UReCA: The NCHC Journal of Undergraduate Research and Creative Activity 2020 Edition

Performance Training: Preventing Playing-Related Injuries in Amateur Instrumentalists

Abstract  

Concerning levels of playing-related musculoskeletal disorders (PRMDs) among student to  professional instrumental musicians have been reported over the past several decades. From  minor aches and pains to serious disorders threatening the capability to play, PRMDs are  seemingly becoming an inevitable part of the instrumentalist’s future if actions are not taken  against this fate. Significant concern for the musician’s physical well-being signals an urgent  need for preventative training. The purpose of this research is to address the leading injury prevention strategies for amateur instrumentalists. This study examines major global research  conducted in the field of performance health. The sources covered are not exhaustive, rather the  focus is on select studies that address the most prominent injury-prevention strategies. This  research identifies several health-risk factors associated with music performance as leading to  alarming rates of injuries in performing artists. These findings indicate a lack of education  received by instrumentalists on their risk of performance-related injury. Poor maintenance of  physical and emotional wellness in musicians, improper body alignment while playing an  instrument, and an excessive practice schedule are found to be the prominent causes of PRMDs.  This research concludes that in order to reduce the prevalence of injuries among musicians, these  factors must be eliminated through preventative training. At the onset of their playing, musicians  need to be informed of healthy performance habits that include physical fitness, ergonomic  playing postures, and a balanced practice schedule. Future research must target the role of the  music teacher in implementing these strategies into the music classroom in order to reduce the  risk of PRMDs and allow all instrumentalists from now on the opportunity to sustain a lifelong  future in the arts without the limitations of pain.

Performance Training: Preventing Playing-Related Injuries in Amateur Instrumentalists  

“No pain, no gain.” This notion that progress is made through pain-staking practice  silently plagues driven musicians of all backgrounds. Research over the past three decades  indicates that the prevalence of musicians encountering playing-related musculoskeletal  disorders (PRMDs) is exceedingly common (Jacukowicz, 2016, p. 658). Injury rates reported  among childhood learners to professional adult musicians are alarmingly high, as great as 67- 84% of instrumentalists (Wijsman & Ackermann, 2019, p. 870). Without proper injury  prevention awareness it is unlikely an artist will surpass pain or injury in his or her career  (Horvath, 2014, p. 26), but through the application of several preventative strategies playing can  be pain-free. This research aims to shine light on the best practices for preventing playing related injuries in amateur instrumentalists. Through health education, physical wellness, proper body alignment, and a balanced practice schedule musicians can embark on a life-long career playing without pain.

Playing-Related Musculoskeletal Disorders  

The most common playing-related health problems for musicians are musculoskeletal  (Ajidahun, Myezwa, Mudzi, & Wood, 2019, p. 8). Playing-related musculoskeletal disorders  (PRMDs) are described as “any pain, weakness, numbness, tingling or other symptom that  interfere with the ability to play your instrument at the level you are accustomed,” and include  symptoms ranging from “minor pain, burning or muscle tiredness up to serious disorders and  chronic, severe pain debilitating the capability to play” (Jacukowicz, 2016, p. 658). 

Among other risk factors, musicians are particularly susceptible to PRMD’s due to the  physical demands of playing an instrument. The type of pain experienced and the area of the  body most affected is oftentimes specific to the instrument being played. Each instrument  demands something different of its player based on how it is held, how sound is produced, and  the type of musical passages typically played. For example, violinists and violists most often  experience shoulder injuries because when holding a violin or viola the arms are in an unnatural  position away from the body, at or above shoulder level, and are required to extend in a back and  forth motion to glide the bow across the strings while holding this position (Chan & Ackermann,  2014, p. 1). On the other hand, brass players commonly suffer from orofacial and embouchure  problems because of the pressure put on their facial muscles to buzz through their mouthpiece  (Chan & Ackermann, 2014, p. 1). That being said, across all instrument families it is the upper  extremities and trunk that musicians most often injure (Ajidahun et al., 2019, p. 8). 

Despite the increased risks musicians face and the prevalence of PRMDs among them  today, playing-related pain is not an inevitable part of an instrumentalist’s future. With the right  efforts taken toward a healthy career, musicians can exceed these expectations.

Health Education  

First and foremost, performance health and wellness literacy needs to be integrated into a musician’s education from the beginning. Most musicians lack the proper awareness and  understanding of their heightened risk of injury, nonetheless the knowledge of pain prevention  strategies. Due to this foundation of ignorance, “the seeds for health problems encountered by  adult musicians are sown early in their lives” (Wijsman & Ackermann, 2019, p. 870). It begins  with the instrumentalist’s lack of understanding of injury causes, leading to the development of poor habits, and resulting in varying degrees of performance pain. From there, musicians may  seek unreliable sources for health advice, therefore inadequately managing their injury and  potentially putting themselves at risk of increasing their pain (Chan & Ackermann, 2014, p. 3).  Without addressing the source of the problem, this cycle will never cease to exist.   The ideal time to attend to the prevention of musicians’ injuries is at the beginning of  their musical training. This will ensure that appropriate performance techniques and postural  habits, a positive attitude, and a healthy lifestyle will be the foundation of their playing (Pierce,  2012, p. 163). By starting here, performance wellness becomes a regular aspect of playing an  instrument, and musicians are allowed the opportunity to develop these skills and competencies  over a lifetime, rather than seeking this understanding partially through their established career in  a desperate plea for pain relief (Wijsman & Ackermann, 2019, p. 872).  

The Role of the Music Teacher  

Most beginning instrumentalists learn how to play their instrument while in school.  Thus, the music teacher plays a vital role in establishing his or her students’ performance health  and wellness into the future. According to the National Association of Schools of Music  (NASM), it is the responsibility of these institutions to “assist students to acquire knowledge  from qualified professionals and authoritative medical sources regarding the maintenance of  professional health and the prevention of performance injuries” (Guptill & Zaza, 2010, p. 28).  During a musician’s training, students should receive wellness information with applicable  materials introduced at the appropriate levels and reinforced based on learning goals set  throughout the educational process (Pierce, 2012, p. 169). 

Although prevention education programs are not widely available, several have been  developed and implemented in the classroom. For instance, in 2014 the National Association of  Schools of Music (NASM) partnered with the Performing Arts Medicine Association (PAMA) to  advocate for the importance of musicians taking steps to protect their neuromusculoskeletal  health (p. I-15). Together they developed a set of advisory documents on neuromusculoskeletal  and vocal health for musicians, designed for the purpose of institutions to use as a practical  approach for promoting performance wellness in their schools. These papers provide a necessary  guide for the uninformed teacher of how to educate his or her students on a topic he or she most  likely has never learned.  

To address today’s music teachers’ lack of health education, it is recommended that a  performance wellness program be integrated at the college-level as an essential component of the  musician’s training (Montello, 2010, p. 110). In 2001, the Performance Wellness Seminar was  developed as a collegiate course offering “musicians, music students, and educators a clinically  proven systematic approach to diagnosing, treating, and preventing performance-related  disorders” (Montello, 2010, p. 110). Through topics such as breath awareness, joint and gland  exercises, relaxation techniques, and numerous approaches used in music therapy, by the end of  the course musicians were well-versed in methods to prevent themselves and their future  students from playing-related injuries (Montello, 2010, pp. 111-113). The idea behind this is that  as more teachers become trained in wellness in the earlier stages of their musicianship, music  students will view wellness as a natural part of their education, and wellness and injury  prevention training will be an expected part of their curriculum (Pierce, 2012, p. 169). 

Physical Wellness  

A healthy body is the basis of a healthy musician. Just as important as taking care of the  musician’s instrument, is taking care of the musician’s body. Since the act of simply playing an  instrument already puts the musician at a higher risk of injury, it is crucial to establish a solid  foundation of a healthy body before playing can be safely introduced. There are many elements  that make up physical wellness. These include getting adequate sleep, eating a nutritious diet,  exercising regularly, socializing with family and friends, refraining from hazardous or  recreational drug use, and maintaining positive mental health (NASM-PAMA, 2014, p. I-15). If  one of these elements is missing, it can have profound effects on the body, let alone put the  musician at a greater risk of injuring him or herself.  

Exercise  

In many ways, a musician is like an athlete. Just as an athlete needs to continually  condition his body to handle the demands of his sport, so does a musician. It is extremely  important for instrumentalists to maintain regular physical activity (Loria, 2016, p. 31).  Although any movement is better than none, there are specific exercises a musician should target  to achieve and maintain optimal performance. Weekly participation in cardiovascular fitness and  resistance training is an important element in leading a long, healthy career as a performing artist  (Chan & Ackermann, 2014, p. 5). Recommended cardiovascular fitness exercises include “brisk  walking, cycling at an easy pace, swimming leisurely, or jogging,” while resistance training  exercises consist of shoulder rotators, low back and hip extensions, leg presses, squats, lunges,  and pushups (Chan & Ackermann, 2014, p. 6). These exercises, completed over a period of  time, can reduce musculoskeletal problems and perceived exertion in instrumentalists (Ajidahun et al., 2019, pp. 21-23). By targeting the muscles that support instrumental playing demands,  regular physical exercise can aid in the prevention of PRMD’s (Chan & Ackermann, 2014, p. 7). 

Stretching  

Incorporating stretching exercises within the musician’s fitness program can also reduce  the risk of musculoskeletal injury (Aijdahun & Phillips, 2013, p. 2074). In one study, simple  stretches to the muscles in the shoulder and forearms during breaks in practice greatly reduced  discomfort and exertion among string instrumentalists (Ajidahun et al., 2019, p. 23). The most  beneficial stretches are ones that adopt different postures from those used in playing (Guptill &  Zaza, 2010, pp. 29-30). For a pianist, standing, lifting the head and chin, and extending  backward, along with lengthening the wrists and fingers is a way to relieve the stress put on the  muscles held in playing position (Guptill & Zaza, 2010, p. 30). When stretching, the safest  approach is slow and gentle movements that relieve pain, not add to it (Guptill & Zaza, 2010, p.  29). It is important to note that it is not how far the muscle stretches that counts, it is the  duration of time the stretch is held for. Therefore, stretching should not be forceful, rather it  should be relaxed and purposeful (Guptill & Zaza, 2010, p. 30).  

Warm-ups and Cool-downs  

With the knowledge of how to stretch and condition the body outside of rehearsal,  musicians should apply these exercises toward preparing the body before and after practice  through warm-ups and cool-downs. Muscles that are warmed-up are more efficient, strong, and  resilient, while overused, fatigued, and under-conditioned muscles are tense and demand more  work for the completion of a task (Horvath, 2014, p. 29). Musicians should be provided with  enough time to physically and mentally warm-up before playing. Especially if practice is to be done in a cold environment, time to warm-up the hands and instrument is necessary for injury  prevention (Guptill & Zaza, 2010, p. 29). Warm-ups to the whole body, not only the common  affected areas of PRMDs, should be completed over the duration of five to fifteen minutes prior  to rehearsal (Ajidahun & Phillips, 2013, p. 2074). In this time, the muscles and joints should be  mobilized to increase blood flow throughout the body and prepare them for the physical demands  of playing (NASM-PAMA, 2014, p. I-15). Warm-up exercises can consist of various stretches,  deep-breathing techniques, and slow, comfortable playing, such as long tones and moderately paced scales and arpeggios (Guptill & Zaza, 2010, p. 29). It is standard practice for the cool down exercises after playing to directly reflect that of the warm-ups.  

Nutritional needs  

Outside of various performance exercises, another integral element of physical wellness  is nutrition. Due to the physicality of playing an instrument and the long hours dedicated toward  it, it is likely that a musician’s nutritional needs are above that of the average person, therefore  proper nutritional education can help prevent PRMD’s (Chan & Ackermann, 2014, p. 4). Eating  a healthy, well-balanced diet is of utmost importance, but taking additional efforts toward  fulfilling nutritional needs specific to the musician can be helpful, as well. Musicians also need  to be aware of their water intake. Even a slight case of dehydration can affect cognitive and  physical functioning, leading to “tiredness, muscular weakness, dry and sticky mouth and  tongue, headaches, dizziness or lightheadedness” (Chan & Ackermann, 2014, p. 4). This  weakened state makes the instrumentalist prone to greater risk of injury, so it is vital that the  musician stays hydrated throughout the day, and especially while playing. 

Stress Management  

It is not enough for the musician to solely be physically fit; he or she should be  psychologically fit, as well. Injuries are much less likely for the instrumentalist who manages  stress and allows for relaxation (NASM-PAMA, 2014, p. I-15). Stressors can come from many  areas of one’s life, both related to playing and not. There are psychological stressors that plague  the mind, and physical stressors that create tension in the body. However, stress is a part of  everyday living, therefore it needs to be regularly attended to. When stress is brought into the  practice room, whether mentally or physically, it heightens the musician’s risk of injury.  Relaxation from stress is an essential aspect of preventing PRMDs.  

Tension and Relaxation

Stress management begins with a release of built-up tension.  When the mind is tense, the body is tense, and vice-versa (Cornett-Murtada, 2012, p. 16). The  existence of undue tension can lead to long-term pain and injury (Guptill & Zaza, 2010, p. 31).  In order to avoid unnecessary tension, “stability, control and correct technique should be  prioritized,” no matter what level the player is at (Lonsdale & Laakso, 2014, p. 75). The  existence of good technique not only reinforces safe practice habits, but it reduces the amount of  repetition and time spent learning new passages, and allows the musician to perform more  comfortably, bringing less tension into the rehearsal (Guptill & Zaza, 2010, p. 31). Additionally,  physical fitness should be reinforced to reduce tension from building up in the muscles. Tight,  weak, and untoned muscles, compared to strong, flexible, and resilient muscles are more prone to  injury (Horvath, 2014, p. 29). Activities such as yoga, stretching, swimming, Alexander  Technique, and massages are helpful in relaxing muscle tension (Horvath, 2014, p. 29). 

When working to relax the muscles, it is important to recognize that relaxation does not  mean letting the muscles naturally collapse. This results in “flimsy fingers or floppy hands, a  lack of wrist and elbow support or an overall weak technical approach” (Wan, 2016, p. 8).  Inevitably, some degree of tension in the muscles is required in order to simply hold the  instrument up. An effective approach to relaxation comes with the knowledge and awareness of  which muscles should be firing while others are relaxing in any particular movement (Wan,  2016, p. 8). Unnatural tension causes discomfort and pain in the body, but when the right  muscles are contracting, the tension resulting is not a technical barrier (Wan, 2016, p. 8).

In her article “What Relaxation Means for Musicians,” Agnes Wan discusses a number of  factors that determine the degree of muscular relaxation experienced by music students. She  begins by saying that in order to eliminate or reduce tension, one must first be aware of it, not  only in the areas of the body most affected by playing, but throughout every part, seeing that  tension can manifest itself anywhere. While taking breaks during a practice session, musicians  should recognize where they hold their tension, whether it be hiking their shoulders up or  clenching their jaw, and take this time to return back to a relaxed position (Guptill & Zaza, 2010,  p. 31). According to Wan, progressive muscle relaxation techniques can help musicians raise  their bodily awareness and learn to keep their muscles in a relaxed state for a longer time period.  Effective breathing techniques are another way to relax the body. Nervousness can lead to  shallow breathing, or lack thereof, restricting the muscles from getting the oxygen they need  (Horvath, 2014, p. 29). Breathing deeply works to calm the muscles, among providing the body  and mind with a multitude of other benefits. 

Yet, despite these efforts taken to promote relaxation, Wan recognizes that the musician  inevitably has to deal with a degree of unavoidable tension due to the technical and physical  demands of his or her instrument. Rather than trying to fight it all off at once, which can bring  forth more tension than beginning with, it is about gradually reducing unnecessary tension and  moving toward relaxation one step at a time. Therefore, during times of heightened stress, it is  recommended to take more breaks, increase warm-up time, do more stretches, and practice more  mindfully, rather than overworking the body while it is down (Horvath, 2014, p. 29).  Nonetheless, even with inevitable tension present, musicians can take steps toward playing with  a healthy, relaxed physical disposition, enough to yield the onset of PRMDs.

Proper Body Alignment  

A critical step in not only reducing physical tension, but lowering the likelihood of  performance pain and injuries is proper body alignment. Due to the shape and weight of the  instrument and technical difficulty of the music, instrumentalists develop awkward body  positions to simply perform their craft (Guptill & Zaza, 2010, p. 29). This misalignment,  however, disrupts the natural balance of weight, causing the muscles to work harder and produce  greater tension to support the body from collapsing (Wan, 2016, p. 10). On the other hand, when  the body is aligned, the bones can support the weight of the muscles, and without muscular  discomfort, stiffness, or pain, minimal effort is required to hold the body up (Wan, 2016, p. 10).  As this is the ideal posture, musicians should strive for proper body alignment and technique in  both seated and standing positions. Although it is hardly possible to maintain a fully neutral  position with the demands every instrument asks of the body, it is feasible to avoid superfluous  postures and exaggerated positions while playing (Lonsdale & Laakso, 2014, p. 74). Allowing the body to move freely during practice, providing adequate postural support, and being mindful  of balance and weight delivery are all ways to combat the effects of misalignment and reduce the  risk of PRMDs (NASM-PAMA, 2014, p. I-15).  

Posture  

Proper body alignment is a result of proper posture. Poor posture stresses the muscles,  ligaments, and joints, resulting in physical pain (Lonsdale & Laakso, 2014, p. 74). While  playing an instrument, higher levels of muscle activation are required to support the musician  and compensate for reduced balance and control, and adding improper posture on top of this  increases the stress of neuromusculoskeletal structures and can lead to muscle fatigue and  tension, increasing the risk of developing PRMD’s (Chan & Ackermann, 2014, p. 7). Therefore,  musicians need to constantly be aware of the postures they are holding to ensure they are ones  that will help the body perform most efficiently.  

It should be known that correct posture does not necessarily mean sitting or standing up  “straight,” as this may unknowingly lead to overextending the spine and back muscles or pulling  the chest upward, which can result in more stiffness (Wan, 2016, p. 10). Rather, upright posture  should be thought of as allowing the joints to relax and letting the bones support the muscles  (Wan, 2016, p. 10). This allows “supportive muscles to sustain efficient static or dynamic  movements and stability of the joints during performance actions” (Chan & Ackermann, 2014, p.  7). Altogether, proper posture provides a strong, stable foundation in which playing an  instrument can be introduced in a way that supports the natural alignment of the body without  compensating for the added pressures of the instrument. In this case, the instrument is brought to  the body, rather than bringing the body to the instrument. 

Healthy posture is also directly related to healthy breathing. Wind instrumentalists are  aware that in order to achieve full volume and a pure quality of sound, they need to have  adequate breath support. This support comes from an appropriate posture that allows the ribcage  to fully and freely expand. Slouched postures increase respiratory effort, as well as considerably  decrease breathing capacity and control (Chan & Ackermann, 2014, p. 7). Not only does this  negatively impact breathing, but it increases tension in the abdominal muscles. To avoid  unnecessary tension and allow for full breath support, musicians need to maintain postural  alignment.  

When working to achieve a balanced posture, it is important to always consider the  particular anatomy of the student and make adjustments off the individual. Based on unique  characteristics such as height, weight, bone structure, and instrument, proper body alignment will  look slightly different for everyone. It is encouraged to work with the individual to find the  particular posture that works best for him or her.  

That being said, there are several overarching components that yield postural alignment.  All instrumentalists should aim for neutral or natural positions (Horvath, 2014, p. 27). This takes  an awareness of the natural curves of the spine and working to maintain these curves when  sitting or standing (Guptill & Zaza, 2010, p. 30). In general, the “head, thorax and pelvis should  always be arranged in the body’s longitudinal axis as this results in a natural flection of the  spine,” and protects the musculoskeletal system from the stress of holding instrument-specific  postures (Ohlendorf, Wanke, Filmann, Groneberg, & Gerber, 2017, p. 2). Additionally, all joints  should be softened, balanced, and naturally curved when possible. Maintaining these elements  of posture while playing will safely align the body into a healthy playing position. 

Alexander Technique  

For support in achieving individualized proper body alignment, musicians may benefit  from the Alexander Technique. The Alexander Technique (AT) is “an educational method that  addresses how we coordinate our whole selves in activity” (p. 78), for the purpose of bringing  “conscious awareness to habitual patterns of movement that were previously unconscious”  (Wolf, Thurmer, Berg, Cook, Smart, 2017, p. 81). It is centered around creating efficiency in the  work environment, called ergonomics. When AT concepts are incorporated into practice,  playing tension can be reduced, lowering the risk of injury, and improving performance quality  (Wolf et al., 2017, p. 78).  

Tension-Free Set-Up 

Altogether, these principles can be applied to creating a practice environment free of  tension, the foundation of safely playing an instrument. Along with proper postural alignment  comes proper seating position. Musicians spend most of their rehearsal time in chairs, which can  have a profound effect on their posture. Ideally, the musician deserves to spend his or her time  in a good chair that promotes optimal body alignment. Characteristics of favorable chairs  include a seat that is relatively flat and lightly padded, as well as a supportive backrest (Guptill &  Zaza, 2010, p. 31). Accommodations can be made to inadequate chairs by using seat cushions  and footstools to satisfy individual seating preferences.  

In a seated position, musicians should sit tall and evenly distribute their body weight  through their buttocks, legs, and feet (Guptill & Zaza, 2010. p. 31). They should be sitting far  enough forward on the seat so that their feet comfortably rest flat on the floor. Crossing the legs  or curling the feet under or around the chair should be avoided while playing (Horvath, 2014, p. 29). Additionally, their music stand should be at eye level to encourage a tall posture, allow for  a neutral head position, and avoid neck strain (Horvath, 2014, p. 27). This correct stand height  should not only be implemented while sitting, but musicians should also raise their music stands  while practicing standing.  

In order to comfortably support proper seating posture, it is the responsibility of the  ensemble director to avoid seating and visibility issues within the ensemble (NASM-PAMA,  2014, p. II-18). Oftentimes, an instrumentalist’s posture is compromised in rehearsal due to a  crowded set-up. Adequate space should be provided between ensemble seating to allow for  optimal playing positions (Lonsdale & Laakso, 2014, p. 76).  

Ergonomic instrument modifications

Sometimes it is not only the rehearsal set-up that  restricts the instrumentalist, but also the instrument set-up. Rather than adjusting the body to fit  the instrument, the instrument can be adjusted to fit the needs of the player. String instruments  are available in many different sizes, and can be modified with various types of chin and  shoulder rests. Although most wind instruments only come in “one size fits all,” modifications  can be added for these instruments, as well. Tools such as key extensions, neck straps, and  thumb rests are just a few of the many resources available for musicians to tailor their instrument  to their needs. A personalized set-up is not only more comfortable for the player, but it reduces  the strain of the physical demands put on the instrumentalist, making it effective in injury  reduction.  

Balanced Practice Schedule  

Since the musician spends most of his or her musical career in the practice room, it is  imperative to discuss healthy practice habits. If these endless hours dedicated toward perfecting their craft is not done so with utmost care, musicians substantially increase their risk of  developing PRMDs, potentially ending their journey as an instrumentalist altogether. To avoid  this fate, there are several guidelines musicians should follow when safely determining their  practice schedule.  

Avoid Excessive Practicing  

For starters, musicians need to monitor their practice by setting limits on the amount of  time spent playing daily. This will vary by instrumentalist, for the duration of time spent  practicing should be tailored to the individual, as there is no standardized schedule common for  every player (Lonsdale & Laasko, 2014, p. 76). As a reminder, the quality of practice is more  beneficial than the quantity of time practiced. Therefore, a rapid increase in playing hours can  do more harm than help by predisposing musicians to injury (Guptill & Zaza, 2010, p. 29).  Rather than dramatically raising the time spent in a practice room, musicians are encouraged to  gradually increase their time in smaller increments of ten to twenty minutes (Guptill & Zaza,  2010, p. 31). It is also helpful to distribute one’s practice schedule throughout the day, instead of  in one long session. This allows the body adequate rest and recovery time and supports better  skill refinement and consolidation (Chan & Ackermann, 2014, p. 3).  

It is also important for musicians to carefully plan their practice schedule around their  rehearsals and performances to monitor their full load. When there is a higher number of playing  requirements outside of individual practice, instrumentalists need to reduce the amount of time  spent practicing, as opposed to after periods of minimal playing, it is just as necessary for  musicians to increase their practice time to prepare the body for a return in workload (Chan &  Ackermann, 2014, pp. 3-4). 

While in the practice room, if possible, the musician should avoid repertoire that is  beyond his or her physical or technical reach, as this greatens the muscular strain on the body  (NASM-PAMA, 2014, p. I-15). If playing challenging or high intensity music is unavoidable, it  should be practiced for shorter durations of time with easier repertoire in between to prevent  muscle fatigue (Chan & Ackermann, 2014, p. 3). When approaching practicing difficult music,  one should slowly play a few bars or phrases at a time until accurate, avoiding excessive  repetition, and then work to gradually increase the tempo without sacrificing the integrity of the  sound and technique (Guptill & Zaza, 2010, p. 31). Not only is this practice method safer on the  body, but it is an effective technique for learning new repertoire, as well.  

Move  

Another way to guard the body against injury is adding movement to one’s playing.  Oftentimes, instrumentalists, especially amateurs, tend to play sitting very still. Holding a static  posture for long hours builds up tension and should be refrained from (Horvath, 2014, p. 29).  Students should be encouraged to move with the music as far as their instrument allows (Guptill  & Zaza, 2010, p. 30). If anything, at least pausing during long practice sessions to move, shake  out built-up tension, and stretch can help reduce the effects of static posture. Allowing for  fluidity of motion is good for the body, especially with how restraining playing can be. 

Take Breaks  

To combat the muscular strain of practice, it is vital that musicians take breaks  throughout rehearsing. Instrument-playing puts the body at an elevated state of physical stress,  which is damaging to musculoskeletal structures, and can lead to the breakdown of tissues,  causing injury if adequate rest is not taken (Chan & Ackermann, 2014, p. 4). Frequently and regularly taking time to pause from practicing assists in “reducing the constant strain and load bearing on the joints, as well as allowing recovery of supporting musculature and fine-control  muscles of the fingers and lips” (Chan & Ackermann, 2014, p. 4).  

To reap these benefits, musicians should incorporate both short and long breaks into their  practice routine (Guptill & Zaza, 2010, p. 30). Short breaks in playing are not meant to be longer  than thirty seconds. It is a quick way to reset the body and briefly release sustained muscle  tension. These breaks can be as simple as counting rests when practicing a piece with  accompaniment, but the advantages are great in preventing injuries and increasing perceived  stamina (Guptill & Zaza, 2010, p. 30). In addition to these brief pauses, it is a good guide to take  a longer break of about ten minutes for every hour of practicing (Horvath, 2014, p. 29). During  this time, the musician should change position, stretch out, and do an activity which does not  incorporate the muscles and postures used while playing (Guptill & Zaza, 2010, p. 30).  Although this time does not need to be spent forgetting about music, it should not involve  fingering parts, since this does not give the muscles in the fingers, hands, arms, and body a break  from holding these postures (Guptill & Zaza, 2010, p. 30).  

Breaks from playing not only apply to individual practice sessions, but also to ensemble  rehearsals. Directors should provide their students with breaks during rehearsals exceeding the  duration of an hour (NASM-PAMA, 2014, p. II-18). These breaks can come in several different  forms, many in which do not need to disrupt the educational process. As long as the musicians  are receiving an adequate pause from playing, it is up to the ensemble director’s discretion to  determine what that time consists of. 

Practice Away from the Instrument  

One method of pausing from practice without deterring the performer’s musical focus is  through mental practicing. Mental practicing is defined as “a technique by which someone with  the intent to practice creates a mental representation of a preconceived idea or action in order to  enhance performance” (p. 275) through approaches such as “conducting a formal analysis of the score, listening to a recording of the piece, forming auditory imagery of the pitches, imagining  movement (visually and/or kinesthetically) and using visual imagery of the score” (Bernardi,  Schories, Jabusch, Colombo, & Altenmüller, 2013, p. 276).  

These ways of cognitive practicing not only put no harm or strain on the body, but they  are especially helpful for memorization and performance anxiety (Horvath, 2014, p. 29).  Research indicates that imagining a successful performance helps increase the musician’s self efficacy and often improves his or her performance outcome (Guptill & Zaza, 2010, p. 31).  Taking the time to mentally prepare the repertoire, while silencing any doubts and fears, can  calm the subconscious and help the musician prepare for a performance in a way physical  playing cannot achieve. It is a safe and productive strategy to protect the body from injuries  caused by over practicing.  

Conclusion  

When it comes down to it, the pursuit of performance injury prevention strategies is truly  a search for lifelong musical enjoyment. Music has the power to change lives, and the thought  that this capability could be taken away through pain and injury does not sit well with  instrumentalists. PRMDs have plagued dedicated musicians for too long. But through health  education, physical wellness, proper body alignment, and a balanced practice schedule, this no longer has to be the case. The future of the healthy musician is in the hands of music teachers.  The only way this problem can be reversed is to start at the beginning with amateur  instrumentalists. When performing artists are informed of ways to sustain a happy and healthy  career from the onset of their playing, they are empowered with a bright future ahead, guarded  against the agony of pain and filled with the joy of music. Only then can musicians truly know  gain with no pain.  

Implications for Further Research 

The past three decades have seen an emergence in research regarding the prevalence of  playing-related pain in instrumentalists. While there is an abundance of information promoting awareness to this issue, there is less knowledge available concerning evidence-based practices  preventing the development of PRMDs. As a continuation of this research, further studies  should be generated investigating a practical and specific approach to integrating pain-prevention  methods into the music classroom. This paper introduced an overarching review of the  necessary elements of injury reduction for amateur instrumentalists. From here, a more detailed  breakdown of each aspect on what this specifically looks like for the music teacher is warranted.  Topics such as a thorough design for a health education program in the classroom, definitive  stretches to be done before and after rehearsal, an instrument-specific postural analysis, and a  medically-driven practice schedule should be explored into the future. Once this research is further developed and implemented, a reduction in playing-related injuries should result.