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Basic Information on
Neuromuscular and Vocal Health
STUDENTS
Sources of This Information on Hearing Health
 National Association of Schools of Music (NASM)—
provides contextual issues in music programs
regarding neuromuscular and vocal health
 Performing Arts Medicine Association (PAMA)—
provides information of a medical nature
Disclaimers for Information in This Presentation
 Information provided is generic and advisory.
 Information is oriented toward musicians and lay
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persons.
Information does not substitute for professional
judgments of medical or other experts.
Information is not to be considered medical advice.
Current information does not supersede present and
future empirical research.
Information does not serve as basis for NASM
accreditation functions.
Information does not endorse accompanying reference
materials.
Responsibility for Neuromuscular and Vocal Health
 Health and safety depend in large part on personal
decisions of informed individuals.
 This information does not relieve individuals of personal
responsibility for avoiding risk and preventing injuries to
self before, during, and after study or employment at any
institution.
 This information does not relieve the individual of personal
responsibility for appropriate, prudent, and safe behaviors
or actions.
Responsibility for Neuromuscular and Vocal Health
 This information does not shift responsibility or
liability for consequences of inappropriate,
imprudent, and/or unsafe behaviors in any
instance or over time to any institution, to NASM,
or to PAMA.
 Neuromuscular and vocal health are important for
everyone, but especially for musicians.
Neuromuscular and Vocal Health: Basic Issues
 Neuromusculoskeletal System (NMS)—nervous
system, muscular system, and skeletal system
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These support the body’s physical structure and enable
movement
These include the body’s position in space
These include the relationship of the skeletal system to
corresponding muscles and tissues
Terms like “alignment” and “posture” involve spinal
positioning, weight distribution, muscular support, and
balance
Important for musicians and their neuromuscular and vocal
health
Neuromusculoskeletal and Vocal Health
 “Neuromusculoskeletal” encompasses not only overt
physical movements (e.g., pressing keys, strumming
strings), but also small internal movements (e.g., to
produce breath or modify vocal sounds).
 Neuromusculoskeletal health includes vocal health.
Neuromusculoskeletal and Vocal Health
 Vocal health is important to all musicians because
the voice is used in speaking and singing in
professional roles (e.g., conductors, coaches,
teachers, recording engineers, researchers, and
therapists).
 Good health and healthy behaviors are important to
all musicians, regardless of their instruments and/or
areas of specialization.
Sources of Neuromusculoskeletal/Vocal Disorders
 Genetic factors
 Infections
 Trauma or injury
 Behaviors—either in isolation or repeated over time
Music, The Musician, and Neuromusculoskeletal Health
 Musical performance = physical activity involving
large and small movements—those we can see and
those inside the body.
 Musical performance—involves conscious
positioning of the body into specified playing and/or
singing postures, which may be unnatural at first.
Music, The Musician, and Neuromusculoskeletal Health
 Practice routines are physically demanding and
time-intensive, with few “days off” for the serious
musician at an advanced level.
 Some musicians may develop NMS conditions,
complications, or disorders related to their musical
activities.
Music, The Musician, and Neuromusculoskeletal Health
 Personal decisions about practice and performance
are important in the individual’s NMS health and
fitness.
 Musicians are responsible for their art form and for
supporting the well-being of all musicians.
 It’s important to have a positive relationship between
musical performance and NMS health.
The Neuromusculoskeletal System (NMS)
 Musculoskeletal system—includes muscles, tendons,
ligaments, bones, joints, and associated tissues that move
the body, allow for speech, and help the body maintain
its form.
 The term, “neuromusculoskeletal” adds the nervous
system, which coordinates voluntary and involuntary
actions by transmitting signals to different parts of the
body.
 Nervous system contains:
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Central nervous system (CNS)—brain and spinal cord
Peripheral nervous system (PNS)—nerves that allow the CNS to
communicate with the rest of the body
Vocal Anatomy: Contains Four Component Systems
 “Generator”—breath provided by the lungs
 Main muscle involved is the diaphragm, a dome-shaped
muscle extending along the bottom of the rib cage
 Diaphragm is assisted by various muscles in the abdomen,
ribs, chest, and back
 “Vibrator”—larynx, commonly called the “voice box”
 Vocal folds (or vocal cords) = 2 infoldings of mucous
membranes
 When breath regulated by the generator passes along the vocal
folds, they vibrate creating sound
Vocal Anatomy: Contains Four Component Systems
 “Resonator”—cavity above the larynx responsible for
giving the voice its tonal quality.
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Includes vocal tract, much of the pharynx (the throat), the oral
cavity, and the nasal passages
 “Articulator”—tongue, lips, cheeks, teeth, and palate
 Helps to shape sounds into recognizable words and specific
vocalizations
 NOTE: These four components work together to
produce human speech and singing.
Disorders of Neuromusculoskeletal System:
Temporary or Permanent
 Causes
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Genetic or related to preexisting medical condition
Related to trauma or
injury
Related to specific
behaviors which are
subject to
modification/change
 Common symptoms
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Pain
Stiffness
Aching
Throbbing
Cramping
Muscle weakness
Disorders of Neuromusculoskeletal System
 Temporary Disorders may respond to
 Rest
 Behavior modification
 Medical interventions
Causes of Behavior-Related Neuromusculoskeletal Disorders
 Overuse--any practice or activity in which
anatomically normal structures are used in a socalled normal manner, but to a degree that exceeds
their biological limits
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Produces physical changes that can cause symptoms or
complaints
Degree of excessive activity needed to produce
symptoms/damage varies from person to person and seems to
be related to a person’s individual anatomy and physiology
Causes of Behavior-Related Neuromusculoskeletal Disorders
 Misuse—a practice in which anatomically normal
structures are used in an abnormal manner and/or to an
excessive degree, sufficient to produce specific
symptoms. Places certain bodily structures under stress
 Abuse—occurs when an activity is performed not only
excessively (overuse) or improperly (misuse), but also in
a conscious, willful manner, often producing deleterious
physical effects
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Common instrumental example = “playing through the pain”
Vocal example = repeated instances of singing too loudly or singing
out of range
Also includes use of dangerous substances
Causes of Behavior-Related Neuromusculoskeletal Disorders
 Genetic factors—most common one influencing
behavior-related NMS disorders = hypermobility
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Also known as “joint hyperlaxity” or “double-jointed”
May predispose a person to muscle pain syndromes and/or
tendinitis (inflammation of tendons—tough bands of fibrous
connective tissue that connect muscle to bone)
Causes of Behavior-Related Neuromusculoskeletal Disorders
 Hypermobile joints have greater than normal range
of motion
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People with these tend to use more muscle tension when
completing movements or tasks involving the hypermobile
joint
Excess tension allows for better control, but can increase risk
of damaging or straining muscles
Individuals with this condition are generally advised to
monitor and actively reduce the tension carried in muscles and
sometimes to do specific strengthening exercises and use
external methods of joint support, such as splints or tape
Facts and Conclusions
 Facts
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NMS health is essential
for musicians.
Many behavior-related
NMS disorders are
preventable.
 Conclusions
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Musicians have basic NMS
health responsibilities.
Healthy NMS behaviors
are a critically important
addition to the musician’s
portfolio of essential
disciplines.
Facts and Conclusions
 Constant attention is necessary because NMS
damage sometimes occurs gradually over time.
 Severe or advanced symptoms of certain NMS
disorders may be career-ending for a musician.
 Even if initial problems are not debilitating, they can
cause career activity to become increasingly difficult
and finally impossible.
Meaning of Facts and Conclusions
 Musicians necessarily engage in repeated NMS
behaviors and hold particular postures when they
rehearse and perform.
 Such behaviors and postures do NOT equal
automatic risk of one or more NMS disorders.
 Many factors are involved in determining inherent
risk.
 Managing NMS health starts with understanding
basic facts and avoiding the most obvious
problematic behaviors, postures, and situations.
Meaning of Facts and Conclusions
 A behavior is risky when it involves overuse, misuse,
or abuse of certain bodily components.
 A behavior is risky when it fails to recognize and
adapt to an individual’s physical limitations, genetic
or otherwise.
 Thoughtful judgment about what to do and what not
to do for yourself and others involves gaining indepth knowledge and applying it with sophisticated
understanding.
 A number of variables interact at the same time.
These are unique to specific settings and situations.
Variables Influencing a Musician’s Risk of
NMS Disorders
 Intrinsic Factors—non-modifiable
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Gender—more problems in female than male instrumentalists
Related to smaller average size of the female hand and fingers
 Related to smaller bulk and cross-sectional dimensions of female
muscles
 Females have higher vocal ranges than males
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Anatomy—factors like height, hand size, lung capacity, and joint
hypermobility may affect the way students play certain instruments
as well as the choice of repertoire
Singers—factors = lung capacity, vocal range, tessitura, timbre
 Affect assignment of voice parts and songs singers are expected and
selected to sing
 Since anatomy cannot be changed, technique and an approach to
playing and singing music must take anatomy into account
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Variables Influencing a Musician’s Risk of
NMS Disorders
 Intrinsic Factors—modifiable
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Alignment—poor posture can increase risk of injury
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Quality of movement—micro and macro movements affect the
quality of sound
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Involves good balance and body positioning
High levels of body awareness are needed to avoid bound, stiff, or
limited movements that can lead to injury
Stress and psychological health—injuries/pain more likely if
musician is under stress and/or depressed
NMS problems can lead to depression
 Psychological health is important for overall physical health
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Motivation and effort—improving muscle strength and endurance
require motivation and consistent effort
Exercise and conditioning are important
 Musicians may seek guidance from physical therapists, somatic
educators, vocal coaches, and other healthcare specialists
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Variables Influencing a Musician’s Risk of
NMS Disorders
 Extrinsic Factors—non-modifiable
 Assigned musical repertoire—certain musical pieces pose particular
physical and vocal challenges
 Venue—once selected, the setting for performance/rehearsal can make
injury more or less likely
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Acoustics, temperature, lighting, and seating affect performance
Instrument—though some instruments can be modified somewhat, some
characteristics cannot be changed
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Frequency of injury is higher for instruments that require many repetitions of
finger action and for instruments that must be held in difficult postures
Large instruments may involve more problems
 Wider stretches for keys, strings, and valves
 Greater muscle tension and increased use of the smaller and weaker hand
muscles
 More difficult to play quickly because of great size and complexity of
keywork and valve travel or greater space between strings and fingerboard
Variables Influencing a Musician’s Risk of
NMS Disorders
 Extrinsic Factors—modifiable
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Time spent playing or singing—the single most important risk that
can be managed by musicians is TIME (i.e., practicing; frequency
and nature of rest breaks during practice sessions; how quickly one
increases practice time when major performances are approaching;
how one approaches more technically demanding passages)
Non-music related activities that can involve overuse or misuse
Fitness and conditioning activities, such as sports participation,
especially if overdone or done incorrectly
 Excessive use of certain electronic devices, such as computers, tablets,
cell phones, and gaming systems
 Loud social events and those in which cigarette smoke or alcohol are
involved pose serious risk to vocal health
 Some forms of outside employment may involve excessive or
improper use of the NMS system
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NMS Issues Affecting the Body
 Muscle Pain—principal cause is sore muscles
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May be related to overuse, misuse, abuse, postural factors, tension,
technical problems, or poor conditioning
When muscles get fatigued and are placed under further stress,
microscopic damage and disruption of muscle fibers can occur
(called “muscle strain”)
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Muscle contraction involves specific chemicals
 When in short supply, optimal efficiency is lost
 Muscle contraction produces lactic acid; if this accumulates, it
decreases the muscle’s ability to continue efficient contractions
Muscle strain and incorrect muscle contractions can lead to pain
Playing-related NMS disorders at all ages are more commonly seen
in shoulders, neck, hands/fingers/wrists, and lower back
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Specific locations may be related to specific instruments
NMS Issues Affecting the Body
 Neuropathies—a general medical term meaning “diseases
or malfunctions of the nerves.”
 Classified according to types or location of affected
nerves.
 Focal neuropathy—restricted to one nerve or group of
nerves or to a particular area of the body.
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Symptoms may appear suddenly and include pain, sensory
disturbances (e.g., numbness, tingling, “pins and needles,” burning,
itching) and weakness
May occur at site of nerve compression or entrapment in extremities
Entrapment = compression on the nerve as it passes through a
narrowed channel bound by bone, fibrous bands, bulky muscles, or
enlarged arteries
Three Most Common Entrapment Neuropathies
 Carpal Tunnel Syndrome—median nerve (runs from
forearm into palm of hand) becomes pressed or
squeezed at wrist
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Carpal tunnel—a narrow, rigid passageway of ligament and
bones at the base of the hand containing the median nerve and
several tendons
When tendons are irritated or strained, they may swell and
narrow the tunnel compressing the nerve and causing pain,
weakness, or numbness in the hand and wrist that radiates up
the arm
Three Most Common Entrapment Neuropathies
 Ulnar Neuropathy—ulnar nerve (runs from neck
along the inside edge of the arm and into the hand
on the side of the pinky finger) becomes inflamed
due to compression of the nerve
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Symptoms include tingling, numbness, weakness, and pain,
primarily along the elbow, the underside of the forearm, and
along the wrist or inside edge of the hand
Often linked to repetitive wrist or elbow movements—e.g.,
sustained elbow flexion among players of bowed instruments
can contribute to this condition in some cases
Three Most Common Entrapment Neuropathies
 Thoracic Outlet Syndrome–a group of disorders that
occur when the blood vessels or nerves in the
thoracic outlet (the space between the collarbone
and the first rib) become compressed
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Most often the result of poor posture
Can be caused by constant muscle tension in the neck and
shoulder areas
Symptoms include pain in the neck and shoulder areas and
numbness in the fingers
NMS Issues Affecting the Body
 Dystonia—disorder of sustained muscular
contractions, producing unwanted movements or
abnormal postures
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Focal dystonia—affects a particular area of the body
More prevalent in men (genetic or hormonal factors may be
involved)
Repetitive movements, especially those that are painful, seem
to trigger it
In musicians, symptoms usually appear in upper limb for
keyboard, string, percussion, and woodwind players or in
embouchure in brass and some woodwind players
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Right hand of keyboard players and left hand of string players
most commonly affected
NMS Issues Affecting the Voice
 Phonatory Instability
 Phonation—process by which air pressure generated by the lungs is
converted into audible vibrations
 “Voicing” occurs when air from the lungs passes along the vocal folds at
the base of the larynx causing them to vibrate
 Production of a tonal, pleasant voice with smooth changes in loudness
and pitch depends upon the symmetrical shape and movement of the
vocal folds
 Phonatory instability occurs when there is asymmetrical or irregular
motion of the vocal folds that is superimposed on the vocal fold
vibration–often manifests itself as an unsteadiness, hoarseness, or
roughness of voice (long or short-term possible)
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Short term causes include fatigue, certain medications, drug use, and
anxiety—to eliminate these, the causative agent must be removed
Over-the-counter medications, antidepressants, and highly caffeinated drinks
can cause vocal tremors—a form of phonatory instability
NMS Issues Affecting the Voice
 Vocal Strain—overuse of the voice (singing or
speaking) can produce this
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Singers must exercise caution when singing at the extremes of
the vocal range
Misuse can also occur
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Examples = attempting repertoire beyond vocal
maturity/development and improperly learning and practicing
certain vocal styles
Prolonged overuse can lead to development of vocal nodules
(i.e., soft, swollen spots on the focal folds)
As abuse continues, nodules become callous-like growths
 Require specialized and prolonged treatment and rehabilitation
 Can have grave consequences for singers
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Basic Protection for All Musicians
 Avoid situations that put your NMS health at risk.
 Refrain from behaviors that compromise your NMS
health.
 Warm up before practice and performance to
mobilize muscles and joints and increase blood flow
to body parts being used in performance
 Lubricate the vocal folds. Drink water.
Basic Protection for All Musicians
 Take breaks from practice and rehearsal whenever
possible (rule of thumb—5 minutes of rest per half
hour).
 Avoid excessive practice time and stress.
 Set daily practice limits and vary repertoire during
practice sessions.
Basic Protection for All Musicians
 Avoid excessive repetition of difficult repertoire,
especially if progress is slow.
 Avoid repertoire that is beyond your technical or
physical reach.
 Refrain from sudden increases in practice times;
slightly REDUCE practice time before juries, recitals,
etc. to allow mind and body adequate energy for
performance.
Basic Protection for All Musicians
 Ensure proper body alignment and technique.
 Be mindful of balance and weight distribution
 Ensure adequate freedom of movement and support during
practice and performance
 Use external support mechanisms, such as shoulder rests, neck
straps, and flute crutches, when necessary
 Maintain good “mental hygiene.”
 Get adequate sleep, good nutrition, exercise, time with friends
and family
 Manage stress; make time for relaxation
 Refrain from hazardous activities or recreational drug use
 Seek help of mental health professionals, if needed
Vocal Protection
 Drink plenty of water—vocal folds need lubrication.
 Drink 8 glasses a day
 Avoid and/or limit caffeinated and alcoholic
beverages.
 Do not smoke; avoid secondhand smoke.
 Be aware that some medications, such as allergy
pills, may dry out your vocal tissues.
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Stay well hydrated if you use them
Check with your doctor if you have questions
Vocal Protection
 Avoid dry air environments, and consider using a
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humidifier at night.
Avoid yelling or raising your voice unnecessarily.
Avoid throat clearing and voiced coughing.
Use vocal amplification systems when available and
appropriate.
Rest your voice, especially if you are sick. Give
yourself time to recover.
Marching Music—A Special Consideration
 Marching requires:
 Playing an instrument while also moving along a street or
across an athletic field, often rapidly with irregular movement
patterns
 High levels of physical conditioning, strength, and endurance
 Good general health and physical fitness
 Great physical demands on neck, torso, lower back, and legs
from carrying heavy instruments
Marching Music—A Special Consideration
 Marching activity-related physical disorders include:
 Sprained ankles
 Toe contusions
 Knee strains
 Sunburn and dehydration (esp. in summer heat)
Marching Music—A Special Consideration
 Marching requires:
 Physical warm-up
 Times of rest and rehydration
 Appropriate sun protection
 Appropriate ear protection, if needed
Basic Things Musicians Need to Know and Do
 Understand and share with others risk inherent in
excessive and improper NMS use while playing and
singing music, including the risk of prolonged or
permanent damage
 Recognize that playing and singing music in
inappropriate ways or for extended time can cause
playing and singing-related NMS disorders
Basic Things Musicians Need to Know and Do
 Monitor practice time and intensity, choice of
repertoire, and playing/singing techniques to
prevent development of playing- and singing-related
disorders
 Apply health knowledge to specific musical context–
practice, performance, production, education,
competition, and listening