Acupuncture for muscle-skeletal issues in a group of musicians

Authors: Mafalda Pires, Sofia Pires,

António Vassalo Lourenço, Silvério Cabrita

Universidade de Aveiro

Masters in Music Teaching

Mafalda.vilan.pires@gmail.com

Keywords: Alternative Medicine, Acupuncture, Musicians, Muscle-
Skeletal Pahtologies, Anxiety in Performance

Abstract:

Musicians tend to look for complementary and/or alternative therapies

more and more, as opposed to methods utilised by conventional medicine.
The several methods of Chinese medicine (especially acupuncture, Chi Kung
exercises and plant-based medication) are some of the most used.

Acupuncture and be defined as a therapeutical technique that has the

insertion of needles in the periphery of the human body as its predominant
method. The effect of the needles originates alterations in the energetic
system of the patient, which will result in beneficial physical change
(Quaresma 2010).

Muscle-skeletal pathologies reveal a particular interest in our days,

since they are caused by overly-repetitious activities, repetitive movements,
sedentarism and muscular hipertonia related to stress in the work or personal
contexts, something that is very common amongst musicians.

What brings me to discussing this matter (besides the problematics of

muscle-skeletal pathologies in musicians) is the growing number of these
professionals with anxiety problems and the contribution of this type of
medicine as an alternative way of treating, since it does envolve the nervous
system of the patient.

Introduction

Musicians tend to look for complementary and/or alternative therapies

more and more, as opposed to methods utilised by conventional medicine.
Some scepticism about the latter is related to the strong fear that some
prescribed medication may actually have serious contrary effects (Federspiel
and Herbst 2001). The growing search and need for information and
orientation on the alternative therapeutical methods should lead us to
searching answers to the issues that arise, making available to the interested
parties the necessary knowledge for its understanding and utilisation:

- What real use is there in the different naturalist or alternative

methods?

- What are the involved risks in using a certain method?

A Alternative therapies use natural products, encourage physical

exercise and diets, rejecting the use of anxiolytics, with the goal of stimulating,
exercising and strengthening the human body, as well as arguing for the need
of the patient to actively contribute to his own recovery (Federspiel and Herbst
2001). As Federspiel and Herbst state, “conventional medicine and alternative
therapies have the same purpose: the search for the cure, experiments the
that reveal the true therapeutical potential of certain methods and the ambition
to decipher the enigma of health and disease” (Federspiel and Herbst 2001,
p. 18).

Amongst different alternative medicines, that which probably is mostly

spread around the world is Traditional Chinese Medicine, a denomination
commonly used to the set of traditional medicine practices in use in China,
which were developed across its thousand-year history. It being one of the
oldest forms of oriental medicine, Traditional Chinese Medicine is based on a
systematic and embracing theoretical structure of a philosophical nature (Abe
2006). Its principles include the studying of the ying/yang relationship, the
theory of the five elements (water, earth, fire, wood and metal) and of the
2

circulation of energy through the human body meridians. It seeks to apply the
understanding of both the treatment of diseases and the maintenance of
health through several methods.

The several methods of Chinese medicine (especially acupuncture,

Chi Kung exercises and plant-based medication) are some of the most used.
These therapies are more and more respected, not only by patients who have
achieved their benefits, but also by part of the western medical community,
which was initially very sceptical (Williams 1996).

Acupuncture and be defined as a therapeutical technique that has the

insertion of needles in the periphery of the human body as its predominant
method. It has as its main goal the improvement of health through the
modulation of the internal systems that are responsible for the homeostasis of
the human organism, i. e. the balancing of the energy and the betterment of
the physical well-being (Quaresma 2010). In physiological terms, acupuncture
can also be defined as a stimulation technique for the sensitive peripheral and
autonomic nerves, which stimulates several self-regulatory mechanisms of
our body through the nervous, endocrine and imune systems through the
insertion of needles (Quaresma 2010). The thin needles are inserted in the
energy system of the patient in a series of properly selected vortexes, or
acupuncture points. The effect of these will be to provoke changes in the
patient’s energy system pattern, which result in beneficial physical changes
(Quaresma 2010).

According to the Traditional Chinese Medicine creed, the ying and

young opposing forces must be balanced in the human body in order for the
chi (vital energy) to conveniently flow across the meridians. The disturbances
in the chi movement across the meridians would actually be the cause of
health problems. It is believed that it ceases to be congested with the insertion
of needles in certain points. That way, vital energy is back flowing across the
meridians. The harmonious interaction of the organs is re-established and the
symptoms disappear (Federspiel and Herbst 2001).

 Western and modern medicine, however, suggests that the method
stimulates the release of chemical substances that alter the nervous system
and can affect the rest of the body, thus promoting a balanced organism (Abe
2006). Krist Federspiel and Vera Herbst present several theories that explain
the effects of acupuncture:

- The acupuncture points are located in certain insertion spots of the

nervous, vascular and muscular terminations. These can be recognised by
touch, by pressing the fingers on the skin. The stimulus executed by the
needles in those same places cancels pain in the cerebral torso, in a way
that the pain impulses don’t arrive at their destination.

- The insertion of needles in the acupuncture points brings about the

release of a higher number of endorphins in the brain, which attenuates
pain.

- It is proven that acupuncture may lead to a considerable relaxation of

certain muscles or groups of muscles and to a rise in blood circulation. Its
effect in the autonomous nervous system can be that of a tranquiliser
(Federspiel and Herbst 2001).

Muscle-skeletal pathologies reveal a particular interest in our days,

since they are caused by overly-repetitious activities, repetitive movements,
sedentarism and muscular hipertonia related to stress in the work or personal
contexts, something that is very common amongst musicians. When it comes
to those pathologies, the association of natural therapeutical means with them
shows to be the most beneficial in arriving at a solution, given the speed of
the results that can be obtained (Williams 1996). Acupuncture should be
integrated in the context of body repair, i. e. it should it seen as an interactive
bioenergetic and repairing technique (Quaresma 2010).

According to Tom Williams, “the muscle-skeletal pathology and

acupuncture have a long way to walk together, with the therapist having in his
hands an excellent therapeutical weapon for the correction of a great number
of pain causing pathologies, as well as often incapacitating. Tiredness,

incorrect food habits, injuries and sexual excesses can be the cause of
diseases (Rothfeld and Le Vert 1997). Generally, one considers that a
disease is more than the consequence of the disturbances that occur in the
normal flow of vital energy (Chi), by blocks and a sense of excessive or lack
of something in the organism (Federspiel and Herbst 2001).

As with everything, there are risks to which the patients may be

subjected to: badly sterilised needles can provoke infectious diseases. If they
are used incorrectly, acupuncture needles can break, having to be removed,
in some cases, through surgery. The inappropriate use of this technique can
bring about hemorrhages and organ, nervous and tissue lesions (Federspiel
and Herbst 2001).

What brings me to discussing this matter (besides the problematics of

muscle-skeletal pathologies in musicians) is the growing number of these
professionals with anxiety problems and the contribution of this type of
medicine as an alternative way of treating, since it does envolve the nervous
system of the patient. Anxiety appears from a combination of factors (eg: our
temperament, the rise of the cognitive capacity, the type of family and inter-
person experiences, our growing perception and interpretation of the world
around us, technical ability and mastership and specific performance
experiences that can have positive or negative results (Dews and Williams
1989). As Margaret Osborne and Dianna Kenny state, anxiety while
performing is generally seen as a group of three self-influencing factors, such
as cognition, autonumus excitation and evident behavioural responses
(Osborne and Kenny 2005).

Musical performance requires a high level of ability in several

parameters, such as motor coordination, attention, memory and repetitive
movements, which turns it into an activity particularly susceptible to muscle-
skeletal pathologies and anxiety (Kenny and Osborne 2006). It is precisely in
that space that acupuncture is introduced.

 By believing in the real value of this therapy as a science and an
efficient therapeutical technique, I intend to find out if it is truly beneficial to
musicians. It is my intention to know if one can reduce, controlo and/or
prevent muscle-skeletal pathologies and thus diminish the state of anxiety
which surrounds us before and during a performance.

Material and Research Methods

This study is based on questionnaires, tests and surveys conducted

before and after a group of 28 musicians – aged between 19 and 47 years of
age – completed four sessions of acupuncture. The questionnaire
administered was Spielberger’s State Trait Anxiety Inventory. This test is
divided in two parts, measuring State Anxiety (STAIY 1), and Trait Anxiety
(STAIY 2) respectively, in which State Anxiety is the level of anxiety reported
when completing the questionnaire and Trait Anxiety is the level of anxiety
that the individual feels on a day-to-day basis. The test employed was the
Toulouse-Pierón, relating to attention, which measures Resistance to Fatigue
and Concentrated Attention (capacity to concentrate). The application of these
tools aimed to verify the level of anxiety and the degree of attention which
existed before and after each musician underwent acupuncture treatment.
The conducting of surveys, in which the musicians indicated the areas
of their bodies which presented the greatest incidence of pain, was designed
to measure the degree of intensity of these muscular pains before the first
session, and after the last session of acupuncture.
Before beginning the acupuncture sessions, it was necessary to
effectuate a diagnosis, by collecting data from each musician, such as their
instrument, age, sex, body mass index, but also their complaints in relation to
muscular pains, the muscular areas in which each musician felt pain, and the
ways in which this pain would intensify or ease. The diagnosis also collected
data such as temperature, blood pressure, spinal problems and the possibility
of ocular diseases, as these are factors which could influence the state of
6

anxiety of the individuals. For those who have problems with myopia and
astigmatism, the state of anxiety can aggravate this condition, it overloads the
nervous system, sending wrong information to the brain, which may result in
blurred vision (Grohol 2014).

The acupuncture sessions were held over the course of a month,

with one session per week, resulting in four sessions which were administered
by Professor António Silvério Cabrita, of the University of Coimbra’s School of
Medicine.

The State-Trait Anxiety Inventory is a psychological inventory based on

a four level scale, comprised of forty questions, with two scales of twenty,
completed from a self-reporting perspective. Hence, this questionnaire is an
instrument of self-reporting which considers the normal state of anxiety of an
individual as central to cognitive assessment and the importance of the
concepts of the State Anxiety and Trait Anxiety as psychological concepts
(Gonçalves 2003).

Attention was measured using the Toulouse-Pierón Test, which aims to

evaluate attention according to Resistance to Fatigue (the capacity to work)
and Concentrated Attention (capacity to concentrate) axes. The relation
between them demonstrates the individual’s attitude compared to their mental
effort, as the strength of external stimuli is practically nil, with attention
depending solely on internal factors. This test is presented on an A4 page
consisting of 40 lines, which each have forty figures (small squares), with
eight kinds of orientations (like compass markings) of a small line extending
from each square. Each musician had ten minutes to complete the test, which
consists of finding the figures identical to the figures highlighted on top, and
tracing a line to and from them. This requires speed and precision, tracing
each figure from left to right and from top to bottom, making sure not to leave
any behind. After ten minutes, the test is terminated.

The inventory and the tests were analysed and evaluated by the
psychologist Sofia Pires.

 The survey relating to the musicians’ complaints of muscular pains
consisted of four drawings of the human body, from four perspectives: the
front, the back, the left profile and the right profile, whereby before the first
acupuncture session the participants indicated the zones in which they had
complaints, and using a scale of 0 – 10, described the intensity of the pain. In
order to determine whether the acupuncture improved the problems, after
each session, the musicians used the same scale to indicate the intensity of
pain they were feeling.

Results

Of the 28 musicians that participated in this study and the acupuncture

sessions, only 17 results were considered valid according to the analysis of
the Toulouse-Pierón test and the Spielberger questionnaire, as the other
responses were not complete. Of the 28 surveys relating to muscular pains,
all were considered valid.

For the Toulouse-Pierón test, with regard to Resistance to Fatigue

measurements, in order to demonstrate improvements, the result obtained in
the first test must be inferior to the value obtained in the repetition of the same
test, completed after the sessions, as these values measure the level of the
individual’s fatigue. As can be observed in table 1, the results show that all of
the musicians that constitute the test group (17), did in fact improve following
the acupuncture sessions, namely in terms of their levels of Resistance to
Fatigue, presenting a greater attention capacity before beginning the
acupuncture sessions (the average measurement showed an almost two-fold
increase, from 111.12 to 214.53). In relation to gender, it was proven that on
average, the men displayed slightly higher levels than the women (M: 112.73;
W: 108.17). However, following therapy, the average value of the female
group increased by higher values than the male group (M: 209.36; W:
224.00), demonstrating, in some cases, a substantial improvement in levels of

Resistance to Fatigue. This is the case of two female individuals (Female 3
and Female 4) who, before the acupuncture sessions, presented negative
values, and after treatment, had the most notable increases in the entire
group (table 1). This data shows that the therapy significantly improved levels
of Resistance to Fatigue.

Table I

Fig. 1 – Table showing the attencion precision teste Toulouse-

Pierón results.

With regard to Concentrated Attention, the lowest marks achieved on

the repetition of the test correspond to the greatest precision, i.e. an
improvement in the capacity for concentration. As we can see in Table II, only
one participant (Female 5) had a higher mark following therapy. Two

participants (Male 2 and Male 9) did not show any significant alterations, but
all the others showed improvements. With regard to gender, as with the
previous test, the female group demonstrated a more accentuated evolution,
in this case corresponding to a greater decline in values between the initial
and final test. Before the therapy, the female group had an average of 49.95,
which afterwards descended significantly to 17.03. In the case of the male
group, apart from always maintaining higher levels of Concentrated Attention,
their evolution was not so marked. The test conducted before the acupuncture
sessions presented an average value of 39.85 (10.10 lower, or better, than
the female group), with the repetition showing an average of 16.56 (just 0.47
less than the females). These results show that, in relation to Concentrated
Attention levels, the therapy also had a significantly positive effect and these
musicians were able to greatly improve their levels of concentration.

Table II

Fig. 2 - Table showing the resistence fatigue teste Toulouse-Pierón results.

10

 In relation to the Spielberger questionnaires, the results obtained
before the application of acupuncture show that the values presented by the
participating musicians are, in the case of the STAIY 1 questionnaire, very
close to the Portuguese National Average, although in the case of the STAIY
2 questionnaire, these values were slightly higher than this average. In other
words, a slight tendency towards a permanent state of anxiety was detected,
which was marginally more elevated in men than in women.

As we can see in Table III, for the STAIY 1 questionnaire, State of

Anxiety, the Portuguese National Average for female individuals with higher
education is 39.2, and the national average for male individuals, also with
higher education, is 37.8. These national results demonstrate that women
tend to be more anxious than men. However, the values - which are part of a
group, in which the mean value is subtracted and the standard deviation is
added, according to gender and academic level, which in the case of women
is 10.21 and men is 8.93 - are considered normal. The female group’s results
of this survey, which range from 23 to 50, indicate an average of 39.25. The
male group’s results, which range from 15 to 51, indicate an average of 37.3.
These results show, as already mentioned, that the participants’ values are, in
both cases, close to the national average.

Regarding STAIY 2, Trait Anxiety, the Portuguese National average for

females is 40.1 and 38.3 for males, as displayed in Table III. The
questionnaire results of the female group range from 23 to 50, indicating an
average of 42.13, which means that the participating female musicians are
above the Portuguese national average, with a difference which is not
negligible. The male group’s results, which range from 21 to 49, show an
average of 40.7, thus the male musicians present a greater deviation from the
national average than the female group.

For a more detailed analysis, the values that lie between the national
average and the lowest value, on applying the standard deviation, was called
lower average and the values that fall between the national average and the
highest value, equally applying standard deviation, was called upper average,

11

as these values are considered normal. Therefore, we can more accurately
understand the anxiety levels of this sample in comparison to the values
considered normal in Portugal, as shown in Table III.

As can be verified by the STAIY1 survey results conducted before the

acupuncture sessions, there is only one case of a female musician who
presented a value below the values considered normal. Two female
musicians present values that fall within the lower average and three in the
upper average. Two situations are above values considered normal, which
means that the level of anxiety of these individuals is quite high. In the case of
the male sample there is only one case in this situation, and there are also
two cases that are below the normal average, where one presented values
within the upper average and the remaining seven within the lower average.
As previously stated, despite the cases that are outside the normal range, in
the questionnaires conducted before the therapy, the participants’ overall
average is very close to the national average.

On the other hand, the repetition of the STAIY 1 questionnaire, after

four sessions of acupuncture, showed a clear improvement in the values
relating to State Anxiety – the level of anxiety recorded whilst completing the
questionnaire. The female group’s average reduced to 34.88 and the male
group’s to 33.5, a notable decrease of 4.37 in women and of 3.8 in men. In
relation to STAIY 2, according to the questionnaire completed before the
acupuncture sessions, as previously stated, the values of both groups were
above the national average. In the case of the female group, we can verify
that two cases were above the normal values, meaning a substantially higher
level of Trait Anxiety, the level of anxiety felt on a day-to-day basis, and only
one case presented values below those considered normal. Two female
musicians presented values that are situated in the upper average range, and
three in the lower average range. In the case of the male group, two
musicians presented values which are above normal, but conversely, three
musicians had below average values. The remaining six were equally divided
between lower and upper average values.

12

 In the questionnaire completed after the therapy, the results show a
significant improvement in the levels of anxiety presented by the participating
musicians. As previously verified by the results of the repetition of the STAIY
1 questionnaire, the effect of acupuncture on the musicians is also obvious in
this case. Both the male and female groups demonstrated an average which,
after therapy, fell below the national average. The female group showed
values of 37.38, and the male group 36.7, which is a significant decrease of
4.75 and 4.0 respectively.

Table III

Fig. 3 – Descriptive table showing the questionnaire

STAY 1 e 2 results by gender.

13

 In relation to the pathologies presented by the musicians, as shown in
Table IV, we can verify that the majority (15) of the musicians (from a group of
28), experienced shoulder pains, 4 felt lower back pain, 2 reported thoracic
spine pain, in addition to shoulder and neck pain, 1 felt pain along the spine, 1
complained of shoulder, hand and leg pains, 1 felt shoulder and lower back
pain, 1 had elbow pains and 1 had wrist and arm pain. In relation to
aggravating or easing the pain, 22 confirmed that the pain was aggravated by
movement and 6 confirmed that the pain was aggravated by rest. For the
majority (22/28) rest brought improvements, and for 6 participants, the pain
improved with movement. Blood pressure levels were considered normal for
25 participants, but considered high for 3 participants. With regard to vision,
14 participants had no complaints, 5 had myopia, 1 had astigmatism, and 4
presented with myopia and astigmatism. In this case, as this majority of the
participants presented normally, we cannot consider that their existing vision
problems had an impact that should be taken into account in diagnosing each
musician.

In relation to the degree of pain experienced before each session of

acupuncture, 3 musicians reported their pain as level 8. After the four
sessions of acupuncture, these musicians, 2 with shoulder pain and one with
shoulder and arm pain, affirmed that their degree of pain had decreased to
levels 3 and 0 respectively. Another two musicians presented level 7 pains,
one with lower back pain, and one in with shoulder pain. After the sessions,
these levels decreased to level 2 and level 0 respectively. With complaints of
level 6 pain, 4 musicians – two with shoulder pains, one with shoulder and
lower back pain and another with shoulder and neck pain, verified that their
pain levels had decreased to levels 0 and 2 respectively. A further four
musicians identified a level 5 pain level, one with lower back pain, one with
pains along the spine, and two with shoulder pain. These pain levels
decreased to level 2 for lower back pain, level 1 for pain along the spine and
shoulder pain, and level 0 for shoulder pain. Three musicians indicated a pain
level of 4, in the lower back, another with shoulder and neck pain, and one
with thoracic spine pain. After the acupuncture session, the levels of pain

14

reduced to 1 in the lower back, shoulders and neck and 0 in the thoracic
spine. Seven musicians identified level 3 pains – three with shoulder pain, one
with lower back pain, one with elbow pain, one with thoracic spine pain, and
one with shoulder, hand and leg pain. After the acupuncture treatment, these
pain levels reduced to level 2 in the lower back and shoulders, 1 for shoulder
hand and leg pain, and 0 for elbow/thoracic spine pain. Three musicians
considered their pains as level 2. Two had shoulder pain, and one had wrist
and arm pain. This pain level reduced to 0. Only one musician selected level
1, with shoulder pain, but this diminished to level 0 after the acupuncture
sessions. One musician did not respond.

Table IV

Fig. 4 – Descriptive table data by instrument.

15

Discussion

The aim of this study was to investigate the effect which acupuncture
could have on musicians with skeletal muscular pathologies and anxiety
problems.

When anxiety affects an individual, it can cause a range of problems,

influencing both physical and cognitive aspects, such as attention (Grohol
2014).

With regard to Resistance to Fatigue, it can be stated that all the

participating musicians showed improvements after the acupuncture sessions.
This proves that the sessions were beneficial in this case. Therefore, following
therapy, the musicians have a greater capacity for attention. We can also
verify that all the musicians improved their capacity for concentration after the
sessions. All participants scored lower values on the repetition of the test,
meaning that the participating musicians are now more resistant, and can
better control their tiredness. In relation to gender, before the acupuncture
sessions, the men showed a greater capacity for attention. After the sessions,
the situation was inverted, as the women showed a more accentuated
evolution in their levels of Resistance to Fatigue.

In the area of Concentrated Attention, these musicians were able to

improve their capacity for attention due to the acupuncture sessions. Thus,
these musicians now have greater discipline in relation to attention, as the
applied therapy can activate sensitive nerves. This can help combat fatigue in
rehearsals, for example. With regard to gender, as in the previous test, it was
again the women who achieved a more accentuated evolution in the levels of
Concentrated Attention, although, in this case, they maintained levels which
were inferior to those of the men.

These results demonstrate that acupuncture had a positive effect on

the reduction of the State Anxiety of these musicians. Through the application
of Spielberger’s STAIY 1 questionnaire, it was verified that in the case of the
16

participating women, the two individuals that presented above normal values
before the therapy now present values within the lower average range, and in
general, more participants now fall into this range than before the therapy. On
the other hand, another female individual, who had been in the upper average
range, now has above average values. In the case of the men, not one
individual now presents values which are higher than considered normal, and
four diminished their values to below the national average, which means that
they have significantly decreased their levels of anxiety.

Again, these results demonstrate that acupuncture had a positive effect

on the reduction of Trait Anxiety (STAIY 2) amongst the participants.

In the case of the female group, it was proven that of the two
individuals who presented above average values, only one maintained these
levels after the acupuncture sessions, and now there are more individuals
with values below those considered normal, whereas beforehand only one
presented these values, and now three fall into this category. Again, in the
male group, none of the participants now present values which are above
normal, and one presents values below the national average, therefore as
three were in this category before the therapy, now four are below the national
average, which shows that the therapy diminished their anxiety levels.

In relation to skeletal-muscular pathologies, again, the acupuncture

sessions were beneficial in the eradication, or at least reduction and control of
these pathologies. Data relating to the aggravation and improvement of pain,
movement or rest, indicates that the majority of the musicians try to alleviate
their symptoms with rest, and that movement aggravates the pain. This
situation shows that acupuncture can, in fact, be beneficial, as the treatment
is administered in a relaxed and calm manner, promoting a restful
environment, which is necessary for these musicians. All the participating
musicians reduced the degree of intensity of the pain that they felt before the
sessions. Of all the muscular areas mentioned, the shoulders were the area
with the highest incidence of pain. The majority of the musicians that suffered
shoulder pain, and all those who felt pain in other areas, had a much lesser

17

level of pain after the treatment, as in many cases, the treatment was the
solution of eliminating these pathologies. The most important cases are those
in which the pain levels indicated by the musicians were levels 7 and 8,
considered the most severe. Following the acupuncture sessions, it can be
stated that acupuncture was beneficial, reducing the pain levels to 3, 2 and 0,
which are considered mild.

Conclusion

The effect which acupuncture had on the participating musicians

proves that this therapy is wholly beneficial in the prevention or control of
physical and emotional pathologies and promotes physical and emotional
balance. As acupuncture does not merely treat physical ailments, but also
affects the nervous system, it can be a very successful, therapeutic treatment.
Acupuncture stimulates the nervous system, so that muscles, ligaments and
tendons work in tandem. This therapy is a natural means of preventing
injuries, as Traditional Chinese Medicine treats the imbalances present in the
body, promoting holistic health (Barrios 2009). Acupuncture relieves pain,
reduces inflammation and increases movement. The only treatment the
musicians received was acupuncture, and they quickly achieved positive
results.

The Toulouse-Pierón and Spielberger tests proved to be useful tools

for a correct diagnosis of each musician, before and after the acupuncture
sessions, also aiding to demonstrate the benefits which this treatment had on
the participants. The results were extremely positive and show us that this
therapy significantly improved levels of fatigue, lack of attention and the
anxiety which the musicians presented before having therapy, which also
contributed considerably to the resolution of problems related to skeletal-
muscular pathologies identified by the participants. Acupuncture calmed the
musicians, so that, following the treatment, they may be better able to engage

18

in, and enjoy, their musical performance. These musicians now suffer
substantially less muscular pain, and are thus more concentrated, calmer, and
more relaxed.

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