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Texas Music Education Research 95

Medical Problems of Saxophonists: Physical and Psychosocial Dysfunction among Classical and Non-Classical Performers
Michael Thrasher North Central Texas College Kris S. Chesky University of North Texas
In recent years, writers have produced information regarding occupational problems related to music performance. Attention to medical and occupational issues has led to an increased awareness among musicians and health professionals, as illustrated by the increasing numbers of research studies, symposiums, and pedagogical articles in the professional literature. Because most reports are based on samples of classically trained student and professional musicians, however, significant gaps exist in the body of published data. Entire genres of musicians who perform rock music and jazz, for example, are not included in the available data. Omissions are particularly noticeable in regards to popular non-orchestral instruments such as the guitar or saxophone. Although many research reports address medical issues, authors tend to limit their subject pools to members of established organizations such as professional orchestras, college and university music departments, or public schools. For example, Fishbein, Middlestadt, Ottati, Straus, and Ellis (1988) reported high percentages of both musculoskeletal and nonmusculoskeletal problems among musicians; however, their survey was limited to members of the International Conference of Symphony and Opera Musicians, an organization consisting exclusively of professional musicians. Fry (1986) conducted an investigation of overuse syndrome, but limited his subject pool to members of Australian, English, and American symphony orchestras. Other authors have focused research efforts on university music students. In a study of 246 university-level music majors, Pratt, Jessop, and Niemann (1992) reported high percentages of musculoskeletal problems in musicians backs, necks, wrists, and shoulders. Another report compared 90 college instrumentalists with 159 non-instrumentalists and found that musicians were two times more likely than nonmusicians to experience upper-body pain (Roach, Martinez, & Anderson, 1994). Lockwood (1988) and Shoup (1995) focused their efforts on high school and junior high school band and orchestra students. The tendency to examine narrow populations of musicians is unavoidably related to the problems encountered when attempting to survey large, heterogeneous populations of performers.

Thrasher & Chesky 96 Another problem found in the literature deals with the manner of evaluation of instrumentspecific medical problems. Studies have organized data into categories such as woodwinds, strings or brass, which make it impossible to identify instrument-specific problems. For example, Newmark and Hochberg (1987) evaluated problems based on the following categories: keyboard, bowed string, guitar, and all others (in which harp, woodwinds, and percussion were combined into one group). Overall, these findings are limited because of the unique and varied demands associated with each instrument. The saxophone is unique among woodwind instruments. Its physical size, shape and performance requirements are different from other woodwinds, but the saxophone has received almost no consideration in studies addressing medical problems of musicians. It was not included in studies of professionals because it is predominantly a non-orchestral instrument, and studies of school musicians failed to isolate and analyze saxophone-specific medical problems. Even within the literature dealing directly with saxophone playing, acknowledgment of medical issues is scant. For example, an orthodontic device for pain relief to both clarinet and saxophone players experiencing embouchure and lip irritation has been described (Krivin & Conforth, 1975). In the New England Journal of Medicine, a case study was presented describing severe headache problems of a young student that intensified while playing the saxophone (Hanigan & Winer, 1991). Studies of musicians health should also include effects associated with the types of music that musicians perform. These issues are associated with various lifestyle issues and vocational demands that include performance requirements. For instance, a jazz musician may perform in environments that are less formal or more stressful than those of the classical musician. These differences for jazz saxophonists were described in an historical account of four famous saxophone players, in which Patalano (1997) identified the presence of significant psychosocial stressors on jazz saxophonists, including substance abuse, high travel demands, marital discord, haphazard working conditions, and lack of appreciation and respect for the art form. Classical musicians may encounter different problems than those experienced by jazz musicians; therefore, reports of musicians medical problems should consider these perspectives. More detailed information is needed to answer many questions regarding the physical problems experienced by saxophone players, the percentages of saxophonists who suffer from such problems, and genre-specific psychosocial concerns. In an attempt to address these issues, a unique approach was developed at the University of North Texas that utilizes the World Wide Web. Following successful pilot studies and research funding from the National Academy of Recording Arts and Sciences, the UNT Musician Health Survey (UNT-MHS) has developed into a viable platform for obtaining information from musicians across the nation and around the world. To date, over 4,000 musicians have participated in the project. Information from the survey has already been utilized in describing medical issues relevant to other instruments (Thrasher & Chesky, 1998). The purpose of the present study was to describe medical problems of saxophonists with an emphasis on genre-specific factors. Method A non-probability method for creating an accidental sample population was achieved by recruiting subjects through the World Wide Web (WWW). The main advantage of this process is the ability to find and recruit musicians from diverse locations and backgrounds. A major limitation is the inability to know what specific attributes are present in those who offer themselves as subjects via the WWW. The authors recognize that those who volunteer to take

Texas Music Education Research 97 the survey may be atypical of the target population of all musicians in terms of socioeconomic status, motivation, and other variables. Following approval by the UNT Institutional Review Board, subjects were recruited through messages posted to Internet links, Internet discussion groups, professional publications, and professional societies and organizations. Subjects were directed to log on at: Once logged on, standardized instructions prompted subjects through various sections of the survey. Subject participation was considered anonymous. At the end of the survey, subjects were invited to submit additional comments. Data files received over the Internet were downloaded into a master file for periodic preliminary inspection. This step allowed for identification of bogus, duplicate, or faulty data. Following screening procedures, data were merged into a master SPSS file. The UNT-MHS is divided into five sections and asks questions regarding (1) demographics, (2) musculoskeletal problems, (3) nonmusculoskeletal problems, (4) lifestyle and environment, and (5) feedback and comments (Corns, Edmonds, & Wilson, 1996). The development of the UNT-MHS allows for direct comparison of data to other well-known musician health surveys. The musculoskeletal section seeks information on 16 bilateral body locations. Questions regarding pain severity utilized a 5-point, graded severity score developed by Fry (1988), which incorporates a measure of functionality and problem duration. The scale is as follows: Grade 1: Pain while playing; should be consistent rather than occasional; pain ceases when not playing. Grade 2: Pain while playing; slight physical signs of tenderness; may have transient weakness or loss of control; no interference w/other uses of this location. Grade 3: Pain while playing; pain persists away from instrument; some other uses of this location cause pain; may have weakness, loss of control; loss of muscular response or dexterity. Grade 4: As for Grade 3; all common uses of the location cause pain housework, driving, writing, turning knobs, dressing, washing, etc. but these are possible as long as pain is tolerated. Grade 5: As for Grade 4; including loss of use of location due to disabling pain. Similar to the study by Fishbein et al. (1988), the nonmusculoskeletal section asks questions regarding incidence and severity of several possible problems. The lifestyle/environment section seeks information about marital status, diet, travel demands, work-related stress levels, and alcohol and cigarette use.

Thrasher & Chesky 98 Table 1 Musculoskeletal Problems Reported ______________________________________________________________________________ % of Respondents Reporting ____________________________________________ No Grade Grade Grade Grade Grade Problem 1 2 3 4 5 2 p ______________________________________________________________________________ Right Finger Classical 72.4 10.3 0.0 10.3 6.9 0.0 Non-Classical 83.0 9.4 5.7 0.0 1.9 0.0 8.69 .069 Left Finger Classical 72.4 3.4 10.3 6.9 6.9 0.0 Non-Classical 83.0 13.2 3.8 0.0 0.0 0.0 10.73 .030 Right Hand Classical 72.4 6.9 3.4 17.2 0.0 0.0 Non-Classical 88.7 3.8 5.7 1.9 0.0 0.0 7.20 .066 Left Hand Classical 86.2 0.0 3.4 10.3 0.0 0.0 Non-Classical 90.6 9.4 0.0 0.0 0.0 0.0 10.09 .018 Right Wrist Classical 65.5 24.1 0.0 3.4 6.9 0.0 Non-Classical 81.1 5.7 5.7 7.5 0.0 0.0 11.67 .020 Left Wrist Classical 75.9 6.9 10.3 3.4 3.4 0.0 Non-Classical 81.1 9.4 5.7 3.8 0.0 0.0 2.60 .626 ______________________________________________________________________________ Table 1 continues.

Texas Music Education Research 99 Table 1, continued ______________________________________________________________________________ % of Respondents Reporting ____________________________________________ No Grade Grade Grade Grade Grade Problem 1 2 3 4 5 2 p ______________________________________________________________________________ Right Forearm Classical 86.2 10.3 0.0 0.0 3.4 0.0 Non-Classical 96.2 0.0 3.8 0.0 0.0 0.0 8.61 .035 Left Forearm Classical 93.1 6.9 0.0 0.0 0.0 0.0 Non-Classical 94.3 3.8 0.0 1.9 0.0 0.0 0.93 .630 Right Elbow Classical 89.7 3.4 0.0 3.4 3.4 0.0 Non-Classical 94.3 1.9 0.0 3.8 0.0 0.0 2.07 .559 Left Elbow Classical 93.1 3.4 0.0 0.0 3.4 0.0 Non-Classical 96.2 3.8 0.0 0.0 0.0 0.0 1.85 .396 Right Shoulder Classical 69.0 6.9 17.2 3.4 3.4 0.0 Non-Classical 92.5 5.7 0.0 1.9 0.0 0.0 12.43 .014 Left Shoulder Classical 79.3 13.8 0.0 3.4 3.4 0.0 Non-Classical 90.6 7.5 0.0 1.9 0.0 0.0 3.04 .386 Right Neck Classical 62.1 10.3 6.9 6.9 13.8 0.0 Non-Classical 66.0 11.3 9.4 11.3 1.9 0.0 4.94 .294 Left Neck Classical 62.1 10.3 6.9 6.9 13.8 0.0 Non-Classical 73.6 9.4 7.5 7.5 1.9 0.0 4.75 .314 Right Up. Back Classical 69.0 6.9 17.2 6.9 0.0 0.0 Non-Classical 81.1 5.7 1.9 9.4 1.9 0.0 7.136 .129 Left Up. Back Classical 69.0 13.8 6.9 10.3 0.0 0.0 Non-Classical 86.8 3.8 0.0 7.5 1.9 0.0 7.69 .104 ______________________________________________________________________________ Results Subjects included 82 musicians (19 females, 62 males, 1 whose sex was not identified) selected from an accidental sample of over 4,000. Subjects were included if they reported saxophone as their primary (most-played) instrument. Sample stratification occurred based on subject

Thrasher & Chesky 100 identification of primary performance area. Twenty-nine saxophonists (15 males, 13 females, 1 whose sex was not identified) described themselves as primarily classical performers; 53 saxophonists (47 males, 6 females) described themselves as non-classical performers. The nonclassical category included saxophonists who primarily performed jazz, blues, country-western, rock, or gospel music. Although the average age of classical performers (29.0 years) was less than non-classical performers (32.7 years), the classical saxophonists averaged more years of both formal college music instruction (3.7 years, compared to 2.92 years) and professional musical activity (9.16 years, compared to 8.30) than the non-classical saxophonists. Saxophonists reported various musculoskeletal problems at a wide range of severity. Table 1 identifies the problems, grade of severity, and statistical analyses for both classical and nonclassical performers. The leading problems reported were related to the neck, right wrist, right upper back, and right and left fingers. In all cases, the incidence of problems was greater among classical performers than among non-classical performers. In five instances, these differences were shown to be statistically significant: right shoulder, left hand, right wrist, left finger, and right forearm. Table 2 describes incidence and severity of various nonmusculoskeletal problems. A high percentage of saxophonists reported problems with fatigue, headaches, and depression. In all categories except for hearing loss, classical performers experienced a higher percentage of problems than did non-classical performers. The two groups were statistically different with regard to: mouth lesions, sleep disturbances, respiratory allergies, and blackouts/dizziness. Classical and non-classical saxophonists also illustrated differences in various lifestyle and behavioral areas. For example, 58.6% of classical saxophonists admitted to some degree of alcohol use, while 80.8% of non-classical players used alcohol. Non-classical players also experienced higher work-related stress levels, with 73.1% labeling their work environment as moderately to highly stressful. Only 58.6% of classical performers identified their work as moderately to highly stressful. One hundred percent of the classical saxophonists described themselves as non-smokers, compared to 78.4% of non-classical performers (p = .007). Discussion The results of this study identify numerous physical problems experienced by saxophone players and illustrate differences in frequency and severity of problems between classical and non-classical players. Both groups demonstrated frequent problems in upper body areas, especially the right and left areas of the neck and in the right upper back. This issue may be related to the unique practice of saxophonists, transferring the weight of heavy brass instruments to the neck and back area through the use of neckstraps. Another problem for saxophonists was the right wrist, an area identified as the most significant problem for performers of the clarinet (Thrasher & Chesky, 1998). In the case of saxophonists, classical players experienced problems at significantly higher levels than non-classical performers. In all musculoskeletal areas, classical players demonstrated higher percentages of problems at greater levels of severity than did non-classical players, an aspect of performance not dealt with in saxophone literature. The leading non-musculoskeletal concerns for saxophonists were fatigue, headaches, and depression. Classical players again reported much higher and more severe problem levels than did non-classical players. Over 50% of classical saxophonists suffered from depression, and almost 35% suffered from acute anxiety. Although non-classical players experienced higher levels of work-related stress and alcohol and cigarette use, they tended to report being in better condition both physically and psychologically.

Texas Music Education Research 101 Medical issues affecting saxophonists may be compounded by a variety of factors. For example, many players are expected to perform on all types of saxophones, including soprano, alto, tenor, or baritone. Although the instruments of the saxophone family have much in common, each instrument also presents unique performance demands. Each instrument varies significantly in size and weight, and these factors may influence posture, hand position, and demands on the neck and upper back. Many non-classical players are also expected to double on other woodwinds such as clarinet or flute. This exposes performers to the potential for sharply contrasting medical issues.

Thrasher & Chesky 102 Table 2 Non-musculoskeletal Problems Reported ______________________________________________________________________________ % of Respondents Reporting _____________________________________ No Problem Mild Severe 2 p ______________________________________________________________________________ Acute Anxiety Classical Non-Classical Asthma Classical Non-Classical Blackouts/Dizziness Classical Non-Classical Depression Classical Non-Classical Eyestrain Classical Non-Classical Fatigue Classical Non-Classical Headaches Classical Non-Classical Hearing Loss Classical Non-Classical Mouth Lesions Classical Non-Classical Respiratory Allergies Classical Non-Classical Sleep Disturbances Classical Non-Classical TMJ Syndrome Classical Non-Classical Stage Fright 65.5 75.5 69.0 86.8 62.1 84.9 48.3 69.8 69.0 71.7 44.8 62.3 51.7 66.0 72.4 66.0 62.1 88.7 65.5 86.8 62.1 84.9 75.9 86.8 31.0 20.8 20.7 7.5 34.5 15.1 31.0 24.5 24.1 24.5 34.5 30.2 34.5 26.4 27.6 34.0 31.0 11.3 20.7 11.3 27.6 15.1 13.8 7.5 3.4 3.8 10.3 5.7 3.4 0.0 20.7 5.7 6.9 3.8 20.7 7.5 13.8 7.5 0.0 0.0 6.9 0.0 13.8 1.9 10.3 0.0 10.3 5.7

1.08 3.96 6.31 5.55 0.40 3.78 1.80 0.35 9.31 6.55 8.25 1.58

.584 .138 .043 .062 .820 .151 .407 .553 .010 .038 .016 .453

Texas Music Education Research 103 Classical 79.3 17.2 3.4 Non-Classical 83.0 17.0 0.0 1.86 .395 Weight Problems Classical 55.2 34.5 10.3 Non-Classical 75.5 22.6 1.9 4.86 .088 ______________________________________________________________________________ These results of this survey should be interpreted with considerable caution. Due to the uneven gender distribution within the non-classical subgroup, a statistically significant gender bias is present. More importantly, the lack of a randomized sample prevents generalization of these results to the total saxophone-playing population. The higher levels of physical problems reported by classical performers as compared to non-classical performers raise important questions not dealt with in the literature. Further research is warranted. References
Corns, J.S., Edmund, D., & Wilson, S. (1997). World Wide Web research in performing arts medicine: The University of North Texas Musician Health Survey. In: K. Chesky and B. Rubin, (Eds.) Applications of Medicine in Music (pp. 13-18). Denton, TX: University of North Texas. Fishbein, M., Middlestadt, S. E., Ottati, V., Straus, S., & Ellis, A. (1988). Medical problems among ICSOM musicians: Overview of a national survey. Medical Problems of Performing Artists, 3, 1-8. Fry, H. J. H. (1988). Patterns of over-use seen in 658 affected instrumental musicians. International Journal of Music Education, 11, 3-16. Hanigan, W. C., & Winer, S. J. (1991). Saxophone headaches [Letter to the editor]. The New England Journal of Medicine, 325, 1888-1889. Krivin, M., & Conforth, S. G. (1975). An embouchure aid for clarinet and saxophone players. Journal of the American Dental Association, 90, 1277-1281 Lockwood, A. H. (1988). Medical problems in secondary school-aged musicians. Medical Problems of Performing Artists, 3, 129-132. Newmark, J., & Hochberg, F. H. (1987). Doctor, it hurts when I play: Painful disorders among instrumental musicians. Medical Problems of Performing Artists, 2, 93-97. Patalano, F. (1997). Psychosocial stressors in the lives of great jazz musicians. Perceptual and Motor Skills, 84, 93-4. Pratt, R. R., Jessop, S. G., & Niemann, B. K. (1992). Performance-related disorders among music majors at Brigham Young University. International Journal of Arts Medicine, 1, 7-20. Roach, K. E., Martinez, M. A., & Anderson, N. (1994). Musculoskeletal pain in student instrumentalists: A comparison with the general student population. Medical Problems of Performing Artists, 9, 125-130. Shoup, D. (1995). Survey of performance-related problems among high school and junior high school musicians. Medical Problems of Performing Artists, 10, 100-105. Thrasher, M. & Chesky, K.S. (1998). Medical problems of clarinetists: Results form the U.N.T. musician health survey. The Clarinet, 25, 24-27.