Good morning, guys. Hi. My name's Heidi. I am a current interventional spine and musculoskeletal medicine fellow at OSS Health. But I have the distinct pleasure of being your moderator today for this Performing Arts Medicine session. I have somewhat of a connection to both of these lovely ladies up here. And again, super excited to have them both talk. So first up, we have Lauren Elson. She is an instructor in PM&R at Harvard in Spaulding. She's the director of dance medicine there. She attended Tufts University School of Medicine and did her residency at New York Presbyterian Hospital Columbia Cornell, which is where I did my residency. So that's how I know her. And she completed a fellowship in sports medicine at Stanford University. She was a former professional dancer and instructor of jazz, ballet, tap, hip hop, African swing, and salsa. A lot of things I can't do, really. She has lectured nationally and internationally on dance health and injury prevention to dancers and professional organizations. She is a board member of the International Association of Dance Medicine and Science, was recent program committee chair of the Performing Arts Medical Association, and is chair of the independent slash freelance dancer committee for the Dance USA Task Force on Dancer Health. In 2017, she published an introductory guide for practitioners performing arts medicine. Dr. Elson has organized the Boston Dance Alliance Dancer Health Day since its inception in 2018. And so we are super, super excited to have her here today. Yeah, so take it away. She'll talk to us first, and I'll introduce our next speaker after that. Good morning, everyone. It's great to see you all here and excited to see people who are interested in performing arts medicine. Because this is my passion, this is my love, this is why I went into physiatry. And I really think that physiatrists are the best people cut out to do performing arts medicine. So we need to get everybody involved and up and running and show the world what we can do. When I started, I had one physiatry mentor who was in this field, and now we are taking over. So welcome to the ranks. We want to get everyone educated and excited. So we're going to do a whirlwind tour. I have 15 minutes to talk about dance medicine. So this talk could go on for days. We have dance medicine conferences. So I'm going to skim over the topics that I think are the most important. And I have no disclosures. Quickly go through what is dance medicine, a little bit about epidemiology, biomechanics, and treatment considerations. And one thing that you want to think about is that dance really encompasses all realms. And so just like all of our other patients, we really want to get to know our patient. And so where are they coming, what type of dance do they do, what role does it play in their life. It's very different when we're treating a professional performer versus a student. But we need to take all that into consideration. And that's what we do as physiatrists. And dance medicine, just like everything else, is looking at diagnosis, treatment, rehab, injury prevention, but really getting into the psychological and physiologic needs. Because if you can't meet where that performer is on the psychological level, they are out of your clinic. So dance medicine really is sports medicine for dancers. However, you really need to have that interest and that curiosity to know what exactly it is that they're doing. So that way you can rehab them to what they need to do. And that's really where we're different than other practitioners, is that return to play decision or that return to dance position. And as I mentioned, physiatrists, we are the best because we focus on function. And you might want to go out there and be like, OK, I'm a performing arts practitioner. I'm going to hang my shingle. No, it's a team sport. If you don't have at least the physical therapist in your area that you can refer to, you're kind of dead in the water. You really need to have that team. You need to create the people around you. Now, if you're working with professionals, you're going to have to have the whole team involved. Because nutrition, psychology, the management, and very often the families of the dancers are involved. So just like the rest of physiatry, we need to incorporate all of that. So one thing that's very different from a lot of the other. But we do know that a lot of the sports medicine science applies to dance medicine, so a lot of things happen because of the lack of cross-training and overall physical fitness. And you would think that dancers are fit, but they're actually not. Recent data has shown that dancers that add strength training actually get injured less and have less pain and miss fewer performances and rehearsals. So there's a lot of stigma that's out there about strength training for dancers, and that's one of the things that we're trying to overcome. The other thing is that there's been all this talk recently about sports specialization in other fields and how it can't be done early, but for women professional ballet dancers, they have to specialize early. But if you actually look at the dancers who make it up high, they don't just do ballet, they do other forms. So we need to apply what we're learning to sports specialization and apply it to the dancers and really try to start getting that cross-training going. So one of the reasons why dancers are perceived as being really difficult is because they'll come in and they'll be like, you know, I feel this spiraling energy when I'm trying to do this thing, and a lot of practitioners, especially not to name names, orthopedists, will just dismiss them and it's like, okay, but where does it hurt? But dancers have a really good intuition, and so if you ask them what they think is going on, you'll probably learn a lot. It doesn't mean it's always right, but it'll help get you going on what you need to be able to do with them. The other thing to remember about performing artists is that it's not just about that sports aspect, but it's also there's an emotional part, they're performing. So it's not like a football player who does something and they hurt and they can grunt or yell or scream. The dancer's actually communicating a story and has to have their mind in a different set. So that changes what they have to be able to do. One thing to think about with a lot of the professional dancers, especially ballet, is the amount of time, financial, familial contributions, social consequences on missing out on other things that they go through in order to get where they are. So this isn't just someone playing... If you're dealing with a dancer who's on the pre-professional track, that's very different than someone who's taking a dance class once or twice a week. So being able to counsel your patients and think about where they're coming from is important. Unlike medicine, where once you're in, you're in. If you got through medical school and you don't do something crazy, you pretty much have job security. A dancer can be at their best level, have an injury, and then they have no more career. So really understanding that mindset. And a lot of times, especially before we're starting to make some headway, but we are not there yet, there is a big stigma about dancers seeking out medical care because in the past, including when I was growing up, if you had an injury, basically the answer was, well, don't dance for three weeks and it'll heal. And that's really not an option. And for chronic overuse injuries, that's actually not going to fix anything. So rightfully, dancers don't trust medical practitioners. So we're trying to change that stigma and show that there are actually clinicians that understand what dancers do. And within that education of both dancers and teachers, we're actually starting to help dancers keep dancing. And we know that by the time the dancer often comes in, there's a lot of complications. It's not just one thing wrong. It's, well, that little thing hurt, so they started compensating, so then by the time they come in, they have three things in the kinetic chain that are off. So we're really trying to get people to come in a little bit earlier. I think it's interesting, there was this study from Harkness where the dancers talked about their top five goals, and if you look at them, interestingly, only one of them is something that they can actually control, which is the eating component or the no fat. Everything else is what you're given genetically and what you train for. So that's why we see such a high prevalence of eating disorders within dance, and this is something that we are actively working on within the dance medicine community. But within that, we know that there are ways that we can intervene, and that's why having your, especially if you're dancing, if you're taking care of this population, you need to have psychological backup. And don't want to dwell on these things for too long, but we know that these dancers are at risk for the female athlete triad with stress fractures, and there are a lot of long-term consequences. There are actually some parents who I've seen that facilitate... When you get into what an injury is, that's a whole other story. We don't have time for that right now, but injury rates are high and it really comes down to what style of dance. So ballet dancers, it's going to be lower extremity. In terms of the actual acute injury risk, that's going to be hip-hop and break dancing. And there's factors with how often they're dancing, the level of the level that they're at, and then also what choreography they're doing. So in professional ballet dancers, we see really high injury rates when they switch from choreographer to choreographer. There's a great study that looks at these different types of modern techniques. So on the left you have Graham technique and on the right you have Horton technique, and they actually have different injury patterns. So knee injuries were more common in the Graham and back injuries were more common in the Horton. Also thinking about different things like costumes and stuff like that, my sister was on the national tour of Cats and I got to hear all sorts of funny injuries from like someone stepping on someone else's tail during an acrobatic thing. So wearing a mask in a new theater and walking into a low-hanging ceiling and getting concussion. So really kind of thinking about these things that we don't necessarily have to deal with in our daily lives. So the one thing that I can't hammer home enough is that a lot of these things are kinetic chain issues. So dancers don't like to be told that there is some type of faulty technique going on. However, there's usually some kind of compensation. They're trying to force something and that will often lead to other things. So I don't love the term like overuse injury. Like if you're slowly building something up appropriately, it shouldn't be overused. Misuse is very, very common. And so very often people want to get their legs higher. They want to turn out more and that's where we start to see the risk develop. And there are, this list could be a hundred things long. The things I like to highlight are for ballet dancers that goal or that desire to get to 180 degrees of turnout of the lower extremities. Hypermobility, which if you take care of dancers you have to be good at treating hypermobility and understanding it. Unfortunately that may or may not get you the reputation of being good with hypermobility and that's a whole other conversation because a lot of our generalized population really needs help with this. But it's really important to know how to approach hypermobile people. People that want to get on to point too early and then also at the end of the day, especially in this in this time of media, there are people see things online and they try to replicate it without having the body awareness. And so we see a lot of injuries from that. So one thing I want you guys to do really quickly is stand up and we're going to try to make a hundred eighty degree turnout. So I'm going to step away from the microphone for a second and try to project. All right, so this is what all dancers are trying to do, but not everybody has the anatomy to do it. So you can imagine that these dancers who are told, oh, I have to be in this 180 degrees, you guys can have a seat, what that's actually doing to their structures. So we see knee pain, hip pain, back pain, foot pain, all a result of this forced turnout. So we're trying to educate teachers and dancers how to not have that. And does this, oh, we can actually see this, okay, excellent. So you can see this dancer right here is forcing her turnout, that's giving her increased recruvotum at the knees, lordosis of the lumbar spine, she's rolling through and has increased pronation of the feet. So all of these things. And one of the things I do with my ballet dancers that have pain anywhere, I just have them show me how they do their first position, and we can talk about corrective ways of addressing that in the future. So you can see here with the dancer's feet, this is what happens when you're trying to force a turnout, and so you're rolling over into that pronated range. And so if you're trying to jump and you're trying to do things with this, you can imagine all the injuries that you're going to be coming in with. And so one of the other things I like to highlight within dance medicine, but I think serves us well as physiatrists, too, is you need a diagnosis. Yes, you have posterior tibialis dysfunction, but that's not really the important point. The important point is why are you having it and how do we fix why you got it? An injection to take away that pain is going to do nothing in the long run. So how are we going to fix these biomechanics? So with the hypermobility, because of that increased recruvitum at the knee, in order to balance, they have to have an equal amount of hypermobility at the toe in order to actually balance and have their center of gravity. And I didn't put that picture in that I usually like to use for that, showing that. But so making sure that the dancers' degrees of hypermobility are equal in the different parts of their body so that they're not stressing one area more than the other. And then also training dancers to not stand in a recruvitum position when they're not supposed to is a very important thing. So when they're standing around like this, they're going to get knee and ankle issues and probably low back issues as well. There's great papers and great talks about how and when a dancer is ready for point, happy to point people into the right resources for that. When people cheat and they're not where they are, that's an issue. Using these torture stretching devices is not a good thing. We do not support those. And so the picture on the left here shows a dancer who is well-trained, who is well-supported and has a very nice curve and mobility of their lumbar spine and neck. And then you look in this classroom and you can see what's happening. And apparently there's no instruction on how to do this because every single one of those people in there is going to end up with neck, shoulder, or back pain. So really we're trying to get teachers to instruct a little better so you can see those awkward positions. Also teaching correct lifting mechanics. So the dancer on the left is going to end up with back pain eventually. The right side of the picture is improved, but I would say he's actually probably tucking a little too much. We've come to more of a neutral position nowadays. But just demonstrating how we can look at how to get dancers with less pain overall. And again, you know, this is for a longer talk, getting into the details. This dancer is just hiking her leg up without the right core control and alignment of the pelvis. So if she does this over and over again, we're going to get a hip flexor tendonitis. As I mentioned before, you can identify that anatomic diagnosis, but treat the impairments. Really consider the intrinsic and extrinsic risk factors, address the nutrition. I really love this study that the Harkness Dance Center did, where they looked at 653 dancers over three years, 49 dancers presented with iliopsoas syndrome. 100% of them got back to full dancing with dance-specific PT. This is very interesting because this is opposite of another study that was done 10 years earlier by a very prominent dance medicine clinic. And they were like, oh, dancers with iliopsoas syndrome, you should inject their anterior hip. So 50% of dancers got back to their full dancing, and then another 20% got back to partial dancing. So if you do the dance-specific rehab, you get better. The dancers will not come back to you if you tell them to stop dancing. So how you approach this population is you tell them what they can do. Well, you can go to class, but you can't jump, or you can't turn, or you can do a floor bar instead of a standing bar. So you really have to give them a program of how they can be active. Otherwise, good luck seeing them again. And we try to minimize NSAIDs in this population. We try to look at technical factors that we're looking for, and really looking at what the artists in this field or what other modalities they're using, like gyrotonics or Pilates. Have those people in your corner that you can refer to, because they can all help with the rehab. There's great studies on how to actually get back to dance-specific activities. Happy to share those resources. Really thinking about not just the strength, not the hardware, but the software, how that program is running in that particular dancer. It's nice that your hip abductor is strong, but can you use it when you're trying to do a dance maneuver? And really, some of the things that we look at is what we call limb-core dissociation. So can they hold their core stable and move their limbs separately without everything needing to move everything else? And so we have a lot of excellent whole-body neuromuscular reeducation tools. So in summary, the evaluation and treatment of the dancer requires attention to what they're doing. Kinetic chain, kinetic chain, kinetic chain, this is how you're going to prevent injuries. And then really, we can't do this on our own. We should be the leaders of the team. We should be the people that are moving this field forward, but we need a team. And so just a couple quick references. I really encourage you, if you're interested in these things, you can get dance glossary terms from the ABT website. Dance USA has great handouts for dancers. And then PAMA and IADMS are also really important organizations if you're interested in anything. And just a quick plug, the IADMS conference is next week, but you can register virtually. So that's where I learned most of what I know about dance medicine. All right. I'm going to hand it over to Dr. Lee. All right. Thank you for that, Dr. Ellison. So we are going to hold off on questions until Dr. Lee presents, okay, and then we'll do a Q&A at the end of it all. So the next speaker is Dr. Yin Li. She is an associate professor at the University of North Texas Health Science Center at Fort Worth. It's even longer than I thought. Texas College of Osteopathic Medicine. She is a graduate of UMDNJ School of Medicine, which is now the Rowan University School of Osteopathic Medicine. Go Jersey. She completed her physical medicine rehabilitation residency at Thomas Jefferson University Hospital in Philadelphia. Then she completed an additional training in neuromusculoskeletal medicine, osteopathic medicine, manipulative medicine fellowship. Currently at HSC, she has a musculoskeletal medicine practice focusing on performing arts medicine. She is a medical educator and enjoys teaching student doctors in residence. At one point in her life, she was a violinist, and on clinic days, you can find her singing with her patients. Please give a warm welcome to Dr. Lee. Hi, everybody. Hello. Maybe I should use this one. Hi. Good morning. How are you? Are you awake? Yeah? Okay. We'll wait until... So we're waiting for the PowerPoints to come up, because I don't have my PowerPoint memorized, but I can talk about this without a PowerPoint anyway. So anybody, musicians, previously here? Yes. I love it. Okay. All right. When you were a musician, or when you are, when you're playing still, I hope you're still playing. Did you ever have any injuries? Raise your hands. Any injuries? I didn't know that you had injuries. Maybe. Yeah. Yeah. All right. Great. Okay. So this is... Is that okay? Yeah? Yeah. Okay. I have nothing to disclose. I hope I do one day. Any of you out there need someone? Maybe I can get a little stakes in one of your innovative companies. I don't know. We'll see. I like to start with this a lot when I talk about music medicine, because it's not new. It's not new at all. As long as we've had musicians, and that's forever, since human beings have been here, we've created music and we've created art. And so as long as there were specialized group of humans who are creating art, there were injuries. And Robert Schumann had a lot of issues, but one of them was musculoskeletal issues. And he wrote a lot about it in his letters to his wife. Eventually he's got a lot of mental issues and didn't really have a beautiful ending of his life. But isn't that the case with a lot of our artists, right? Yeah. So when I talk about music medicines, I usually talk about three things. Who are they? Are they different? Why are they different? What's different about them? Those are big things that I think about. And you heard Dr. Elson saying, really, the beginning of arts medicine is really understanding our patients. Understanding our patients, not just understanding who they are, but where they work, what they do at work, what they do when they don't work, right? So really understand who they are inside and out, right? So it's not just a hard word, but a soft word, too. And then common things are common. I'm not going to talk about this today because you know musculoskeletal injuries, and I don't think I have in 15 minutes I can talk about all the common things that musicians come in to see me for. So let's just talk about who they are and why are they different, and then we'll go into questions. Yeah? Sounds good? Okay. All right. And so are musicians different? They're different, not just because they're different, but their brain's different. So there are many, many studies out there. These are just two examples that I just sometimes bring up. So Goffers and Schlag, he did a lot of functional MRI and also structural MRI studies comparing mere mortals and musicians. And also other group of people did similar studies, and you can see the frontal temporal region, very different for dancers and musicians versus non-musician dancers, right? And so brain's different, but they're also different, you know, more specifically, they're different individuals. A lot of them start really young. I started piano when I was four. I didn't have a choice. My mother was a pianist. So, you know, there was no choice. You had to start piano, basis of all music, okay? And then I played violin when I was, I started violin when I was six, seven, okay? So very, very young. So when I was growing up, I was playing at first hour and two a day, and then when I was really serious, three, four, five, six hours a day, and my body grew up with it. So my body changed with my instrument, okay? So that's really different. And their problems have been there forever. If they have problems, they have problems since they're very young, and they didn't know. They didn't know at all. A lot of times, the culture is very similar in dance, is that art is suffering, and suffering is art, and it's, everybody has suffering. It's okay. Live through it. Play through it. It's okay. And that's hopefully changing with some of us working through the instructions and educators, really getting involved with the pedagogical, like the structural self to try and bring in wellness, but it's still out there. It's really tough, especially for young, motivated musicians. And then, you know, they think art is the best, and their art form is the most important thing. So their body is not very important. So their health takes over, their health, their music takes over their health, okay? And they're also freelancers, right? A lot of them are. There are some classical musicians who belong to orchestras. I work in Dallas, Fort Worth area. And there are some tenured musicians with these symphony orchestras who have somewhat of a security with their life and their financials, but a lot of them don't. So if they're not tenured, for example, with symphony orchestras, or if they're jazz musicians who are playing gigs every weekend, or they have a band that they're trying to make it, if they don't play, they don't make money. And on top of that, sometimes when they play, they don't get payment with money. They get payment with something else. And we'll talk about that a little bit more later, okay? And then, just like dancers, they have very strange chief complaints, okay? So when you first hear them, you sit there, you think, hmm, this sounds very strange. For example, you know, a clarinet player will come in and say, when I just do this, just this, just this, it hurts, and I can't play. And just one finger, one movement, that's it. Exams normal, when you try to palpate it, everything's normal to you. But then for them, something feels different. Or a singer will come in, and I say, when I sing this passage, I go from chest voice to head voice, and that sound's off. Just sound, just sound is off. Something's not right. I feel a little tightness, or it's not pain, it's not complaint, it's nothing else. They can't work that through. And so how do you work with that? That's really difficult, right? It's very difficult, especially if you don't have a music background. And so these are very weird, sort of strange complaints. When you actually really talk to them, you start to realize there are causes, anatomical causes and other sort of biopsychosocial factors that contribute to that complaint. So I wanted to focus on this, because I think a large part of you are all training, right? So I wanted you to see, take this and say, if you see a musician, then use this as an evaluation tool, because I don't think I knew how to do that. I just knew how to talk to musicians, because I was part of it. So when you're approaching musicians, I think about three things. So really learning the music world. So understanding. If you don't know them, ask them, okay, ask them, what kind of world do you live in? And then musician-focused evaluation, I'll go over that. And then musician-appropriate interventions, which we kind of will talk about. I don't have time for that, probably. So learning the world of musicians. So Dr. Elson talked about extrinsic and intrinsic factors for dancers. Violinists have similar issues. There are things they can control, things they can't control. For example, I'm a violinist, so I'm a violinist, but depending on what kind of ensemble I belong to, the problems can be different. So I could be a pit orchestra musician, so in a musical theater, perhaps, or opera, and I'm in a crowded space, and I'm trying to not hit my stand partner, and there's really dark light, I can't see my music, so I'm squinting, I'm looking at my conductor, right? That's one issue. But let's say I am a jazz violinist with a band, right? I don't have any of those issues, okay? So I might be on stage with five other people, and I'm just jamming, right? There's no other sort of one of those issues. But I might be playing in a bar full of cigarette smoke, or any other, right? So it's different issues. You've got to understand where they work, and then also what they do with their instrument. Even if they're saxophonists, they could be doing completely different things, depending on what genre, what discipline. So if you're not familiar with it, you have to ask them, okay? And some intrinsic factors play into it, too. So just like dancers, their bodies, their playing position, and fatigue, and poor nutrition, and lack of sleep, those things also play into their performance as well. Those of you who are interested in sports medicine, or understand sports medicine principles, some of those principles kind of play into taking care of musicians as well. And then really understanding, actually learning some of the language might be helpful. So knowing that that part of the bow is a frog, or a tip, or whatever, and just kind of telling them, hey, what position do you feel pain or discomfort? Or when I'm playing pizzicato versus big bow and swings, and things like that. Or understanding different types of instruments. For example, if you're alto saxophone player versus bass saxophone player, instrument size is different, right? Trombone players, too. Regular sort of classic trombone versus like a bass trombone is a huge instrument. So you've got to kind of ask them, and then have them bring their instrument and ask questions. I'm a string player, so sometimes with horn players, I have a little bit of a, you know, I ask a ton of questions, and then get a lot of education out of that. OK, so how do I approach musicians when I take care of them? And I see them for the first time in my office. What are the questions do I ask? So these are the questions that I ask. So what kind of musician are you? So I say, hey, what kind of musician are you? What do you play? What kind of instrument did you bring with you today? And if you do have it, take it out. Let me see. Let me take a look at it. How's your setup looking like, right? So let me see you play. Let me see you stand in front of me. So how do you play when you practice? I have them sit in front of me and show me the position of play. What do you do when you're rehearsing with your ensemble, with your job? Do you stand to play? Do you sit? Where's your stand? Do you sit on the left side versus right side if you're in an orchestra? Where's your conductor? Is your conductor here, or is your conductor there, right? These are some of the questions that I ask a ton. And then I ask about pain level, if the chief complaint is pain. But then more importantly, I ask about their functions. The function is, how does this affect your play? So how long can you play? And how far can you play? So do you have to stop in the middle of rehearsal? Do you fake it if you're in an orchestra sometimes because it hurts to play? Or what do you do, right? What do you do to compensate because you feel this kind of discomfort or pain when you play? So these are some of the things that I focus on. And more so than pain intensity and severity, I try to focus a little bit more on the influence of pain on their play. And then we talked about some of the environmental stuff, like do you play in a cold environment? How's your chair? Where's your venue and whatnot? Those things are important to ask. And then practice habits. How long do you play at a time? Musicians sometimes go into, especially collegiate musicians, I see a lot of collegiate musicians. And then when they're preparing for an audition, they go into a room and they practice for hours. And there is no real sort of nice set of schedule of rest and exercise in between. Do you remember when you were in medical school and you were studying for boards? And you were just in the library all day and you didn't see the light in the day? Musicians are like that. They're very similar. They go into a room. They don't come out. They don't eat. When they eat, they eat terribly. They don't sleep. So it's those things I really ask a ton about that. And then I ask about their playing. So did you start a new music, new piece? What's your repertoire? Are you working with a teacher right now? If you're working with a teacher, did you change your setup? Are you holding your instrument differently? These are some of the questions that I ask for them. And then if you're a musician, sometimes you have to genre switch. So for example, you're a singer and your love is opera. And you just want to make it as an opera singer. But you're not marketable, right? Sometimes the market isn't there for you. So maybe you do a gig at a church or maybe you do a gig at a musical theater production. And you're auditioning for a pop thing. And then so you're switching your voice in between and you get injured, right? Or you're a string player and you're used to play just regular violin or viola or cello. And then you became like a Baroque orchestra person and your instrument changes and you get injured by that. So these are some of the things that most of the times you don't really think about. But if you have it with you and you see a musician, you can just ask these questions. They already know, oh my goodness, this person knows who I am. I can trust this doctor. And I can tell you all about my weird complaints that nobody really wanted to hear about. And that's my goal and that's Dr. Elson's goal, right? More of us need to go out there and take care of these people because they don't really see doctors, guys. And they can't see doctors because they are either underinsured or uninsured. So anyway, so and then you do your physical exam. I want you to do your good physiatric exam, good physiatric exam. Don't forget that, good exam. But have them play, do an observation of their play, do a good postural evaluation, and then also hypermobility screening for musicians as well. And so some people are just hypermobile genetically, but musicians have hypermobility because of their instrument. And so for example, if you're a flutist and you always have to extend your pinky for 15 years of your life, you would probably have hypermobility in the fifth MCP, right? Or people who have an instrument in front of them. Like me, a violinist, I have a lot of hypermobility in my left pinky because I've played that instrument for a long time. And a lot of times, hypermobility comes with misuse and overuse and some of those musculoskeletal complaints that could be easily treated with your rehab team that it's been ignored. So don't forget about those. OK, and then don't forget about the social history, diet, exercise, sleep. Musicians don't exercise. They don't exercise at all, but there has been some studies out there that people with even myofascial pain, if you do not even toning or strengthening, but if you do daily cardiovascular exercise, it decreases their myofascial pain amongst musicians. And so this is something that's very important to kind of go over with your musicians. And then that alcohol, cigarettes, coffee, caffeine, some of the recreation and drugs. So remember earlier that some musicians don't get paid with money? Some musicians, when they play a gig, they get paid with drugs. Ask about that. Ask about that, and you'll be surprised. And so they go hungry, but they are full of recreational drugs. It is incredible how this world is like right now, even to this day. And just think about what that does to a musician, right? And you put your soul out there, and there you go. Here you go. For your payment, here's your cocaine, right? It's terrible, terrible culture. And then also, if you're working with musicians who are also composing, or maybe they're trying to make it out there. Musicians these days are huge on social media. So they're playing them. They're recording their TikTok videos and getting it out there. And they're trying to share their art with everybody else. And then all they're doing when they're not playing, they're doing this when they're practicing. And they're doing this when they're not practicing. It's awful. So just ask them about those things. Ask about mental health, and then especially performance anxiety. Okay, these are some of straightforward things. Music world is hierarchical, and it's apprenticeship. And so they have a lot of power struggles between their instructors versus their students. Also, there's a lot of unhealthy culture in terms of let's play through pain. Or if you don't play today, then there's so many more who could replace you. You're rather dispensable. And they feel that way. They feel very vulnerable. And so it's very competitive. So if they could open up to you about these things, and it will really help you see them as a whole person. And make sure that you give and provide them good, physiatric, comprehensive care for each individual one of them. Okay, I don't think we have time for that, right? We're pretty good on time? Yeah, that's gonna be the last one that I'm gonna talk about. So a lot of the common medical problems among musicians are musculoskeletal injuries. And so just know that in all your training right now to learn how to evaluate and treat them, don't forget them. Stay with your good physiatrics exam and make sure that you can take comprehensive history. And then go through your treatment with your team. Treat the primary pathology, but you need to have your team around you, just like any other rehab practice. So if you have a good physical therapist who's been a musician before, that's great. If you haven't, then they have to have an interest. And so have them, go and visit them, give them a call, talk to them. Occupational therapy is so key cuz a lot of them have upper limb injuries, right, the musicians? So if you could really recruit a few occupational therapists who really want to treat musicians, again, talk to them, get them involved, bring them into your team. But also speech language pathologists for voice users. And then psychiatry, very important. And psych counseling and mental health, so important. And then if you have a performance psychologist amongst you, that's a plus. If you know a performance psychologist who have worked with athletes before, they would be great with your musicians. So try and see if you can recruit them to refer your musicians to them. And then talk to your music teachers. If they're collegiate musicians or are the young musicians or growing musicians, call them. Call their music teachers and say, hey, this is what's happening. Do you think we can work together to adjust their setup? Do you think we can work together so that they can play not two hours a day, all in one go? And then making sure if they have other issues of voice users, do they need ENT referrals, right? Or aging musicians, orchestra musicians or others who are aging, if they need surgical referral, you could be the quarterback, cuz arranging that and organizing that. We talked about postural playing analysis and making sure you're working with their equipment to problem solve ergonomically. And then lastly, other than lifestyle changes, we've already talked about that. But lastly, educating our musicians about connecting their brain to their body. That's gonna be the last thing I wanna say to you. When they were growing up, when they first starting to play something, as opposed to let's say you're in a little league and then you're learning how to throw, right? And they learn that body moves this way to throw a ball, right? They do, sort of it's logical. You know that you have to move a certain group of muscles to move something. But musicians don't learn that way. When they learn, especially when they start to get good, a lot of times the pedagogical structure in music is that the teachers model and say you need to play this piece this way. They listen and then try to somehow mimic that or make it better for their own art, right? But they don't really think about what do I have to move? How do I have to stand? What do I have to do to stand or what do I need to do with my body to create the sound? They don't think about that. Therefore, their body awareness is extremely poor, very different from dancers actually. Dancers are very, very body aware. They might have a really unusual way to describe that, but dancers are very good. But musicians, they don't have this sort of normal body map in their brain. So this is really important for you to consider if you ever see a musician. And if you teach them home exercise program, for example, or PTs do that, they may not be able to do it properly. They just don't understand it. And they think they understand because they're highly intelligent, but they don't. And so these are some of the creating that connection between their brain and their body is really important. That's gonna be where I stop. Okay, and then we're gonna move on to questions, right? Yeah, great. Thanks for your attention. All right, well, thank you both, Dr. Elson and Dr. Lee, really insightful stuff. And I really love the use of the term misuse instead of overuse and something I definitely wanna start incorporating into my language. So without further ado, if anyone has any questions, there's a microphone up there, or I know it's a relatively small group. Feel free to ask your questions from down there. Yeah, absolutely, come on up. We're all friends. Hi, I'm Stacey from Philadelphia. Hi, Stacey. I'm an occupational therapist. So thank you for mentioning OT in the talk. I really do appreciate that. I have two questions. One, I know you touched on, what is the link with dancers and musicians with depression and suicide rates? I work in a pediatric facility, so teens and in your 20s, I feel like that's a high area of concern. And then my other question was, what's your recommendation for access to the healthcare? Because I find a lot of dancers and musicians don't have health insurance. So it's really hard to find where they should be go seeking the treatment and stuff like that. All right, those are, can you guys hear me okay? All right, so those are both really, really great questions. And I think that the mental health connection is something that we are very aware of. So within all of our performing arts medical association, IADAMS, the mental health component is a huge part. And in fact, for Dance USA, which is the, Dance USA is the overarching organization that takes care of all the, not doesn't take care of it, it's like for all the professional dance companies. So the managers, everything. And then they created the task force on dance health within that about 15 years ago, and so every six months we talk and we meet about important topics. And our last topic was mental health. And so it's very community driven. So I think it's something that we need to educate the practitioners about and have the referral sources. So I'm lucky I'm in Boston. We have many, many performing arts psychologists that I can refer to, so I'm very lucky. But I realize that not everybody has that. But I don't know the suicide rates and I don't know the prevalence. I do know that with COVID, everything went up because the job security was significantly affected. There were some great talks or programs that were developed in Europe, where they actually did outreach to one of the professional dance companies and they had psychology outreach and they showed some really good results with that. But it is a big problem. And then in terms of access, I think that's very city and state dependent. So I can speak, so within Dance USA, we do something where we go out into different cities across the United States and we do dancer wellness days. And what that looks like depends on what city we're in. So it's a day where we get all the local dance medicine practitioners together. And then, for example, in LA, we do it in November, which is at the time of open enrollment, and we help dancers get involved. In Boston, we have a universal healthcare state where if you don't make a lot of money, you actually pretty much get free care. It's almost better to make no money than some money, but we can get them plugged in. Now, which doctors they have access to might be a different story, but they actually all do have PT and OT services. But I think that that's gonna vary throughout the country. Within a lot of the cities that I work with through Dance USA, the local organizations will offer discounted care for dancers and musicians. So I think that that's something to, within my longer talk, we get into a lot of the barriers to access. And I think that that's something that in our communities, we have the opportunity for outreach. For musicians, so state of Texas doesn't have universal healthcare. Yeah, so for musicians, it depends on what ensembles you belong to. So there are some ensembles that provide healthcare. And so let's say, for example, you're a tenured musician at a Dallas Symphony Orchestra. They have good insurance. So they may not make a lot of money, but they can come and see you. But there are other types of musicians who are freelancers, really large majority of them. So they have a hard time getting to a physician or any other healthcare providers, especially PT, OT services. Because each time they have to pay a co-pay, for example, if they're underinsured. And then they get discouraged almost right away financially. And that is one of the, barrier to access is one of the biggest problems that I want to solve in my lifetime, hopefully. But you all have to understand that, I think you're getting the point here is. First of all, we have to understand that performers are a group of people who have very limited access to healthcare. And those of us who are in this world, we know that part of our practice is going to be service to this group of people. So I think, so therefore, lucrative outcomes is not going to be there when we're taking care of musicians and dancers and other performers. And I think I want to be very, very clear about that. You know, I'm not in this world to basically make money, right? You know, you're not doing that. But then there are such special group of people who brings us so much joy and so much happiness and so much enrichment in our lives. And there's just a little bit that we can do as group of people who could really understand them comprehensively compared to other group of physicians out there. Physiatrists are just so perfect in their ability to understand these group of populations. So that's why Dr. Elson and myself and others, we just want to go out there and talk about this as much as we can so that let's say, you know, you have a very successful practice in the future. Maybe you can see a couple of these patients, maybe a little bit less money, you know, with maybe a, you know, discounted visit or even, you know, pro bono visit. And that's kind of how we do things. Just a little bit more, if you want to talk more about practice management, those of you who are going to be in AAP, Dr. Elson and a bunch of others, we're going to talk about how to incorporate some of this stuff into your practice and not lose money, not go underwater. We're going to talk about these things in the future as well. In terms of mental health, I cannot stress that enough amongst musicians. And overall, I have to tell you, their identity, I think this is actually similar to our profession, right? A lot of you associate your identity as being a doctor, maybe not too much, I hope, but, you know, really, without being that physician's self, some of that identity goes away, right? But musicians are the same. So their identity equals their identity, their identity equals being a musician. So let's say they don't practice enough, right? So I practice five hours a day. I'm a great musician. Therefore, I'm a great person. That happens a lot. So what if you get injured, and you can't play, you can't practice? I'm not a good musician. Therefore, I'm not a good person. These things happen a lot. Or, you know, extreme performance anxiety, where this is the only thing that they love, and they want to do this. And once they get on stage, they can't play. What does that do to that person's psyche and their identity? There's some of the musician-focused mental health issues that I've seen that are not handled very well, even in the psychology world. And I talk to a lot of counselors about this. And that's why I was saying, if you have an access to a great performance psychologist, man, utilize that source, because I learn so much just by talking to them and just kind of talking to them about my patients' struggle on how to coach them back. Because guess what? They don't have money to go see a counselor every week. That's another thing. And so, just, you know, eventually, I think, hopefully, we'll try to gather more people who can take care of these people, so that there's only a few handful of us doing this, but more of you guys go out there and take care of these people. I think better these situations will become. Thanks. Any other questions? Hi, my name's Brian. I'm from NYU. Thank you for the great talk, by the way. My question is, you touched upon some of the barriers that these patient populations face. Given that it's somewhat of a niche area, how do you build a patient population? How do you market yourself as interested in this field and essentially get your name out there for people to find you? Do I start? Oh, okay. How do I build my practice? It was not hard at all, by the way. They need you so bad. Basically, you start with one musician, one dancer. Really, that's it. Word spreads so fast. I was a bit lucky. I joined Dr. Sash Survey, who started a performance medicine program down in Dallas, Fort Worth area. And so, we already had a bit of a infrastructure down there. And so, therefore, I already had patient populations to see. But even in residency, though, one or two patients, that's all you need. And then, that kind of sort of snowballs into a practice. It's just a matter of how do you make your practice financially healthy, while also providing meaningful healthcare to these group of people who really need it. And that is more of an extensive talk of more business management, I think. Yeah. I agree with the one dancer, one musician start. One of the reasons why I decided to work in the Boston area is that's where I had done most of my dancing. So, I already knew the dance population. So, I came out there. I already knew the dance PTs, because I was in med school, and half of them were in PT school, and we all danced together. So, that was really nice. So, it was a built-in network. However, it's also a very political dance medicine city, because the founders of dance medicine are there, and it wasn't open to physiatry when I first started. So, basically, I was like, well, I'm different. So, I'm a physiatrist. I'm different than you guys. I'm anybody who wants to come see me can. And so, that's how I started. And then, also, I have a lot of musician connections in the area. So, again, one musician comes in. They get results. They send all their friends and colleagues. So, the good and the bad thing about the dancers and musicians is they tend to get better. So, they're not necessarily the patients that stay in your practice forever. They come in and out with things. So, I would say 90% of my practice is not performing arts. 90 to 95 is not performing arts. The performing arts part is what makes me happy and keeps me going. And then, I take care of a couple smaller dance companies. And so, I will take a half day off, go do a screen, go do a lecture. And then, one of our physical therapists provides pro bono work sponsored by our institution once or twice a month. And then, if an injury happens, then they know where to come. So, I think, you know, and by going out and doing little amounts of free coverage or just screens, that's how the dancers know who you are, the musicians know who you are. You're in New York, right, you said? It's a very different market. You and I need to talk. It's very different. In New York, it's a whole nother world. And the performers, they are a whole nother animal. So. Yeah, there's been a lot of performing arts clinics that have come and gone in New York over the years, so. It's a very different world. It's very difficult. They always, like, listen to you talk about this access issue. I think about this one patient I had in a fellows clinic at HSS, and it was a dancer, an ex-dancer, because she fractured her hip years and years and years ago. But, and this comes back to the word of mouth thing, her friend had some surgery performed by one guy. And so, in her mind, she internalized that she had to have surgery by this one guy, but he didn't take care of uninsured people. And so, she went for years like this, and so, you know, it just healed really poorly. And so, she was externally rotated, shortened limb, and she ended up walking like this. And it's really something that's really awful. So, this is really important to really keep in mind. That breaks my heart. Yeah. I got someone to do it, though. Fix it. Yeah. Yeah, I did. I was like, this is awful. You can't let her walk around like this. Go, psychiatrist, go. Sorry, that's my little aside there. Okay, and so, I guess, how, I don't know, does anyone have a question out there? Okay, I guess my question would be, I mean, how, I know you were saying, like, this is not anything that's really, like, a moneymaker, necessarily. At what point would you say, for someone who's starting out, at what point can we comfortably feel comfortable with, like, changing our schedules and, like, setting aside time for this? Like, how do you know the time is right for it? And how do you go find these opportunities? And how do you go out and find therapists that you trust? I think that's something that's really hard, and no one tells you how to do it. I think that one of the ways to look for networks is through the professional organizations. So, iADAMS has a practitioner directory. PAMA, I think, has a practitioner directory. So, if you move to an area, you can look at those people in the area, and I think that would be a good jumping off point. Google searches, like, who does dance medicine in your local area would be a good place to start. In terms of setting up a practice and, like, when to start, I think that that depends on what type of practice you're starting in. I think it might be a little bit harder in private practice because you need to get the cash coming in right away. A lot of the more academic places, you'll be protected for the first year, so that's the time when they don't expect you to be busy and they give you a buffer, and so then you could take a little bit, a couple hours here and there when your schedule's not busy, and start to build those networks. You know, when I had graduated and I had a gazillion amount of loans and things like that, I was working five days a week, 10, 11 hours a day, and it wasn't until I was in practice for a while that I felt comfortable taking off that half day regularly to donate to my dance medicine time. And so that's an individual financial situation and it's gonna be different depending on where you're at. I do a lot of weekend and evening stuff, but that's what I enjoy. So, like, it doesn't, when I do dance medicine, it doesn't feel like work. It's, like, it's gonna, it's fun, and it's gonna get the dancers in my clinic, which is gonna make my clinic better, so I don't really think of it as a chore. Like, if I'm gonna cover a show, like, that's free tickets to a show. It's cool, yeah. It's super fun. It's so fun. Yes. So, I think that's actually a really good question for general practice management for those of you who are entering practice, you know? Because, you know, let's face it, our residencies don't really teach us how to build our practice, right? And it, and our field is so big that those of you might go into inpatient rehab or other sort of specializations, spinal cord injury, brain injury, and other things, or maybe you'll go into musculoskeletal medicine like me, or, you know, Dr. Elson, sports medicine. So, everybody is so different, and then how you will start your practice is gonna be a little bit different. And I think, first, you have to look at your, the health of your practice first. And, you know, depending on the region you're at, you wanna see musicians or dancers. Get your name out there. For an introverted person like me, I think it was difficult for me to just kind of randomly call people and go to these dance studios, or, you know, talk to Dallas Opera, Fort Worth Opera. It was a little hard for me. But I think because I just love these group of people, it was, I think it made up for it. And then people just heard that, yeah, I do wanna see these people. And so, once in a while, some of these patients will call you and call your office, and they actually have insurance. So, you start with those patients. And then, you know, now I'm eight years in, you know, I have a good understanding of, okay, what is financially healthy and what is not, and then what you can do, what you can't do. And recently, I've gone down to 80% of work, so I have 20%, sort of like Dr. Elson, where I can just kind of, I don't have to make that much money, I'm all right. I can go and do stuff, the things that make me happy, and it gives me some fulfillment with my work. So, that's kind of how I balance things. You hear a theme here, right? So, there's gotta be a little bit of a sacrifice in terms of your, you know, robustness of your patient population and your practice. There's gonna be a little bit of a dedication of your time and energy, some financial dedication and input. It's just that this is, what we're trying to advocate for here isn't really easy for day-to-day physiatrists, and we understand that. We just want to just get the word out there. So, if those of you who are interested in this and really want to pursue it, you understand what the reality is, and then also maybe with us, we could work together to improve all of the situation for this special group of people that we love so much. I think that's an important thing to highlight is this stuff doesn't happen overnight. Like, I'm 12 years out of fellowship, and so while I always knew that I wanted to do performing arts medicine, it takes a long time to build. So, I encourage people not to get frustrated, especially if it's not the primary thing when you're first working, and the thing that I can encourage you to do is just be good at what you do, because it doesn't help to get the dancers in the door and be green. Like, you want to have them come in the door and be like, okay, I got this. I mean, the most terrifying thing is when you see that first patient on your own when you're in attending, and like, wait, nobody's checking what I'm doing? And so, that's a big transition, and so I think it's good to put your name out there and say, this is what I do, and get really good at what you do, and then your patients will be like, oh, my friend is a, oh, you specialize in dance medicine? Well, my friend is a dancer. I'll have to let her know about you, because I've had a good experience here. And I think that actually is one of the big places, because on my cards, they said, oh, you're director of dance medicine. I thought, that's nice, what does that mean? But I think that people are like, oh, you take care of dancers, that's great, and so that, I think, was a huge, one of my biggest referrals. And then also, both Dr. Lee and I have gotten other training and other certifications. Like, I'm trained in acupuncture as well, and so we do, like, the performing art, we didn't get a chance to get into all this stuff, but a lot of the performing artists are looking for less invasive interventions to help them along the road, in terms of, in addition to everything else that we've already talked about. So being able to offer that skillset, I think, adds for a little bit of buy-in, too. And then being able to talk, so a lot of the performing artists will do different types of somatic education, or somatic practices. So within the music world, the body mapping, within the dance world, the Feldenkrais and gyrotonics, and then there's all sorts of other things out there, and it's just kind of like ways to internalize Alexander technique. And so getting to know those practitioners can also help, because a lot of times, dancers will seek them out first, and if something's not getting better, those practitioners can then send back to you. Yeah, that's great, great comment. Any other questions? Oh, that's one thing that you're right to mention, though. Don't forget, performers don't really like medical interventions in general. So good luck getting that injection going for that musician. I actually currently have a violinist who actually has a transposition of biceps tendon along with pretty degenerative joint. He's an aging musician, and he's playing with a very, very anatomical disadvantaged shoulder. And good luck injecting that inflamed bursa, good luck giving them NSAIDs, good luck. There's no way. All I'm doing is osteopathic manipulation and acupuncture. That's all I'm doing. And working with Pilates instructors, body mapping, PT, and he's playing every day. It's amazing what they can do. They're so motivated. They'll get it going. Any other questions? If you want to start seeing musicians, day one, or dancers, day one, I have a fellowship. Congratulations, yes. Shameless plug there. My little selfish, PM&R training is long, and I know that we know that our world is very niche. And so we have no grandiose ideas of having like 15 fellows working with us every year. But if you are really interested in taking care of these group of people, we here, we down in Dallas-Fort Worth region, we can give you so much experience and exposure just because of the location we're at, because we're not in crazy New York City with. And we have a lot of, actually, I would say at times, almost 50% of my patients are musicians. So I do see a lot of performers. And so we can give you an enriching experience if you can spare one year with us, it'll be fun. Anyway, that's a little like selfish plug. All right, well, thank you all for coming. And a big thank you again to Dr. Lee and Dr. Ellison. Thank you. One more selfish plug, please join the Fisk Forum, the performing arts community, because that's how we reach out to all of you guys. We're going to have journal clubs and other things there. So please, if you're not on there, join that. We're fun, join us.

performing arts medicine

care of dancers

care of musicians

psychological needs

physiological needs

mental health issues

eating disorders

stress fractures

musicians' health challenges

comprehensive care