From the Editor

Fatigue, Performance, and Overtraining

A lmost by definition, the perform-

ance of dance, music, or any other
performing art involves physical exer-
the second performance and highest
during the third, even though all of the
physiologic indicators of exertion
uncommon for instrumentalists (espe-
cially pianists and string players) to tell
me that they practice for 2 hours before
tion of some type and some degree. In increased steadily from rest through the taking a break. How much benefit are
most performances, the amount of three performances. The authors attrib- they really getting after the first half
energy expended appears to be substan- ute the increase in errors to fatigue, but hour? How much faster might they
tially higher than the resting state but some caution is warranted in drawing improve, and how many fewer injuries
significantly lower than many athletic this conclusion. Without the individual might they incur, if they were to take
events that last about the same amount data correlating the indictors of exertion more frequent breaks?
of time. Performing artists and per- with error rates, it’s hard to know how
forming arts medicine specialists have
long been interested in the interactions
between physical exertion and the qual-
strong the association between fatigue
and error is. While Drinkwater and
Klopper collected data showing that the
T he preliminary findings in the
Drinkwater and Klopper study
also raise the question of whether
ity of the artistic effort. Does some performers’ anxiety levels decreased instrumentalists might be suffering
amount of physical activity actually during the course of the three rendi- from “overtraining syndrome.” If play-
improve performance through a “warm tions, it is possible that the musicians ing a wind instrument for 30 minutes
up” effect? At what point does the were bored by the third performance. once causes measurable fatigue, it is
amount of physical activity expended Future studies with more participants possible that playing an instrument for
start to cause lower quality of the per- and different instruments will improve 30 hours/week over many months may,
formance? What role does mental our understanding of the effects of in some individuals, lead to cumulative
versus physical fatigue play? The article fatigue on the quality of performance. damage that results in both physical
by Drinkwater and Klopper1 in this If it turns out to be true that playing and mental health problems.
issue of the journal provides new infor- a musical instrument for 30 minutes is Overtraining syndrome is defined as
mation on how fatigue during a per- fatiguing and that fatigue causes a “a prolonged maladaptation (to physical
formance may affect the quality of the higher error rate, we should be able to exercise) of multifactorial origin,”3 typi-
music produced. design interventions that could cally in athletes who are training at an
It is worth reviewing how Drinkwater improve the quality of performance. It intense level. A recent study of college
and Klopper designed their study so is possible that instrumentalists should athletes in the US showed that 50%
that we can draw appropriate conclu- be doing more aerobic exercise, not reported chronic injury, with over 30%
sions from the data. They studied a con- only for the physical and mental health of men and over 25% of women feeling
venience sample of 10 wind instrumen- benefits but to be better musicians. physically exhausted frequently during
talists (six woodwind, four brass) with a While we don’t have a lot of data on their competition season.4 Women
wide range of playing experience and the aerobic exercise habits and fitness were more likely to suffer from chronic
age. We do not know the gender mix or levels of musicians, aerobic training has injury, whereas men were more likely to
baseline fitness of the study participants. not been widely recommended for or have acute injuries, and training inten-
Each of them played a self-selected piece practiced by musicians. I am not aware sity levels correlated with exhaustion.4
of music that lasted 10 minutes, then of any studies that have used aerobic These student-athletes were averaging 2
rested for 3 minutes, played the same exercise as a means of preventing to 3 hours of moderate to high-intensity
piece again, rested for 3 minutes again, injuries or improving performance. Dr. training per day, 4 to 5 days/week year
and then played the piece for a third Brandfonbrener’s study of orchestral round in addition to lighter training
time. Various physiologic parameters musicians2 used strengthening and and leisure physical activity.4 Abnor-
were measured at rest and after each 10- flexibility exercises. malities of hormone levels (e.g., corti-
minute performance, and self-ratings of Such a finding could also lead to a sol) have been described in athletes
perceived exertion and anxiety were change in practice schedules, since with this condition.3
recorded. The performances were then many wind, string, and keyboard musi- How might overtraining syndrome
analyzed for errors. cians currently practice for much more apply to instrumentalists? Many univer-
In a nutshell, the data showed that than 30 minutes continuously without sity and professional musicians “train”
the number of errors was lowest during so much as a 3-minute break. It is not (practice and rehearse) at least as many

June 2010 47
hours per day as the student-athletes familiar to experienced performing arts undertaking. Even if we don’t find a
mentioned above. Chronic injury rates medicine professionals: the violinist direct explanation, there’s a good
for orchestral musicians in the ICSOM who was doing well until the end of a chance that we will make other discov-
study5 were similar to the 50% point relationship, when left arm discomfort eries that will improve our understand-
prevalence rate for university athletes,4 developed; the pianist who struggled ing of this puzzling clinical scenario. At
and two studies on instrumentalists with hand symptoms after the death of the same time, we should do similar
have reported that about 15% of those a parent; the flutist whose neck pain studies in dancers and other perform-
with a performance-related muscu- became unmanageable coincident with ing artists with chronic performance-
loskeletal disorder still had persistent the arrival of a new conductor. related pain.
symptoms 1 year after initial presenta-
tion.6,7 It is well accepted that female
instrumentalists have a higher injury
rate than do male instrumentalists, even
B oth performing artists and perform-
ing arts medicine professionals have
to choose among competing priorities
RALPH A. MANCHESTER, MD
Rochester, New York
[email protected]
after controlling for instrument,8 con- when deciding on preventive and thera-
cordant with the higher chronic injury peutic strategies, and we are often 1. Drinkwater EJ, Klopper CJ. Quantifying the
rate in the female student-athletes.4 making these decisions with a dearth of physical demands of a musical performance
and their effects on performance quality.
The full spectrum of symptoms high-quality scientific evidence to guide Med Probl Perform Art 2010;25:66–71.
affecting athletes with overtraining syn- us. We don’t have randomized con- 2. Brandfonbrener AG. Report on a multi-
drome includes not only the physical trolled trials of intensive vs moderate orchestra injury prevention program. Pre-
sented at the 10th Annual Symposium on
but also the mental/emotional.3 practice loads or constant vs periodized Medical Problems of Musicians and
Anyone who has seen musicians with schedules,9 and we probably won’t in the Dancers, Aspen, CO, June 1992, pp 2-5.
more chronic “overuse syndrome” foreseeable future. Lacking those, it may 3. Roose J, deVries WR, Schmikli SL, et al.
Evaluation and opportunities in overtrain-
symptoms has observed the same phe- be useful to look at the conclusions of a ing approaches. Res Q Exerc Sport 2009;
nomenon: in addition to a combina- paper written by several physicians and 80(4):756–764.
tion of specific and ill-defined somatic scientists on the prevention of physical 4. Vetter RE, Symonds ML. Correlations
between injury, training intensity, and phys-
complaints, the patient often describes training-related injuries.10 They used a ical and mental exhaustion among college
symptoms consistent with depression multistep process to review 40 preven- athletes. J Strength Condition Res 2010;
and other affective disorders. The latter tion strategies that had been studied and 24(3):587–596.
5. Fishbein M, Middlestadt SE, Ottati V, et al.
are frequently thought to be secondary published in peer-reviewed journals. In Medical problems among ICSOM musi-
to not being able to play their instru- addition to education, leader support, cians: overview of a national survey. Med
ment and advance their career, but surveillance and research, the first rec- Probl Perform Art 1988; 3:1–8.
6. Knishkowy B, Lederman RJ. Instrumental
they may be a more intrinsic part of an ommended intervention was overtrain- musicians with upper extremity disorders: a
overtraining syndrome. ing prevention. While the overlap follow-up study. Med Probl Perform Art
One of the interesting aspects of between the physical training that is 1986; 1:85–89.
7. Manchester RA, Lustik S. The short-term
overtraining syndrome is that the com- done by army recruits and the musical outcome of hand problems in music stu-
plexity of its effects (i.e., the symptoms training that instrumentalists do is far dents. Med Probl Perform Art 1989; 4:
and objective abnormalities) is probably from complete, it is worth some thought. 95–96.
8. Manchester RA, Flieder D. Further observa-
mirrored by the multiple factors that While it may be shown in the future tions on the epidemiology of hand injuries
contribute to its evolution. While one that musicians with chronic perform- in music students. Med Probl Perform Art
theory is that overtraining syndrome is ance-related pain have a totally differ- 1991; 6:11–14.
9. Manchester RA. Periodization for perform-
caused by excessive physical training, an ent set of physiologic aberrations than ing artists? Med Probl Perform Art 2008;
alternative theory holds that it results do athletes with overtraining syn- 23:45–46.
from the combination of several factors, drome, the process of looking for the 10. Bullock SH, Jones BH, Gilchrist J, Marshall
SW. Prevention of physical training-related
including both training and nontrain- markers of overtraining syndrome in injuries. Am J Prev Med 2010; 38(1S):S156–
ing related events.3 This, too, will sound musicians will probably be a fruitful S181.

CALL FOR PAPERS:

Hearing Protection at Schools of Music
Papers presenting data on the state of hearing protection at music schools, as
well as descriptions of hearing protection programs that have been imple-
mented, are invited for consideration in MPPA. For information or to submit
papers, please email the Editor at [email protected].

48 Medical Problems of Performing Artists