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July 10, 2016

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Health and safety advice for musicians

Most people love listening to music and many enjoy playing an instrument but for those who do so professionally, the range of injuries and health effects they can encounter during the course of their work is surprisingly wide, as Dr Chris Ide explains.

I would imagine that a sizeable number of SHP readers will, like me, have spent a portion of their childhood in receipt of piano (or violin/trumpet/clarinet – insert as applicable) lessons. I’m not sure what benefit our parents thought that we (or they) would derive from this, although I’m sure that some readers are now capable of holding their own against the finest professional instrumentalists!

However, most of us have fallen by the wayside, with, in my case, music having lost out to the equally misguided pretensions that the mantle of people like Stanley Matthews or Fred Trueman would settle on my shoulders.

Nonetheless, as most of us now just sit back and enjoy the music, we shouldn’t overlook the fact that the performers may be suffering on our behalf in order to bring us our pleasures, and we ought to consider what might be done to alleviate their problems, and perhaps even prevent them.

I’ve been involved in full-time occupational medicine for almost 30 years. One thing that has struck me is that in analysing the health problems of any occupation – from archaeologists to zoo-keepers – musculoskeletal disorders figure prominently, and musicians are no exception. Various papers have been published on this subject over the years but, while they have produced some useful information, they have suffered from a number of drawbacks, such as vague definitions of subject groups, small numbers involved, and low rates of response. In an attempt to remedy this, Leaver et al studied musicians who were members of leading UK orchestras.1 Overall, 51 per cent of 478 players in six orchestras responded.

The results showed that 86 per cent of respondents had suffered musculoskeletal pain in the previous 12 months, with 41 per cent describing it as ‘disabling’, by which they meant the pain lasted for at least one month, and resulted in at least one missed performance, or day’s sickness absence. The most common body regions affected were the neck, low back and shoulders.

The sort of instrument played also had a strong bearing on the body part affected. For example, wrist and hand pains were reported almost three times more often in woodwind players but, surprisingly, elbow pain featured only half as frequently in that group, and string players had about double the amount of back pain.

In part, these problems can be explained by the requirement of orchestra players to adopt and maintain postures that place heavy static loads on these parts. Women tended to be more affected than men, probably because the instruments they use generally weigh the same as those used by their male counterparts, yet women may well have less muscle mass than men, making strain more likely, particularly when the weight of some brass instruments may exceed five kilos, and require to be held for over three hours.

This research also tried to address the extent to which other health and bio-psychosocial factors impacted on musculoskeletal matters. Not surprisingly, the risks of significant pain were highest in those whose mood was persistently low, particularly in those who were assessed as having a high tendency to somatise, i.e. a likelihood of reporting distress from bodily symptoms.2 Interestingly, performance anxiety was surprisingly infrequent, being persistently reported in only about 14 per cent. While about 90 per cent reported both feeling under time pressure and having little choice over work, a similar proportion reported very high levels of job satisfaction.

These problems appear common to all sorts of musicians, since there were similar findings reported in a survey of US Army bandsmen.3 This is surprising since, although they are musicians, they are also soldiers, and would be expected to be fit enough to carry out their normal military duties. Regarding military musicians (regular readers will probably be aware of my penchant for introducing the historical context!) Charles Thackrah, while not mentioning musculoskeletal problems, did write in 1831 about the good lung function of wind-instrument players from the band of the 14th Light Dragoons.4 This resonated with me, since, just under a century-and-a-half later, I became Regimental Medical Officer to their successors, the 14th/20th King’s Hussars!

Hit the right note

Having stated these problems, what are the solutions? Well, finding them has proved surprisingly difficult, but a basic requirement is the provision of advice about posture, adjustable instrument stands and harnesses to transfer loads to parts of the body better suited to bear loads, and the design and manufacture of instruments that are lighter, etc.
However, any changes will have to be feasible, without changing the tonal qualities of instruments, and ergonomic solutions will have to be able to fit into working and rehearsal environments that may be quite cramped, unless the will exists to redesign the workplace – something that might be easier to do when new performing venues and concert halls are designed and built, or the older ones refurbished.

Because they affect the limbs (among other parts of the body), and so may be confused with musculoskeletal problems by the untrained observer or sufferer, it would be appropriate to consider a group of conditions called focal dystonias. It is estimated that they affect between a half and 1 per cent of musicians. However, they are not evenly distributed, with the highest prevalence among soloists and, in particular, pianists, violinists and guitarists, whose index and ring fingers seem most vulnerable.

They present as involuntary muscle contractions, which cause slow, repetitive movements, or give rise to abnormal postures. They may be painful, and/or be accompanied by tremors, or other neurological symptoms or signs. Wind players may also suffer these, but affecting the tongue, lips or facial muscles.

The cause is often unknown, although they may result from significant head injury, or recent prescription of some medicines, particularly anti-depressants, and some anti-emetics (drugs to prevent nausea and vomiting). Generally, stopping the medicine will relieve the symptoms, but those contemplating stopping one of the above medications would be advised to consult early with their own GP, especially if they do not have access to an occupational-health service, since unfortunate consequences may arise from the sudden cessation of some drugs.

Treatments often involve a combination of methods – prescription of medicines, injections of botulinum toxin (botox), and retraining. Safety advisors may be able to help by redesigning and repositioning instrument keys, and other ergonomic interventions, if feasible.5

It’s all about the scales

While carrying out research for this article, I was intrigued to find that musicians are vulnerable to myriad skin problems. Various forms of dermatitis are surprisingly common, affecting the players of many different types of instruments. Intimate contact between skin and instrument is a necessary part of music-making. Safety advisors who are employed in other work settings will recognise such materials as colophony, nickel, chrome, potassium dichromate and para-phenylenediamine.

An article by Gambichler et al6 gave many examples. String-instrument players, such as violinists and cellists, use rosin to help their bows grip the strings, and the dust generated can give rise to contact dermatitis – so called ‘fiddler’s neck’ – and the fingers can also become affected from plucking the strings. Nickel and chrome can be found in mouthpieces of brass instruments, and in strings of guitars.

The spread of these allergens and irritants is facilitated by contact with body fluids, such as sweat and saliva. To some extent, the problem can be resolved by using parts made from other materials, such as plastic mouthpieces, or strings made from bronze, copper, or nylon. Potassium dichromate may be used as a tanning agent of strings. Exotic woods, such as rosewood, ebony and cocobolo are used in the construction of many instruments, and can contain allergens that can trigger contact dermatitis. By contrast, boxwood does not, so would seem to offer hope to musicians whose dermatitis may be attributable to this.

Repetitive plucking can also give rise to mechanical trauma. Cohen described a condition called ‘harpist’s finger’ in a young harpist, who developed a persistent blister and corn on her left index finger as a result of plucking her instrument. Guitarists may be similarly affected.7

As well as musculoskeletal disorders postures can give rise to a variety of other problems. I was fascinated by correspondence in the British Medical Journal about ‘Guitar-player’s nipple’, a traumatic mastitis affecting young girls learning to play the classical guitar, which has to be held very closely to the body.8 Semple and Gillingham9 described a more serious condition – deep venous thrombosis – in a guitarist who spent four to six hours a day practising, hunched over his instrument in such a way that the veins in his leg were compressed.

Dr Ross, himself a guitarist, explained the importance of posture in avoiding these problems, adding that, in his personal experience, the use of a small footstool for resting his left foot had prevented him developing ‘guitarist’s foot drop’ by reducing compression of the sciatic nerve in the lower limb.10 (What was also fascinating was that, in the days before e-mail and electronic publishing, this correspondence – which included letters about ‘Cellist’s chest’ and ‘Cellist’s scrotum’ – took place over a two-month period!)

A good ear

Noise is usually defined as unwanted sound. This may seem paradoxical for a body whose raison d’être is to produce sound, and for an audience that is usually paying to hear it. Nonetheless, I’ve heard it said “decibels equal deafness”, and a survey of hard-rock musicians in 1972 showed evidence of temporary and permanent threshold shifts in hearing acuity – typical of noise-induced hearing loss.11 Although this paper included details about age and duration of noise exposure, as musicians the noise volumes were not recorded. However, the authors did note that hearing protection did reduce temporary threshold shift, and recommended its use.

Classical musicians may also be exposed to noise hazards and, while they may be exposed to high levels of impact noise on occasions, when averaged out over an eight-hour period, this has usually been found to be below any harmful level. Nonetheless, there may be sections within the orchestra whose members are exposed to higher noise levels than others, and these may exceed occupational standards.

For example, the trumpet players in a performance of Mahler’s 9th Symphony created noise levels of 96 dB (8-hour TWA) with peak levels of 112 dB. Suggested remedial measures included hearing protection and use of baffles in front of the loudest players, but simply re-arranging the programme, so that quieter pieces reduced the overall noise exposure, was thought to be the most practicable solution.12 It is important to remember that rehearsal time also needs to be included, as well as performance time when assessing noise exposure.

In the 20 years or so since this paper was published, the hearing loss of individual orchestral musicians has been studied and, although some hearing loss appears to have been indentified that may be compatible with the effects of noise, surprisingly, this is not greatly in excess of what would be expected in the general population.

This was shown by a study of Finnish orchestral players,13 where the relative lack of hearing loss was attributed to healthy lifestyles (as exemplified by low cholesterol levels, etc.) although the authors noted that the hearing losses were greatest in players exposed to loudest noise, and that tinnitus was troublesome. Perhaps the lessons learned the hard way by earlier musicians had been put into practice, or the noise exposure of the general population has increased!


While these illnesses and injuries that can afflict professional and amateur musicians are not usually life-threatening they can impact on general well-being and, occasionally, be severe enough to deprive someone of their chosen way of earning their living, or filling their leisure time. I greatly enjoy the Savoy operettas of Gilbert and Sullivan but the next time I take my seat for ‘The Mikado’, and Nanki-Poo enters, serenading the dignitaries of the town of Titipu that “A wand’ring minstrel I/ a thing of shreds and patches/ of ballad songs and snatches/ of dreamy lullabies. . .” my opera glasses will be scanning him for signs of dermatitis and postural disorders, etc. I will then gaze into the orchestra pit, hoping that the safety advisor will have done his or her job and that the real musicians are not similarly afflicted.

1    Leaver R, Harris EC, Palmer KT (2011): ‘Musculoskeletal pain in elite professional musicians from British symphony orchestras’, in Occup Med 2011,61;8:549-555
2    Palmer KT, Calnan M, Wainwright C et al (2005): ‘Disabling musculoskeletal pain and its relationship to somatisation: a community-based postal survey’, in Occup Med 2005,55;8:612-17
3    Knapik JJ, Jones SB, Darakjy S, et al (2007): ‘Injuries and injury risk factors among members of the United States Army Band’, in Am J Ind Med 2007;50:951-61
4    Turner, CT: The effects of the arts, trades and professions on health and longevity –  pp21-22
5    Aranguiz, R, Chana-Cuevas, P, Albaquerque D, Leon M (2011): ‘Focal dystonia in musicians’, in Neurologica 2011,26;1:45-52.
6    Gambichler T, Boms S, Freitag M (2004): ‘Contact dermatitis and other skin conditions in instrumental musicians’, in BMC Dermatol 2004, 4, 3. doi 10.1186/ 1471-5945-4-3
7    Cohen, PR (2008): ‘Harpist’s finger: case report of a trauma-induced blister in a beginner harpist and review of string instrument-associated skin problems in musicians’, in Cutis 2008,82;5:329-34
8    Curtis P (1974): ‘Musical bumps’, in Brit Med J 1974 p226
9    Semple R, Gillingham J (1974): ‘Musical bumps’, in Brit Med J 1974 p504
10    Ross D (1974): ‘Musical bumps’, in Brit Med J 1974 p669
11    Reddel RG, Lebo CD (1972): ‘Ototraumatic effects of hard rock music’, in Calif Medicine 1972, 116;1:1-4
12    McBride D, Gill F, Proops D et al (1992): ‘Noise and the classical musician’, in Brit Med J 1992;305(6868):1561-63
13    Toppila E, Koskinen H, Pyykkö I (2011): ‘Hearing loss among classical-orchestra musicians’, in Noise Health 2011;13:45-50

Dr Chris Ide is an occupational physician and regular contributor to SHP.

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In this episode  of the Safety & Health Podcast, ‘Burnout, stress and being human’, Heather Beach is joined by Stacy Thomson to discuss burnout, perfectionism and how to deal with burnout as an individual, as management and as an organisation.

We provide an insight on how to tackle burnout and why mental health is such a taboo subject, particularly in the workplace.


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11 years ago

I am a safety adviser and a musician in various pop bands. I’m nearly 50 and never had the hearing damage risk drilled into me, likewise my fellow band-members of similar age, none wear hearing protection during rehearsal or performance. However, I also play in a band where the rest of the musicians are half my age. They ALL carry hearing protection and use it. Ergonomics and posture are also important to them, especially with drummers and keys players. I think the message is getting through.