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Vocal and Laryngeal Symptoms and Associated Factors in Wind

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DOI: 10.1016/j.jvoice.2019.08.024

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 ARTICLE IN PRESS
Vocal and Laryngeal Symptoms and Associated Factors in
Wind Instrumentalists: A Systematic Review
*Carla Rodrigues de Lima Silva, *Aryelly Dayane da Silva Nunes, †Lourdes Bernardete Rocha de Souza,
‡Javier Jerez-Roig, and §Isabelle Ribeiro Barbosa, *yNatal, and xSanta Cruz, Brazil, and zVic, Spain

Abstract: Objective. This is a systematic literature review to identify vocal and laryngeal symptoms and asso-
ciated factors in adult wind instrumentalists.
Method. The authors performed a systematic review in the electronic databases Science Direct, Scopus, Web of
Science, PubMed and LILACS, gray literature, and manual search. There were no language or publication time
limitations, as recommended by the preferred reporting items for systematic reviews and meta-analyses. They
also performed title and abstract analysis followed by full-text analysis, risk of bias assessment (Quality Assess-
ment Tool for Observational Cohort and Cross-Sectional Studies), and result synthesis. Two researchers con-
ducted the research independently.
Results. Although six articles met the eligibility criteria, none of them fulfilled all the criteria for the methodo-
logical quality analysis. According to the six studies selected for this review, the main vocal symptoms in wind
instrumentalists are dysphonia, altered vocal quality, hoarseness, and voice failures; and laryngeal symptoms are
dryness, sore throat, throat irritation, throat clearing, discomfort, and tension. The associated factors identified
for those symptoms were shorter working time, intense use of the instrument, and individual vocal issues.
Conclusion. The several vocal and laryngeal symptoms found in wind instrumentalists in the selected studies
were associated with individual factors (prior vocal alteration, inappropriate vocal habits) and organizational fac-
tors (working time, intense use, and instrument type and technique). Although wind instrumentalists' vocal health
is recognized in the literature, and vocal and laryngeal symptoms are identified and associated with playing a
musical instrument, broadening studies with precise methodologies and analyses is necessary.
Key Words: Music−Occupational health−Voice.

INTRODUCTION manner, so they play their instruments, such as lungs, vocal

Wind instrumentalists are an understudied population at
risk of developing voice disorders, which requires continu-
ous research in the field.1 For musicians to reach the perfor-
mance they finally present to the audience, it takes hours of
dedication and study2,3 besides concentration, attention,
memory, precision, strength, synchrony, creativity, and dis-
cipline.2 In addition to these specific conditions, the search
for better financial compensation leads musicians to work
more and in different environments, which diversifies and
increases their exposure to risk.4
Sound production in wind instruments take place when
the air column is set in motion within a tube after emission
by the performer;5 wind instrumentalists are part of a group
who needs to use several structures in a coordinated
Accepted for publication August 22, 2019.
Conflict of Interest: The authors declare that there is no potential conflict of interest
in this study.
From the *Public Health Graduate Program, Federal University of Rio Grande do
Norte, UFRN, Natal, RN, Brazil; ySpeech-Language Pathology and Audiology
Department, Federal University of Rio Grande do Norte, UFRN, Natal, RN, Brazil;
zResearch Group on Methodology, Methods, Models and Outcomes of Health and
Social Sciences (M3O), Faculty of Health Sciences and Welfare, Centre for Health
and Social Care Research (CESS), University of Vic-Central University of Catalonia
(UVIC-UCC), Vic, Spain; and the xHealth Sciences College of Trairi (FACISA), Fed-
eral University of Rio Grande do Norte, UFRN, Santa Cruz, RN, Brazil.
Address correspondence and reprint requests to Carla Rodrigues de Lima Silva,
Public Health Graduate Program, Federal University of Rio Grande do Norte,
UFRN, Avenida Senador Salgado Filho 1787, CEP 50056-000, Lagoa Nova, Natal,
Rio Grande do Norte, Brazil. E-mail: carla-adson@hotmail.com
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2019.08.024
tract, oral cavity, and orofacial musculature.6 These musi-
cians may present vocal complaints such as hoarseness,
throat clearing, and vocal failures after intense use of their
instruments, which may be related to inappropriate voice
use and vocal habits, or yet associated with other factors.7
Such complaints can be explained by the active larynx activ-
ity needed to play a wind instrument,6,8,9 by glottis constric-
tion and opening for controlling airflow,9 with the possible
presence of laryngeal symptoms. Due to the similarity in the
use of the vocal tract during the execution of wind instru-
ments, in this study, professional musicians or those under
training who have played wind instruments − such as the
flute, oboe, bassoon, clarinet, and trumpet − were consid-
ered wind instrumentalists.
Due to the physiological larynx activity while playing
wind instruments, that population may present vocal and
laryngeal symptoms. The authors did not find any system-
atic reviews of papers in the indexed literature on this rele-
vant, current theme, which usually does not consider wind
musicians as voice professionals. However, it is accepted
that there are studies in this subject that can contribute to
the content of this review. The information found in the lit-
erature will be useful for health-related aspects of such pro-
fessionals, making it easier for them to be included in public
policies in different locations and contributing to health pro-
motion and disease prevention. This study aims to perform
a systematic literature review on vocal and laryngeal symp-
toms in adult wind instrumentalists and determine which
factors may be associated with these symptoms.
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2019
METHODOLOGY
The steps and procedures of this review were conducted
according to the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA),10 and the proto-
col registered on the International Prospective Register of
Systematic Reviews under No. 125239 aims to answer the
following question: “What are the vocal and laryngeal
symptoms and associated factors in adult wind instrumen-
talists?”. All of the following steps and subsections of the
article follow the recommendations of the mentioned
guideline.
Eligibility criteria
The researchers included studies with adult wind instrumen-
talists, either professional or under training. They aimed to
investigate the relationship between vocal tract when play-
ing a wind instrument and the presence of vocal and/or
laryngeal symptoms. Cross-sectional studies including vocal
and laryngeal symptoms were included. There were no lan-
guage or publication time limitations.
Information sources
The authors searched for articles in the following databases:
Science Direct, Scopus, Web of Science, PubMed, and
LILACS. For gray literature, they searched on OpenGray,
Proquest, and Google Scholar. Extensive search strategies
were adopted so that all the studies involving the focused
research question were retrieved from the databases, and
the analyses according to the eligibility criteria were applied
by the authors. Search equations were broad to ensure high
sensitivity (Appendix 1). Besides, the authors performed a
manual search in the references of the included studies. The
experts recommended no articles.
Study selection
Two independent researchers (CRLS and ADSN) per-
formed and analyzed the search queries. The first stage of
the study selection comprised of search in the databases and
exclusion of duplicate studies, followed by the analysis of
title and summary of the articles identified by the Rayyan
QCRI app. There was no need for a third reviewer to
resolve any conflicts. In the eligibility stage, the remaining,
previously screened articles were fully read, and those that
did not meet the review proposal were excluded.
Data collection process
The selected articles were analyzed during the full text read-
ing and assessed according to the inclusion and exclusion
criteria established in Eligibility Criteria section, and that
answered the research question focused on the systematic
review. The analyses were performed by the authors blindly,
and the consensus meeting was held at the end of the indi-
vidual analyses.
Data extraction
Data were collected by the first author (CRLS) and checked
by the second author (ADSN). They extracted author and
year of publication, population, sex, age, city, and country
where the study was performed, as well as the method used,
instrument played, vocal and laryngeal symptoms, and asso-
ciated factors found.
Risk of bias among studies
The first authors evaluated the risk of bias by using the
Quality Assessment Tool for Observational Cohort and
Cross-Sectional Studies.
RESULTS
Study selection
Based on the search strategies conducted in the selected
databases, the authors identified 2.398 articles: 250 in Sci-
ence Direct, 1,229 in PubMed, 538 in Scopus, 319 in Web of
Science, and 62 in LILACS. They also identified an article
in the manual search for included references. The search in
the gray literature found 70 reports in Proquest, 65 in Open
Gray, and 4,480 in Google Scholar. Of the Google Scholar
total, 850 were read. After excluding duplicate articles, the
authors read both titles and abstracts of 1,954 articles. Of
those, 1,943 articles were excluded, and 11 articles were fully
read, which resulted in six articles included in this review
(Figure 1).
Characteristics of studies
Included studies were published in 1990, 2006, 2010, 2016,
2017 and 2018. One study was published in Malaysia,11 one in
the United States,12 one in Germany13 and three in Brazil.8,9,14
Six articles assessed professional musicians,8,9,13,14 one publi-
cation assessed amateur musicians,13 one article assessed
music teachers,12 and two articles assessed music stu-
dents.11,12 Regarding instruments, studies also varied
(Table 1).
The methods used to identify vocal and laryngeal symp-
toms varied between the studies, and questionnaires were
used by six authors.8,9,11−14 The other methods used included
the Vocal Tract Discomfort Scale in one article,14 auditory-
perceptual analysis using the GRBASI scale in one article,9
and videolaryngoscopic assessment in two articles.8,13
Analysis of the associated factors was not unanimous
among the included studies, being associated working
time,14 instrument use,8 and technique.13 By performing
clinical and historical analysis of the musicians, the authors
observed the factors associated with the reported symptoms,
correlating with inappropriate vocal and health habits.9
Included characteristics can be seen in Table 1.
Risk of bias
The authors observed clinical, methodological, and statisti-
cal heterogeneity between the articles. No study met all the
 ARTICLE IN PRESS
Carla Rodrigues de Lima Silva, et al Vocal and Laryngeal Symptoms and Associated Factors in Wind Instrumentalists 3

Reports found in the search Report found in other sources

Identification
database (n=2,398) (n=1)

Selection Reports found after eliminating duplicates (n=1953)

Reports tracked (n=1,954) 1,943 reports excluded

Eligibility

Full-text articles assessed for 5 full-text articles

eligibility (n=11) excluded
2 full-text articles
unavailable
3 do not answer the
question
Inclusion

Studies included (n=6)

FIGURE 1. Bibliographic search process outline.

criteria for risk of bias, and they had mixed study methods.
All articles showed a similar high risk of bias (Figure 2).
Some domains did not apply to observational studies, such
as items related to exposure of interest and follow-up.
Besides, the studies did not present detailed sample alloca-
tion and selection, as well as sample calculation and partici-
pation rate.
Risk of bias among studies
Only one study showed the detailed origin of the researched
population,14 but it does not present any detailed sample size
or participation rate. Regarding the risk of bias, the studies
were homogeneous despite the heterogeneity in the method-
ologies applied to the study of vocal and laryngeal symptoms
in wind instrumentalists. Exposure of interest and exposure
time does not apply to observational studies, so they were all
classified as “NA” - not applicable. Potential confounders
were not detailed or discussed in the studies.
DISCUSSION
This systematic review investigated the vocal and laryngeal
symptoms in adult wind instrumentalists. After applying the
established inclusion and exclusion criteria, six studies were
included.
Among the studies included, the authors observed different
methods used to investigate vocal and laryngeal symptoms,
but questionnaires were used in all of the studies.8,9,11−14
These questionnaires are essential in descriptive studies since
they can provide a profile of individuals and investigate fac-
tors associated with some discomfort.
Two types of scales have also been used: the GRBASI
scale,9 which is used and recognized internationally for audi-
tory perceptual analysis of voice; and the Vocal Tract Dis-
comfort Scale,14 which is a self-assessment scale that has
been translated into Brazilian Portuguese, but not validated
in the country. Therefore, the description of different symp-
toms is expected since they also have different analyses. The
first analysis is regarding vocal quality applied by the evalua-
tor, and the second one is an instrument to identify symptoms
reported by the subject.
Among the selected studies, three presented vocal
symptoms8,9,13 and five presented laryngeal symptoms.8,9,11,12,14
Both types of symptoms were addressed in only two studies.8,9
It is important to note that these last two studies used question-
naires for clinical identification and not at the epidemiological
level, which shows a significant research gap on the vocal health
of such population.
Among the wind instrumentalists, there are specific groups
according to the instrument they play; in the same way, there
are group-specific disorders, and there are those that occur
equally across all groups.15 This hypothesis may justify the
heterogeneity of the results found, both related to symp-
toms and associated factors since the wind instrumentalists
were variable. Likewise, the different methods employed in
each study may have found different vocal and laryngeal
symptoms.
The main laryngeal symptoms found in the studies were
sore throat,9,11,12,14 dryness,9,14 and throat clearing.8,9 The
 4
TABLE 1.
Summary of Key Information from the Studies Included in the Review
Age (Average in Laryngeal
Author/Year City/Country Population/n Men (%) Years) Method Instrument Played Vocal Systems Systems Associated Factors
Cappellaro; Caxias do Sul, 37 orchestra 78.9% 33 (16-68) Questionnaires - Mixed group (such NS Dryness Sore Shorter working
Beber, 2018 Brazil musicians demographic and as, but not limited throat Throat time
professional infor- to, the transverse irritation
mation; Voice- flute, French horn,
Related Quality of trombone, saxo-
Life (V-RQOL); phone, clarinet)
Vocal Tract Discom-
fort (VTD) scale;
additional items
about fatigue after
playing the instru-
ment and pain in
the cervical

ARTICLE IN PRESS
muscles
Eckley, 2006 Brazil 10 professional 60% 42.5 Questionnaire, Fiber- NS Dysphonia Throat clearing Intense use of
players optic Nasal Laryn- instrument
goscopy - behavior
of the larynx, phar-
ynx, and tongue
when playing
Lonsdale; Boon, Malaysia 98 music students 43.9% 21.9 (18-50) Self-report online Mixed group (such NS Discomfort, NS
2016 (29 woodwind, survey as, but not limited throat tension,
14 Brass) Age 18 to, the flute, oboe, and sore
−50 (21.9) clarinet, saxo- throat
phone, trumpet,
trombone)
Ocker, 1990 NS 63 players NS NS Questionnaire, clini- NS Altered vocal NS Previous altered
cal evaluation - quality voice, inappropri-
voice quality, ate technique
microlaryngoscopy,

Journal of Voice, Vol. &&, No. &&, 2019

microstroboscopy

rio et al,
Silve Curitiba, Brazil 42 Army Band 100% CG: 37.1 (25−54) Questionnaire, vocal NS Hoarseness Dryness Sore Inappropriate vocal
2010 musicians EG: 33.5 (21−45) assessment Vocal failures throat Throat and health habits
(GRBASI), assess- clearing
ment of respiratory
type, and cervical-
scapular region
physical therapy
evaluation
Stanek et al, USA 1007 college 40.5% 27 (15−71) Online survey Mixed group (such NS Sore throat Type of instrument/
2017 musicians (218 as, but not limited voice
woodwind Fam- to, the trumpet,
ily, 145 brass trombone, saxo-
musician) phone, clarinet,
bassoon)
Abbreviations: CG, control group; EG, experimental group; NS, not specified.
 ARTICLE IN PRESS
Carla Rodrigues de Lima Silva, et al Vocal and Laryngeal Symptoms and Associated Factors in Wind Instrumentalists
FIGURE 2. Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
presence of these laryngeal symptoms after playing an
instrument may indicate tension and lack of laryngeal
hydration.
Wind instrumentalists often use the oral breathing tech-
nique to play wind instruments, the rapid, deep inspiration
is followed by a delayed expiration13 which requires a mas-
sive flow of air through the vocal tract and oral cavity and
favors dryness. The circular breathing technique is also
used, but at specific times, such as during long notes or long
musical phrases without the need for strategic breathing
pauses, but generally the air needed to play the instrument
is obtained through the oral cavity14 According to studies
on oral breathing and xerostomia, this can lead to altered
vocal tract.16
These laryngeal symptoms may or may not be accompa-
nied by vocal symptoms and altered voice.9 The main vocal
symptoms reported in the included studies were dysphonia,8
hoarseness, and voice failures,9 as well as altered voice qual-
ity.13 Previous studies suggest these vocal symptoms related
to playing instruments may be associated with inappropriate
vocal habits and also lack of vocal hygiene.7
Among the included studies, besides vocal and laryngeal
symptoms, subjects reported pain in other parts of the
body,9,11,12,14 revealing musculoskeletal discomfort in these
professionals. The literature on musicians' health shows cervi-
cal pain is among the most frequently cited by musicians,17
and such intrinsic and extrinsic musculature of the larynx,
which is located in the cervical region, is used while playing
5
instruments. Therefore, excessive effort or overload of that
musculature can lead to discomfort in the vocal tract.6
Cappellaro and Beber's study14 reinforces that the pres-
ence of vocal tract discomfort in musicians, even at low fre-
quency and intensity, can significantly impact these
professionals' quality of life regarding their voice. Therefore,
there is a need for further studies, speech-language pathol-
ogy and audiology intervention, as well as vocal health edu-
cation.
A study investigated the strategies and treatments musi-
cians adopted when they experienced any work-related
pain.12 It found out there are a plethora of strategies among
musicians, from searching for different professionals (teach-
ers, doctors, massage therapists) to alternative therapies and
nonprescription anti-inflammatory drugs. However, most
,
musicians do not seek help. In his research, Dawson9 18
reported that a prolonged rest interval for health care might
result in financial and technical skill loss, which often justi-
fies little or no search for care.
Also, the competitive nature of the profession may lead
musicians to avoid seeking care as they might fear that the
treatment demands or public knowledge of an injury may
cost them their job. Such competition in the workplace may
also be related to the high rates of stress and depression
symptoms reported,19 which may negatively affect the vocal
health of this group.20
Of the six studies selected for this review, five analyzed the
factors associated with vocal and laryngeal symptoms in
 ARTICLE IN PRESS
6 Journal of Voice, Vol. &&, No. &&, 2019
wind instrumentalists. These included aspects related to
work organization8,12−14 and personal issues.9,13
Beginner musicians and those who have been studying
certain instrument for a shorter period of time showed more
laryngeal symptoms in comparison to more experienced
professionals.14 Such difference can be attributed to the lack
of necessary conditioning for performance, which requires
the need for physical performance efficiency, or even to
excessive glottic tension observed in young instrumental-
ists.21 Similarly, intense use of instruments (long periods of
instrument practice, rehearsals, individual studying, partici-
pation in several groups) was associated with complaints
such as coughing and dysphonia, which shows how vocal
folds are active during instrument sound production,8 and
the need for attention to this audience regarding their vocal
and laryngeal aspects, whether they are professional or
under training.
Despite that, it is known that adjustments in the vocal
tract may vary according to the instrument type and tech-
nique. The articles included were not unanimous regarding
the inclusion of the type of instrument played by the sur-
veyed musicians: Half of them used groups with various
types of instrument, and half did not specify the types of
instruments played. The adjustments made by each type of
instrument are a limitation of the study, which points to the
need for more primary studies by categories.
Particular aspects, such as vocal and health habits, as well
as previous altered voice,13 were also associated with vocal
and laryngeal symptoms. In Silv
erio et al's study,9 musicians
who used their voice to compete, had cold drinks, and drank
alcohol reported more vocal and laryngeal complaints.
Likewise, Ocker's research13 reports a higher risk of vocal
symptoms in musicians who have previously had altered
voice due to the additional effort they make while playing
their instrument. The diversified composition of the groups,
with professional musicians,8,9,13,14 amateurs,13 music
teachers,12 and music students11,12 probably confirmed the
differences found. These different compositions may also be
influenced by the different realities among the musicians'
routines in different international institutions11 since the
studies were carried out in different places with different cul-
tural and work characteristics.
As an example of such differences, it is worth mentioning
that students in Malaysia do not begin their formal studies
on instrument upon entering university. Rather, they need
to study subjects such as vocal technique, piano proficiency
and theory. Starting as a beginner at a university level
instrument is common in this country, and students are not
little involved in high performance activities.11 In the United
States, on the other hand, students begin their instrumental
practice early in their academic life and are constantly eval-
uated, receiving grades for essays and presentations.12 In
the reality of Brazil, trained musicians can perform in pro-
fessional orchestras.
Also, analysis of the associated factors in the included
studies is limited and does not rely on statistical analysis to
verify the factors, which can also be seen in the risk of bias
assessment of the publications. These methodological char-
acteristics bring limitations to the results of this study, as
well as the small samples of the studies and the heterogene-
ity of the methods used, which does not allow meta-analysis.
Likewise, the instruments for identifying vocal and laryn-
geal symptoms are distinct, which requires population-
based studies and diagnostic validation of evaluation meth-
ods that indicate the most appropriate and specific instru-
ment for diagnosis in this group.
Therefore, the possibility of publication bias exists and
should be considered. However, despite these limitations
and results, the literature reinforces how important it is to
publish negative results for interpretation of the general
meaning of a research field.22
Despite the limitations above, two independent authors
carried out this review with a rigorous methodology by fol-
lowing the PRISMA checklist, as well as its flow diagram.
This study brings essential information to this field as it
describes the main vocal and laryngeal symptoms found in
the studies aimed to address musicians' health. Besides, the
results point out that wind instrumentalists' vocal health is
recognized in the literature, and also highlights that such
symptoms are a reality in their daily lives. That contributes
to the understanding of which factors may be associated
with these symptoms and reinforce the need for health edu-
cation for this professional group.
CONCLUSION
In this review, researchers identified the vocal symptoms of
dysphonia, altered vocal quality, hoarseness, and voice fail-
ures; among laryngeal symptoms, the authors found dryness,
throat pain, throat irritation, throat clearing, discomfort, and
tension. The associated factors identified for those symp-
toms were shorter working time, intense use of the instru-
ment, and individual vocal issues (previous altered voice,
inappropriate vocal habits, and cervical pain). However, it
is important to highlight that there was no consensus on the
methods of the included studies, being difficult to fully
appreciate the research question. In addition, the wind
instrument categories of the groups studied were not the pri-
mary object of investigation, and thus the symptoms were
not related to the wind instrument categories. The authors
of this study emphasize the importance of more studies on
this population so that the factors associated with these
symptoms and instruments can be investigated and preven-
tative strategies can be implemented. That is necessary
because these voice symptoms can interfere with the stu-
dents' development, with teaching practice, and in the pro-
fessional performance of these musicians, causing emotional,
social, and economic losses.
FINANCING
This study was financed by the Brazilian Coordination for
the Improvement of Higher Education Personnel (CAPES) -
financing code 001.
 ARTICLE IN PRESS
Carla Rodrigues de Lima Silva, et al Vocal and Laryngeal Symptoms and Associated Factors in Wind Instrumentalists 7

APPENDIX 1. SEARCH STRATEGIES IN THE 8. Eckley CA. Configuraç~ao gl
otica em tocadores de instrumento de
DATABASES sopro. Revista Brasileira de Otorrinolaringologia. 2006;72:45–47.
9. Silv
erio KCA, et al. Avaliaç~ao vocal e cervicoescapular em militares
Database Strategy instrumentistas de sopro. Rev Soc Bras Fonoaudiol. 2010;15:497–504.
10. David MAL, Alessandro L, Jennifer T, et al. The PRISMA Group.
Science Direct (voice AND music)
Preferred reporting items for systematic reviews and meta-analyses:
Scopus (voice AND musician) the PRISMA statement. PLoS Med. 2009;7:1–6.
Web of Science TS = (voice) AND TS = (musician) 11. Lonsdale K, Boon OK. Playing − related health problems among
PubMed (voice) AND music instrumental music students at a university in Malaysia. Med Probl
LILACS voice [words] and music [words] Perform Artists. 2016;31:151–159.
Open Gray Music and voice 12. Stanek JL, et al. A cross sectional study of pain among U.S. college
Proquest Voice and music and wind music students and faculty. Med Probl Perform Artists. 2017;32:20–26.
instrumentalist 13. Ocker C, et al. Voice disorders among players of wind instruments?
Google Scholar Wind instrumentalist and voice Folia Phoniatr Logop. 1990;42:24–30.
symptoms 14. Capellaro J, Beber BC. Vocal tract discomfort and voice related qual-
ity of life in wind instrumentalists. J Voice. 2018;32:314–317.

15. Zuskin E, et al. Health problems in musicians. Acta Dermatovenerol
Croat. 2005;13:247–251.
16. Roh JL, Kim HS, Kim AY. The effect of acute xerostomia on vocal
REFERENCES function. Arch Otolaryngol Head Neck Surg. 2006;132:542–546.
1. Erickson ML. The traditional/acoustic music project: a study of vocal 17. Reijani N, Benetti FA. Principais queixas osteomusculares em m
usicos
demands and vocal health. J Voice. 2012;26:664. e7-23. da regi~ao do ABC paulista: um estudo de preval^encia. ABCS Health
2. Frank A, M€ uhlen CAV. Queixas musculoesquel
eticas em m
usicos: Sci. 2016;41:40–45.
preval^encia e fatores de risco. Rev Bras Reumatol. 2007;47:188–196. 18. Dawson WJ. Trauma to the high-level instrumentalist’s hand and
3. L€uders D, Gonçalves CGO. Trabalho e Sa
ude na profiss~ao de m
usico: upper extremity: an epidemiologic and outcome study. Med Probl Per-
reflex~oes sobre um artista trabalhador. Tuiuti. 2013;47. 123-13. form Artists. 2007;22:105–109.
4. Lima RC, Pinheiro TM, Dias EC, et al. Development and prevention 19. Raymond DM, Romeo JH, Kumke KV. A pilot study of occupational
of work related disorders in a sample of Brazilian violinists. Work. injury and illness experienced by classical musicians. Workplace Health
2015;51:273–280. Safety. 2012;60:19–24.
5. Methfessel G. Myofunction in players of wind instruments. Dtsch Zah- 20. Brito AF, Ferreira LP, Souza, LAP. Marcadores de estresse e sintomas
narztl Z German. 1990;45:48–50. vocais: algumas relaç~ oes possíveis. 2014; 26: 414-416.
6. Weikert M, Their J. Laryngeal movements in saxophone playing: video- 21. Hullet Christopher M. The Effects of Embouchure and Breathing Instruc-
endoscopic investigations with saxophone player. J Voice. 1999;13: tion on Beginning Brass Students’ Performance. DMA essay, Arizona
265–273. State University; 2006:115.
7. Falchetti AC. Comportamento Vocal Em M
usicos De Sopro: Uma 22. Joober R, Schmitz N, Annable L, et al. Publication bias: what are the
Revis~
ao De Literatura. [Monografia]. Florian
opolis: Universidade challenges and can they be overcome? J Psychiatry Neurosci. 2012;37:
Federal de Santa Catarina; 2014. 149–152.

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