Citation
Musculoskeletal health

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Title:
Musculoskeletal health a review of literature
Creator:
Brewster, Brittney ( author )
Publication Date:
Language:
English
Physical Description:
1 online resource (33 pages) : ;

Subjects

Subjects / Keywords:
musculoskeletal disorder -- pain -- set-up -- physical therapy -- yoga -- exercise
Music Education capstone project, M.M. in M. Ed

Notes

Abstract:
String musicians can experience pain while playing their instruments. In fact, research indicates that the majority of string musicians suffer from constant pain and musculoskeletal disorder. This can happen to all string musicians, from beginner students through professionals. Therefore, a review of literature was needed to help teachers to better understand the musculoskeletal system of a growing student and how to provide instruction so that pain and injury can be avoided. Research suggests that musicians should see a physical therapist, physician, and/or a chiropractor to prevent pain and musculoskeletal disorder. Adding exercises such as weight training, cardio conditioning, yoga, and stretching on a regular basis will help prevent overuse of muscles. In children, the musculoskeletal system is continuously growing and teachers need to ensure the students are sized correctly and are shown the proper set-up for their instrument. Proper set-up throughout a students' growing period along with exercising and stretching before, during, and after practice and rehearsals can help students avoid injuries during their school and/or continued music career.
Bibliography:
Includes bibliographical references.
General Note:
Music Education terminal project
Statement of Responsibility:
by Brittney Brewster.

Record Information

Source Institution:
University of Florida
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All applicable rights reserved by the source institution and holding location.
Resource Identifier:
035637427 ( ALEPH )
Classification:
LD1780.1 2016 ( lcc )

UFDC Membership

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University of Florida Theses & Dissertations

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MUSCULOSKELETAL HEALTH: A REVIEW OF LITERATURE BY BRITTNEY BREWSTER SUPERVISORY COMMITTEE: DR. MEGAN M. SHERIDAN, CHAIR DR. WILLIAM I. BAUER, MEMBER A CAPSTONE PROJECT PRESENTED TO THE COLLEGE OF THE ARTS OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF MUSIC IN MUSIC EDUCATION UNIVERSITY OF FLORIDA 2016

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MUSCULOSKELETAL HEALTH 2 Abstract String musicians can experience pain w hile playing their instruments. In fact, research indicates that the majority of string musicians suffer from constant pain and musculoskeletal disorder. T his can happen to all string musicians, from beginner students through professionals. Therefore, a review of literature was needed to help te achers to better understand the musculoskeletal system of a growing student and how to provide instruc tion so that pain and injury can be avoided Research suggests that m usicians should see a physi cal therapi st, physician, and/or a chiropractor to prevent pain and musculoskeletal disorder Adding exercise s such as weight training, cardio conditioning, yoga and stretching on a regular basis will help prevent overuse of musc les In children, t he musculoskeletal system is continuously growing and teachers ne ed to e n sure the studen ts are size d correctly and are shown the proper set up for their instrument. Proper set up throughout growing period along with exercising and stretching before, during and after pract ice and rehearsals can help students avoid injuries during their school and/or continue d music career. Keywords: Musculoskeletal Disorder, Pain, Set up, Physical Therapy Yoga, Exercise

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MUSCULOSKELETAL HEALTH 3 Musculoskeletal Health : A Review of Literature Musculoskeletal disorder can plague a musician for a short time or can ruin a career. The pur pose of this capstone project was to develop a document that examined the literature related to the musculoskeletal system in children and adults in order to better understand how to prevent pain while playing an in strument. This document will help teacher s to recognize when a student is starting to compensate f or pain or discomfort and provide guidance on how teachers can re evaluate and help reposition the instrument for perfect playing set up. In addition to t he r eview of literature, I examine d and suggest ed warm up and cool down exercises that can be used in the classroom or practice room prior to playing. These tasks are inf ormed by the literature and include physical activities such as stretching and conditioning. The researc h questions for this project were : 1. W hat is the musculoskeletal system? 2. How can teachers put student s into the proper playing position and instrument set up so as to prevent pain and injury ? 3. What preventative measure s should be ta ken and what can be added to the daily routine in order to maintain musculoskeletal health when playing an instrument? Musculoskeletal Disorder O ne might associate pain with a professional string musician who has been playing their instrument for over 20 years, logged hours of practice sessions, and engaged in mult iple performances in one season; however, beginning string students can also experience pain and discomfort. Much of this pain can be cau sed by musculoskeletal disorder a disorder in which muscles and tendons in the human body become overused from repetitive motion as well as the static load on muscles from holding a string instrument for long periods of time. Manchester

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MUSCULOSKELETAL HEALTH 4 (1988) explained that tissues, bones, ligaments, and the nervous syst em work together to enable movement in the body All of the communication comes from our brain down to where the muscle needs to move something specific. Without this system we could not move to participate in everyday life, let alone play an instrument. I some young instrumentalists are (Dawson, 2006, p.36). What Every Violinist Needs to Know about the Body points out not available to aid in making support and mo vement feel effortless. In the a bsence of the bony balance and the APPs [automatic postural patterns], muscle grou ps not designed for the task at Research on Musculoskeletal Disorder There are multiple studies on t he pain of adult musicians. Additionally, some researchers have in vestigated this issue in younger musicians. Brandfonbrener (2009) looked at 350 freshmen entering college ; out of 350 students, 79% had a history of pain from playing their instrument. That is a staggering number for a freshman class to report pain while p laying their instrument Brandfonbrener (2009) used a 22 question survey for his study to look at age, gender, the instrument and the years studied on the instrument, as well as th e habits the string musicians have every day There was still a significant amount of students who deal t with pain on a daily basis. Just as Brandfonbrener (2009) looked at college age students, other researchers went a step further. Barton (2008) surveyed college age music students as well, but with two different typ es of questi onnaires: the DASH (Disabilities of the Arm, Shoulder, and Hand) survey and a descriptive survey that looked specifically at the activities string musicians were doing In t he

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MUSCULOSKELETAL HEALTH 5 DASH survey, the participants were asked to identify the pain and the region whe re it was located, and to describe what type of activities they did on a regular basis. There were two different modules from which the string musicians could pick E ach one had four specific questions that related to the module picked. In t he descriptive survey students were asked about their physical make up and habits they had while p laying their instruments. Barton (2008) found that 64.9% of students reported dealing with pain while playing their instrument. When we see young musicians playing in band and orchestra at school, we are aware of what they accomplish musically and the discipline that comes with learning an instrument. What is not readily visible is the fact that learning a string instrument is not easy and students can be affected by pain. I n related reports on the percentage of students who either report or complain to their teacher about pain when they are playing, the percentage could be very similar in the school setting. Brandfonbrener (2009) and Barton (2008) have found that college age students reported suffering from pain at the secondary school level. Y oung musicians start learning an instrument in school while they are still growing and developing muscularly. Rardin ithout proper care, the complex and repetitive physical movements that are so fascinating to watch on stage can endanger a s ability to make mus 1). Those repetitive movements include the side to side motion of the bow arm an d the left hand fingers that play the notes Each time a student grows his or her violin, viola, cello or bass must change with them. S tudent s will grow into the next size or there will be small adjustments made with the current instrument if they are not ready for the next size up. When a younger student moves up to the next size, the teacher has to make sure the student is

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MUSCULOSKELETAL HEALTH 6 ready for t he next size. It may be safer to keep the student on the smaller instrument for a few months be fore moving on to the next size because the smaller instrument will not elongate tendons whereas the next size up may cause the student pain if the change is made to o fast. P oor set up of the string instrument can also be a cause of pain The set up of a string instrument entails how the student places the instrument on the shoulder, between the legs or how the instrument leans against the body When playing a string instrument the body becomes asymmetrical; however our bodies are made to line up perfectly so we have free movement and no restrictions. Each student will have a slightly different set up for their in strument to be in a comfortable pl aying position. For string musicians, pain can be an indication of misalignment in the body. Fransson Hall, Gloria, Kilbom and Winkel (1995) brought computer technology into their study to find out the areas in which string musicians feel pain They studi ed a number of occupations including musicians collect ing data about posture and how the body performed during everyday tasks of playing a string instrument The researchers went on to a ttach wires to the participants which were connected to the computer in order to collect data Through analysis of this data, the re searchers found when a shoulder is at a high angle for too long shoulder pain was experience d by many of the participants, specifically string musicians Foxman and Burgel (2006) gave out a survey to musicians to see what risk factors were associated with pain. In the first survey the musicians were asked simple questions regarding their primary instrument and the basic set up of that instrument They also asked if any of the musicians experienced performance anxiety, str ess from their job, fatigue, wrist or hand pain, ringing in the ears, and for woodwind and brass players dental problems Based on the data they collected Foxman a nd Burgel (2006) ga ve the music ians information on improving their

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MUSCULOSKELETAL HEALTH 7 current pain situation by modifyi ng their practice s essions. The musicians were given ten minute breaks after every half hour to forty five minutes of practicing. Foxman and Burgel (2006) noted m usicians also have to keep their muscles warm, e specially in the hands because playing without warming up may cause an injury within the hand or the surrounding muscles that assist the hand. Zar a and Farewell (1997) used a survey as we ll for a portion of their study; The 36 page Playing Related Health Questionnaire included five categories of questions: 1. Phys ical and Demographic Variables 2. Psychological Variables 3. Practice Behaviors and Other Playing Relat ed Variables 4. N on Music Related Variables 5. I nstrument Groups (p. 294). Zara and Farewell (1997) noted that string players were more likely to suffer from musculoskeletal diso rder compared to a non musician. Additionally, females were at a higher risk than males to experience pain and musculoskeleta l disorder I n their study, Zara and Farewell (1997 ) did not explain why females are more likely to suffer from musc uloskeletal disorder than males, but it was mentioned that the body structure between ma le and females are different. Alt hough Z ara Farewell (1997) do not give reasons for pain between genders, string players are set up in an asymmetrical balance where muscles are in a static position for a number of hours and p erhaps this can lead to the higher number of females suffering from musculoskeletal disorder. String musicians often feel pain in the upper half of the body including the back, neck, shoulders, arms, hands, and fingers Leaver, Harris, and Pal mer (2011), found that musculoskeletal pain was very common among string musicians who particip ated in their study

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MUSCULOSKELETAL HEALTH 8 particularly in the lower back, neck and shoulder. String students may complain of pain in similar areas. Hagber, Thiringer, and Brandstorm violin or viola had a fourfold increase in right forearm pain and twice the risk for neck pain, right oxman & Burgel, 2006, p. 310). Playin g a string instrument requires a lot of static load that causes the muscl es to become fatigued and over u sed resulting in injury. As Zara and Farewell (1997) noted there is a higher risk of being in an awkward playing position resulting in overuse injury o f a string musician Hagberg, Thir inger and Brandstro m (2005) observed 36 music teachers ov er an eight year period They looked at tinnitus, hearing loss and musculoskeletal disorder. From their fin dings they concluded: A mong the musculoskeletal symptoms the highest incidences per 1000 years of instrument practice were found for pain in the neck and in the left shoulder with a rate of 4.4 and 4.6 disorders per 1000 years of instrumental practice, respectively. There was a 2.4 times incidence for musculoskeletal disorders in the right hand/wrist and a 2.2 times incidence for musculoskeletal disorders in the left elbow/forearm for musicians who practiced for 20 h [ours] or more per week before the onset of disorders compared to those who practiced fe wer than 20 h [ours] per week when controlling for age and gender (p. 582 583). S tring musician neck s and sh oulders became the main focus of Hagberg, Thiringer, and Brandstrom (2005) study. These areas of the body are where the majority of the load for the violin and viola player holds static for hours during personal practice, rehearsal s and performance s For the cello and bass this area may become over used as the shoulder joint is the one of the main pivot points for bowing as well as being static.

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MUSCULOSKELETAL HEALTH 9 Th e Effect of Pain on S tudents Young students are still developing physically when they begin to learn an instrument in school. The size of an instrument, particularly larger ones, and playing position can cause students to hyper extend joints. Larsson, Baum, Mudholkar and Kollia (1993) found that students with hypermobility were more likely to suffer from pain than those who did not have hypermobility. Hypermobility is where a joint extends past the normal range. According to Larrson et al (199 3) hypermobility can be an asset or a liability depending on what joint is hypermobile. Specifically, subjects who played instruments requiring much repetitive motion were t involved in repetitive motion but subjected to stress during the activity more often had symptoms than those with j oints that were not hypermobile (Larsson et al, 1993, p. 1081). The weight of an instrument can also play a role in contributing to discom fort and pain a string playing student may experience Multiple factors are in play when it co mes to musculoskeletal disorder. D aw son (2006) gives three reasons why students may develop an overuse injury while playin g. First the body is taking on more than it can handle such as overuse during an intensive even t like band camp. Second, students may not be properly set up to play the ir instrument. T hird student s with hypermobility may also end up with a performance injury. Larsson et al. (1993) looked at the benefits and disadvantages of being hypermobile. They found adult musicians who have hypermobile joints were more likely to have pain than those who do not have hypermobility of the joints. Although Larsson et al. (1993) looked at adults, young students can be very hypermobile. Hypermobility can cause a person to be stiff in the joints that can be hyper extended. With hypermobility students can struggle with their bow

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MUSCULOSKELETAL HEALTH 10 arm at the elbow joint as well as keeping the left hand fing ers curved while playing the instrument. Besides being hypermobile Hagber, Thiringer, and Brandstrom (2005) also string instruments are not positioned properly and/or the shoulder rest and chin rest are not the correct height that will cause pain in the neck and shoulders. ome music teachers maintain that improper technique is the major culprit, but the technique that works well for most students and for the teacher may not 150). Every student is different in growth rat e and height. When student s grow at a rapid r ate muscles cannot keep up w ith the demand that is expected in an instrumental classroom (Dawson, 2006) T his may cause mu scles to become overused or may result in tendinitis. S ome s tring musicians do not view playing their instrument as a physical activity, neglecting physical warm up s and cool down s as part of the ir daily routine. Russell (2006) conducted a study with middle school string students to see if warm ups had an impact on eliminating any discomfort. He found that w arm up frequency had no significant impact on Russell, 20 06, p. 99). F rom this study warm ups had no true impact on younger students in the present ; however over time students may start to feel the impact of not doing any warm ups before playing their instrument. When a string musician ignores doing a warm up the muscles may become more quickly fatigued D oing a warm up at the beginning of a practice session will reduce the risk for pain Russell and Benedetto (2014) conducted a study that focused on middle school age students. T he stu dents were in their first to third year of learning a string instrument and they implemented a warm up schedule to be added to the start of the rehearsal Russell and Benedetto

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MUSCULOSKELETAL HEALTH 11 (2014) state it is important for young string players to practice healthy habits especially while prac ticing to reduce risk of injury and that teachers are to watch and take an active role in making sure their stud ents are not playing with pain. Teachers, need to make sure their students are set up for success in every aspect of play ing an instrument. Often teachers are not trained in what to look for in making sure their students have the proper se t up Russell and Benedetto (2014) stated : I f it is the responsibility of the institution to educate future music teachers in injury prev ention, it follows that those music teachers are responsible for using their expertise to help their students develop healthy practice habits, prevent pain, and avoid injury. In this what pain his or her students experience and what p ractices may best mitigate pain (p. 260). By providing a class for future instrumental music teachers on the human body and what to look for in the proper set up of a string instrument could be very bene ficial. Teachers would learn to correct the students physical and instrumental set up to reduce the risk of injury. Relieving Pain in Young Musicians There are several treatment options for students playing with pain related injuries, including doctors who specialize in working with these specific types of injuries Alternative medicine can also be added to what the physician prescribes Although surgery can help in certain circumstances, physical therapy or seeing a chiropractor can usually alleviate pa in and discomfort When surgery is needed it is important for the doctor and physical therapists to communicate with one another to make sure the healing process is going smoothly.

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MUSCULOSKELETAL HEALTH 12 Physical Therapy String Musicians have a lifetime prevalence of performance related musculoskeletal disorders (Chand, Driscoll, & Ackermann, 2012). When an injury happens, string musicians often will visit their regular p hysician or a therapist, who are not trained in inst rumental injuries, but try to give the best care they can for the musician However, sometimes the treatment and/or diagnoses of the injury can be wrong. O ver the past few years medical clinics have opened to ser ve the injured musician (Manchester, 1998); however, medical practice for musicians is new, but musicians can educate the doctor and therapist about what is involved while playing their instrument (Quarrier, 1993) Quarrier (1993) found that a regular physician had a low success rate in treatment, whereas the physical therapist had a higher rate of success in working with the injured musician. These inconsistencies suggest that a specialized clinic for musicians could provide the care needed to heal and prevent further injury. Although string musici ans typically see p hysicians and physical therapist s when a problem arises another type of doctor the chiropractor, can also provide effective care The possible healing and realignment for that musician. Through manipulation of the musculoskeletal system the chiropractor is able to make adjustment to ensure everything is properly aligned Keeping the back and spine healthy is very important for string musicians When the spine is compressed, the nerves that run all of the information need to be subluxated to make sure the signals from our brains reach the certain part of the body that has to do a specific task. Depending on age and the wear and tear that a music ian has put on the body will determine what needs to be done so no further damage to the spine and other joints continue. Either within weeks or over a few months a person can feel the difference in their physical health and overall health.

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MUSCULOSKELETAL HEALTH 13 Dr. Timothy Jameson is a chiropractor who created a website called Musicians Health and founded a network of chiropractors throughout several states that specifically work with musicians The se chiropractor s e nsure musculoskeletal health is getting the best adjustment as an alternative or extra assistance to the care they are already receiving Practice is one of the primary ways musicians improve their technique and playing style, and prepare for concerts. Along with practice exercising is another w ay to prepare for playing an instrument. Quarrier (1993) stated most musicians are not properly trained in exercises and stretches; however, a physical therapist can educate a musician on stretches and exercises that help to avoid injury. For instance, whe n a player is injured during a sporting event, the medical staff immediately tends to the player, starts working in that area and the relating areas to start the hea ling process and, if needed, ed, she has her form and stroke analyzed by her coach. The injured musician also needs her Li and Buckle (1999) suggested using videotaping, self assessment, and pen and paper to help musicians doctors, and physical therapists to diagnose the injury. Every musician sho uld be doing a self assessment of some sort at home while practicing. When musician s self evaluate while playing they are learning what hurt s and when to make an adjustment to stop the pain A musician can videotape themselves and evaluate the tape later with a doctor, physical therapist or the chiropractor to see what adjustments can be made. I have personally videotaped myself to see what I needed to adjust to relieve pain in my shoulders. P racticing in the mirror and making adjustments along the way will improve the playing quality and help to prevent injury Mirror practic ing is great for young students as t hey can see what they are doing and make the minor adjustments in placement of their instrument on the shoulder,

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MUSCULOSKELETAL HEALTH 14 between the legs for cello or how they stand with a bass Mirror practicing also gives the students a chance to see what their bow arm is doing and make the adjustments needed. My students do mirror practicing in order to learn what adjustments are needed to their body, instrument set up, etc Teaching young musicians the tools to succeed while learning to play their instrument is necessary Exercises and Stretches Exercises can be a tedious task a nd are often left out of A workout r outine should be added to a musician s schedule. When a musician adds a workout, it not only improves the health of the musician, but strengthens the areas that are put under a lot of stress when playing an instrume nt. By doing a regular routine of cardio and strength exercises a musician can prevent injury while playing their instrument; however, the musician has to be ng, as with the athlete, should consist of basic progressive resistive exercises and endurance conditionin r, 1993, p. 93). Musicians, do not put in enough time for physical conditioning for the long hours of playing Without conditioning the mus cles an over use injury of a muscle can occur. Pacelli (19 89) interviewed a violinist from the New York Metropolitan Opera Symphony who said, certain instruments and maintain posture during practice and performances of up to several Stretches Besides going to the gym and keeping physically fit, stretching is a very important for a musician A string musician should include stretch ing in their warm up s routine before every practice, rehearsal and performance. The upper body is the main fo cus in stretching for a string

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MUSCULOSKELETAL HEALTH 15 musician. An article from the magazine The Strad provided excellent information of eleven stretches that s tring musicians should use. For instance standing tall, you let everything relax as you breathe in and ou t while stand ing tall. This will allow you to set up properly and have your head in the correct position. When standing tall think of a string pulling you up from the c rown of your head and allowing your upper body to become limber and relaxed. Stretching the arms and fingers is important for string musicians. For example, to stretch the arms and fingers, hold your arm straight out in front of you with your palm up. With your other hand gently pull down all of your fingers, including the thumb. Gently push your fingers down and towards your body bending your wri s ts. You will do the same process for the other hand. You can also do this stretch by pulling your fingers up as well ; this will start with the palm facing the ground. After stretching out the hands and arms string musicians should proceed to stretch out the and back through and ro ll downs For roll downs you will reach down to the toes and slowly roll back up extending your arms over the head will open the spinal cord disks back to position. Obliques are side muscles of the torso and part of the bend to the side and then to the other Musicians do not realize that they use quite a bit of their back muscles while playing their instrument. Doing stretches at the beginning and end of playing your instrument will prevent pain and overuse in the long run Yoga Yoga can be beneficial for string musicians as it provides stretchin g, and promotes relaxation and flexibility. Khalsa, Short er, Cope, Wyshak, and Sklar (2009) performed a study at Tanglewood during the eight week su mmer program where musicians were invited to participate in a Kripalu Yoga and meditation program. Faulds (2006) stated Kripalu is a classic yoga

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MUSCULOSKELETAL HEALTH 16 practice that includes breathing techniques and meditation ( as cited in Khalsa et al 2006 ). Khalsa et al (2006) discussed that in a n eight week period yoga showed and proved that it can reduce stress and performa nce anxiety Yoga can improve core strength, as many of the positions require a lot of balance YJ (2013) suggested different yoga positions that a musician can easily learn and do at home or in the yoga studio, including positions for the arms, like Warrior I and II, Cow Face Pose arms, a nd few others. These positions can help regain all of the motion in the arm. For the back, doing poses like the Cobra, Sphinx and the Locust position help the back from becoming rounded, especially for str ing musicians where the back is rounded while playing their instrument. All of these poses also include the leg s, where the legs are elongated through stretching This is very helpful for someone who sits while playing the majority of the time Although many yoga poses can be done at home, attend ing a class lead by a yoga instructor can ensure that the body is properly aligned as poor technique can be a cause for injury. Weight Training A w eight lifting routine can be done by using free weights or weight machine s to build muscle. When using a weight machine, follow the displayed instructions Begin with a weight that is light but that will challenge the targeted muscle. When the weight becomes to light to feel the workout, start slowly increasing the weight When using weight machines, musicians must work out all muscles involved in the movement. For example, if a musician uses an abdominal machine, he or she should also use a machine the focuses on the lower back. W orking out the front and back muscles of the abdominal section will ensure evenness and stability. While using free weights, musician s have to use the proper amount of weight and the correct stance for the best results Trainers are available to work with you on any machine and/or free weights

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MUSCULOSKELETAL HEALTH 17 While working out, the musician can do two to three sets of 10 to 15 repetitions with one minute of rest between each set The one minute res t gives the muscle time to fully recover. Som (2004) wrote an article for Body B uilding stating that the 60 90 seconds of rest is optimal for the muscle to make a full recovery Som (2004) also stated when a person wait s too l ong between sets they will lose the drive to continue; whereas, if there was not enough time, then the person will become fatigued a lot faster. Resting in between also helps prevent injury, whether using the weight machine or free weights this is crucial in making sure the muscle recovers before continuing with the next set. After working on a par ticular section of the body, musicians must give the area 48 hours to recover and heal. During this time, the musicians may work on another area of the body. Rotating muscles groups is very important in reducing injury and o veruse of the muscles that are worked on By establishing a n exe rcise routine that includes stretching before and after exercising string musicians can enable themselves to play for a longer period of time S tretching before, musculoskeletal system healthy and injury free. This goes not only for the professional musicians but for students at every stage of playing a string instrument. Their exposure starts in the classroom, so setting the example that stretching before, during and after everything they do to play their instrument will continue on with them as they grow in their playing. In the classroom Many teachers are guilty of star ti ng right into the lesson for the day without any type of physical warm up routine as part of their rehearsal. However, playing with cold muscles can lead to injury. Za ra and Farewell (1997) discussed that doing a warm up and taking breaks should be rning

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MUSCULOSKELETAL HEALTH 18 process and will prevent injury. Making sure the hands through the shoulders and neck are warmed up will h elp them be ready for faster p assages and playing for a long duration of time. Without a physical warm up of some type, playing cold will result in an overuse injury. Throughout the rehearsal taking mini breaks where students put down their instruments wil l prevent an overuse injury This will also give the muscles that are static time to relax before playing again. Sizing Instruments Ranelli, Straker, and Smith (2011) found that students complained the most about their back, wrists, hand, forearm, elbows, and neck. As teachers, we need to make sure that our students are having the best musical experience in the classroom This not only includes the type of instrumental curriculum that is taugh t for the school year, but instruments from the first day of study Violin and Viola To fit a violin and viola, the left arm will be extended out with the scroll sitting in the palm of the hand for the correct size St udents will constantly change how they set the instrument on their shoulder ; to where teacher s need to check the height of the shoulder rest and chin rest to insure the violin and viola students are comfortable. T he student should not be lengthening their neck in any way to ma ke the instrument properly fit The students has to be relaxed from the neck down through the shoulders with the violin and viola sitting there. Should er rests have adjustable feet to make it higher or lower based on the height of the chin rest and the distance between the chin and shoulder of the student The feet on the shoulder rest can be marked off with permanent marker to let the student know this where the feet of the shoulder rest needs to be at all times, when the feet have cha nged height positions.

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MUSCULOSKELETAL HEALTH 19 There are different height s shapes and placements for chin rests as well. The chin rest needs to fit the student comfortably along with the shoulder rest placement Trying out different chin and shoulder rests take s a bit of time b ut once the chin rest and the shoulder rest work together to provide a comfortable fit for the student, the adjustments will be easy from there. Along with the proper fitting of the shoulder and chin rest, Johnson (2009) give s a five point of contact for t he violin and viola player to follow: 1) jawbone; 2) collarbone shelf; 3) side of the neck; 4) left hand; 5) friction of bow hair on string. When these are followed the student will be less likely to develop an overuse injury while playing their instrument Cello and Bass M aking sure that the end pin is at the correct length and the students are sitting and standing correctly for their instrument is paramount for cello and bass players For th e cello students can sit on a foam padded seat t hat is angled to improve their seated postur e The foam padded seat will also cor feet so that they stay flat on the ground and not on their tip toes. With the padded angle seat the end pin will be at the same length every time. A teacher can also mark off on the end pin that is needed for each student in different permeant marker colors when multiple students are sharing a cello in different classes. Basses can se t up a couple of different ways: standing and sitting. The bass end pin can be marked the same way as the cello as the basses are often shared from class to class. While in a standing position the bass will be angled into the student to a certain degree creating a small feet and end pin. The student has to be able to reach for bowing and have the hand width to play the instrument. Making sure they have t he correct size bass is critical. As such, most often stude nts are not started on bass until second or third year of string e ducation The ba s ses can also have a stool if they decid e to sit but the stool has to be at the correct height along with the end pin to make everything work Students still

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MUSCULOSKELETAL HEALTH 20 have to be able to reach down to bow and finger the notes in first position. Just as the standing bass must be in the correct position, when they are sitting the bas s will angled between the legs s o the bow arm is able to reach each string. The left foot mu st be on a rung of the stool that best fits the student with the knee touch ing t he back of the bass. The right lower corner of the C bout point the curve in the middle of the instrument, will be resting on /or inside the right knee for the extra stability. The end pin may have to come out longer for the bass to be in the correct spot for both the bow arm and the left arm for playing the notes. Furniture In making sure that students have the correct size of the instru ment neede d and are set up properly, the type of furniture in the classroom may need to be adjusted. As teachers we might not think about the height of the stand or the type of chair the students are sitting on. Just as t eachers have their own personal pre ference for their own home practice or in an ensemble of how they set ev erything up, so do students and the classr ooms have to be flexible for everyone Reel (2005) interviewed Judy Palac of Michigan State University about the health y habits for students, including the t ype of chair a student sits in. Reel (2005) rev ealed that Palac pointed out your knees should not be ab ove your hip joint, resulting from the chair being too low to the ground, rather the knee should be parallel to the ground with the legs a t a 90 degree angle. It is important for a t eacher to have students help test out chairs before deciding which ones to purchase Music stand will also need to be adjusted. A student should be sitting up tall with a straight back while playing. In orchestra students share a stand, and finding the perfect balance between th e two students can be difficult. Teach er s and students will make the adjustment needed to insure that everyone is sitting tall and can still read the music. No one should be hunched over t o play their music.

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MUSCULOSKELETAL HEALTH 21 Classroom stretches In the classroom, teachers need to make sure the students muscles are warmed up by doing physical warm up activities before starting a rehearsal. This will reduce fatigue during class time. Wilke, Priebus, Biallas, F robose (2011) give a whole mobility program for musicians to work on in the gym or at home. Students can easily do running, biking and swi mming and stretching at home and in the classroom. The exercises and stretches presented earlier can also be done in t he classroom. For example, the following stretches can be done in the classroom at the beginning and end of rehearsal: Arm circles: big and small, circling forwards and backwards ten times The neck: stretching the sides, front and back. Do not roll the neck around. Thirty seconds each. Shoulders: circle forward and backwards ten times. The back: stretching from your toes and rolling up slowly then extending the arms above right. Arm and hand stretches: described later, hold for thirty second each. Studen ts can benefit from stretching out the chest area To open the chest area and stretch out the muscles students will ha ve to spread out in the room Their arms are placed out to the side like they were going to do arm circles. Point the thumb towards the ce iling and reach back to open the chest up; then do the same thing with the thumbs down towards the floor. Another way to stretch the chest is to clasp your hands behind your back Chan, Driscoll, and Ackermann (2012) discussed that in a sitting and standing playing posture, the cor e muscles are used to stabilize and support the musician. Making sure that the abdominal area is stretched out before and after playing is important. The abdominal muscles are

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MUSCULOSKELETAL HEALTH 22 held static while playing; by doing the oblique stretch and the cobra yoga position the muscles will relax. A nother stretch for the abdominal muscles is to bend backwards while in a standing position, or doing the yoga po se called the one arme d camel. The one armed camel starts by knelling and bending ba ckwards with the right hand t ouching the ground and the left arm extending behind the body, then switching sides Wilke, Priebus, Biallas, and Frobose (2011) looked at ways to prevent musculoskeletal injuries for string musicians; one that they focused in on was motor activity. They looked at endurance and strength as the main factors for string musicians. In the classroom working on endurance can be difficult. O ne way to work on endurance is to have students do simple cardio exercises to elevate the heart rate Students can spread out in the room to do simple jumping jacks, running in place, or walking around in a circle to get their heart rate up and ready to pl ay. Playing exercises To keep students on their toes, a teacher should always be changing up the rehearsal so the class is not doing the same thing day in and day out. Students love to lead the stretches and warm ups once they know how the classroom is ru n. By giving students the chance to run the beginning portion of the class, the teacher has time while stretching and playing. There can be a different student every day or a student for the week that runs the b eginning of class. Students will be motivated to do the stretches and warm ups in class as well as doing them at home for their own personal practice. It gives them a sense of ownership while the teacher still has control of the classroom. There are multip le type s of warm ups that students can do together as a whole. Scales can help to get the ear in tune with everyone els e, and get muscles warmed up even further Scales should start out slow and gradually get faster. Depending on the level students are at the scales

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MUSCULOSKELETAL HEALTH 23 will range from one octave to three octaves. Scales should start out as six beats per bow with the quarter note beat set at 60. Students are challenged to use the whole bow in six beats. From six beats the students will play whole notes and all the way down to sixteenth notes still with the quarter note set at 60. This gradually warms up the fingers and gets the ears listening to themselves and everyone else. The technique books at every level should be used at the beginning of class. Many of the technique books touch on rhythms, bowing technique, shifting counting and listening to each other. These not only warm up the students bow arm and finger s but it also gets them thinking as well. Besides technique books teachers and students c an create their own warm up activities by taking a section from their pieces they are working on and focusing on the rhythm in the key the piece is performed in. During rehearsal s students should not be play ing their instrument constantly without restin g in between. Students, just like adults, need small break s throughout the rehearsal. Placing in little change ups is critical to keep students focused and a chance to relax. After rehearsing a piece for a period of time, take a couple of minutes to stretch out and shake out the arms and hands. This will get students to relax and a chance to digest what they were just doing before going back and working on a section of a piece. When going back to work on a small section within the piece start out slo w to hit all of the notes and make sure that all fingerings for the passage is correct. By taking passages slow students are memorizing with their fingers where everything needs to b e placed. A dding rhythms to a passage of eighth or sixteenth n otes in vary ing ways the fingers and bow arm start to memorize the passage Gradually speeding up the rhythms in place of the passage gets the students concentrating where everything is to go. Taking away the rhythm and playing the passage as is will show im provement and give the students another way to practice.

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MUSCULOSKELETAL HEALTH 24 When the notes in a piece are simple, it is a great time to take away the left hand and practice with just the bow arm. This is great for working on a difficult bowings and string crossing. The can go into rest position, still sitting with good posture and air bow the string passage. In doing so the students can say the bow movements of up, down, up, a slurred down to a slurred up bow. T eacher s a re able to see who is not doing the corr ect bowing or i s confused about the bowing For air bowing this should start out slowly to make sure everyone is on the same page with the bow changes and work up to the tempo of the piece. Another way students can practice bow changes is by placing their bow on the strings. The students will still say the bow changes within the passage they are reading. A great way to practice string crossings, is to have students place their left hand on the shoulder of the instrument and l et the right hand do the work. E very student will play just the open strings when working on string crossings, but keep in mind that the students have to keep their bow on the string where the notes are played before crossing over to the next string. These two rehearsal techniques give the students a different pace and some time to relax here and there. Dawson (2006) stated that for every 25 minutes of practice there should be five minutes of down time or a break. When a high school orchestra class runs for an hour it is a good idea to take a break where the students sit down their instrument. Here the teachers can go over a few spots for marking in bowing, fingerings and the road map to a piece. This can also be a time where students reflect and do small journal writ ing about what they have worked on so far and save some for the end of class before they leave to go to the next class For younger students who are just starting out on their instrument, breaks should be taken more often. The younger student muscles are becoming use d to h olding an instrument and staying static for the 25 40

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MUSCULOSKELETAL HEALTH 25 minute period they are in class. Making sure that younger students understand the importance of taking a break and stretching will be a tool in their tool box for the rest of their li ves. The rule of 25 5 is wise for any string musicians to take small breaks while practicing to reduce fatigue and pain This regains focus and lets the muscles relax before continuing on. Students can b ecome mentally fatigued as well. E nsuring that there is a break between each piece or during a piece after a hard rehearsal on a specific section, gives the students time to reflect and digest what they have learned and worked on. At the end of rehearsal it is important that students cool down so their mu scles do not come to a screeching halt. The same stretches and playing exercises that were done at the beginning of class can also be done at th e end of class. For playing exercises, teachers can begin a scale with sixteenth notes with the quarter note at 60 beats and working the way back down to six beats per bow. A great way to end out the class is by doing some breathing exercises where student inhale for four counts and exhale for eight counts to calm everything down in the body. This also reduces the s tress that was put on the m uscles during rehearsal and calms the brain before students continue on with the school day. Conclusion Playing a string instrument can be a very rewarding activity for everyone involved ; however, pain and injury can dampen that reward Professional musicians are not the only ones who suffer from pain. Brandfonbrener (2009) noted that 79% of college music students reported playing with pain at a young age. This is a staggering number to think about for college students who alread y deal with pain. Even though there is no percentage given to beginning students, many of them play with p ain just as their adult counter parts in the music profession.

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MUSCULOSKELETAL HEALTH 26 To keep the musculoskeletal structure of the body pain free is to keep the body health y. Exercising and stretch ing will help to prevent the overuse injuries that many string musicians encounter. While exercising it is important to remember that strength and cardio will help pre vent musculoskeletal disorder. String m usicians can exercise at home or in the g ym, by doing weight lifting, weight machines and cardio activities including biking, swimming, and jogging. When the body has proper conditioning playing an instrument will become easier and there will be less stress on the body. All str ing musicians should focus on the upper half of the body as it holds the most static load from the abdominal section through the back and shoulders. Yoga is another great exercise that works with stamina and strength throughout the body. Yoga can be pract iced at home or in a studio where the yoga teacher can correct the positions when needed. Medicine has come a long way for musicians; many doctors are now specializing in working with musicians. Regular physicians, physical thera pists and chiropractors are form s of medicine that benefit the musician in staying healthy and injury free. Physical therapist s work with musicians on stretching and on specific area s to reduce pain and fatigue. Chiropractors can help to alleviate pain when a muscle has become overused. Chiropractor s also work within the spinal area to realign the spin e In doing so the nerves are no longer pinched when adjusted back to the correct position. F or both physical the rapists and chiropractors, making sure musculoskeletal structure is in the proper position will reduce pain and start to heal with continued sessions. Studen ts can benefit from seeing the correct doctor when dealing with an injury They will also benefit from the correct fitting of the string instrument that they are learning. Making sure the instrument has the proper fit for the student will go a long way in preventing pain as they grow. Teachers have to keep a watchful eye on their s tudent s p osture and playing position

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MUSCULOSKELETAL HEALTH 27 to make sure that are set up properly to prevent pain The size of the instrument is also very important and ensuring that each student has the correct size While in the classroom teachers need to m ake sure that they are adding physical warm ups at the beginning of class to taking breaks in between pieces or after a hard rehearsal on a particular se ction. As well as doing physical cool downs to relax the muscles at the end of rehearsal to prevent pain It is important that at every leve l music ians are receiving and doing everything that they can to reduce and prevent pain for future practice, rehearsals and performances. Musicians need to stay healthy and not let exercises and stretching be put on the back burner. Beginning string stude nts will learn from the start that stretching before, during and after they are playing will keep their muscles healthy. No musician wants to play with pain throughout their musical career. D oing simple exercises and seeing a doctor on a yearly basis will insure a healthy musculoskeletal system.

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MUSCULOSKELETAL HEALTH 28 References Abru Ramos, A. M. (2007). Lifetime prevalence of upper body musculoskeletal problems in a professional level symphony orchestra: Age, gender, and instrument specific results. Medical Problems of Perf orming Artists, 22 (3), 97 104. Barton, R. (2008). Occupational performance issues and predictors of dysfunction in college instrumentalists. Medical Problems of Performing Artists, 23 (2), 72 78. Bejjani, F. J., Kaye, G. M., & Benham, M. (1996). Musculosk eletal and neuromuscular conditions of instrumental musicians. Archives of Physical Medicine and Rehabilitation, 77 (4), 406 413. Black, J. (2014, May 13). 11 stretching exercises for musicians The Strad. Retrieved June 27, 2016, from http://www.thestrad .com/cpt latests/11 stretching exercises for musicians/ Brandfonbrener, A. G. (2009). History of playing related pain in 350 university freshman music students. Medical Problems of Performing Artists, 24 (1), 30 36. Chan, C., & Ackermann, B. (2014). Evidence informed physical therapy management of performance related musculoskeletal disorders in musicians. Frontiers in Psychology, 5 706. Chan, C., Driscoll, T., & Ackermann, B. (2012). Development of a specific exercise programme for professional orc hestral musicians. Injury Prevention Inj Prev, 19 (4), 257 263. Dainow, E. (1977). Physical effects and motor responses to music. Journal of Research in Music Education, 25 (3), 211 221. Dawson, W. J. (2006). Playing without pain: Strategies for the develo ping instrumentalist. Music Educators Journal, 93 (2), 36 41.

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