OCCUPATIONAL HAZARDS IN MUSIC

                 By Miriam C. Daum  P.T., M.P.H.



   Through the centuries, instrumental and vocal musicians have

encountered a wide variety of difficulties: fiddler's neck, horn

player's palsy, trumpeter's lip, cellist's dermatitis, harpist's

cramp and bagpiper's fungus are just a few examples of the long

and diversified list of musicians' medical problems.  During the

last several years health professionals in a number of areas

(neurology, orthopedics, dentistry, otolaryngology etc.) have

begun to research and address issues of "arts medicine".  Much

information, however, is still needed, about the problems as well

as their solutions.  With the combined efforts and

cooperation of performing artists together with medical

practitioners significant strides in prevention and treatment of

performance related problems are underway.

   This data sheet will cover the major occupational hazards

encountered by vocalists and instrumentalists.  Musculoskeletal

problems and noise induced hearing loss are discussed in detail

in separate data sheets.



VOCALISTS PROBLEMS

   The vocalist's "instrument" is not an external object but a

part of the body, and may therefore be subject to significant

abuse not only during performance but in daily non-professional

use as well.

   Signals of vocal trauma or irritation may be noticed only

during performance or may persist even when the voice is not

being used.  Symptoms may include hoarseness, throat pain,

tickling, choking or irritation.  Other signs are volume

disturbance or fatigue, described as a loss of range, change in

timbre, breaking into different registers and uncontrolled

aberrations.  Evidence of vocal mechanism insult, on physicians

examination may include vocal cord edema (swelling), hemorrhage

(bleeding) and/or nodules ("callouses" on the vocal cords as a

result of vocal abuse).



Factors Affecting the Voice

1. Vocal Abuse: Among the major causes of voice abuse is improper

technique, often resulting from insufficient or incorrect

training.  Optimal training by qualified instructors is crucial

whereby faulty techniques can be corrected and modified in a

timely manner.

   Overuse of the vocal mechanism is a common outcome of

excessive and strenuous rehearsal and performance time.  A

familiar example would be the combined voice requirements of a

rehearsal, matinee, and evening performance during one day.  An

adequate warm-up before performance may be a factor in prevention

of trauma. Training and conditioning for performance should

include appropriate balance between muscular tension and

relaxation of the head, neck, chest and abdominal regions.  Voice

alteration, such as the imitation of animal sounds or "unusual"

human sounds is another form of vocal abuse.  Although these

methods are generally not recommended, appropriate training in

optimal technique can minimize any negative effects.

   Opportunities for vocal abuse outside the performance realm

are plentiful.  Shouting at sports events and "grunting" during

forceful physical exercise and marshal arts activities may have a

deleterious effect on the vocal mechanism.  Poor speech habits,

screaming, forceful laughing as well as excessive and loud

talking (including telephone conversation) may all prove harmful.

   Defective hearing or excessive background noise reduces

important feedback for volume regulation and can result in

excessive vocal loudness as one often notices in "hard of

hearing" individuals whose speaking voice is a shout.  For more

information, see CSA's data sheet, "Hearing Loss in Musicians".



2. Travel: Aircraft cabins typically are maintained at cool

temperatures and low humidity, both producing a significant

drying effect of the vocal mucosa.  Cabin air is recirculated, so

pollutants (including cigarette smoke) are distributed and

redistributed to all passengers.  These effects can be reduced by

drinking quantities of water, breathing through a moist cloth and

wearing warm garments.  Noise levels on aircraft are fairly high

(approximately 80-90 dB), which may result in louder speaking

volumes than normal.  Therefore speaking as little as possible

while on the plane will also aid in reducing vocal stress.  In

addition, generalized fatigue from airport waiting and prolonged

flying time will compromise optimal performance potential.

An adequate rest interval should be allowed between travel and

performance.  Efforts should be initiated for managerial control

of transportation/performance scheduling to reduce fatigue as

much as possible.



3. Theater Environment: Indoor temperature control via

airconditioning or heating results in low humidity producing a

drying effect.  "Old historic theaters have old historic dust".

Performance spaces accumulate dust from curtains, props,

costumes and residue of special effects materials.  Since dust is

composed of a broad array of particulates from various

sources, one may be exposed to a variety of irritants.  Special

effects including smokes, fogs, and pyrotechnics provide

additional chemical hazards not only for the duration of their

intended effects but may persist in the atmosphere throughout the

performance.  The concert hall, by virtue of its acoustical

construction may present an additional challenge to the

vocalist.  A cement floor or wooden seats can significantly alter

vocal requirements of the performer.

   Assurance of optimal environmental conditions in the

performance space should again be approached via administrative

controls. Ideally, contract language should specify required

temperature, humidity and dust control during rehearsal and

performance. Chemical composition of substances utilized for

special effects should be investigated and the safest materials

then substituted as necessary.  Optimal ventilation should be

required and cigarette, cigar and pipe smoking prohibited.



4. Geographical Location:  Los Angeles is infamous for its smog,

Mexico City for its air pollution and Denver is renowned for its

altitude and low humidity.  Climate and air pollution are

particularly significant for the vocalist and must be taken into

consideration when performance is scheduled.

   When a performance is scheduled in a geographical location at

an altitude to which the performer is not accustomed, adequate

time should be allowed for acclimatization - usually a 24 hour

period is recommended.  Once again, this requires managerial

controls of scheduling.



5. Medications: Medications often have side-effects, some of

which may prove particularly deleterious to the vocalist.

Antihistamine decongestants (many available over the counter) may

produce excessive drying effects as well as drowsiness.

Diuretics ("water pills"), tranquilizers, antispasmotics and

blood pressure medications also produce drying effects.  When

medication usage is necessary, appropriate precautions should be

observed.  It is wise to consult a knowledgeable

physician concerning any possible effects or side-effects that

may influence vocal performance.  (In some instances, an

alternate medication may be substituted for one interfering with

optimal voice production.)



6. Lifestyle: Use or abuse of recreational drugs and

alcohol in general decreases psychological and emotional

inhibitions, thereby reducing the individual's awareness and

caution against voice abuse (e.g. allowing screaming, excessive

laughing, etc.).  Alcohol acts as a diuretic, and thereby a

drying agent, whereas marijuana produces both drying and mucosal

irritation.  Cocaine has been noted to destroy the cilia, (hair

cells) lining the upper respiratory tract as well as destroying

mucous membranes.

   Tobacco (most commonly cigarette smoking) is well known for

its irritant properties as well as its role in lung and heart

disease.



7. Food: Caffeine (found in coffee, tea, cola and chocolate) acts

as a diuretic and thereby a drying agent.  In tea, the drying

agents are tannic acid and caffeine.  Although there is a

widespread belief that ingestion of milk and dairy products

produce an increase of mucus, this has not been proven

scientifically.  Some individuals may, however, be sensitive to

dairy products, tomatoes, yeast, chicken, etc. and an allergic

response may include increased mucus production.



OCCUPATIONAL STRESS

   Within the world of music making there is ample opportunity

for psychological stress.  Long hours of practice, rehearsal and

performance allow little opportunity for recuperation.  Fierce

competition and lack of job security often leave their mark. Even

when a musician is "securely employed", stress producing

situations persist.  The pressures associated with travel are

well known to anyone having been on tour.  Conductors' demands

and conflicting requests remain a well known source of tension

and even the virtuoso or diva cannot escape the critics'

inevitable review.

   The effects of stress are numerous and vary greatly in both

short and long term results.  Perhaps of greatest immediate

concern to the performer is the reduction or loss of fine motor

control leading to an increased likelihood of physical injury. 

The primary "solution" of choice in the area of stress is

prevention.  Contract language that clearly and specifically

addresses issues of concern can provide significant protection

from some of the unnecessary sources of excessive tension.

   Treatment of occupational stress includes stress management

programs, psychotherapy, hypnosis, relaxation techniques and

biofeedback among others.  Where indicated, medication

judiciously prescribed can contribute to the treatment approach

of choice.



Performance Anxiety (Stage Fright)

   Although an optimal level of "anxiety" or excitement enhances

a performance, when it is out of control it becomes problematic.

The process of musical training itself appears to be contribute

to stage fright, with its relentless succession of auditions,

competitions and juries, setting the stage for excessive

apprehension upon appearing before an audience.

   The physical reactions of performance anxiety are via the

autonomic nervous system and appear as a "fight or flight"

response.  Increased heart rate, palpatations and heart rhythm

irregularities contribute to the sensation of fear.  Other signs

and symptoms include sweaty palms, nausea, diarrhea and a

persistent urge to urinate.  Mouth dryness is especially

problematic for wind players.  A singer who hyperventilates

(breathes rapidly and shallowly), will have increased difficulty

sustaining a note.  Excessive muscle tension and tremors can

seriously disrupt performance as well as increase the likelihood

of injury.  The psychological manifestations of this stress

phenomenon include uneasiness, depression, irritability and lack

of concentration, again potentially having deleterious effects on

performance quality.

   Treatment options include psychotherapy, desensitization

techniques, relaxation exercises etc.   Beta blockers, e.g.

Inderal, have been welcomed by some as a medication that

controls the discomfort and disability of performance anxiety

without compromising perfomance quality.  As with any

medication, beta blockers should be used only as directed by a

physician, since specific precautions must be considered

concerning possible side effects and sensitive individuals (i.e.

asthmatics, individuals with low blood pressure, diabetes or

heart rhythm irregularities).  Substances such as alcohol and

mind altering drugs are notorious in their harmful and

undesirable effects.



VISUAL PROBLEMS

   Instrumentalists are exposed to different lighting situations

depending on their location.  The bright illumination on symphony

orchestra stages will create problems of glare.  For example, a

Swedish concert hall study reported musicians complaining of

"being blinded by lights" with subsequent tearing and eye

discomfort.  The sharp contrast of black musical notes on stark

white paper further produces visual strain in bright lighting.

   Instrumentalists in orchestra pits (theatrical productions,

opera, etc.) are exposed to the another type of lighting

problem.  Since illumination is of utmost importance to the

theatrical quality of the performance, orchestral pits are

essentially dark except for small electrical bulbs on the music

stands.  Musicians' eyes are therefore repeatedly adjusting from

conditions of relative darkness to focal lights on the stands,

again resulting in eye strain.

   Several possibilities to alleviate these problems have been

suggested.  Music paper of a beige hue would decrease the sharp

contrast of the black print on a stark white page and reduce some

of the visual discomfort.  (Indeed, musicians have reported less

eye discomfort when using "old" music, where the paper has become

darker with age.)  Eyeglasses with yellow lenses have been

recommended to cut down on glare.  New design of music stand

lighting with particular attention to the position and direction

of bulbs can optimally focus the necessary lighting.



CARDIOPULMONARY PROBLEMS

   Wind instrumentalists typically produce high intralaryngeal

pressures while playing.  (The larynx is the structure at the top

of the trachea, or "windpipe" which contains the vocal cords.)

This extreme pressure may result in laryngoceles (air sacs near

the larynx, sometimes appearing as bulges on the outside of the

neck).  Another potential effect of increased air pressure is a

temporary weakness or paralysis of the palate (the partition

between the nasal and oral cavities).  This is described by

musicians as "losing their seal", and occurs most commonly with

oboists and bassoonists.

   Double reed players have reported headaches and occasional

retinal hemorrhages, again due to excessive air pressures

produced during playing.

   An interesting and fortunately harmless phenomenon has been

described in horn players and brass instrumentalists, termed

"occupational arrhythmias".  Seen also in some athletes, this

appears as a disruption of "normal" heart rates and rhythms.  It

is believed to have no pathological significance and should be

mentioned to your physician when undergoing medical examination.



TEMPOROMANDIBULAR JOINT SYNDROME

   Temporomandibular Joint Syndrome (TMJ) has become

progressively more recognized in the medical and dental community

during the last several years.  It has recently been described in

musicians, particularly violists and violinists as well as

singers.

   When opening and closing one's mouth, the actual movement is

taking place at the temporomandibular joint (the jaw joint). TMJ

Syndrome can produce pain and/or clicking upon jaw motions.

Discomfort in some of the jaw and neck muscles may occur.  Some

individuals report chronic headaches and an "awareness" of the

jaw upon awakening.

   Although individual anatomy plays an important role in TMJ

Syndrome, positioning and movement are often the determining

factors of an actual problem.  The position of neck and jaw on

the instrument's chinrest, excessive pressure in holding the

instrument and teeth clenching are the primary causes associated

with performance related TMJ Syndrome.  As in previously

described situations, correct technique can often alleviate the

problem.  Modification of shoulder pad and/or chinrest resulting

in positional improvement is recommended.  When teeth clenching

or jaw/neck muscle tension is the causitive factor, relaxation

techniques (including biofeedback) may prove useful.  Needless to

say, identification and elimination of the source of stress

expressed in muscle tension is of primary importance.  Where

indicated, an appropriate dental appliance, such as a bite

plate, can improve or restore optimal anatomical alignment of the

jaw.



DENTAL PROBLEMS

   For the wind instrumentalist, correct embouchure is of utmost

importance.  Tooth hypermobility and/or loss, often resulting

from periodontal disease could produce changes in embouchure and

thus seriously compromise performance.  The importance of

frequent dental examinations and optimal periodontal/dental

health cannot be overemphasized.



SKIN PROBLEMS

   Skin problems among musicians include fiddler's neck,

cellists' dermatitis and callous formation in string

instrumentalists. Fiddlers's neck indicates a skin rash, actually

a type of "mechanical acne", where the left side of the neck is

in contact with the instrument's chinrest.  Cysts may form in the

affected area and local infection is a possibility with

inadequate hygiene.  This problem may result from excessive

pressure due to poor technique or inadequate grip on the

chinrest.  Friction resulting from incorrect chinrest fit, an

inadequate shoulder rest and/or insecure technique is another

contributing factor. Perspiration buildup between skin and

chinrest further aggravates the irritation.  Optimal technique

(in addition to improving performance), will reduce both the

pressure and friction factors.  Proper chinrest fit and adequate

shoulder rests provide positional correction.  A "Strad pad"

(foam rubber pad used to absorb perspiration), has been reported

to be helpful.  Use of a handkerchief on the chinrest is a

simple, although less elegant solution.  Some musicians have

found beards to provide additional cushioning and protection for

vulnerable skin areas.

   Cellists may develop a dermatitis in the inner area of the

thigh resulting from pressure and rubbing against the instrument.

Careful attention to positioning of the individual in relation to

the instrument can reduce this problem.

   Another area of dermatological concern is callous formation on

the fingertips of the left hand of string instrumentalists. These

appear particularly after prolonged practice/performance time due

to the constant pressure against the strings.  Guitarists develop

callouses on the inner aspect of their forearms.  Modification of

technique usually alleviates the problem.  Problems arise when

callouses become cracked and bleeding and/or irritation occurs. 

Several commercial creams are available to protect susceptible

areas and promote healing. 



ALLERGIES 

   Although allergic hypersensitivity is not a common

occupational problem in musicians, there has been a report of

this occurring. Rosin (used by string players) contains abietic

acid which can cause asthma in sensitive individuals as well as

contact dermatitis (skin inflammation).  Cases have also been

reported of allergic reactions to woodwind mouthpieces (e.g.

rosewood) and metal keys on instruments.



CHEMICAL HAZARDS

   Many theatrical scenes are particularly beautiful for their

hazy, filmy effect.  Unfortunately, that cloudy atmosphere may be

produced by chemicals that can result in less desirable

consequences.  Performers in immediate proximity to irritant or

toxic gases, vapors, mists, fumes or dusts may be receiving an

exposure that is considered unsafe.  Even if effects are "only"

irritant in nature, the irritation may significantly hamper

performance and compromise the musicians' fine musical control.

Wind instrumentalists, in particular, have different breathing

patterns during performance, faster and/or deeper, and may

therefore be subject to even higher doses of an air pollutant.

   In some cases, safer substitutions are available for the

chemicals being used to create special effects.  In situations

where there are no safer substitutes, it is of utmost importance

to determine exactly what the chemical and safety hazards of a

particular substance are.

   Additional chemical exposures may occur from cleaning

materials used to clean the stage, props or costumes, especially

when these activities are carried out in close proximity to the

actual performance area (and/or in temporal proximity to

performance time).  Adequate ventilation is of primary importance

to prevent unsafe levels of exposure.  The chemical nature and

composition of all materials used should be determined and

whenever possible, safe substitutions provided for those

identified or suspected to be potentially hazardous.



GENERAL GUIDELINES FOR PREVENTION

1. "Be In Tune" with your body.  Pay attention to any signs or  

symptoms that appear.  They may not necessarily be significant,  

but on the other hand, they may.  Appropriate medical evaluation

can usually discern the difference.



2. Be aware of any practice/performance difficulty that was not  

previously present.  Decreased motor control or endurance may  

signal a problem.



3. Seek medical attention early.  Sometimes frightening signs or 

symptoms are far less serious than imagined.  Often, a problem  

identified in its early stages can be easily and rapidly dealt  

with.  Conversely, if allowed to persist without attention, a  

minor disorder may progress to a more complicated situation.



4. Provide your physician with as much information about yourself

as possible.  In some aspects, a musician's evaluation and  

treatment may differ from a non-musician's.



5. If you are experiencing sign or symptoms that may be related 

to your practice/performance, bring your instrument with you when

undergoing medical evaluation.  Duplicate the posture,

positioning, and movements that produce your symptoms.



BIBLIOGRAPHY

1. Brantigan CO, et al: "Effect of beta blockade and beta

stimulation on stage fright." Am J Med 72(1):88-94 (Jan 1982)



2. Caldron P, et al: "A survey of musculoskeletal injuries in

high level musicians." Clin Res 32:820A (1984)



3. Gates GA, et al: "Effect of beta blockade on singing

performance." Ann Otol Rhinol Laryngol 94(6 Pt. 1):570-4 (Nov/Dec 

1985)



4. Harman SE: "Occupational diseases of instrumental musicians;

literature review." Md State Med J 31(6):39-42 (Jun 1982)



5. Hirsch JA et al: "Jaw dysfunction in viola and violin

players." J Am Dent Assoc 104(6):838-43 (Jun 1982)



6. Peachey RDG et al: "Fiddler's  neck." Br J Dermatol

98(6):669-74 (June 1978)



7. Sataloff RT: "Professional singers: the science and art of

clinical care." Am J Otolaryngol 2(3):251-66 (Aug 1981)



8. Ziporyn T: "Pianist's  cramp to stage fright: the medical side

of music making." JAMA 252(8):985-9 (Aug 24-31, 1984) 



SOURCES OF ADDITIONAL HELP

   For more information about noise induced hearing loss and

musculoskeletal problems in musicians, the Center for Safety in

the Arts has prepared two data sheets:



Daum, M: "Hearing Loss in Musicians" 4 pp

Daum, M: "Musculoskeletal Problems of Musicians"  5 pp



   This data sheet has been made possible through funding from

the New York State Department of Labor, Occupational Safety and

Health Training and Education Program.



(c) Copyright Center for Safety in the Arts 1988