Published 12 December 2008, doi:10.1136/bmj.a2646
Cite this as: BMJ 2008;337:a2646

Feature

Christmas 2008: Music

A symphony of maladies

Sarah Bache, core surgical trainee 1 in plastic surgery 1, Frank Edenborough, consultant respiratory physician1

1 Northern General Hospital, Sheffield S5 7AU

Correspondence to: S Bache sarahbache{at}doctors.org.uk

Sarah Bache and Frank Edenborough uncover scores of health problems associated with making music


Key points

Touring with a band or orchestra may lead to disrupted routines, late nights, poor food, reduced exercise and stress, all of which take their toll on general health
The instrument itself, as result of its composition, weight, and shape, together with the force required to play it and the prolonged and repetitive nature of practice, may lead to a host of instrument specific injuries
Overuse syndromes, focal dystonias, dermal sensitisation, and respiratory, oropharyngeal, and cardiovascular anomalies may result
Minor injuries are amplified by the precision required to play at the highest standard and may be career threatening


Classical musicians have never been considered a daredevil bunch, and playing classical music is one of life’s more genteel pastimes. Yet the perils of the seemingly innocuous activities of the orchestra have long been a closely guarded secret. Fearful of being exposed as weak and jeopardising their place in the orchestra—or worse, their livelihood—musicians often suffer in silence rather than advertise their injuries. As two interested musicians, we carried out a Medline search of the available medical literature and scoured the internet for supportive organisations. We discovered the dangers hidden within the confines of the orchestral practice room; we also briefly looked at the dangers associated with other types of music making. Welcome to the world of fiddler’s neck, laryngeal blowouts, and Satchmo’s syndrome.

Musicians who tour have unique stresses placed on their health, many of which are well documented on the website of the Performing Arts Medicine Association.1 Hours of travel disturbing the normal circadian rhythm, lack of healthy food and exercise, time spent away from home and family, and the pressures of maintaining performance excellence2 and of stage fright all take their toll on physical and mental wellbeing.3

Overuse syndrome

Many hours are spent in preparation for musical performances that can last several hours. Athletes undergoing repetitive, prolonged, muscular activity are considered to be "training" and their injuries relate to the specific sports equipment used. Similarly, playing a musical instrument requires highly coordinated, repetitive fine movements under adverse conditions of unusual posture and considerable force. Thus, musicians experience similar instrument specific injuries.

Overuse syndrome is characterised by pain and tenderness in muscles and joints as a consequence of excessive use, manifesting itself as loss of agility and accuracy.4 Prolonged practice at the extremities of range of motion results in a plethora of disorders including tendinitis or tenosynovitis and neurological disturbance.5 Overuse syndrome is a valid cause of anguish for musicians: in one study, a listening panel could distinguish between pianists’ hands affected and unaffected by overuse.6

Instrument specific causes of overuse syndrome include strain in the right thumb of clarinettists, from loading the weight of the instrument on to the thumb rest. It may be reduced by neck straps7 or more ergonomic thumb rests. Supports for the right hand of flautists have also been developed.8 However, many overuse syndromes are not limited to a single instrument.9

Focal dystonias

Characterised by unwanted muscle contraction, focal dystonias are thought to be caused by overactive neural plasticity in the motor cortex, predisposed by a hereditary component and male sex.10 They are usually painless but nevertheless can be devastating to a musician who needs to perform repetitive, accurate hand movements.11 Treatments involve botulinum toxin injections,12 sensorimotor retraining,13 technical exercises,14 and developing ergonomic instruments. Players of keyboards and plucked instruments are mainly affected in the right hand. Conversely, string players who use bows—who carry out more complex movements on the left—are affected on the left side.15 Woodwind instruments tend to cause bilateral problems.16 Brass players experience embouchure dystonia, causing involuntary muscle contraction around the mouth,17 tremor, and jaw closure.18

Part of the problem with treating both overuse syndrome and focal dystonias is the reluctance of musicians to interrupt practice.19 In 1985 Leon Fleisher, a professional concert pianist, told an interviewer that "there was something macho about practicing through the pain barrier." He spent 30 years playing only left handed concerts after excessive practice resulted in pianist’s hand, a type of focal dystonia.20

Dermatological conditions

Hours of close contact with instruments can lead to dermatitis.21 Irritant culprits include nickel in trumpets22; chromium and brass in guitar strings,23 flute heads, and brass mouthpieces; cane reeds of saxophones and oboes24; and exotic woods, rosins, and varnishes in stringed instruments.25 26

The ubiquitous brown mark on the left side of the neck in players of upper string instruments (violins and violas), known as fiddler’s neck, is caused by a combination of skin sensitisation, pressure, and moisture. Hyperpigmentation and lichenification produce scaling, pustules, and eventually scarring.27 Flautist’s chin may similarly result from friction and salivation.28 Both conditions may be alleviated by beard growth, although we have yet to discover a solution for women. Similar dermatoses causing tenderness, erythema, and oedema may be seen over anatomical protuberances secondary to pressure and irritation. Guitarist’s nipple,29 cellist’s chest,30 cello knee,31 and cello scrotum32 are all described, although the awkward playing position required to produce the latter make it a rarity that has been questioned.33

Guitarists and harpists can develop calluses, subungual haematomata, and paronychias, while Garrod’s pads are thickenings over the extensor aspect of the interphalangeal joints in string players, which may mimic Heberden’s or Bouchard’s nodes.34 Damage from playing an instrument is not restricted to damage to the musician: extreme sweating may cause discoloration of lacquered instruments and has been reported to erode instruments such as a flute and trombone.35

Maxillofacial and dental disorders

Musicians even have specific orthodontic problems.36 Pressure under the left mandible of upper string players may be associated with dysfunction of the temporomandibular joint, producing crepitus, pain, and a predisposition to bruxism: 73% of violinists grind their teeth, compared with 34% in a control group.37 Excess pressure on mouthpieces in brass players may also lead to pain from the temporomandibular joint as well as gradual repositioning of front teeth.38

Satchmo’s syndrome (rupture of the orbicularis oris), named after Louis "Satchelmouth" Armstrong, results in reduced range, agility, and stamina for high notes. Treatment is rest or surgical repair, leading to resumption of playing at a pre-morbid level.39 40

Laryngopharyngeal disorders

Oboists, horn players, and trumpeters perform high pressure, low flow volume Valsalva-like manoeuvres to play loudly or high in the register.41 Such high pressures can cause haryngeal incompetence, with reports of nasal speech and regurgitation of liquids, or snorting while playing. Treatment includes speech and language therapy, lipoinjection of the soft palate,42 or surgical grafts or Teflon inserts to the soft palate.43 Laryngocele or "laryngeal blowouts" are herniations of the laryngeal saccule, a vestigial remnant in humans.44 They manifest as neck swellings noticed during playing and may be associated with carcinoma of the larynx.45

Cardiovascular disorders

Whereas sinus tachycardia related to performance anxiety comes with the territory,46 47 FE, as a horn player, was alarmed to discover reports of players of French horns developing wandering atrial pacemakers during recitals48; and carotid dissection can occur in wind players, probably because of increased intrathoracic pressure when playing.49 Performing the Valsalva manoeuvre when playing brass or wind instruments is associated not only with changes in blood pressure and heart rate50 but also with epidural haematomas51 and recurrent transient ischaemic attacks, secondary to patent foramen ovale, permitting microemboli to pass into the middle cerebral arteries as a result of increased right to left shunt.52 Circular breathing—which enables wind players to produce a continuous note by inhaling through the nose while exhaling air stored in the cheeks through the mouth—may affect autonomic control of the heart.53

Respiratory problems

Musicians and the Musician’s Union were some of the most ardent supporters of the recently introduced smoking ban in pubs and clubs after links were made between passive smoking and respiratory disease54 and the deaths of several high profile musicians, including the British trumpeter Roy Castle.55 Wind musicians have decreased pulmonary function compared with a control group, possibly as a result of developing asthma or barotrauma when playing.56 57 Yet, conversely, playing wind instruments has been found to reduce symptoms in asthmatic teenagers.58

Ophthalmic problems

High resistance wind players, such as trumpeters and oboists have been shown to have an increased intraocular pressure when playing,59 resulting in a small but significant increase in visual field loss.60

Deafness and tinnitus

Concern for the hearing of musicians is increasing, and members of an orchestra have been found to have more than twice the expected hearing loss for their age.61 Prevention includes earplugs, baffles, and positioning of players within the ensemble.62

Conclusion

Beneath the sublimity of music lies hard work and dedication. Each instrument may exact a specific toll on any who try to master it, and even apparently minor injuries may be devastating. We must recognise the unique requirements of this special group of patients so that they may continue to produce the music we so enjoy.


Useful resources
Bernardino Ramazzini first summarised disorders of musicians in the early 18th century in his De Morbis Artificum Diatriba (Diseases of Tradesmen). More recent help has become available, fortunately, from organisations that can provide musicians with contacts and advice on stress management and injury avoidance.


Cite this as: BMJ 2008;337:a2646

Contributors: Both authors carried out a Medline search of the available medical literature and scoured the internet for supportive organisations. FE is the guarantor.

Competing interests: FE is a member of the British Association for Performing Arts Medicine and is principal horn of the Sheffield Philharmonic Orchestra and occasional soloist. SB is an out of practice pianist.

Provenance and peer review: Not commissioned; externally peer reveiwed.

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