TUBA PLAYING AND HEALTH - HKB Interpretation
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TUBA
PLAYING
AND HEALTH
Images adapted from macrovector and gstudioimagen - www.freepik.com
By Monika Leitner, Patric Eichelberger,
Irene König, Lorenz Radlinger,
Adrian von Steiger, and Rex Martin
The following article has been approved for publication through a process of peer review.
INTRODUCTION
Playing a musical instrument involves complex motor skills. The daily training loads on the musculoskeletal systems of the body
from playing the tuba at an elite level can be compared with those of elite athletes[1]. Complaints that result from playing an
instrument are called performance-related musculoskeletal disorders (PRMDs)[2, 3]. Not many of those are known in tuba players.
Yet, a high percentage (84%) of professional orchestral musicians experience performance-impairing pain [3]. In tuba playing, it is
not only the challenge of holding and stabilizing the heavy instrument, it is also awkward postures, the duration of the many daily
hours of practicing time and the repetitive physical loads that might increase the risk for those complaints. Although these aspects
sound similar to sports related complaints/injuries, the perspectives of prevention, health promotion and therapy management are
SUMMER 2020 | 18 | ITEA JOURNAL
PROMOTING HEALTHY TUBA ERGONOMICS
GENERAL SITTING
RECOMMENDATIONS POSTURE
INSTRUMENT INSTRUMENT
DESIGN HANDLING
INSTRUMENT
TRANSPORT
very different. While sports Arts, with a multi-professional that can promote health and all possible. The often-heard
medicine and sports phys- team with expertise in music, wellbeing in tuba players. allegation that sitting in the
iotherapy (physical therapy) sport-science, biomechanics, “wrong” way will damage the
Light on the Major Activities
management seems to be engineering and physiothera- spine is probably incorrect. It
of a Tuba Player
highly developed for athletes, py. An ergonomic test (“Ergo- is a fact that sitting for long
the professional healthcare In this section, we want to periods can cause problems,
Test,” provided by the Swiss
management, including display the observational so rather the duration of pos-
National Accident Insurance evaluation of
education, advice and therapy ture should be addressed. A
Fund) was applied in order more appropriate goal would
for musicians, does not seem 1. playing the instrument in a
to investigate the physical haz- be to sit in a “healthy” upright
adequately provided[4]. seated posture,
ards in sitting activities. Due to way. This is a physiological
PRMDs not only compromise forced and awkward postures 2. safe handling of the instru- (natural) way of sitting which
the musician’s skills and and the duration of sitting in ment (picking the tuba up and allows the vertebral column to
performance but also impact putting it down) and assume its natural double-S
tuba playing, the evaluation
psychological factors, such as shape (Figure 1a) as much as
reveals a high to very high 3. transporting the tuba. With
music performance anxiety possible. In order to adopt this
physical load. Additionally, these perspectives, we finally
and depression [3, 4]. The position, a seated person must
an ergonomic inspection was also want to give
management of PRMDs in tilt his pelvis slightly forward.
tuba paying as well as health performed with various types 4. cues for instrument His chest straightens up and
promoting practical strategies of tubas in the sitting posture. manufacturing and the neck sector of his verte-
may increase performance and This article, written from a bral column is stretched. His
5. general recommendations
wellbeing of musicians. physiotherapy perspective, for the tuba player. abdomen is freed of pressure,
summarizes the most import- which assists breathing.
This manuscript is one out-
ant aspects of this analysis. 1) PLAYING THE
come of a bigger project that INSTRUMENT (SEATED The upright posture can be
was conducted at the Bern It also aims at providing
POSTURE) compared to the interaction
University of Applied Sciences, information about potential of cogwheels: when the
risk factors for PRMDs among Seated Posture
Department of Health lowest cogwheel (the pelvis)
Professions, in collaboration tuba players and illustrating It has to be questioned moves forward, the next
with the Bern University of the feasible recommendations whether “correct” sitting is at one moves backward in the
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T U B A P L AY I N G A N D H E A LT H
Figure 1: Healthy
upright sitting
1a From the side
Fig. 1b From the front
Fig. 1c Cogwheel
a b c
Figure 2
Fig. 2a: Head in upright and in
continuation with the spine.
Fig. 2b: The head is bent to the side.
opposite direction (lifting the
chest). This, in turn, moves
for the individual sitting
posture. In case the height is a b
the third wheel forward too much, the tuba player is
again (straightening the neck compelled to compensate for
promote muscle balance can between your outer forearm
section of the spine and thus this by lifting the heel from
be helpful. and the wall (fig. 6). Lean
lifting the sitter’s head and the floor in order to raise the
against the wall by putting
stretching his neck). (See fig. thigh (fig. 3a), upon which The following recommenda-
more weight on the muscle.
1c.) It is important that from the instrument is supported. tions can be made:
By bending your knees roll
the back-view the sections of For a longer practice time
In a standing position, bring it slowly out from the elbow
the spine are well aligned (fig. this could lead to a higher
your arms together in front of down in the direction of the
1b), so that pelvic with lumbar demand on the calf-muscles.
your waist (fig. 5). Straighten wrist. Alternatively, you can
spine, thoracic spine as well If the chairs do not present
the arms, rotate them inward stay on pain points for about
as cervical spine with the adjustment options, they offer
and cross your arms. Then try 15 seconds. (If there is strain
head, are above one another. no other alternative than the
to interlace your fingers. To on the finger and hand flexors,
body’s adaptation to the given
Neck and head placement stretch the right forearm, pull the same exercise can be done
circumstances.
are important, and the focus with your left hand in order on the inside of the elbow.)
should be on a neutral spine High Demand On Finger and to completely bend the right The use of self-myofascial
posture. The tuba player has Hand Extensors wrist and the fingers of the release via a foam roller is
to resist the temptation to side Depending on the type of right hand facing your body. becoming increasingly popular
bend the head (fig. 2). instrument, the activity of the When you feel a stretch along in athletes and physically
hand- and finger extensors can the back of the forearm, then active people but not yet much
The Chair
be demanding. Tuba players it is done correctly—hold it for known among musicians.
The type of chair that is used that play an instrument with 20–30 seconds. Repeat this Although some of the study
during practicing and in front action might be at risk to stretch with your other hand. results are heterogeneous,
concerts seems to be a rather develop tight muscles in the Do two or three stretches with self-myofascial release is
neglected topic, although the forearm. Breaks in rehearsals both arms. Breathe slowly. effective at improving power,
height of the chair and the or at least after every 60 SMR for the outer forearm: agility and strength [5] and
form of the back is crucial minutes with exercises that Place a small foam roller appears to have a positive
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Figure 3
Fig. 3a: Compensation for
increased sitting height by lifting the
heel from the floor in order to raise
the thigh
Fig. 3b: If the chair is too high,
one solution could be to put the
appropriate foot on a firm block
(like the ones that are used in Yoga
classes).
a b
Fig. 3c: An anti-slide mat can be
very helpful. It sits on the thigh of
the tuba player that carries the
most weight of the instrument and
prevents sliding of the instrument on
the fabric of the clothing. c
argue for this self-treatment
Figure 4 technique (fig. 7)
High Demand on Hand and
Elbow Flexors
Playing the tuba also involves
high demands for the hand
and finger flexor muscles as
well as the biceps-muscle,
especially in playing an
instrument with pistons (fig.
8). Biceps stretch and opening
of the chest: Interlace your
hands at the base of your
spine (Fig. 8c). Straighten your
arms and raise your arms up
as high as you can. Hold this
position for up to 30 seconds.
Repeat 1 to 3 times.
Unilateral and bilateral fore-
arm flexor stretch (Fig. 8e):
Lift your arm up to shoulder
height, straighten the elbow
and keep palm facing up-
wards. Next use the opposite
hand to push the wrist back
effect on range of motion and a valuable tool for musicians, promote blood flow, maintain into an extended position.
soreness/fatigue following allowing them to self-treat or improve the mobility To stretch both arms at the
exercise. As an aid for at a time (i.e., breaks in of connective tissue and same time, place both hands
recovery following exercise, rehearsals or concerts) and a promote relaxation of the palms down on a stool (fig. 8f),
it has also been observed to frequency (i.e., several times or other supportive surface,
muscles [9]. Besides some
decrease soreness following a day) convenient for them with the fingers pointing in
evidence of a benefit from
delayed onset muscle sore- by eliminating the need for a the direction of your thighs,
ness, which may indirectly self-massage [10] there are
massage or physiotherapist. and with both elbows straight,
enhance performance [6–8]. many practical reasons and gently push your shoulders
Self-myofascial release via a Massage has traditionally independent research from backward until you feel a
foam roller therefore could be been used to relieve pain, health practitioners that stretch on the flexor surface
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T U B A P L AY I N G A N D H E A LT H
Figure 5
Muscle
Stretching
a b c
Figure 6
Fig. 6a, 6b: Self-myofascial release (SMR)
using a foam roller
a b
Figure 7 of both forearms. Hold this and advantageous in order
position for up to 30 seconds. to enhance the general
Fig. 7a: In case Repeat 1 to 3 times. health and wellbeing of office
of a thumb-ring, General Compensatory and
workers [12].
much pressure
is applied to Equalizing Movements The regular daily training
a stabilize the As a large proportion of tuba
loads resulting from practice,
instrument that players experience musculo-
rehearsals and performances
might result in skeletal pain and discomfort,
place great demands on the
muscle strain. neuromuscular and musculo-
one crucial aspect of preven-
skeletal systems of the body.
tion and treatment is the orga-
Fig. 7b: Self- When studying the instrument,
massage for nization of practice and break
3–4 hours are spent on
thumb muscles schedules. In office workers,
average in practicing, while
supplemental rest breaks and
professionals reach up to 10
Fig. 7c: Self- workstation exercise breaks
b massage for tight
forearm extensors
have demonstrated decreased
work related musculoskeletal
hours of practice per day. As
a sudden increase in practice
time is an important risk
disorders[11]. Exercise breaks
factor for PRMDs [13], a slow
are small breaks during work,
process of extending practice
timed to diminish muscular
time should be targeted in
discomfort. Therefore,
order to allow soft tissues of
exercise breaks along with
the body to adapt.
supplementary rest breaks
have been implemented as an The idea of compensatory and
c organizational intervention as
both of them are inexpensive
equalizing movements is to
provide an alternate posture/
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Figure 8
a b c d e f
Figure 9
Fig. 9a: Deltoid stretch Fig. 9c, 9d: Pectoral (chest) Fig. 9h-i Reach for the stars
Fig. 9b: Self-myofascial stretches Fig. 9j-k Chest stretching
release for the deltoid Fig. 9e-g Shoulder circles
muscle
a b c d e
f g h i j
k l m n o
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T U B A P L AY I N G A N D H E A LT H
Figure 10
a b c d e
f g h i j
k l m n o
movement in order to give area. Exercises that open up the elbow straight, and rotate the backrest (fig. 9e–g). Draw
the challenged soft tissues the chest can also improve your body away from the wall up your shoulders. Then move
a rest, to promote perfusion posture. In an upright posture, until a stretch in the chest can them backward, then as far
and metabolism of the tissues reach one arm across your be felt. Repeat this exercise downward as possible, then
and enable motion/stretching body using your other arm with the hand position lower
forward and finally upward
in sections of the body that (Fig. 9a). Slowly begin to pull and higher than shoulder.
again. This circling movement
do not move for long peri- your arm toward your chest, The stretch can be performed
ods of time. as far as possible, allowing bilaterally with both arms can be repeated several times
the stretch to reach deep into actively stretched in different and duplicated in the opposite
Deltoid stretches: As the direction. Breathe in when
the back of your shoulder. angles of shoulder abduction.
deltoid and pectoral muscles
Hold this position for up to 30 Hold this position for up to 30 you draw your shoulders up;
have to work consistently in
seconds. Repeat 1 to 3 times. seconds or stretch dynamical- breathe out when you let them
order to stabilize the heavy
ly. Repeat 1 to 3 times. fall. Note: Slowly increase the
instrument, stretches can Pectoral (chest) stretches (Fig.
increase the flexibility of mus- 9c–d): Turn your body and Shoulder circles: Straighten radius of the shoulder circles.
cles and reduce tightness and feet away from the wall. Put your spine while keeping some Emphasize the backward
tension in the shoulders/chest your hand back on the wall, distance between yourself and and downward movements.
SUMMER 2020 | 24 | ITEA JOURNAL
Figure 11 a plié or straight legs. (The a slight lift and guide it to your
latter places some strain on thighs (fig. 10 a–d).
the lower back and may be Putting the tuba down to the
more difficult for beginning or front: Use the thighs as a
less-flexible people). sliding surface to slowly bring
Self-myofascial release (SMR) it down to the front between
for the back muscles (fig. your feet (fig. 10 e–h).
9n–o).Softly lean against a Putting the tuba down to the
wall, with a small foam roller side: Place the shorter side of
or foam ball in between the the instrument on your thigh,
wall and your back. Put slight roll the instrument over the
pressure (as convenient) thigh and keep contact until
on your muscles and by you slowly place it on the floor
bending your knees slowly (fig. 10 i–l).
Figure 12
Handling
of the
tuba hard
case
a b c d
As an alternative,
you can stand to do
outward (fig. 9k). At the same
this exercise. roll your back muscles or Standing up with the tuba:
time, breathe in.
the tight spots on the foam Bend your hips and knees to
Reach for the stars: You can
Spine roll down and straighten material. Either maintain the squat down to your instrument
do this exercise sitting upright
up: Begin in a well-aligned pressure for 20–30 seconds or like a weight lifter, grasp the
on your chair or preferably
stance with your weight dynamically roll your muscles tuba and keep it close to your
standing. Stretch your hands evenly distributed over the very slowly. body while you straighten your
toward the ceiling (fig. 9h–i). feet. Start the movement legs to lift (fig. 10 m–o).
Imagine reaching for the stars, with the head, which will 2) SAFE AND HEALTHY
Carrying the tuba: Embrace
and try to get taller and taller. drop forward with your chin HANDLING OF THE
the tuba where possible and
Feel how your back stretches. toward the chest, start flexing INSTRUMENT
hold the tuba against your
Give more attention to stretch- the spine, one vertebrae at a In terms of health promotion, upper body. In this way you
ing the right side, then the time (fig. 9l–m). Sequentially this section deals with the can safely move around
left side. As in all exercises, release the shoulders forward, various ways in which the (fig. 10o).
make sure your breathing is followed by the upper and musician can be fitted to his
continuous and relaxed. middle back. daily work, thereby covering 3) TRANSPORTING
the aspect of human behavior
THE TUBA
Chest stretching: Bend your As the head lowers toward the
head and the upper part of ground, the back of the legs (“Fit the man to the work”). As Travelling with the tuba and
and lumbar spine (lower back) tubas weigh up to 14 kg, the transporting it is a challenge.
your back forward, draw your
will be stretched. way in which its handling is Special luggage is needed
shoulders forward, and turn
performed seems to be crucial to prevent damage to the
your thumbs inward (fig. 9j). This movement can be instrument. The weight of the
At the same time, breathe in the prevention of PRMDs.
reversed to bring you back instrument plus the oversized
out. Straighten up, push your to an upright stance with Picking the tuba up from the luggage needs to be handled
breastbone forward and lifting the arms to the ceiling front: Grab the instrument, put with care. Transporting
upward, push your shoulders as if you would like to reach one foot carefully underneath instruments and other musical
back, and turn your thumbs for the stars again. Either it, give the tuba with this foot equipment is regarded as a
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T U B A P L AY I N G A N D H E A LT H
high-risk activity with regard Figure 13 fast (14–16+ mph) and
to musculoskeletal disorders contribute to aerobic fitness.
[13]. The weight of the case
• Improve overall conditioning,
adds to the weight of the tuba.
especially add specific resis-
For transportation, rolling cas- tance training for strength,
es are highly recommended. stretching or flexibility,
The case should be lifted by a coordination.
carrying handle. An important
There is evidence that
aspect for the stability of the
professional orchestral mu-
transportation is the distance
sicians benefit from exercise
between the wheels. If the
programs [17], with significant
wheels are constructed too
reductions in PRMD levels and
narrowly the case can tilt.
self-reported improvements
Preferably, a wide distance in playing-related posture,
between the wheels promotes strength, fatigue, anxiety and
easy and safe rolling (fig. 12). ability to cope with work-re-
lated stress.
In case of short distance trans-
portation, a lighter alternative Exercise programs that
to the case, the gig bag, can focused on strengthening the
be used (fig. 13). This bag thumb ring, status quo, see musician and can assist in supportive musculature of
does not provide rollers and preventing PRMDs: commonly injured areas in
fig. 14a. The thumb ring in a
therefore should be carried musicians were effective in
wishful position, showing the • Enhance physical activity
symmetrically as a backpack. reducing PRMDs and improved
elbow with less flexion, more numerous other playing-relat-
As playing tuba is predomi-
4) CUES FOR relaxed forearm extensors and ed factors [18].
INSTRUMENT DESIGN nantly performed in a static
probably less demand on the
sitting position, there might • Training body awareness
The word ‘ergonomics’ is trapezius muscle, fig. 14b.
be a tendency for physical (e.g. with Alexander technique,
derived from the Greek Secondly, another relief of the inactivity, which is detrimental Feldenkrais, Yoga) might
words ‘ergon’ (work) and increase relaxation and body
forearm muscles might be to overall health and counts
‘nomos’ (law). According to awareness during playing.
reached by repositioning the as the fourth leading cause
the International Ergonomics
valves to allow a more neutral of death worldwide [15]. The • Interrupt the practice/re-
Association (IEA), ergonomics
position of the hand, minimiz- Physical Activity Guidelines hearsal frequently, especially
(or human factors) is the
scientific discipline concerned ing the awkward hand position recommend that adults obtain every 30–60 minutes, and
with the understanding of (ulnar deviation (Fig. 11a)). at least 150 minutes/week of stretch, change positions, per-
interactions among humans moderate-intensity physical form self-myofascial releases,
Thirdly, the height of the activity or 75 minutes/week as described in section 1.
and other elements of a
mouthpiece should be indi- of vigorous-intensity physical
system and the profession • Deepen your breath regularly
that applies theory, principles, vidualized so that the sitting activity [16].
during practice or perfor-
data and methods to design posture is not disrupted.
Moderate-intensity activities mance, when possible.
in order to optimize human
well-being and overall system 5) GENERAL are those that get you moving
• Sleep is important, as it
performance [14]. RECOMMENDATIONS fast enough or strenuously helps tissue healing and
FOR HEALTH enough to burn off three to regeneration during a good
The interface between musi- PROMOTION six times as much energy per night’s sleep [19].
cians and their instruments minute as you would when you
In case of complaints, the
is the focus of ergonomic are sitting quietly, like walking CONCLUSION
perspective. In the original assessment and management
very briskly (4 mph), cleaning Due to the heavy instrument
meaning, ergonomics analyzes of PRMDs should be individu- (washing windows, vacuum- and its lever actions,
how the instrument can be alized, as every person has a ing, mopping) or bicycling with prolonged sitting times and
fitted to its user („Fit the unique physique, history and a light effort (10–12 mph). awkward postures due to
work to the man“) in order to resilience. Nevertheless, there Vigorous-intensity activities the construction/position
promote safety, performance are general recommendations, make you breathe much faster of valves and slides, tuba
and wellbeing. which are mentioned below and make you sweat, such as players endure substantial
Firstly, the thumb ring position that can improve the overall hiking, jogging at 6 mph, car- loads on their musculoskeletal
should be adapted. The vitality of the individual rying heavy loads or bicycling system. Musicians seem to
SUMMER 2020 | 26 | ITEA JOURNAL
Figure 14
Imagining the ideal valve and thumb
ring position
be underserved in the health in professional orchestral
care system and health musicians: a population study.
a b
promotion and sometimes Psychology of Music, 2015.
play through the pain until 43(1): p. 43-60.
they can no longer manage the
4. Chan, C. and B. Ackermann,
discomfort. Therefore, more
Evidence-informed physical
focus should be put on the art: Part 2. Physiological and International Ergonomics
therapy management of
observation and management therapeutic effects. British Society. p. 1.
performance-related musculo-
of performance-related pain in journal of sports medicine,
skeletal disorders in musi- 15. Kohl 3rd, H.W., et al.,
musicians. With this article we
cians. Frontiers in psychology, 1994. 28(3): p. 153-156. The pandemic of physical
aimed at providing an analysis
2014. 5: p. 706. inactivity: global action for
of and recommendations for 10. Atkins, D.V. and D.A.
some challenging aspects of 5. Peacock, C.A., et al., An public health. The lancet, 2012.
Eichler, The effects of
tuba playing. We hope that acute bout of self-myofascial 380(9838): p. 294-305.
self-massage on osteoarthritis
this can facilitate musicians to release in the form of foam of the knee: a randomized, 16. Tucker, J.M., G.J. Welk, and
better manage their loads and rolling improves performance N.K. Beyler, Physical activity in
controlled trial. International
help to enhance their health testing. International journal US adults: compliance with the
journal of therapeutic massage
and wellbeing. of exercise science, 2014. physical activity guidelines for
& bodywork, 2013. 6(1): p. 4.
7(3): p. 202. Americans. American journal
6. Schroeder, A.N. and T.M. 11. Lee, K., et al., A review of preventive medicine, 2011.
Acknowledgement
Best, Is self myofascial release of physical exercises recom- 40(4): p. 454-461.
Thanks to Rex Martin for being an effective preexercise and mended for VDT operators. 17. de Greef, M., et al.,
a model for the inspection/ recovery strategy? A litera- Applied Ergonomics, 1992. Impact of the Groningen
analysis and generously ture review. Current sports 23(6): p. 387-408. exercise therapy for symphony
allowing us to make the medicine reports, 2015. 14(3): orchestra musicians program
photo recommendations in p. 200-208. 12. Osama, M., M.B.A. Jan,
on perceived physical com-
this article. and H. Darain, A RANDOMIZED
7. Cheatham, S.W., et al., The petence and playing-related
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