Volume 2 I, No.
2 1989
Special Reviewed Article
Medical Problems of Musicians
Lockwood, A.H.: N Engl J Med 1989; 320:221-7
Reviewed by Graham H. Burke, M.D., Reinsurance Medical Direc-
tor, Manufacturers Life, Toronto, Canada
Approximately 200,000 people in the United States earn their
living as performing artists. Interest in their medical problems
has led to the creation of about 17 centers that "focus on the
unique medical problems encountered in high level per-
formers" and to the publication of the journal "Medical
Problems of the Performing Artist." Ths article from the
Department of Neurology Performing Arts Clinic of the
University of Texas addresses these "unique problems" and
provides a wealth of information for anyone who is involved
in the underwriting of disability income, health, or life insur-
ance; in the processing of insurance claims; or in the initia-
tion and monitoring of rehabilitation programs for the per-
forming artist.
By way of introduction to disability in the musician,
Lockwood reviews the physics of the violin in order to show
how minute differences in the accuracy of finger placement
and in the coordination required between the bow and finger
placement differentiate a "violinist" from a "Jascha Heifetz"
and therefore, how "small decrements in function are what
define total disability."
The prevalence of "playing-related disorders" is quite high.
Seventy-six percent of the International Conference of Sym-
phony and Opera Musicians (ICSOIV0 report having had at
least one medical problem that was severe enough to affect
performance and many have recurring difficulties. The com-
monest cause of disability in musicians is the "overuse syn-
drome." The prevalence of this problem varies with the type
of instrument being played. It ranges from about 75 percent
among string players to about 30 percent among
percussionists.
"Overuse" symptoms are due to musculotendinous injuries
which are secondary to "the cumulative effects on tissues
of repetitive physical stress that exceeds physiologic limits."
They affect women more often than men; they may be related
to physical and psychological stress, and they may be
anteceded by congenital anomalies. The author reviews the
clinical presentation, pathophysiology and treatment of the
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Special Reviewed Article
problem and illustrates how the unique size and shape of
musical instruments can lead to specific injuries. An unusual
example is the pa/nful laryngoceles and pharyngeal pouches
that develop in oboe and trumpet players secondary to the
high intrathoracic pressures that they must generate in order
to play their instruments.
Musicians also suffer pain, weakness and sensory changes
secondary to nerve-entrapment or plexus-entrapment syn-
dromes. The commonest sites of injury are the carpal tunnel
and brachial plexus. An intriguing characteristic of this type
of injury is that symptoms may only be present when the
individual is playing his or her instrument.
Lockwood also reports that musicians may be unusually
susceptible to the development of focal dystonias. These
"writer’s cramp" types of disorders are quite ominous.They
may persist for long periods of time and eventually lead to
complete disability. Their pathophysiology has not been
established and unfortunately, the results of treatment have
been disappointing.
Performing artists generally suffer from a fair amount of
"psychological stress." An ICSOM study found that the
biggest stressor to its members was the fear of "performance
anxiety." However, 25 percent were also worried about their
use of alcohol, prescription and non-prescription drugs, and
17 percent suggested that they were suffering from depression.
As the symptoms of performance anxiety can be prevented
by taking propranol, apparently without any detracting side
effects, this drug is "frequently used without medical super-
vision by a large number of performers." Benzodiazepines
significantly impede performance so there does not seem to
be an abuse problem with the drug among high level
performers.
Lockwood see a general increase in awareness of the
significance of medical injuries related to music making. An
increase in disability claims is an obvious result of the recogni-
tion that the musician’s aches, pains and performance prob-
lems are bonafide disabling conditions.
This very enlightening article and its list of 71 references will
certainly be of help to anyone in the insurance industry who
is dealing with the unique and interesting group of indivi-
duals who are the performing artists.