PAM Rounds is a new series of face to face events bringing together health professionals and students to discuss performing arts medicine clinical cases. Organised by the department led by Dr Hara Trouli, PAM Rounds will be held approximately quarterly at the ISEH (Institute of Sport, Exercise and Health), on Tottenham Court Road, London. The first session takes place on Wednesday 22 February, 2023, 6 – 8pm and focuses on musculoskeletal problems in the performing arts. PAM Rounds events are free of charge to attend.

To register, please email hara.trouli@ucl.ac.uk�� �� ��

BAPAM-registered chartered physiotherapist Dominique Royle sent us her recent article which explores the management of playing-related musculoskeletal disorders (PRMD) in musicians. First published in , which focused on occupational health, we are grateful to Physio First for their permission to share the article here: Playing-Related Musculoskeletal Disorders in Musicians (pdf)

Dominique’s article helps us gain a better understanding of the incidence of PRMD in musicians, and appropriate physiotherapy management strategies to facilitate musicians’ recovery and return to optimal performance. She describes the problems that musicians face with seating. Seating provided by practise and performance venues often does not cater for the various body shapes and sizes, causing difficulties for those who spend a considerable amount of time sitting while playing. Dominique also examines the importance of the ratios of work:rest and acute:chronic workload when considering the length of practise sessions.

Managing musicians’ problems is a dynamic and reflexive process which requires a deep understanding of the demands placed on the musician. Dominique stresses the need for physiotherapists to adjust their hands-on education and exercise techniques to mirror the experiences, thought processes and language used by musicians, especially when considering self-management strategies such as adjustments to lifestyle and practice routines.

In our guest blog, Osteopath and former professional ballet dancer, Toby Pollard-Smith, considers his journey from dance to healthcare, and strategies for working collaboratively with performing artists to solve problems.��

Who am I and how did I get here?��

I am an osteopath. Before osteopathy, I was a professional ballet dancer. Quite a jump, you might think.

I remember being taken to ballet classes from about 4 years of age. My older sister did ballet, so it must have been convenient. The next thing I remember is winning some competitions (much to my sister’s annoyance) and becoming a Junior Associate at the Royal Ballet School, which I never enjoyed. Despite this, by the time I was a teenager I had become good at ballet and was being pushed towards professional ballet school.

A career in dance seemed attractive, and I went to the Central School of Ballet aged 16. I graduated in 2000 and got a contract with The Israel Ballet. Up to that point I had always been one of the better dancers in any room or studio, but as I settled into company life, I realised there were plenty of professional dancers who were much, much better than me.

I became a steady, reliable dancer over the next few years, and after leaving Israel I did some shorter dance jobs followed by two seasons with Matthew Bourne’s Swan Lake. Having been bowled over by that show as a 16-year-old, it was great to join the cast and travel the world, throwing myself around stages and getting paid for it. In fact, towards the end of my time in that show, I wondered if I would ever again enjoy dancing quite as much. I had seen some colleagues start online courses or degrees while we were touring, and it made me think that I should start to plan the next chapter of my life.

On my return to London, I researched the pathway to becoming an osteopath. After an open day at the British School of Osteopathy, I remember a long, blurred period of studying, and working in a pub to pay my fees. I qualified in 2014 and in 2015 published my undergraduate research investigating dancers’ injuries. I’ve been in private practice ever since, joined BAPAM as a registered practitioner, gotten married, bought a house and had two kids. So here we are.

How do I feel now?

Being an osteopath is a slightly strange existence. People don’t seem to really know what we do. The typical suggestion is that we are back Ģ��tvs, or bone doctors. Eyebrows raise when we point out that we treat the entire body, and all its parts, hard or soft. The general suspicion seems to be that we either solve every problem by cracking a joint, or by sitting still and silently holding someone’s head.

In reality, a good number of my patients think I’m a physiotherapist, despite my repeated assertions that I am not (I’m not making a political statement – it just needs clearing up for invoicing and insurance).

Does this frustrate me? A little, but I’m learning to get over it. Patients typically make a bond with a practitioner, and if that bond is successful, it matters not whether the practitioner belongs to one tribe or another.

But does Osteopathy work?

What a broad question this is. Are we expected to be able to answer it? Do we ask if “medicine” works? Where would you start to answer such a question?

For start, it would be nice if osteopaths could give a nice succinct explanation of what we do. But we struggle. There are some who propose that we should merge with physiotherapists and chiropractors into a more general field of manual therapy, but others fear for the loss of an osteopathic (pseudo-)philosophy that they hold dear and that perhaps comes closest to defining us.

As Dr Murgatroyd wrote recently¹, the contemporary spotlight of manual therapy, powered by its currently favoured biopsychosocial model shines harshly on osteopathy. Patients are seen to assume too passive a role in the therapeutic relationship when “traditional” osteopathy is considered. I don’t disagree with this and was disturbed, for a start, at how little provision of rehab there was in a four-year osteopathy degree. As an injured dancer, I had always relied on a mixture of treatment and rehab.

So, I embarked on my journey to become the sort of practitioner that I hope I might have found useful. As I reflect on seven years in practice, I might humbly offer the following topics for describing what I have had to learn.

Step One: Listen

The communication between patient and practitioner is an area of expanding academic interest, and awareness of the importance of language is becoming more established.

Patients possess the information that a practitioner needs, even if they are not aware of it. It is therefore the duty of a practitioner to create an environment in which patients are free to narrate the history of their condition, describe their lived experiences, and share their fears and beliefs.

As Matt Low writes: “A person’s story is a phenomenological account that far supersedes that of a descriptive and categorical diagnosis with regards to how to frame and personalise a treatment or management approach.” ²

With a narrative approach, it is possible to explore shared experiences. In the realm of performing arts medicine, this offers greater opportunities to develop relationships between patient and practitioner. Performing artists fear a lack of understanding when they seek treatment, whether it is about the specific nature of their injury, or about the reality of that injury within the context of their career³.

It is in these discussions between patient and practitioner that any Ģ��tv area of medicine earns its existential stripes. If practitioners can appreciate how their patients navigate through daily struggles to reach their goals, their contributions can in return become more valuable to those patients.

There are plenty of medics who specialise in treating a body part or area, but it is also of value to find practitioners whose expertise resides in helping a cohort of patients with whom they have shared experiences. Performing artists will naturally derive benefit from spending time with practitioners who know their environment, and that is a central reason for BAPAM’s existence.

The better that the lived experience of your patient is understood, the easier it is to unleash their potential for transformation.

Step Two: Avoid the traps

A lack of time causes pressure, and pressure can force people to cut corners. When time is limited for diagnosing patient presentations, pattern recognition can start to take priority over deductive reasoning.

• Pattern recognition provides a short cut to allow swift decision making, but it can lead to mistakes in diagnosis.
• Deductive reasoning is slower, and while thorough, can waste valuable time in clinic for delivering manual treatment, sharing rehab ideas, or formulating a management plan.

There is inevitably a tension in clinic between these two approaches. While they each have utility, we must minimise the occasions when we might jump to a conclusion based on incomplete or flawed information. Perhaps the most common trap in clinic is following a diagnosis that has been ready made for us.

In practical terms, it’s important to ask patients who arrive with a diagnosis how they came to be given that diagnosis. Who gave it to them and based on what information? How long ago was this diagnosis settled upon, and have the patient’s symptoms altered since then? What treatment or management has been instigated, and has it produced the desired results?

There’s no need to argue with everyone, but a healthy index of clinical suspicion can help turn cases around, delivering best results to patients, especially performing artists who often get passed from practitioner to practitioner as they travel.

Step Three: Offer value

Once a sense of a presenting problem has been established, the notion of value is of utmost importance to patients and cannot be overlooked. It’s not a commercial question, but rather a case of effectiveness.

Should a patient only have the funds to pay for a single consultation, or a schedule that takes them on the road immediately after their appointment, we should be able to adapt what we provide to offer them the greatest possible value. Education and advice might become more beneficial than starting a course of manual therapy.

Should a performing artist find that their greatest pressure is the need to keep performing for a series of important dates, the most valuable approach might be to offer advice on how best to prepare for each performance, and what to do after those performances to keep their condition in check. It could well be a very different protocol compared to what might be offered to “cure” the condition, but the patient’s needs dictate a different approach.

Only through appreciation of the needs of the patient can such strategies be offered. The desire to fly under the radar is very valuable in many performing arts circles and receiving advice from someone who has flown that path can be of huge value.

What do I do that’s different?

I typically feel that my answer to this is a bit of a let-down, since I don’t typically feel that I do anything differently with performing artists compared to non-performing artists. A consultation with a performing artist might appear very particular to an outside observer, but I believe that the underpinning logic is the same as for any other patient.

With all my patients, I listen, I watch out for traps, and then I try to offer value in what the session contains. Yes, I know more about being a dancer than any other career and that shared experience is an asset to dancers. But I also feel that a performing arts injury is unique only in that it has happened to a performing artist. We treat people, not conditions.

References

 

1. Murgatroyd, D. (2021) The Hands-On Approach of Osteopathy and the Performing Arts Physician. BAPAM website, /the-hands-on-approach-of-osteopathy-and-the-performing-arts-physician/
2. Low, M. (2020) ‘Above and Beyond Statistical Evidence. Why Stories Matter for Clinical Decisions and Shared Decision Making’, in Anjum, R.L. et al (eds.), Rethinking Causality, Complexity and Evidence for the Unique Patient. Springer, open access book, pp 127-136
3. Pollard-Smith, T., Thomson, O. P. (2017) Professional ballet dancers’ experience of injury and osteopathic treatment in the UK: A qualitative study. Journal of Bodywork and Movement Therapies. 21(1), pp 148-156

By Dr Charlie Easmon

Performers may be perfectionists and perfectionists are more prone to mental health problems and included in this are eating disorders. In at least 50% of people with eating disorders there is an existing mental health disorder of depression or anxiety. In many cases the individual has been dealing with issues of low self-esteem and/or past traumas.

I rephrase ‘eating disorders’ as ‘disorders of thinking about eating’ and in this way the mental disruption is always kept to the forefront.

Eating disorders are never easy to treat or manage and are deep psychological problems.

Examples of problems caused may be the performer with ‘chalk like’ bones’ who breaks them after a simple fall. The singer who has to use mints to hide the vomit smell on their breath. The locked hotel room as the performer binge eats having ‘maxxed out’ room service food and/or drink.

Dr Marianna Kapsetaki (a student on the UCL course initiated by BAPAM in Performing Arts Medicine) and I in 2017 wrote a paper on Eating disorders in Musicians. This showed that 18% (almost 1 in 5) of those who replied had a current eating disorder and 1 in 3 had a history of eating disorder.

Florence Welch acknowledged her eating disorders in the song “Hunger’. Taylor Swift and Janet Jackson have talked openly about the pressures of unreasonable ‘figure expectation’ in female artists.

A performer wanting to look good in costume and dieting to achieve that is not an eating disorder.

Touring (once it restarts) makes healthy eating and nutrition difficult for everyone.

I think of the 3 main types of eating disorders as a horror movie playground. The scary slide is the anorexic descent to a declining weight by variations of cutting calories and exercising. The bulimic see-saw is the binge/purge cycle of eating vast amounts of food followed by various combinations of vomiting and laxatives. The binge eaters are on a ‘not so merry go round’ as their weight balloons.

If you think that someone has an eating disorder try to understand that they need careful management. Some people will need hospital or residential care, and some people will need to stop touring, as Ed Sheeran famously took a year off. Now is a good time to have systems in advance of touring or at least have a ‘resource’ handbook available to the key managers concerned with the performer’s welfare.

The UK Eating disorder charity is an excellent resource. Performing arts Ģ��tv counsellors and therapists can be found using the BAPAM Directory. Online counselling is available and both the and also list registered professionals.

References and links

Self-Harm and Eating Disorders in Schools by

 

BAPAM training events are a key resource for healthcare and education professionals.

We��explore��key topics in current performing arts medicine practice��and share unique insights into performance health and wellbeing. The approach is multidisciplinary: physiological and psychological care, preventing as well as treating problems, supporting healthy and sustainable creative practice.

Through 2020/21, we are delivering a series of monthly CPD webinars, expanding our training provision and enabling wider access to a flexible ongoing programme. Sessions are held on the last Wednesday of the month from 7pm.

Our first session,��Lockdown Health of Performance Professionals, takes place on October 28 at 7pm. The full programme for this event has now been published. All events in the series are open for booking, and we will be adding��detail for future events in the series soon.

Find out more and book tickets here

We plan to make sessions available for ticket holders to view after the event if required.

Ticket prices per session:

General:��£25

BAPAM Registered Practitioners:��£15

BAPAM Registered Practitioners who paid us a fee in 2017/2018��for their BAPAM Directory listing are welcome to contact us about complimentary booking options for these events.

BAPAM Assessing Clinicians and Colleagues:��£10

For clinicians working in BAPAM clinics and colleagues providing services administered directly by BAPAM. If unsure, or to request authorisation, please��reply to this email.

It was a great privilege to be invited to Sydney to speak at the����(ASPAH) conference at the end of 2019, and inspiring to hear about the great practice happening in Australia. The conference��Lasting the Distance: a Lifetime in the Performing Arts��considered physical and psychological approaches to support career longevity. Dr. Sue Mayes, the Australian Ballet’s principal physiotherapist and keynote speaker outlined how their approach to healthcare had minimised injuries over the years, measured by insurance claims – a compelling argument for the value of investing in performance health.

There were some really interesting presentations on dance, from child education to��foot adaptation of wearable technology and athlete management systems used by athletes, and developing a career in health after dance. On mental health, identification and intervention in eating disorders and management of music performance anxiety were explored, and Ben Steel, former Ģ��tv and Away star, movingly discussed his documentary on depression in the performing arts. I presented on our experience of��Developing Evidence-Based Policy and Practice in Psychosocial Health in the Performing Arts.

There is a thriving performing arts medicine community in Australia and we were honoured to be part of the discussions, and look forward to a continued relationship. ASPAH has produced a great set of healthcare guides which they have kindly allowed us to share with you:��

There are intrinsic relationships between health and performance excellence, and educational and clinical expertise in the performing arts. In overcoming medical problems, Ģ��tv diagnostic and medical expertise can be complemented by performance technique and lifestyle and health-related guidance. In a new joint clinic at BAPAM,��Mr Mark Phillips, Hand Surgeon, and Penelope Roskell, Professor of Piano at Trinity Laban, are exploring this opportunity for clinicians and educators to provide each other with unique insight and feedback. We asked them to tell us more about this innovative approach.

Could you explain the idea behind the joint clinic and why you decided to do it?

Mark Phillips: In my experience when treating musicians I found quite an overlap between the physician’s knowledge and the Ģ��tv physiotherapist/hand therapist’s knowledge, who’s an expert in musicians. But I soon realised there was a huge gap for the third element which is filled by the expert tutor on that instrument. I happen to be a trumpet player so as a musician I have some insight into the patient but that’s not enough when it comes to some of the issues they face. I can relate to some of the psychological performance issues, but the expectation patients have is of someone that can really understand how the technical demands of the instrument interface with the physiological problems they’re having and anatomical problems they may have and the outcome of the clinical assessment.

Penelope Roskell: The knowledge we have between us is enormous. My students have included musicians with injuries for 40 years, and so we fill in the gaps. Seeing musicians together in a joint clinic is very important because you can then see the whole picture and then decide on the best way forward. Sometimes it may be steroid injection and sometimes it may be surgery. But sometimes it may be that a tweak or a change of technique will solve that problem and reduce the need for further intervention. So, seeing them together we can get to the root cause, which we can’t always do if seeing them independently.

How do you decide if a patient would benefit from this dual approach? What can a patient expect at a typical joint session? How do you each approach the patient?

How do you prepare for a joint clinic session?

Mark��Philips: Normally I will contact Penelope to say I’ve got a patient or she may say she has a student. We will both select patients for this clinic.

Penelope Roskell: Sometimes Mark will send me over a video of that person playing, so I’ll have a chance to look at it and pick out the obvious problems about what I think may be causing it. I’ll also have a clinic letter which will give some sort of background.

Mr Phillips: We then meet up for a coffee and chat about the patient. So then the patient comes in, and if it’s my patient I present it to Penelope and on one occasion Penelope presented the patient. And then we do the history in the normal way, present findings and run through it all. I then suggest what may be the anatomical or physiological problem and how that relates to this person’s technique. The technique may have worked well for a long time but now there’s a problem which is unique to them. Looking at the technique can help if I’m referring to Penelope. Or similarly if Penelope is referring to me is there a way that some of my interventions such as hand therapy or injections or my approach to examination would throw some light on the matter. It’s that overlap which is invaluable really.

Penelope Roskell: So for instance one of my students came to the last clinic and she had problems for the last year and had come to me for that reason. And Mark gave her quite a different diagnosis to what she had been given in the past, which then informed me. So now we are working slightly differently in the lessons that I have with her privately, having now had this intervention from Mark and he also suggested a steroid injection which we are waiting to see the results to. We can then see the whole picture about the ways forward, because there isn’t always one solution. A patient may need a steroid injection or piano playing adjustments to the technique.

Mark��Phillips: It’s multi-faceted, there may be Alexander Technique, hand therapy and it may be someone looking at their posture. I learn so much by looking at Penelope tutoring at the piano in terms of elbow position, shoulder position and what impact that has in terms of the way the fingers lie on the key for example. Each presentation has its own unique cocktail of remedies really.

There are complex multi-faceted problems by the time they come here and it comes down to how we triage these patients essentially. I don’t bring every pianist to this clinic.

Penelope Roskell: It’s inevitably going to be someone with a piano related injury. If they’ve broken their wrist by falling down the stairs then they should go straight Mark. Whereas it’s different when it’s something like accumulated stress from years of playing with a technique which is a tiny bit off balance. They may be very experienced players and their technique has lasted them well, but there’s something that just tips it over.

Mark��Phillips: What I see in my patients is that half of them have the same problem as everybody else and that may affect how they use their instrument. And the other half have instrument related problems and it may be a combination of the two. And say if someone broke their wrist a year ago and it may be throwing out their elbow, their shoulder or their posture and it may well be a good way down the line that it’ll come to me that a session with Penelope would be helpful. Because it may be to do with their elbow and shoulder which may be making some notes inaccessible and we can work around. They’re so unique each of these cases an each of them would have their own relative roles for the two of us sitting together and discussing the case. It would be good to extend this to guitar, violin and cello and get tutors to do a similar thing. And it’s pretty unique, I don’t think there’s anyone else out there in the world doing it.

What do you feel are the benefits of having an educator in a clinical setting?

Penelope Roskell: It is a very formal environment which is a positive thing and it focusses everything which is very important.

It is a sort of pilot, it’s the first of its kind and I think it is very valuable and let’s hope that other clinics may take the idea from this and develop that further.

What are the direct benefits for patients of having the educator and clinician in the same room in a clinical setting?

Mark Phillips: We often find that patients are often reticent about coming to these clinics. They really don’t want to look at their own techniques and I suppose they remember back to days when they were being tutored and they feel self-conscious. They have to want to come to this clinic and to be looked at. It isn’t like going for a piano lesson or being taught. We are looking to see whether there’s anything about their technique that may be in anyway connected to the clinical problem they have. So we’re not trying to look at the way they play from any other perspective than that. People play in lots of different ways. Also videos are really useful, anyone with a smartphone can record themselves. When we look at them we can slow them down, go back over a sequence, look at it carefully, look at it together and see how that relates to their clinical problem.

Penelope Roskell: There is something different about the joint clinics, because I’m there involved in the consultation I’m able to ask them questions from my own point of view so that I’m well informed as to how best to help them in the future. Because a piano teacher is not qualified to diagnose and that is absolutely number one and nor am I qualified to answer questions that students sometimes ask me, like should I have that steroid injection or that operation and it’s not for me to advise on that but in this situation between the three of us we can discuss the best way forward viewing it from all the different angles.

Any challenges you are finding with the joint approach?

Mark Phillips: It’s 30 minutes long, which is short. We are just getting into our flow by half an hour.

We haven’t had a chance to find out what patients think, especially how they feel about the added value of seeing us both together.

The four patients we have seen in this format have individually expressed to us they thought it was a good session and it stimulated a lot of discussion and ideas. It would be great in the future to include a hand therapist and do a proper multi-disciplinary clinic. Hand surgeons always work very closely with hand therapists. Because there are so many different joints in the hand and different diagnoses. In the hand you’ve got unique problems to one finger or there will be a combination of problems. So your hand therapy is always bespoke, it’s all tailor made to that patient so you have to discuss each patient individually and with musicians it’s even more so.

Certainly with the three most commonest instruments this is going to be a major area of growth in the next ten years and it’s very exciting.

During the half an hour the patients sense the trust we have with each other (Penelope: we work very well as a team, we both have a lot of respect for each other’s knowledge. So I think they go away feeling they’re whole picture has been seen and assessed and we are seeing them as an individual with a problem that can be resolved.)

All patients have been bought over by the end of the 30 minute sessions. You can see the reticence and slight nervousness at the start of the half an hour turning into trust and outpouring of confidence and sharing of the problem and by half an hour we are in to the nitty gritty aren’t we. The output of that is usually I will see them again or Penelope will see them again.

What they can do is continue seeing Penelope for a while and see me in the clinic two months later and see how things have been going on in the meantime. And because we know each other well we can send secure emails back and forth and stay in touch.