Welcome, everyone, to the Performing Arts Community Session. We are all very excited to have you here. So just to get started, I know people are still trickling into the room, so this might not be the best time to do this, but I really would like to know who's here tonight. So for that, we're going to start the poll right now. So can you just let us know if you're a medical student, resident, fellow, or attending. So that should be popping up in just a second. And while we're doing that, I'll just give you a quick rundown on the session tonight. So I'll give a brief introduction. And then we have introductory talks going through, and tonight's lectures are going to be a little bit more, like I said, introductory to performing arts medicine. And we're hoping that this will be a way to get people excited about the field, and if this is something that you do and that you practice, we hope to involve you in the conversations moving forward. And then we'll talk about Part 2 in a second, but let's see if we can get the results of the poll up. So a couple residents, excellent, welcome. And then a lot of people are already practicing, perfect. All right, next. All right, so I'd like to know your prior experience. So are you here because you're interested in learning about performing arts medicine, you know, a little bit, but you want to know more about other topics, or you already treat artists regularly? So please go ahead and submit that. And then, so just so you know, our second session is going to be on Wednesday, the 27th. And that evening, we're going to be sharing more advanced topics and more current up-to-date topics on performing arts medicine. And we really hope to get as many people there and as involved as possible. So please, if you have ideas, and we're going to put out calls many times over the years, let us know what you want to hear, so that we can make sure that we can get everybody's preferences in. All right, so just curious to hear who's here already. Okay, so we have a very nice split, excellent. All right, so again, quickly, what's to come? And so right now, I have 15 minutes to give you about two hours worth of talking. So we're going to fly through things pretty quickly. And really, you know, I have many, many more resources. So just touching on the basics in the brief introduction here. So reviewing what performing arts medicine is, understanding artists, and I think really importantly, what I'm going to focus on is why here at AAP Menar, what is our role as performing arts medicine physicians. And I'm supposed to go over the history and physical of the dancer, and that is a whole hour lecture in and of itself. So just a quick couple of tidbits for that. Performing arts medicine is really regular musculoskeletal medicine, but it's specifically about understanding the physical and psychological needs of this particular group. It's basically sports medicine, but it really does require a little bit of added knowledge. As a good musculoskeletal physiatrist, you can apply your curiosity and your interest in the field to really get to understand these really interesting artists. And it does help if you've done certain things before, but really having that passion there can help you learn enough to be able to take care of this population. Are performing arts, are they really, are they arts or are they sports? And the type of medicine that we need to take care of this population really is equivalent to what we need to take care of our athletes. The big difference, though, is that when you're getting an artist back, they have to perform at the same time. So they can't be like a football player and grunting on the field. You don't want to see a musician breathing heavily as they're trying to get through a difficult passage or a dancer sighing when they just finish a very difficult passage. Artists very often require impact at physiologic extremes. So whether that be with musicians, super slow movements going really quickly, or with certain types of dance genres, extreme ranges of motion. When we're thinking about how we're addressing these performers, we need to understand the demands on them. So that very often, especially in the younger population, there are a lot of familial and financial demands that are placed on them. Very similar to other athletes, but a little bit more dissimilarly, some of the specialization does start a bit earlier. For this population, their careers, I would argue, are even less certain than those of the professional athletes, because you can make it big in the performing arts and still not make enough to make a living out of it. Performers are often seen as very difficult to treat because they over-dramatize things. But when we think about it, they're just very attuned to how their bodies work. And so being able to listen and understand where they're coming from can be very important for how we take care of them. There are a lot of barriers to why, in the past, performing artists have not sought out physicians. And I'd like to think that within the performing arts field, we are helping to show dancers and musicians and other artists that starting with a physician that specializes in treating performing artists is especially the best place to go. Because the perception that we don't understand, or that we have to have some huge intervention, I'd like to think we could get rid of that stigma. There is also a lack of full health insurance for this group. So in the future, we'll talk about ways to help out with that. So why performing arts medicine at AAPMNR? Well, now with these new community sessions, we're really trying to help all physiatrists have a home at AAPMNR. And even for those of us who are passionate about performing arts medicine, we really want this to be our place to collaborate. Physiatrists have really been getting involved with performing arts medicine, maybe starting about 20, 25 years ago, but really much more intensely over the last 10 years. And I would argue that we are the best physicians to be able to take care of this population, or at least as part of the team and for them to start out with, but we need to collaborate with each other because we do overall have a great breadth of expertise. But it does get very subspecialized. And so I know that I've learned a lot from my colleagues here, and I know I have a lot more to learn. So hopefully we can get everybody here and getting everyone presenting. We hope that by having this at AAPMNR, this is a place where we can network. This is a place where we can find peer support. And it is really important that we stay connected to our academy, because this is where we're going to get our resources and our leverage as physiatrists to be able to practice the medicine that we want to practice. So here, what we want to do is introduce some of the resources that are available and develop content for future presentations, and again, get to know each other. For those of you that got a chance to join us, we started journal clubs this year, and our goal is to continue doing this about every other month. One of our goals is to eventually collaborate with other groups like iADAMS to share journal club resources. Also, you have the PhysForum to ask questions, and there is a library where we can put relevant articles on the PhysForum. Please, it's never too late. Please send your content ideas for 2022. I will be serving as chair for this community for one more term, and then I am looking for a replacement. So please reach out to me if that is something you are interested in, and there are plenty of ways to get involved. Also, we have Dr. Survey and Dr. Lee here. They have their first Performing Arts Medicine Fellowship in the country. Please reach out to them to find out more about this, especially for the residents that are in the audience. This is a really unique opportunity. For those of you who are looking for more information on other groups, the International Association for Dance, Medicine, and Science and the Performing Arts Medical Association are wonderful resources. There are also many others on here. There are different ways that you can get involved. All right, so five minutes to get through history and physical exam of the dancer. Again, these are just a quick couple of tidbits from much, much more in-depth talk. The history, just like any other physiatric history, you know what's involved with that. The thing that's going to really help you connect to your dancers to get into the specifics of what they're doing, you know, exactly how many hours a week they're doing of which type of genre. You want to know what their training history is, what their cross-training history is, if they're actually trying to supplement what they're doing at all. You always want to ask what brings on their symptoms. You want them to demonstrate what actually hurts, and then you want to be able to speak in their language. So if they're mentioning a particular dance move and you don't know what it is, ask them to teach it to you. The other important thing for dancers is to understand what their ideas are or what their perceptions are about what they think is going on. And very often they'll be able to tell you where they might be compensating or what started first or where things have been coming from. Other things to consider for dancers are costumes, shoes, so you want to know if their feet are growing, if they've grown out of their shoes, the wear of their shoes, how often they're replacing them. You can look for wear imbalances. And when we get to the physical exam, more importantly than anything else, the point I want to drive home is the kinetic chain. When you look at all the injury data, there are far fewer injuries depending, again, on the exact genre of most forms of dance compared to other sports. Very often what we see are overuse versus misuse injuries. And very often this is a result of postural, I want to say issues, but sometimes related to fatigue, asymmetries, and just different patterns that aren't working very well. So keep in mind that your dancers are going to very often have a different range of motion than your normal population, so you're really comparing for symmetry. So a pass of straight leg raise at 90 degrees is not necessarily negative. Also, one of the concepts that I stole from sports medicine is when you're looking at strength, hardware versus software. So if they have good side-lying hip abduction, that doesn't necessarily mean that they can balance on their leg very well. So we want to look at them and their functional patterns. And then for their overall recruitment patterns, one of the things that we're really looking for for dancers is one of the most common recruitment patterns, variant recruitment patterns that we see is very often they'll overuse their hip flexors without engaging their transverse abdominis first. So again, these are all much more detailed, nuanced things to look for, and I'm happy to share slides and share full slide decks for anybody who's interested. A couple other quick things, and this is more for the ballet side of things, turnout, hypermobility, and the desire to get on point as soon as possible are things that I think are the basics that within dance medicine we need to see, because these are the things that the parents are going to be asking us for the young dancers that are coming in. Within ballet, there's this desire to be in a turned-out position at 180 degrees, and you can get an idea of the biomechanical forces that are going on through the body if that 180 degrees is not natural. If it's natural, then the dancer is able to stand how they should and use their muscles optimally. But when they're forcing it, like in this dancer here, you're going to get a lot of excessive strain through the lower back, through the knees, and they're not going to be able to, number one, perform as well, but they are going to be more at risk for many different injuries. Also with the hypermobile dancer, there are a lot of considerations. So hypermobility can be a desirable aesthetic for certain choreographers, but if it's not used well, then we end up treating a lot of injuries that are related to misuse. And again, many dancers are very interested in getting on point, and there are some great resources on the IADAMS webpage for what is necessary for a dancer to be able to get on point, and these are just quickly taken from there. And at the end of the day, it comes down to range of motion and neuromuscular control and experience. So in summary, the evaluation and treatment of the dancer requires attention to the details and kinetic chain, kinetic chain, kinetic chain, and we, as physiatrists, are really the best doctors that can take care of this population. Thank you for being here, and now we are going to move on to Dr. Stanek. All righty, I am going to try to get through things as efficiently as possible. All right, so I'm going to give you a little bit of information on history and exam of instrumentalists. I have no disclosures. Here are our objectives. We're going to try to understand a little bit better about, you know, how do we approach our examination of instrumentalists, but are there any unique things that we need to think about when we are taking a history with these performers? So some of the considerations that you need to ask yourself, what are some of the injuries that may walk into your clinic? Are there specific requirements that the musicians have or specific techniques that you need to know about? Anything specific to their instrument? Do you know their lingo? So you're going to hear a few things that I'm going to tell you that just occurred in the last 15 minutes as well. Do you know what to look for on exam? Do you know what kinds of questions to ask an instrumentalist when they walk into your clinic? So there are a wide variety of injuries that you can encounter. You name it, and it can walk in your door. You know, musculoskeletal, those things are the easy ones to think about, tendinopathies, joint pain, things like that. There are some other things farther down on the list here that you may not necessarily think about. So neurologic injuries. Most of us as physiatrists are very, very familiar with carpal tungus syndrome, but there are other things that you may encounter. You may have an instrumentalist that has a tremor. You may see someone who has a vocal dystonia. Otologic, pulmonary, laryngeal, those are very, very common as well. Psychiatric is more and more common, and if you are a performing arts specialist or performing arts provider, you may be the first person that someone comes to you, or the first person that someone approaches with some kind of psychiatric issue, such as performance anxiety. Dermatologic, these are things that you can see as well. A lot of people don't think about derm issues with instrumentalists, but it does happen. For example, your viola players and your violin players are resting their instrument on their chin or on their neck almost the entire time. Additionally, brass players can have an allergy to whatever type of metal is used to plate their mouthpiece. So you can see derm issues. You can also see eye issues. I've had this as well. So as you can see, there are a ton of different contributing factors to injuries. I'm not going to go through this whole list right now. We're going to talk about some of these things as we talk about the history and exam, because you'll see there's a lot of pertinence to this. So some helpful hints just right off the bat. Try to familiarize yourself at least a little bit with some of the more popular instruments. You don't have to know how you play a zither or something like that, but at least make yourself aware of what does it take to play a brass instrument, what are the parts of a brass instrument, how about woodwinds, how about strings. So you don't necessarily have to be an expert, but at least knowing some of the basics can be very, very helpful for you as a provider, but also helpful for how you treat your patient and make your patient feel more comfortable with seeing you. Knowing at least some of the lingo is also helpful, and that will help you better assess and manage your patients. There's a lot of stuff to learn, but just know some of the basics. For example, knowing that forte means loud, piano means soft, as far as how loud or how soft someone is playing, because you may have someone come in who says, yeah, I only get this pain whenever I'm playing forte, but I don't have any problems when I'm playing mezzo forte or mezzo piano. Know that brass players use a mouthpiece to play their instrument. Woodwinds, they use either a single reed or a double reed, with the exception of flute, because flute has a tone hole and a mouthpiece that they just pull across. Percussion, that can be just about anything that's kind of a grab bag. They may use their hands only, they may use mallets, you have no idea when they walk in the door. String players, they might be using a bow, like violins use most of the time, however, they can also pluck with their fingers, or you'll also see some instrumentalists that use a pick, such as banjo, mandolin, and guitar. So some of the things that you want to really focus on on your history, again, basics. Basics are always important. So think of the basic things first. Where does it hurt? How long has it been hurting? What's the quality? What makes it better? What makes it worse? Have you tried any treatments for it? Have those things helped? Are there other comorbidities that you have that may be corresponding with this? Another really important thing is to ask, do they have a similar pain with non-musical activities? So their injury may be completely unrelated to playing their instrument, but it might be related. You don't know if you don't ask. Sometimes a non-musical activity can, either it could have caused the problem or it can prolong it and keep it from improving. So really make sure that you ask about non-musical activities and if they have similar symptoms. Remember that everyone gets old, so that shoulder pain that they're having may not be a result of them playing their instrument. It just may be glenohumeral arthritis due to their age. When you're thinking about, okay, the basics are done, how do we really hone in on the musician themselves? Ask them how long have they been playing? And this is similar to seeing an athlete. How long have they been playing? Have they had similar injuries in the past? What is their level of playing? Are they in school? Are they an amateur? Are they a professional? And what genre do they play? Do they play marching band music? Do they play in a jazz band, rock band, play in an orchestra? And this can be very, very important because usually each genre has different demands on the musician. It's very important to get an idea of what a typical day or a typical week is like for each of these musicians. And that'll really be variable depending upon what level they are, whether you're in college or an amateur or a professional. A lot of people will kind of forget about asking about the warmup, but this is very, very important. Ask as much detail as you can about their warmup because this can have a really significant impact on them being susceptible to developing an injury. Have them describe what do they do for a typical warmup. It's also important to find out, do they even do one? Because not every musician does a warmup. Sometimes they'll just get their instrument out and they'll go in full bore, and that may be what's causing their problem. Do they start soft and then get louder? Do they start slow and then get fast? Really get the details. Ask them a lot of information about individual practice time. How much time do they spend either in group rehearsals or performances? The amount of total time played per week really adds up really, really fast. And it's something that most musicians and providers don't think about a whole lot. But just like our athletes, the amount of time that they're practicing can really be a cause to why they got their injury. How often do they take breaks? And then how long are those breaks when they take them? And then do they do a warm down or a cool down when they're finished at the end of the day? Do they do any stretching? It's also important to ask, when do they do stretching? Because a lot of musicians are notorious for doing stretching before they've done any kind of warmup whatsoever. Other things, just like in athletes, any recent changes in the amount of playing? What are the themes that they are playing? Any big changes in the type of repertoire that they're playing? Anytime you've had a sudden increase in the amount of practicing or playing you're doing makes you more susceptible to injury. Ask if they have any upcoming concerts or big auditions, anything like that. Because those are things that can really increase the stress on the musician. That can further lead to injury. What type of environment are they playing in? Are they playing in a concert hall? Are they playing outdoors? Are they playing indoors? Are they spending all of their time in a practice room? Any recent changes in their equipment? Equipment changes can really lead to big time issues, especially if that change has been made without any supervision. And this is seen more so in students than it is your professionals. But even in professionals, you can see problems as a result of equipment changes. An example would be if you have a violinist that decided to play a viola as well, because the viola is a little bit bigger, and so their body mechanics are gonna be a little bit different. So that might make them more susceptible to injury. Moving on to physical exam quickly. You know, do your standard physical exam first. Common things are common. So if they have pain at the lateral epicondyle, it might be lateral epicondylitis. It may have absolutely nothing to do with their instrument whatsoever. So your standard exam will give you a lot of great information. Whenever you are seeing an instrumentalist, always, always, always make sure that they bring their instrument with them. Now granted, there are some exceptions. For example, piano player's not gonna be able to bring their nine-foot grand piano. In my clinic, we have an electronic keyboard. It's full 88 keys. It's got weighted keys, so it feels like the real thing. You can get those fairly inexpensively, and so having something like that can be very, very handy for evaluating a keyboard player. With percussionists, it's not very realistic for them to always bring in their equipment, but if they have a practice pad, they can bring in some of their standard mallets and a practice pad and use that to demonstrate what their technique is. It's very helpful if they've already done some kind of a warmup before they get there. That way, as soon as you start examining them while they're playing their instrument, it's more of a realistic kind of situation as far as they're warmed up, they're ready to go, and maybe they can demonstrate the different things that are causing the pain that they have. It's helpful, I find, to have them play things that are easy, but also have them play things that are difficult. You can either have them bring their own music, or you can supply music for them. Having them play something familiar, something that reproduces their typical pain is gonna be very, very helpful for you in the long run. You'll also wanna test them a little bit. When I'm seeing brass players and woodwind players as well, I always have them play the full range of the instrument from lowest to highest and back down, because this is gonna change day-to-day pretty much with brass players, not so much with woodwind players, but with brass players, it's gonna change on a daily basis. It may be fine if their lips feel good or don't feel that good. And so you really wanna kind of test them, and you can use that as a measurement over time of how are things progressing or regressing. Other things, don't be afraid to walk around, touch them, really look at them very closely. There are very, very small nuances that you can pick up when you're watching very, very closely and if you're not paying really careful attention, you may not pick up on those nuances. And those really small things that are going on may actually be either a cause of their pain or a result of their pain or whatever other issue they have going on, which may not be painful. I find video to be very helpful as well. There are some video tools that will allow you to slow down the speed. And so that can be beneficial for you and the patient, because you can slow things down. You can also show the patient exactly what their body is doing in time, and then you can help use that as a teaching tool for them as well. Depending upon what your EMR is, you may be able to save that video in the electronic medical record, and then you can also use that as a way to track their progress over time. Don't be afraid to make small changes with them as well. Ask them to really give you good feedback on what they feel when you make changes as well. Musicians are usually very, very aware of sensations of the body whenever they make really small changes. And so this can be really helpful for you as well as far as figuring out what's the best treatment option. Some examples of changes, brass instrument mouthpieces. Up on the top right is just a cartoon of a cross-section of a trumpet mouthpiece. You can see you've got a lot of parts to this. You've got the backbore here on the right, the throat kind of towards the left third. You've got the cup, and then you've got the width or thickness of the rim. All of these parts of a mouthpiece can be changed. They don't all have to be changed at one time. You can change just the thickness of the rim. You can change the shape or depth of the cup. You can see down here is a picture of some of the mouthpieces that I keep with me in my office. So just making a small change in a mouthpiece can make a big difference in a musician's perception and effectively treating their problem. Some other examples, there are different types of grip that you can use with bows, as well as with mallets and percussionists. All different things that you can do that are subtle but can make a big difference. So you don't always have to be an expert at that instrument. You know, when you look at, say, this kid on the left with the tuba, he is clearly way too small for this instrument. So, you know, that's an easy one. With the girl on the right, you can see the picture on the right. Her elbows are quite flexed, and her feet are, you know, plain or flexed, she's got her tippy toes touching on the floor. You make a small adjustment. Now her elbows are at a 90-degree angle, and her feet are flat on the surface. So look for, you know, postural issues that can cause problems. That's an easy one. So closing points, you don't necessarily have to be an expert at everything. Look for easy, low-hanging fruit like that. The more details that you can get from your HNP, the better off you're going to be with treating and educating your patient. And education is a big issue. We should be doing more than just prescribing PT medications and giving injections. We can educate our patients because we're the experts at what we do. And if you're unsure of something or need help, don't be afraid to ask one of us. I ask my colleagues questions all the time, and that's why I love having this resource because I know my limitations. I know I don't know everything, but I know people to ask if I know there's something I don't know. Thank you so much, Dr. Stanek. Next, we have Dr. Lee. Thank you. Okay, I will also try to be as efficient as I could. Good evening, everybody. All right, so I am going to talk about osteopathic manipulative treatment for performers. Today's focus is going to be just me sharing how we utilize OMT for performers at our practice at UNT Health Science Center. Maybe you can share a little bit of what OMT can provide in terms of value for performers, and maybe do a little plug at the end about how you can learn more about OMT for performers. I'm not going to talk about details of techniques or evidence of manual medicine. If you're interested in this, though, just let us know because I think we can definitely add something like that in our future programming. So our practice is actually really busy right now. Dallas Symphony, Fort Worth Symphony is both up and running. Dance studios are all open. Texas Ballet Theater is back to full schedule. Our Musicians Clinic at UNT College of Music has been open since September. During this time, OMT becomes a really essential tool for our performers. If I were to generalize how we utilize OMT in our practice, I would say we use it as an adjunct to treatment for various musculoskeletal diagnosis and to help alleviate various somatic complaints during the season to support the performers. This is just a brief slide. I just wanted to start with this because, and you've heard this already, musculoskeletal injuries dominate performers and their injuries, their problems. We already talked about it in the previous meetings and also already tonight. And we're really all too familiar with types of pathologies that we would see in our performers, I think our audience, especially tonight. But what about these complaints? How do we approach patients like this? Let's say the 22-year-old dancer with a stuck feeling in the ankle. And oh, by the way, the dancer feels that this tension is kind of spiraling into the lower lumbar and SI region. What about this patient, 34-year-old violist with a fingertip pain? It only occurs when playing double stops. 26-year-old soprano with a pull in the jaw. There is pain in the jaw and a tension in the tongue, but most importantly, this is limiting her ability to sing, especially really super unhappy with her lower passaggio. And then 18-year-old trumpet player with a sound that isn't clean. That's it, right? And so often cases like these, our assessments are unremarkable. And in fact, they come and find us because they have already seen other doctors and they were told that there's really nothing wrong with them. But when we start to add our osteopathic evaluations, we start to find somatic dysfunctions that exist that contribute to the patient's chief complaint. So those of you who are unfamiliar with the term somatic dysfunction, in short somatic dysfunction refers to palpatory exam findings that exhibit tissue texture changes, asymmetry, restriction of motion, and tenderness. You know, we tell our students, year one and year two osteopathic students, that we can technically call somatic dysfunction a somatic dysfunction if you find two out of the four of the start criteria. So in our case of the dancer, while our history and physical exams are unremarkable, we were able to diagnose somatic dysfunctions of the ankle, fibular head, sacrum, pelvis, lumbar spine, explained by a particular section in a new choreography. So in another word, the performance itself caused a somatic dysfunction that could potentially explain for the patient's complaints. So with OMT, the symptoms could completely resolve, but then they will come back because the dancer will go back to rehearsals and practices. And therefore the dancer will come back to our clinic during the season every week or every two weeks during the rehearsal. The symptoms went away after the performance was complete. This is often how we utilize OMT in our practice. The patient's primary complaint is direct result of the somatic dysfunction, likely related to what they do every day, day in and day out for hours at a time. And so while they're in season, we try to support their somatic complaints with OMT. As for the 34-year-old violist's fingertip pain that only occurred with plain double steps, our assessment, again, was unremarkable. Just the fingertip, right? But then we found somatic dysfunctions of the cervical, thoracic spine, AC joint, glenohumeral joint, radial head, and carpals and IP joints. And this patient had a recital to prepare for. So while training for this recital, patient came to see us for OMT. Of course, the complaint resolved, again, as the patient stopped playing this particular repertoire after the recital. So amongst ourselves, we sometimes call this like a training model, following after the sports medicine model, where we are utilizing OMT to support our athletes in the arts with OMT during the season for their optimal function. What are some of the other ways that we utilize OMT? I wanted to add an example of OMT that we use as an adjunct to existing treatment plan. This is our 24-year-old soprano with a pull in the jaw and then really unhappy with her lower passaggio. And this patient is not a professional musician, but an amateur. And on her first visit, she was diagnosed with TMG syndrome. We had suggested to her to see a counselor for anxiety, and then especially performance anxiety, and she did. And we also referred her to a dentist for a night guard. And then she's taking acetaminophen sparingly as needed. We had counselor on possible risk of vocal fold hemorrhages with NSAIDs and aspirin use. And then we offered her osteopathic manipulative treatment. This is a video of her first and second visit. I hope you can see the subtle differences in her jaw and the range of motion of the jaw. So this is her first visit. And then this is her second visit. With the subtle differences like this and improvement of the range of motion and jaw deviation, most importantly, she reported subjective improvement of the sound. And that's what she was most happy about. And really the ease of singing when she was singing during rehearsals. Another example of addition of OMT in existing treatment plan. And this is a violist with musculoskeletal neck pain, upper thoracic pain, and a pain in the lower back. Musculoskeletal neck pain, upper thoracic pain, myofascial trigger points, trapezius scaling, the upper quarter region, very typical for viola and violinist. Pain was severe enough for her to think about taking a break from the season. Very high level player. I hope you can see this in the video because I tried to block out her face. Let's try again. Do you already feel that when you look towards that side? Yeah, I feel it over there. So what she's trying to do here is that her cervical side bending is always side bending towards the left. And in this season, she's explaining to me that she actually needs to look at her music that is on her right side. So while side bending left, she also needs to rotate quite a bit towards her right too. And so what we did is we also changed her chin rest and raised her shoulder rest higher. And then we started her on physical therapy, counselor on posture and ergonomics, and she's trying very hard right now in the symphony, try to sort of adjust her seat so that she doesn't have to rotate so much towards the right. But she also didn't want any medications, injections, not even dry needling. So in this case, OMT was kind of the only option for pain management. With physical therapy and improved ergonomic problems, her pain really improved significantly. But while we were getting there, OMT was used as a pain management option to help her function as a symphony musician without taking any time off. This is my final example of OMT as an adjunct treatment. This is a 19-year-old male trumpet player with a primary diagnosis of overuse syndrome. This patient, he rested all year last year because of the pandemic. They didn't play at all. And then they returned this year fully schooled, all the ensembles are back on, and then got injured playing like 20, 25 hours a week. So what we did, we reached out to his professor, and he's now out of all ensembles, rested for two weeks. Now he's playing without any pain or fatigue for about 15 minutes, but then now super, super unhappy and extremely frustrated with his sound. So a primary improvement of this, obviously, is going to be his weekly lessons with his professor. But then what we did was reutilize OMT to see if we can treat his somatic dysfunctions of the head and neck and the muscles of mastication and muscles of facial expression and the muscles that he used to create an embouchure to see if we can help him create the sound. So again, hopefully, this will... And then this is after treatment that day. Of course, you know, this isn't perfect yet, but after treatment, he reported some improvement of the sound, but most significantly improvement in effort. For me, I see that I hear that. I couldn't show you his face, obviously, for protection of his identity, but this is kind of what we use OMT for when we're using it as an adjunct treatment. So in summary, we use OMT to support our performers for the somatic sort of MSA complaints during the season. OMT can be used as an adjunct to satisfy sometimes somewhat esoteric complaints coming from the performers and support their function and their ability to create art. And also finally, really, actually, very importantly for me, OMT gives me opportunity for time. I'm able to use my hands to address their concerns, however different and unique it may be, and also gives me opportunity to ask and educate about body awareness, mindfulness, lifestyle changes to achieve more of this holistic visit and address mind, body, spirit as a whole. I have about two minutes, see if I can achieve this. This isn't anything significant yet, but we're starting to kind of get some survey results back from our Musicians' Clinic here, and we're starting to ask some questions about their function. We're seeing positive results for OMT effect on their sound compared to the group that did not receive OMT. I'm not really sure where this will lead yet, but I thought I would share with this group a little bit about what we have as we collect this kind of data. So lastly, how do I learn, if you want to, how to use OMT for performance? If you're a DO and you're just kind of go back to what you learned in school, simple, just go back to simple techniques. I have a YouTube channel just so that our students look at the videos so that they can go over techniques, and there are other people, some of our faculty also have a YouTube channel sort of demonstrating techniques that are easily, you can easily review. And then little sort of shameless plug for our program here. Now, if you're really serious about this type of an approach, musculoskeletal management for performers, but with an osteopathic addition to that, we do have a performer's medicine fellowship, and you can learn a ton of what we do and how we use OMT for performers. That's what I have for you. Okay. Thank you so much. All right, we're going to transition to Dr. McKay. Hi, everyone. So I will be discussing complementary treatments for performing artists, and I've got no disclosures. And there are just a few things that we're going to discuss as far as objectives go, things to consider when treating performers, which Dr. Stanek had discussed briefly, as well as Dr. Elson, the traditional treatment approach and other considerations. So first and foremost, performing artists really know their bodies better than most people. They're a different breed in the sense that they're really attuned to their bodies. They know when something's off or if something's changed. So if they're voicing a concern, it's pretty valid. The problem is that performers can often hyper-focus on one area of pain, which then distracts them from performing at their best. You want to be careful with your words. Remember that these people make a living off their art form, so we need to be cautious and not catastrophize their injuries. We should be empathetic with all our patients, but our performers in particular can benefit from a simple statement like, I know this is really difficult, but we're going to work together to get you back to doing what you love. And, you know, as physiatrists, we're pretty good about that stuff to begin with. We understand function and we're the best people to manage their recovery. And another point to be aware of, foot and ankle injuries are most prevalent in the dance community, whereas upper extremity and head neck injuries are most often seen in the musician and vocalist populations. So of course, the usual rehab team players, we are all familiar with them as physiatrists. We're going to begin with physical and occupational therapy for treating musculoskeletal injuries. It's important to seek out a therapist who's comfortable treating performers. And I often recommend that the performer bring their tools with them to their appointments, whether that be their instrument, their shoes, or anything that they're using in their art form. It's important for the therapist to understand the nomenclature used by their patient, as well as the biomechanics involved in the art form, so that the root of their injury can be addressed appropriately. There are performing arts fellowships out there recognized by APTA, which is the American Physical Therapy Association, as well as national networks of healthcare providers that are well versed in treating performers. The trippy thing is that some of these networks require clinicians to pay into the system to be members and to be advertised. So that's just something to be aware of. But outside of this, you can also find well-versed therapists if you happen to be near large academic institutions that have performing arts centers, voice centers, dance centers, and occasionally centers with specialists in treating musicians. We can't forget our speech and language pathologists, like PT and OT, not every, well, like the PT and OT treating performers, not every speech therapist is knowledgeable about the needs of a singer. So it's important to find a therapist who subspecializes in something called vocology, which is additional training and voice research and the clinical management of a singer. Last but not least on the rehab team is psychology. Cognitive behavioral therapy is a great tool to utilize and will often work wonders with the performing artist population. So now let's talk about acupuncture and eastern medicine, which has become pretty popular in the performing arts community. So what is it? Acupuncture is part of the ancient practice of traditional Chinese medicine that utilizes pathways or meridians in which our inherent energy called qi flows through us. This qi is believed to be responsible for a person's general health and wellbeing and disruption of this energy is believed to cause disease. Acupuncture is thought to stimulate the central nervous system by regulating neurotransmitters that control health and diseases such as serotonin, norepinephrine, acetylcholine, dopamine, and GABA. A good majority of performers don't like to take oral medications because they feel like they're masking their pain and they want to make sure that they don't further injure themselves. Though an NSAID might sometimes help their conditions, I can understand. I mean, it makes sense why they wouldn't want to take these medications, especially if they're doing these activities day in and day out for hours on end. Acupuncture in that scenario would be a great alternative for them to help boost their immune systems and decrease inflammation if the injury is in fact from an overuse injury. Like Dr. Lee had just discussed really well, we can also consider OMT and chiropractic. So OMT or OMM is a holistic approach to medicine that involves hands-on training and is performed by osteopathic physicians. Osteopathic medicine was developed by Dr. Andrew Campbell in 1884. He believes that the treatment of these disorders is harmful. OMM uses techniques that include stretching, gen pressure, and wrist muscles, soft tissues, and joints. The school of orthotics was developed by Dede in 1895. Chiropractic is also a hands-on treatment. It's for alignment of bodies and muscles, particularly when chiropractors believe that the alignment of the spine in turn enables the body itself. The last thing that I wanted to discuss with you is movement awareness and how it is used to treat the performing artist. It's been shown to be extremely helpful, and it's not typically something that's talked about within the rehab community. So this of course is not an all-encompassing list, but rather just a short one of some of the most popular techniques that are used. As you can see here, we have Alexander body mapping, Feldenkrais, and pedagogical retraining. So I'm going to go through these pretty quickly. The first one is Alexander technique, and this was founded by F.M. Alexander. He was an Australian actor who experienced chronic laryngitis whenever he performed. Doctors at that point really couldn't figure out why this kept happening to him, but Alexander later learned about the tension that was held in his neck and how that affected 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. This is really important for the performing artists, since so much of training, especially in the dancer and musician, is based off of copying a particular aesthetic or technique. So we sort of want to get them out of that at times. The next movement awareness technique I want to discuss is something called body mapping, which is BMG. This was founded, well, BMG for short. This was founded by William and Barbara Conable, and this provides an understanding of the anatomy involved in the movements that are required to perform a task and is really popular in the musician population. So for those that practice and treat with body mapping, they treat the idea that the body map is a person's representation of their body and their own brain. And by facilitating the ease of movement, one actually decreases the possibility of injury, because for many, music is movement and movement is music. Music can't exist without the body and its movement, and otherwise you would just have the instrument. So unlike Alexander technique, much of body mapping is a hands-off process that involves verbal coaching and visual aids that include mirrors, anatomical models, and pictures. In the music community, BMG often involves watching the musician during their activity and coaching them through their movements. We've got five minutes. I promise we'll cover it. So this is actually a photo taken from bodymap.org, the main organization, and their course, you know, just so you have an idea here, they introduce you to it, of course. Then they focus on your balance and then your arms and how it relates to your torso. They focus on breathing, and then they work their way down to the legs, and they really kind of help you understand where your weight is and where you transfer the weight when you're moving or performing. And then, of course, at the end of this, nothing in the performing arts world would be complete without a master class. So this gives you the opportunity to use those techniques that you learned in class while being evaluated by your teacher and peers. The Feldenkrais Method was founded by Moshi Feldenkrais, and this is a method of movement as well that re-educates, and it's offered in two methods. One is a group setting, one is one-on-one. So the group setting is called Awareness Through Movement, and this is where participants follow verbal instructions from the teacher, and they deconstruct general movement patterns while exploring other variations. So on the left there, you see that's the group class, and then the one-on-one session is called Functional Integrational Sessions, and these are where the fully clothed participant is guided through touch, movement, and verbal instruction. The last thing I want to discuss with you is pedagogical retraining for musicians. So the most disabling professional disorder diagnosed in musicians is focal dystonia, which 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 actually 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 their faulty technique or insufficient preparation, and then of course, you know, being the type A people that classical musicians usually are, this often leads to worsening of the condition as they practice more and they hyper-focus on their impairment. So the real aim of pedagogical retraining involves rewiring the nervous system. Often this involves starting from the basics of playing, even if that means playing scales non-stop on a piano, but of course somebody is watching, and then the musician would be closely observed here, as I said, and they would be advanced based off of how they're doing and how they progress. Treatment could involve anything from fixing a musician's posture, their arm placement, or even their breath work. And that's it. Thank you so much. All right, next we're going to move on to Dr. Servais. All right, good evening everybody. Let's pull this up here. All right, so I'm Saj Servais. I am the Program Director for the Performing Arts Program at the All right, so I'm Saj Servais. I am the Program Director for the Performing Arts Medicine Fellowship that Dr. Lee and Dr. Elson mentioned earlier in the evening, and I spoke last year at our Community Day presentation on voice. So at our clinic we treat all performing artists, so dancers, instrumentalists, actors, singers, and I spoke on voice last year, and what I thought this year we would do is kind of back things up a little bit and just give a little voice boot camp, understanding that based on the feedback from last year's session. Voice is something that's generally relegated to the ENT docs. Physiatrists are maybe not as natural at dealing with vocalists and voice-related problems. Obviously we can deal with musculoskeletal problems related to singers, but the voice itself may not be as natural a fit for us. So what I thought I would do is take these next few minutes here just to give a bit of a rundown on how the voice works so that we have hopefully a better understanding of that, and then let me just make sure we got that. And then also we'll just talk about how to obtain an occupational history from a vocalist. So this is a slide that I borrowed, or I presented initially last year. This is the vocal tract, and this is how sound is produced by humans, by the human voice. So it's broken into different parts. The first part is what's called the air generator, which is our lungs and diaphragm, right? So that's gonna move air up through the trachea. It's generated by the diaphragm contracting and creating that negative interthoracic pressure to pull air from the environment into the lungs. And then as the air is expelled out through the lungs, it passes through the vocal folds, which is our sound generator. That's where the actual vibration is occurring that determines pitch and the sound that we hear. But then very shortly thereafter, that sound that's been generated is going to make its way through the oropharynx and nasopharynx on its way out. And this area are called the resonators. And so this is what's going to change and modify and modulate the sound as it's produced at the vocal folds to produce what we would think of as either speaking voice or sung voice when we hear it. And then finally, we have the ability to shape that sound as it exits the mouth using what are called articulators. So the tongue and palate allow us to then shape that sound as it just before it exits out through the mouth. And that's what is then transmitted to the audience and heard by the audience. And so problems anywhere along this length of vocal tract can produce problems in sound production. So problems that produce tension in the tongue, problems in the jaw that don't allow for proper articulation, problems obviously in the nose or sinus congestion or allergies or any issues that are producing mucus in the nasopharynx is going to affect the voice. Problems in the pharynx itself, so things like acid reflux might influence the voice in that way if it's irritating the tissues here. And then of course the vocal folds themselves are critically important. So let's dive a little bit deeper for a moment here. So here's a view top down of the vocal folds, which are right here in the center in this V section here, the vocal folds, which is a ligament, the vocal ligament that is wrapped and surrounded by a layer of mucosa that forms those vocal folds. And then we have the muscles in the back, the thyroarytenoid muscles in the back, which contract and bring those vocal folds together. And when they do, it's like squeezing the neck of a balloon, right? So if we have blow a balloon full of air, those are our lungs. And then if we just do nothing and let the air out, air just kind of exits the balloon quickly. But if we pull the neck of the balloon together, it brings those edges together. And then as the air passes through, it produces vibration. And we hear that pitch that gets produced when you squeeze the air out of a balloon. It works the same way for us. And so how these come together is through something called the Bernoulli effect. So the vocal folds are not exactly like a line. They actually have some depth to them. And so as those vocal folds collide, they don't just come together and come apart. They actually produce a wave-like motion as they come together and then make their way up and then they come apart and then they open and then they repeat that process. That same process is also happening up and down the length of the vocal folds. So it's a two-fold wave-like collision. So from front to back, and then also from top to bottom. And the faster those collisions are occurring are what determines what's called the pitch. So the pitch that we hear. And the more energy that you have in that collision, the more volume you have. And so in other words, loudness, how loud the sound is. And there's different ways that you can introduce energy into the system. One option is that you can move more air. If you take a deeper breath and you move more air through as you're producing pitch, you're exciting more air molecules with your vocal folds. So that's gonna increase your volume. But the other way to do it, which could potentially be maladaptive, is you more forcibly bring the vocal folds together. So if you force those vocal folds together and try to hold them together a bit more as the air is passing through, it's going to create tension and then the vocal folds are going to explode open rather than gently moving open. So that forcibly pushing air through by forcibly contracting the vocal folds is gonna also produce more volume. But at the same time, it's also gonna shear those vocal folds against each other and create the potential for injury within the vocal folds. And so when we sing a pitch, you don't just hear a single pitch. The loudest pitch that you hear is what's called the fundamental frequency. And then you have a whole, remember we said that that fundamental frequency is just like a sine wave if you were gonna hear it, it'd just be a pure tone. But voices don't sound like that because the harmonics above that are going to also resonate. And how these harmonics resonate is entirely determined by things like how wide or long your pharynx is, how much space you have in your nasopharynx, how high your soft palate is. Now, these are all things that can be controlled and changed and they're gonna produce different resonations. So this is a kind of a graph of a spectrogram of pitch. So our fundamental frequency is up here at 280 Hertz, which is roughly middle C on the piano. So, somewhere in there. And so at that 280 fundamental frequency, that's the note that we hear and hear as a fundamental pitch, but we're also gonna hear all the multiples of that. So double, 280, and then triple, quadruple, quintuple. And those multiples of 280 Hertz are gonna sound with differing amounts of intensity. When we see we get up to the 2230 Hertz region here, we get a little bit of a spike in the energy of these harmonics or partials. And that's gonna produce a secondary sound up in here in this region of the acoustic spectrum. And so that secondary piece here is called a formant, where there's a secondary bit of energy there. And singers can learn to change that formant, move it up or down within the spectrum. So maybe they sing in a way that pushes more energy into these partials rather than those, or these partials, or maybe those. The way that those resonate produce the unique characteristics of a voice. So then we call this timbre, or it's spelled timber, but we pronounce it timbre. And so certain voices have a dark quality to them, or a light quality, or a reedy quality. We use a lot of subjective terms to describe these different timbres. But the reason that those are happening is because every singer has a unique configuration and has somewhat control over that. So these formants can be changed just in our own speaking. So here is somebody you sing the same fundamental frequency, but they sing it with an ah vowel. So ah is gonna produce something that maybe looks like this, but that same pitch with an ah, with an E sound, E is gonna produce a different frequency profile to it versus an ooh. So the fundamental frequency is staying the same, but the partials are changing. So it makes it sound fundamentally different to our ears. And so these formants are really important. This is something that singers work on in their training. And this is something that can potentially be problematic because if they can't produce these different partials, it changes the quality of their sound, which is something that they rely on to make a living. When we talk about different voice parts, there's different vocal ranges in relation, and this is just mapping them on top of a piano so that you can see how they're organized. So in the male vocal ranges, the lowest end is typically called the base range. And then you have baritone and tenor and countertenor. These are very uncommon. Certain classical music requires the use of a countertenor. So that's more unusual. And then in the female vocal ranges, the bottom is called the contralto, which is also somewhat uncommon. More commonly are what's called mezzo-soprano Mezzo-soprano, if you sang in choir at any point, this would be your altos, right? And then your sopranos. And this is giving a sort of neat range. You know, oh, this bass can sing from down here up to there on the piano. Real singers don't fit into this paradigm so neatly. You know, some singers can go much lower or much higher, may have ranges above and below. And so sometimes it's a bit murky to figure out what voice part somebody sings. But in general, you know, a tenor is going to have a different set of problems than a bass because they sing different types of literature. And that's true across the genre, whether that's country music, all the way up to, you know, heavy metal, to opera, you know, different voice parts are gonna have different constraints and different problems. So it's important to understand that. And to speak to Dr. Lee's point before, the range is not accessible in the same way to all these different singers. So there's what are called registers, which show how you produce these different pitches. So for a bass, you know, the bottom of the range might be a low D, and they use this first register, which is called chest voice. Chest voice is when you speak from your chest. It's a very resonant type of sound. And so, as you can see, all singers have some version of chest voice, but different portions of the range fall into that chest voice. So in a bass, most of their range is in chest voice versus a soprano, very little of their range is in chest voice. Most of it is up here, right? This second register, this yellow portion is sometimes referred to as head voice, right? And then the third register is called falsetto. Roughly, this is, depending on how you ask it, this could also be considered mixed voice or belt register, depending on who you're talking to. If you talk to like a Broadway person, they would say that this blue here would be more of a belt range. And then this high tone in women is sometimes called a whistle register, because those are those like Mariah Carey, like super high squeaky notes are way up here in the top register. And so different singers, you know, use these different partials or different modes of singing to sing their different types of notes that they're going to produce. And so where one register switches into a different register, so I'm singing my low notes, and then I'm in my chest voice. And then at some point, as I go up the scale, I have to switch into head voice, as I just did there in the course of that sentence, where one register switches to another register that's called the passaggio. So this is the lower passaggio that Dr. Lee was mentioning earlier from chest voice to, yeah, from chest voice to head voice. And then you can have an upper passaggio from the head voice into maybe belt or belt into whistle tone, right? So there's different points where the voice will actually transition from one register to another. And this is a common source of problem for singers is that they have difficulty managing these passaggios or also known as the break, right? Managing the break in voice from one register to another. So when we obtain an occupational history from our singers, these are the kinds of questions you wanna ask. So what voice part do you sing, right? So regardless of what type of genre they're singing, they're gonna know what their voice part is. And as we said, there's different considerations depending on if you're speaking to a bass versus a tenor versus a mezzo. And what ensembles and context does this person sing, right? So do they sing in a choir? Do they sing in a smoky jazz bar? Do they sing accompanied with a full big band? Are they singing alone? Are they singing just them and a guitar? You know, what context do they sing in? Are they singing in stadiums or in band halls or in church? Maybe they're a church musician. So understanding this, and most singers are gonna sing in multiple contexts. So they're gonna have maybe a studio where they give lessons, and then they also sing in a chorus, and they also have a solo career that they're working on. That would be a typical singer that we would see. Do they sing amplified or unamplified? This is critically important to understand for our singers because obviously the implications of that are huge. If you have a microphone, then you don't have to sing as loud because the microphone is going to provide the amplification for you, versus if you're singing opera, which by definition is unamplified. You know, it's on you to produce all that volume. So you're gonna see a lot of those issues of trying to create all that extra energy, either through hopefully moving more air, but more likely by squeezing the vocal folds together to eke out as much volume as you can. When you see amplified musicians like musical theater or pop music, that's entirely amplified. And so those are less of a concern. They still have their own issues, but it's less of a problem. And then as Dr. Stanek mentioned earlier and others, just the basics of what do you do in any given week? How many hours do you practice? How many hours are you in rehearsals? How many hours do you perform? Just getting your head around what this person does in their given week. Well, vocal hygiene. So are they doing the things to prevent them from having vocal problems? And if not, we need to advocate for this. I gave a whole talk on this last year on vocal hygiene. So I'm not gonna dive into it too deep, but a lot of it is just avoiding misuse, avoiding abuse of the voice. So if you're gonna sing for eight hours tomorrow, tonight might not be the time to go to a concert in a really loud environment and try to speak or go to a really loud environment and try to speak, or maybe it might not be the time to pick up vaping as a hobby right before you're supposed to sing something. So using good vocal hygiene is important. Do you work with a voice coach or not? That's an important thing. If they do work with a voice coach, you wanna know who that person is so that you can talk to them and understand what the coach is working on with this person so that you can get on the same page. And then lastly, of course, do they have a history of vocal fold injury? So have they injured them before? Have they had surgery on the nodes before? Have they had to have periods of vocal rest? And who have they seen before in terms of an otolaryngologist? And so it's not that we're gonna take over otolaryngologist's job. It's not that we're going to box them out of this population. Obviously we need otolaryngologists and speech language pathologists to provide care for this population in terms of being able to scope them and visualize the vocal folds in order to give them adequate speech exercises to try to help them rehab from injuries. But that doesn't mean we have no part to play either, especially if you're in the larger context of being a performing arts health professional where you're gonna have to work with people in this environment. It's really important for us as the gatekeepers to the performing artists to be able to take an adequate history and really understand what things need urgent evaluation and what things can we wait on maybe a little bit, or maybe we can just send them directly to speech and not have to have them scoped. So having a good understanding of who this person needs to see and what kind of things we can do to help. So if we're finding that their voice issues are related to a jaw problem, for example, we can manage that. We know how to deal with TMJ issues, or if they have a previous whiplash injury that is giving them a lot of neck tension and that's why they can't produce the tone they wanna produce. We can help with that too, right? So not everything has to go to otolaryngology. There's definitely a role for physiatrists to play in this space. And I agree with everyone who's spoken so far that our field is absolutely an excellent field to work with this population. So those are my remarks. As Dr. Lee mentioned earlier, if we have any questions, I'd love to field them, but I would also encourage you to learn more about our Performing Arts Medicine Fellowship if you'd like to get more training in this area. Thanks for your attention. Thank you so much. Thank you again all for being here. I'd like to open the floor right now for questions and discussion. So please, you can either, let's see if I can put us on gallery view. So you can either raise your hand or you can submit them to the chat and I will help direct them to, we have both our speakers there and then we have several other panelists tonight. So I want to introduce Dr. Gerson, who is the founder of the Performing Arts Clinic in Seattle. Correct me on the name on that. And Dr. Davenport is here. She's the physician for the Miami City Ballet and also many others that have been very involved in our journal clubs. The other plug that I want to put in, because it's very timely, that the International Association of Dance Medicine and Science is having the annual conference starting on Thursday. It is not too late to sign up for the virtual content and is a great way to network and to learn. I know that I have learned a lot of my physical exam skills from the other practitioners. So just as it's important for us to meet as physiatrists to advance our field, it's also important for us to learn from the other allied professionals that are taking care of these artists, because that's going to make our exam and our view much stronger as well. So do we have any questions so far? Okay, so our first question is, what are modifications and suggestions that some of you have utilized to assist string musicians with significant arthritis? I guess I can go first. Some of the things that I see is if they have significant arthritis, you're going to treat it like a typical arthritis. Making sure that they keep the temperature of the hand fairly well controlled can be very, very helpful. Colder temperatures tend to make arthritis a lot more painful for people. So if they can keep the hand warmer, then that's going to be helpful. Make sure that they do a proper warmup, just like any other physician will be very, very helpful for keeping their pain a little bit under control. You can use natural anti-inflammatories. So things like turmeric can work well if they don't want to take an NSAID. Let's see what else. Topical diclofenac also works pretty well for them. Maybe depending on their instrument, just having changed their hand position a little bit. So if it's a violinist, depending on how much they're bringing their wrist into flexion or not bringing into flexion can be very helpful. That way they can use more pressure of the entire finger itself, rather than having to flex one of their joints to push down on the string and produce the tone is super easy. It takes a little bit of time for them to get used to that new wrist position, but it can be really, really helpful for people. Working with an occupational therapist is really helpful, too. Actually, they have a lot of creative suggestions in terms of taping and bracing, and over-the-counter ones, too. You can purchase a lot of interesting bracing options. For some musicians, they don't like the aesthetics of it, and some others really don't care. They just want to play without, and they really don't. Musicians tend to really hate taking medications, and they would rather do that instead of taking medications. So I've had a lot of success just working with occupational therapists, asking for their input, and just come up with creative ways for bracing. I'd like to encourage you, if you're interested, please feel free to unmute, and I'm sure if you'd like to ask the question in person, either way, we can do chat or live questions. And anything vaguely related to the performing arts is fair game. And while we're waiting for any further questions, I would love just to hear briefly from Dr. Gerson, just what resources did you need to have in place when starting your own private performing arts medicine clinic, and then what type of model do you use, considering that we talked about briefly, that performing artists are often underinsured? Great questions. So it is sometimes hard, if you're in a bigger system, to really carve a niche for performing arts medicine. It's one of the reasons why I went into private practice, and I was able to join a practice where I've got some freedom to really do what I want to do and see the types of patients I want to see. And so one of the most important things in terms of resources for your practice is to create a familiar environment for the performing artists. For instance, I do see probably more dancers than musicians, but I do see both, and sometimes even have a little bit of divot in the ground where they can put their cello or having a mirror in a bar. And I love the idea of just even having a weighted electric keyboard. Those types of things are not really very expensive and can make a big difference. But in terms of overall resources, it can be hard because in a lot of areas, performing artists don't have health insurance. And if you're in private practice, you eat what you kill, for better or worse. And so if you're seeing a population that doesn't have health insurance, it's hard to really make that sustainable. And so often I do see varied types of people in my practice, and some of the more bread and butter aspects of my practice ends up paying for essentially the other more fun things that I do. It's not just fun, but it's fulfilling, and it's actually a really important service that we provide to the community. Another thing that we've done is we started a nonprofit here in Seattle where we have many volunteers of physical therapists, occupational therapists, massage therapists, chiropractors, physicians, so physiatrists, orthopedic surgeons, rheumatologists, family practice docs. We actually just had a clinic this past weekend and saw many musicians and ranging from people aged 12 all the way up to age 70 was just at this clinic this last week. And it was really interesting to see. And in communities where there's that type of support to build that type of clinic, it's a lot of work, but and there are different models around the country where they've been able to set up similar clinics. And so, you know, as people are moving forward in their careers, if they want to explore these types of things, everybody here on this Zoom call at the Academy, we're all just very interested in spreading the word and helping people create other pockets around the country, because when we started out, there wasn't a lot of resources. And now we're starting to build those resources and we want to share them with everybody. Thank you so much, I think that's really helpful, especially as I see that there's a few earlier early career physicians here. So as you're thinking about how you want to put performing arts medicine into your practice. We, you know, we have this forum, this is a relatively new initiative. And so this was the first year that we started having journal clubs. And I know I had a great time with those just learning from from everyone that was there, they're informal and just a chance to talk about our clinics, share ideas and review a little bit of literature while we're at it. If you have ideas or things that you want to see coming up, you know, please send that off to us. And if we have a local expert that we can that we can have discussed, that would be really helpful. Dr. Davenport, if you have a second, it would be great to hear just about, you know, the connections that you developed when you started working with Miami City Ballet, if people are interested in something along those lines, how to best get started. And then, yeah, we'll start with that. Yes. So I'm Dr. Kathleen Davenport, I'm the company physician for Miami City Ballet. Thank you guys. Really great lectures tonight. Thank you so much. In terms of working with a large ballet company, a lot of it is about timing. Like if you hear lectures from our colleagues in traditional sports, you know how someone started to be the doctor for the Mets or another team, a lot of it is about timing. There happened to be a transition when they were looking for someone to join the Miami City Ballet team. And of course, it is about as a physiatrist, we are excellent people to be that team physician, right? We're used to working with a team, not just a sports team or a dance team, but also with the other medical providers that are part of that team. So, for example, at a large company like a Miami City Ballet or Boston Ballet, New York City Ballet, the people who are on site 24-7 tend to be the physical therapists and the athletic trainers. And so as an MD, I don't do onsite clinical care 24-7. How I work with Miami City Ballet is I do a clinic intermittently for them. And how many companies also work is that they do clinics intermittently for those larger companies. So that's kind of the nuts and bolts of how I work with the company. And then I tend to be on call. So if a dancer needs something, of course, we work them in last minute, any time. I always say any dancer, any time to my staff. So I think that is one of the most important things that many people have always already said, is making sure that these dancers and performing artists have easy access, you know, to make sure that you're available when you're building this clinic so that they'll be able to get into you. Thank you. Just I wanted to make sure that everybody knows I did get a question about, you know, making sure or wanting to know how to get involved with Journal Club. So if you go into the FIST forum and you sign up for the Performing Arts Medicine community and then make sure that you set your alerts for however frequently you'd like to get them, I suggest maybe just one a day. That way you won't get too far behind on announcements, but you also won't get completely slammed. But we do. So last year we did three or we did four or five total journal clubs. And so what we'll do is we'll once we have the dates, we'll send out save the dates. And then I typically will send out a reminder about a week before and then a day before for those. And so this last year we did a vocal one, a music one, a dance one, and then a general networking. Hang out, talk about our practices one. So again, please, please, please feel free to reach out to us if you have things that you'd like to hear about, if you see an article that you'd like us to discuss. If you have any other questions, we have a lot of great resources here that that we'd love to share. Any other questions? I don't think I've missed any, but feel free to raise your hand and wave at me. But we really appreciate you all being here and when we get to get be back in person, it's going to be even better. But until then, this is a nice substitute to. To keep everyone around. All right, it was great to see you all. Thank you for being here. All right, it was great to see you all. Thank you. Thank you again and see you on the 27th. Don't forget. Good night.

complementary treatments

performing artists

non-conventional therapies

acupuncture

massage therapy

chiropractic care

herbal remedies

musculoskeletal pain

stress and anxiety

physical performance

faster recovery

injuries