Hi, everyone. Welcome. We're so excited to see all of you here. Welcome to the Performing Arts Medicine Member May event. And as you probably have seen on the itinerary for tonight, tonight's an introduction to Performing Arts Medicine. We're going to go through dance for dancers, musicians, vocalists. And also, we would love to get your feedback for what include for the for the fall presentation. So I don't want to take up time because we have a lot of great content for you tonight. So we're going to start off with Dr. Lee. Good evening, everybody see that okay? Awesome. Make that a little bit more focused there. So, my name is Ying Li. I myself and Dr. Cerver, that's on this call as well. We run the performance medicine program here in Fort Worth, Texas, at University of North Texas Health Science Center of Fort Worth. I just wanted to kick off this talk with just a brief introduction to performance medicine. I just have three topics for you today. I'm just going to go over who are the performing artists, what is performance medicine, and then brief epidemiology because it's brief because other people will go into detail more. Unfortunately, I have no disclosures. I don't have any fancy sponsors for sponsoring this talk today. I'm going to start out with saying the performers are different. They're highly motivated and they're goal oriented. They often feel like their art takes precedence over their physical conditions. They're freelancers. They don't get paid if they don't play. Even a small or subtle change in their body can affect their ability. It can be really obscure complaint and you may not have exactly have an idea what their problem is right off the bat because they may describe their chief complaint in a little different way. They also start at a very early age. For example, I have this YouTube video for you. I hope it plays. So that is their Chang probably age like five or something really young. So for string players, they can start that young and be that good at that age. They might actually become because of that they might actually become anatomically shaped to their instrument if they're musicians. If they're dancers, they have they start also very young age. So they have age related as they grow and they have issues because of that as well. So their problem might have been there forever when you meet them. That's another reason why we need to pay attention to their age. Their brains all the different to so this is an interesting study. It's from a can Canada International Laboratory for brain music and sound research in Montreal. They studied expert dancers and expert musicians, and they compared it to untrained controls. They use battery of bands and music related tasks like dance imitation and rhythm synchronization melody discrimination tasks, and they did a structural MRI. And actually it's not a surprise they what the brain MRI show the greatest changes compared to controls in the temporal regions in their brains, so they're the musicians and dancers show differences in the temporal regions of your brain. If you look at this red areas, the superior temporal gyrators mirror middle temporal gyrators region dancers have greater cortical thickness there compared to controls. If you look at the blue areas. The post central gyro central sulcus region, musicians have greater cortical thickness, and both musicians and dancer have greater cortical thickness in this region so you know we have evidence that their brains are the friend. And the typical performer look like this and their lives look like that they have huge huge stress. Their world is extremely competitive they're always auditioning. And their hours are very long too, and they're late, their rehearsals and performances happen over the weekend when everybody's resting. They travel a lot. It doesn't matter who you are orchestra musicians opera singers actors dancers. Performances, all of the world and all of the country so they travel for auditions and performances, they have for finances, of course if you're a rock star they don't have finance issues, but majority of performers that most of all ensembles and dance companies gigs pay very modestly. They don't really exercise and diets really for dances are very active, but they don't really exercise musicians, really really don't exercise, and their diet, especially many of the patients that I see who are collegiate musicians and, and others, they often So, and then also this culture of grit, you know they this attitude of no pain, no gain some discomfort or pain, experiencing during their performance is absolutely normal, and they have this idea of like sure has to go on no matter what, that's really And finally they don't really see doctors, they have this fear that treatment may threaten their performances or demand possibly possible changes in their technique or their repertoire so they're afraid to come and see us. Obviously the money issue and then healthcare coverage so this is state dependent but here in Texas, you don't have to offer healthcare coverage or workers comp coverage. There are big ensembles like Texas Valley Theater that are our center cover they do cover for first comp but not every ensembles will do that. So, there are a couple things that I wanted to just kind of bring up. Musicians and athletes, because you guys, I think probably will understand where, like how athletes lives look like that's more common knowledge, but there are a lot of musicians and let's say other performers have similar lives to, you know, they were on a game day, for example, they could sort of have the same type of a schedule like they sleep late and then wake up late, they'll have sort of that late beginning of the performance day, they'll finish their performances or their play or their game at like 11 o'clock, and they'll have maybe have a meal at the end and then they might just go to sleep or travel to a new city, but what's really different about athletes and performers of the athletes have like a whole team of support around them. They have nutritionists they have, you know, maybe sports medicine doctors and physical therapists and athletic trainers, and they also have a policy to protect their body for example pitch hills for pitchers. They also have mental health support to what I'm trying to convey here is that this is definitely a population, and if you've heard me speak before and this is sort of like, I say this all the time if I'm like a broken record here, that this is a population that desperately desperately needs support and as physiatrists we're really uniquely positioned to do so. So I'll talk a little bit about what is performing arts medicine. Performing arts medicine is a branch of occupation medicine that address the medical concerns of any kind of performing artists, so they can be individuals who play musical instruments or dance or any kind of performance, you know, I see, you know, balloon artists balloon animal artists I see all kinds circus performers all kinds dance medicine specifically because I'm not going to go too much into it because we're going to talk about a little bit later is generally involving taking care of the answer related injuries prevention rehabilitation and return to dance dance medicine look at the full breadth of biomechanical psychological neuromuscular skeletal aspect of dance nutrition, as well as but not limited to mental health issues and music medicine similar looking at overuse injuries and other neuromuscular skeletal problems and musicians but not limited to that music medicine also looks at full breadth of biomechanical physiological aspects of music performances, also nutrition, hearing health mental health, etc. We also want to include related fields such as backstage and costume staff sound team, etc. This is sort of what I think about when I say when I think of performance medicine, I'm a physiatrist, I always think about it as sort of physiatric perspective performing arts medicine. trained to take care of performing art medicine so if you're looking at sort of that typical outpatient practice and performing arts medicine I think of this detailed discussion of history pain level psychological factors, including their sort of what they do and practice habits and changes in planning, etc. But also, I think about comprehensive care injury related but also non injury related. Some of the performance specific injuries, but like not specific non injury related stuff will be like what I mentioned before hearing health mental health, or for dancers relative energy deficiency in sport, and our treatments, obviously would include like the whole team right so appropriate referrals and treatment coordination with PTs and OTs and SLPs ENTs orthopedics behavioral health, etc. Now, I think I have a little bit of time to just do a brief epidemiology, and it hopefully will be a good segue to dancers and musicians more specifically with Dr. Allison and Dr. survey. So for dancers. Here, a lifetime prevalence of injury among professional ballet dancers have been reported to be as high as 95%, and modern dancers and younger ballet students, probably about 40 to 80%. Not surprisingly, majority of their injuries are in their foot and ankles, I think I hope that's not a huge surprise for men, there are more shoulder and back injuries and foot and ankle injuries. There are certain risks to consider sort of their skill level for example, amateur and younger dancers tend to have more entries than professional and elite dancers costume type shoe shape and types of shoes that they wear dancing surface like for example, you know, are which is perfect condition versus some of our dancers that are quincy you know they're dancing out like a modern art museum of concrete floor and dancing in some really obscuring environment, their repertoire and technique, the rehearsal time and frequency and performance So those things can be a risk to their injuries and their, their problems, and then musicians injuries and musicians are also extremely common and this is first really quantified really long time ago but recently in the modern era. First identifiable good study that I can come up with is in the 1990s, there is a international conference of symphony opera musicians they surveyed over like 2000 orchestral musicians they found that 82% had medical problems at some point in their careers and they also said 76% experienced a problem that severe enough to affect their performance ability. Actually, there's another study done in 2012 this is study that's really well known amongst us who who do performance medicine is done by Brown and at University of Sydney, they show similar numbers I think she said 84% instead of 82%. And so, the musicians usually experiencing injuries in their upper limb, I hope that's also not a surprise and also face the cervical thoracic spine region, large majority of the problem is labeled the PR and be that stands for performance related musculoskeletal disorders, and some of the risk factors that you should consider are sort of similar as the answers you know playing time every rehearsal schedules type of instruments so that their equipment basically sort of like shoes for the answers for people, they have complexities or joint that's to be focused city, they have obesity. And repetitive work and their techniques repertoire and temperature of their playing environment and then stress level. These are some of the things that you should consider. So, did I get under 10 minutes, I talked really fast. And so we'll probably save everything for questions at the end, but I'm going to share, and then we'll move on to specific disciplines of performing medicine. Thank you so much Dr. Lee for that great overview, and I'm really excited to talk to you about my, my love of dance medicine, and like Dr. Lee I do not have any disclosures. So, in terms of, we're going to do a very brief quick overview of history and physical some biomechanics of some dance specific injuries, and then treatment considerations for the dancer. When we're, when we're talking about dance we need to know like what type of dance or dancers doing because, as you can imagine there's many many different kinds and it's almost like individual sports. You know, Dr. Lee mentioned pitch counts for baseball players well you could probably have different load requirements for every one of these and just a little quick aside we're having break dancing for the first time this year in the 2024 Olympics so good role for us in the dance and sports worlds. So we talked about what sports medicine is and really what we're trying to do is figure out how to get people back to that return to play or return to dance. So people come in, you know, it's hard as Dr. Lee mentioned it's hard to get dancers to show up at the doctors in the first place because of a lot of different barriers. So one of the ways that we can really connect with the dancers is to ask them specific questions. So, you know, getting into the specifics of what type of dance they're doing what they're training for if they're a dancer, what type of dance they're doing how many days a week they're doing each particular form of dance. What kinds of cross training are they doing, you'd be surprised most dancers think that they don't need to cross train, they think that they're, they think that ballet is going to do everything for them. So that's part of our education that we'll get into a little bit later, but other really important things to get into especially with your teenage dancers are you know where are they in terms of their growth spurt. How old are female dancers, the age of onset of menarche and if their periods are regular. And then also what's been more relevant recently as if they've had COVID and how their recovery has been. When we're doing screens we often will include questions in a general screening on if they, especially for ballet dancers if someone's ever told them to gain or lose weight. If they've had any recent loss, because these are all opportunities for us to really put that whole holistic care of the artists together. And dancers are very intuitive if you ask them what they think is going on, you know, they'll give you a good idea and it's very common that by the time the dancer shows up in your office. It's not an easy answer if they just had knee pain they wouldn't be in your office. So they've had knee pain, they've had foot pain which has caused them to walk differently which is causing some knee pain but now they're really there because their body is what's getting in the way of things. And they like that opportunity to be able to explain all of that to you. So we talked about a lot of the stresses that dancers come into at the beginning, and Dr. Lee did a really great review of some of the extrinsic factors, I think for dancers even though this is less frequent now but alcohol smoking has been a big issue in the past. And then the other thing which I think is true for all performing artists, actors, but especially dancers are right stages. And so that's when the stage is actually on a diagonal to give the audience a different perspective. I just treated a dancer recently that you know they've been practicing on a flat rehearsal studio and then as soon as they get into the theater they're on a completely different perspective. So it really changes their footing and it changes the stress that they're enduring. Dr. Lee mentioned the high rates of injuries and I think the really interesting difference between these performing arts and general sports medicine is dancers really tend to have more chronic injuries or less acute injuries. And so what that comes down to is the biomechanics of how they're doing things. Faulty technique is the number one cause of injuries, however you can't tell them that their technique is faulty. And it's not necessarily that they're, they're not trained right they're not doing something right but it's really that they're trying to do something with a certain ideal in mind but maybe their body's not ready to do it. You know, maybe one hip flexor they've been kicking a lot on their right leg and now that hip flexors tight. And now they're trying to do something else and make it look symmetric. And then they end up straining themselves because they're trying to compensate for something else that they were doing. And really understanding that principle of the systems interdependence and that whole kinetic chain. And I think physiatrists are really optimal physicians to be dealing with us because we're trained to look at the kinetic chain. Just this weekend, I was working with a lot of other primary care sports medicine docs, and they were saying, Oh, yeah, they see new patients every 10 minutes. I was like, there is no way I would be able to do a good kinetic chain evaluation in 10 minutes. But that's why as physiatrists are really optimal to be looking at these performing artists, because we look at the whole person. When when someone walks into our office, we look to see if they're hypermobile. A lot of dancers are hypermobile, and it's going to change how you treat them. So we'll get a Bainton score, we'll look for any significant leg length inequalities. We also watch them walk a lot of the young ballerinas like try to walk with their legs turned out, that's actually not good. And we have to do a lot of education. And then we also look for their their posture, seeing if they have any major scoliosis or hyperlordosis. One of my favorite tests to do initially I started with dancers, I really like to do it on everyone is just an active straight leg raise, it doesn't have to be high. But what I'm looking for is just the ability to transfer load through the pelvis, we're looking for what we call pelvic limb dissociation. So the pelvis stays neutral and the leg, the limb is going up and down. And dancers tend to like to compensate. So what you'll see is that they're going to use their hip flexor to try to like, to try to drive things. And so their whole pelvis will wobble when they're doing that active straight leg raise. So we're really trying to get that leg to go up without anything else moving. And then so sometimes that will actually bring on pain. And then you can have them, you can teach them how to use their transverse abdominis and turn and like kind of decrease the tone in the hip flexor. And then all of a sudden, they see that they're better. And they're like, Oh, that's a reason to go to physical therapy. It's not that they're weak, it's that we have to change their movement. Also, when we're checking for hip abductor strength, we need to get into the nitty gritty. It's not just how good their hip abductors are, we really need to see what their gluteus medius specifically is doing. So making sure that we get out of that TFL and out of the other lateral muscles to so that we know what's going on, because dancers are really good at compensating. And there has been some association between lateral ankle sprains and hip abductor and gluteus medius weakness. So we tend to see a lot of ankle sprains, and we tend to see a lot of hip abductor weakness. And it's interesting, sometimes the muscles are truly weak, sometimes they're inhibited because of myofascial tightness, but it's just good to make sure that we're screening for this. If they even if they come in for a foot and ankle problem, we have to test their core and we have to test their hips. Dancers, of course, they have tight hip flexors because of the reasons that I mentioned above. So we like to use this modified Thomas test over here, where you can check the where the hips are lying. This dancer, you can tell the rectus femoris is tight because the knee is actually not hanging down completely. And then the leg is also up here. And also in that position, you can check the IT band because the leg will come out and kind of add up a little bit while that's tight. When we're doing our dance exam, this obviously is just relevant to our, our ballet dancers, but having that language and being able to talk with them in that language can be helpful. So on here, I have a little glossary of dance terms. And so if you can, like for a ballet dancer, have them, if you can throw out just plie, they'll appreciate that. Or if you know, like I always have people walk on their toes to see how their plantar flexor strength is doing. So if you just ask them to walk in releve, they'll be really excited. And so one of the things that I like to look at for is to see how well they're they're turning out or if they're forcing their turnout, because if they force their turnout, that's going to cause compensations up and down the chain. And so normally, in this talk, I have everyone stand up and try it, we don't have time for that. But if you think about having people stand with their feet parallel, and then you have them keep their heels down and at the same time, bring both feet out. And that will make it so they can't do one foot and then kind of screw their legs and try to get the other one in there. That'll make it so they have to be able to see where they're actually turned out. And if you actually have turnout discs, that's a way to get them so they really can't cheat at all. And so that's a really good first position is a good functional guide for other positions. And so when I'm having them do a demi plie or grand plie, for a demi plie, just making sure they're keeping their heels on the ground. And for both demi and grand plie, the knees are going over that second, that second metatarsal, and that they're really flexing at their ankle, at their knee and at their hip. For releve, this is a great place to look for symmetry. So a lot of people who have ankle issues will have decreased range of motion on one side or the other. And then you can also make sure that their, that their talus is neutral and that they're not adducted or abducted. And so we can watch their technique and how they're doing what we call a cambré. So just looking at trunk movement, and then looking at alignment and balance. So, you know, depending on what we're looking for, we're really looking to see where their trunk position is. So this could be a great piece of choreography, but this is not a great center of gravity or balance for for this particular position. So her center of gravity is way out here as opposed to being back. A lot of times we get asked to weigh in on whether or not someone should be dancing on point. And this is a very long talk. And one of my colleagues Dr. Shaw just just validated a screen, the Harkin Center for Dance Medicine has a really nice, has a really nice test that you can do in the office. But I think that most things can be worked on to get someone ready to go on to point, there's one thing that could get in the way. And that's like physical anatomy. So if someone doesn't have this flat plantar flexion here, then that's it, then you're not going to, they're not going to be able to get on to point because they need to be able to get over that, where their base of support is. So it's right under their center of gravity. The trunk for trunk control, the heart from the Harkness test, the airplane test, where they're in this position here, and then they plie and their hands come down, and they go up and down five times, it's called the airplane test, you can see, you can see videos of this test. And this was correlated, this is one of the tests that was correlated to show how if someone has the coordination and strength to be able to, to do point, and then some of the other tests they did were a single leg hop test. And again, the details of what that should look like balancing with one leg up and on their, on the ball of their foot for five seconds, and then doing what we call an on the door pirouette, which is a normal outside pirouette, and then looking at the control of the landing. So I'm going to jump over all the biomechanics of the dance specific injuries, because I think that these are all things that we could talk for hours and hours about, but just keep in mind that, and you will have access to these slides. But what, what we really need to think about as we're treating this, this population is to identify the diagnosis, but really treat the impairment. You know, it's like having ankle arthritis is not a big deal. Having ankle arthritis hurts, on the other hand, is a whole other story. So we need to figure out why it hurts. Is it because they've had too many ankle sprains, and now the ankles unstable? And how are we going to address that? And we really want to try to educate our dancers to try to get get them on, get them in earlier to prevent progression to worse injuries. Consider the extrinsic worst work factors, that's really an opportunity for us to weigh in on their occupational safety. So look at the psychosocial factors and the nutrition. So very quick anecdote, very quick study, dancers that came in with iliopsoas syndrome, 100% of them improved with dance specific training, whereas other ones in the past, we're looking at dancers, we're like, oh, if we do injections, like how many of them get better, maybe 50% of them got back to dance. But if we actually work on these chronic overuse injuries with a PT that is trained, they'll get better. Most important thing when you're treating a dancer, always start for what they can do. Because if you just tell them to rest, they will not listen and they will not come back. Bottom line, you can't say take two weeks off. What you can say is, I'd like you to do floor bar and not weight bearer, and work on some Pilates and work on your core, but that's instead of class. You tell them what they should be doing and how to stay active. We know that there's different forms of cross training. And then also, we really don't want them taking NSAIDs before dancing or before class, we don't want them masking things on a regular basis. And also with the evidence of NSAIDs maybe interfering with healing, that can be an issue as well. So we want to address our technical errors. We never say that they're weak, we always say that we're working on balance, we're always improving on balance. Dancers will take things personally, they're going to see pass and fail. We're not passing or failing anyone, we're getting things better. And we also really want to think about expanding our core work and our proprioception control. Dancers like rehab tools that they can incorporate their whole body. MJ Lederbach has some really great progressions for dance rehab. And just like everything else, we get mobility first, get rid of the myofascial pain, then work on the stability, then work on the strength, and then work on the endurance. And then with dancers, we work on things like metronome and other things like tempos and power, and there's really a lot of different factors that you can throw in there. So once that dancer can hold their leg up, that's nice, they've got the hardware, do they have the software to run it? Can they actually stabilize their pelvis during their activities? And that's where we get into the dance specific physical therapy. Make friends with your dance physical therapists, I can tell you they taught me everything I need to know. It really makes you a better clinician when you have that level of physical exam and that level of manual skills. Dancers like gyrotonics, doing things in front of the bar and the mirror are familiar to them, so they like them. Whether or not that's good is a whole other story, but they like them. And so very quick in summary, when we're treating the dancer, we need to look at everything, we need to look at the whole kinetic chain, and we need to put things in terms of the dancer's perspective. All right, we are going to take questions at that end. And so next, I'm going to introduce Dr. Stanek. Thank you very much, Dr. Elson. Hi, everybody. I am Jeremy Stanek with Stanford University. Get my screen going for you here. All right, so I'm going to be talking about history and exam of the instrumentalist. And some of the things that I mentioned have been said already. So there's a reason for that. All right, I have no disclosures. Here are our objectives. I'll be going pretty quickly through this as well. So I'll be throwing a lot of information at you, but definitely feel free to ask questions at the end. So considerations for you as a provider, you know, what kind of injury might you encounter if a musician comes into your office? And these are all things that you really need to kind of have in the back of your head. Do you have a knowledge of the requirements of the instrument that the musician plays? Do you know anything about their technique? Do you know the music lingo? That's really important as well. Just like you need to know, you know, dance lingo, or at least it helps to know a little bit when you're treating dancers. Same thing is there for musicians. And, you know, when you're examining them or taking a history, do you know what kinds of things that you need to ask them? So there are a lot of different types of injuries that can walk into your clinic. And, you know, remember that we as physiatrists are function doctors. And so that's what makes us superb at being performing arts medicine providers. So always keep that in mind. When we think about the types of injuries, there's a laundry list of things that you may encounter. Now, some of these things you may not ever see, like the ophthalmologic or dermatologic or psychiatric, but you might see these things in your clinic, either as a standalone thing that someone comes to see you for, or they may have one of these things going on in addition to what they're seeking care from you for. So at least knowing, hey, who can I send this person to, or having someone in your back pocket that you can ask about, that's good to know as well, because you will encounter these things. Know that common things are common. So, you know, musicians get the same types of injuries that everybody else gets. They get knee arthritis, they get carpal tunnel syndrome, all of those things. When it comes to more musician specific things, you know, your general MSK type of stuff, you're going to be seeing tendinopathies, you're going to see joint pain, those are going to be the more common things that you see. Low back pain is still very, very common in the musician population, just as much as it is in the non-musician population. When it comes to neurologic issues, that's more going to be your mononeuropathies. So, cubital tunnel syndrome, carpal tunnel syndrome, occasionally thoracic applet syndrome. So these are things that we should be great at treating and diagnosing. So, again, contributing factors to injury. A lot of things that the musicians have as contributing factors. Equipment is a big one, especially for your younger folks. And I'll show you some pictures here in a little while that kind of illustrate that. We've already learned that general health and conditioning can be a struggle for performers. On the right hand side, those bullet points are very, very important. And you'll notice that those are very similar to some of the contributing factors that you'll see with your athlete population. So there's a reason why we sometimes refer to these folks as arts athletes, because there's a lot of crossover in the things that you'll see with them. So, some helpful hints. Keep in mind that you do not have to be an expert, but it does help if you know some of the basics. And that's kind of why we do these types of presentations. And so we can at least introduce you to some of the basics. If you know that you have a musician coming in, try to at least familiarize yourself with their instrument a little bit if you don't already have a basic understanding. Knowing some of the lingo is also very helpful so that you can better connect with your patient. That will instill a little bit more trust in them with your confidence and you knowing what you're doing. So know that, you know, if they play loud, that's called forte. If they play soft, that's called piano. There are a lot of Italian words in music. Know that brass players use a mouthpiece. That's how they produce the sound on their instrument. Woodwinds actually use either a single reed, like a clarinet or a saxophone, or a double reed, which is basically two pieces of reed that are stuck together. And so bassoon, English horn, and olo are your double reed instruments primarily. Flute is considered a woodwind instrument, even though most of them are now made out of metal. But they're the the exception of woodwind instruments that don't use a reed. Percussion, they may use a variety of mallets, they may actually use just their bare hands, though they may use their bare feet as well. Strings, they can either use a pick, they can use a bow or may just use their fingers. So things to ask on history, always start with your basic exam. You know, where does it hurt? Describe your symptoms. When did it start? How long has it been going on? What makes it better? What makes it worse? What things have you tried? These are all things that we started learning in medical school. So that does not change at all when you're seeing a musician. When you do see a musician, it's good to ask them, do you have a similar kind of pain when you do things that aren't involving music? So if they have lateral elbow pain, does it only hurt when you're playing your violin? Does it also hurt when you turn a doorknob? Does it hurt if you're picking up a bag? Does it hurt? You know, if you're trying to open up a jar, things like that. See, is there, you know, something that they're doing in their daily life that may be contributing to the pain that they're getting when they're playing their instrument? That's very, very important, especially with as much typing as people do nowadays. A lot of piano players who get pain in their upper extremities don't realize oh, when I'm typing, that's actually a similar type of motion as when I'm playing my piano. So try to, you know, put those things together, because that can be very, very helpful. Similar again to our athlete population, you know, how long have they been playing? When did they start? Have they had any injuries like this in the past? And it's also important to find out, you know, what level of playing are they? Are they an amateur? Or is it, are they a pro? Do they play with a group? Do they do freelance? And what's their primary genre of music? Because the genre that they play can really have a big impact on, you know, the types of venues in which they're performing. Is it indoors? Is it outdoors? You know, what type of rehearsals are they in? That can have a lot of factors in giving you more information on what could potentially be, you know, a contributing factor to their injury. Other things, it's really important to get more information about what do they do with their craft? So, you know, how much time do they spend playing on a typical day? Do they do a warmup? There are a lot of musicians that do not do a warmup at all. They just, you know, sit down at the piano and start going at it, or they put their mouthpiece in their horn and just start, you know, playing in a rehearsal. So that can really have, you know, a big effect. You know, if you don't do a warmup as an athlete, you're significantly increasing your risk for injury. Same thing holds true for a musician population. When it comes to the amount of time that they're playing, a lot of musicians don't consider how much time they're actually spending on the instrument on a daily basis. They think of, oh, this is how much time I'm spending practicing on my own. They don't think about how much time they're spending practicing, plus the amount of time they're performing, plus the amount of time that they're in rehearsals with however many ensembles. And your collegiate musicians may be in four to six ensembles at one time. So they can be doing an extensive amount of playing, but don't really think about how much time they're actually spending on their instrument. So are they taking any breaks? That's very, very important. A lot of musicians, especially when they're practicing on their own, they'll just keep on going for an hour or two hours and never take a break. And then do they do any cool down or stretching? Some musicians do cool downs to try to get the blood flowing, try to wash out that lactic acid. When it comes to stretching though, a lot of musicians will stretch at the beginning of the day before they've done any warmup whatsoever. So as we know, if you stretch something that's cold, you're more prone to injure it, rather than waiting until you warm up or doing any dynamic stretches. So other things similar to athletics. Have there been any recent changes? That's very, very important. What type of music are they currently practicing? Are there any big changes? If they're a collegiate student who is an undergraduate, they may be practicing really hard or ramped up the amount of playing they're doing for a recital or an upcoming audition. That can definitely set them up for an injury if they have a sudden increase in either the volume or frequency that they're playing. What type of environment are they playing in as well? So your collegiate musicians usually spend a lot of time in a small room called a practice room, and they're in there anywhere from three to six hours a day. However, when you get into an ensemble rehearsal, that's usually gonna be in a larger room. And if they're getting ready for a concert, that's gonna be in a larger hall. So they may really have to increase the demands that they're playing when they go from those smaller rooms to those larger rooms. And if they haven't prepared properly, then that might set them up for an injury. Now, most of your pro musicians are already rehearsing and performing in those large venues. So they may have kind of that high demand at all times. And so again, that might be a contributing factor for their injury. So if they have had any changes in their equipment, that's also something to really keep in mind. So on your exam, again, do your standard physical exam first, because that can give you a lot of awesome information. Whenever you see a musician, always ask them to bring their instrument with them so that you can observe them playing on their instrument. That is really important. Always make sure that your staff knows that if you've got a musician coming, they need to tell that musician bring their instrument. Exceptions would be if you have a piano player who's coming in. My clinic, I've got an electronic keyboard in a room that way we can watch somebody play piano. They don't have to try to bring in their own equipment. Percussionists, they don't necessarily have to bring in a drum. They might be able to bring in just the mallets that they use regularly, and then a practice pad to play on. So there are some workarounds for these things, but make sure that they always bring some kind of an instrument that can demonstrate the type of activity that they normally do and how that may be contributing to their injury. It's always helpful if they have already done some kind of a warmup for the day. By the time they come into your clinic, that way they can be ready to go. I always like to challenge my patients a little bit when they come in. So I'll have them play easy stuff, and then we'll progressively get a little bit harder. Some musicians will have certain types of symptoms within a specific range of their instrument, within a certain loudness of playing, or within a certain difficulty. So for example, some musicians who have, say, a hand dystonia, they may only get symptoms when they're playing over a certain speed, or if they're playing specific notes. Similarly, brass players may only exhibit an embouchure dystonia when they're playing specific notes. So you really want to test kind of the full breadth of their instrument and their capabilities, because that'll yield some very good information for you. When you're examining them, do not be afraid to walk around them. Watch very closely what they're doing. If it's like a brass player or a woodwind player, you're gonna be watching their hands, you're gonna be watching their mouth. Especially pay close attention to wherever their anatomy is having the problem. In some cases, you can actually touch them and feel what the tendons are doing as they're moving their fingers, things like that. Watch for very, very small nuances, because you may have to pick up something that's very, very subtle, and sometimes it's almost imperceptible, but that little thing might lead you to a clue on what's actually going on, especially when it comes to dystonias. For brass players, there may be just a little bitty quiver in the upper lip or the corner of their mouth, and it's almost imperceptible, but that one thing might be what's causing their entire problem. It might be very helpful for you to take photographs or to do a video of the musician while they're in your clinic playing their instrument, and that can also potentially help you not only with diagnosis now, but you can maybe track any changes over time as they improve or hopefully not get worse. So as you're making adjustments or small changes with them in the clinic room, ask them what they feel. There should be a lot of two-way conversation between you and the musician, and musicians are very, very in tune with their body. They are very perceptive to even the smallest change, especially as they are more advanced as far as a player go. So definitely be asking them questions as you make changes. So this guitarist right here, you can see that there are different postures that are being maintained, and each of these postures can create either good things or bad things going on, depending upon what part of the anatomy is the problem. So you can see on the left is a pretty nice neutral position, but in that middle picture, hunched over quite a bit. And so if this person's having some upper back pain, that's a good reason potentially. Also, if they're holding the guitar really hard into the upper arm, you can cause a nerve compression right there. Sometimes just moving where they hold their instrument can make a big difference. On the far right, that's where some of your more classical guitar players will hold their instrument is in that position. And sometimes they'll use a footstool, sometimes they won't. If they do use a footstool, that allows them to not have to use their upper extremities as much to try to support the instrument. It can just sit on their legs, and that can be very, very beneficial. Also, look at their fingers. What are they doing? And that involves both hands. So your guitarist, they may be plucking with their fingers, they may be using a pick. You may have to just change what's the position of the thumb when they're plucking or holding a pick. A lot of times as well with their left hand, guitarists will hyperextend their thumb and put a lot of pressure on the back of the neck of the guitar. Looking at everything that their hands are doing is very, very important. And remember, you're a physiatrist, you're a function doctor, so pay attention to functionally what they're doing because that likely has a big impact on the cause of their injury. And as you heard earlier, oh my gosh, it just left me, so nevermind. Okay, when it comes to brass players, again, look at the face. What's the face doing? What's the position of the mouthpiece? That can also play a big factor. How much of the mouthpiece is on the upper lip? How much of it is on the lower lip? Again, you want to watch for symmetry in the face. Is there any abnormal movement as they're playing? Here's a patient I had come in recently. This is a French hornist. You can see that it looks a little bit different on the upper picture as opposed to the lower picture on how much of the lip is actually being used to play the instrument. So on the upper picture, that person's actually playing their actual instrument. On the lower picture, that's a device called an embouchure visualizer. So it's basically a mouthpiece rim and a rim only. And so there are a lot of little gadgets like this that you can utilize that can help you get a good look at what's this musician actually doing. So you can see the inner mechanics of what this person's lips are doing as they're buzzing to produce the sound on their instrument. And so when I talked about these really, really small changes that you can make, even when it comes to like a brass instrument, there are a lot of different changes you can make just with the mouthpiece alone, a lot of different parts to a mouthpiece. But the main ones that you can make changes to are the thickness of the rim and the shape and depth of the cup of the mouthpiece. So here are a few examples of my mouthpieces. On the left, it may be hard to see a little bit, but there are vastly different rim thicknesses between those three mouthpieces as well as the depth of each of those mouthpieces. And that will make a difference not only in the sound, but the feel and potentially the symptoms that they're going to get. When it comes to percussion, a lot of different grips that you can use and you can try different sized mallets as well as different styles of grip. Similarly with your string players, you can try different styles of grip and that can make a big difference. So remember, you do not have to be an expert at that instrument. This little kid on the left, you can clearly see that instrument is way too big for him. Maybe you can make a quick modification and that makes it easy to solve the problem. With the girl on the right, with the picture on the right of that, you can see that her elbows are flexed. She's really having to plantar flex her feet to get her feet to touch the ground. You can make some simple modifications by raising the piano bench and giving her a footstool. Now she's got a more neutral position. So remember, try to know some basics. You do not have to be an expert at this. And if there's something you're unsure of, do not hesitate to ask a colleague. All of us that do performing arts medicine, it's a pretty tight knit group. We know one another. We're always open to having questions. And so always reach out to any of us. That's what we're here for. Okay, I think I'm up next. Yeah, is that right? Okay. Ah, fantastic. Let me just share my screen. Okay, hi everybody. Good evening. I appreciate you sticking with me and sticking with us for this late evening. I'm Saj Surve. I'm co-director for the Texas Center for Performing Arts Health at UNT and also founder of our Performing Arts Medicine Fellowship for which Dr. Lee is our program director for that. And this topic is a little bit different than the ones we've had so far because everything we've talked about up until this point has been really in our PMNR wheelhouse in terms of musculoskeletal problems and things that are related to that. So we're kind of good with tendonitis and managing those kinds of things. When it comes to voice, there's a whole nother specialty for this otolaryngology, right? So there's all ear, nose and throat specialists who handle this area. And so for anything that's particularly serious, we absolutely want to refer these patients out to our ENT colleagues. That being said, that doesn't mean that there's nothing we can do as physiatrists. We can absolutely triage these problems. A lot of times voice issues are not necessarily related to the voice per se. There might be neck issues or jaw problems that we can influence and can make a profound difference on this person's voice and spare them the trouble of having to go to an otolaryngologist and get scoped and sort of deal with all those kinds of problems. So this talk, because we don't have as much training in this area, it's gonna be a bit more basic, just like bootcamp, as far as like, what is a voice and how do we deal with voices and how do they work? And so if you have any other additional questions about voice, please throw them in the chat. I'm happy to field those at the end. Again, no financial disclosure. If you wanna give me some, I'd be happy to take them, but I do not have any financial disclosures. So we just wanna understand some very, very basics of voice science and then get an occupational history. And up until now, we've had outstanding overviews on occupational history for performers. This one is just gonna be a little bit more tailored to voice users, so singers and actors and other people who use their voice for a living. So the biggest thing to understand about voice is that it's a tract. So the voice tract has certain parts to it. And this is how we think about the voice and problems in the vocal tract is like, where along the course of that is this problem occurring? So we have a general, the air has to get generated first. So this is our diaphragm and lungs are going to produce a column of air through exhalation, right? So we think about singing or speech, they're really like controlled exhalation. That's what's happening. And we're pushing air out of our lungs and we're controlling that air and vibrating it as it exits. And so any problems with breathing or diaphragmatic issues are gonna affect the voice. And that's an area where we might have to say, this person has a problem with generation. Maybe they can't hold notes for as long as they would like because they have problems with their diaphragm, right? Then we have the sound generation. So in the case of that, in the case of the human voice, sound generation happens at the vocal folds. So that's where the inside of the larynx, those two ligaments come together and we'll see a slide of that in a second and how about how that works. But as those folds come together, they vibrate and they produce a pitch. And then that air that's been shaken up to a specific frequency is then gonna continue through the vocal tract now excited at a basic pitch. From that point, that sound is gonna resonate, it's gonna travel through the oropharynx, through the nasopharynx, it's gonna amplify, bounce off of the sinuses and make its way through our mouth. And so during this portion of it, that sound is gonna amplify and it's gonna change. We're gonna modulate that sound to make it take on different characteristics depending on what type of singing we're doing or what we're trying to accomplish. And then we're gonna articulate that sound. So we're gonna have a column of air, but we're gonna cut it off and we're gonna turn it back on and off. We're gonna change the pitch. So we're gonna use our lips and tongue and palate to cut it off. So if we say like a B or a P sound, that requires our lips to come together and cut off the sound versus an L sound, a la la la, we're using our tongue to cut off and change that sound. So depending on which consonants and vowels we are using, we are gonna change the way that this sound is traveling. And then I'll just say before we get there, and then finally, that sound is gonna exit out of your mouth, right? And that is where the sound is gonna project out of your mouth. And so generally, the bigger your space is in the mouth, the more volume you're gonna get. So when you look at opera singers, for example, they train their jaws to be extremely open, right? They have to force their jaws open to produce as much volume as possible. So you get a lot of jaw problems related to that. So when we look at the vocal folds, so this is a view, if we've intubated anyone, we're familiar with this view. So this is our, we have a vocal ligament, which is there, it's a ligament, connective tissue. And then that layer of connective tissue is surrounded by a covering of mucosa, which we call the vocal folds. And so it's not the ligaments that come together, the ligaments bring the mucosa together, and then it's the mucosa that touch and vibrate and produce that pitch. Just like in brass, it's your lips, the mucosa of your lips that are vibrating to produce sound. Here it's the mucosa of your vocal folds that are vibrating to produce sounds. And you have muscles in the back, the arytenoid muscles, which are what contract and bring those vocal folds together. But that's neither here nor there. We're just trying to get to the basics now. So here's a slide of how that looks. So the folds don't just come together and then pull apart. They actually start at the bottom and they roll together and then they roll apart. And this is looking at it sidelong. If you looked at it top down, the folds still don't come together this way. They also roll front to back this way. So it produces a wave-like motion as those folds come together. That's called the Bernoulli effect. What that does is it means that at any given time, only a portion of the folds are together. Because if you think about it, on a hard glottal, if you sort of forced your folds together, no air could pass through, so you wouldn't have any sound, right. But we can sing and speak continuously, that occurs because if we sustain a pitch, ah, as we hold that pitch, the folds come together, a certain part is vibrating, but the other part is open to allow air to pass. And then that continuously changes to allow for a steady column of air that's vibrated to a specific frequency. The faster the frequency, the higher the pitch. So the faster the folds are coming together, the higher the pitch that you hear, the more energy you put into the collision of those vocal folds, the more volume you create. So you can do that either by pushing more air through your tract, which is the right way to do it. Or you can do it by forcing those vocal folds together by forcibly contracting those arytenoid muscles. And that forced contraction and then explosion of the vocal folds apart is also going to increase your volume. But it's going to do it in a way that's potentially detrimental and harmful to your to your vocal health. So we want to talk with our, our vocalists about, you know, doing things in the proper way. Now there are things called vocal formants. This is getting into a bit of math. So if you start to glaze over don't just just bear with me on this. So so when we talk about pitch, so here's your frequency. And in hertz, and then decibels in terms of loudness. So the loudest pitch that you sing, if you sing like a concert, a that's at the 440 range, this is 280. So this is somewhere below the lower half of the piano. But if you produce that pitch, that's called the fundamental frequency. That's the main pitch that you produce. But depending on your your unique vocal tract, you're also going to produce multiples of that as well. So not just 440, you're going to produce a 80 and 1660 and all the all the multiples of that up there on the way up. And they're going to so you'll see tiny little peaks in here that are occurring at all of the multiples of that that initial base frequency, and they occur at different heights, right. And so the the sort of unique palette of how those those peaks occur is unique to every voice and unique to every sound. And that's what gives voice its timbre or unique characteristics. So when you hear Adele sing, you know that it's Adele, right? You don't need anyone to tell you that that's Adele singing, you just know it. And that's because she has a very unique timbre to her voice that gives it that quality. So if you look at the profile of that, you'll see that, oh, that's that's the Adele profile. But you do have to control over this, you can't change it. So if this is producing the same frequency, but if you use an ah sound versus an e versus an ooh, this is the same person singing the same pitch, it's going to have very different profiles in terms of how those different formants get produced. And so how we sing a pitch and how you place a pitch can actually vary, which is kind of an interesting thing. So within yourself, you have the ability to change your profile. And so how do these voices so in terms of lingo, right, so here's our piano. So down here at an E, this is like the lower half, the C4, that's in gray, that's what we call middle C, that's like the middle of the piano, right? So your lower voices, you look at the bass voice, right? So that's living kind of down here where the high end is right at middle C, right? And then you have above that would be a baritone voice and then tenor, countertenor, then contralto, mezzo soprano. Now mezzo soprano, we sometimes interchange with alto sometimes depending on the context. And then soprano, technically contraltos and sopranos are their own thing. And mezzo soprano is a different thing. But sometimes if somebody will come to you and say, I sing alto, and they probably sing mezzo soprano, contraltos are fairly rare in the in the voice term, just like countertenors are fairly rare. So most are in the bass, baritone, tenor, mezzo soprano, or soprano range. And these are rough, you know, some singers have ridiculous range and can go above or below these in either direction. But this is a basic idea of where those voice ranges sit. And then within those voice ranges, there's different registers. So bass, as you can see, they have a first register sometimes called your chest voice. So you can sing very low down here in your chest, or you can sing very high in here in your in your nose or in your head. So your local register, this is called your sort of natural voice, or throat voice. And then this blue red register is called your head voice. And then some people have what's this fourth register in tenors, we call that falsetto. In sopranos, we would call that either like whistle register or something along those lines. And again, these are your mileage may vary, these notes, these notes are not exact, it depends on the person. But where you see this crossover, right, so when you're crossing over from first to second register, that's there's a natural break in the voice there, that's called the passaggio or the break. And so when you talk to singers, they will tell you things like, I have trouble, you know, I'm a tenor, and I have a problem when I have passaggio from my chest voice to my head voice, right. So now you know what that means. It means they have a problem kind of crossing over in this region, right. So being able to understand that lingo is really helpful. And just to speak that language, and be able to get a good history. So what is a good history from a singer? So we want to know what is their what voice part do they sing? And again, it's really variable some some, what would some would consider a baritone, others would consider a tenor, but how they self identify is important. So if they consider themselves a baritone, that gives you some idea of their rough vocal range. We want to understand what ensembles and content and other contexts they sing in. So they may be an opera singer, but they also sing in a church on the weekend, or maybe they have a gig, they have a studio, and they give lessons, or maybe they're part of a jazz ensemble, you know, every other week, and they sing in some smoky bar with a lot of environmental exposures, right. So we want to understand the context of how this person is using their voice, is their voice amplified or unamplified. So if you're an opera singer, you sing without the assistance of a microphone. So you so they have to just be able to produce that pitch. Versus if you're a pop singer, or jazz or country singer, you generally sing with a microphone, which is a very different style of singing, where you're able to have more control over that. And then like before, we want to ask you know, basic questions about how much time they spend on task with with practicing rehearsal. What do they have a voice voice coach? Do they have what kind of vocal hygiene? So do they take care of their voice at all? Do they rest when they're not singing? Do they shout constantly? You know, do they what's what's the usage of their voice, so we can understand all of that. And then any history of vocal fold injury. And along with this, I would also ask, have you ever been seen by an otolaryngologist? Right? Do you have somebody that you've seen and you trust? Because we would want to to get in touch with that person. Or if they don't, you know, would they be open to seeing ones and hopefully you would have somebody nearby you who you trust, who you can forward these folks to if they feel that they need a laryngoscope evaluation. So that's a very basic overview of voice concepts. Again, we just want to be able to understand some basics of how the voice is formed and understand the lingo and be able to get a good history from somebody. And if they have musculoskeletal issues that we can understand and address, then we can address them. But if not, and you're not comfortable about it, then you can absolutely send that person onwards to an otolaryngologist to get that addressed more formally. So those are my remarks, and I'll hand it off to whoever's next. I think it's Tracy. Yes. Sharing, sharing. All right. So. All right. So I am Tracy Espiritu McKay. I am at NYU Rusk as well as the Harkness Center for Dance Injuries. Sorry, Harkness Center for Dance Injuries. And I will be talking very briefly about the treatment options for our performing artists. I have no disclosures. And we're going to talk about things to consider when treating performers, the traditional treatment approach, which won't take long at all, and some other stuff. So first thing, we've all mentioned it, performers know their bodies. And sometimes they hyper focus on these injuries. So this will often distract them from performing at their prime at their best. You want to be careful with how you speak to them. You have to be empathetic with these patients, because ultimately, these injuries can lead to ending their career. So just be very careful how you speak with them. As many of us have already said, dancers have predominantly foot and ankle injuries that comprise 34 to 62% of injuries. And if you are curious to see what studies I'm referring to, I did include them in the slides. And musicians, particularly string players have upper extremity injuries that comprise 73 to 88% of all their reported injuries. So we have our usual rehab team players, you know, PT, OT, but it's really important that you pick people who are comfortable treating this population, someone who understands the lingo, their biomechanics, their technique, the vocab and their needs. And with the singing popular singers, you can have speech and language pathologists, but you can't just have any SLP treating them. You want to look for somebody with a subspecialty in vocology, and they would be considered a voice specialist. And these people get additional training in voice research and clinical management of the vocalist. So it's important to find somebody that is familiar with treating the singer and the vocalist. And of course, like the athletes, you have the psychologists who come in handy when you want to consider cognitive behavioral therapy. Alright, so let's talk about the other stuff. We've got about six minutes. Part of Eastern medicine is acupuncture, and it is technically considered a part of traditional Chinese medicine. And this has become really popular in the performing arts community. And this utilizes pathways or meridians in which an inherent energy called qi flows through all of us. This ancient qi is believed to be responsible for a person's general health and well being. And any disruption of this energy flow can cause disease. acupuncture is thought to stimulate the central nervous system by regulating neurotransmitters that control health and disease, such as serotonin, norepinephrine, acetylcholine, dopamine, GABA, and a good majority of performers don't like taking oral medications because it masks their pain. And they don't want to injure themselves further, which of course makes sense. So acupuncture is a really great option for them because it can help boost their immune system as well as decrease inflammation from an overuse injury. All right, some other things to consider are osteopathic manipulation, OMT, as well as chiropractics. OMT is performed by a licensed medical physician. It was formed and created, founded really by Dr. A.T. Still. And OMM uses techniques that include stretching, gentle pressure, as well as resistance on parts of the body that include muscles, soft tissue, and joints. The School of Chiropractics was founded by D.D. Palmer in 1895. And this is a type of hands-on treatment that focuses on proper alignment on the body's MSK system, particularly the spine. Chiropractors believe that this in turn enables the body to heal itself. So the other form of treatments that I really am going to spend the next four minutes talking about is movement awareness. So Alexander Technique, body mapping, Feldenkrais, and pedagogical retraining, particularly in musicians. This is, of course, not all encompassing, but rather just a short list of some of the most popular techniques that are used in the community. So first, let's talk about Alexander Technique. This was founded by F.M. Alexander. He was an Australian actor who experienced chronic laryngitis whenever he performed. Doctors couldn't really figure out why this kept happening. But Alexander later learned about the tension he held in his neck that was affecting how he worked and performed. Since that time, Alexander Technique has developed into an alternative therapy that focuses more on natural posture, and movement patterns, and less on taught exercises or postures. And this is really important for the performing artists because so much of their training, especially in the dancers and musicians, is really from copying a particular aesthetic or technique. The next one that we're going to go through is body mapping. And this was founded by William and Barbara Conable. This provides an understanding of the anatomy involved in the movements that are required to perform a task and is popular in the musician population. For those that practice and treat with body mapping, they treat with the idea that the body map is a person's representation of the body in their brain. I will show you a little bit more about this in the next slide. And the idea is that by facilitating the ease of the movement, one actually decreases the possibility of injury, because for many, music is movement and movement is music. So let's show you this. This is from the bodymap.org website. And the course pretty much gives you an introduction to what body mapping is. It talks about balance and finding the balance throughout the body, arms and its relation to the torso, breathing, and how it supports the structures a little bit better, legs and how you distribute your weight properly, as well as the body mapping masterclass, which sort of ties it all together, as well as with your instrument. Feldenkrais method. This is another form of movement awareness. And this was founded by Moshe Feldenkrais. This movement method is a system that re-educates through two methods. One is a group session. And that is where the participants follow verbal instruction from the teacher and deconstruct general movement patterns, while also exploring other variations. And the other is one on one where a fully clothed participant is guided through touch movement and verbal instruction. Let's see, is this my last slide? This is my last slide. Okay. This last one is the pedagogical retraining for musicians. And this is, well, when you talk about this, you're pretty much focusing on focal dystonia, which is a neurological disorder. And it's considered the most disabling professional disorder diagnosed to musicians. It is neurological task specific movement disorder. It is a neurological task specific movement disorder, where the muscles contract involuntarily. In the musician population, it's often limited to one part of the body, hence being called focal, and only occurs while playing their instrument. In fact, musicians dystonia seems to affect advanced players more often than the amateur and almost all those affected are classically trained. I've listed the top three instruments often affected here just in case you were curious. And early on when the symptoms arise, musicians often blame faulty technique or insufficient preparation, which then leads to worsening of their condition as they practice more and then they hyper focus on the impairment. So the real aim of pedagogical retraining involves rewiring the nervous system. This involves starting from the basics of playing even if that means playing scales on a piano repeatedly, and the musician would then be closely observed and advanced based off of their progress. Treatment could involve anything from fixing their posture to arm placement, or even breath work. Dr. Elson, I'm going to let you take over from here. That was great. Thank you to all the presenters for being here and sharing your expertise. We welcome questions and also really remind everyone that the FITS Forum is here for us to engage. So please feel free to ask questions. I think you can personally message and also I'm going to ask all the presenters just to drop your email in the chat so that way if people have questions later. I think one of the things that we really want to be there for is networking. I mean, this is, you know, physiatrists really are the people who can best take care of these performing artists. But sometimes as we're getting started, we have questions. And it's great to be able to share with everyone and we are planning on a session we won't know yet if it's virtual or in person for the fall. And if you have a question, feel free to come on screen and ask or to drop it in the chat or to drop it in the chat. We have lots of lots of experience amongst all the fields here. I will ask a question. Sure. So can you give us some examples of how some of these folks might be able to get more training on performing arts medicine if they want to put that as part of their practice. Absolutely. Before I hand it over to Dr Lee and Dr survey for for plugging of their fellowship program. We have. There are lots of places to get more information. So for the Performing Arts Medical Association is having its annual assembly in July, early July this year I know many of us will be there and speaking and it's really a great way to network and learn from physician, mostly physicians and physical therapists that take care of, of, I would say it's an equal to more musically focused conference but really, really great information. And then the International Association of Dance Medicine and Science is a really nice combination of everybody who takes care of dancers so we're thinking about that holistic part of things it's a great opportunity. I know I've learned a lot of my physical exam skills from the physical therapist, a physical therapist there. I'm just seeing in the questions to quickly answer the case based examples yes we are going to do that in the fall so thank you for bringing that up and specialized physical therapy is, yes, 100% best type of thing. Can't do it without it you cannot hang your shingle as a performing arts position without physical therapists that are trained in this. So for people who don't have access, I will write very very very very detailed prescriptions and talk to the therapist. And so I've had that a few times has worked very well. Sometimes I just need to get on the phone with it or I will say you know for a dancer use sermon protocol so that's basically doing everything I described before and so patient therapist was able to teach themselves that and we're able to move along with that. In terms of registries for therapists. Adams has one for dance medicine physical therapists. Pamela, I don't know if it's as robust for the music ones, it's a lot of networking in your area. I would say once you, you can once you know where you're practicing. Google is amazing. And so, I mean a paid registry that some people can be a member of its doctors for dancers.com I mean you don't really know who you're working with there. I'm listed on there I pay to be listed there. So there's a lot of changes from therapists to physicians to acupuncturists, and all of these people in this registry supposedly have a special interest in dance medicine. The other thing is that if you're near an academic center, I'm sure many of them have access to very specific therapists and remember there's virtual PT now which helps if you're in a rural area and you don't have access to care like that. Thank you. Do you guys want to talk about your fellowship. Yes, I'll hand it off to Dr. Lee is the program director. I'm so happy to talk about our fellowship. We have a fellowship in performing arts medicine, it is the only one, as I know that isn't in existence, and, and if you are in training. It's something to consider, because we are, we were able to create a community and here in DFW region Dallas Fort Worth area network of doctors, physical therapists, speech language pathologists, and to give you a full breath and experience that you can learn how to take care of a special population of performing artists, and you would get to also go and observe performances interact with the artists themselves, and also have your own clinic to take care of performing artists with us. It is not an ACGME accredited fellowship, because, as you probably know by now there's a very small niche area of specialty, but we are, we believe that we will be able to give you a very enriching experience for years so if you're interested. Just shoot me an email, I will be more than happy to share the details with you. Another way to find performing arts specialist in your area is to start networking with all of the, with all the different physical therapy companies in the area and like for example in Boston we started a performing arts or dance medicine journal club. After some discussions with the Boston Ballet physical therapist we realized that there's a lot of people hanging their shingles out there is performing arts medicine, with varying degrees of expertise so we figured we can't, we can't keep people from advertising So we started performing arts, or we started journal club so that we can get everyone up to date on current literature, talk about techniques, and then that really evolved into a community where we have, we have what people will have a list of the last questions, we do a screen for freelance dancers and we get everybody involved and so it's been a really nice way to meet the dance PTs in the community. Any other questions. I hope I didn't miss any of them. I always tell people to be a good performing arts medicine physician, get good at what you do. And then use that expertise on what you know from whatever your passions are. And physical therapists teach a lot. So, if you can hang out with a good therapist. That would be really helpful too. So I saw the So the International Association of Dance Medicine and Science. Also, Dance USA has some good resources it's not necessarily for position papers written up position papers and information papers written at the high school level so they're technically written for the dancers but I think just brief overviews and things that you can share so if you print them out and have them in your clinic. Definitely things that you can share with your dance population. So good resources there. You know the Harkness Center has an online learning program. PAMA has a certification program where you can learn more and get certified. Adams is in the process of some type of certification program. So lots of ways, lots of ways to get a curriculum. Oh, here's a question for Tracy. Well, I mean, I guess it could be for all of us, but we'll have Tracy answer that one about Alexander Technique. You know, so the question is, how much of Alexander Technique do you use? I don't actually use it. I have the added benefit of working at Harkness. So I work very closely with the therapists there, and they're very knowledgeable about movement patterns. Outside of Harkness, I've had one patient tell me that they practiced Alexander Technique, and I think it's because everything else failed then, and they weren't being treated by the appropriate therapists. So I don't use it all too often, but I don't think I'm the appropriate person to ask because I'm at Harkness. Alexander Technique is great. A lot of musicians do take lessons from, I guess, certified Alexander Technique practitioner. And in our region, there are few, not very many, and they can be costly. So in my experience, that has been the biggest barrier for my musicians to have access. And so I always suggest, especially if I think that they have a posture issue and traditional coaching, home exercise program, and physical therapy. I mean, at that point, physical therapy isn't affordable for them either. But if that is not possible, then I would suggest it, but then it's always been that the cost has been always the issue. So I would like you to be aware of that. There are a few people who do Alexander Techniques online, and these are all like individually, what is it? Self-employed people. And some of my patients do go to them or see them regularly online and have, I don't know exactly how they do it online because I think it's most effective in person, but I've experienced that with my patients too, but it's at a discounted rate. So look into it in your community. Alexander Technique also has a website. And I think, let me see if I can find it, but they also have a website and they also have practitioners that they sort of certify online as well. I find that as you go to some of these other conferences or make connections, you start to meet these other practitioners and you can get on their listservs. Like there's the Franklin Technique. And so I'm on the list for a couple of Franklin Technique practitioners. And so I'll see what classes are coming up and then I might have a patient come in that has a foot problem. So I'll send them to the Franklin foot class. We're also very fortunate in the Boston area to have physical therapists that have Feldenkrais background or have gyrotonics background or have Pilates background. So I think it really helps to be familiar with these different types of modalities because then you can refer your patients to the right place. And at the end of the day, we're only as good as the people we refer our patients to. So having that referral resource is really nice. And just to touch a little bit also on what Dr. Chervé said about the athletes and the arts. The dance medicine and performing arts medicine actually is really a little bit behind the game in terms of optimizing performance in some ways and we're ahead of the game in others. In terms of like the neurology and the neuroanatomy and stuff like that, I think that's where all of our research has been focused and very technique specific, but there are, I mean, but we're, the artists are athletes also and we have kind of forgotten about all that literature and all that information that we have on sports medicine. And so the whole athletes in the arts initiative is really trying to bring these two fields together. And it's been really interesting within the dance world is that we know that when dancers do physical conditioning, it improves their artistic work, their endurance, it prevents injuries, but trying to sell that to some of the old school and like understanding the culture behind that is really challenging. So we're not there yet. We're working on trying to find ways to make training more palatable and to prove that it's not gonna be a detriment to the dancers. But yeah, so just some interesting things to be aware of and some of the kind of the newer concepts. So a little preview of the fall, we will be doing some case-based reports. We will talk about ultrasound applications. We'll probably talk about some procedural applications bringing in PRP, shockwave for this population. I know that Dr. Popoli is preparing a talk on everything he learned to be a good physiatrist. He learned from dance medicine. So I think if we don't have any other questions, we look forward to seeing you in the fall. Keep an eye on the Fizz Forum in case we do anything else in the meantime. Oh, kinesio tape uses. Yes, artists like that. Helps with proprioception. We're not sure that it does anything like anatomically, but we like proprioception use. Anybody else feel free to jump into. I'm sure that that's good. I'll put that on the list of things to add. Oh, and I like the point clearance idea. So we'll add that to the list too. Great to see everyone reach out. We'd love to hear from you. Have a good night.

Performing Arts Medicine

Challenges in performing arts

Unique characteristics of performing artists

Prioritizing art over physical health

Obscure complaints of performing artists

Comprehensive care for dancers

Multidisciplinary approach in performing arts medicine

Physical therapists in performing arts medicine

Orthopedics in performing arts medicine

Behavioral health professionals in performing arts medicine

History and examination of instrumentalists

Common injuries in musicians