Peter Schönenberger - "God put the diagnosis before the treatment". Many a medical student hears this phrase from their instructors when they want to come up with a treatment for a symptom. Our advice center also occasionally has to respond to inquiries that directly ask for a specific treatment technique without any preliminary clarification having taken place. For example, in the sense of "I am suffering from pain; can you recommend a hand surgeon". This is not helped by the fact that many diagnoses are imprecise or inaccurate. Terms such as rheumatism, burnout and tendinitis are among them.

Basically, medical examinations for musicians also follow the same principles as all conventional medical examinations. Preliminary information is collected. Knowing of any other illnesses, the complaints that are relevant to music-making are specifically investigated. Information about the environment is important both for the search for the causes and for the planning of therapies. On the one hand, the physical examination collects general findings and - in the case of frequent complaints of the musculoskeletal system - necessarily assesses posture and function on the instrument. The clarification can take place in a musician's medical practice or a corresponding university contact point and can be supplemented by an interdisciplinary assessment.

The example of a young alto horn player is intended to illustrate what has been said. For didactic reasons, the description of the problem does not exactly match the actual medical history. The musician attends a secondary school and has been playing the alto horn since she was eight years old, currently in two formations. Following a fracture of a carpal bone in her left hand at the age of fifteen, pain remains in her left wrist. This was later joined by pain in her right wrist. She is right-handed and has to write a lot by hand at school. Neither after immobilization in a cast three years ago, nor later, did she ever receive physical or occupational therapy. The wrist pain becomes severe after an hour of playing music and forces her to change the support position of her left hand (photos). It also occurs on the right when writing. The young woman is exempt from all hand activities in school sports.

The musician attends the consultation of the Bern specialist group for musicians' health. Due to the evidence of wrist arthritis on the MRI, a rheumatologic evaluation is requested. Fortunately, an inflammatory rheumatologic disease can be ruled out. However, there is a clear general hypermobility of the joints, which is responsible for the irritation of the wrists. Due to the lack of muscle development after the accident, the loose joints and the freehand holding of the instrument weighing almost two kilograms, the muscles from the hand to the shoulder blades became tense and caused pain radiating into the hands (trigger point pain).

In several occupational therapy and physiotherapy sessions, which take place in the musician's region, the forearm muscles causing the pain can be relaxed and strengthened. In addition to dynamic stabilization of the lax joints with tapes, the young musician also receives instructions on how to take breaks during individual practice. Over time, she will be able to play with less pain for longer. The partial dispensation from school sports can soon be relaxed.

Dr. med. Peter Schönenberger

... is a FMH specialist in general internal and occupational medicine and Vice President SMM.

Martina Berchtold-Neumann - Unfortunately, pain is a very common topic in musician's medical consultations and is a leading symptom in the majority of musician-specific illnesses. A distinction must be made between acute and chronic pain. The IASP (International Association for the Study of Pain) describes the following differences: Acute pain has a warning and protective function. It is usually linked to recognizable triggers, is usually localized and can be described, and is accompanied by autonomic and endocrine activation and stress reactions. Chronic pain is defined as pain lasting three to six months or longer. It can occur both in connection with a persistent illness as well as detached from structural changes as an independent illness.

Chronic pain is increasingly shaping the way we live our lives. It is characterized by complex biological, psychological and social interactions. Acute pain usually triggers appropriate behaviors. Going to the doctor can ensure that someone takes care of this suffering. Chronic pain, on the other hand, loses its positive protective effect. Living with pain becomes the normal state with the risk of a resigned attitude to life. The treatment of chronic pain requires patience and perseverance as well as a multimodal and interdisciplinary approach.

There are two aspects to pain - on the one hand it is a sensory perception, on the other an affect. You cannot speak of pain without also addressing the adversity in it - it evokes the motivation to get rid of it as quickly as possible. Moreover, pain is a tyrant. Usually without much notice, it breaks into our lives and makes its presence felt. From this moment on, it occupies our existence. It takes us captive.

Epidemiological studies reveal a fairly consistent picture: 40 to 60 percent of orchestra members and instrumental teachers at music schools suffer from back pain that interferes with the practice of music. But even students suffer from physical complaints. It can be assumed that at least 45 percent of them visit a consultation due to music-specific health problems.

The therapy of pain

Physical and psychological dysfunctions interact in the development and chronification of pain. Pain makes the limits of performance visible. If one's own body was previously instrumentalized in order to be able to make music - often against obvious physical warning signals - it now takes center stage itself and demands "its right". Musicians must therefore engage in self-reflection and critically question their practice, behavior, habits and obligations. These include questions about the self-concept, performance orientation and attitude towards the music profession. While temporary abstinence or a reduction in instrumental playing can be successful in the case of acute pain, chronic pain requires a much more fundamental rethink of the entire concept of life. This can usually only be achieved with the support of specialists from the fields of medicine, psychology, physiotherapy and other therapeutic disciplines.

The Swiss Society for Music Medicine (SMM) has such a pool of specialists throughout Switzerland who can be consulted depending on the individual problem. This year's symposium "Warning Signal Pain" in Lucerne will also provide an insight into the topic. The most important current views and experiences, including those from our musician consultations, will be presented and discussed here.

Martina Berchtold-Neumann

... is a qualified psychologist FSP and President SMM

This year, the symposium of the SMM will be dedicated to " la douleur comme signal d'alarme ". It will take place on October 27 in Lucerne.

> www.musik-medizin.ch

Karoline Renner, Sieglinde Fritzsche, Susanne Schlegel* - - Music physiology training at German conservatoires has improved significantly - both in terms of quality and quantity. As a result, orchestras have also become more aware of the need to take responsibility for their own health care. At the Südwestdeutsche Philharmonie Konstanz, for example, a cycle of health-promoting activities has been developed over two seasons since 2016. These "health days" are divided into lectures, workshops and consultation hours. The conceptual arc of the event cycle ranges from the "tangible" physical stresses to the "subtle" psychological content. Health days do not offer blanket solutions, they can only provide impulses and make possible paths tangible, which the individual musician can use individually and on their own responsibility.

Orchestra musicians are subject to strict hierarchies during their work. A clear regulation of communication forms proves to be very useful during artistic work. However, it is superfluous or even harmful to carry hierarchical thinking and learned speechlessness into the rest of everyday working life. Frustration and feelings of powerlessness build up, real opportunities to exert influence are overlooked and misunderstandings remain unresolved.

In Constance, attempts are being made to change such communication patterns. For example, there is a model of active feedback from the musicians at the regular conducting courses for young conductors. The aim is to make these projects known in other orchestras and to hold health days once a year if possible.

Other orchestras have entered into partnerships with medical facilities or music-medical institutes and are supported by them as part of a complex health management program. Not all orchestras attach the same importance to this. Different financial and time resources play a role here.

Eleven years ago, the German Orchestra Association (DOV), the professional association of professional orchestras and radio choirs, formed the Health and Prophylaxis Working Group (WG). Its members are active members from various professional orchestras and radio choirs. With staff and logistical support from the DOV office, they are involved in the comprehensive and complex field of musicians' health. They promote developments and make musicians' medical knowledge and new prevention options accessible.

The direct work of the working group in the orchestras can currently be seen in the "Willibert Steffens soundproofing project". The DOV provides sound insulation walls specially developed for orchestral use for loan to the orchestras. The project is combined with personal advice from one or two members of the working group in order to pass on the necessary knowledge and existing experience and to get to know the working environment of the respective orchestras. A long-term vision is a network of health officers in the individual orchestras who work closely with the working group to promote the health of their colleagues.

*Karoline Renner and Susanne Schlegel are members of the Südwestdeutsche Philharmonie, Sieglinde Fritzsche is a member of the Mecklenburgische Staatskapelle Schwerin.

Horst Hildebrandt, Oliver Margulies, Marta Nemcova - If you examine the sources on the centuries-old traditions of violin pedagogy as well as the musicological contributions of recent decades, you will discover the following: There are often only imprecise or contradictory recommendations on individually suitable instrument positions or ergonomic aids (for example chinrests, cushions and shoulder rests).

The existing recommendations could be influenced, among other things, by the individual anatomical requirements of the school founders who formulated the recommendations. It was not until the 1970s that the enormous range of individual anatomical characteristics that are experienced as facilitating or limiting on musical instruments was systematically researched. In 2009, the handbook that was instrumental in this research was handed over to the Zurich University of the Arts by its founder Christoph Wagner and further expanded by the team of authors of this article (www.zzm.ch).

In view of the worrying number of complaints among high string players and the increasing demand for music physiology support for everyday teaching, a research project recently completed at the Zurich University of the Arts and funded by the Swiss National Science Foundation, the Ernst Göhner Foundation and the Swiss University Center for Music Physiology (www.shzm.ch) has produced the first scientifically sound results on individually suitable violin positions.

Other cooperation partners were Barbara Köhler (Zurich University of Applied Sciences) and Matthias Nübling (Gesellschaft für Empirische Beratung).

The cross-sectional study Objective Criteria for the Individual Selection of a Physiologically Advantageous Violin Position investigated over a period of several years how instrument position, muscle tension and the feeling of exertion in the left arm are related. Data was also collected on individual biomechanical and muscular hand and arm characteristics.

A preliminary study at the Musikschule Konservatorium Zürich with 24 students of different playing and age levels laid the foundation for the subsequent data collection under laboratory conditions with 15 violinists playing a given tone sequence in four standardized violin positions. In addition, comparative data was collected when playing with the usual position and ergonomic set-up. The standardized violin positions were tested without chin rest and shoulder rest in order to enable an objective, comparative analysis and to be able to incorporate playing traditions of historical performance practice.

Initial evaluations of the various phases of the research project show that clear differences can be measured between the various instrument positions in terms of objective muscle activity and subjective feeling of exertion across genders.

Based on the results of the study, a laboratory-independent test procedure was also developed for everyday teaching at all training levels. This procedure has already been presented at a workshop for the European String Teachers' Association ESTA. The results and test procedures presented make it possible to make physiologically sound recommendations regarding ergonomic optimization for playing high string instruments in everyday professional life. They also facilitate the prevention and treatment of activity-specific health problems.

Inspired by the results obtained, a chinrest model was developed in collaboration with the Wittner company under the name of Zurich which, thanks to various height and angle settings, allows adaptation to individual needs and different head positions, even while playing, in order to prevent fatigue. (www.wittner-gmbh.de/neuheiten.html)

SMM - In recent decades, musicians have come to realize that self-help concepts are of great importance in both professional and amateur circles. As Horst Hildebrandt, Head of Music Physiology at Zurich University of the Arts (ZHdK), will explain at the symposium, this applies both to common musculo-fascial complaints and to psychosomatic stress situations. According to Hildebrandt, the activation of individual psychophysical resources is playing an increasingly important role in promoting health and dealing constructively with job-specific stress.

Markus Weber, Head of the Muscle Center/ALS Clinic at St. Gallen Cantonal Hospital, will talk about the highly complex neuronal processes involved in making music and their disruptive factors. These include impairments of concentration, attention and memory as well as chronobiological aspects (working hours), pharmacological influences (medication) and psychosocial stress.

Maja Storch, Director of the Zurich Institute for Self-Management and Motivation (ISMZ), will show how an innovative form of goal formulation helps people to act more and more often in the way they would like to: so-called motto goals are an element of the Zurich Resource Model (ZRM), a self-management training program that systematically involves the unconscious. It succeeds in addressing the unconscious directly and feeding the intention to act into it.

In a fourth lecture, mental coach Reinhold Bartl - he is head of the Milton Erickson Institute Innsbruck - will present hypno-systemic concepts, training tools for "developing your own coherence in demanding professional contexts".

Two workshops round off the program: Reinhold Bartl will show how musicians can deal with irritations (discords) in their professional development in a meaningful way, both in individual situations and with a view to "form crises" in everyday life, during practice, rehearsals and concerts. Finally, Berlin doctor Giovanna Eilers will provide insights into the practical application of the CRM self-management method to complement Maja Storch's presentation. Anyone who wants to can try this out for themselves in the workshop for their own topic.

The one-day symposium, which runs from 10 a.m. to 5 p.m., will be chaired and moderated by SMM President Martina Berchtold-Neumann.

More information and a registration form can be found on the web at:

> www.musik-medizin.ch/aktuelles-symposium

Andreas Burzik -Practicing in the flow is a method that aims to lead musicians into a state of deep fusion with what they are doing when practicing an instrument. It enables the experience that conscious, deliberate control of the practicing process can be abandoned in favour of a process that unfolds from within and is guided by sensory perception. Basis of the Practicing in the flow is a highly refined perception in the key sensory channels, the sense of touch, hearing and kinaesthetic sense of movement.

The sense of touch, for example, is about the points at which a player has direct contact with their instrument. Optimal and effective power transmission to the instrument is expressed in the feeling of a "rich" connection to the body of sound. Listening is about developing a subtle sense of sound. Basically, the sound quality produced when practicing should please the player. This sounds like a banality. However, if you observe musicians practising, you will notice that their attention is often caught up in other aspects and that the beauty of the sound does not constantly play an important role. (For intonating instruments, it is then a matter of sensitizing oneself to an intonation organized by the overtones, which leads to a fusion of sounds and an extremely satisfying "passing on" of the sound from note to note).

In the case of intonating instruments, a sensitization to intonation organized by the overtones is then important. This leads to a fusion of sounds and an extremely satisfying "passing on" of the sound from tone to tone.

The kinaesthetic feeling of movement is about the quality of effortlessness. What is meant here is not complete relaxation or limpness, but a physical feeling of not straining, light, flowing action, a feeling of swinging. Surprisingly, many instrumental methods lack a consistent and subtle involvement of the whole body in one's own playing. Many musicians play their instrument using only their arms, a form of movement that never occurs in everyday life. It leads to muscular tension and is probably the cause of numerous musical illnesses. Needless to say, a "paralyzed" body also costs sound. Musicians who resonate produce significantly more overtones and a wonderful, "full-bodied" and sustainable sound.

Once these "guiding feelings" have been established in the decisive sensory channels at the beginning of a practice sequence, the student can begin to work on the current literature. The first steps in approaching a piece then consist of inviting the sounds of this piece into your "comfort zone", so to speak; they consist of a playful and consistently musically designed exploration and cultivation of the sounds of the piece and the sensations experienced, without paying attention to note values, ties, phrasing, tempi, dynamics or interpretations.

With growing confidence in listening to and feeling the piece, a clearly perceptible will to approach the desired concert version emerges, to try out the ties, tempi, dynamics and different interpretative versions. The personal comfort zone begins to expand, it starts to pulsate. The result is a flowing back and forth between risky excursions and a retreat and playful "recreation" of processes in which disturbances in contact with the instrument or the sound were perceived. In this way, the comfort zone expands pulsatingly until, in the best case, it encompasses the desired concert version.

Practicing in the flow does not feel like "practicing". It is rather a highly concentrated and highly committed performance of the piece, which is based on an extremely short feedback loop between sensory perception and creative action and requires no mental interference. Trustingly and patiently surrendering to this process, which is controlled from within, is one of the mental challenges of Practicing in the flow.

Andreas Burzik

... is a qualified psychologist and trained violinist. In addition to his international teaching and seminar activities, he works as a psychotherapist and coach in his own practice. 2007-2016 Mental coach of the Orchestra Academy of the Bavarian Radio Symphony Orchestra, Munich.

More information at

> www.flowskills.com

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