Professional musicians with craniomandibular dysfunctions treated with oral splints

For Fiddlers on the Roof and in the Pit: Healthcare and Epidemiology of Playing-Related Problems in Violinists

Musicians, specifically violinists, may experience pain or loss of function as a result of poor playing hygiene, environmental factors, and insufficient guidance from teachers, parents, conductors, and physicians. The causal occurrence of these pathologies and the efficacy of general treatment, along with referral to other specialists for adjunct therapies and rehabilitation, were examined in this literature review. A systematic PubMed search was conducted in May 2022 to gain insight into the current state of the published literature. Inclusion criteria were cross-sectional or comparative studies that address relevant pathologies among violinists by specialty. The search resulted in 25 cross-sectional, 5 comparative studies, and 1 case review including a total of 6010 musicians, among them at least 920 violinists. Orthopedists, neurologists, dentists/orthodontists, dermatologists, and audiologists are most commonly consulted to treat violinists' complaints. Other internists and various paramedical specialists can equally be affected and should be sensitive to the complaints of musicians. In conclusion, the field of performing arts medicine is extremely wide and requires multidisciplinary specialist attention. The studies chosen highlight that violinists may suffer great discomfort at the hands of their instrument and merit adequate guidance from physicians in order to be able to continue playing in a safe, ergonomic way.

Orofacial Pain, Musical Performance and Associated Coping Behaviors, Psychological Distress and Disability among Asian Young Adults

Musicians often report orofacial pain (OFP) and performance-related psychological distress related to occupational neuromuscular overuse, but to date, no study has been performed in Asian musicians to assess these factors. This study evaluated OFP, psychological distress, coping behaviors, and disability among Asian musical performers. A total of 201 participants in Singaporean music ensembles were surveyed from which 159 met the inclusion criteria for vocalists or instrumentalist musicians (mean age 20.26 ± 2.20 years). Self-administered questionnaires assessed musical practices, jaw/neck pre-conditioning exercises, pain-related temporomandibular disorders (TMD), OFP descriptors, pain chronicity and disability, coping behaviors and psychological distress. Univariate and multi-variate analyses were carried out. OFP, while performing, was more than two-fold higher in instrumentalists when compared to vocalists (41.4-48% vs. 17.2%, p = 0.002). A similar trend occurred for OFP that progresses while playing (p = 0.035) and for persistent OFP that reduces playing (p = 0.001). There were no differences in psychological distress, pain coping and disability between groups. Vocalists were found to practice jaw/neck pre-conditioning exercises more frequently (75% vs. 4-12.9% in instrumentalists, p < 0.0001). While performing, Asian vocalists reported less OFP when compared to instrumentalists. Future prospective studies are needed to confirm if pre-conditioning exercises play a protective role against OFP in vocalists.

Orofacial myofunctional changes and electromyographic activity of the orbicularis oris muscle in trombonists

ABSTRACT Objective: to analyze whether trombonists present orofacial myofunctional changes and compare the electrical activity of the orbicularis oris muscle before and after playing their instrument. Methods: an observational, descriptive, and cross-sectional study. The sample consisted of 20 university trombonists. Data collection involved three steps: application of a questionnaire investigating some peculiarities of trombonists (Orofacial Myofunctional Evaluation with Expanded Scores - OMES-E), and electromyographic analysis of the orbicularis oris muscle before and after performing a piece with the trombone. The mean, standard deviation, frequency, and percentage were calculated, and the paired Student’s t test was used to compare the means of the electromyographic records before and after playing the trombone, at a 5% significance. Results: seventy per cent of trombonists reported some symptom of orofacial myofunctional alteration, namely, muscle compensations, tension, and pain. The myofunctional evaluation showed a mild change in cheek volume (90%) and labial commissure asymmetry (60%). The electrical activity of the lower orbicularis oris muscle decreased significantly after the trombone practice (p = 0.04), while that of the superior orbicularis oris muscle remained unchanged. Conclusion:trombonists show clinical and self-reported oromyofunctional changes as well as decreased electrical activity of the lower orbicularis oris muscle, after playing the trombone.

Musculoskeletal disorders and complaints in professional musicians: a systematic review of prevalence, risk factors, and clinical treatment effects

PURPOSE

Musicians' practice and performance routines reportedly lead to musculoskeletal complaints and disorders (MCD) that impact their wellbeing and performance abilities. This systematic review aims to assess the prevalence, risk factors, prevention and effectiveness of treatments for MCD in professional musicians and consider the methodological quality of the included studies.

METHODS

A systematic literature search was performed in December 2017 using electronic databases and supplemented by a hand search. Case-control studies, cohort studies, cross-sectional studies, interventional studies and case reports investigating the prevalence, risk factors, prevention or treatment effects of MCD in professional musicians or music students (age ≥ 16 years) were included. Quality assessments of the included studies were performed using an adapted version of the "Study Quality Assessment Tools" from the National Heart, Lung, and Blood Institute.

RESULTS

One case-control study, 6 cohort studies, 62 cross-sectional studies, 12 interventional studies and 28 case reports were included and assessed for methodological quality. The study designs, terminology, and outcomes were heterogeneous, as the analyses mostly did not control for major confounders, and the definition of exposure was often vague. Therefore, evidence that being a professional musician is a risk factor for MCD as well as the causal relationship between these factors remains low despite the fact that a large number of studies have been performed.

CONCLUSIONS

Studies with high internal and external validity regarding the prevalence, risk factors and effectiveness of the prevention or treatment of MCD in professional musicians are still missing. Further high-quality observational and interventional studies are required.

How do we assess musicians' musculoskeletal symptoms?: a review of outcomes and tools used

Recent reviews of musicians' musculoskeletal symptoms (MSS) have reported heterogeneity in the outcomes reported and data collection tools used, making it difficult to compare and synthesise findings. The purpose of this present review was to improve the consistency of future research, by documenting the outcomes reported in recent studies of musicians' MSS and the data collection tools used. All English language, peer-reviewed studies, published 2007-2016 that reported musicians' self-reported MSS outcomes were identified. Details of the types of outcomes reported and the tools used were extracted, and synthesised descriptively. A range of MSS outcomes were reported, including MSS with a temporal relationship to activities performed, and the consequences of symptoms. Only 24% of studies used standardised questionnaires, with the Nordic Musculoskeletal Questionnaire (NMQ) being the most commonly used. To improve the homogeneity of outcomes and data collection tools when investigating musicians' MSS, we recommend using the NMQ, where appropriate. Recall periods of 12-months and 7-d are the most appropriate for prevalence, and 7-d recall periods for ratings. Importantly, outcomes and the tools used to collect data should be reported in sufficient detail to ensure that the study can be replicated, critiqued, and accurately interpreted.

Evidence-based review on temporomandibular disorders among musicians

Background

Playing a musical instrument that loads the masticatory system has frequently been linked to temporomandibular disorders (TMDs). Previous literature reviews on this topic do not conform to the current standards of evidence-based medicine.

Aims

To investigate the effects of playing a musical instrument (i.e. violin/viola and wind instruments) or singing on the presence of TMDs, based on evidence derived from observational studies.

Methods

Databases of Medline, Web of Science and Google Scholar were searched using MeSH and other relevant terms. For each study, a quality assessment was undertaken using a modified version of the Newcastle-Ottawa Scale (NOS).

Results

Fifteen relevant papers were identified for inclusion in this review. Of the seven possible points that could be scored with the NOS, the majority of these studies scored under half. Based on the available evidence, the purported relationship between the playing of specific musical instruments and TMDs was not as evident as reported in previous literature reviews.

Conclusions

There is limited evidence to conclude that playing a wind instrument is a hazard to the temporomandibular system. Furthermore, there is no available evidence to suggest that vocalists experience more TMDs than controls. The studies that investigated the presence of TMDs among violists and violinists yielded ambiguous outcomes; some studies reported no association between the playing of these instruments and the presence of signs and symptoms of TMDs, whereas in studies where a clinical examination was performed (though of lower methodological quality), an association was found.

Prevalence of temporomandibular joint disorders and neck pain in musicians: a sytematic review

Abstract Introduction: The instrumental practice for a long time, the high performance level, the strict technique and the specific shape of each musical instrument can take musicians to overcome their physiological limits, giving a high prevalence of musculoskeletal injuries. Objective: Investigate the prevalence of temporomandibular joint disorder and neck pain in musicians. Methods: Between August and September 2015 were reviewed five databases: LILACS, SciELO, Medline / PubMed, Scopus and Web of Science. The articles were read and evaluated by the criteria of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE), items, that obtained a percentage above of 50 percent, were considered in the analysis of this work. Results: 15 articles attended the inclusion criteria. Among all musicians the prevalence of TMJ pain ranged from 10 - 81% and the prevalence of neck pain ranged from 29 - 80%. Conclusion: In this study was observed that the musicians showed both, temporomandibular joint disorders and neck pain, watching a high prevalence especially in violinists and the horn players. In the risk factors identified in the literature for the emergence of painful symptoms in musicians, stand out the biomechanical factors involved in maintaining anti-physiologic postures.

Clinical Signs and Subjective Symptoms of Temporomandibular Disorders in Instrumentalists

PURPOSE

Most of the reports on instrumentalists' experiences of temporomandibular disorders (TMD) have been reported not by clinical examinations but by subjective questionnaires. The aim of this study was to investigate the clinical signs and subjective symptoms of TMD in a large number of instrumentalists objectively.

MATERIALS AND METHODS

A total of 739 musicians from a diverse range of instrument groups completed a TMD questionnaire. Among those who reported at least one symptom of TMD, 71 volunteers underwent clinical examinations and radiography for diag-nosis.

RESULTS

Overall, 453 participants (61.3%) reported having one or more symptoms of TMD. The most frequently reported symptom was a clicking or popping sound, followed by temporomandibular joint (TMJ) pain, muscle pain, crepitus, and mouth opening limitations. Compared with lower-string instrumentalists, a clicking or popping sound was about 1.8 and 2 times more frequent in woodwind and brass instrumentalists, respectively. TMJ pain was about 3.2, 2.8, and 3.2 times more frequent in upper-string, woodwind, and brass instrumentalists, respectively. Muscle pain was about 1.5 times more frequent in instrumentalists with an elevated arm position than in those with a neutral arm position. The most frequent diagnosis was myalgia or myofascial pain (MFP), followed by disc displacement with reduction. Myalgia or MFP was 4.6 times more frequent in those practicing for no less than 3.5 hours daily than in those practicing for less than 3.5 hours.

CONCLUSION

The results indicate that playing instruments can play a contributory role in the development of TMD.

Relationship Between Wind Instrument Playing Habits and Symptoms of Temporomandibular Disorders in Non-Professional Musicians

Background:

In this study, we focused on the habits of wind instrumentalists as well as the presence of playing instruments, and investigated associations between the risk of temporomandibular disorders (TMD) and playing wind instruments in non-professional musicians.

Material and Methods:

Seventy-two non-professional players of wind instruments (instrument group) (mean(SD), 20.0(1.1) y; 42 women) and 66 non-players (control group) (22.0(2.6) y; 45 women) participated in this study. Factors were investigated using questionnaires (a screening questionnaire for TMD, instrument playing habits, years of experience, and time played per day).

Result:

The prevalence of a high risk of TMD was not significantly different between the instrument group (29.2%) and control group (21.2%). In the instrument group, the frequency of subjects who felt mouthpiece pressure in the high risk of TMD group (47.6%) was significantly greater than that in the low risk of TMD group (21.6%). Mouthpiece pressure was found to be a significant factor contributing to a high risk of TMD (odds ratio, 3.31; 95% CI, 1.12–9.79).

Conclusion:

This study suggests that pressure from the mouthpiece was one of the contributing factors related to a high risk of TMD in non-professional wind instrument players.

Is there an association between temporomandibular disorders and playing a musical instrument? A review of literature

Temporomandibular disorders (TMDs) have a multifactorial etiology. Among others, parafunctions and oral habits have been suggested as important initiating and perpetuating factors. Playing a musical instrument that loads the masticatory system, like wind instruments and the violin or viola, has been suggested to be part of this group of etiological factors. However, the evidence base for this suggestion is lacking. Therefore, the aim of this study was to review the literature on the possible association between playing a musical instrument and developing and/or having a TMD. A PubMed search, using the query ['Music'(Mesh) AND 'Craniomandibular Disorders'(Mesh)], yielded 19 articles, 14 of which were included in this review. Six of 14 papers had a case-control or pre-test-post-test design; the remaining eight papers were case reports of expert opinions. The former papers were analysed and tabulated according to the PICO (Patient/population-Intervention-Control/comparison-Outcome/results) system; the latter ones were only summarised and tabulated. All articles with a case-control or pre-test-post-test design suggested a possible association between TMD and playing a musical instrument, especially the violin and viola. However, no clear-cut conclusion could be drawn as to whether playing a musical instrument is directly associated with TMD, or only in combination with other factors. More and better research on this topic is needed, as to enable a better counselling and possibly even a better treatment of the suffering musician.

Symptoms of craniomandibular dysfunction in professional orchestra musicians

BACKGROUND

Up to 80% of professional musicians are affected by playing-related musculoskeletal disorders, but data regarding the frequency of craniomandibular dysfunction (CMD) in professional orchestra musicians is scarce.

AIMS

To evaluate the frequency of CMD and its relation to musculoskeletal pain in various body regions.

METHODS

A questionnaire-based survey approach assessing CMD symptoms and musculoskeletal pain in professional orchestra players was adopted. Relative prevalence rates and prevalence ratios for different instrument groups were estimated.

RESULTS

A total of 408 musicians completed the questionnaire (response rate 57%). Playing-related pain in the teeth or jaw was reported by 19-47% of musicians and TMJ pain by 15-34%, depending on the instrument group. Current pain in the face indicating a painful CMD was reported in 6-10% and related symptoms such as teeth grinding in 25-34%, jaw clenching in 33-42% and jaw locking in 11-18% of musicians. Females were 2.4 times (95% confidence intervals (CI) 1.49-3.84) more likely to report having had orofacial pain within the last month. Musicians reporting orofacial pain within the last month were 4.8 times (95% CI: 2.83-8.02) more likely to report pain in the neck and 2.5-3.8 times (P < 0.05) more likely to report pain in other body regions, including shoulders, right wrist, left fingers and the thoracic and lumbar spine.

CONCLUSIONS

Symptoms suggesting CMD were common in this study of professional orchestra musicians and were associated with pain in the neck, shoulder and hands. There is a need to enhance awareness of CMD to optimize early medical diagnosis and treatment.

Chin force in violin playing

Force generated between the left mandible of violinists and the chinrest of the violin was examined using a force-sensing chinrest developed in this study. A strain-gauge force sensor was built, and it was fixed between the violin's top plate and a chin cup. Fifteen professional/amateur violinists held the violin statically, played musical scales with different sound properties and sounding techniques, as well as an excerpt from a Max Bruch concerto. Peak and mean forces were evaluated for each task. In a separate experiment, lateral movement of the lower teeth due to different levels of voluntary chin force exertion was measured. Static holding forces observed were 15 and 22 N with and without the help of the left hand, respectively. Peak force increased from 16 N at soft dynamics to 20 N at strong dynamics during scales. The force further increased to 29 N with the use of vibrato technique and 35 N during shifts. Tempo and hand position did not affect the force. Playing a Bruch concerto induced a mean peak force of 52 N, ranging from 31 to 82 N among the violinists. The developed force-sensing chinrest could accurately record the generated chin force. Typical chin force to stabilize the violin during ordinary musical performance was less than 30 N, but it could momentarily exceed 50 N when technically demanding musical pieces were performed. The lateral shift of the mandible was fairly small (<0.4 mm) even with high chin-force exertion, possibly due to clenching of the molars.