traduzionimedicinaesicurezzasulavoro

from Occupational Medicine Journal

In the virtual issue on the occupational health of musicians 

 by David McBride

 

Ramazzini, to whom we often look for the historical context in 

occupational medicine, wrote about ‘voice trainers, singers and 

the like’ in Chapter 38 of De Morbis Artificum [1]. It seems 

appropriate that the first musician-related article to be

published in Occupational Medicine in 1992 was written by 

Eller et al. [2]. They looked at the ‘health and lifestyle 

characteristics of professional singers and instrumentalists’ with 

a study of 91 instrumentalists and 51 opera singers. Their 

hypothesis was evident from the idea that that instrumentalists 

would act as controls for voice symptoms and singers as 

controls for musculoskeletal disorders (MSDs). The most 

statistically significant finding was a much-reduced prevalence 

of hip, knee and foot pain in musicians and, of course, the 

opposite for singers. Ramazzini wrote about blood being ‘the 

seat of the soul’, being convinced that using the voice heated 

the body more than any other kind of exercise. He might have 

been surprised to find, in our Danish musicians, it was both 

male and female instrumentalists who had hypertension, 

attributed to a higher alcohol intake, at least in males. The 

artistic temperament perhaps?

Sarah Palin’s article ‘Does classical music damage the hearing 

of musicians’ [3] starts by referring to a friendly dispute 

between two otolaryngologists on whether pianists were at risk 

of noise-induced hearing loss. This study had problems with 

recruitment with only 30 of 150 invited pianists taking part. 

The study found better hearing in respondents but the non-

responders might have been mindful of how, in later years, the 

presbycusis stricken Beethoven was, at least anecdotally, rough 

with his instrument [4]. Better not admit to that. Many of the 

other studies she found were also of low quality, so her answer 

to the review question was ‘probably’, recommending the 

strategy of protecting musicians from their own music. Nerys 

Williams [5] also faced the quality barrier in looking at voice 

disorders in terms of self-reporting, but linked disability to 

work task: actors rated ‘power’ of the voice as most affected, 

singers the ‘dynamic’ features.

Repetition strain injury was first described in Australia by 

Ferguson in 1971 [6], so it is appropriate that the 2006 paper by

 Bragge et al. [7] was written from Melbourne in the era of the 

‘work-related musculoskeletal disorder’ or, as the authors 

coined it ‘playing-related musical disorder’ (PRMD). The 

method was a systematic review, the focus pianists. Over 

773000 Australian children played a musical instrument at the 

time, the piano being one of the most popular instruments. The 

authors, from the School of Physiotherapy, emphasized the 

‘athleticism of performance’ as the reason for doing the study. 

They concluded that an operational definition of PMRD was 

needed, with valid reliable measurement tools used in cohort 

study designs. A prospective study sounds good, but it can be 

difficult to sort out the ‘true incident’ cases from the ‘new 

prevalent’. Of which more later.

In 2011, Kaufman-Cohen and Ratzon [8] returned to classical 

musicians, the former (K-C) attending performances. They used

 standardized ‘outcome’ tools, the Nordic Questionnaire and 

the ‘Disabilities of the Arm, Shoulder and Hand’ (DASH) 

instrument. The Rapid Upper Limb Assessment (RULA) 

provided the exposure assessment and the NIOSH Generic Job 

Stress Questionnaire the psychosocial component. The two 

strongest predictors were biomechanical factors and the 

physical environment. Psychosocial factors were not predictive, 

the authors attributing this to emotional investment so intense 

that players ignored discomfort, the performance itself 

overcoming the anxiety induced by it.

Leaver et al. [9], showed the extraordinary association between 

somatization, a tendency to worry about disease, as measured 

by the Brief Symptom Inventory, and regional pain. In this 

sample of British symphony orchestra players, risks were 

higher in women and those with low mood. Elbow pain was the 

exception, being associated with age and male sex. Neither 

psychosocial factors nor performance anxiety were predictive 

of regional pain.

In the study by Leaver et al. [9], brass players came out rather 

well in the overall pain stakes, but not so in repetition strain 

injury of the soft palate. As Evans et al. pointed out [10], 

velopharyngeal insufficiency is an inability to close the soft 

palate. It was most prevalent in clarinet and oboe players, less 

so in bass trombone, tuba, bassoon, trumpet and French horn 

players. The most common causes were muscular fatigue and 

stress.

Patil et al. [11] examined army musicians, who had started to 

fill ‘frontline roles’ because of staffing shortages, hence a need 

for good hearing. In this case, the woodwind, brass and 

percussion players showed no differences in hearing compared 

to their non-musician administrator colleagues. An equal 

probability of exposure to that potent risk factor for traumatic 

hearing loss, weapons impulse noise, seems the most 

reasonable explanation.

The next study is from Australia where Chan et al. [12] 

managed to get symphony orchestra players to participate in an 

intervention for PRMD through the medium of a DVD-based 

exercise programme. It appeared to be effective!

Back to the head and neck but this time, craniomandibular 

dysfunction. Of concern to Steinmetz et al. [13] were firstly the 

biomechanical effects in violin and viola players caused by 

mandibular pressure on the temporomandibular joint and 

secondly how the embouchure of brass players caused increased

biomechanical and intra-oral pressure. In terms of pain 

intensity, the woodwind and brass seemed to come out the 

worse for their experience. That other interesting phenomenon, 

multisite pain, was also to the fore.

Lee et al. [14] examined how dystonia, a sort of scriveners 

palsy in musicians, affected life satisfaction. They introduced 

us to a sterling concept, the ‘hedonic treadmill’, through which 

people tend to adapt to life events and return to a set point, 

providing that, so their hypothesis went, ill health did not 

intervene. Eysenck illustrated the trait in Elvis Presley, who 

attempted to cheat the treadmill by running faster and faster, 

‘more drugs, more alcohol and more women’ [15]. Elvis fell off 

the treadmill; however, German musicians with dystonia in this 

sample were no less happy than their dystonia-free counterparts.

Thence to Tasmania with Stanhope, Milanese and a systematic 

review of MSDs in flautists [16]. The prevalence of 

musculoskeletal symptoms seemed high but confounded by the 

different instruments, meaning study questionnaires, used.

Finally, and bringing us right up to date, Baadjou et al. [17] 

carried out a comprehensive review of MSDs, the initial yield 

being 2141 citations, reduced to 61 after screening. The 

unfortunate conclusion was that no conclusion was possible due 

to poor study design. The Occupational Medicine studies 

included in their review [7,9] did however provide consistent 

evidence, part of the reason being good study design and the 

use of the Nordic Questionnaire.

To the writer, a B♭bass tuba player, it was disappointing to see 

the absence of that singular British, and indeed New Zealand, 

institution, the brass band. The Baadjou paper did however 

reference a study by Levy and Lounsbury which looked at the 

relationship between the big five personality traits and 

marching music injuries [18]. The ‘big five’ were 

agreeableness, conscientiousness, emotional stability, 

extraversion and openness. Of these, openness had a strong 

positive correlation with injury and emotional stability a slight 

negative correlation. The authors wrote that openness was the 

trait most often likened to creativity. That artistic temperament 

again.

As would be expected, the majority of the papers had a 

musculoskeletal focus, and musculoskeletal complaints are not 

the easiest of things to study, even with a prospective design. 

As McBeth and Jones point out, musculoskeletal complaints 

are common, so identifying true incident or ‘first ever’ cases is 

problematic: the best predictor for an new MSD is a previous 

episode [19]: aye, there’s the rub. The difficulty therefore is 

that most studies find new prevalent cases. A proportion of 

cases will simply be, in this recurrent complaint, pain free at 

the time of recruitment but poised to complain. One must also 

look for chronicity, especially regional pain, assess 

psychological factors, use diagrams in locating the pain and use 

standard questionnaires. If asked for an editor’s pick, Leaver et 

al. [9] would win the design stakes by at least a head.

As we started with the text of the Hippocratic epidemiologist of 

Modena, we should leave the penultimate words to the Bard of 

Avon [20]. As written for Lorenzo in the Merchant of Venice:

The man that hath no music in himself,

Nor is not moved with concord of sweet sounds,

Is fit for treasons, stratagems and spoils;

The motions of his spirit are dull as night

And his affections dark as Erebus:

Let no such man be trusted. Mark the music.

   Which we shall.