout. Data suggest that these health issues can be significant enough to jeopardize careers; however, health-promoting behaviors may offset some of the risks associated with music therapy practice. Research has shown that simple prevention strategies like proper lifting techniques, modifying instruments, and taking breaks when playing instruments can reduce the risk of injury. Early and aggressive treatment can also promote long-term occupational health and well-being. 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Retrieved from http://search.proquest.com.proxy.lib.fsu.edu/docview/220166703/83FB18BDFB464CACPQ/1?accountid=4840 Zaza C. H. , & Farewell V. T . ( 1997). Musicians’ playing-related musculoskeletal disorders: An examination of risk factors. American Journal of Industrial Medicine , 32, 292– 300. doi: 10.1002/(SICI)1097-0274(199709)32:3<292::AID-AJIM16>3.0.CO;2-Q Google Scholar CrossRef Search ADS PubMed  © the American Music Therapy Association 2016. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Music Therapy Perspectives Oxford University Press

Occupational Health and Well-Being: Hazards, Treatment Options, and Prevention Strategies for Music Therapists

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Abstract

Healthcare is the fastest growing sector in the U.S. economy, and healthcare workers face a wide range of job-related hazards, including injury, illness, violence, and work-related stress. Data suggest that occupational injury and illness in healthcare workers are among the highest of any industry (Centers for Disease Control and Prevention, 2014). Music therapists, like other healthcare professionals, are exposed to work-related stressors that can adversely impact both their physical and mental health. However, unlike other healthcare professionals, music therapists also face additional risks associated with the musical aspects of their career. Research suggests that up to 93% of professional musicians experience playing-related injuries during their career (Kok, Huisstede, Voorn, Schoones, & Nelissen, 2016) and that professional musicians are at risk for contracting hearing disorders (Schink, Kreutz, Busch, Pigeot, & Ahrens, 2014). The literature also suggests that musicians are at risk for various psychological disorders, including anxiety disorders (trait, performance, social) and depression (Kenny, Driscoll, & Ackermann, 2012). Widespread interest in musicians’ job-related hazards first emerged in the 1960s and 1970s (Gaál, 2001). Today there is a growing body of research related to the anatomical, physiological, and psychological components of musicians’ health and well-being. Data suggest that musicians, like athletes, face physical injuries and/or mental health issues significant enough to jeopardize their careers (Pierce, 2012). Consequently, university music programs and professional music and arts organizations like the National Association of Schools of Music (NASM), the International Society for Music Education, and the Performing Arts Medicine Association now provide information on musicians’ health, well-being, and safety (Clark, Williamon, & Redding, 2013). NASM, the organization that establishes standards for undergraduate and graduate degree programs, first began to address the need for inclusion of health and wellness information in academic programs in 2010 (Pierce, 2012). Current NASM policies state that higher education programs should provide or facilitate access to education, counseling, and professional care associated with the maintenance of physical and mental health (NASM, 2015; Pierce, 2012). Hazards Facing Musicians Musicians typically spend many hours per week in both performance and practice. Many musicians start playing at an early age, which means that even young professionals have been playing for years or decades. Some researchers even suggest that most professional musicians have played more than 10,000 hours by the age of 20 (Lee, Eich, Ioannou, & Altenumüller, 2015). This ongoing, long-term exposure increases the risk for playing-related disorders that result from overuse or cumulative trauma (Pierce, 2012; Raymond, Romeo, & Kumke, 2012). Playing-related disorders vary and are often associated with the instrument played; possibilities include (a) muscle/tendon injuries, (b) joint injuries, (c) nerve compression or entrapment disorders, and (d) central nervous system disorders (Kenny & Ackermann, 2015). These disorders, which can be broadly divided into neuromuscular or musculoskeletal disorders, are collectively known as neuromusculoskeletal disorders and involve injury to the muscles, nerves, tendons, joints, and cartilage. Neuromusculoskeletal disorders are caused, precipitated, or exacerbated by persistent exposure to repetition, force, vibration, or awkward posture (Lederman, 2003; NIOSH, 2012). Research has shown that the lifetime prevalence of musculoskeletal disorders in musicians ranges from 62 to 93% (Kok et al., 2016). Playing-related musculoskeletal disorders (PRMDs) can be painful and debilitating, and can limit or even prohibit work (Chong, Lynden, Harvey, & Peebles, 1989; Foxman & Burgel, 2006; Lee et al., 2015; Raymond et al., 2012; Wu, 2007). Hearing Loss Hearing loss has been studied in a wide range of musicians, from orchestral performers to rock musicians, and the importance of hearing protection has been widely documented (Ackermann, Kenny, O’Brien, & Driscoll, 2014; Auchter & Le Prell, 2014; Chesky & Henoch, 2000; Federman & Picou, 2009; Schink et al., 2014). High sound levels can negatively impact musicians, yet musicians often have little control over the environment (Halleland, Harris, Sornes, Murison, & Ursin, 2009; Raymond et al., 2012). Researchers have suggested that musicians are often unaware that prolonged exposure to sound levels over 85dB can cause permanent hearing loss. As a result, the need to promote hearing health has been stressed with recommended strategies including, but not limited to, reducing the amount of time exposed to hazardous sounds or giving the ears a rest after exposure (Chesky, 2008). Hearing protection is especially important given recent research that suggests musicians are almost four times as likely to experience hearing loss (Schink et al., 2014). Unfortunately, the data suggest that hearing protection use among musicians has been limited, and that most musicians do not use hearing protection until symptoms are already present (Olson, Gooding, Shikoh, & Graf, 2016). Psychological Concerns In addition to neuromusculoskeletal conditions and hearing loss, musicians may also be at risk for various psychological concerns. It has been suggested that the mental health needs of musicians are not well understood and often poorly managed; concerns range from substance use to mental health disorders like anxiety and depression (Kenny et al., 2012). Performance anxiety in particular has been noted for its potentially debilitating effects (Pierce, 2012; Zaza & Farewell, 1997), and Kenny and colleagues (2012) found a complex relationship between performance anxiety and depression in their study of orchestral musicians. Research has further suggested that a large percentage of musicians will experience mental and/or physical health issues significant enough to jeopardize their careers (Pierce, 2012). Access to Healthcare Regardless of the type of health concern, data suggest that musicians often attribute symptoms to (a) the impact of an excessive workload on tired muscles, (b) poor posture, (c) poor practice technique, and (d) lack of fitness. As a result, they may not seek professional care for existing or potential issues (Raymond et al., 2012; Williamon & Thompson, 2006). Furthermore, it has been reported that many musicians lack health coverage, leaving them underserved in primary care. This lack of appropriate care can result in untreated or undertreated conditions, social and psychological stress, the inability to play music, permanent disability, and/or the inability to earn an income (Foxman & Burgel, 2006). Risks Associated with Music Therapy Practice Music therapists, like other musicians, are at increased risk for playing-related disorders (PRMDs), hearing loss, and psychological concerns. Music therapists also face risks specifically associated with music therapy practice. Current AMTA Professional Competencies require individuals to establish functional skills in voice, piano, guitar, and percussion (AMTA, 2013). In a 1992 study of performance-related injuries in music therapists, Yovich found that three of these instruments (guitar, voice, and piano) were cited as both the most played and the most pain causing. Though Yovich’s data is over 20 years old, functional skills on voice, piano, and guitar, along with percussion skills, are still considered “very desirable” to “essential” by music therapists (Jenkins, 2013), highlighting their ongoing importance to music therapy practice. It is therefore important that music therapists are aware of risks associated with these instruments. The following information highlights some of the more common hazards linked to each instrument. Voice Vocal problems have been well documented in fields with high voice demands. In 2008 Boyle and Engen wrote about the lack of information on the impact of vocal use in music therapists. Though information within the field of music therapy is limited, data are available from other professional voice users like singers and teachers (Doherty, 2011). One commonly cited problem is vocal fatigue (Boyle & Engen, 2008). Breathiness, aphonia (voice loss), and pain have also been cited in the literature (Doherty, 2011). Causes of voice problems include (a) misuse or overuse, (b) inflammation, (c) infections, (d) vocal nodules, and (e) neurological diseases (NIDCD, 2014). Symptoms of possible voice problems include (a) hoarse or raspy voice, (b) diminished range, (c) sudden deepening of the voice, (d) raw, achy throat, (e) difficulty talking, and (f) repeated need to clear your throat (NIDCD, 2014). Music therapists must also be aware of other factors that contribute to vocal health. For example, noisy environments (Houtte, Claeys, Wuyts, & Van Lierde, 2011), poor acoustics (Doherty, 2011), and moving between large and small groups (Boyle & Engen, 2008) can impact vocal health. Long days of speaking and singing, voice-compromising postures, singing in keys that are beyond the therapist’s comfortable range, and lack of focus on good posture and breath support when simultaneously singing and accompanying oneself may all contribute to vocal health issues (Boyle & Engen, 2008). Strategies for preventing and/or treating vocal conditions can be found in Table 1. Table 1 Common Music Therapy Instruments, Associated Injuries, and Prevention Strategies Instrument  Conditions/Disorders  Symptoms  Strategies to prevent/combat injuries  Voicea  • Organic disorders: related to anatomy/physiology (e.g., nodule, infection) • Functional disorders: related to improper use  • Hoarseness • Voices tires easily • Difficulty singing/speaking softly • Difficulty projecting • Loss of singing range • Discomfort • Chronic throat dryness or soreness • Difficulty swallowing • Shaky voice • Monotone voice  • Warm up • Ensure adequate sleep, hydration, and nutrition • Conserve the voice when possible (i.e., using nonverbal or written communication) • Amplify the voice when needed  Pianob  • PRMDs caused by misuse • PRMDs caused by overuse  • Pain/aching in wrist, hands, and fingers  • Warm up/cool down • Stretch • Take breaks to reduce tension • Maintain appropriate sitting posture (normal curve of the back, adjusted bench, etc.) • Use cognitive rehearsal (e.g., play on a tabletop before playing on the piano)  Guitarc  • PRMDs caused by overuse  • Pain • Decreased functioning • Motor coordination problems  • Use neutral playing positions • Adjust playing position when sitting vs. standing • Warm up • Take breaks • Use of soft carrying cases to reduce load  Percussiond    Pain Problems in hand, elbow, shoulders, and back  • Use neutral posture and ensure postural alignment • Warm up; take breaks • Use stretching/strengthening exercises • Be conscious of posture when standing  Instrument  Conditions/Disorders  Symptoms  Strategies to prevent/combat injuries  Voicea  • Organic disorders: related to anatomy/physiology (e.g., nodule, infection) • Functional disorders: related to improper use  • Hoarseness • Voices tires easily • Difficulty singing/speaking softly • Difficulty projecting • Loss of singing range • Discomfort • Chronic throat dryness or soreness • Difficulty swallowing • Shaky voice • Monotone voice  • Warm up • Ensure adequate sleep, hydration, and nutrition • Conserve the voice when possible (i.e., using nonverbal or written communication) • Amplify the voice when needed  Pianob  • PRMDs caused by misuse • PRMDs caused by overuse  • Pain/aching in wrist, hands, and fingers  • Warm up/cool down • Stretch • Take breaks to reduce tension • Maintain appropriate sitting posture (normal curve of the back, adjusted bench, etc.) • Use cognitive rehearsal (e.g., play on a tabletop before playing on the piano)  Guitarc  • PRMDs caused by overuse  • Pain • Decreased functioning • Motor coordination problems  • Use neutral playing positions • Adjust playing position when sitting vs. standing • Warm up • Take breaks • Use of soft carrying cases to reduce load  Percussiond    Pain Problems in hand, elbow, shoulders, and back  • Use neutral posture and ensure postural alignment • Warm up; take breaks • Use stretching/strengthening exercises • Be conscious of posture when standing  aDoherty (2011). bAllsop & Ackland (2010); Guptill & Zaza (2010). cFjellman-Wiklund & Chesky (2006); Foxman & Burgel (2006); Marques et al. (2003). dBrandfonbrener (2009); Sandell et al. (2009). View Large Table 1 Common Music Therapy Instruments, Associated Injuries, and Prevention Strategies Instrument  Conditions/Disorders  Symptoms  Strategies to prevent/combat injuries  Voicea  • Organic disorders: related to anatomy/physiology (e.g., nodule, infection) • Functional disorders: related to improper use  • Hoarseness • Voices tires easily • Difficulty singing/speaking softly • Difficulty projecting • Loss of singing range • Discomfort • Chronic throat dryness or soreness • Difficulty swallowing • Shaky voice • Monotone voice  • Warm up • Ensure adequate sleep, hydration, and nutrition • Conserve the voice when possible (i.e., using nonverbal or written communication) • Amplify the voice when needed  Pianob  • PRMDs caused by misuse • PRMDs caused by overuse  • Pain/aching in wrist, hands, and fingers  • Warm up/cool down • Stretch • Take breaks to reduce tension • Maintain appropriate sitting posture (normal curve of the back, adjusted bench, etc.) • Use cognitive rehearsal (e.g., play on a tabletop before playing on the piano)  Guitarc  • PRMDs caused by overuse  • Pain • Decreased functioning • Motor coordination problems  • Use neutral playing positions • Adjust playing position when sitting vs. standing • Warm up • Take breaks • Use of soft carrying cases to reduce load  Percussiond    Pain Problems in hand, elbow, shoulders, and back  • Use neutral posture and ensure postural alignment • Warm up; take breaks • Use stretching/strengthening exercises • Be conscious of posture when standing  Instrument  Conditions/Disorders  Symptoms  Strategies to prevent/combat injuries  Voicea  • Organic disorders: related to anatomy/physiology (e.g., nodule, infection) • Functional disorders: related to improper use  • Hoarseness • Voices tires easily • Difficulty singing/speaking softly • Difficulty projecting • Loss of singing range • Discomfort • Chronic throat dryness or soreness • Difficulty swallowing • Shaky voice • Monotone voice  • Warm up • Ensure adequate sleep, hydration, and nutrition • Conserve the voice when possible (i.e., using nonverbal or written communication) • Amplify the voice when needed  Pianob  • PRMDs caused by misuse • PRMDs caused by overuse  • Pain/aching in wrist, hands, and fingers  • Warm up/cool down • Stretch • Take breaks to reduce tension • Maintain appropriate sitting posture (normal curve of the back, adjusted bench, etc.) • Use cognitive rehearsal (e.g., play on a tabletop before playing on the piano)  Guitarc  • PRMDs caused by overuse  • Pain • Decreased functioning • Motor coordination problems  • Use neutral playing positions • Adjust playing position when sitting vs. standing • Warm up • Take breaks • Use of soft carrying cases to reduce load  Percussiond    Pain Problems in hand, elbow, shoulders, and back  • Use neutral posture and ensure postural alignment • Warm up; take breaks • Use stretching/strengthening exercises • Be conscious of posture when standing  aDoherty (2011). bAllsop & Ackland (2010); Guptill & Zaza (2010). cFjellman-Wiklund & Chesky (2006); Foxman & Burgel (2006); Marques et al. (2003). dBrandfonbrener (2009); Sandell et al. (2009). View Large Piano Musculoskeletal disorders are more common in pianists than in any other type of instrument, perhaps due to the motor demands placed on the arm, hand, and fingers (Allsop & Ackland, 2010). Musculoskeletal disorders include conditions like tendonitis (inflammation/irritation of the tendons), arthritis, and ligament sprains. Pianists often complain of tenderness in the wrists and fingers, and playing-related disorders typically include inflammatory problems like tendonitis, nerve and motor injuries, compressions or entrapments (e.g., carpal tunnel syndrome), or degenerative joint problems related to continued trauma (Lai et al., 2015). Some studies have suggested that risks for piano-related injuries or conditions are greater if the pianist is older and has a smaller hand size. Risks have also been associated with gender (female) (Bragge, Bialocerkowski, & McMeeken, 2006), unstable joints, or less playing experience (Redman & Tiernan, 2001). Given the predominance of females in the field of music therapy, it is important that female music therapists are aware of the potential for increased risks. Music therapists should also note that right-sided symptoms have been found to be more common, and that specific piano techniques, like octaves, arpeggios, and wide extent passages, have also been connected with injuries. Awkward playing positions, arguably a common issue for music therapists, can also contribute to injury (Heinan, 2008; Redman & Tierman, 2001). However, neutral playing positions may increase optimal functioning and reduce the likelihood of injury (Guptill & Zaza, 2010). Other aspects that have been associated with piano injuries include typing, caffeine consumption, and poor habits. Poor habits connected with injury include (a) tension, (b) bad posture or body mechanics, (c) extended practice sessions, (d) lack of practice breaks, (e) poor technique, (f) playing multiple instruments, (g) sudden increases in practice time, and (h) difficult repertoire (Redman & Tiernan, 2001). Strategies to address piano-related conditions can be found in Table 1. Guitar Musculoskeletal problems in guitarists are usually associated with the upper extremities (left hand, wrist, and neck) and back (Fjellman-Wiklund & Chesky, 2006; Rigg, Marrinan, & Thomas, 2003). Studies have shown that guitarists, both classical and popular music performers, are at risk for neck and shoulder disorders, with left-side problems more common (Dawson, 2002; Fjellman-Wiklund, Brulin, & Sundelin, 2003). Pain complaints have also been well documented, and some researchers have suggested that awkward sitting postures may be a major cause of guitarists’ pain-related complaints (Dhriti, Agrawal, & Aju, 2003). Guitarists, like pianists, can face additional issues, including inflammation and nerve problems. They may even deal with guitar string dermatitis and finger fractures, as well as shortening of the distal phalangeal finger bones from mechanical stress (Fjellman-Wiklund & Chesky, 2006). Other non-musculoskeletal concerns associated with playing the guitar include (a) stress, (b) fatigue, (c) sleep problems, (d) depression, (e) anxiety, (f) stage fright, and (g) substance abuse (Chesky & Hipple, 1999; Raeburn, 2000). Stressful work environments have been connected with headache and eye strain in guitarists, and many of the above problems are the result of extreme postures, repetitive movements, and static muscle work (Bosi, 2016). Again, like playing the piano, females are also potentially at increased risk. Music therapists must be aware of differences in sitting and standing playing positions and strive for a neutral playing posture that balances static (fixed holding position) and dynamic loads (force during movement) (Foxman & Burgel, 2006). More information on guitarists’ risks can be found in Table 1. Percussion Perhaps more so than any other instrument, playing percussion instruments places great demand on the musculoskeletal system (Mishra, De, Gangopadhyay, & Chandra, 2013; Sandell, Frykman, Chesky, & Fjellman-Wiklund, 2009). The playing motion for most percussion instruments involves wrist volar flexion (bending wrist toward palm) and dorsiflexion (bending wrist toward back of hand), medial rotation of the elbow (toward the body), and internal rotation of the shoulder (toward the body). Because of these movement patterns, most injuries occur in the muscle origins of the elbows and the extensor muscles of the forearm and the hand muscles, as well as the ligaments of the wrist and at the base of the thumb. The repetitive striking motions used to play most percussion instruments can result in overuse and tissue injuries from the elbow down, and stress can increase the likelihood that muscular problems occur (Fry, 1984; Judkins, 1991; Lederman & Calabrese, 1986; Sandell et al., 2009). Given that many percussion instruments require individuals to stand while playing them, poor posture can also lead to back pain. Hard surfaces, especially those found in keyboard instruments, can also contribute to injuries. Music therapists should be aware of the physical demands placed on the performer when playing percussion instruments and take them into consideration when using them during music therapy practice. More information on percussion-related injuries can be found in Table 1. Risks Associated with Helping Music therapists may be at risk for a range of conditions associated with the therapeutic or helping aspects of their career. These conditions are precipitated by stressors like poor working conditions, exposure to client trauma, and work–life balance (Trondalen, 2016) and can lead to distress, dissatisfaction, psychosomatic illnesses, reduced quality of life, and diminished service provision (Ruotsalainen, Verbeek, Mariné, & Serra, 2015; Trondalen, 2016). Specific stressors identified by music therapists include difficult referrals, ongoing need for advocacy for music therapy, poor working conditions, lack of professional recognition, and relationships with interdisciplinary team members, among others (Clements-Cortes, 2006; Trondalen, 2016). If stressors are not adequately managed, they can lead to both physical (i.e., headaches or hypertension) and psychological symptoms (i.e., anxiety or irritability). One of the most common issues faced by helping professionals is burnout, a syndrome that includes physical exhaustion, emotional exhaustion, distress, decreased motivation, and reduced personal accomplishment (Chang, 2014; Ruotsalainen et al., 2015). Burnout has been cited as a concern for music therapists, much like others in helping professions or human service fields (Chang, 2014; Clements-Cortes, 2006, 2013; Fowler, 2006). Specific job characteristics like lack of support, limited control, and unfair decision-making processes have been cited as risk factors for burnout, and the onset of burnout has been found to be moderated by personality characteristics (Skodova & Lajciakova, 2013). Anxiety, in particular, has been found to be predictive of emotional exhaustion, a primary symptom of burnout (Chang, 2014; Vega, 2010). Some research has suggested that music therapists may have a proclivity toward anxiety as a personality trait (Vega, 2010); music therapists may therefore need to take special precautions to identify and address anxiety associated with work life. Additional conditions or stressors identified in the literature include compassion fatigue and compassion stress (Clements-Cortes, 2006; Trondalen, 2016), as well as high levels of stress on the job, physical exhaustion (Murillo, 2013), secondary traumatic stress (Swezey, 2013) and emotional exhaustion (Vega, 2010). Music therapists have further cited concerns about self-awareness, personal health, appropriate boundaries with psychiatric consumers, transference/countertransference, working as part of an interdisciplinary/multidisciplinary team, and time management (Silverman, 2014). Research has suggested that these issues may impact music therapists’ professional well-being (Swezey, 2013) and prompt individuals to consider leaving the profession (Murillo, 2013). Music Therapy–Specific Research Very little research has been conducted on playing-related injuries among music therapists. A search of the literature revealed only one study investigating music therapists’ experiences with playing-related injuries (Yovich, 1992). (A second study by Howard [2002] was also found; it included music therapists but did not focus on them.) Yovich (1992) surveyed 200 music therapists regarding the frequency of performance-related job injury and usage of medical care for such injuries. Results showed that 40 of 117 individuals who responded to the survey (34%) had experienced pain and/or injury at some point during their career. Females were injured more frequently than males, which is consistent with research among other musicians. Guitar was the most frequently cited instrument that caused pain and/or injury, followed by piano and voice, respectively. However, guitar pain was usually cited as minor, while the voice was associated with more severe injury. Specific areas of the body cited as locations for pain were fingers, hands, and wrists. Only 35% of the respondents who reported injuries sought medical care, which is again consistent with data reported for other types of musicians. Those who did not seek out medical care often attributed pain as just part of playing their instruments. Specific conditions cited in the study included carpal tunnel syndrome, cramps, upper back problems, or overuse syndrome (pain/loss of function in muscles/ligaments due to excessive use). Polyps were also cited. Anti-inflammatory medications were the most frequently prescribed drugs given to treat the conditions, and over-the-counter medications like ibuprofen were also used. Most therapists who participated in the study were able to recover without time off work, although voice rest was required for some therapists. Research related to conditions associated with the helping aspects of music therapy is somewhat limited, but burnout appears to be the most common condition studied. Studies have investigated burnout among students (Clements-Cortes, 2015), clinicians (Chang, 2014; Clements-Cortes, 2006, 2013; Murillo, 2013; Oppenheim, 1987), and music therapy educators (Oppenheim, 1987; Richardson-Delgado, 2006). Risks associated with burnout among music therapists have included (a) financial issues, (b) personal issues, (c) work overload, (d) isolation or lack of understanding from other professionals, (e) amount of training required to practice music therapy, (f) lack of benefits, and (g) lack of awareness (Chang, 2014; Clements-Cortes, 2013). Physical, psychological, and emotional symptoms have also been identified; they have included (a) insomnia, (b) injuries, (c) poor quality of life, (d) shame, and (e) loss of enjoyment of work and lack of motivation (Chang, 2014). Finally, the importance of self-care in preventing burnout has been recognized in the literature, as has been the need to educate students and professionals on the health risks associated with music therapy practice (Clements-Cortes, 2013; Trondalen, 2016). Preventing and Treating Injuries Patient health and well-being is an important factor in therapeutic decision-making. Music therapists regularly consider aspects like healthy sound levels (Standley, 2014) and the physical demands required to play instruments when choosing the most appropriate instrumentation and musical strategies for music therapy practice (Rafieyan & Ries, 2007). The information available on music therapists’ health and well-being, however, appears to suggest that the same consideration is not always afforded to music therapists themselves. Clements-Cortes (2006) interviewed music therapists about work stressors and was surprised to find that no therapist mentioned playing instruments and/or using their voice for substantial periods of time as occupational health stressors. Boyle and Engen (2008) were similarly concerned about the limited information regarding vocal health issues faced by music therapists. Yovich (1992) further cited concerns about music therapists and performance-related injuries, suggesting that music therapists were prime candidates for overuse syndrome. Given the risks associated with music therapy practice, more emphasis is needed on music therapists’ health and well-being. Prevention Preventing injuries starts with maintaining instruments in good working order. Size too should be considered a preventative measure; for example, lightweight, narrow-body guitars can reduce injury in musicians who are smaller in size (Foxman & Burgel, 2006). Evaluating and modifying instruments to ensure ergonomically correct playing position may also be beneficial, as can supportive chairs, proper lifting techniques, and proper chair playing position (Heinan, 2008). Proper techniques when transporting instruments are equally beneficial; straps that go over the head and across the chest can distribute instrument weight more evenly, and gig bags or backpack-style cases can reduce strain. Cases with wheels, rolling suitcases, and hand dollies (or carts, in the case of multiple instruments) can further reduce strain for very large and/or heavy instruments (Foxman & Burgel 2006; Music Therapy Round Table, 2011; Norris, 2011). Development of healthy performance/playing habits can also prevent injury (Guptill & Zaza, 2010), as can instrument-specific strength and endurance training. Stretching, along with maintaining overall good physical health, has even been cited as an effective means of prevention (Kenny & Ackermann, 2010). More information on specific prevention strategies can be found in Tables 1 and 2. Table 2 General Prevention Strategies Practice routine  Adjust to new instruments before significant playing.a Take frequent breaks and vary playing styles.a Increase practice sessions progressively across time.a Warm up and cool down.a Incorporate stretching and strengthening exercises.a If pain is present, modify your activities to prevent further progression of symptoms.d  Posture  Use a neutral playing position.a, b Use less force when possible.a Modify instrument position in relation to body with pads or cushions or specialized seating.a  Playing technique  Seek out technique modifications from other performers to reduce risks.a Consult teachers about health-promoting playing technique.c  Health-promoting behaviors  Avoid smoking.a Get adequate nutrition and sleep.a Participate in bodywork like Alexander Technique and Feldenkrais or meditation and/or mindfulness exercises.a  Practice routine  Adjust to new instruments before significant playing.a Take frequent breaks and vary playing styles.a Increase practice sessions progressively across time.a Warm up and cool down.a Incorporate stretching and strengthening exercises.a If pain is present, modify your activities to prevent further progression of symptoms.d  Posture  Use a neutral playing position.a, b Use less force when possible.a Modify instrument position in relation to body with pads or cushions or specialized seating.a  Playing technique  Seek out technique modifications from other performers to reduce risks.a Consult teachers about health-promoting playing technique.c  Health-promoting behaviors  Avoid smoking.a Get adequate nutrition and sleep.a Participate in bodywork like Alexander Technique and Feldenkrais or meditation and/or mindfulness exercises.a  aFoxman & Burgel (2006). bMitchell (n.d.). cRedman & Tiernan (2001). dSafety & Health in Arts Production and Entertainment (2003). View Large Table 2 General Prevention Strategies Practice routine  Adjust to new instruments before significant playing.a Take frequent breaks and vary playing styles.a Increase practice sessions progressively across time.a Warm up and cool down.a Incorporate stretching and strengthening exercises.a If pain is present, modify your activities to prevent further progression of symptoms.d  Posture  Use a neutral playing position.a, b Use less force when possible.a Modify instrument position in relation to body with pads or cushions or specialized seating.a  Playing technique  Seek out technique modifications from other performers to reduce risks.a Consult teachers about health-promoting playing technique.c  Health-promoting behaviors  Avoid smoking.a Get adequate nutrition and sleep.a Participate in bodywork like Alexander Technique and Feldenkrais or meditation and/or mindfulness exercises.a  Practice routine  Adjust to new instruments before significant playing.a Take frequent breaks and vary playing styles.a Increase practice sessions progressively across time.a Warm up and cool down.a Incorporate stretching and strengthening exercises.a If pain is present, modify your activities to prevent further progression of symptoms.d  Posture  Use a neutral playing position.a, b Use less force when possible.a Modify instrument position in relation to body with pads or cushions or specialized seating.a  Playing technique  Seek out technique modifications from other performers to reduce risks.a Consult teachers about health-promoting playing technique.c  Health-promoting behaviors  Avoid smoking.a Get adequate nutrition and sleep.a Participate in bodywork like Alexander Technique and Feldenkrais or meditation and/or mindfulness exercises.a  aFoxman & Burgel (2006). bMitchell (n.d.). cRedman & Tiernan (2001). dSafety & Health in Arts Production and Entertainment (2003). View Large In addition to the specific strategies listed above, a number of health-promoting behaviors can improve both physical and psychological health and promote wellness. Ensuring adequate sleep, participating in regular exercise, and practicing other aspects of self-care can improve health and prevent problems (Chong et al., 1989; Clements-Cortes, 2013; Foxman & Burgel, 2006; Trondalen, 2016). Self-care involves taking responsibility for your own health and well-being, and it can include prevention of illness or injury and/or managing or coping with symptoms. It may be implemented independently or in conjunction with a healthcare provider (Godfrey et al., 2011). Self-care is particularly important for helping professionals, and the importance of self-care for music therapists has been well recognized (American Music Therapy Association, 2015; Clements-Cortes, 2013). Effective self-care strategies address a range of issues, including workplace safety, ergonomics, hearing health, vocal health, and injury prevention, among others. Maintaining adequate work–life balance, using positive self-talk, meditation, relaxation techniques, and counseling, have all been suggested as ways to prevent occupational health problems (Chong et al., 1989; Clements-Cortes 2013; Trondalen, 2016). Music therapists themselves have highlighted the need to use career-sustaining strategies that span the psychological, physical, and spiritual domains; specific strategies suggested have included (a) humor, (b) healthy diet, (c) rest, (d) recreation/leisure time with loved ones, (e) exercise, (f) hobbies, (g) prayer, and (h) using music outside the workplace (Murillo, 2013; Salmon & Stewart, 2005; Swezey, 2013; Trondalen, 2016). Supervision has also been suggested as a professional self-care strategy, particularly as it relates to personal development and greater self-awareness (Gardstrom & Jackson, 2011; Kennelly, Daveson, & Baker, 2015; Murillo, 2013; Trondalen, 2016). Calls for (a) increased information, (b) access to health-related support services, (c) distribution of materials among schools of music, musicians’ unions, and other organizations that regularly employ or train musicians, and (d) screening programs can be found in the music literature (Clark et al., 2013; Foxman & Burgel, 2006; Trondalen, 2016; Williamon & Thompson, 2006). The need for self-care education among music therapists and music therapy students has also been identified, with incorporating self-care into the curriculum and offering self-care workshops suggested as possible strategies for promoting occupational health and well-being (Clements-Cortes, 2013). Music therapists must be educated about burnout and other conditions that can negatively impact their career satisfaction. More research is needed to better understand how to prevent—and treat—the occupational health hazards faced by music therapists. Treatment Early diagnosis and aggressive treatment of PRMDs is important not only to address presenting problems but also to prevent future issues (Foxman & Burgel, 2006). Careful attention should be paid to pain, tightness, or numbness, and it is important to remember that pain, in particular, is a signal of overuse (Rietveld, 2013). When symptoms like pain present, music therapists should consult a medical professional to rule out specific injuries (Foxman & Burgel, 2006; Rietveld, 2013). During the consultation, it is important to communicate how symptoms impact your ability to function as a music therapist. Other relevant information to discuss may include (a) changes in instruments, (b) hours of practice, (c) practice habits, (d) playing conditions, and (e) previous pain/injury (Heinan, 2008). Conservative treatment (nonoperative) is the typical approach for musicians’ injuries (Rietveld, 2013), and rest is considered a key component of treatment (Heinan, 2008; Lederman, 2003). Individuals should intersperse rest breaks into any practice regimen, avoid playing in pain, and split rehearsals into smaller segments instead of longer, more intense periods (Foxman & Burgel, 2006). “Mental practice” (Reitveld, 2013, p. 431) during physical rest is additionally suggested as an effective means to maintain musical capabilities while also allowing sufficient recovery time. Depending on the type of injury, other treatment approaches may include icing, splinting, and the use of non-steroidal anti-inflammatory medications or analgesics like ibuprofen to reduce pain, swelling, and/or inflammation (Chong et al., 1989; Foxman & Burgel 2006; Lederman, 2003; Rietveld, 2013). Somatic educational practices like the Feldenkrais method or the Alexander technique can facilitate postural and movement training (Williamon & Thompson, 2006), while other body-oriented techniques like biofeedback, massage, and altering playing positions or the instruments themselves may also be included in the treatment process. In more pronounced or resistant cases, injections, immobilization/stabilization, and physical or occupational rehabilitation may be required, although operative treatment is rare and is generally undertaken only after unsuccessful conservative treatment (Heinan, 2008; Lederman, 2003; Norris, 2011; Rietveld, 2013). Psychological needs must also be addressed, and music therapists may need to be taught not to ignore their own needs (Trondalen, 2016). Beta blockers may even be prescribed in cases of performance anxiety (Norris, 2011). Conclusion Music therapists are at risk for a number of health-related occupational hazards. Specific concerns range from playing-related neuromusculoskeletal conditions brought on by overuse or misuse to hearing loss and psychological conditions such as performance anxiety and burnout. Data suggest that these health issues can be significant enough to jeopardize careers; however, health-promoting behaviors may offset some of the risks associated with music therapy practice. Research has shown that simple prevention strategies like proper lifting techniques, modifying instruments, and taking breaks when playing instruments can reduce the risk of injury. Early and aggressive treatment can also promote long-term occupational health and well-being. 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Music Therapy PerspectivesOxford University Press

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