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rationale: Musculoskeletal problems are widespread in performing artists and are due to the special demands of instrument playing, singing or dancing. Additionally, various other factors might contribute to performance-related musculoskeletal problems. In order to provide a specific physiotherapeutic management for performing artists, it is important to gain information about the performing art, the individual (biomechanical) demands and contributing factors. The subjective examination is the basis of the clinical reasoning process and the hypothesis forming, which is important for goal setting in further clinical examination and biomechanical analysis. In the present protocol, the subjective examination consists of a questionnaire based section and an interview based section and is part of the evaluation process of the neuromusculoskeletal examination of a performing artist specific reference laboratory.
purpose: The aim of this study was to develop a standardized protocol for an interview based subjective examination of performing artists with musculoskeletal problems. The results of this section of the subjective examination will be combined with the results of the questionnaire based subjective examination , in order to gather as much relevant information as possible to specifically address the individual’s musculoskeletal health status.
methods: A common physiotherapeutic recording of findings which addresses the relevant questions of the subjective examination of musculoskeletal problems was used. In order to adapt the anamnesis to performing-related musculoskeletal problems, questions specific to instrument playing, singing and dancing were selected on the basis of a literature search and the expertise of the research group.
results: The protocol is based on the five aspects of clinical practice described by Maitland and the Musculoskeletal Clinical Translation Framework by Mitchell et al. (2017) .The performing art specific questions especially address (1) performing art specific considerations including style, genre, education and professional level, practice habits, repertoire, and external factors, e.g. concert conditions, (2) performing art specific physical and psychosocial contributing factors, and (3) performing art specific activities which trigger the musculoskeletal problems and help to form hypotheses for the following clinical examination. Individual tracks lead through the subjective examination so that irrelevant questions are skipped depending on the kind of musculoskeletal problem and the performing art practiced by the individual client.
conclusions: A pretest of this standardized anamnesis protocol is ongoing in a special physiotherapy clinic for performing artists since spring 2022. In an iterative approach, the protocol will be continuously improved based on patient feedback and clinical considerations.
Hintergrund: Instrumentalisten leiden häufig unter spielbedingten (neuro-) muskuloskelettalen Erkrankungen. Diese zeigen sich bei Streichern, wie Violinisten, Bratschisten und Cellisten, am häufigsten in Form von Beschwerden im Oberkörper – insbesondere im Schulter-Nacken-Bereich. Die apparative Bewegungsanalyse hat sich bereits als hilfreich bei der Beurteilung von muskuloskelettalen Erkrankungen und schädlichen Bewegungsmustern erwiesen und wird für die Diagnostik bei funktionellen Störungen empfohlen. Es wurde bereits gezeigt, dass die apparative biomechanische Bewegungsanalyse ein valides und klinisch praktikables Werkzeug für die genaue und objektive Untersuchung von Bewegungen bei Streichern ist, jedoch ist ihr Einsatz in der klinischen Konsultation immer noch sehr unüblich. Aus diesem Grund existiert ein Mangel an gut etablierten Bewegungsanalyse-Protokollen zur Untersuchung funktioneller Störungen bei Streichern unter Einsatz biomechanischer Instrumente in einem klinischen Umfeld wie der Physiotherapie.
Ziel ist es daher, die Entwicklung und Anwendung eines solchen Protokolls vorzustellen für die Beurteilung der funktionellen Spielbewegungen des Oberkörpers bei sowohl hohen als auch tiefen Streichern in einem physiotherapeutischen Umfeld.
Methode: Zunächst wurden auf Basis einer klinischen Fragestellung relevante Symptombereiche und Messparameter bestimmt. Anschließend wurden beteiligte Segmente, Gelenke und Muskeln selektiert. Darauf basierend wurde ein umfassendes (mechanisches) Modell des Oberkörpers sowie die dazugehörigen Koordinatensysteme und Rotationssequenzen definiert. Dies lenkte sowohl die Spezifikation eines speziell angefertigten Marker-Sets sowie fortgeschrittener Ansätze wie zur funktionellen Bestimmung von Gelenkzentren und -achsen, als auch die Auswahl und Platzierung von Oberflächenelektroden. Schließlich wurden Aktivitäten zur Kalibrierung und Untersuchung der Bewegungsfunktion sowie relevante Analyseparameter und deren Darstellungsformen festgelegt.
Die Protokolldurchführung beinhaltet zunächst die Auswahl der zu untersuchenden Segmente, Gelenke und Muskeln ausgehend von einer oder mehreren klinischen (Arbeits-)Hypothesen bzw. von den spezifischen Symptombereichen. Darauf basierend werden die benötigten Marker und Oberflächenelektroden konfiguriert und platziert. Anschließend werden die festgelegten Kalibrierungsmessungen und Bewegungsaufgaben durchgeführt. Schließlich werden die relevanten Ergebnisparameter zur Überprüfung der Hypothesen extrahiert.
Der klinische Einsatz der Methode wird exemplarisch anhand einer Violinistin mit spielbedingten Schmerzen erläutert.
Klinische Implikationen: Die potenzielle Anwendung des vorgestellten Vorgehens ist die intra-individuelle Evaluation von gleichzeitig der Gelenk- als auch der Muskelfunktion bei hohen und tiefen Streichern während der physiotherapeutischen Konsultation. Dies soll sowohl zur Diagnose funktioneller Erkrankungen des Bewegungsapparates in Form einer objektiven, umfassenden und dennoch klinisch praktikablen diagnostischen Untersuchung als auch zum prä-post-interventionellen Vergleich beitragen.
background: Musculoskeletal problems (MP) are widespread in performing artists and are due to the special demands of instrument playing, singing or dancing. Additionally, various other factors might contribute to performance-related MP. To provide a specific physiotherapeutic management for performing artists it is important to gain information about the performing art, the individual demands and contributing factors. The subjective examination (SE) is the basis of the clinical reasoning process and the hypothesis forming for further clinical examination and biomechanical analysis. In the present protocol, the SE consists of a questionnaire-based section and an interview-based section and is part of the evaluation process of the neuromusculoskeletal examination of a performing artist specific reference laboratory.
purpose: To develop a standardized SE protocol divided into a questionnaire-based section (Part 1) via web application and an interview-based SE (Part 2) to address MP of performing artists.
methods: The questionnaires for part 1 were selected based on the expertise of the research group and the psychometric properties of each possible questionnaire. A common physiotherapeutic recording of findings which addresses the relevant questions of the SE of MP was used. To adapt the anamnesis to performing-associated MP questions specific to instrument playing, singing and dancing were selected on the basis of a literature search and the expertise of the research group.
summary of content/results: Part 1 consists of three topics. (1) information about the performing art, professional level and sociodemographic data, (2) information about pain and pain processing, and (3) the anatomical location of the main MP including a body region-specific questionnaire. Part 2 is based on the five aspects of clinical practice described by Maitland and the Musculoskeletal Clinical Translation Framework by Mitchell et al. The performing arts specific part is particularly focused on performing art specific considerations, physical and psychosocial contributing factors and art-specific activities.
significance: This standardized SE protocol should help clinicians evaluating the musculoskeletal health of performing artists in a standardized and specific way.
Background: Musculoskeletal problems (MP) are widespread in performing artists and are due to the special demands of instrument playing, singing or dancing. In order to specifically evaluate these problems, a reference laboratory is under development. The evaluation covers 4 steps: a subjective examination (SE) including (1) a questionnaire-based online survey and (2) an interview-based anamnesis. On the basis of the results of the SE, hypotheses are formed for (3) an individual musculoskeletal clinical examination and a (4) biomechanical analysis. Here, the focus is on the clinical examination.
Purpose: to develop a standardized protocol for a clinical examination addressing especially musculoskeletal problems in performing artists.
Methods: A common physiotherapeutic clinical examination should be supplemented with techniques, which are specific to performance-related musculoskeletal problems and/or their risk factors. The development was based on a literature search and the clinical expertise of the physiotherapeutic research group.
Summary of content/Results: The performing arts specific clinical examination includes the common analysis of posture as well as passive/active movement capacities and specific differentiating tests in relation to the signs and symptoms of the individual artist. The examination is supplemented by a functional demonstration focusing on the special demands of playing the respective instrument, while singing or dancing. Common overuse risk factors like hypermobility, special anthropometric data or an examination of the motor control of different body regions are addressed. Optional, the various parts of the examination process could be skipped, if not relevant for the individual artist.
Significance: This clinical examination protocol should help clinicians evaluating the musculoskeletal health of performing artists in a standardized and specific way.
Rationale:
Instrumentalists often suffer from playing-related (neuro-)musculoskeletal disorders (PRMDs). Most common PRMDs in string players are related to upper-body regions. Motion analysis has proven to be helpful in the evaluation of functional disorders. It was already shown that it is a valid and clinically feasible tool for accurate, repeatable, and objective assessments of functional movement in string players. Thus, it may guide clinicians to improvements in injury prevention, diagnosis, and treatment. Nevertheless, its application in clinical consultation is still very uncommon. For this reason, there is a lack of well-established motion analysis protocols for the examination of PRMDs in string players using advanced biomechanical instruments in clinical settings.
Purpose:
To demonstrate the development and application of a motion analysis protocol for the evaluation of functional upper-body movements in violinists, violists, and cellists in a clinical setting for the investigation of PRMDs.
Approach:
The protocol was to be integrated into a clinical reasoning process for testing clinical hypotheses and evaluating treatment outcomes in physiotherapy. As a starting point, a primary clinical question was defined, and then, specific upper-body symptom regions as well as measurement parameters (relative rotation angles and muscle activities over time) were identified. Subsequently, involved segments, joints, and muscles were assorted. For quantification of upper-body kinematics a novel, marker-based method was used which provides multi-segmented shoulder and spine models while providing simple application. Based on that, a comprehensive mechanical model of the upper body as well as the associated coordinate systems and rotation sequences were specified. This further guided both, the definition of a custom-made marker set as well as the selection and placement of surface electrodes. Furthermore, required static and functional calibration trials as well as movement tasks for functional assessment were specified. Finally, advanced approaches, such as a comprehensive kinematic model and functional determination of joint centers and axes were established for extraction. Then, outcome parameters and their form of representation were determined for further analysis and interpretation.
The application of the method first includes the selection of segments, joints, and muscles to examine – originating from one or more clinical (working) hypotheses or symptom regions. This drives the configuration and placement of required surface markers and electrodes. Then, the required calibration and functional movement trials are executed. After measurement, the outcome parameters get extracted and analyzed. Based on the results the hypothesis is discarded or verified.
Content:
The method was applied to a violinist (female; 18 years old; 13 years of experience; practicing 2 to 3 hours per day, 7 days per week) with playing-related demands in the left cervical-shoulder-arm region.
Subjective findings indicated that the pain regularly occurred after 30 minutes of playing fast or difficult musical pieces. Physical examination showed that strength testing of left serratus anterior muscle caused pain, lower trapezius muscles seemed weak, forearm muscles were sensitive to pressure, movement of the cervical spine to the left was reduced, and upper limb neural tension test was noticeable.
This led to the following working hypothesis: Neck-related arm pain with neurodynamic component and motor control problem in the scapulothoracic region. Thus, left-sided cervical-shoulder-arm region was selected for functional examination.
Optoelectronic motion capture system and surface electromyography were used for data collection. Static and function calibration trials as well as functional assessment trials (chromatic scale with different tempi) were conducted. Afterwards, data was further processed, and outcome parameters were extracted.
Results showed that greater tempo and pain had an impact on the rotation angles and muscle activities. They led to less overall joint movement and range of motion, to less muscle activity in the forearm muscles, and to greater activity inputs in the scapulothoracic muscles. Overall, greater tempo and pain led to a different motor program which verified the working hypothesis.
The procedure was repeated after treatment (four appointments over one week) with manual therapy, training, and education. The pre-/post-interventional comparison showed changes in the motor program. There was noticeable higher mean activity in upper trapezius and deltoid muscles and simultaneously less in the remaining ones. In addition, only marginal differences in ranges of motion and muscle activity inputs were found between tempi. The playing style appeared to be more stable now. Overall, it appeared that nearly the same motor program was used for each tempo.
Clinical Implications:
Potential applications are intraindividual evaluations of simultaneously joint and muscular function in string players during clinical consultation. It is intended to contribute to the diagnosis of PRMDs in terms of an objective, comprehensive and yet clinically feasible diagnostic assessment as well as pre-post-intervention outcome evaluation.
Nonetheless, motion analysis must be used with care in clinical decision making. Motion data is subject to both, intraindividual variations, and measurement errors. In addition, the smallest clinically relevant changes are not clear yet. Therefore, results should only be interpreted together with other clinical findings.
Currently, the treatment of musicians is an interprofessional approach. Playing-related health complaints may impact the performance of a musician. In Germany, a medical consulting hour for musicians exists, but those for athletes in sports medicine are not so common. The diagnosing and treatment procedure within the physiotherapy consultation for musicians follows a specific concept-b and requires knowledge of instruments and musician-specific complaints. Based on the consulting hour in a clinic in Osnabrueck, 614 case reports were part of this sample, of which 558 data sets were complete. The focus of the analysis is the instrument and the primary complaint. Also, the type of therapy is characterized, and the amount is calculated. Primary complaints of musicians, in general, are found most frequently in the spine and upper extremity. Musician complaints are different between instruments. Instrumentalists have a significantly higher chance to suffer from a primary complaint in the area of the upper extremity. Furthermore, the groups without an instrument (e.g., singing or dancing) are developing complaints in the anatomical area which they primarily use. Therefore, these types of therapy were used: physiotherapy, manual therapy, and osteopathy with an average of 5.9 treatment units. This study underpinned the importance of musician-specific physiotherapy as a profession to treat musicians. Also, an interdisciplinary approach is necessary to treat all aspects of complaints.
Rationale:
Performing artists are exposed to high strains during their performance. These strains are similar to the ones of professional athletes, but in contrast to athletes there is a comprehensive undersupply of care regarding preventive and rehabilitative therapy offers.
Purpose:
The purpose of RefLabPerform is to develop a reference laboratory for the assessment of neuromusculoskeletal disorders using physiotherapeutic assessment methods in combination with biomechanical motion analysis. This includes the automatized integration of the physiotherapeutic assessments with the technical biomechanical analysis for an individual treatment recommendation with decentralized health care recommendations for a home-based therapy based on evidence-based prevention and rehabilitation strategies.
Methods:
Several work packages are processed systematically, whereby according to the requirements in the course of the project an overlapping of work packages occurs. First, the component planning of the innovative reference laboratory structure is carried out, on which the clinical and technical development of the reference laboratory is based. The next steps are the development of individual clinical assessment protocols, prevention and rehabilitation strategies as well as the setup of the laboratory and the development of technical routines. Parallel to this, various analysis tools are being developed for biomechanical data as well as for physiotherapeutic diagnostics and merged at the end of this work package for individual results for different groups of performing artists. Overlapping with the previous work packages, the reference laboratory will be tested for application and manageability. Clinical and technical data are brought together and checked by means of individual case trials on various groups of artists. In terms of an agile software development process, the results flow back into the previous work packages in order to optimize them and then test them again.
Results:
At the end of the project a functional and proven reference laboratory for the comprehensive analysis of performing artists will be developed.
Conclusions:
This reference laboratory is specialized to the diagnosis and treatment of playing- and performance-related dysfunctions with a focus on clinical findings and biomechanical movement analysis.
Educational Objectives:
At the end of the presentation, the participants will be able to…
1. describe the innovative content of the project RefLabPerform
2. understand the advantages of merged analysis strategies by physiotherapeutic and biomechanical examinations
3. understand the complex interdisciplinary process to develop a reference laboratory for performing artists
Rationale:
Performing artists are exposed to high strains during their performance. These strains are similar to the ones of professional athletes, but in contrast to athletes there is a comprehensive undersupply of care regarding preventive and rehabilitative therapy offers.
Purpose:
The purpose of RefLabPerform is to develop a reference laboratory for the assessment of neuromusculoskeletal disorders using physiotherapeutic assessment methods in combination with biomechanical motion analysis. This includes the automatized integration of the physiotherapeutic assessments with the technical biomechanical analysis for an individual treatment recommendation with decentralized health care recommendations for a home-based therapy based on evidence-based prevention and rehabilitation strategies.
Methods:
Several work packages are processed systematically, whereby according to the requirements in the course of the project an overlapping of work packages occurs. First, the component planning of the innovative reference laboratory structure is carried out, on which the clinical and technical development of the reference laboratory is based. The next steps are the development of individual clinical assessment protocols, prevention and rehabilitation strategies as well as the setup of the laboratory and the development of technical routines. Parallel to this, various analysis tools are being developed for biomechanical data as well as for physiotherapeutic diagnostics and merged at the end of this work package for individual results for different groups of performing artists. Overlapping with the previous work packages, the reference laboratory will be tested for application and manageability. Clinical and technical data are brought together and checked by means of individual case trials on various groups of artists. In terms of an agile software development process, the results flow back into the previous work packages in order to optimize them and then test them again.
Results:
At the end of the project a functional and proven reference laboratory for the comprehensive analysis of performing artists will be developed.
Conclusions:
This reference laboratory is specialized to the diagnosis and treatment of playing- and performance-related dysfunctions with a focus on clinical findings and biomechanical movement analysis.
Educational Objectives:
At the end of the presentation, the participants will be able to…
1. describe the innovative content of the project RefLabPerform
2. understand the advantages of merged analysis strategies by physiotherapeutic and biomechanical examinations
3. understand the complex interdisciplinary process to develop a reference laboratory for performing artists