Welcome, my name is Jordan Burkhart. I am the Director of Member Engagement for AAPMNR. I have a few housekeeping notes to share before we get started with today's session. The views expressed during the session are those of individual presenters and participants and do not necessarily reflect the positions of AAPMNR. AAPMNR is committed to maintaining a respectful, inclusive and safe environment in accordance with our code of conduct and anti-harassment policy available at aapmr.org. All participants are expected to engage professionally and constructively. This activity is being recorded and will be made available in the Academy's online learning portal. An email will also be sent after this activity with a link to bring you to the recording and evaluation. For the best attendee experience during this activity, please mute your microphone when you're not speaking and to ask a question, please use the raise your hand feature and unmute yourself if you're called on or you can use the chat feature to type your question, but please note that time may not permit every, the panel to feel every question. And with that, I am going to turn it over to Dr. McKay to begin this session. Thanks, Jordan. Hello, good evening, everyone. Welcome to the Performing Arts Medicine Community's Member May presentation. We've got a really exciting event presentation for you tonight. We have a collection of residents and attendings who are going to share their expertise with you. We're going to cover the injury, the common injuries and treatment plan for singers, dancers, musicians. And our hope is that for those who are new to the field, we can introduce you to how wonderful it is and how you can incorporate it into your day-to-day practice, whether or not you actually treat performers on a regular basis. Everybody is going to be presenting for about 15 minutes or so. I'll introduce everyone before they come up and we will have some time, we have some time set aside for you at the end if you'd like to ask any questions or just kind of get to know everybody in this community here. So let's start. First up, we have Dr. Kevin DeJesus. He is a PGY-3 at the University of Puerto Rico presenting on musicians. Good night, everyone. I'm going to do the classic, can you see my screen? Yes, we can. Perfect. Well, I'll begin with the challenge of doing the iceberg. I'm going to be the first one to present. We have a great group of people tonight and I want to thank Dr. Marquette for inviting me today. Like she said, I'm a PGY-3 at the University of Puerto Rico. I also have a certification in performing arts medicine for the Performing Arts Medicine Association. And I'm finishing my first year as a master's student in performing arts medicine for the University College of London. I'm actually here right now, it's 12 a.m. So I'm excited to be talking about this this whole week. So I'm going to be presenting a little bit about musicians and we are an interesting breed. I wanted to share a little bit of how we can be fun and awesome and be predisposed to some injury. If I'm a bassist myself, this is an interesting topic for me. Why do we care? Why does it matter? Musicians have a high prevalence of MSK injuries and performing arts in general share some knowledge and interventions in some of the concepts with occupational medicine and sports medicine. So there is something that we can do in there as a physiatrist. So I think it's something important that we can talk about. So we're going to be talking about common performance related injuries in musicians. We're going to be talking about normal concepts and concepts that you know, just apply to musicians. We're going to discuss some approaches and management principles in musicians. And hopefully we can highlight some of the role of how I can physiatrists can come into the care of musicians as well. Something important, there was a survey done by our sister association, the Performing Arts Medicine Association in 2018 about how providers can address musicians' health. And we can be all over the spectrum from prevention treatment, helping the longevity of musicians. Musicians tend to play onto the lake forever, basically throughout their whole life. So how do we care for the musicians along their careers? That is something important that we can do. Mental health, we can also provide some support in there. And definitely there's a lot of room for research. That is something that we're hoping to expand the field on that end. I wanted to show some misconceptions that there is among musicians. A lot of teachers and people, they tend to promote the idea that we need to have pain for us to be playing or to play at a good level, which is not necessarily true. That musicians can do with strength training, but for some reason that's a misconception that's out there. But the biggest one is that some of the doctors that musicians go to see, they're not helpful. And they tell musicians to stop playing, to take some ibuprofen and all that stuff. Sadly, I had the experience one time of seeing one doctor ask a saxophone player if they could just change hands. So not necessarily the best advice that we can give us, caretakers for this group of people. So hopefully we can take something from here and be mindful about the advice that we're giving this group of people that come for us for advice. So MSK injuries, they're pretty high, more than half of musicians at some point in their career have some MSK or performance-related concern or pain. Most of the time in their upper extremities, obviously that's the most that they're using most of the time. And we see a higher incidence in professional musicians probably because most of the injuries that we see are overuse injuries. So throughout their time, they go accumulating some of the changes that we're gonna see in the pathologies that we'll see in comparison with amateur musicians. So these acute injuries tend to get chronic and in some aspects, it gets to the inability to perform some addictive performance, suffer from this. So that is what we know at this point. We also know that there's a lot of hours of exposure from practice. You practice, in average, musicians practice five to seven hours, and then they're performing the weekend, so they're in constant exposure to this type of injuries. As well, some instruments are more prone to some injuries, depending on the biomechanics, how physiologically the body's moving. So some musicians are gonna tend to have some of the injuries that we're gonna be talking about, which are cervical spine, shoulder, and then other instruments, depending on how they're moving. So the most common areas, it's the cervical spine, shoulder, the wrist and the hands, obviously those are the areas that are most more used by musicians. And the top two definitely are the violin and the piano. One factor can be that there's more stress with these instruments. They're classically trained. There's more stress to be a good performer and a good soloist and all that stuff, but also some of the positions that they use can make them prone to some types of injuries. As for the violin, and as well for the viola, you tend to lateral bend your head. You get some tightness on your neck muscles and your upper back. So you get some of upper back cross syndrome. So you can get some tightness in some areas. And with the piano, you can have certain movements of the wrist and positioning of the wrist and the fingers that can predispose to some injuries and some pain while you're playing. The cello is also a highly prone instrument, specifically because, as you can see in here, let me see if I can see it real quick. Yeah, we can see here in the back, you're not sitting completely behind in the chair. You're sitting in the front, so you need to have good stability. And also the neck, if you're not aware of your position, you can get a little bit of flexion of your cervical spine. And if you don't relax your hand, you can get some pain in there too. And guitarists, you see that they have this footstand. Not everyone uses that actually in the real world. So sometimes the position of the guitar and how they're holding and the engagement that they use with their back predisposes. Some of the early injuries that we can see with musicians, obviously pain, something painful is not okay. So that is something that we need to look into. Some neuropathic manifestations of something else that is happening could be weakness, some specific muscles, burning sensation, tingling in specific areas that we can think about. Some nerve compression along the upper extremity or even the cervical spine. So that is something that we need to think about all the time. And also about numbness. Carpal tunnel is something very common that we need to be thinking about too. If we see some changes that indicate some inflammation, that is something that we need to be looking forward to. If there's some bursitis or something else or something rheumatological, that's important. If there's a lump or something that is not supposed to be there, that is something we need to be looking out for. And specifically if there's uncontrolled movement of the hand, something that is not the usual way that a muscle should be moving, that is something that we need to address too. So aside from the usual history that we take, I wanted to bring this. I think this is important because this is the piece of information that it's gonna get you the information that you need as a physiatrist, as a caretaker for this group of people. And these are the key elements in the history that is gonna give you more information. First of all, what instrument are they playing? For how long have they been playing that instrument? Have they have any recent changes in their instrument? Maybe some equipment that they're using that is different. Maybe they're dedicating more time to their instrument. Are they playing a secondary instrument? So that is something important to address, something important to ask. Are they practicing a little bit more? How many hours do they spend practicing during a day and during the week? What is their routine? Are they using any warmups, cool downs? Are they resting? Sometimes they just go into it and they just start playing and they don't take attention to this. Any changes in technique that they are using? Are they having more frequent lessons? Or if they're a teacher, are they giving more lessons than before? Do they have more students? Definitely that is more exposure time for these musicians. Are they practicing for their, some important performance that is coming up and they are ranking more time with their instruments? The conditions of the performance, the location where they're performing is something important to address as well. Are they practicing a new repertoire? Is it faster or more difficult? You need to adjust your hand in a different way or like putting more stress in the hand is something important as well. And just go through the basics and explore their symptoms and how that is affecting their performance. So these are just the basics. We have some system that we can grade the severity of injury or the pain that they're experiencing. Is the pain only while they're playing? Well, that is something that maybe is something more acute that is not affecting their playing. But is that pain persisting after they're playing? Is it not going away between practice time and between sessions? Or is it just a little bit of a pain and between sessions? Or is that pain just there all the time? It gives you a good idea if this is something mild or more severe, if there's something acute or something fine that is happening. So this is a good grading system that you can use in your practice just to get a pretty good sense of what's happening. So some of the common stuff that we see in musicians, this is not something obscure or something different from what we normally see in some other patients, but we see a lot of MSK growth and some overuse, right? We tend to do a lot of preparative movements with your shoulder, with your hands, with your elbow. So that is something that's going to get affected and we're just going to wear and tear at different joints in the upper extremity a little bit more. So that predisposes to overuse injuries, osteoarthritis. Some musicians present with dystonia, musician dystonia, or musicians cramps. There's several names to it, but that is something that we see in the clinic with these patients. And obviously we're thinking about nerve entrapment. Musicians and performers as a group, they sometimes present with hypermobility and some of them with tricycle syndrome. So before we dive into the diagnosis and the conditions that musicians present, I just wanted to present an overall of the management alternatives that we have for this group of people. We can perform just a relative rest from the activity that they're performing. Do we need to adjust the technique of their instrument that they're playing? That's something we're going to be working with their coach or their teacher. Medications that we can use for pain relief. Do we need to refer them for therapy? That is an important assessment that we need to do. Do they need to be more relaxed and more aware of their bodies? That is something as well that we need to do. That interface between the musician and their instrument, is there some modification that we need to do? And some interventional modalities that we can use as injections and obviously emotional support because most of the time, this is what they have for financial support. So if they're not playing, they're not getting any money. So that's a cause of stress that this group of people have. As I said, overuse injuries are the most common. Here we have from the shoulder to the elbow to the hand. We're going to have several pathologies at the level of the shoulder and those include impingement, pussitis of the subarachnoid, subdental bursa, tendonitis, and we're going to go into this a little bit more. Impingement syndrome would be overuse of the vertebral cuff muscles. They can become a little bit weak. You tend to depress a little bit the humeral head. So you cast compression below the acromion. So you can have the supraspinatus and a little bit pinch in there. So that is something that we're going to see. The common examination that you can do is just see the arc in the original motion of the shoulder in a scapular plane, a little bit more abducted and then see the original motion causing some level of impingement while in the examination. So that is something that we can see. Obviously with these injuries, we'd have to have some relative rest. So I started implementing an exercise program at home, trying to increase that range of motion, strengthen the rotator cuff muscles and maybe some short bursts of 10 sets. And probably if they keep playing, they would lead to chronic tendonitis, which would need more aggressive management in a way that they need to rest a little bit more. Maybe we need an injection or we need to be seen for if there's calcification in the area or something else that we need to be looking for from a bone perspective. Poresitis is something that can co-exist with impeachment. They're going to have pain both in the active and passive. So that is something that is sometimes difficult to distinguish between impeachment. So that is something that we need to be looking for. Similar alternatives. Yeah. I just wanted to give you a one minute warning. Okay. Sounds good. Thanks. I'm just going to run through the different diagnosis that we can see. There's some stuff that I want to show you on some of this because they're important for the context. For tendonitis, something important is, are the instruments a little bit heavier than others? For example, the viola is approximately half a pound more heavier than the violins. And that's important to take into consideration. For lateral picondylitis, we have seen that more than two hours per day with the repetitive movement is something that we need to be looking for, especially for percussionists, that they're using their hands a little bit more than other instrumentalists. So that's important to look for. Their core veins, internal synovitis is something they're going to be seeing in pianists, especially if they're crossing their hand across their thumb under the pinky finger. That is something that we're going to see, especially with small-handed pianists is something that's going to predispose into more pain. Finger is something that we need to be looking for. Obviously, this is a common pathology, something that we can address. Osteoarthritis, there are some studies that say that more activity predispose these musicians to osteoarthritis, specifically in the smaller joints, and that has been proven with pianists and violinists, specifically in temporal and mandibular joints, so that's important to know. Hypermobility symptom can be an asset for some musicians. Something we can look at is the hyperextensibility of the MCP and the PAP joints. More than 10 degrees is said to be a predisposing factor for more injury, and that's not something that we look in the big-time store, so that is good to know. And obviously, nephrotrombin across the upper extremity, that is something to be looking for if we have some neuropathic pain. And musician dissonia, this is one of our patients in the clinic. There's stuff that we can do. Specifically, we can do some Walsach's injection, anticholinergics, and help those musicians, as well with thoracic outlet syndrome. There's been some treatment with Botox to the escalene and petrolysis minor muscles, and that's something that we can use, too. So to close up, high prevalence of overused MSK injuries in musicians. There's some key performance-related history questions that you can ask, and we review them. Some musicians are more prone to certain conditions than others, and there's a lot of stuff that us physiatrists can offer for our generals to continue performing. Thank you. Thanks so much. Up next, we have Dr. Oscar Fuentes, a PGY-4 from Montefiore, as well as Dr. Francis de Assis, who is currently a fellow at the University of North Texas, to discuss singers' injuries and the treatment of those injuries. Hello everyone, starting to share my screen here so that we can start. I'm Ricardo Fuentes. I have the honor to be co-presenting with my friend Francis who is the current fellow of UNT for performing arts medicine and I am the incoming fellow. So it's kind of cool that we get to like pass the baton a little bit through this presentation. Super fun to be today. I have great like love for this community since like remember May was the way that I discovered performing arts medicine and now like it's super fun to be here presenting and discussing what we all love to do and we have passion for it. Now let me just try to slideshow. Can everyone see the presentation? Yes, I also apologize that I introduced you as Oscar Fuentes and not Dr. Ricardo Fuentes. That's okay Tracy. A little slow, sorry. So I kind of struggled with the same thing that Kevin was saying. There's so much to talk about our performance. It's kind of hard to condense everything. So we're going to try to like talk a little bit about singers in this presentation. Voice users are unique in performing arts medicine because like the voice is something really difficult to assess the office and sometimes it's complicated. So it's good to really do a very focused history. Dr. Fuentes, I can't see your screen. Can anybody else see your screen? No. Yeah, I would recommend just presenting it maybe in the slide view mode just so we can see your slides. Let me see what's going on. If you want, I can try loading the slideshow too and run it and you can, I'll move it. Yeah, can you try that Francis? I don't know why mine is like hitting me. There we go. Sorry about that. I guess my computer is old. So back to what I was saying, something very unique about the voice users in general is that a lot of them, especially within the performing arts world, are not only just singers, right? They play tons of roles within the performing arts for their dancers most of the time. Sometimes they're musicians as well. They're playing an instrument as they sing. So all of these things that we're going to discuss for both the dancers and the musicians can apply for singers as well. Next. So when we do a very specific directed history for the singers, it's important to talk about how is the regular use of the voice, right? And what is new, what's happening that has been different, right? Those changes, as you would ask for any sports player or anything, it's similar in that matter. Next. The chief complaint, of course, is going to be directed to the use of voice, but it can come in different tones of like hoarseness, breathiness. The quality, the description of the voice becomes really crucial to try to like differentiate what's happening to the voice in this moment. And it's the time that is very important. Is this something acute or chronic that can determine how are we going to focus on both the diagnosis and the treatment? Fatigue is something very important and common for the overuse of the voice. Like a lot of people will just start having fatigue. And different to some musicians, voice users can only use their voice, especially professionally, to sing for a few hours a day. So overuse of voice can rapidly cause fatigue. It's important to discuss the volume if we're talking too loud, or if we're singing too loud, and the conditioning, right? If there is any other physical activity that's enhancing or helping for the use of the voice. The nuance or the description of what's happening in the use of the voice is extremely important. Are they having issues controlling their voice, singing piano or singing forte, or like even talking, discussing, having a conversation loudly or not? Is that something that is happening primarily with their technique? Are they having changes in their far or are they're having changes in how they are approaching their voice? Are they're changing from singing classical to jazz or is there anything happening with that? Or is there any hormonal experiences during pregnancy or during the periods? It can be something that affects their voice in many times. You can also see while singing if there's any overuse of the musculature, and that can also be a hint for overuse or injury itself. As we were talking with the musicians, the description of the activity towards singing is very important. Are they're having new performances? Are they're having upcoming engagements that are like forcing them to sing more or increasing their time to sing? And also the kind of venue where they're singing, right? Is this a friendly venue where the resonance is adequate or is there any problems or any changes in the accompaniment? It's different to sing with an orchestra of 80 musicians or a small chamber recital, or when you sing in a huge concert open venue, the voice has to adapt to all the venues itself. It's important as everything in rehabilitation to determine goals. What is what the singer is wanting from this experience or what this intervention or what's happening to their voice and what are their goals they have for their career itself. In their level of training or experience, it's very important to determine what accompanies that goal of care. Are they're amateur in college? Are they're professionals? Do they have teachers? How much time do they use to practice? We want to know what they think the problem is. A lot of the voice users have a lot of knowledge from their voice. It takes a lot of time and effort to learn your voice and learn how to use it properly. So they might have an idea of how are they hurting themselves or what's going on that is causing them an issue. Is there a misuse during singing or speaking? Is there any other outside irritants or causing any issues like allergies, like being on flights too much and having poor air pollution, smoking, any relationship with other people? So it's very important to evaluate what's happening with the voice itself with any other musculoskeletal or medical things going on like tension in the jaw or any hearing issues, neck problems that can be related like having a blood injury or something adjacent to singing or if they have had prior surgeries of any kind. Medications. Singers and all performers tend to self-medicate before coming to us just as the fear of the intervention with the physician or someone that might not have enough information to give them. So a lot of them in a lot of medications can have relationship with the voice like they have semantics or some OCPs and not only the environment of performing arts can be very stressful dealing to the use of alcohol or other recreational drugs. So it's important to inquire about this so that we can determine if there's damage to the voice because of them. The physical exam includes an oral exam to see if there's structure deficits that are or different movements that are happening that shouldn't be happening and the auditory exam. So have them sing, right? We want to evaluate the voice quality, the resonance, the phonation. It's important to listen to your patient. And of course there's objective measures. As a society we work in a team where sometimes there's laryngology, ENT, or even our speech pathologists can perform stroboscopy or laryngoscopy to see the vocal cords and see there's vibratory asymmetry, structural abnormalities, masses, scars. Sometimes it's good or important to evaluate bone-marrow fracturing tests to see if there's changes in the mechanical of singing. And I think we're going to go now with the pathologist with Francis. Yeah. All right. So as Dr. Fuentes said, alluded to, you know, when taking care with, you know, and as like most things in rehab, you know, the care of our artist is very much a team sport. So, you know, as you, as the physiatrist, but of course we, especially in the, you know, when we're thinking of our voice users, we also have our ENTs, our pulmonologists, sometimes neurologists, and of course our therapists and our speech, speech therapists, especially PTs, OTs, social workers, mental health professionals, all of that. And so, you know, all of them for all these pathologists, they will play some sort of role. And, you know, with the remainder of the time we have, I'll just quickly run through some of the common things that we do see and not to bury the lead, but, you know, the essentials of treatment is mostly the same. It does involve some type of voice therapy. It does involve some type of rest, whether it's absolute or relative. And occasionally with some of these things are also be surgical intervention. But the first thing I wanted to talk about is muscle tension dysphonia. And that's basically when you have excessive tension that eventually can result in vocal inefficiency. We have two different types. We have primary, which involves the actual muscles of the neck. And then we have secondary where it's just more structural abnormalities of the larynx. These patients will present, you know, very hoarse, they might sound breathy, or maybe they just are aphonic. And as I said before, voice therapy is going to be your first line. Other things include, you know, vocal abuse and misuse. If anyone has heard this song by Disturbed, you know, because that was a very good example of what that might sound like. Um, but, you know, this is, you'll see this a lot in, you know, cheerleaders, or maybe even preachers or things like, or, you know, just people just cheering and screaming really loudly. So that's the abuse portion and misuse is more so from the technical side, maybe this person is not, or, you know, has not had the best training, or they are still in training. So any one of those things can cause can cause muscle change and dystonia. Another one, and this is probably the most, the most high yield thing to look out for, because it is the only one that, you know, requires absolute vocal rest. And that is vocal fold hemorrhage. It is associated with upper respiratory infections. And you know, if it is untreated, it can cause scarring of the vocal folds. And you know, this is something and, you know, this is something that you can diagnose with stroboscopy. And also just a really quick thing about absolute rest, this absolute vocal rest, that's going to mean that they say they can't they they cannot even whisper, they're going to need to communicate with either a whiteboard, a piece of paper or something else. They cannot use their cords at all. Anyway, so, you know, upper respiratory infections, not not totally surprising. So for example, laryngitis, whether or not the etiology is infectious or not, you will, these patients, you know, you can have them go on relative vocal rest. And the difference between absolute and relative rest is that, you know, the patient can use their voice, they just should be very particular about it, you're going to want to advise them to, you know, minimize the volume that they use, be very particular about when they use their voice, so only use it when absolutely necessary. And then also, if they're, if they can try to stay in the upper registers and also use their abdomen, their abdomen for, you know, supporting their voice. And you know, this is one of those things where you have to weigh the risk and benefits of performance, right? Because, you know, sometimes they do have those performance that can be career, that can, you know, rocket them into the stratosphere. And so, you know, you can work with them and trying to, you know, go over those risk and benefits and how to, and also how to, they can properly prepare for things like that. Versus, you know, maybe it's just a side, a side gig that's just for extra money, maybe they, maybe it's better off for them to just take that one off. Another one is called vocal fold hypomobility. And that's, you know, really this is just kind of an umbrella term. And they have a number, a number of different things that can cause this, which all of which I have listed right here. So whether that's paralysis or dislocation of the retinoid cartilage or maybe dysfunction of, you know, certain joints, but, you know, either way, voice therapy is going to be your first line treatment. And all right. And then finally, just talking about some structural abnormalities. These are going to be your nose. These are your cysts, your polyps, all of these have, you know, slightly different etiologies. For example, you know, it's going to be caused by vocally abusive behavior. Some mucosal cysts can, you know, are actually structural in biology. And then you have things like polyps, you know, which can develop from trauma or hemorrhage. And, you know, again, like every other thing we just talked about, voice therapy is going to be your first line, generally at least a couple of months. And if necessary, and this is, you know, one of the few, the pathology where, you know, you actually do involve a surgical option if needed, but, you know, this is going to be for polyps. And, you know, and if your patient does choose to go through with this, it is very, very important to prehab and also obviously rehab. And that's it. Thank you so much. Next, we have Dr. Ken Pizer, who is a fellow at NYU Rest Rehabilitation to talk about common injuries and treatments of dancers. All right, so I'm going to be giving a brief introduction. Um, and to Dan's medicine. Are you able to see yes, you are in presenter mode just so, you know, so we can see your notes. But it looks fine. Okay, all right, I'll just leave it in presenter mode. Sorry. All right, well, I'm the current and why you came in our 4th fellow. I have no financial interest or relationship to disclose. And say, we're going to discuss the epidemiology of dance medicine, intrinsic and extrinsic risk factors for dance injuries and review potential oversight and dance training. We're really all echoing the same common theme. And so you kind of see that repeated throughout this presentation as well in the past 10 years, the number of public injury studies has increased 5 fold. And so I assist are uniquely poised to evaluate and manage dance injury as well as reduce dance injury risk because of our training. Dancers are athletes, and they require extensive physical training to acquire highly specific and refined motor skills. And I just also want to add vocalists or athletes, musicians or athletes too. And in contrast to some other forms of sport dancers, ultimately hone their physical prowess for the sake of artistic expressivity. So, how is dancing different from sport training? Well, dancers typically adhere to a cultural perspective of training that's based in artistic rather than scientific tradition. And the work and training environments for dancers often don't incorporate modern principles of condition. Dancers may be relatively unprepared for stresses encountered during their career. Here, for instance, you have a ballet bar, and the male ballet dancer will be partnering with female partners, possibly other male partners, and that involves lifting. And so we kind of have an art form that uses the same warm up and the same method of training without kind of any addition, let's say, of resistance strength training. So, how common is dance injury? 3 professional ballet companies were prospectively monitored weekly during 1 season with the performing artist and athlete health monitor in the study that was done in 2024. And they found that over a period of 44 weeks. 57% of their. 57 dancers filled in weekly report. And about 82% of them reported having musculoskeletal. And most of the 320 health problems that were reported by the 57 dancers were injuries. Some of those were also illnesses and mental health problems, because those are also issues when we're practicing dance medicine, but we're kind of focusing more on the musculoskeletal side. And those injuries that were musculoskeletal nature affected mainly the ankle, the side of foot and lower back, and we're mostly encouraged during rehearsal and training, which are periods of high fatigue and high workload. The most frequent subjective reasons of injury were too much workload tiredness, exhaustion and stress overload. And this is echoed through some other prior studies. It's just 1 of the more recent ones that I found. Between 2018 and 2023, another study, looking at musculoskeletal injuries in the professional ballet dancers in Paris. Found that the most commonly sustained injuries were those of the foot and ankle with 75% of dancers, sustaining a lower limb injury. I will say this is very ballet centric literature and you will find. And in most of our Western dance medicine literature, it is very ballet centric, but by no means is ballet the only art form. And so how overall do we approach dance injury, regardless of what the dance form is. The is paramount again, we've been going over that with the vocalist, we've gone over that with the musicians and specificity is key because if you don't ask, you're not going to get the information. So you want to ask the frequency and the type of class, the participation level, whether or not they're student, pre professional or professional. Where are they training and what is that training environment? Like, often they're training in multiple places. What period of the year are they in relative to their performance season? Their rehearsal season, especially for those of us practicing in New York. It's really difficult because most dancers statistically are freelance workers and so they may be less say, rehearsing with 1 company while doing a performance for another company. And they're also often teaching class too. That's another 1 that should be incorporated here because that's still represent exposure. And then any prior dance injuries, what are they having difficulty with? Is it with turning with dumping or with point work? So, just getting as specific as we can. Here is a map that was adapted from a prior study, just looking at epidemiology specific to dance. So how many, what is the frequency, the prevalence, the incidents in terms of the occurrence of injury? Who is it happening to? I think we can sit on from this. I illustrated this with the break dancer because again, we can think about how different this training environment. Is from the ballet bar, but in some ways it's also not because again, it's not well adapted necessarily from a scientific standpoint to what it is that they're doing and performing. Dance injuries, multifactorial. So, here we kind of return to another model we can talk about intrinsic risk factors. Those are things like BMI, strength, age, their sex, whether or not they have any lastity or hypermobility syndrome, any prior injuries that they have. And then we also have extrinsic risk factors, which we'll delve into a little bit more deeply. Extrinsic risk factors, as a, for instance, we have this flamenco dancer named Conta Jareño. She said, it's very natural for me to dance with the bata de cola, which is that long dress behind her. It's like my own appendix, but in my early career, I was injured from the weight and strain of working with a heavy train. My neck was paralyzed. I was unable to move it for a month. I had to improve how I was dancing, be less rough and take better care of my body. I now choose lighter fabrics for the dress as well. And she actually ended up designing her own dresses, incorporating her own fabrics, and then modifying that so that that extrinsic risk factor was less prone to causing injury to her. Other extrinsic risk factors we can think about, the shoes someone wears, so the flamenco shoes that you're seeing kind of in the center bottom there, whether or not the stage is raked. Typically, a stage can be raked up to about 5 degrees. This was used classically to help facilitate the audience's view of performers. We're also looking at one of the most famous emblems of dance, especially in the Western world, and again, a primarily ballet-centric world. This is the point, too. And then over here, we have a performer in the Lion King, who is very interesting for physiatry. And this I've actually seen in a talk by Dr. Melody Rubich, was really speaking to how the performers there are almost engaging with that, like, in the way that we would think of an amputee. So, thinking about weight-bearing surfaces and trying to control for injuries by putting them on pressure-tolerant areas. So, we always want to think about the influence of equipment and environment on injury hazard, and it's really important to ask for specifics. This devil is in the details. This is a really great movie, by the way, if you've never seen it. And then, briefly, as we come to a close, we're going to talk about training oversights in traditional dance settings. Periodization, and again, this also applies to the vocalist. It applies to musicians. So, you have to allow for sufficient time between workouts for tissue growth and for biochemical resynthesis to occur. The greatest numbers of injury per year among dancers are reported during the end of the day and the end of performance season, when dancers become most vulnerable to fatigue. Fatigue has been demonstrated to have adverse effects on neuromuscular control, coordination, reflex activity, and muscular power. And then specificity is another training principle, and classroom technique training remains relatively constant, but choreography evolves. And so, we have to kind of address that and counsel our dancer patients on potentially getting a regimen that is more specific, working with the dance therapist that's able to incorporate movements that strengthen where they maybe have a deficit in the biomechanical chain. And then overload training. Some dancers may actually be underloaded, relatively speaking. And then the last principle is overtraining. So, when training stress is imposed in a long-term manner, when it's highly intense and repetitive, athletes may cease to adapt positively. And so, lack of proper rest cycling, formal prioritization to load buildup, and a possible lack of cardiovascular endurance training inherent in dance training. Because dance actually is typically an anaerobic activity. It's commonly misunderstood to be an aerobic activity, but in fact, dance performers are typically performing in an anaerobic manner because they're not sustaining their activity for more than 30 minutes continuously. So, it typically is quite rare to be on stage dancing by yourself, or like you continuously dancing for 30 minutes. There are usually breaks built in there, and in a dance class, there are frequent breaks. That quick dance is that reference break. So, thank you guys so much. I'm going to stop sharing so that we can go to Dr. Quirolico. Thanks, Dr. Pizer. Next, we have Dr. Christina Quirolico from Campbell Clinic in Tennessee, and that was a great segue because she will be talking about strengthening and conditioning for our dancer population. Yes, that was a perfect segue. So, let me go back. Yes, so I'm a sports medicine physiatrist at Campbell Clinic in Memphis, Tennessee. I also am the company physician for Ballet Memphis. And so I'll talk to you guys about strengthening conditioning for dancers. As we just learned, in terms of injuries for dancers, the majority is due to overuse, and then followed by acute trauma. Foot and ankle, by far, has the most prevalent injuries, followed by low back, hip, and then knee. And then Dr. Pizer gave a very good overview over the intrinsic risk factors, as well as the extrinsic risk factors, which we unfortunately don't have much control over. And then he also mentioned how dancers are athletes. And just like right now, it's currently recommended that we have cross-training for athletes. And so, likewise, we should have cross-training for our dancers. It's been found to improve endurance, cardiovascular fitness, strength, agility, and balance, and also helps with injury prevention. Right now, the majority of the companies don't have resistance training or conditioning built into their schedule. And this is despite the fact that literature has been showing that the addition of resistance training and strengthening has led to reduced injury incidence in these dancers. Just a quick overview. This is a meta-analysis from 2024 of 36 studies that have been done, which found that resistance training and plyometrics have improved lower body power, upper and lower body strength, as well as flexibility. And this is another systematic review that was done in 2021 of eight studies. And they found that supplemental training for one hour two to three times a week for eight weeks was found to enhance performance, actually, as well. Of note, the majority of these studies were of collegiate women dancers. So, a shout out. The DanceUSA Task Force on Dancer Health has currently recommended integration of strength and conditioning into the professional dancer schedule. This is a little bit difficult because dancers have packed days in between their classes and rehearsals, so it can be a bit challenging with compliance. The other challenge is buy-in with artistic directors and administration. And this is despite the fact that the literature has been supporting use of this. One thing that if you do have a voice or, like I say, a relationship with the artistic directors and administrators of a dance company or a dance studio, you can kind of bring up that there is this decreased rate of injury, which can lead to less workers comp filing. You know, whenever you bring money into it, sometimes that helps drive change. And then the DanceUSA Task Force on Dancer Health is coming up with a 20 to 30-minute strength and conditioning program. And this can often be integrated into the classes. You can break it down into different days. And right now, we're kind of in the final stages of a sample strength and conditioning program. And there's going to be videos put out also that's available for the public for free. And so just stay tuned for that because that is exciting. You can kind of direct the dancers that you take care of to the website for that once it comes out. So just really quick, I'm going to go over a sample of what DanceUSA Task Force has come up with. And so to start, it's this dynamic warm-up. And it's basically a movement-based warm-up to help warm up all the joints. It's not very long. Typically, it should only take about five minutes. And this is just an example of some of the things that they had mentioned. A lot of the movements, you're going to be moving multiple limbs and joints at the same time. So that way, you can kind of cut down on the amount of time that it takes to do this and warm up. This is a sample of a strengthening program. Overall, it should take about 12 to 15 minutes. This doesn't necessarily have to be done every day. You can actually break it down into different groups. And then each group, you can do one day a week and then the other different day of the week. At Ballet Memphis, I actually was able to have the teachers incorporate this to the end of the dance class, which is mandatory for the dancers and their contract. So that is one way that you can get that built into their schedule as well. And then Tabata is something else that has been included in the program. And so overall, this should take four minutes. And it's split up into two different days. The nice thing about this is that this is a great way for dancers to be able to do this in between rehearsals and kind of keep up their cardiovascular endurance. And there's no equipment needed in the moves that have been in the sample program that DanceUSA is putting together. There's also other versions that they're putting together of some equipment that dancers might have on hand already, such as a thera-band, foam roller. And then there's also alternate versions where you'll actually be able to do partnered strengthening and conditioning. So just keep an eye out for that. This presentation is very short. Take home points. Dancers are athletes. They have the same recommendations as our athletes. Definitely, this is a link to the DanceUSA Dancer Health Task Force website. So just periodically look on there because once we get that program out there, we do want to have it disseminated to all the dancers to have it available because we want to keep our dancers healthy and strong. And here are my references. Wow, you went through that. Thank you. Thank you to all of our speakers. It was really fantastic to have all of you here and to have all levels of training. And I don't know what you would call an attending, like PGY, I don't know, whatever year now we are. But it's wonderful to just hear the experience that we all go through treating these performers every day. So, Jordan, I don't know if anything came up in the chat. I mean, if anybody has questions, by all means, feel free to ask it, raise a hand, put it in the chat. We're here for a few more minutes. Thanks, Dr. Elson, also one of the OGs here. Dr. De Asis, I have a question for you with the scopes. How often are you sitting in and watching? I mean, I'm assuming you're not doing them, right? The ENTs are doing them or the speech and language pathologists? Yeah, so typically we try to have the ENT do it and then, you know, sometimes if that's not possible then the speech therapist. But yeah, I'm not usually, unless I'm not, you know, in the room for it though, unless I happen to be at the clinic, but because the way for us, we don't have an ENT department at UNT. We usually refer out to UT Southwestern. So it's on the other side of town. So, but yeah. We do have two questions here. Do any of you use nutritional supplements with performers? I have my own take on this, but I'll let any of you answer first. No. Dr. Kourouliko, do you use nutritional supplements for your performers? I don't know if this counts as a nutritional supplement, but I often recommend Arnica, you know, if they have inflammation and they want to take something that's more natural. It comes in peel form, but then there's also a cream form and you can use the cream up to four times a day. So that's probably the one that I recommend most for my dancers. I actually don't recommend any nutritional supplements. Arnica I use for pain relief. I tend to not use supplements because there is no FDA oversight. I mean, I don't know what's happening to our FDA, quite honestly, but there is no oversight with supplements. You don't know the quality of the product that is going in, things that you're buying off Amazon versus Target versus, you know, any of these places online. And I've had this discussion with endocrinologists and some of my primary care colleagues. If you're eating a well-balanced diet, there's really no need to even take multivitamins unless you have a clear deficiency. So the short answer to your question is I do not use any supplements for my performers. Another question is in a place like India, how can I plan to do research on dancers where they're not formally integrated with clinical medicine? Are you associated with any academic centers in your area? I was going to say, I can talk a little bit about that. I think the research in the performing artists is something challenging that we all have encountered. But I think the most important thing is to set up a good team and look at your setup, right? Like if you're in an academic institution, the most important thing is to have a good association with the group of people who, first of all, have access to see this kind of population. And second of all, inquire into the most important issues that the artists are having in general so that then you have a plan to establish what it is that you want to research. And from that on, follow the steps that that requires, requiring ethical approval, or what we call here in the US IRB, and follow up with that, just try to establish what is the end goal for it to happen. So having a proper structure plan that includes like a group of people that not only has taken care of this artist, but also are going to collaborate with you for that to happen. Because even in the US, I don't think it's formally integrated with clinical medicine. It's mostly just a lot of us who have a special interest in treating a certain population. And we seek out these performers, because we know about them, and we just care about them. We want them to get the appropriate care that they need. So I guess my advice would be just like Dr. Fuentes had said, if you have access to these research groups, and people who are well-versed in doing research, just generally, I think it would be good to build a support system there and collect the information you need. Thank you. Ronnie Lindsey writes, what advice would you all give to a medical student when the end goal of wanting to work with performance artists? Ooh, you're my dear residents and fellows. Feel free to answer that. I think in our field, in performing arts medicine field, I know we are in need of more education to our performers and to our colleagues in the field. So I would establish some connections with the local companies and groups that are interested in working and start offering some volunteer work about some of the stuff that we talk about today and sharing that knowledge with them, because most people don't know, and there's still a lot of stuff that we can share and we can support them. I would say with that, with this kind of activities, right? We are here to share our experiences, our knowledge. As I mentioned before, this is how I discovered performing arts medicine back when I was applying for residency. And now I'm looking into doing a fellowship that has a high prevalence of that, that I'm gonna be super excited to go learn and want to collaborate with this community. And there are many ways to participate. There's like the Performing Arts Medical Association, and it's good to join it. And you'll see how this is a very welcoming community. We know each other, we hang out with each other, we like look and help each other. And the more we like start like having relationships amongst us, then the knowledge grows, the ability to help this community grows and it will place you in the right position to do what you wanna do and work hard towards that. So I thought it was important that the residents voiced how their experience was because when I was a resident, when I was a med student, I didn't have any support system. I had no direction. So the field has significantly grown in the last 10 years for sure. I think Dr. Karoliko, you might have a different perspective on this as well. Yeah, so what I did as a medical student was I shadowed at the Harkness Center for Dance Injuries because I happened to be near New York City and that kind of exposed me to dance medicine. And that's how I actually learned about Pumanar. And then in my Pumanar residency, there were a couple opportunities that where a dance company, the Battery Dance Company actually asked us to provide medical coverage. And so I was like, me, I wanna be on top of that. I wanna be the one in charge of that. And then they're like, okay. So the opportunities are there. And then also I personally reached out to a bunch of the dance schools in the area. And I said, hey, I am in medicine and I like working with dancers. Would you guys be interested if I came in and gave like a dance injury prevention workshop? And then they were all about that. And it was like a lunchtime lecture for like the dancers during a summer camp, but then that's like a way you can get involved. And then once you get into residency and fellowship and you have like your own clinic, like sometimes maybe some of the dancers will come and see you in like your resident clinic because you reached out to them, they are aware of you because you gave that injury prevention workshop. And then same thing, once you become an attending, you reach out, just reach out to like the community, reach out to the studios in the area, the dance companies in the area. You can kind of do the same thing like, hey, I'm a dancer or a performing artist. I take care of like musicians, performing artists. And if you have any issues, you can come see me. And then it's just putting yourself out there and then taking advantage of any opportunities that come up. And Dr. Fuentes had also said that he found a lot of support in this community. Again, the performing arts medicine community is small and we like to support each other. So if you have access to the community board and you need access to attendings who are willing to take on students for a week or two to shadow, I for one welcome students with me to work with me. I'm over at Harkness. I have performers in my own private clinic. So, I mean, if our presenters would be willing to share their email addresses in the chat, anybody here would be able to see it. Feel free to reach out to us. We'd be happy to speak with you. And there is a comment in the chat also saying to pay attention to the regular athletes that are non-performers. Their injuries are very similar to what performers get. The difference is typically the mechanism of how it's obtained, how their injury is, how it's obtained, how they get it. A lot of musician injuries are overuse injuries. More of the trauma-based injuries are found in dancers if like they land wrong, if they get dropped, crazy things like that. But the idea is that the injuries are similar. So if you understand the mechanism of how athletes are injured, then you should understand how performers are also injured. Just let me put my email address. I can't see the chat with my box here. So if anybody wants to read that, feel free. And people are putting their emails and someone agreed with the comment about athletes as an option as well. But other than that, there are no new comments. All right. I'll give it, what, like two more minutes for people to ask any other burning questions. Man, I need a voice therapist right now. What? The M exercises, Tracy. I guess so. I have to sing at a wedding next weekend. I don't know if this is going to go over very well. This is the overwork that happens. I'm singing in an opera and everything's like crazy. This stinks, right? Because as physicians, we're speaking all day to patients nonstop. So we have to start applying some of the techniques that we learned. Self-care. I guess so. Separate needs to talk about performing arts medicine for performing arts physicians. Dr. Pizer, you could put that together and start. All right. Well, everyone, to our presenters, thank you so much for sharing your wealth of education with us, your expertise. It's really a pleasure to hear all of you speak. Thank you for taking the time out of your days to do this. To all those who have joined us, it was a pleasure having you as well and sharing our love for the community and our love for the field. Again, by all means, reach out to us if and when you need us. We'll see you around. Come to annual assembly and come find us to chat. Thank you all so much. Good night.

Performing Arts Medicine

musculoskeletal injuries

musicians

singers

dancers

injury prevention

physical therapy

vocal therapy

multi-disciplinary care

training programs