Dance and Performing Arts Medicine
Devin P. McFadden
Performing arts medicine is a growing specialty field that focuses on the care of actors, vocalists, musicians, and dancers.
Although millions of Americans participate in these activities at a recreational or amateur level, it is estimated that there are over 200,000 professional-level performers in the United States alone (12).
To discover the biomechanics of injury, physicians who care for these specialized performers must commit to understanding the art form of their patients.
Just as different sports have unique injury patterns, so to do the performing arts, with each art form, instrument, and dance step carrying with it an inherent set of risks.
Because there is no universally accepted governing body or centralized medical oversight in the performing arts realm, it is difficult to determine the exact incidence or prevalence of injury.
Performing artists tend to seek medical care late in the course of an injury because many are self-employed and uninsured. Injuries are also presumably underreported due to fear of missing an audition, losing a part, or being supplanted by an understudy.
Current medical knowledge is based primarily on smaller studies investigating a single school or dance troupe. Anecdotal reports of improved injury rates with preventative strategies have been difficult to validate due to sparsity of supporting data.
The highest prevalence of injury, and therefore the greatest amount of injury data, is found in musicians and dancers. These populations are at increased risk for insidious, chronic, overuse injuries caused by repetitive microtrauma, rather than acute traumatic injuries with a definable onset. Diagnosis and management are more challenging in this setting, and treatment frequently requires activity modification or restriction to allow healing to occur.
MEDICAL CARE OF THE MUSICIAN
Injury is a threat to the musician just as it is to other athletes and performers. One recent study of orchestral musicians found lifetime prevalence of music-related injuries to be 82%, with 76% experiencing a condition that negatively affected their musical performance (1).
Historically, musicians are more prone to injury when learning a new technique, practicing a particularly challenging piece, or using a new instrument (12).
Poor posture, excessive playing force, improperly fitting instruments, and insufficient rest between rehearsals are modifiable risk factors placing the musician at risk for injury (4).
Environmental risk factors have also been identified, including cool temperatures decreasing circulation to the distal musculature required for fine motor control and inadequate lighting causing eyestrain and abnormal posturing in musicians struggling to read their notes (4).
Musculoskeletal injuries and tendinopathies are common in musicians and tend to present in the same way that they would in nonmusicians. Meanwhile, neurologic injuries are vastly more prevalent than in nonmusical populations, making focal neuropathies, cervical radiculopathy, thoracic outlet syndrome, ulnar neuropathy, carpal tunnel syndrome, overuse syndrome, and focal motor dystonia important diagnoses to recognize and maintain in your differential diagnosis.
In what has been called the “trumpet player’s neuropathy,” focal neuropathies of the neurovascular supply to the lip have been identified, primarily in brass and woodwind players (8). Playing woodwinds with leaky valves or pads increases the effort required to produce a note and may be a risk factor for this injury type (4).
Due to the leftward rotation and lateral flexion of the neck required to cradle the instrument, cervical radiculopathy is common in string musicians. This posture causes loading of the facet joints and anatomic narrowing of the ipsilateral neural foramen. Upon physical examination, one should perform a Spurling test (also known as the quadrant test)
where downward pressure is placed on the top of the rotated and extended head. A positive test is defined by pain and paresthesias spreading distally in the distribution of a cervical nerve root on the side that the patient is facing. Multiple studies have shown the Spurling test to be a reliable diagnostic tool with specificities ranging from 92% to 100%. Although with sensitivities of only 28%-60%, it should not be used for screening purposes (10). Consequently, even without suggestive exam findings, a magnetic resonance imaging (MRI) or electromyography (EMG) must be pursued if clinical suspicion is high.
Thoracic outlet syndrome results from compression of the neurovascular structures passing through the superior thoracic outlet. The brachial plexus, subclavian artery, and subclavian vein are all at risk of compression while passing between the anterior and middle scalene muscles. Compression may be functional, due to shifts of the clavicle in relation to the shoulder girdle during performance, or static, as in the case of those with a cervical rib. Symptoms typically begin as vague paresthesias and pain located in the medial forearm and hand (C7, C8, or T1 dermatomes). Multiple exam maneuvers have been developed to identify the condition, but retrospective studies have found that Adson’s test, Wright’s hyperabduction test, Roos test, and the costoclavicular maneuver all have high false-positive rates (10). Therefore, clinical diagnosis must be made with a thorough history guiding a focused radiographic exam. The treatments of choice are postural training and physical therapy. However, when conservative methods fail, surgical decompression is sometimes required.
With the elbow maintained in a constant state of flexion during prolonged periods of play, ulnar neuropathy at the elbow is a common injury resulting from the strain of supporting a string instrument. Diagnosis is suspected based on history and can be confirmed if a Tinel sign is present at the cubital tunnel. Conservative management with nonsteroidal anti-inflammatory drugs (NSAIDs), avoidance of aggravating activities, and splinting typically leads to resolution of symptoms within weeks.
Often seen in pianists, carpal tunnel syndrome can result from repetitive flexion and extension of the wrist. The condition can also develop in the bow or pick hand of string instrumentalists and is common in keyboardists as well. Typical symptoms include numbness, tingling, pain, and, in severe cases, weakness of the lateral three and a half fingers, which are supplied by the median nerve. The Phalen test is a good screening exam with poor specificity reported but a sensitivity of about 80%. Meanwhile, a positive Tinel sign at or just distal to the carpal tunnel is virtually diagnostic with specificities approaching 100%, but it should not be used for screening due to poor sensitivity (11). Treatment options include avoiding provocative activities, night splinting, NSAIDs, steroid injections, and surgical release if conservative management fails.
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