Occupational Medicine 2016;66:592–594
doi:10.1093/occmed/kqw124
In the virtual issue on the occupational health of
musicians
Ramazzini, to whom we often look for the historical con-
text 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 musculoskel-
etal 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 pia-
nists 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’, recom-
mending the strategy of protecting musicians from their
own music. Nerys Williams [5] also faced the quality bar-
rier 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 disor-
der’ (PRMD). The method was a systematic review, the
A virtual issue of research papers on the occupational health problems in musicians can be accessed through the Occupational
Medicine website.
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focus pianists. Over 773 000 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
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from the ‘new prevalent’. Of which more later.
In 2011, Kaufman-Cohen and Ratzon [8] returned
to classical musicians, the former (K-C) attending per-
formances. 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 expo-
sure 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 pre-
dictive, the authors attributing this to emotional invest-
ment 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 dis-
ease, as measured by the Brief Symptom Inventory, and
regional pain. In this sample of British symphony orches-
tra players, risks were higher in women and those with
low mood. Elbow pain was the exception, being associ-
ated 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 ina-
bility 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 staff-
ing 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 partici-
pate 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, cranioman-
dibular dysfunction. Of concern to Steinmetz et al. [13]
were firstly the biomechanical effects in violin and viola
players caused by mandibular pressure on the temporo-
mandibular 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 experi-
ence. That other interesting phenomenon, multisite pain,
was also to the fore.
Lee et al. [14] examined how dystonia, a sort of scrive-
ners palsy in musicians, affected life satisfaction. They
introduced us to a sterling concept, the ‘hedonic tread-
mill’, through which people tend to adapt to life events
and return to a set point, providing that, so their hypoth-
esis 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 preva-
lence 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 disap-
pointing 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 lik-
ened to creativity. That artistic temperament again.
OCCUPATIONAL HEALTH OF MUSICIANS  593
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 pro-
spective design. As McBeth and Jones point out, mus-
culoskeletal complaints are common, so identifying true
incident or ‘first ever’ cases is problematic: the best pre-
dictor for an new MSD is a previous episode [19]: aye,
there’s the rub. The difficulty therefore is that most stud-
ies 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 epide-
miologist of Modena, we should leave the penultimate
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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.
David McBride
References
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3. Palin SL. Does classical music damage the hearing of
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8. Kaufman-Cohen Y, Ratzon NZ. Correlation between risk
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594  OCCUPATIONAL MEDICINE
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11. Patil ML, Sadhra S, Taylor C, Folkes SE. Hearing loss in
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12. Chan C, Driscoll T, Ackermann B. Exercise DVD effect on
musculoskeletal disorders in professional orchestral musi-
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13. Steinmetz A, Zeh A, Delank KS, Peroz I. Symptoms of cra-
niomandibular dysfunction in professional orchestra musi-
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14. Lee A, Eich C, Ioannou C, Altenmuller E. Life satisfac-
tion of musicians with focal dystonia. Occup Med (Lond)
2015;65:380–385.
15. Eysenck M W. Happiness: Facts and Myths. Hove, UK:
Erlbaum, 1990.
Why I became an occupational physician….
In 1983, sheltering in a shell-damaged hangar dur-
ing an artillery battle at Beirut International airport
I  found myself wondering about my career. I  was
accompanying a wounded American marine whilst for
the first time in my life carrying a loaded pistol with
the safety catch off as the RAF Chinook helicopter that
had delivered me there, disappeared into the distance.
The American helicopter that was meant to be pick-
ing us up was late. Having trained in general medicine
and latterly in general practice, I joined the RAF partly
because of disillusionment with the NHS and partly
due to a fascination with aircraft. Whilst the current
situation was exciting, and in the emergency medi-
cine connotation appropriate, this was not something
I wanted to do for the rest of my career. Three weeks
later I  found myself landing in the middle of Beirut,
again during an artillery battle, with a medic in the
middle of the night, to pick up a wounded television
sound recordist. Neither of these episodes appeared to
be about preventing injury or rehabilitating ‘patients’.
My interest in flying had been present from an early
age, but my manifest myopia had been a preclusion to
starting a flying career in the 1970s. After joining the
RAF, I was privileged to be able to fly with the aircrew
that I looked after and to be informally trained in flying
fixed and rotary wing aircraft. The latter became very
real as a skill in Northern Ireland, Cyprus and The
Falklands, where I was involved in retrieving casualties,
16. Stanhope J, Milanese S. The prevalence and incidence of
musculoskeletal symptoms experienced by flautists. Occup
Med (Lond) 2016;66:156–163.
17. Baadjou VA, Roussel NA, Verbunt JA, Smeets RJ, de Bie
RA. Systematic review: risk factors for musculoskeletal dis-
orders in musicians. Occup Med (Lond) 2016. doi: 10.1093/
occmed/kqw052.
18. Levy JJ, Lounsbury JW. Big Five personality traits and per-
formance anxiety in relation to marching arts satisfaction.
Work 2011;40:297–302.
19. McBeth J, Jones K. Epidemiology of chronic muscu-
loskeletal pain. Best Pract Res Clin Rheumatol 2007;
21:403–425.
20. Shakespeare, W. The Merchant of Venice. Shakespeare: The
Complete Works. London: Michael O’Mara Books, 1988;
197–198.
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doi:10.1093/occmed/kqw077
supporting them in flight and delivering them to sec-
ondary care. Normally on the return trips to base
I would be in control of the aircraft. Subsequently, the
RAF formally taught me to fly and I gained my private
pilot’s licence, partly achieving my ambition.
I completed my first formal occupational medi-
cine course—the Diploma in Aviation Medicine—
and acquired skills to assess the capability of aircrew
to return to operations after illness and injury. It was
one particular aircrew assessment after injury that con-
vinced me that a career in occupational medicine was
where my interests would be fulfilled. I had to assess a
fighter pilot after musculoskeletal injury. His future fly-
ing career would be affected significantly by an adverse
assessment and might have condemned him to non-
flying duties. Much to his relief, my assessment and
report allowed him to return to flying duties, and as it
turned out to an interesting future career. This assess-
ment, among others that I completed in my role, con-
firmed my desire and satisfaction with occupational
medicine and led me to apply for formal occupational
medicine training. The rest is history as they say and
that former pilot is the current world land speed record
holder! Partly thanks to him, I have had an amazingly
satisfying career, but perhaps in some way I also con-
tributed to the UK holding a world record.
Chris Sharp
e-mail: chris.sharp@clara.co.uk