Felicitas Sigrist - Pressure to perform, stage fright, competition, job insecurity: everyday life as a musician brings together working conditions that are well-known risk factors for burnout. With regard to such factors, working hours are less relevant than unfulfilled expectations, a lack of recognition and interpersonal disagreements. An accumulation of professional and private stress often triggers decompensation.

As a snapshot, burnout manifests itself as exhaustion with unspecific symptoms on an emotional, mental, physical and social level - for example listlessness, difficulty concentrating, susceptibility to infections, social withdrawal or irritability. This condition often leads to psychological or physical secondary illnesses, usually depression. This is preceded by a process of interaction between work-related and personal factors. The external demands are accepted with the self-request "I can do it" - often without reflection. Interpersonal conflicts are avoided.

Once a challenge has been successfully overcome, the next, perhaps bigger, task is entrusted to you. If relaxing activities are reduced, this cycle inevitably leads to excessive demands. This is not recognized as self-protection against insult - inner conflicts are avoided here. Instead, the reduction in performance is met with an increase in commitment - in other words, more of the same. With dwindling energy, the task increases in the subjective perception. As new strategies become less and less likely with increased stress, this burnout spiral can hardly be stopped.

Self-confident, emotionally unstable people who experience the outside world as difficult to influence and react inflexibly to increasing stress are particularly at risk. As these personal risk factors are often linked to previous relationship experiences, burnout can be explained as a resonance disorder. Individuals have little direct influence on framework conditions. This makes it all the more important to deal with them confidently.

Music is effective against burnout in many ways. The health-promoting aspects of music are scientifically well documented. Music is doubly important for musicians: for self-care and for teaching music. Music has a direct influence on mood and the autonomic nervous system. It can be used specifically for both relaxation and activation - but only if the individual music biography is taken into account. By consciously listening to music, the level of arousal can be specifically influenced - to relax, promote concentration or activate - and thus serve to regulate emotions. However, if music is misused, for example as a stimulant, it can also lead to a burnout spiral. Music as medicine is usually used therapeutically as a relaxation method to create islands of calm. Relaxation and a mindful attitude are prerequisites for neurological learning processes - also in psychotherapeutic treatments.

Active music-making is a good way to compensate - as long as it is not performance-oriented but remains experience-oriented. In addition to the multiple biological effects of making music, the social aspects are particularly important in preventing burnout. Playing together enables encounters outside of the working environment, regardless of professional role or identity. The experience of self-efficacy and belonging as well as the improvement of social skills strengthen the personality. Music education, especially in the amateur sector, is therefore not only justified for the sake of art, but also as an effective prophylactic measure.

Finally, music is used as a medium in music therapy, which is a proven psychotherapeutic method in the treatment of burnout. The key point here is to deal constructively with interpersonal and inner conflicts, in musical terms with dissonances.

Dr. med. Felicitas Sigrist

... is a specialist in psychiatry and psychotherapy FMH, music psychotherapist MAS/SFMT, head physician at the private clinic Hohenegg, Meilen near Zurich, specializing in burnout and stress crises.

Literature reference

Sigrist F. (2016) Burnout and music therapy. Basics, state of research and praxeology. Reichert-Verlag, Wiesbaden 2016.

SMM - How do you differentiate between professional and amateur musicians today? Jürg Kesselring, a neurologist from Valens, reminded the audience in the Great Hall of the Bern University of the Arts (HKB) that the boundaries are fluid. Musical competence and earning a living go hand in hand in the most diverse ways. There is the trained professional who only makes music on the side, as well as the technically rather modest performer who nevertheless makes his living entirely from music. In fact, as the conference revealed, the most striking difference seems to lie in the attitude towards music: "Only with the dilettante", Kesselring quoted Egon Friedell, "do man and profession coincide".

Music as a leisure activity is increasingly becoming a place of longing. Andreas Cincera, Head of Studies at the HKB Continuing Education in Music, also pointed out that the demand for adult lessons is increasing. Semi-professional ensembles, which are currently experiencing a boom, particularly in contemporary folk and world music, are likely to be important role models. Music schools are not yet exploiting the potential and are only now really beginning to reflect on what the ideal forms of teaching should look like. Perhaps, according to Cincera, the experiential and low-threshold aspects should be given more weight for adults than the intensive technical training that is important and useful for adolescents.

At the HKB, the relevant knowledge is imparted to future teachers in the form of a CAS (Certificate of Advanced Studies): Students are taught by renowned experts and informed about the opportunities and limitations of musical learning for adults up to very old age.

It is undoubtedly a privilege of amateurs that they can - in the spirit of Friedell - indulge in the so-called "flow", a trance-like state of complete oneness with the music, without restriction. The theory behind this was presented at the symposium by Bremen musician and psychologist Andreas Burzik. It goes back to the American happiness researcher Mihály Csíkszentmihályi. Burzik highlighted the aspects of practicing in flow: The consciously perceived sense of touch creates contact with the instrument, attentive listening creates contact with the sound and the sense of movement, or rather the feeling of effortlessness, creates contact with the body; finally, the mindful approach to the practice material awakens the desire to explore, investigate and discover. The "unconscious effortlessness of the child" remains the model.

When it comes to technique and physical strain, professionals and ambitious amateurs face the same challenges. Contributions to the symposium on voice, posture and physicality took this into account. Salome Zwicky from the SingStimmZentrum Zürich explored the limits of vocal strain in a presentation; breathing, speech and voice teacher Nicole Martin Rieder devoted a workshop to the theory and practice of breathing and in another workshop, physiotherapists Marjan Steenbeek and Sibylle Meier Kronawitter looked at the interplay of the body parts when making music.

14th SMM Symposium, The Amateur Musician - Between Sick Ambition and Healthy Pleasure, October 29, 2016, Bern University of the Arts, Great Hall.

SMM - The Performing Arts Medicine Association (PAMA) was founded in 1988 by a group of physicians who had previously worked in isolation on the health problems of musicians and dancers.

The first contacts were established back in 1983 at a symposium on the health aspects of music-making in Aspen (Colorado). The first joint publication platform was subsequently created in 1986 with the specialist journal "Medical Problems of Performing Artists". The symposium and journal were largely shaped by Alice Brandfonbrener, the founding president of PAMA.

Around a fifth of PAMA members now come from outside the USA. In addition to doctors, these now include other healthcare specialists as well as artists, administrators and educators.

Martina Berchtold-Neumann - Thanks to the generous support of the SIS (Swiss Performers' Foundation), the author was able to attend the Pama conference in New York in July of this year. Pama is an organization that looks after the interests of performing musicians and dancers. The focus is on the prevention and treatment of health problems. All medically relevant specialist areas, in addition to psychological sciences and physiotherapy with related procedures, are included in research and teaching. The members of Pama are spread all over the world. Around 400 participants, mainly from the USA and Canada, but also from Australia and Europe, attended the four-day congress. The congress focused primarily on musicians' medicine. Dance medicine was integrated.

The organizers' self-imposed goal was for the participants of the conference to gain a comprehensive overview of the current state of research in musician's medicine and also to be able to take practical tools from the workshops back into their daily practice. This goal was achieved. There were countless lectures to choose from, usually every 15 minutes, which were held in parallel in three lecture halls. The lectures were intended as inputs, so that the topics could then be studied in greater depth later on. There were also parallel 45-minute workshops. It was therefore not easy to choose what was important to you from the consistently appealing contributions. Unfortunately, some interesting sessions were also missed.

The bottom line is that musicians' medicine is at roughly the same stage of development in all the countries represented. Both the problems and their solutions are roughly comparable. The research questions and scientific settings are also structured in a similar way.

The contributions included studies on musculoskeletal disorders, physiological studies on string and wind instrument maintenance, hearing, the psychological issues of anxiety and stress and suitable physiotherapeutic treatment. The majority of the relevant studies focused on the pain experienced by musicians. This also appears to be a major topic in musicians' medicine internationally, as we already know from the studies here. Of course, American topics in particular were also touched upon, such as the poverty of the "New Orleans jazz musicians" in general and in particular after Hurricane Katrina. In New Orleans, for example, a clinic was set up by sponsors in which jazz musicians are treated free of charge, as they are generally not covered by health insurance due to poverty.

The science of musician's medicine is still very young and is characterized by the pioneering achievements of those involved. One has the feeling that a science with a lot of passion has emerged from the often individually justified interest of the participants and is continuing to develop. The work and research here is practice-oriented. Solutions are sought for artists so that they can pursue their profession in a better and healthier way. Due to the increasingly competitive music business, this research and its application in practice is absolutely essential. Our efforts to work in the field of musicians' medicine were confirmed. It was nice and motivating to see that there are colleagues all over the world who also represent our cause and are willing to enter into a collegial exchange in order to learn from and with each other. Many thanks to the SIS and to all our fellow campaigners with their great commitment to the SMM.

Martina Berchtold-Neumann

... is President of the SMM, qualified psychologist, Stein am Rhein

SMM - The symposium, which will be held this year at the Bern University of the Arts (HKB), will cover a wide range of health aspects. Even music lovers who are able to devote themselves to their hobby regardless of financial pressure face a variety of physical and psychological challenges: Even without aspiring to professional excellence, they are required to train their technique and expression wisely or to keep their body and mind fit for the sonorous art as they get older. However, amateurs often lack the time and energy that professionals are able to invest due to other professional pressures.

Andreas Cincera, Head of Continuing Education in Music at the HKB, wonders whether it makes a difference in good quality music lessons whether children, young people or adults are learning. What technical, physical, emotional and other challenges are more common among adults? How can these be mastered in an enjoyable and health-promoting way? And the Bremen psychologist and musician coach Andreas Burzik shows how practising in the flow as a practice method can combine the impartiality of the amateur with the extreme precision of the professional and thus meet the neurobiological requirements of an ideal learning environment.

FMH ORL specialist Salome Zwicky from the SingStimmZentrum Zurich discusses the factors that determine the quality of a voice - with the insight that voice disorders are not always the result of intensive use, nor do they always have to be caused by poor technique. Neurologist Jürg Kesselring, on the other hand, questions whether the distinction between professionals and amateurs is really sharp. He points out that, on the one hand, there are fully trained professional musicians who cannot make a living from their profession and therefore pursue other livelihoods, and on the other hand, there are amateurs who are not trained or only trained part-time and who earn their living through music. According to Kesselring, in music, as in many artistic professions, the educational requirements are not the only decisive factor for success and certainly not for the joy that arises from practicing music.

In three workshops at the symposium, Andreas Burzik, breathing, speech and voice teacher Nicole Martin Rieder and physiotherapists Marjan Steenbeek and Sibylle Meier Kronawitter will focus on breathing, practising in flow and correct posture when making music. Rieder will shed light on the systems and control loops through which breathing affects the voice, posture and the autonomic nervous system and will make the connections tangible with practical exercises on her own body. As part of a teaching demonstration, Burzik shows the four principles of practicing in flow: a special contact with the instrument, the development of a special sense of sound, the feeling of effortlessness in the body and the playful handling of the study material. Finally, Steenbeek and Meier Kronawitter discuss the anatomy of the different parts of the body and show how movements can be used to train their perception.

Sebastian Barth, Sebastian Kerber - Fortunately, awareness of musicians' illnesses has existed for many years. In particular, illnesses that restrict musicians in the performance of their instrument are recognized at an early stage and treated accordingly. These disorders include orthopaedic problems, neurological disorders, musician's dystonia and stage fright. Cardiovascular aspects, on the other hand, were ignored for a relatively long time.

Historically, famous musicians from different stylistic eras have suffered from a wide variety of illnesses. Cardiovascular diseases often played a role in this. Arnold Schönberg himself underwent resuscitation, which at the time was still successful thanks to a heroic injection directly into the heart. Thoracic pain is a common leading symptom of cardiovascular disease. For some time now, Tako Tsubo cardiomyopathy has been added as an important differential diagnosis. This is a stress-induced cardiac insufficiency which, in extreme cases, can lead to intensive medical treatment. This clinical picture can be triggered by excessive emotional and physical stress, particularly in exposed musicians. Post-menopausal women are particularly frequently affected (80 percent of patients), although the overall prognosis is good with a hospital mortality rate of 1 to 3 percent.

The "widespread disease" of high blood pressure plays a major role among active musicians. Numerous groups of musicians are exposed to significant increases in blood pressure, as rehearsals and performances are very stressful situations. Particularly excessive increases in blood pressure and heart rate have been documented in wind players.

Due to the progressive ageing of the Western world, the diagnosis and treatment of heart failure is becoming increasingly important. In addition to its prognostic significance, it leads to a considerable loss of quality of life, similar to depression or the need for dialysis. If left untreated, heart failure has a poor prognosis. Clarification of the underlying disease is essential to determine the therapeutic approach. The most common of these include coronary heart disease, valvular heart disease, high blood pressure, arrhythmia and myocarditis.

Depression is an important concomitant symptom of heart failure, although it is still unclear whether it is the result or cause of heart failure. In the case of a depressive mood, further diagnosis of underlying heart failure is therefore recommended.

Due to the further development of diagnostic and therapeutic procedures in invasive electrophysiology, this area of cardiology has gained enormously in importance for musicians. Cardiac arrhythmias are classified according to their place of origin (atrium or ventricle) and frequency (tachycardia or bradycardia). Atrial fibrillation, which is the most common arrhythmia, should be emphasized first and foremost. "Palpitations", "palpitations", fainting spells, dizziness or a feeling of warmth are frequently reported symptoms. In addition to taking a medical history, ECG documentation is of central importance in identifying the cardiac arrhythmia. The invasive electrophysiological examination also offers the advantage of ablating diagnosed cardiac arrhythmias in the same session and thus curing the patient. Differentiating somatic findings from psychological problems is often particularly difficult. It is not uncommon for outpatient diagnostics to be carried out "at the workplace" with the instrument on site in order to detect cardiovascular changes or cardiac arrhythmias on a situational basis.

Diagnostics and therapy will be successful if, in addition to broad internal medicine and cardiology training, there is a high degree of sensitivity to the specific professional situation of musicians and in-depth knowledge of the effects of the instrument.

Dr. med. Sebastian Barth, Senior Physician Cardiology, Cardiovascular Clinic Bad Neustadt

Prof. Dr. med. Sebastian Kerber, Chief Physician Cardiology I Cardiovascular Clinic Bad Neustadt

Hormones are biochemical messengers that are produced in special cells and transported via the blood. They have specific effects on various organs. During puberty, the larynx and vocal tract grow rapidly and are even more pronounced in boys under the influence of androgens (the male hormones) than in girls, in whom the "voice break" is usually not noticed.

Almost fifteen-year-old Mara has been taking singing lessons for more than a year. She is planning to take a music exam. For the past six months she has not been able to sing at all, her voice has become much deeper. The examination shows at most a slight reddening of the vocal folds. But Mara has not yet had a period, which suggests a hormonal problem. The hormone specialist also found a predominance of male hormones. Mara's voice has therefore broken to a certain extent, although her voice has not dropped by an octave as in boys, but it is lower than the voice of girls of the same age, which physiologically drops by about a third.

The hormonal disorder can be treated, but the voice will not become higher, the virilization of the larynx cannot be reversed. Mara will probably be able to regain access to her singing voice when her larynx gets used to the new situation, and speech therapy is initially indicated for this. However, it is uncertain what range of voice she will be able to sing in and whether she will be able to pass a music exam.

Fourteen-and-a-half-year-old Mike comes to see me because he had caught a cold two months previously and still hasn't found his singing voice again. He sings solo in an ensemble as a mezzo-soprano. He speaks with a somewhat unnaturally high, thin and brittle voice. The examination shows a larynx without irritation, but already significantly larger than that of a child.

What is the problem? Mike has actually already gone through the voice change, i.e. the hormonally stimulated growth of the larynx has taken place. However, due to the cultivation of high-pitched singing, he has also become stuck in a high-pitched voice when speaking. This is not a hormonal disorder, but a faulty adaptation to normal development. What now?

This voice pitch, which has not yet stabilized when the mutation has already largely occurred, is called cambiata. The boy's speaking voice must be lowered into the male register by an experienced speech therapist and stabilized there, because constantly speaking too high strains the voice and leads to vocal fatigue and hoarseness. For this reason, Mike's voice did not recover after the cold. Mike can still sing at a high pitch for the time being. The recording of a concert that Mike was able to sing again a few months later with his high voice sounds perfect.

If the voice remains high despite growth, this is referred to as a mutation disorder. In men, this pathological voice is highly conspicuous, but can be treated well with speech therapy. In girls with a mutation disorder, voice fatigue and hoarseness occur much later and the diagnosis is more difficult to make. Speech therapy is also the treatment of choice here.

Mutational disorders are fairly common. Genuine hormonally induced voice disorders, as described in Mara's case, are much rarer. If an adolescent does not or only partially reach the male vocal range, an examination by a phoniatrist is indicated. If a girl's voice drops noticeably, or if she can no longer sing at all without being under increased strain or having been prone to voice disorders in the past, then this should also be checked medically.

Imagine the audience naked. Nervous debutants have often been given advice like this in music training when they are struggling with performance anxiety. It usually works. Today, however, the strategies for combating performance anxiety are much more differentiated. Most of them use the same tactics: using humor to take some of the emotional sting out of meaningful tasks and tensions. The Munich pianist and music psychologist Adina Mornell explained a whole range of such approaches at the SMM symposium, which this year was dedicated to the topic of "Stress and music-making" and was once again extremely well attended with almost 200 participants. Turning seemingly unsolvable, daunting tasks into solvable and enjoyable ones seemed to be the basic pattern. According to Mornell, unclear goals should be replaced by clear sub-goals. Excessive self-demands, on the other hand, could be broken by "self-handicaps": Practicing extra less than possible, for example, is suitable for being able to say to yourself after mistakes that you could have done better if only...

Horst Hildebrandt from the Swiss University Center for Music Physiology put common stage fright myths into perspective. In training and counseling prospective professional musicians, he says, it has been the experience at music universities that a great deal of what students initially experience as fateful performance anxieties can be dealt with by the vast majority of them using suitable self-management tools. Only very few of those seeking advice actually need personal coaching or even therapy. According to Hildebrandt, it is helpful to realize that most of the symptoms of stage fright - sweating, palpitations, narrowing of the horizon and so on - are completely normal reactions to being on public display. In evolutionary terms, the latter is seen as a dangerous situation and the body is mobilized accordingly. The aim is therefore not to make such reactions disappear, but to develop techniques to avoid being hindered by them.

Two workshops offered practical strategies to combat anxiety, stress and overwork. SMM President Martina Berchtold-Neumann demonstrated hypnosis techniques and sent her audience on an inner journey - for what felt like five minutes, but was in fact twenty. And psychotherapist Ines Schweizer addressed the fear of fear, i.e. the stage fright that makes it destructive in the first place. If you realize that performance anxiety manifests itself on numerous levels - thoughts, feelings and the body - it becomes possible to use it productively.

In an extremely humorous contribution, cardiologist Sebastian Kerber pointed out that the focus with regard to musicians' illnesses is almost exclusively on the skeleton and the nervous system. The cardiovascular system is neglected. Music is literally also a "matter of the heart": the diagnosis of blood pressure and cardiac arrhythmia is therefore also part of the overall health care of musicians. Preventive measures can also be defined in this respect.

Finally, Zurich psychologist Victor Candia pointed out that we learn many movement patterns without realizing it. Many virtuoso skills, such as maintaining balance when walking, do not provoke any mental stress. This is quite different in the case of music-making, which we have to learn consciously and which is therefore a source of mental tension, which in turn causes physical stress. The symposium was once again excellently organized by SMM founder Pia Bucher and, as usual, expertly moderated by Ticino doctor Adrian Sury.

Making and listening to music are among the most important leisure activities. Musical activities are no longer limited to children and young people, but an increasing number of older adults want to learn an instrument for the first time. Their share has been stabilizing at around 10 percent of music school enrolments for many years.

Making music is one of the most demanding activities of the human central nervous system. The coordinated activation of numerous muscle groups must be performed with maximum temporal and spatial precision and often at very high speed. The movements are subject to constant control by the ear, the sense of sight and the body's own perception. In addition, memory systems and emotional networks are activated.

It is undisputed that making music promotes the development of the nervous system at all ages, even in old age. In older professional musicians, numerous adaptations are found that are signs of "brain plasticity": Broca's speech center in the left frontal brain region is enlarged - which is explainable, as musicians "speak" in sounds. The cerebellum, responsible for fine motor coordination, is larger, and the auditory cortex in the upper part of the temporal lobe also has a greater neuronal density. Exercise-dependent neuroplastic adaptations of the nerve fibers also affect other fiber structures in addition to the beam: the so-called pyramidal tract, which runs from the motor cortex to the motor nerve centers in the spinal cord, is more pronounced in pianists than in non-musical controls.

The influence of musical-sensomotor learning on the neuronal networks of the cerebral cortex was also demonstrated over ten years ago in older musical amateurs learning to play the piano. The temporal dynamics were surprising here: after just 20 minutes of practicing the piano, a functional coupling with simultaneous activation of the nerve cell networks in the auditory cortex and in the sensorimotor areas developed in adult beginners. This rapid change can only be explained by an increase in connectivity. After five weeks of training on the piano, these initially only temporary changes in neuronal networking were stable and there was an increase in neuronal exchange and neuronal conduction velocity between the auditory and motor regions. These changes can already be explained by increased labeling of the nerve fibers that connect auditory and movement processing. But does this also benefit general cognitive performance?

The most informative study to date, which used psychological methods to investigate the transfer of musical activity to other cognitive skills in older people, was conducted by Bugos and colleagues. The authors gave piano lessons to 16 senior citizens aged between 60 and 85 for six months and compared their cognitive performance with a control group of 15 subjects of the same age before and after six months of piano lessons. Three months after the end of the training, a final test of cognitive skills was carried out. The piano group had improved performance after the lessons, which included working memory and executive functions such as planning and strategizing. However, these improvements in performance were rather weak and in some cases were no longer detectable three months after the end of the lessons. Nevertheless, initial evidence of the above-mentioned changes through musical training has been obtained.

Today, health complaints can be assessed in interdisciplinary medical consultations or in the practices of the specialists involved. Their disorders and illnesses can thus be treated in a targeted manner. The latter can essentially be divided into musician-specific clinical pictures and generally common clinical pictures with particular significance for musicians.

Medical conditions are specific to musicians if the symptoms are directly related to making music. It is not uncommon for similar problems to be observed in members of other professions when similar ergonomic challenges and psychological circumstances are present.

The specialists strive for the most precise diagnosis possible. To this end, they propose the usual diagnostic and diagnostic-technical clarifications in their specialist field. Their expertise in music medicine allows them to analyze the predisposing and triggering factors and to develop a therapeutic concept. Unfortunately, symptoms are too often suppressed or concealed by those affected - sometimes for understandable reasons - or they are treated without diagnosis, sometimes with unsuitable means.

The intensity and timing of music-making often need to be adjusted. Ergonomic adjustments to the instrument are possible to a certain extent. There seem to be clear limits to workplace adaptations. There is hardly any other workplace in a production company where people work in such a confined space as in an orchestra. In no library do two readers share a book in the same way as two musicians share a music stand at an awkward distance. At least in the classical music business, there is a dress code, and no musician performs at his peak as lightly clothed as a long-distance runner, however much he may sweat.

A family doctor refers a 19-year-old flautist for pain in the flexor side of his right wrist and the extensor muscles of his right forearm. He plays the piano for 30 minutes and the flute for 3 to 4 hours a day - with one break. He has been experiencing the pain for three years. It mainly occurs on his second instrument, the piano. The pain, now also in his neck, had been alleviated two years previously with the help of craniosacral therapy. After the history has been taken, the flautist is physically examined and his playing of the flute is recorded with a video camera.

In a second session, the musician presents at the interdisciplinary musician's medical consultation. Muscular insufficiency in the area of the thoracic spine and an overuse syndrome of the right forearm muscles were diagnosed. A dynamic ultrasound examination rules out dynamic carpal tunnel syndrome - a position-dependent compression of the median nerve by muscles. The flautist receives recommendations regarding playing posture on the flute and for special coaching by a specialized therapist or teacher, as well as advice on the importance of planning breaks and the preventive effect of body-centered techniques. A musician's doctor prescribes active muscle-building physiotherapy to treat muscular insufficiency in the back and forearm muscles.

Muscular overload (overuse)

Tendon problems

Chronic myofascial pain

Nerve compression

Hypersensitivity of the fingertips

Focal dystonia

Skin irritations and allergies

Jaw joint and dental problems

Glaucoma

Inner ear dysfunction

Vocal cord disorders

In view of the enormous individuality of the human hand, with differences of over 9 cm in span widths 2-5 (between the index finger and little finger) and up to 7 cm in span widths 3-4 (between the middle finger and ring finger), an initial impression of the range and limits of a musician's hand can hardly be gained from a measurement accurate to the millimetre. Even the Pragmatic Hand Evaluation (PHE) by music physiology pioneer Christoph Wagner can help to track down the causes of excessive fatigue and overuse syndromes. The PHE, the "little sister" of the Biomechanical Hand Measurement (BHM) developed by Wagner and based at the Zurich Musician's Hand Center at the ZHdK since 2009, records hand size, all thumb and instep widths and ten other hand characteristics. Using the measurement sheets from Wagner's book Hand und Instrument, individual values are compared with those of professional musicians.

The individuality of the hand is contrasted with the standardized keyboard - and the dream of many pianists to also tap into those gems of piano literature whose technical requirements may exceed their own limits. For a 53-year-old piano teacher, playing on the modern grand piano was "always associated with cramp. What I always found difficult was playing chords." Her playing experience was completely different when she played the fortepiano for the first time at the age of 47: "I had the feeling that this was my instrument. I could play more fluently."

The hand profile of the technically accomplished pianist shows rather small thumb and inner spans despite rather large hands. The span 2-4 was clearly limited and she could only spread her right thumb to a maximum of 65 degrees. After the PHE, when the piano teacher once again traced difficult passages on the modern grand piano, she was amazed to discover: "There are actually all passages that require internal tension, which have always meant extra effort." An Allegro assai passage from Mendelssohn's Trio op. 49. "I've never really mastered it." - Presumably because of the almost simultaneously required fifth with index and ring fingers and seventh with index and little finger.

Looking back on her time as a student, the piano teacher sums up: "I was told that I had a big hand and fast fingers. If I had known that I had these ranges, I would have played completely different pieces, for example. I always thought I had to try harder. My teacher said to me: 'You just have to want to'." And she continues: "If I had realized this earlier, my approach to myself and my practice methods would have changed. As far as the pieces were concerned, I did orientate myself towards small-scale literature relatively soon after my studies, but always with a slight resentment towards myself for not having the 'right' technique to be able to play Chopin ballads or Brahms."

Several things become clear in these statements: the quite sensitive perception of one's own biomechanical limits already during one's studies, the trust in one's own perception that had been lost in the meantime, the teacher's lack of empathy, the orientation towards a repertoire standard and effort ..., the regained perception, already through the changed playing feeling on the fortepiano and further through the objective comparison - and the mental relief through the knowledge of the individual biomechanical conditions.

For those who are new or returning to music at an advanced age, the aim is to (re)discover music for themselves, sing, play or learn an instrument. They have the opportunity to join instrumental ensembles or a choir and deepen their knowledge of music theory or music history.

However, old age often no longer knows music because conditions change and make it more difficult to make music. However, making music should be possible at every stage of life in old age. This applies to mobile older people who can still easily attend music school or join a choir or ensemble. But it also applies to people with impaired health and possibly dementia, to whom music schools or freelance music teachers offer their services and also enter into cooperation with institutions for the elderly. Intergenerational musical activities are also often considered to be particularly successful, especially popular between grandchildren and grandparents.

Music schools should therefore give even more thought to how singing, making music and learning music can be successful in old age. The goal: a comprehensive and barrier-free offer in easily accessible and well-designed rooms for older people in a wide variety of life situations. It must be geared towards individual needs and possibilities - also financially and in terms of time - and create high-quality music.

Making music in old age can then mean filling free time in a meaningful way, experiencing self-efficacy, (continuing to) participate in public cultural life, maintaining social contacts and experiencing sociability. This also helps to prevent health problems and prepares people for everyday life in old age on various levels - cognitive, motor, emotional and social. Music in old age can also develop spiritual dimensions. Even in such a delicate area as end-of-life care, music can gently reach in and offer a protective cloak (pallium).

Music can also support caregiving. Many things are easier to handle when people sing or hum, simply mention songs and pieces of music or talk about music or past experiences in which music played a role.

Time and again, it has been observed that music has a calming effect on restlessness or challenging behavior. It is also extremely pleasant for the carers and the care institutions when the atmosphere within the care situation is significantly improved by the involvement of music. In this context, appropriate music can mean affection or, in the case of dementia, also have an identity-enhancing effect.

Music programs for older people should by no means be seen as an imposition of later musical education, but solely as an enabling didactic approach. It is about initiating aesthetic fields of experience in which older people can engage in self-determined musical activities, but also learn and educate themselves. Music education understood in this way will have to be oriented towards the needs, life stories and lifeworlds of those involved in dialogical processes and appreciative communication - including validation, for example in the case of dementia. The biographical dimension in particular plays a special role for older people due to their long life experience.

Music geragogy should not be confused with music therapy: There are certainly overlaps between the two, for example in terms of target groups, instruments and methods. But the objective is clearly different: Music education creates the conditions for musical learning, education and practice. But music education does not aim to provide therapy, which requires targeted anamnesis, diagnoses and standardized procedures. Of course, this does not exclude the possibility that many extra-musical and health-promoting transfers arise through musical activity and experience. In fact, such transfers are very welcome.

Further materials:

The cardiovascular system shows typical reactions when playing a wind instrument: Tone production and blowing pressure cause short-term physiological fluctuations in blood pressure, heart rate and heart rhythm. They vary depending on the instrument, pitch, dynamics, blowing technique and constitution. During performances, stress hormones can also lead to an increase in blood pressure and heart rate. Nevertheless, these are generally physiological reactions that are harmless in healthy people. In order to assess the stress and resilience during playing, the cardiological guidelines are followed. In addition, the individual reactions during music-making must be recorded. This is done by means of long-term measurement of ECG and blood pressure under practice, rehearsal and possibly performance conditions, sometimes also by means of ultrasound of the heart during playing. After cardiovascular diseases, reintegration with a gradual increase in the music-making load may be necessary.

Beta-receptor blockers can be used to reduce the vegetative symptoms that can be caused by the fear of performing. Musicians often resort to self-medication, even though these are prescription drugs that affect the cardiovascular system. They should be strongly advised to take beta-blockers only after consulting a doctor, especially if cardiovascular problems are involved. This ensures a sensibly coordinated therapy, and the numerous non-drug strategies for dealing with performance anxiety can also be worked out together.

According to current knowledge, respiratory diseases do not occur more frequently in wind players. The often postulated connection between the development of emphysema and oboe playing has also not been confirmed. However, the constellation of several risk factors (such as smoking and environmental influences) can lead to playing-related illnesses. In the case of childhood asthma, playing wind instruments often has a positive effect on lung function and the management of the disease. Today, it is therefore often seen as a valuable component in asthma therapy.

Hormonal and metabolic disorders are sometimes accompanied by functional impairments during music-making. Due to the extraordinary sensorimotor demands, musicians become aware of these disorders at an early stage. Thyroid dysfunctions in particular lead to complaints that are relevant to musicians' medicine, but are usually easy to treat. They can manifest themselves in a variety of symptoms, including in the area of the arms and hands or the singing voice. In principle, the treatment of musicians does not differ from that of other patients, but additional therapeutic measures such as physiotherapy or speech therapy may be necessary.

In wind players and singers, reflux with reflux of gastric juice into the oesophagus seems to occur more frequently. The mechanisms behind this are complex and have so far only been partially understood. It is known from sport that physical "endurance work" - which singers and wind instrument players also perform - plays a role in reflux. The symptoms are often exacerbated by increased breathing with deep inhalation and an abrupt or prolonged increase in pressure in the chest and abdomen. This kind of breathing effort is constantly required when singing and playing wind instruments. Reflux complaints require a differentiated musician-specific anamnesis and diagnosis. In the case of singers, this is carried out on an interdisciplinary basis by a gastrointestinal specialist and phoniatrist. They can prescribe medication to inhibit the release of stomach acid and recommend diets and behavioral measures.

We have been running half-day workshops on "Posture and movement on the instrument" for teachers at music schools for over a year now. They are divided into two thematic blocks: "Back and neck" and, building on this, "Shoulder girdle, arm and hand".

The workshops are geared towards the teachers' own well-being when making music and their teaching activities with pupils. The aim is to impart basic knowledge of anatomy and physiology as well as instrument-specific complaints. We also teach exercises for perception, strengthening and promoting coordination.

The theoretical principles of anatomy are best experienced when the respective body parts are felt and moved. A key experience for many is when they feel each other's shoulder blade movements, parts of the body that are often terra incognita in our perception. The in-depth study of the physiology of muscle function makes it clear how a muscle works, what fatigue means and why exercise breaks are worthwhile. Controversial questions are also discussed: Does good posture and movement replace muscle training? Should strength training be used to build up reserves in order to meet the challenges of making music?

The joint analysis of problems using video examples makes it clear that posture and movement are personal and deserve individual consideration. Despite all individuality, however, the teacher - apart from their musical abilities - always has a role model function in terms of posture and how they deal with their own body. As one music school director says: "You can recognize the teacher by the way the pupils play music".

The group work is consistently popular: teachers with similar instruments discuss pupils' posture problems and exchange information on possible assistance and tried-and-tested exercises.

The practical exercises for the different parts of the body literally loosen up the program. For example, the course shows the effects of a lack of tension in the erection of the back on the motor skills of the arms and hands. Various movements are used to show how the dynamic stability of the torso can be improved and how playing music can be made easier.

Ultimately, however, there is still the question of when a problem can no longer be tackled in the classroom alone. The authors encourage a dialog with the parents of those affected and with instrument making experts. However, persistent problems should definitely be assessed by specialists. They are no fun for children or professional musicians, nor do they enable them to reach musical heights. Making music with complaints is unnecessary!

The question of whether good posture and good movement are the basis for making music is the subject of lively discussion in every workshop until the coffee break. Is it important to straighten a child's overly flexible back on the cello chair? To what extent should making music simply be fun and at what age does a more serious professional career begin? Experts exchange views on these and other questions with professionals "at eye level" - provided they have straightened up correctly beforehand!

The hall at Bern University of the Arts on Papiermühlestrasse seems to be bursting at the seams. The topic is moving in many ways: making music in old age can be an opportunity for people to fill their twilight years (or even their late afternoons) with emotions and good experiences. However, for those who have made music all their lives and earned a living from it, it can also mean a painful process of letting go and winding down. The annual symposium of the Swiss Society for Music Medicine, which focuses on these aspects of the sonorous art, can report record attendance.

The Trio Poetico, three woodwind players who used to sit in the spotlight of the Tonhalle Orchestra, among others, set a confident sign in this respect right at the beginning, continuing to develop artistically at an excellent level after their retirement and discovering new repertoire, such as the fascinating music of the Brazilian "Messiaen" Heitor Villa-Lobos.

In their presentations, medical expert Maria Schuppert from the Center for Musicians' Health at the Detmold University of Music and Zurich neuropsychologist Lutz Jäncke confirmed that a lot has changed with regard to music-making in old age. Until not so long ago, the human ability to acquire new skills was underestimated until old age. However, not least the work of Jäncke and his colleagues on brain plasticity shows that even with white hair and average health, far more resources can be called up than was believed not so long ago. Even high-class expressive possibilities do not have to be sacrificed if one does not pay homage to an ideal of youthfulness, but rather understands the characteristics of one's own age as original peculiarities.

Of course, the senses deteriorate with age, the hearing, the eyes; the voice also changes. The male voice, for example, becomes higher, but loses volume due to physiological degradation processes, as Eberhard Seifert, Head of Phoniatrics at the University ENT Clinic of the Inselspital in Bern, points out. And while it used to be unthinkable to take part in an ensemble with a hearing aid, modern technology has made so much progress that it is still possible to sing in a choir or play in an orchestra even with the corresponding impairments, as master hearing acoustician Michael Stückelberger explains.

The increased confidence is also being felt by music schools, which are able to adapt to more and more music students in the third stage of life. In a workshop, musician and journalist Corinne Holtz, who also heads the CAS "Musical Learning in Old Age" at the Bern University of the Arts (HKB) and the Institute of Ageing at the Bern University of Applied Sciences, reports on a research project entitled "Mach dich schlau - Lern- und Lehrstrategien im Instrumentalunterricht 50plus". And choirmaster Karl Scheuber, who is getting on in years himself, will show how age-appropriate singing exercises and clever repertoire management can contribute to quality of life even in old age.

As Hans Hermann Wickel from the Department of Social Services at Münster University of Applied Sciences points out, there is now even a dedicated specialist field on the subject, music geragogy. Its aim is to optimize music offerings for the very elderly, people who may suffer from multi-morbidity or dementia, and to explore the possibilities in palliative care.

Conversations at the symposium's concluding aperitif showed that, in addition to experts, interested outsiders who were looking for opportunities for musical activity at an advanced stage of life also attended the event - an indication that a special contact point could meet a need.

Guttural singing is throat singing, which is formed with the pocket folds ("false vocal folds"). The pouch folds are two pairs of folds lying horizontally on top of each other in the larynx, directly above the actual vocal cords. They are normally used to hold your breath or clear your throat.

Throat singing is used in many cultures to extend the normal vocal range up or down an octave. The voice becomes rough and somewhat distorted due to the vibrations of the pocket folds and is reminiscent of the sound of a didgeridoo. A similar effect can be achieved by using the so-called straw bass register (also known as the pulse or snoring register), the lowest vocal register in which the vocal cords are so loose that the individual vibrations are perceived as a kind of rattling or individual pulses.

Guttural singing is also used in modern music, mainly in extreme metal. The vocal techniques are mainly referred to as "growling", "screaming" or "shouting", depending on the pitch and proportion of "voice", the ratio of vocal cords to vocal folds. In other words, pocket folds as well as vocal cords are usually used. Depending on whether the sound is produced during inhalation or exhalation, the term "inhale" or "exhale" screams are used. There are numerous other names and variants of guttural singing in metal.

Growling is reminiscent of the growling of an animal and is mainly used in death metal and grindcore. The proportion of vocal chords varies greatly, especially in grunting, the lowest variant, they are hardly ever used. Screaming is usually high-pitched, uses almost exclusively the folds of the throat and is mainly used in black metal. Shouting is preferred in thrash metal and hardcore and is characterized by a high proportion of vocal chords. With this form of guttural singing, the risk of damaging the voice is highest, as the vocal cords are heavily strained.

The high intensity and volume and the extreme pitches in this music genre can quickly lead to vocal overload, which can manifest itself in hoarseness - temporary or permanent -, a sore throat or, in the worst case, blood in the mouth. If this happens repeatedly, long-term damage to the vocal cords cannot be ruled out. It can lead to dysphonia or, in the worst case, even aphonia.

Metal singing is also susceptible to typical "singer's diseases". These include rhinitis (colds), pharyngitis (inflammation of the throat), laryngitis (inflammation of the larynx), tonsilitis (tonsillitis), tracheitis (inflammation of the windpipe), bronchitis, sinusitis (inflammation of the maxillary sinuses), nodules or oedema on the vocal cords and enlarged tonsils as a result of multiple tonsilitis. These conditions can affect the voice, even if they are not caused by incorrect use of the voice. It is therefore important to protect them until they are completely healed.

The big problem with the use of guttural singing techniques is that there is a lack of training and further education opportunities and a uniform theory, which is due to the fact that it is rarely used and is often not really recognized as an art form, but ridiculed as "noise". It is therefore advisable, even if you "only" want to growl or scream, to attend singing lessons to learn the basics of breathing and vocal technique. It is also advisable to follow the principles of vocal hygiene as a preventative measure, just as with classical singing or other professions that put a lot of strain on the voice. Even metal singers cannot do completely without vocal chords.