FROM PERFORMER TO PHYSICAL THERAPIST: WHAT IS PERFORMING ARTS MEDICINE?
Dr. Julia Muller, PT, DPT takes the blog today to talk about her performing arts journey and how that has shaped her love for performing arts medicine and working with performers.
My performing arts journey
If I weren’t a physical therapist, I was going to be a music teacher. I started learning the flute at age 9 and it quickly became an integral part of my identity. Music class was the highlight of my school day, I was eager to go home and practice new assignments, I entered every local competition possible, and I met my closest friends in the world through music camps and various ensembles. Before age 18, I was keenly aware of how magical this art form is and how much it fueled my soul. I was very tempted to go to school for music education to be able to continue this magic and share it with the next generation of students.
I enrolled in ballet at age 6 and it quickly became my dream to study it long enough to get those cool pointe shoes that all the older girls danced on. Spoiler alert: I made it that far and it was indeed as cool as younger me had hoped. I studied ballet, tap, jazz, (a dash of) hip hop, and settled into modern dance in high school as my main focus. I’ve now come to realize how meditative dance is as a form of exercise—a way to move, strengthen, and lengthen your body while creating a larger art form with a great community of people. I forever will be grateful for the memories and knowledge I’ve gained about the human body through these formative years.
I ended up going to school to become a Doctor of Physical Therapy and it was truly the best decision I have ever made for myself. I’m proud of 18 year-old me for seeing how special this career is and deciding to embark on this path. However, I knew that I was never going to truly feel fulfilled unless I found a way to make both rehabilitation and performing arts a part of my life. I ended up completing both Bachelor of Science and Bachelor of Music degrees simultaneously at a school that highly valued the arts. (Ithaca!) I fully immersed myself in flute lessons, ensembles, music theory, music history, while also gaining experience treating injured musicians and dancers, both on and off campus. Since then, I have had the honor of working with performers at the Eastman School of Music, Garth Fagan Dance Company, as well as the cast of “Chicago” on tour. I would like to think that 18 year-old-me is beyond stoked to hear that.
What is performing arts medicine?
Performing arts medicine is a special branch of sports medicine that includes the treatment of ailments impacting music, dance, acting, and acrobatics. This is a multi-disciplinary field that includes physicians, physical and occupational therapists, speech pathologists, athletic trainers, psychologists, etc. Performers are impacted by unique injuries related to their craft and train in unique environments; this requires specialized knowledge to best manage their injuries. In other words, as a performer, you want to seek out a health care provider that truly understands the demand of your art.
How are performing arts injuries different than sports injuries?
While I firmly agree with the statement: “Performers are athletes,” that does not imply that performers should be managed exactly as athletes in professional sports. Performers train as much, if not more, than some professional sports athletes, however usually with more cumulative load on smaller, more isolated muscles. Think about how much work the muscles of the forearm/fingers have to do for a pianist that practices 5 hours per day. It is similar to how the shoulder of a baseball pitcher fatigues after maybe 1 hour of throwing. Musicians and dancers are also highly impacted by the presence of muscle imbalances, given how long they may find themselves in certain postures or doing repetitive movements. The key to managing pains that arise and promoting injury reduction is to be aware of what is proper technique for the task at hand, and support that position with strength, stability, endurance, mobility, and ease.
What are some common aches and pains we see?
For musicians, we commonly see the following in physical therapy:
Neck pain: Usually neck pain results from stiffness/fatigue in the upper back, fatigue of the upper shoulder muscles which attach into the neck, or stiffness from being in one position for a while from practice. When dealing with neck pain, it is important to rule out other areas to ensure we are treating the root cause of it!
Shoulder pain: The shoulders, being responsible for connecting the arm to the torso, have a lot of weight to carry when holding instruments. Often shoulder pain arises from:
a lack of endurance in the shoulder and shoulder blade to hold up instruments
strength imbalances between
the front and back of the shoulder
the big muscles and smaller stabilizing muscles
relative tightness in muscles
a combination of all of the above
Elbow pain: Pain near the elbow can often arise from the tendon attachments of the wrist and finger muscles. The muscles that control the lift and press of the fingers travel from the fingers, through the wrist, into the forearm, and attach onto the sides of the elbow onto the epicondyles of the upper arm bone (humerus). When these muscles are used beyond their capacity to recover between playing sessions, they can develop “tendinopathy” and experience pain at their attachments. If you have ever heard or googled about medial or lateral epicondylitis, this is what I am talking about.
Arm pain: One of the most under-discussed conditions impacting musicians is the concept of nerve related pain. This can impact part of or the entire nerve pathway which starts at the neck and travels into all of the fingers. The nerves of the arm can become tense under a variety of stressors including: holding sustained postures that stretch the nerve, having inefficient posture, poor support of the muscles around the nerve, high stress, poor sleep, and inflammation in the body (more on this later). Management of arm pain involves a comprehensive assessment of all muscles and joints around the nerve to assess the root causes of this tension. This can be incredibly frustrating and painful for musicians.
Back pain: Often back pain arises due to a lack of endurance and stability in the back and core muscles to support prolonged practice positions, which for many instruments, is asymmetrical. Management often involves moving your back into the opposite directions, strengthening the core in playing specific positions, and optimizing postures to find one that is more energy efficient.
Dancers are often impacted by:
Back pain: One of my favorite mottos is “with great flexibility comes great responsibility for stability”. Many dancers can attest to the endless drive for more flexibility in the name of uniformity with other dancers and/or for teacher preference. Back pain in dancers often manifests in pain with bending forward or backward and is related to the need for more strength and endurance in these challenging positions. We take an in-depth look at the painful positions to assess what the body needs.
Knee pain: One of my favorite areas to treat in dance medicine is the knee. The knee often is blamed for poor control and mobility at the hip and ankle. It’s like the “middle child” that gets blamed for the doings of the older and younger siblings. We assess strength, stability, mobility of all 3 joints in both static and dynamic positions to see what may be driving symptoms. If technique looks nearly perfect, pain may be related to insufficient strength of the knee muscles to handle the amount of dancing.
Ankle pain: At the ankle, we often see pain relating to tendons, joint, pain, or arch muscles. Ankle joint instability from sprains and hypermobility is a key driver of symptoms, as this can overly tax the muscles and tendons if they aren’t prepared to support the joint with adequate strength. Proper ankle mechanics are key to having better lines, stronger stability of the ankle, and reducing injury risk. Much like the knee, we want to assess ankle posture and mechanics in static and dynamic positions to treat accordingly.
Importance of overall wellness: Take your MEDS!
MEDS = MINDFULNESS, EXERCISE, DIET, SLEEP
Mindfulness
I cannot emphasize enough how important it is to take care of your mental health as a performer to prevent and manage injuries. Given the high stress yet high reward environment of the arts, it is easy to get caught up in the grind to prepare for the next performance and put all of your energy into practice, leaving nothing left to take care of your own mental health. In the presence of pain, high stress can fuel pain responses, impair recovery, and prolong the rehabilitation process process. Protect your peace and find ways to decompress away from your art.
Exercise
If you haven’t noticed a central theme to the discussion above, strength is key to safeguarding against nearly all ailments to promote longevity in the arts. I think of strength as your body’s “battery” to do the things you want to do. When the battery of a muscle runs out or “fatigues,” we are left vulnerable to discomfort, compensations, and risking poor recovery between sessions. I dislike the term “overuse” injury, as I find the term “underprepared” to be more telling of what is actually going on. We need the muscles to be prepared to support the amount of practicing/rehearsing that you need to do, so that they aren’t fully depleted each session and that a good night’s sleep with proper fueling can recover them enough for your next session.
There are multiple domains of exercise that are important for performers:
Global strength: I think of global strength as the strength of the whole system with the bigger muscles driving multi-joint compound movements. Examples of this would be squats and overhead presses. We tend to see that with more weight you can drive in these movements, the body doesn’t have to work as hard for most tasks in life that weigh less than these tasks. Stronger bigger muscles means that the little muscles needed for moving fingers on an instrument have an easier environment to do their job.
Accessory/Rehab work: Here is where specific recommendations come into play based on assessment. We want to ensure that painful areas have exercise prescription to continually build a bigger battery and engage more support from the stabilizing muscles. This generally involves more of the smaller muscles related to the injury.
Cardio: Train your engine! Stronger cardio fitness means that your relative effort for everything in life is easier. Cardio is also incredibly powerful for pain relief, stress reduction, and improved sleep.
Diet
High inflammatory foods can be detrimental to recovery and worsen pain. For optimal health and performance, focus on filling your plate with whole foods, lots of color, enough protein, and balanced food groups. Stay hydrated to help with muscle recovery and inflammation as well!
Sleep
Sleep is one of the best performance enhancers known to humans. If you want to learn more about sleep science, the book titled “Why We Sleep” changed my life. TLDR; Sleep helps our brain health to have optimal mood and focus, helps us with long term retention of practice sessions, repairs our muscles, and is responsible for regulating our energy. If you are experiencing a performance related injury, start working on your sleep hygiene ASAP!
Ready to get started?
Bring your instrument, dancing shoes, and questions to your first evaluation at THE METHOD. If you play an instrument that can’t be transported, feel free to record yourself during playing or we can do telehealth sessions to assess mechanics. As mentioned above, we will take a holistic assessment of your posture, strength, range of motion, and stability to determine your individualized treatment plan. Taking time off from the arts and “resting” rarely fixes anything long term. We want to see you crush your next performance!
