NASM musculo vocal health guidelines

Protect Your Neuromusculoskeletal and Vocal Health Every Day

Information and Recommendations
for Student Musicians

Student Guide

National Association of Schools of Music
Performing Arts Medicine Association

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Protect Your Neuromusculoskeletal and Vocal Health
Every Day


In working toward a degree in music, you are joining a profession with a long and honored
history. Part of the role of any professional is to remain in the best condition to practice the

For all of you, as aspiring musicians, this involves safeguarding your neuromusculoskeletal and
vocal health. Whatever your plans after graduation ñ whether they involve playing, teaching,
producing, or simply enjoying music ñ you owe it to yourself and your fellow musicians to do all
you can to protect yourself.

The neuromusculoskeletal system refers to the complex system of muscles, bones, tendons,
ligaments, and associated nerves and tissues that support our bodyís physical structure and enable

In this resource document, the term ìneuromusculoskeletalî is used to encompass not only overt
physical movements (the pressing of a key, the strumming of a string) and overall body
alignment, but also the small internal movements our bodies make, for example to produce breath
and modify vocal sounds.

Therefore, vocal health is referred to as a component of neuromusculoskeletal health. When the
term ìneuromusculoskeletalî is used, vocal health is included. A number of direct references to
vocal health are interspersed throughout this guide. Special attention is devoted to issues of vocal
health in the sections neuromusculoskeletal issues affecting the voice and vocal protection.

Good health and healthy behaviors are important to all musicians, regardless of instrument or area
of specialization.

Vocal health is important, too. As current music students and future music professionals, you not
only use your voice to speak, but now or sometime down the road, you may find yourself
engaged with the singing voice in your role as a conductor, coach, teacher, recording engineer,
researcher, therapist, or other music professional.

Of course, there are certain behaviors, especially those involving excessive physical and vocal
stress and strain, which can endanger your neuromusculoskeletal and/or vocal health.

Sometimes our bodies and voices recover from strenuous behaviors rather quickly, but other
times the effects linger. Our recovery time is often tied to our level of fitness and ability.

Many of you may be picturing a novice athlete who doesnít warm up properly, who plays too
hard during a game or match, and who then ends up with an injury ñ maybe a sprained ankle or a
pulled muscle.

But, as you know, athletes arenít the only ones who train and practice in order to reach the
pinnacle of performance. Musicians do that, too.

The work of musicians, like that of athletes, is physically demanding. And musicians, just like
athletes, need to warm up. They need to utilize proper form. They need to take breaks. They need
to avoid ìoverdoing it.î And they need to take the proper precautions to safeguard their
neuromusculoskeletal and vocal health, so that they can continue to play and sing the music they
love for years to come.

Some of you may have already been diagnosed with some sort of neuromusculoskeletal or vocal
condition or disorder. It may be tied to your genetic makeup. It may be linked to a past injury or
infection. Or it may be linked to a particular repeated behavior, your posture, or something else.

The purpose of this resource document is two-fold. First, itís intended to inform you about some
of the most common neuromusculoskeletal and vocal conditions and disorders that affect
musicians. And second, its contents can help to empower you to take control of your own
neuromusculoskeletal and vocal health. The majority of these conditions are preventable. But
youíve got to be proactive and protective of your health. Avoid putting yourself at risk.

The bottom line is this: If youíre serious about pursuing a career in music, you need to treat your
body with respect. You need to demonstrate proper form and technique when playing and
singing. And you need to recognize your physical limitations. Sometimes, the most important
thing you can do is take a deep breath and take a break.


The information in this presentation is generic and advisory in nature. It is not a substitute for
professional, medical judgments or advice. It should not be used as a basis for medical treatment.
If you are concerned about your physical dexterity or your voice, or think you may be
experiencing the symptoms of a particular neural, musculoskeletal, or voice disorder, consult a
certified or licensed medical or healthcare professional.

Purpose of this Resource Document

The purpose of our presentation is to share with you some information on neuromusculoskeletal
and vocal health, conditions, and disorders and to let you know about the precautionary measures
that all of us should practice daily.

Music, the Musician, and Neuromusculoskeletal and Vocal Health

So, for most of you, practice is paramount to your success as a musician. Itís likely that the days
when you donít practice are few and far between. It takes a lot of time, dedication, and skill to be
a successful musician. The act of practicing our music gradually takes a toll on us, especially
when practice involves long hours and infrequent breaks.

We practice alone, we practice with others, we practice for concerts, we practice for juries, and
we practice for competitions. In other words, we practice a lot. We practice to be the best we can
be. And from time to time, we experience aches and pains.

All of us know that the life of a musician is busy and strenuous.

Decisions about when and how we practice ñ and for how long ñ have an effect on our
neuromusculoskeletal and vocal health. So, too, does our behavior outside of music classrooms,
rehearsal halls, and concert venues.

As musicians, are responsible for our art. We need to cultivate a positive relationship between
music and our neuromusculoskeletal and vocal health. Balance, as in so many things, is an
important part of this relationship.

The Neuromusculoskeletal System

The neuromusculoskeletal system refers to the complex system of muscles, bones, tendons,
ligaments, and associated nerves and tissues that allow us to move and to speak and sing. Also,
this system supports our bodyís physical structure.

The ìneuroî part of the term ìneuromusculoskeletalî refers to our nervous system, which
coordinates the ways in which our bodies move and operate. The nervous system consists of the
brain, the spinal cord, and the hundreds of billions of nerves responsible for transmitting
information from the brain to the rest of the body and back to again, in an endless cycle.

Our nervous systems allow us to move, to sense, and to act in both conscious and unconscious
ways. We could not listen to, enjoy, sing, or play music without these structures.

Vocal Anatomy

Our vocal system is a part of our larger neuromusculoskeletal system. Our voice is produced by
four component systems. These are often referred to as the ìgenerator,î the ìvibrator,î the
ìresonator,î and the ìarticulator.î

The ìgeneratorî is our breath that is provided to us by our lungs. The diaphragm, along with
numerous other muscles within our abdomen, ribs, chest, and back, help us to move breath
throughout our respiratory system.

The ìvibratorî is the larynx, commonly referred to as the ìvoice box.î Horizontally stretched
across the larynx are two folds of mucous membrane. These are called the ìvocal folds,î or
ìvocal cords.î And so, when breath from our lungs passes along our vocal folds, vibrations occur.

The ìresonatorî is the resonating cavity above the larynx that gives the voice its particular tonal
quality. The resonator includes the vocal tract, much of the pharynx, or throat, the oral cavity, and
the nasal passages.

The ìarticulatorî includes our tongue, lips, cheeks, teeth, and palate. Together, these parts help us
to shape our sounds into recognizable words and vocalizations; they help us to articulate.

These four component parts ñ the ìgenerator,î the ìvibrator,î the ìresonator,î and the
ìarticulatorî ñ work together to produce speech, song, and all order of vocalizations.

Disorders of the Neuromusculoskeletal System

Sometimes, within our complex physical bodies, something goes wrong, and we find ourselves
victim to a neuromusculoskeletal disorder. The causes and contributing factors vary, but such
disorders generally fall into one of the following three categories: 1) disorders with a genetic link;
2) disorders resulting from trauma or injury; and 3) disorders that are related to our behavior.

Some common symptoms of all neuromusculoskeletal disorders include pain, stiffness, aching,
throbbing, cramping, and muscular weakness.

Some disorders may be permanent, while others may be temporary.

In some cases, a simple change in behavior or some rest and relaxation can help to eliminate or
reduce certain symptoms.

Other times, itís not so simple, and medical professionals may need to prescribe certain
treatments, such as surgery, therapy, or medication.

Contributing Factors

The exact causes of behavior-related neuromusculoskeletal disorders are manifold. However,
these causes generally fit into one of two basic categories or factors. They are: 1) musculoskeletal
overuse and/or misuse and 2) genetic factors.

1. Overuse/Misuse (and Abuse)


The human body, as we all know, has certain physical limits. In arts medicine terminology,
ìoveruseî is defined as a practice or activity in which anatomically normal structures have been
used in a so-called ìnormalî manner, but to a degree that has exceeded their biological limits.
Overuse produces physical changes in our muscles, tendons, ligaments, etc., and thatís when we
experience symptoms, such as pain and discomfort.

So, how much activity is too much? What exactly constitutes overuse? Well, thereís no simple
answer to either of these questions. The amount of excessive activity needed to produce these
results varies from person to person. Often, itís tied to a personís individual anatomy and

Musicians who are dealing with changes to their musical routine may find themselves ìoverdoing
it.î In the face of high self-expectations, musicians who are beginning at a new school or who are
starting lessons with a new instructor may be more apt to overdo it, to push themselves too hard.

Similarly, musicians who are taking up a new instrument may overdo it, as they work to quickly
advance their skills.

Really, any musician who rapidly increases his or her practice time or intensity is likely to overdo
it and increase his or her level of risk.

When it comes to overuse, what we need to ask ourselves the following questions: ìIs my body
well conditioned enough to handle this kind and amount of physical activity? Am I changing my
musical routine too drastically or too quickly? Why am I making this change?î These are
questions that require honest and individualized answers.


ìMisuseî is when we use our bodies to perform physical tasks in abnormal ways ñ and sometimes
to excessive degrees. When we misuse certain bodily structures, we put them under stress. This
can lead us to experience symptoms such as pain and discomfort.

In music, an example of physical misuse is improper technique. Improper technique can involve
poor or ìlazyî posture. For instrumentalists, it can involve playing with excessive pressure or force. It can also involve a physical mismatch between player and instrument. For singers, it can
involve singing too loudly or singing out of range.

Remember, good posture and technique are important. Theyíll make playing and singing easier,
and youíll be less likely to hurt yourself.


Abuse is related to both overuse and misuse. We abuse our own bodies when we perform an
activity not only excessively or improperly, but also in a conscious, willful manner, over a
sustained period of time. A common example is ìplaying through the pain.î Football players can
be frequent perpetrators, but so are some musicians. In their quest to be the best, they let their
own physical well-being take a back seat, and end up hurting themselves.

Playing or singing through the pain is not an acceptable option. If youíre hurting, stop. Tell your
instructor that youíre not okay. Your instructor will likely have a protocol in place. This may
include asking you to sit on the sidelines and make notes in your music, or you may be excused
from class to seek treatment. Ultimately, if you are experiencing chronic pain, consult with a
medical professional, and follow the treatment plan they provide. Your health is too important to
be playing through the pain.

Abuse can also involve the use of alcohol or other dangerous substances. Donít smoke or use any
drug not prescribed by a medical professional licensed to do so.

2. Genetic Factors

There are also some genetic predispositions that can increase a personís risk of developing one or
more behavior-related disorders.

One of the most common genetic factors in this category is double-jointedness. Medically known
as ìhypermobility,î people with this condition have joints, ligaments, and tendons with an
extended range of motion. Such joint instability can increase a personís risk of developing
various muscle pain syndromes. It can also lead to tendinitis, an inflammation of the tendon.
(Tendons, as you may know, are the tough bands of fibrous tissue that connect muscle to bone.)

Individuals with hypermobile joints tend to compensate for this instability by over-tensing their
muscles. While this extra muscle tension can help them to better control their movements, it can
also increase their risk of damaging or straining a muscle.

People with hypermobility are generally encouraged to monitor and actively reduce the amount of
tension that they carry in their muscles in order to reduce the risk of future pain and discomfort.

Specific strengthening exercises may be recommended, or they may employ external methods of
joint support, such as small ring splints or tape.

Neuromusculoskeletal Issues Affecting the Body

Below are a number of neuromusculoskeletal complications and disorders that are likely to affect
the musicianís body.

1. Muscle Pain
For musicians, muscle pain can be the result of overuse, misuse, poor posture, tension, technical
problems, or poor conditioning.

Muscles that are fatigued are less able to contract as strongly and frequently as ìnormalî muscles.
With continued use, fatigued muscles are placed under greater stress, and this can lead to
microscopic damage and disruption of the muscle fibers, a condition known as muscle strain.

Muscle contraction is both a physical and a chemical process. When the necessary chemical
compounds are in short supply, muscles can no longer operate at optimal efficiency. When
muscles contract, they produce lactic acid. When lactic acid builds up in tissues, it minimizes the
muscleís ability to continue efficient contractions.

Some kinds of muscle pain may subside once an activity is stopped, but others will linger.

In the case of muscle strains, the pain may dissipate, but a regimen of rest, ice, and/or anti-
inflammatory medications may be necessary in order to reduce swelling and help facilitate a
quicker recovery. As always, itís best to get your advice and treatment plan from a medical

For musicians, muscle pain that stems from performing music is commonly felt in specific body
locations. The neck and shoulders; the hands, wrists, and fingers; and the lower back are the most
frequently affected areas. Some musicians are more susceptible to certain injuries than others. For
example, clarinetists are at greater risk for right thumb pain. Double bass players are more likely
to experience pain in the lower back.

So, just remember this, when it comes to muscle pain, give your body a break and rest your weary
muscles for as long as it takes. Resuming activity prematurely often exacerbates the problem and
leads to more trouble in the long run.

2. Neuropathies
ìNeuropathyî is a general medical term that refers to diseases or malfunctions of the nerves.
Neuropathies are classified by the types or locations of the nerves they affect.

Focal neuropathies are those focused on one nerve or group of nerves within a particular area of
the body. Symptoms usually appear suddenly and can include pain; sensory disturbances, such as
numbness, tingling, ìpins of needlesî sensations, burning, or even itching; and weakness. In the
case of bodily extremities, the pain may occur at the site of a nerve compression or entrapment.
Nerve compressions, or entrapments, occur when a nerve passes through a narrowed channel
bounded by bone, fibrous bands, bulky muscles, or enlarged arteries on its way to or from its
ultimate destination ñ either toward or away from the brain and spinal cord.

In other cases, the pain may be distributed anywhere along the course of the nerve. Individuals
with this kind of nerve pain may later on find themselves experiencing muscle weakness and
impaired dexterity.

Three of the most common entrapment neuropathies for musicians include: 1) carpal tunnel
syndrome, 2) ulnar neuropathy, and 3) thoracic outlet syndrome.

Carpal Tunnel Syndrome

Often associated with people who type for a living, carpal tunnel syndrome occurs when the
median nerve, which runs from the forearm into the palm of the hand, becomes pressed or
squeezed at the wrist. The carpal tunnel ñ a narrow, rigid passageway of ligament and bones at
the base of the hand ñ contains the median nerve and several tendons. When irritated or strained,
these tendons may swell and narrow the tunnel, compressing the median nerve. The result can be
pain, weakness, or numbness in the hand and wrist that radiates up the arm.

Although some experts tie carpal tunnel syndrome to repeated actions, especially those involving
the hands and wrists, others cite a genetic predisposition. It is also associated with certain medical
conditions, including diabetes, arthritis, and hypothyroidism. It is often very difficult to determine
the precise cause of carpal tunnel syndrome.

Whatever the cause, it is a good idea to occasionally rest and to stretch the hands and wrists when
performing repetitive tasks or musical exercises. For individuals diagnosed with carpal tunnel
syndrome, a doctor may recommend the use of a wrist splint, especially at night.

Ulnar Neuropathy

Ulnar neuropathy is a condition in which the ulnar nerve, which runs from the neck along the
inside edge of the arm into the hand, becomes inflamed due to compression of the nerve.

Symptoms include tingling, numbness, weakness, and pain, primarily along the elbow, the
underside of the forearm, and along the wrist or edge of the hand on the little (pinky) finger side.

Compression of the ulnar nerve is often linked to repetitive wrist or elbow movements. Musicians
of bowed instruments are at a heightened risk for developing this condition, because playing a
bowed instrument involves sustained elbow flexion.

Treatment for ulnar neuropathy may involve pain medication, the use of splints to restrict motion,
and various exercises.

Thoracic Outlet Syndrome

Thoracic outlet syndrome refers to a group of disorders that occur when the blood vessels or
nerves in the thoracic outlet ñ the space between the collarbone and first rib ñ become
compressed. It is most often the result of poor or strenuous posture, or of constant muscle tension
in the neck and shoulder area. Symptoms include pain in the neck and shoulder areas and
numbness in fingers.

Doctors may prescribe a variety of stretches and exercises in order to treat the symptoms of
thoracic outlet syndrome.

Proper body alignment and sufficient muscle strength can both help to decrease the risk of
thoracic outlet syndrome among musicians.

3. Dystonia
Dystonia involves sustained muscular contractions. These muscular contractions produce
unwanted movements or abnormal postures in people. The exact cause of dystonia is unclear.

Like a focal neuropathy, focal dystonia is focused on a particular area of the body, and certain
sets of muscles within that area of the body are involved.

Because men are more frequently affected than women, it is possible that genetic or hormonal
factors are to blame.

Also, as is the case with carpal tunnel syndrome, repetitive movements, especially those that are
painful, seem to be a trigger for dystonia.

In the instrumental musicians, these sustained muscle contractions frequently affect the upper
arm. This is especially true for keyboard, string, percussion, and woodwind players. In brass and
woodwind players, the embouchure may be affected.

Neuromusculoskeletal Issues Affecting the Voice

There are also a number of neuromusculoskeletal issues that can adversely affect the musicianís

Some common medical conditions affecting the voice are phonatory instability, vocal strain, and
vocal fold motion abnormalities.

1. Phonatory Instability
Phonation, as you may know, is the process by which air pressure, generated by the lungs, is
converted into audible vibrations. One method of phonation called ìvoicingî occurs when air
from the lungs passes along the elastic vocal folds at the base of the larynx, causing them to

Production of a tonal, pleasant voice with smooth changes in loudness and pitch depends upon the
symmetrical shape and movement of the vocal folds.

Phonatory instability occurs when there is asymmetrical or irregular motion of the vocal folds that
is superimposed on the vocal fold vibration.

Short-term causes of phonatory instability include fatigue, effects of medication, drug use, and
anxiety. These problems tend to resolve rapidly if the cause is removed. Fatigue is another
common cause of short-term phonatory instability.

Additionally, over-the-counter allergy medications, anti-depressants, and highly caffeinated
drinks, which stimulate the nervous system, can often cause vocal tremors, a form of phonatory

Drug use, alcohol use, and smoking all adversely affect our control of vocal folds and should be

2. Vocal Strain
Another issue for vocal musicians is vocal strain. Overuse of the voice in any capacity ñ singing
or speaking ñ can produce vocal strain.

Singers must be aware of problems associated with singing at the extremes of vocal range,
especially the upper end.

Both duration and intensity of singing are as important as they are for instrumentalists. In other
words, avoid overdoing it.

Singers should also avoid attempting repertoire that is beyond their individual stage of vocal
maturity and development.

Improperly learning and practicing certain vocal styles is also dangerous.

3. Vocal Fold Abnormalities
Prolonged overuse can, in some cases, lead to the development of nodules on the vocal folds. The
nodules appear initially as soft, swollen spots on the vocal folds, but overtime, they transform into
callous-like growths. Nodules require specialized and prolonged treatment and rehabilitation and
can be of grave consequence to singers.

Basic Protection for All Musicians

As musicians, itís vital that you protect your neuromusculoskeletal health whenever possible.
Here are some simple steps you can take:

1. When possible, avoid situations that put your neuromusculoskeletal health at risk.
2. Refrain from behaviors that could compromise your neuromusculoskeletal health and the
health of others.
3. Warm up before you practice and perform.
4.Take regular breaks from practice and rehearsal. A good rule of thumb is a 5-minute rest
every half hour.
5. Limit excessive practice time.
6. Avoid excessive repetition of difficult music, especially if progress is slow.
7. Insomuch as possible, avoid playing and/or singing music that is beyond your physical
abilities or outside your natural range.
8. Refrain from sudden increases in practice and playing time.
9. Maintain good posture in life and when you practice and perform music. Be mindful of
alignment, balance, and weight distribution.
10. Use external support mechanisms, such as shoulder rests, neck straps, and flute crutches,
when necessary.
11. Maintain good ìmental hygiene.î Get adequate sleep, good nutrition, and regular exercise.
12. Refrain from recreational drug use, excessive alcohol use, and smoking.
13. Do your best to limit and control stressors. Plan ahead.
14. Give yourself time to relax.
Vocal Protection

Hereís some extra advice for safeguarding your voice:

1. Drink plenty of water, at least 8 glasses a day.
2. Limit your consumption of caffeine and alcohol.
3. Donít smoke.
4. Be aware that some medications, such as allergy pills, may dry out your vocal tissues. Be
aware of side effects and talk to your doctor if you have questions.
5. Avoid dry air environments. Consider using a humidifier.
6. Avoid yelling or raising your voice unnecessarily.
7. Avoid throat clearing and loud coughing.
8. Opt to use vocal amplification systems when appropriate.
9.Rest your voice, especially if you are sick. Your voice and your body need time to recover.

Marching Musicians

Musicians in marching bands and drum corps need to maintain a high level of physical
conditioning, strength, and endurance. Their rehearsals and performances are very physical and
require very precise movements, all while carrying an instrument.

Marching musicians are at an increased risk for sprained ankles, toe contusions, and knee strains,
and the heavy instruments that you carry place great amount of physical stress on the neck, torso,
lower back, and legs.

In some climates, high heat, humidity, and extended sun exposure may place added strain on
these musicians.

Thorough physical warm-ups, sufficient rest periods, appropriate sun protection, and adequate
hydration are essential in promoting the neuromusculoskeletal health of these musicians.

Future Steps

Now that youíve learned about the basics of neuromusculoskeletal and vocal health, we
encourage you to keep learning. Do your own research. Browse through the links provided at the
end of this document. Thereís a wealth of information out there, and itís yours to discover.


We hope this resource document has made you think more carefully about your own neuromusculoskeletal
and vocal health. Just remember that all the knowledge in the world is no match
for personal responsibility. Weíve given you the knowledge and the tools; now itís your turn.
You are responsible for your behavior in and outside of the music unit. Your day-to-day decisions
have a great impact on your neuromusculoskeletal and vocal health, both now and years from

Do yourself a favor. Be smart. Protect your body and your voice. Donít take unnecessary risks.
Take care of yourself. You owe it to yourself.

Resources  Information and Research
Neuromusculoskeletal and Vocal Health Project Partners

National Association of School of Music (NASM)

Performing Arts Medicine Association (PAMA)

PAMA Bibliography (search tool)

Medical Organizations Focused on Neuromusculoskeletal and Vocal Health

American Academy of Neurology

American Academy of Orthopaedic Surgeons

American Academy of Otolaryngology ñ Head and Neck Surgery

American Academy of Physical Medicine and Rehabilitation

American Association for Hand Surgery

American Laryngological Association

The American Occupational Therapy Association, Inc.

American Psychiatric Association

American Psychological Association

American Physical Therapy Association

American Society for Surgery of the Hand

American Speech-Language-Hearing Association

National Center for Complementary and Alternative Medicine

Other Resources on Neuromusculoskeletal and Vocal Health

Athletes and the Arts

National Association of Teachers of Singing