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Clinical Psychoneuroimmunology and music

Musicians should be considered high performing top athletes, suffering enormous demands on physical, emotional, mental, cognitive and social level. The workload of musicians is influenced by multiple factors including practicing time, light, performing time, performing stress, extreme competition, poor nutrition, play through pain, sleep disturbances, low earnings, high costs, poor social family life, lack of recognition (only a few are really known), tendency to addiction and loneliness.

This workload can cause a variety of problems, including musculoskeletal injuries, psychiatric disorders (e.q. performance anxiety syndrome and obsessive perfectionism) and, as mentioned before, a tendency for addictive behaviour. It seems that 50-80% of all musicians suffer from moderate/severe physical problems, 20% of depression and more than 24% of musical performance anxiety. Another, much less recognized, risk factor causing injuries in certain individuals, is related with negative connotations of inferior technical competency communicated by their peers. Prevention of all these maladies is possible through improvement of many variables, including nutrition, physical condition, mental training and psychosocial training of leading persons in the music industry. Prevention and healing can only be optimal when injuries are explainable through evidence based working mechanisms. It seems that low stress tolerance, endotoxemia and low-grade inflammation processes are at the basis of the development of disease susceptibility of musicians. The use of integrative therapies based on clinical psychoneuroimmunology should therefore be considered when treating musicians, including singers and dancers. CPNI integrates the majority of possible mechanisms in chronic disease and therapies are based on nutrition, exercise, mental/social training, and sleep regulation with the use of the least toxic interventions available in (sports) medicine.


Stress, food intake, emotions, performance anxiety and inflammation

It is well known that musicians suffer from multiple maladies, which very often do not heal completely, leading to loss of practice time and income (Schaefer 2012). Musicians should be considered top athletes with one major difference; whereas top athletes have access to all kind of professional help (psychologists, nutritionists, sports-physiotherapists, etc.), musicians normally do not (Chan 2014).

Risk factors, influencing the musician’s health, range from physical overload up to poor nutrition, sleep disturbances and performance stress (table 1). Musicians face extreme competition with relatively low earning and high life costs (Pinheiro 2009). Very often they also suffer from negative feedback of their peers, increasing daily stress level and the susceptibility for chronification of any malady, including musculoskeletal injuries (Chan 2014). The poor psychosocial guidance of musicians and negative feedback of their peers very often leads to feelings of shame and professional “stupidness”, preventing the search for adequate medical health (Chimenti 2013). The ultimate consequence are individuals playing through the pain, affecting their technic more and more and putting even more strain on their injured body (Hansen 2006). Three of the most deleterious disease-causing factors in the life of musicians are their poor food intake (content, timing and frequency), poor hydration and a complete disturbed biorhythm. Musicians very often do not eat, eat too often small amounts (meal frequency), eat fast food and perhaps even more harmful, eat out of timing. Whereas meal content has been recognized as possibly deleterious for a long time already, it are meal frequency and timing, which are underscored as risk factors for injuries and diseases (Mattson 2014). Musicians have been advised to eat frequently and consume high glycaemic load nutrients during their last meal before performance, including whole grains, pasta, rice, potatoes, energy bars, vegetables, and fruit. A small snack before performing is also recommended (Dick 2014). These data are based on papers published in 2003 (Moseley L, Lancaster GI, Jeukendrup AE. Effects of timing of pre-exercise ingestion of carbohydrate on subsequent metabolism and cycling performance. Eur. J. Appl. Physiol. 2003; 88:453Y8.), which really should be considered outdated. The actual state in sports-science describes completely different scenarios to maintain optimal physical performance and, even more important, mental adequacy when resistance is demanded (Depner 2010, Guerra 2010). It has been evidenced that low glycaemic load diet, higher poly-insaturated fat intake and low meal frequency increases mental health, concentration capacity and injury protection (Varady 2007, Mattson 2005). Anyway, it is important that musicians take care of their daily diet in order to maintain tissue conditions, prevent inflammation and optimize wound healing (see the chapter of resoleomics).

Risk factorMusicianInjury

Poor technic

All (injuries instrument specific, dancers, singers)

Tendinitis, bursitis, overuse syndrome (hypoxia but no inflammation), hernia nuclei pulposi, dystonia

Craniomandibular disorders (producing headaches, migraine)

Wrong posture

Instrument players

Idem as poor technic

Lack of pause


Hours of practice




Idem + eye disorders

Environmental temperature


Idem, Lung disease, viral infections

Poor earnings

All (starters)

All, anxiety disorders, performance anxiety, perfectionism obsessive disorder

Constant negative feedback


Idem, depression, dystonia

Poor sleep


Idem, depression, dystonia

Poor food intake


All, poor wound healing, chronification

Food intake timing


Idem as poor food intake

Meal frequency


Idem as poor food intake

Performance stress

Youngsters, first instruments, soloists

Idem, especially dystonia

Social isolation

Non recognised artists


Hardly off season

All; especially soloists


Extreme competition

Orchestra members, dancers

Overload injuries, poor wound healing

Fear for career-ending injury



Rock singers, Jazz artists

Cancer, early death

Lack of whole body exercise (aerobic/weight lifting)


Leading instruments

Leading instrument players


Sound volume

Orchestra, opera singers, musical singers

Hearing loss, cardiovascular disorders

Poorly maintained instruments


Overload injuries, tendinitis, bursitis

Poorly designed instruments


Overload injuries, tendinitis, bursitis, back problems

Job uncertainty


All, psychiatric disorders

Social isolation


All, psychiatric disorders

Negative relationships


All, psychiatric disorders

Table 1.

Being a musician puts great strain on multiple human systems affecting overall health.

One of the most intruding customs in music is the fact that once a musician has become a professional, they normally cease to attend technical classes or get any technical correction. Bad technic very often leads to one of the most feared disorders in sports in general, but especially music; musicians dystonia (Clark 2014). Focal dystonia consists of involuntary movement of limbs (often fingers or wrists) that occur when a specific motor task is attempted. Even a mild focal dystonia can derail a career due to the accuracy demanded of instrumental athletes (Schaefer 2012). Focal dystonia is very often the non- recognized cause of acute loss of skills in musicians and affects string players (the hands, shoulder), pianists (hands), wind instrument artists (facial muscles) and even singers (vocal cords, Dick 2013). A variety of therapeutic options are available to treat the condition including medications, biofeedback, manipulative and movement therapies, relaxation techniques, stretching and strengthening programs, changes in equipment and technique, splinting, BoTox injections, and surgery. No single approach has proven to be statistically superior and so an integrated approach is often necessary to obtain an improved outcome. We therefore advice an integrative treatment based on clinical PNI and using the so called BERN concept, proposed by Esch et al. (Esch 2010) and adapted by ourselves (figure 1). The actual state of art gives evidence for two mechanisms/etiological factors for dystonia. One describes the impact of peripheral factors on the development of musician dystonia (leynse 2014). They state that dystonia is caused by a conflict between central (read brain) demands and peripheral constraints of instrument-playing requirements. Difficulties in the spreading of fingers in pianists or difficulties in moving fingers separately in guitar players demand compensatory movements to cover central brain needs to execute the task. The more compensation is needed, the greater the possibility for the development of the so feared dystonia. The second explanation of dystonia is based on behavioural observations (Ioannou 2014). Anxiety, perfectionistic and stress characteristics increase the probability for the development of dystonia with a factor 6, but only affect 50% of dystonia sufferers. The authors state that these results reflect two different mal-adaptive processes Iioannou 2014). This would support the double explanation for dystonia as mentioned above. The total picture is probably even more complex including a possible third group combining both mechanisms as causal for their dystonia.

Figure 1 - Dystonia in musicians. The worst nightmare

Whatever the reason of their injuries and diseases, it seems clear that the high workload musicians experience on physical and mental level, demands for an integrative treatment approach in which injury prevention, stress management and improvement of wound healing should be central targets. The next chapters will discuss the possible interventions, which meet the requirements of optimal integrative treatment.


Including pleasurable activities, social interaction, social support, friendship, love, healthy communication, arts and creativity, pacing, cognitive behavioral therapy, motivational and positive psychology.

Aerobic and anaerobic physical activity.

Including meditation, spirituality/belief, sleep hygiene

Diet, including supplements - if indicated

Figure 3. - The BERN concept of stress-handling in general and especially in musicians (adapted from Esch 2010).

Finally, being a musician influences even life expectancy, depending on gender and type of music. Women live longer than men, which is not surprising looking at the normal population. Men instrumentalists show a relative short life expectancy with an average of 70 years (compared with the general population = 78 years, Zharinov 2014). Interstingly, female harp players have the longest life expectancy, while female rock musician show an extreme reduced life span (37,7 years). It seems clear that being a musician puts a severy burden on individuals, demanding an optimal preventive program to improve health and life span of this very special group of persons.

Wound healing, improvement of stress tolerance, resoleomics and biorhythm

Injuries in musicians are, as mentioned, common and very often long lasting. It seems clear that the basic mechanism behind the susceptibility for bad wound healing is based on low-grade inflammation (Pilger 2014, Felger 2014). Low grade inflammation (LGI) is a state of a continuous activated innate immune system located in the blood circulation (Ruiz 2013). This state demands an enormous amount of energy causing energy deficiency in muscles and even the brain (Pruimboom 2011). LGI can be caused by performance anxiety, endotoxemia (increased permeability of gut and other barrieres), lack of omega 3 fatty acids and other anthropogenic pro-inflammatory risk factors (Ruiz 2014, Ruiz 2013, Bosma 2012, Egger 2012a, Egger 2012b, Pruimboom 2011). Many, if not all of these risk factors are present in musicians including poor nutrition/fast food intake, poor sleep, drug abuse, high alcohol intake, smoking and lack of whole body exercise. Wound healing and stress tolerance is influenced by many nutritional factors of which omega 3 fatty acids is of special importance. Omega 3 fatty acids improve mood, concentration, wound healing and stress tolerance (Wellhauser 2014, Rosenblat 2014, Tan 2012). Other nutrients belonging to so called “brain nutrition” are iodine rich foods such as shellfish and green algae, vitamin D and selenium (Gomez-Pinilla 2008). It is therefore highly important that musician cover the need of brain nutrients through high intake of fish and other water based nutrients.


Being a musician puts great strain on multiple human systems affecting overall health. Next to injuries of different muscles and joints, musicians also suffer from mental disorders, social isolation and dystonia. Many factors have synergistic influence on health and well-being and interventions should therefore be integrative. Physical exercise, sitting breaks, a motivational climate and social support are basic to the total amount of possible interventions. Next to those general solutions, regulation of the biorhythm by the use of blue light filter glasses and melatonin and nutritional advice are essential not only for

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