Preventing injuries in young musicians

Many people are labelled pioneers in their field, but Dr Sarah Upjohn has more ‘firsts’ to her name than most. 

She believes she was the first physio to be employed and embedded in a children’s music school when she started working at The Purcell School for Young Musicians in 2008. She is the wellbeing lead for the National Children’s Orchestra and an assessing clinician for the British Association for Performing Arts Medicine (BAPAM), a charity that supports performing artists to access appropriate medical help. 

She’s also the first CSP member to receive a doctorate of education from the University of Cambridge – in 2018 for her research, based on her work at The Purcell School, on the prevention of playing-related injuries in elite young musicians. 

She took an interesting journey to assemble her ‘portfolio career’, which she has built up over many years, and a mission to help prevent injuries in young players.

Dr Upjohn trained at Bristol School of Physiotherapy and qualified in 1983 before working in the NHS, initially in rotational junior jobs. 

She got itchy feet and took a backpacking and working holiday in Australia, where she gained clinical experience. Then she went on to Canada, before spending three years in Boston, Massachusetts where she worked in the teaching hospital linked with Harvard Medical School.

She finally became homesick and took up a senior lecturing post at the University of Hertfordshire on the undergraduate physio course.

‘My main clinical area had been neurology,’ she says. 

‘I had two children and got a job in a MSK outpatient clinic in Cambridge, as it was near my home. It was then that I started working with musicians, because I am one, and was very connected to the musical scene in Cambridge and have two musical children. I grew up playing the piano and sing in two choirs. One of my A Levels to get into physio was music. Music came around in a circle to be part of my job again.’

Identifying risk factors

In 2008, The Purcell School had an advert in Frontline for a physio one day a week. ‘I applied and started and at the same time I learned about BAPAM, and I started working for them too.

‘I think I was the only physio in the country to work with pre-conservatoire musicians within any of the five specialist music schools.

The others use physios, but they will send their students to a local practice, whereas I am embedded in the school.’

But what usually causes physical problems for musicians? ‘It’s the sustained awkward positions for long periods on a poorly prepared body,’ she says.

‘I did the doctorate in Cambridge because I was frustrated that the injuries I was seeing in the children, aged nine-18, seemed to me to be preventable. I couldn’t really sleep comfortably at night because we can’t go on injuring children when we can prevent it. 

‘I did a massive audit of three years of physio notes at The Purcell School and found five main risk factors that makes them vulnerable to injury: a sudden increase in playing time; changing to a repertoire with different technical demands; stress; posture, position or set up of the kit; and growth spurts in the children.’ 

Her audit showed these risk factors had parallels with sport, so the rest of the doctorate examined ways of reducing playing-related incidents in the school. The problems range from being inconvenient for a few days to career ending. 

‘These children have had families who have invested so much. As an adult musician, if you are injured to the point of your career being over it is devastating.’

She explains that the most at risk are the pianists and string players who don’t realise that they are overdoing it and if you hold instruments at awkward angles for hours the damage adds up. The woodwind and brass players have a natural break on how long they can practise for. 

‘The most recent thinking is to get musicians to look after their bodies in the same way that athletes do,’ she says. ‘Warming and limbering up beforehand, cooling down afterwards, and stretching right at the end. 

We are moving towards seeing musicians benefit from being cardiovascularly fitter, stronger, and more flexible. It’s like an endurance sport – they play for hours.

She says musicians did not exercise historically and don’t get the same level of support that athletes or professional soccer players do. They are elite performers in a different field, she says.

Supporting performers

Dr Upjohn’s research was also concerned with developing strategies that work within the school, as it became clear that most people didn’t know what the risk factors were. To combat this, a big health promotion push to pupils, teachers and parents was launched and the pupils’ wellbeing became part of the school’s annual assessment.

She is now implementing similar strategies with the National Children’s Orchestra of Great Britain (NCOGB), which is proactive with wellbeing needs. ‘The sooner you start this the better,’ says Dr Upjohn. ‘You can’t wait until you are at the conservatoire. Morally it’s right. 

‘I go on residential courses, observe at rehearsals and help. When injuries occur, we use sound principles in managing MSK disorders.’

This summer, student physios had an amazing opportunity. Dr Upjohn was involved, along with Jude Coe, teaching fellow in the School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, and her students, as they worked with the 1,500 performing artists (of all genres), rehearsing for the opening and closing ceremonies of the Commonwealth Games.

‘It was the first time that undergraduate or pre-registration physios had been able to do performing arts medicine as a clinical placement as part of their training,’ says Dr Upjohn. ‘We saw dancers, aerial artists, crew building the stage, catering teams, jugglers, drag queens – we saw them all. 

‘These 32 students had the most incredible time within this performance space. We were there for eight weeks of performance, six days a week.’

What’s her advice for physios who are interested in performing arts medicine? 

A lot of private practices in London treat West End performers, she advises, adding that it’s at the rehearsal stage that things can go wrong. Physios also go on tour with big rock bands and big shows like Cirque de Soleil. ‘

You could contact your local dance school or company and ask to observe their work and offer your services,’ she says. 

‘And BAPAM has a directory of medical practitioners, including physios, who have experience of performing artists, so it’s worth contacting them too.

‘Read peer-reviewed published literature, such as the journal Medical Problems of Performing Artists. All the evidence shows that over 75 per cent of musicians will need MSK physio at some point.’ 

Her big message for young physios is:

When I started training in 1980 and qualified in 1983 performing arts medicine didn’t really exist. I had no idea where my job would take me.

Now I work in a job I love combining music, children and education and work in a private MSK practice where I treat injuries. I have a doctorate from Cambridge, and I get up in the morning excited about work. The world of physio in the performing arts is such an interesting field.’