SPECIAL POPULATIONS

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An Intensive Continuing Education Course to

Enhance Care of the Performing Arts Athlete: The
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“Essentials of Performing Arts Medicine”

Bronwen J. Ackermann, BAppSci (Physiotherapy), MPH, PhD;1,2 J. Matt McCrary, BFA, BS, PhD;2,3
Clay Miller, MFA, MD, PMR;4 Randall Dick, MS, FACSM;5
and Christine Guptill, BMus, BSc, MS(OT), PhD, OT Reg. (Ont.)6

artists from limited studies — 80% to 90%

Abstract career prevalence of playing-related muscu-
High occupational injury rates have been reported in performing artists, yet loskeletal disorders in musicians (3–5) and
the quality of preventive and clinical care remains highly variable. Through 67% to 95% annual incidence of musculo-
the Athletes and the Arts collaboration, The Performing Arts Medicine skeletal injuries in dancers (6–9). The qual-
Association, and the American College of Sports Medicine identified that ity of preventive and clinical care for per-
health care practitioners’ existing expertise should be enhanced to address forming artists, however, remains highly
the complex psychophysical needs of performing artists. In response, a 2-d variable and is further complicated by a
continuing education course, “The Essentials of Performing Arts Medicine” prevailing wariness of health professionals
(EOPAM), was developed and has been delivered at least annually since by performing artists (10,11). Performers
2016. This course has been well-received by 149 physicians and 240 allied remain concerned, and often rightly so,
health professionals to date (average ratings, ≥3.5/5 from 2018 to pres- that health professionals do not adequately
ent), with course quality significantly improved by a transition to online understand the complex psychophysical
delivery in 2020 (average ratings ≥4.5/5; P < 0.01). Accordingly, EOPAM requirements of their art (12).
demonstrates that a brief continuing education course can enhance health The Athletes and the Arts collaboration
professionals’ understanding of the unique needs and demands of perform- involving several sports medicine and per-
ing artists, addressing a key barrier to improved care. forming arts organizations was launched
in 2013 to enhance existing sports medi-
cine expertise to address the needs of performing artists (13)
Introduction (see www.athletesandthearts.com). Through this collaboration,
The unique demands of the performing arts athlete are now two of these organizations, the Performing Arts Medicine Asso-
well recognized. Athlete-level physical and psychological de- ciation (PAMA) and the American College of Sports Medicine
mands reported during both music and dance performance (ACSM), identified the need for an intensive continuing clinical
(1,2) are linked to extremely high injury rates in performing education program addressing the unique demands of the per-
forming arts setting (i.e., “Performing Arts Medicine 101”).
1
School of Medical Sciences, Sydney Medical School, The University of
Sydney, Sydney, AUSTRALIA; 2Institute of Music Physiology and Musicians’ Aims
Medicine, Hannover University of Music, Drama and Media, Hannover, Develop an intensive training course to provide health pro-
GERMANY; 3Prince of Wales Clinical School, University of New South
fessionals (physicians and allied health) with an understand-
Wales, Sydney, Australia; 4Sports Medicine North, Peabody, MA; 5Health
and Safety Sports Consultants, LLC, Carmel, IN; and 6School of ing of the unique needs and demands of performing artists.
Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa,
Ottawa, CANADA
Methods
Address for correspondence: Bronwen J. Ackermann, BAppSci
(Physiotherapy), MPH, PhD, Discipline of Biomedical Sciences, School of The intensive training course — the “Essentials of Perform-
Medical Sciences, Faculty of Medicine and Health, 132 RC Mills, A26, The ing Arts Medicine” (EOPAM) — was created based on
University of Sydney, NSW, 2006, Australia; E-mail: Bronwen.ackermann@ best-practice formative and process evaluation methods for
sydney.edu.au. developing and refining educational interventions (14–16).
1537-890X/2112/454–459
Course development involved extensive consultation of a broad
Current Sports Medicine Reports range of both performing arts and sports medicine expertise and
Copyright © 2022 by the American College of Sports Medicine resources, aiming to synthesize evidence- and eminence-based

454 Volume 21  Number 12  December 2022 Essentials of Performing Arts Medicine

Copyright © 2022 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 knowledge across three phases: contextual understanding, forma-
tive evaluation, and process and outcome evaluations (Fig. 1).
Contextual Understanding
Initial high-level meetings between senior PAMA and ACSM
representatives were held to appraise current resources and
identify specific needs to be addressed by an intensive continu-
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ing education course. Performing Arts Medicine Association
representatives highlighted the need for the course to expand
the health workforce capable of effectively caring for perform-
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ing artists by providing broad training in the unique demands
and health considerations of performing artists. Updated ac-
creditation criteria from the National Association of Schools
of Music (17) mandating the integration of enhanced health
care resources into collegiate music degree programs pro-
vided further impetus. ACSM representatives proposed that
existing ACSM continuing education certificate courses pro-
vided an appropriate framework. Performing Arts Medicine
Association representatives identified that existing PAMA ed-
ucational content could be updated and adapted for the new
intensive training course.
ACSM representatives also identified a specific need for a
preparticipation screening tool to identify at-risk performing
artists, similar to existing programs for sport athletes. The de-
velopment of the resulting tool, the Dancer, Instrumentalist,
Vocalist and Actor (DIVA) preparticipation assessment, will
be detailed in a companion article in this issue.
Formative Evaluation
Synthesis of available literature
A review of literature related to the health and care of sport
athletes and performing artists, as well as existing continuing
education course structures (e.g., ACSM, AMA), was con-
ducted to inform the first draft of the course content and de-
sign (Table 1). Given the relatively small amount of perform-
ing arts medical literature, initial course content broadly con-
sidered reported performance health issues, risk factors, and
clinical approaches.
Analysis of existing PAMA educational workshops
The first draft of the course content and design was further
informed by an appraisal of existing educational workshops
run by PAMA and the course designers (first and third authors).
In particular, workshops were reviewed to identify components
that could be used to inform course structure and delivery mode.
Based on this review, lecture-based delivery of content was se-
lected, with each lecture to be accompanied by a written topic
Figure 1: Course development flow diagram. NASM, National Association of Schools of Music; AMA, American Medical Association.
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summary including key references. Considering the limited per-
forming arts medical evidence base, each course module was
conceived to be delivered by two international topic experts with
complementary expertise (e.g., a clinician and musician) to best
integrate relevant evidence- and eminence-based knowledge.
Broad oversight of content development and coordination by
the course coordinator (at various points the first, second, third,
and fifth authors) would be provided to ensure course cohesion.
International experts' consensus
Expert performing arts medical practitioners from PAMA
(led by the PAMA Education Committee) and other interna-
tional performing arts health organizations were contacted once
the first draft of course content and design was completed. Com-
munication and feedback with this group allowed consensus to
be reached, with several experts then serving as course faculty.
Following this process, the course objectives were solidified.
At the end of the course, participants will be able to:
1. Discuss occupation-specific questions that should be
asked during the initial interview with performing art-
ists to identify key injury causes.
2. Identify basic physical elements of performance.
3. Apply key special assessment procedures that are
useful when evaluating performing artists (i.e., DIVA
assessment)
4. Establish goal-oriented and evidence-based treatment
approaches, taking into account the specific priorities
of performing artists.
5. Assess basic requirements of the occupational envi-
ronment of the performing artist.
6. Implement functional return to performance protocols.
7. Describe preventative approaches to medical problems
of performing artists.
A 2-d course was determined to be both the most feasible du-
ration because of time constraints of faculty and attendees, and
the minimum possible time needed to meet course objectives.
Continuing medical education accreditation
Accreditation of the course for continuing medical educa-
tion (CME) credits was considered by PAMA and ACSM rep-
resentatives to be an essential benchmark for ensuring that
course content and delivery met established standards.
To meet accreditation requirements and evaluate partici-
pant learning, course exams were created by the course crea-
tor in conjunction with the course coordinator and faculty
Current Sports Medicine Reports 455
 Table 1.
Outline of formative and process/outcome evaluation methodology
Component
Formative evaluation Synthesis of available literature
Analysis of existing PAMA educational
workshops
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International experts' consensus
CME accreditation
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Process and outcome Fidelity
evaluation
Dose received
Impact on knowledge
Reach
experts, in collaboration with ACSM leadership. Exams were
created using principles of Bloom’s taxonomy to incorporate
three levels of testing — 30% “recall” (one-step) questions,
40% “understanding” questions (two-step), and 30% “appli-
cation” questions (three-step) (18). Exam items were carefully
evaluated on an annual basis, and items that were performing
poorly were removed and replaced (e.g., participant responses
equally distributed across multiple answer choices). In addi-
tion, separate examinations for medical and allied health pro-
fessionals, which were specifically suited to each professional
group's background and training were developed and deliv-
ered from 2017 onward.
Process and Outcome Evaluation
Process and outcome evaluations were used to evaluate
course performance on an ongoing basis according to four
criteria adapted from established methods (19–22) (Table 1):
1. Fidelity — was the course delivered as planned?
2. Dose received — how was the course received by
participants?
3. Impact on knowledge — how did the course impact
the knowledge of participants?
4. Reach — did the course engage the audience needed
to achieve its aims?
As outlined in Table 1, fidelity was evaluated through focus
groups and debriefs of expert course faculty, evaluations of
the course by the course organizers, and participant feedback
(i.e., survey administered by CME provider). The Dose Re-
ceived and Impact on Knowledge were evaluated through par-
ticipant feedback and examination performance. Course reg-
istration data were used to evaluate course Reach.
Results
The EOPAM Course
Essentials of Performing Arts Medicine has been delivered
at least annually from 2016 to 2020. Course topics are de-
tailed in Table 2. From 2016 to 2018, EOPAM was delivered
as a 2-d in-person “preconference” course preceding the an-
nual PAMA Symposia. In 2019, EOPAM was delivered in a
hybrid format, with day 1 content delivered online and day
2 content delivered in-person on the day preceding the annual
456 Volume 21  Number 12  December 2022
Copyright © 2022 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Method(s)
Literature review
Appraisal by course designers
Consultations with international PAM professionals
and PAMA Education Committee
ACSM and PAMA executive consultations
Annual faculty focus groups and debriefs; course
organizer evaluation; participant feedback
Participant feedback; course examination performance
Participant feedback; course examination performance
Course registrations
PAMA Symposium. In 2020, EOPAM was delivered fully on-
line. All versions of the course were accredited for continuing
medical education credits. Each participant who passed the
course examination received a certificate of completion.
Process Evaluation — Transition to Online Delivery
Fidelity
Faculty debrief sessions, course organizer evaluations, and
participant feedback all identified course reliance on a substantial
number of expert faculty to voluntarily deliver course modules as
a challenge to fidelity with face-to-face delivery. In particular,
variable availability of topic area expert faculty required individ-
uals with broad knowledge to deliver multiple modules in the
2017 to 2019 versions of the course. Given course emphasis on
synthesizing evidence and eminence-based knowledge, faculty
changes also necessitated modifications to lecture, topic sum-
mary and examination content, and the coordination of these
changes within the context of the broader course. Management
of faculty and content modifications was thus a significant on-
going administrative burden, which resulted in the hiring of a
part-time course coordinator and a substantial time commit-
ment from course organizers.
Dose received and impact on knowledge
While the course was generally positively received (see Out-
come Evaluation), participant feedback consistently indicated
that in-person content delivery over a compressed 2-d timeframe
limited their ability to engage with course content. For example,
one respondent stated: “The course greatly contributed to my
knowledge and skills. However, it was a lot of material in a short
amount of time” while another commented: “Two full days is
both a lot of time and not much time: the pace and number of
sessions was intense, and there was little (if any) time for review.”
Transition to online delivery
The transition to online delivery was made in 2019 to 2020
to reduce ongoing administrative burden and increase the
amount of time participants had to engage with course content.
With online delivery, international subject area expert faculty
were able to remotely record course content and develop topic
summaries and examination questions, which can be repeatedly
delivered to course participants while reducing the ongoing ad-
ministrative burden. Online delivery also afforded participants
Essentials of Performing Arts Medicine
 Table 2.
Outline of EOPAM course topics/modules in initial (2016) and current (2020) iterations of the course.
Day 1
Both initial (2016) and current (2020) course versions
The performing arts athlete
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Epidemiology and etiology of injuries in performing artists

Psychological health issues in performing artists
Evaluation of the singing voice
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Key principles of injury prevention and management

Initial version only (2016) Current course version only (2020)
Introduction to medical and general health issues of dancers, Musician assessment and management principles
instrumentalists, and vocalists
DIVA preparticipation screening for musicians and dancers Dance assessment and management principles
Prevention of hearing loss in performing artists Neurological issues in performing arts
Assessing music performance anxiety and recommendations
for treatment
Day 2
Both initial (2016) and current (2020) course versions
Demands of ballet
Demands of contemporary/modern dance
Demands of vocalists
Demands of keyboard
Demands of percussion
Demands of strings
Initial version only (2016) Current course version only (2020)
Demands of winds and brass Demands of woodwinds
Demands of other dance disciplines Demands of brass
DIVA preparticipation screening for musicians and dancers
All course topics are delivered as a 45-min lecture-based session except for the DIVA preparticipation screening for musicians and dancers.

additional time to absorb the content and review recordings if
desired — one participant summarized this by saying, “As a live,
two-day course, this course would have been overwhelming, and
there is no way that I would have felt prepared well enough to sit
for the exam. Virtually, I absorbed a lot more material, which
also made the exam more feasible.” In addition, moving the
course to online delivery resulted in a 4-fold decrease in expense
ratio (course expenses per registration dollar) for PAMA. The
online course and corresponding course manual are both consid-
ered “living,” with regular opportunities for faculty to update
course content planned to occur every ~2 years.
Outcome evaluation
Quantitative outcome evaluation results focus on compari-
sons between the final year of in-person course delivery (2018)
and the first year of completely online delivery (2020) to pro-
vide the most valid comparison of EOPAM delivery modes.
Faculty debrief meetings from 2016 to 2018 focused on in-
creasingly more targeted issues, indicating that the course
was approaching a level in 2018 where only refinements were
needed, rather than broad changes. For example, suggestions
were made in 2016 to limit Topic Summaries to two pages
with no appendices to improve the consistency of the manual
and faculty expressed a need for more “level 3” questions for
the examination. Feedback in 2018, by contrast, was much
more specific, for example, ensuring that all faculty were aware
of the need to attend a planning meeting the evening prior to
the course and detailed suggestions on item analysis for the
multiple-choice examinations.
Fidelity and dose received
Participant evaluations of the quality of the course were
generally high for both 2018 and 2020 (≥3.5/5; Fig. 2), but
significantly improved with fully online delivery (P < 0.01).
The variance in quality ratings also was significantly reduced
in 2020 versus 2018 (P < 0.001) (Fig. 2).
Impact on knowledge
Participant feedback indicated that the contribution of the
course to their knowledge was generally high for both 2018
and 2020 (≥3.5/5; Fig. 2). However, feedback also indicated
that the online version of the course (2020) made a significantly
greater contribution to their knowledge than the in-person ver-
sion (2018) (P < 0.001). Examination performance was similar
between the 2018 and 2020 versions of the course (average
scores (2018 vs 2020): Physicians — 81.8% vs 82.5%; Allied

www.acsm-csmr.org Current Sports Medicine Reports 457

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Figure 2: Comparison of average participant satisfaction ratings for day 1, day 2, and the overall EOPAM course, as well as the contribution of
the course to their knowledge, in 2018 (in-person) versus 2020 (fully online). All participant ratings were significantly higher in 2020 versus 2018
(Mann–Whitney U test; P < 0.01). Variances in participant ratings were significantly reduced in 2020 versus 2018 (F test18; P < 0.001).
Health – 73.0% vs 75.6%). In addition, while participants re-
ported that content volume and time constraints limited their
ability to engage with course content in 2018, few participants
indicated that an interactive component would have enhanced
their course experience with the online version in 2020. For
example, in 2018, participants gave the following feedback:
“give detailed study materials when you enroll so we can
study ahead of time, [...] maybe give the exam at the end of
conference for more time to prepare and review all the infor-
mation”; “It was a lot of material in a short amount of time.
I have to regard it as more of an overview.” In contrast, in
2020, a participant wrote: “This program is comprehensive
and great to have online for CME purposes. Excellent pro-
gram.” “Future courses could be arranged where we log on
at certain times for a few weeks to have lectures and structured
discussion to interact with our peers.”
Reach
Course reach was substantially increased by switching from
in-person to fully online delivery. A total of 65 physicians reg-
istered for the EOPAM course over 4 years of fully or partially
in-person delivery versus 84 physician registrations in the first
year of fully online delivery. Similarly, 93 allied health profes-
sionals registered for EOPAM over 4 years of fully or partially
in-person delivery versus 147 registrations in the first year of
fully online delivery. Although we did not ask where partici-
pants were living, there were participants in the 2020 course
who indicated that they were from Japan, the Philippines,
and the United Kingdom, and that their access to this type of
training had been limited due to geography. For example, “I
am [a] Japanese family doctor. I have always wanted to study
Performing Arts Medicine, but I have never been able to go to
a study group abroad.”
Discussion
The Essentials of Performing Arts Medicine is the first con-
tinuing education course aiming to enhance the care of the
Performing Arts Athlete by providing physicians and allied
health professionals with a broad understanding of the unique
458 Volume 21  Number 12  December 2022
Copyright © 2022 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
needs and demands of performing artists. This course has been
created as a collaborative effort between leading sports and per-
forming arts medical organizations, accredited for continuing
medical education credits in the United States, and generally well
received by 149 physicians and 240 allied health professionals to
date. Accordingly, EOPAM comprises a landmark addition to
the continuing medical education landscape with the potential
to significantly enhance the care of performing artists.
In addition, this article highlights the advantages of online
versus in-person delivery of continuing medical education courses,
particularly courses with content dependent on delivery by special-
ist expertise. Online delivery of the EOPAM course dramatically
reduced both financial and time costs of running the course versus
face-to-face delivery modes and increased course reach to a larger,
more diverse audience. Additionally, online delivery facilitated the
inclusion of preeminent international topic area experts in course
faculty, which is particularly critical to EOPAM course aims
to supplement the sparse performing arts medical evidence
base with eminence-based knowledge.
Further, the benefits of online delivery outweighed potential
drawbacks related to the removal of participant-faculty inter-
actions and hands-on demonstration of the DIVA pre-participation
screening — participant ratings of both the quality and perceived
contribution to knowledge of the course were significantly im-
proved with online versus in-person delivery. These results are
supported by prior studies demonstrating physician preference
for online continuing medical education units (23,24). However,
questions remain regarding the ability of didactic continuing
medical education to influence patient outcomes (25). Future
longitudinal studies are required to determine the impact of the
EOPAM course on health outcomes in performing artists.
Current limitations of the course include an inability to ca-
ter to specific specialties, particularly for allied health profes-
sionals (e.g., course content is the same for physical and speech
therapists). The development of additional allied health tracks
of the course featuring tailored content for professional subspe-
cialties is planned. Another drawback of online delivery is the
reduced ability for the participants to interact with faculty
and content, as well summarized by one participant: “It was
Essentials of Performing Arts Medicine
 helpful to have all the sessions online, since that gave [the] op-
portunity to view them multiple times. [...] At the same time,
if it is feasible to do so, I think it would be helpful to provide
some means of interactivity with the participants.” Strategies
for facilitating online interactions between participants and fac-
ulty with minimal additional administrative and faculty burden
are in development for future course iterations. In addition,
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evolving the course from a Certificate of Completion into a Cer-
tification program is under ongoing consideration.
In conclusion, the Essentials of Performing Arts Medicine is
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an accredited, well-received continuing education course capa-
ble of enhancing health professionals’ understanding of the
unique needs and demands of performing artists. Online course
delivery significantly increased course fidelity and reach, with
minimal drawbacks.
Special thanks to all past and present EOPAM course
faculty: Bronwen Ackermann; Eckart Altenmüller; Kathryn
Ananda-Owens; Isabel Artigues; Serap Bastepe-Gray;
Marc Brodsky; Regina Campbell; Cliffton Chan; Marshall
Chasin; Kris Chesky; John Chong; Bill Dawson; Jayme R.
Dowdall; Lauren Elson; Patrick Gannon; Julian Gray; Gayanne
Grossman; Christine Guptill; Lucinda Halstead; Leslie Harrington;
Melissa Hatheway; Erica Helm; Jacqueline Henderson; Melody
Hrubes; Jason Hu; Peter Iltis; Nancy Kadel; Kristie S. Kava;
Robin Kish; Donna Krasnow; Melissa Lewis; Jonathan Livesey;
Cate Madill; Ralph A. Manchester; Deanna McBroom; J. Matt
McCrary; Clay Miller; Dirk Möller; Jennie Morton; Martha
Paterson; Susan Raeburn; A.B.M. (Boni) Rietveld; Bonnie
Robson; Jeffrey A. Russell; Rose Schmieg; Elizabeth Schafer;
Paul Schaefer; Mark Seton; Jo Armor Smith; Annie Strauch;
Melanie Tapson; Chandler Thompson; Hara Trouli; Peter
Visentin; John White; Suzanne Wijsman; Mary Virginia Wilmerding;
Brooke Winder; Jennifer Yang. Additionally, the PAMA ad-
ministration for their support of and ongoing work running
the course: David Allen, Dorry Allen, and Julie Massaro; and
part-time Education Coordinator, Nathalie Reid.
The authors declare no conflicts of interest and do not
have any financial disclosures.
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