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Holistic Health and the Prevention of Performance-Related Musculoskeletal Disor

Holistic Health and the Prevention of Performance-Related Musculoskeletal Disorders in Orchestral String Musicians by F. Lynn Kuo A thesis submitted in conformity with the requirements for the degree of Doctor of Musical Arts Faculty of Music Graduate Department University of Toronto © Copyright by F. Lynn Kuo 2012 978-0-494-97402-5 Your file Votre référence Library and Archives Canada Bibliothèque et Archives Canada Published Heritage Branch 395 Wellington Street Ottawa ON K1A 0N4 Canada Direction du Patrimoine de l'édition 395, rue Wellington Ottawa ON K1A 0N4 Canada NOTICE: ISBN: Our file Notre référence 978-0-494-97402-5 ISBN: The author has granted a non- exclusive license allowing Library and Archives Canada to reproduce, publish, archive, preserve, conserve, communicate to the public by telecommunication or on the Internet, loan, distrbute and sell theses worldwide, for commercial or non- commercial purposes, in microform, paper, electronic and/or any other formats. The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. In compliance with the Canadian Privacy Act some supporting forms may have been removed from this thesis. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. AVIS: L'auteur a accordé une licence non exclusive permettant à la Bibliothèque et Archives Canada de reproduire, publier, archiver, sauvegarder, conserver, transmettre au public par télécommunication ou par l'Internet, prêter, distribuer et vendre des thèses partout dans le monde, à des fins commerciales ou autres, sur support microforme, papier, électronique et/ou autres formats. L'auteur conserve la propriété du droit d'auteur et des droits moraux qui protege cette thèse. Ni la thèse ni des extraits substantiels de celle-ci ne doivent être imprimés ou autrement reproduits sans son autorisation. Conformément à la loi canadienne sur la protection de la vie privée, quelques formulaires secondaires ont été enlevés de cette thèse. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. ii Holistic Health and the Prevention of Performance-Related Musculoskeletal Disorders in Orchestral String Musicians F. Lynn Kuo Doctor of Musical Arts Faculty of Music Graduate Department University of Toronto 2012 Abstract Professional orchestral string musicians represent a population at risk for performance-related musculoskeletal disorders (PRMD). Research literature suggests the influence of stress in the incidence of work-related and performance-related musculoskeletal disorders. The purpose of this study was to qualitatively investigate the role of holistic health (physical, mental, emotional, spiritual, and social) and stress management in the prevention of PRMDs in professional orchestral string musicians. Five musicians representing different instruments, genders, and PRMD histories were recruited and sorted from a single professional orchestra in Canada. This study combined quantitative data—in the form of basic demographic information and a Health and Well-being Assessment—with qualitative interview data. This combined data provided a focused, in-depth view of typical instances in the professional orchestral string population. The musicians reported a variety of occupational and non-occupational risk factors, as well as a range of intrinsic risk factors. They also reported a variety of PRMD prevention strategies and lifestyle behaviours. The musicians in this study provide evidence that stress may play a mediating role in PRMDs and that the management of biomechanical and psychosocial stressors through holistic health practices may positively influence the incidence, severity, and treatment of PRMDs in orchestral string musicians. This dissertation recommends that increased awareness and education in holistic health practices be encouraged for the purpose of improved PRMD prevention in professional orchestral string musicians. iii Acknowledgments Genuine thanks goes to the individuals who supported the conception, execution, writing, and editing of this dissertation: Meran Currie-Roberts, David Dickie (RMT), Carol Gimbel, Jane Kuo, Dr. Mariam Nargolwalla (PhD), Dr. Evelyn Osborne (PhD), Dr. Janna Rosales (PhD), Dr. Anita Shack (DC), Dr. Kris Sheppard (DC), Paul White (OCT), Barbara White, and my Doctoral Supervisory Committee: Dr. Jamie Parker, Dr. Cameron Walter, Dr. Gillian MacKay, and Katharine Rapoport. iv Table of Contents Abstract ........................................................................................................................................... ii Acknowledgments.......................................................................................................................... iii Table of Contents ........................................................................................................................... iv List of Tables ................................................................................................................................. vii List of Appendices ....................................................................................................................... viii Chapter One: Introduction .............................................................................................................. 1 Introduction ................................................................................................................................. 1 Chapter Overview ....................................................................................................................... 2 Definition of PRMD ................................................................................................................... 2 Index of Abbreviations ................................................................................................................ 3 Statement of Problem .................................................................................................................. 4 Rationale for Research ................................................................................................................ 4 Purpose of Research .................................................................................................................... 6 Benefits of Research ................................................................................................................... 7 Limitations and Delimitations ..................................................................................................... 7 Qualifications .............................................................................................................................. 8 Structure of Dissertation ............................................................................................................. 8 Chapter Two: Literature Review ................................................................................................... 10 History and Survey of PRMD Literature .................................................................................. 10 Stress: A background ................................................................................................................. 15 Holistic Health and Well-being, Stress Management, and PRMD Prevention ......................... 21 Related Methodologies ............................................................................................................. 36 v Summary ................................................................................................................................... 41 Chapter Three: Methodology ........................................................................................................ 42 Participants ................................................................................................................................ 42 Procedure .................................................................................................................................. 42 Chapter Four: Results ................................................................................................................... 46 Interview Data Summary .......................................................................................................... 46 Background Data ...................................................................................................................... 47 Health and Well-being Assessment ........................................................................................... 47 PRMD Histories ........................................................................................................................ 47 Practice Schedules and Routines .............................................................................................. 49 Case Studies .............................................................................................................................. 49 Chapter Five: Discussion .............................................................................................................. 87 Stress and PRMDs .................................................................................................................... 87 Case Study #1 ........................................................................................................................... 90 Case Study #4: Flow Experience .............................................................................................. 92 Occupational Risk Factors ........................................................................................................ 94 Non-Occupational Risk Factors ................................................................................................ 98 PRMDs, Their Effect on Stress, and Psychosocial Implications ............................................ 103 General Observations on PRMDs ........................................................................................... 105 Strategies Used for PRMD Prevention and Treatment ........................................................... 109 Strengths of Study ................................................................................................................... 120 Limitations of Study ............................................................................................................... 121 Significance of Study .............................................................................................................. 122 Chapter Six: Conclusion ............................................................................................................. 123 vi Contribution to Knowledge..................................................................................................... 125 Recommendations ................................................................................................................... 126 Future Research ...................................................................................................................... 128 References ................................................................................................................................... 129 vii List of Tables Table 1 Orchestra Strings and PRMD History ............................................................................. 46 Table 2 Case Studies: Profile Summary ....................................................................................... 48 Table 3 Case Study #1: Health and Well-being Assessment ......................................................... 52 Table 4 Case Study #2: Health and Well-being Assessment ......................................................... 57 Table 5 Case Study #3: Health and Well-being Assessment ......................................................... 64 Table 6 Case Study #4: Health and Well-being Assessment ......................................................... 74 Table 7 Case Study #5: Health and Well-being Assessment ......................................................... 79 Table 8 Case Studies: Reported Stressors ................................................................................... 102 Table 9 Case Studies: Opinions and Observations ..................................................................... 108 Table 10 Case Studies: PRMD Prevention and Healthy Lifestyle Practices .............................. 119 viii List of Appendices Appendix A: Brief Preliminary Questionnaire ....................................................................... 138 Appendix B: Recruitment Letter and Consent Form .............................................................. 139 Appendix C: Interview Guide ................................................................................................. 143 Appendix D: Ethics Review.................................................................................................... 148 Appendix E: Health and Well-being Assessment………………………….…………………149 1 Chapter One: Introduction Introduction Performing musicians form a relatively under-represented and only recently acknowledged population in the occupational health literature (Morse et al., 2000; Ro, 2006). Musicians, aptly compared with athletes, are frequently required to perform under pressure, dedicating long periods of focused physical and mental training that require repetitive motions and acute concentration. Regular, structured practice and training often culminate in performance under extreme conditions (e.g., public performances, evaluations, and competitions), which are often perceived as stress inducing. A considerable body of research exists in sports medicine and occupational health literature that studies the nature of stressors and work-related injuries that athletes and other workers experience in their occupations. Performing arts medicine is, in comparison, a relatively new but quickly growing area of research. The literature on performance-related injuries (PRI) has demonstrated that injury risk (Ro, 2006) and injury prevalence are high among musicians (Fishbein, Middlestadt, Ottati, Straus, & Ellis, 1988; Heinzle, 2001; Zaza, 1998). String instrumentalists have been shown to be particularly at risk (Middlestadt & Fishbein, 1989; Ro, 2006). Current trends in literature acknowledge the role of stress on PRIs (Dietrich, Abbott, Gartner-Schmidt, & Rosen, 2008; Ro, 2006; Yoshie, Kazutoshi, & Ohtsuki, 2008), as well as holistic approaches in the prevention (Chesky, Dawson, & Manchester, 2006), etiologic investigation (Hagglund & Jacobs, 1996), assessment and treatment (Guptill & Golem, 2008; Quentzel & Loewy, 2010a) of musicians’ PRIs. 2 The research literature on performance-related musculoskeletal disorders (PRMD) has primarily focused on epidemiological data of a quantitative nature, while qualitative information on musicians’ PRIs has been relatively scarce. As will be discussed in Chapter Two: Literature Review, there are few studies that qualitatively address musicians’ PRMDs through the investigation of the lived experience of professional orchestral string musicians. To this researcher’s knowledge, there are also no studies that qualitatively discuss PRMD prevention under the framework of holistic health and stress management. It is thus the aim of this study to gain further understanding of the needs and experiences of professional orchestral string musicians through their rich, in-depth narrative accounts, and to holistically portray the complex, multi-factorial roles of integrative health and well-being practices (i.e., physical, mental, emotional, spiritual, and social) and stress management on PRMD prevention. Chapter Overview The sections in Chapter One will be presented as follows: • Definition of PRMD • Index of Abbreviations • Statement of Problem • Rationale for Research • Purpose of Research • Benefits of Research • Limitations and Delimitations • Qualifications • Structure of Dissertation Definition of PRMD Performance-related injuries (PRI) have been variably classified and labeled in the literature as 3 overuse syndrome (Hunter & Fry, 1986), overuse injuries (Dawson, 2006), repetitive traumas (Akel & Düger, 2007), performance-related injuries uploads/Management/ pdf-pdf.pdf