Health education for classical musicians

Could compulsory health education at UK conservatoires improve the health and wellbeing of classical musicians? Dr Raluca Matei of Birkbeck’s Centre for Sustainable Working Life shares the findings of a recent study conducted with Jane Ginsborg, Juliet Goldbart, and Stephen Broad.

Picture of classical musicians

Despite rating job satisfaction very highly, many classical musicians also suffer for their art. In the largest survey to date (Fishbein et al., 1988), 76% of players reported a medical problem severe enough to impair performance. The most prevalent were musculoskeletal, affecting the shoulder, neck and back, however, they also reported acute anxiety, depression, and sleep disturbances.

More recent research shows that musicians experience hearing loss (O’Brien et al., 2014), visual problems (Beckers et al., 2016), and eating disorders (Kapsetaki and Easmon, 2017). There is a higher prevalence of insomnia and psychological distress among musicians than in the general population and they may be more likely to use psychotherapy and psychotropic drugs such as sedatives, antidepressants, hypnotics and/or medication for attention deficit hyperactivity disorder (ADHD) (Vaag et al., 2016a,b,c).

Compulsory health education for music students

Our study sought to find out if we could empower musicians to improve their health through a conservatoire-based health education course. The course was delivered to first-year undergraduate music students at a UK music conservatoire. The aims of the study were:

  • To explore students’ hearing and use of hearing protection
  • To design an evidence-based health education course
  • To assess the effects of the course on primary outcomes (perceived knowledge of course content and knowledge and awareness of potential risks to health) and secondary outcomes (including general health, health-related quality of life, health-promoting behaviors, self-efficacy, emotional state, perceived stress, frequency and severity of playing related musculoskeletal disorders (PRMDs), and perceived exertion)
  • To identify the topics within the course that were most salient to students

Unlike previous studies, which provide little information as to how curricula were designed and whether formative methodologies were used, the course curriculum was informed by findings of research on music performance anxiety (MPA) and PRMDs; the findings of evaluations of other courses designed to improve musicians’ health; theories and models deriving from health psychology (Taylor, 2012); discussions with the Acting Head of Undergraduate Studies at the institution where some of the authors are based; and members of the Healthy Conservatoires Network.

The course formed the major component of a module entitled Artist Development 1, compulsory for all first-year students at a tertiary-level music conservatoire in the UK. The module took place over the first and second terms of the academic year and consisted of ten weekly 1-hour lectures delivered to the whole cohort (104 students) and eight weekly 1-hour seminars delivered to ten small groups of 10–15 students. The course covered not only physical and mental health, but also effective strategies for practicing, memorizing and rehearsing, and life skills and behavior-change tools inspired by health psychology.

Students were required to submit a portfolio of assessments including a 1,000-word essay in response to both the following questions: (1) Looking back on the Health and Wellbeing component of Artist Development 1, what new information, useful for your own music-making, have you learned from one lecture or one workshop/seminar?; (2) How have you been able to put this information into practice when making music (e.g., practicing, rehearsing, performing or studying more generally)?

Course evaluation

A mixed-methods approach to evaluation was adopted: quantitative analyses of data gathered at baseline and post-intervention, and between-group data (intervention vs. controls); and qualitative, semi-structured interviews (unpublished).

In terms of hearing, tinnitus and hyperacusis were reported by both groups of respondents, with a higher incidence in the (third-year) control group than in the (first-year) intervention group. Ten percent of the intervention group had been diagnosed with hearing loss, although minorities of respondents in both groups reported having had hearing tests in the previous ten years.

Although respondents were more likely to use hearing protection when rehearsing with others and attending concerts, comparatively few members of either group used hearing protection, or, if appropriate, the mute on their instrument, while practicing alone. This could affect hearing, since private practice can cause over-exposure to risky levels of sound.

Reassuringly, respondents reported increased knowledge of the topics covered in the course, including the sound intensity levels associated with hearing loss and how to deal with the health and safety issues associated with learning and playing a musical instrument. They also reported increased awareness of performance factors related to potential musculoskeletal injuries. The ratings of students who had taken the course and those who had not did not differ significantly, perhaps because the control group had had informal exposure to the other topics covered in the course, with the possible exception of life skills and behavior change techniques.

Students who had taken the course also rated their ability to deal with relevant health and safety issues significantly higher than controls.

In contrast, the only desired secondary outcome to increase significantly from baseline to post-intervention was self-efficacy, which may or may not have been the result of the course. Other significant increases were in the wrong direction: sleep problems, distress and lack of vitality all increased significantly from baseline to post-intervention, and controls experienced more severe depression, distress and lack of vitality.

We attribute these negative findings to the cumulative pressure on students over time. The first time the intervention group completed the questionnaire, they were in their second week at the conservatoire; post-intervention, they were facing deadlines for assignments to be submitted and recitals to be given. They may, however, have fared better than the control group simply by virtue of being a year younger. What we cannot know is the extent to which the health education course may have mitigated the demands perceived by the students in the intervention group.

Finally, from the topics covered in student assignments, it appears that managing MPA and behavior change techniques are of most interest or relevance to them at this point in their studies.

Conclusions

In the absence of a national curriculum for health, all institutions of higher education must develop their own approaches to health education, as do many university music departments and music conservatoires. The questions posed by Ralph Manchester in 2006 remain pertinent: “Who will develop this course? What topics will be included in the syllabus? Who will teach it? Will it be offered to freshmen or seniors, or can it be taken during any year? Can one course meet the needs of performance majors, music education majors, and others? Should we develop some minimal national requirements?” (Manchester, 2006, pp. 95–96).

Further questions could be asked, such as: When can a course be considered successful? What are its desired outcomes? How should they be measured? Once the content and delivery of a course have been evaluated, how should they be adjusted, if necessary? To what extent should students’ requirements and feedback be taken into consideration, given the available evidence and the need, on occasion, to challenge their beliefs? Very few health courses have been formally evaluated to date, and reports of those that have been evaluated do not say how the course was improved as a result.

Although it has been argued for the last 25 years that health education for musicians should be evidence-based (Zaza, 1993), the declarations and recommendations fail to mention the importance of evidence-based teaching. There is now a wealth of research on musicians’ playing-related health problems, and their management, but unless this is disseminated effectively to senior managers and educators, instrumental and vocal tutors, and students, there is a risk that conservatoires will maintain traditional practices rather than responding systematically to the best evidence available.

The topic of how music students, too, can be convinced that health education is a vital part of their training remains largely unexplored. Framing the objectives of health education courses as “performance-enhancing” rather than “preventative” is likely to be more attractive to students.

Although the course described in the present study did not have the hoped-for impact on secondary outcomes including reported health-related behaviors, reduced PRMDs and stress, it was associated with improvements in primary outcomes relevant to health education, namely the perceived knowledge of topics covered in the course and awareness of health risks.

Furthermore, the study itself is the first evaluation of a health education course for musicians that documents the process of designing the course on the basis of a rigorous assessment of the available evidence, and its incorporation in the “real world” context of a music conservatoire.

Further Information

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Training attentional control improves cognitive and motor task performance

This post was contributed by Emmanuel Ducrocq, a PhD student in Birkbeck’s Department of Psychological Sciences. It is about a paper based on research he and his supervisor (Professor Naz Derakhshan) did in collaboration with Dr Mark Wilson and Dr Samuel Vine, and which is published today in the Journal of Sport and Exercise Psychology. Emmanuel tweets at @manuduc and Professor Derakhshan at @ProfNDerakshan

tennis-player-676310Successful performance in sports is usually evaluated in terms of technical, tactical or physical abilities. However a crucial index of performance is the ability to perform under stress and high pressured situations. This is especially relevant sports demanding a high level of attention, such as tennis, golf, archery or shooting.

Recent research in sports psychology has shown that a key factor responsible for poor performance in sports under pressure is the inability to focus on what needs to be done and reduce distraction. This is often referred to as attentional control: the ability to resist distraction and attend to task goals efficiently. If athletes can’t exercise attentional control efficiently then they cannot plan and execute a skilled movement flexibly. The pressure to perform well, increases anxiety and so maintaining attention focus on task goals becomes exceptionally challenging giving way to worries, and doubts about performance  as well.

Attentional control has usually been targeted in sports by trying to promote specific gaze behaviours which has proven to show benefits to motor performance in sporting tasks such as golf or basketball. Crucially though, while this method is useful, it hasn’t been able to identify the underlying mechanisms responsible for sports improvement.

In a series of three exciting studies we wanted to improve motor task performance and we specifically focussed on tennis, which requires good attentional control to flexibly resist distraction. To this end, we trained inhibitory control using a computer-based training task to see how it could improve performance in a tennis task.

In the first experiment, participants were allocated to a training or control group and underwent six days of training on a visual search task that included task-irrelevant distractors requiring inhibition (training) or contained no distractors (control). Performance was measured pre- and post-intervention using an antisaccade task measuring distractibility. We found that training elicited a near-transfer effect; as performance on the antisaccade task was improved in the training group, and not in the control group. This was important to establish, as it showed that training on the visual search task could improve inhibition on another unrelated task.

In the second experiment training on the same paradigm showed transfer benefits on an attentional control index that we validated for tennis performance. Tennis players were assessed on a return of serves task and we found an initial far-transfer effect of training. Participants in the training group displayed an enhanced ability to focus on the ball around the time of contact with the ball.

The third experiment pushed the boundaries of this work further by assessing the potential effect of the training task on an objective gaze measures of inhibitory control during performance of a tennis task. Participants’ pre and post intervention performance was assessed on a volleying task performed under pressure while their gaze behaviour was recorded. We found a substantial effect of training on tennis performance when levels of pressure were elevated. Transfer effects of training were also observed on a specific gaze behaviour index of ‘inhibition’ in the field, confirming the mechanism by which training protected participants against the negative impact of anxiety.

Taken together, we have shown that a simple computer-based training task that reduces distraction and improves attentional control can have direct transfer benefits to tennis performance under pressure. This can obviously have great implications for improving motor performance in any competitive sport that needs to be performed under pressure.

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