In view of the enormous individuality of the human hand, with differences of over 9 cm in span widths 2-5 (between the index finger and little finger) and up to 7 cm in span widths 3-4 (between the middle finger and ring finger), an initial impression of the range and limits of a musician's hand can hardly be gained from a measurement accurate to the millimetre. Even the Pragmatic Hand Evaluation (PHE) by music physiology pioneer Christoph Wagner can help to track down the causes of excessive fatigue and overuse syndromes. The PHE, the "little sister" of the Biomechanical Hand Measurement (BHM) developed by Wagner and based at the Zurich Musician's Hand Center at the ZHdK since 2009, records hand size, all thumb and instep widths and ten other hand characteristics. Using the measurement sheets from Wagner's book Hand und Instrument, individual values are compared with those of professional musicians.

The individuality of the hand is contrasted with the standardized keyboard - and the dream of many pianists to also tap into those gems of piano literature whose technical requirements may exceed their own limits. For a 53-year-old piano teacher, playing on the modern grand piano was "always associated with cramp. What I always found difficult was playing chords." Her playing experience was completely different when she played the fortepiano for the first time at the age of 47: "I had the feeling that this was my instrument. I could play more fluently."

The hand profile of the technically accomplished pianist shows rather small thumb and inner spans despite rather large hands. The span 2-4 was clearly limited and she could only spread her right thumb to a maximum of 65 degrees. After the PHE, when the piano teacher once again traced difficult passages on the modern grand piano, she was amazed to discover: "There are actually all passages that require internal tension, which have always meant extra effort." An Allegro assai passage from Mendelssohn's Trio op. 49. "I've never really mastered it." - Presumably because of the almost simultaneously required fifth with index and ring fingers and seventh with index and little finger.

Looking back on her time as a student, the piano teacher sums up: "I was told that I had a big hand and fast fingers. If I had known that I had these ranges, I would have played completely different pieces, for example. I always thought I had to try harder. My teacher said to me: 'You just have to want to'." And she continues: "If I had realized this earlier, my approach to myself and my practice methods would have changed. As far as the pieces were concerned, I did orientate myself towards small-scale literature relatively soon after my studies, but always with a slight resentment towards myself for not having the 'right' technique to be able to play Chopin ballads or Brahms."

Several things become clear in these statements: the quite sensitive perception of one's own biomechanical limits already during one's studies, the trust in one's own perception that had been lost in the meantime, the teacher's lack of empathy, the orientation towards a repertoire standard and effort ..., the regained perception, already through the changed playing feeling on the fortepiano and further through the objective comparison - and the mental relief through the knowledge of the individual biomechanical conditions.

For those who are new or returning to music at an advanced age, the aim is to (re)discover music for themselves, sing, play or learn an instrument. They have the opportunity to join instrumental ensembles or a choir and deepen their knowledge of music theory or music history.

However, old age often no longer knows music because conditions change and make it more difficult to make music. However, making music should be possible at every stage of life in old age. This applies to mobile older people who can still easily attend music school or join a choir or ensemble. But it also applies to people with impaired health and possibly dementia, to whom music schools or freelance music teachers offer their services and also enter into cooperation with institutions for the elderly. Intergenerational musical activities are also often considered to be particularly successful, especially popular between grandchildren and grandparents.

Music schools should therefore give even more thought to how singing, making music and learning music can be successful in old age. The goal: a comprehensive and barrier-free offer in easily accessible and well-designed rooms for older people in a wide variety of life situations. It must be geared towards individual needs and possibilities - also financially and in terms of time - and create high-quality music.

Making music in old age can then mean filling free time in a meaningful way, experiencing self-efficacy, (continuing to) participate in public cultural life, maintaining social contacts and experiencing sociability. This also helps to prevent health problems and prepares people for everyday life in old age on various levels - cognitive, motor, emotional and social. Music in old age can also develop spiritual dimensions. Even in such a delicate area as end-of-life care, music can gently reach in and offer a protective cloak (pallium).

Music can also support caregiving. Many things are easier to handle when people sing or hum, simply mention songs and pieces of music or talk about music or past experiences in which music played a role.

Time and again, it has been observed that music has a calming effect on restlessness or challenging behavior. It is also extremely pleasant for the carers and the care institutions when the atmosphere within the care situation is significantly improved by the involvement of music. In this context, appropriate music can mean affection or, in the case of dementia, also have an identity-enhancing effect.

Music programs for older people should by no means be seen as an imposition of later musical education, but solely as an enabling didactic approach. It is about initiating aesthetic fields of experience in which older people can engage in self-determined musical activities, but also learn and educate themselves. Music education understood in this way will have to be oriented towards the needs, life stories and lifeworlds of those involved in dialogical processes and appreciative communication - including validation, for example in the case of dementia. The biographical dimension in particular plays a special role for older people due to their long life experience.

Music geragogy should not be confused with music therapy: There are certainly overlaps between the two, for example in terms of target groups, instruments and methods. But the objective is clearly different: Music education creates the conditions for musical learning, education and practice. But music education does not aim to provide therapy, which requires targeted anamnesis, diagnoses and standardized procedures. Of course, this does not exclude the possibility that many extra-musical and health-promoting transfers arise through musical activity and experience. In fact, such transfers are very welcome.

Further materials:

The cardiovascular system shows typical reactions when playing a wind instrument: Tone production and blowing pressure cause short-term physiological fluctuations in blood pressure, heart rate and heart rhythm. They vary depending on the instrument, pitch, dynamics, blowing technique and constitution. During performances, stress hormones can also lead to an increase in blood pressure and heart rate. Nevertheless, these are generally physiological reactions that are harmless in healthy people. In order to assess the stress and resilience during playing, the cardiological guidelines are followed. In addition, the individual reactions during music-making must be recorded. This is done by means of long-term measurement of ECG and blood pressure under practice, rehearsal and possibly performance conditions, sometimes also by means of ultrasound of the heart during playing. After cardiovascular diseases, reintegration with a gradual increase in the music-making load may be necessary.

Beta-receptor blockers can be used to reduce the vegetative symptoms that can be caused by the fear of performing. Musicians often resort to self-medication, even though these are prescription drugs that affect the cardiovascular system. They should be strongly advised to take beta-blockers only after consulting a doctor, especially if cardiovascular problems are involved. This ensures a sensibly coordinated therapy, and the numerous non-drug strategies for dealing with performance anxiety can also be worked out together.

According to current knowledge, respiratory diseases do not occur more frequently in wind players. The often postulated connection between the development of emphysema and oboe playing has also not been confirmed. However, the constellation of several risk factors (such as smoking and environmental influences) can lead to playing-related illnesses. In the case of childhood asthma, playing wind instruments often has a positive effect on lung function and the management of the disease. Today, it is therefore often seen as a valuable component in asthma therapy.

Hormonal and metabolic disorders are sometimes accompanied by functional impairments during music-making. Due to the extraordinary sensorimotor demands, musicians become aware of these disorders at an early stage. Thyroid dysfunctions in particular lead to complaints that are relevant to musicians' medicine, but are usually easy to treat. They can manifest themselves in a variety of symptoms, including in the area of the arms and hands or the singing voice. In principle, the treatment of musicians does not differ from that of other patients, but additional therapeutic measures such as physiotherapy or speech therapy may be necessary.

In wind players and singers, reflux with reflux of gastric juice into the oesophagus seems to occur more frequently. The mechanisms behind this are complex and have so far only been partially understood. It is known from sport that physical "endurance work" - which singers and wind instrument players also perform - plays a role in reflux. The symptoms are often exacerbated by increased breathing with deep inhalation and an abrupt or prolonged increase in pressure in the chest and abdomen. This kind of breathing effort is constantly required when singing and playing wind instruments. Reflux complaints require a differentiated musician-specific anamnesis and diagnosis. In the case of singers, this is carried out on an interdisciplinary basis by a gastrointestinal specialist and phoniatrist. They can prescribe medication to inhibit the release of stomach acid and recommend diets and behavioral measures.

We have been running half-day workshops on "Posture and movement on the instrument" for teachers at music schools for over a year now. They are divided into two thematic blocks: "Back and neck" and, building on this, "Shoulder girdle, arm and hand".

The workshops are geared towards the teachers' own well-being when making music and their teaching activities with pupils. The aim is to impart basic knowledge of anatomy and physiology as well as instrument-specific complaints. We also teach exercises for perception, strengthening and promoting coordination.

The theoretical principles of anatomy are best experienced when the respective body parts are felt and moved. A key experience for many is when they feel each other's shoulder blade movements, parts of the body that are often terra incognita in our perception. The in-depth study of the physiology of muscle function makes it clear how a muscle works, what fatigue means and why exercise breaks are worthwhile. Controversial questions are also discussed: Does good posture and movement replace muscle training? Should strength training be used to build up reserves in order to meet the challenges of making music?

The joint analysis of problems using video examples makes it clear that posture and movement are personal and deserve individual consideration. Despite all individuality, however, the teacher - apart from their musical abilities - always has a role model function in terms of posture and how they deal with their own body. As one music school director says: "You can recognize the teacher by the way the pupils play music".

The group work is consistently popular: teachers with similar instruments discuss pupils' posture problems and exchange information on possible assistance and tried-and-tested exercises.

The practical exercises for the different parts of the body literally loosen up the program. For example, the course shows the effects of a lack of tension in the erection of the back on the motor skills of the arms and hands. Various movements are used to show how the dynamic stability of the torso can be improved and how playing music can be made easier.

Ultimately, however, there is still the question of when a problem can no longer be tackled in the classroom alone. The authors encourage a dialog with the parents of those affected and with instrument making experts. However, persistent problems should definitely be assessed by specialists. They are no fun for children or professional musicians, nor do they enable them to reach musical heights. Making music with complaints is unnecessary!

The question of whether good posture and good movement are the basis for making music is the subject of lively discussion in every workshop until the coffee break. Is it important to straighten a child's overly flexible back on the cello chair? To what extent should making music simply be fun and at what age does a more serious professional career begin? Experts exchange views on these and other questions with professionals "at eye level" - provided they have straightened up correctly beforehand!

The hall at Bern University of the Arts on Papiermühlestrasse seems to be bursting at the seams. The topic is moving in many ways: making music in old age can be an opportunity for people to fill their twilight years (or even their late afternoons) with emotions and good experiences. However, for those who have made music all their lives and earned a living from it, it can also mean a painful process of letting go and winding down. The annual symposium of the Swiss Society for Music Medicine, which focuses on these aspects of the sonorous art, can report record attendance.

The Trio Poetico, three woodwind players who used to sit in the spotlight of the Tonhalle Orchestra, among others, set a confident sign in this respect right at the beginning, continuing to develop artistically at an excellent level after their retirement and discovering new repertoire, such as the fascinating music of the Brazilian "Messiaen" Heitor Villa-Lobos.

In their presentations, medical expert Maria Schuppert from the Center for Musicians' Health at the Detmold University of Music and Zurich neuropsychologist Lutz Jäncke confirmed that a lot has changed with regard to music-making in old age. Until not so long ago, the human ability to acquire new skills was underestimated until old age. However, not least the work of Jäncke and his colleagues on brain plasticity shows that even with white hair and average health, far more resources can be called up than was believed not so long ago. Even high-class expressive possibilities do not have to be sacrificed if one does not pay homage to an ideal of youthfulness, but rather understands the characteristics of one's own age as original peculiarities.

Of course, the senses deteriorate with age, the hearing, the eyes; the voice also changes. The male voice, for example, becomes higher, but loses volume due to physiological degradation processes, as Eberhard Seifert, Head of Phoniatrics at the University ENT Clinic of the Inselspital in Bern, points out. And while it used to be unthinkable to take part in an ensemble with a hearing aid, modern technology has made so much progress that it is still possible to sing in a choir or play in an orchestra even with the corresponding impairments, as master hearing acoustician Michael Stückelberger explains.

The increased confidence is also being felt by music schools, which are able to adapt to more and more music students in the third stage of life. In a workshop, musician and journalist Corinne Holtz, who also heads the CAS "Musical Learning in Old Age" at the Bern University of the Arts (HKB) and the Institute of Ageing at the Bern University of Applied Sciences, reports on a research project entitled "Mach dich schlau - Lern- und Lehrstrategien im Instrumentalunterricht 50plus". And choirmaster Karl Scheuber, who is getting on in years himself, will show how age-appropriate singing exercises and clever repertoire management can contribute to quality of life even in old age.

As Hans Hermann Wickel from the Department of Social Services at Münster University of Applied Sciences points out, there is now even a dedicated specialist field on the subject, music geragogy. Its aim is to optimize music offerings for the very elderly, people who may suffer from multi-morbidity or dementia, and to explore the possibilities in palliative care.

Conversations at the symposium's concluding aperitif showed that, in addition to experts, interested outsiders who were looking for opportunities for musical activity at an advanced stage of life also attended the event - an indication that a special contact point could meet a need.

Guttural singing is throat singing, which is formed with the pocket folds ("false vocal folds"). The pouch folds are two pairs of folds lying horizontally on top of each other in the larynx, directly above the actual vocal cords. They are normally used to hold your breath or clear your throat.

Throat singing is used in many cultures to extend the normal vocal range up or down an octave. The voice becomes rough and somewhat distorted due to the vibrations of the pocket folds and is reminiscent of the sound of a didgeridoo. A similar effect can be achieved by using the so-called straw bass register (also known as the pulse or snoring register), the lowest vocal register in which the vocal cords are so loose that the individual vibrations are perceived as a kind of rattling or individual pulses.

Guttural singing is also used in modern music, mainly in extreme metal. The vocal techniques are mainly referred to as "growling", "screaming" or "shouting", depending on the pitch and proportion of "voice", the ratio of vocal cords to vocal folds. In other words, pocket folds as well as vocal cords are usually used. Depending on whether the sound is produced during inhalation or exhalation, the term "inhale" or "exhale" screams are used. There are numerous other names and variants of guttural singing in metal.

Growling is reminiscent of the growling of an animal and is mainly used in death metal and grindcore. The proportion of vocal chords varies greatly, especially in grunting, the lowest variant, they are hardly ever used. Screaming is usually high-pitched, uses almost exclusively the folds of the throat and is mainly used in black metal. Shouting is preferred in thrash metal and hardcore and is characterized by a high proportion of vocal chords. With this form of guttural singing, the risk of damaging the voice is highest, as the vocal cords are heavily strained.

The high intensity and volume and the extreme pitches in this music genre can quickly lead to vocal overload, which can manifest itself in hoarseness - temporary or permanent -, a sore throat or, in the worst case, blood in the mouth. If this happens repeatedly, long-term damage to the vocal cords cannot be ruled out. It can lead to dysphonia or, in the worst case, even aphonia.

Metal singing is also susceptible to typical "singer's diseases". These include rhinitis (colds), pharyngitis (inflammation of the throat), laryngitis (inflammation of the larynx), tonsilitis (tonsillitis), tracheitis (inflammation of the windpipe), bronchitis, sinusitis (inflammation of the maxillary sinuses), nodules or oedema on the vocal cords and enlarged tonsils as a result of multiple tonsilitis. These conditions can affect the voice, even if they are not caused by incorrect use of the voice. It is therefore important to protect them until they are completely healed.

The big problem with the use of guttural singing techniques is that there is a lack of training and further education opportunities and a uniform theory, which is due to the fact that it is rarely used and is often not really recognized as an art form, but ridiculed as "noise". It is therefore advisable, even if you "only" want to growl or scream, to attend singing lessons to learn the basics of breathing and vocal technique. It is also advisable to follow the principles of vocal hygiene as a preventative measure, just as with classical singing or other professions that put a lot of strain on the voice. Even metal singers cannot do completely without vocal chords.

For a long time, it was believed that musical skills are rarely acquired and used to advantage in old age if they were not acquired in childhood or at least as a young adult. However, as the Zurich neuropsychologist Lutz Jäncke will show at the 12th Symposium of the Swiss Society for Music Medicine (SMM), work on the special expertise of professional musicians has led to the realization that the human brain is much more plastic than previously assumed, even into old age. According to Jäncke, the plasticity of the brain also means that the non-use of mental functions can lead to neuroanatomical and neurophysiological degradation. Against this background, a new and different picture of ageing is emerging, which is much more strongly influenced by self-initiated and self-controlled cognitive functions than previously assumed.

Music journalist Corinne Holtz, who heads the CAS "Musical Learning in Old Age" at Bern University of the Arts, will report that older people at music schools represent a growing target group with diverse potential. Singing in a choir is an obvious choice. Karl Scheuber, choirmaster and former head of the ZhdK study area, will also show how a colorful repertoire of songs, movements and sounds can be built up and expanded with conscious seriousness, mutual empathy, breathing techniques and the joy of the versatile treasure of our vocal memory, which is appropriate for old age. Even a significant loss of natural hearing ability need not be an obstacle. Zurich master acoustician Michael Stückelberger will explain how hearing aids can be adapted with the help of competent acousticians so that they are also suitable for the enjoyment of music and not just for speech comprehension.

Hans Hermann Wickel from the Department of Social Work at the German University of Applied Sciences in Münster will present music geragogy, the discipline of musical learning and musical education in old age. It aims to enable people of all ages to participate actively and receptively in music. The spectrum ranges from instrumental and vocal lessons to making music in choirs or senior ensembles, as well as participation in intergenerational groups and music programs for the very old, or even multimorbid and dementia patients.

Singing is also the focus of the presentation by Eberhard Seifert, Head of Phoniatrics at the University ENT Clinic of the Inselspital in Bern. He explains the physiological basis of sound production and how it changes over the course of a person's life and how this can be dealt with with regard to the ageing process.

Maria Schuppert, who works as a professor at the Center for Musicians' Health at the Detmold University of Music, explains that excellent musical performance on instruments can be maintained into old age, provided there are no limiting underlying illnesses, and Hans Martin Ulbrich, former oboist of the Tonhalle Orchestra Zurich, points out that former professional musicians need to be able to let go. This - and the former professional will not conceal this - can be difficult if, among other things, poverty prevails in old age and there is no money to live carefree, or if an illness forces you to give up your career prematurely.

I often advise patients who come to my practice to integrate music into their lives as a resource against exhaustion syndrome. The situation is different when musicians come to me complaining of exhaustion. In this case, it is the social and personal conditions surrounding music that give rise to burnout symptoms. Music then becomes a source of worry and stress and loses the positive meaning that may have led to this particular career choice.

But what actually is burnout? According to Matthias Burisch (Matthias Burisch: Das Burnout-Syndrom. Springer. 2005, 3rd edition), seven phases are decisive, with clinical and pathological relevance arising from the fourth phase onwards:

First phase of the first warning signs (you work overtime or at weekends to cope with the workload)

Second phase of reduced commitment (you become more silent, develop a negative attitude towards work)

Third phase of emotional reactions (feelings of inferiority and pessimism develop)

Fourth phase of decline in cognitive abilities (concentration/memory disorders, increase in errors and reduced motivation)

Fifth phase of flattening of emotional and social life (for example, loss of previously loved leisure activities)

Sixth phase of psychosomatic reactions (muscular tension, sleep disorders, increased alcohol consumption)

Seventh phase of depression and despair (feeling of futility and fear of the future)

It should be noted that chronic fatigue syndrome can always have a physical cause. On a psychological level, too, a distinction must be made, mainly from depression, but also from chronic fatigue syndrome, generalized anxiety disorder, eating disorder or substance abuse (alcohol or tranquillizers). We call this differential diagnosis.

If there are no findings here, work can begin on the musician's professional environment and personality: The specific nature of the professional environment can promote the problem of burnout. In the case of orchestral musicians, for example, this could be overly busy schedules and communication problems with superiors, while in the case of music teachers it could be the more difficult children and group lessons, to name just two things for the sake of brevity. In both groups, bullying between colleagues and between hierarchies plays a major role. Solutions in this area lie in the structure of the workplace and the colleagues, which must be looked at separately in each case.

But musicians can also work on themselves and learn various strategies to prevent burnout. Psychology distinguishes between different personality types. For example, it has been shown that "a strong identification with the practice of music in combination with great ambition and a lack of ability to distance oneself leads to risk pattern A in a third of music students, which is characterized by excessive stress and susceptibility to performance" (Claudia Spahn et al.: MusikerMedizin: Diagnostik, Therapie und Prävention von musikerspezifischen Erkrankungen. Schattauer, 2011).

This provides clues as to what the musician can improve: He must take the warning signs of the phases mentioned seriously and quickly find cognitive and emotional solutions. In addition to mental training, such as learning to keep your distance, various well-known relaxation techniques can help on an emotional level. I have had very good experience in my practice with the technique of self-hypnosis, in which relaxation also occurs, albeit as a positive by-product. Much more important are the therapeutic suggestions that become effective in this process and that can be adopted as a coping strategy in everyday life.

The scientifically based examination of the musician's hand helps to optimize the interface between hand and instrument. This can be important in the prevention of playing-related health complaints and in questions of performance optimization with regard to movement sequences on the instrument. To this end, Christoph Wagner developed a method for the systematic examination of the musician's hand at the Max Planck Institute for Occupational Physiology in 1964: the Biomechanical Hand Measurement (BHM). The BHM was then used in research and teaching at the Institute of Music Physiology at HMTM Hannover and was transferred to the Department of Music Physiology/Music and Preventive Medicine at ZHdK in 2009, together with all the equipment and databases. The newly founded ZZM is part of the ZHdK's research focus on musical interpretation.

The BHM comprises up to 100 instrument-specific hand characteristics. It records the musician's hand according to playing-relevant categories such as hand shape and size, active mobility, passive mobility and strength. Passive mobility as an indicator of the ease of playing movements can only be recorded in a differentiated manner using the laboratory's specialized measuring instruments. The digital evaluation of the measurements leads to their graphical representation, the hand profile. This shows the individual values of the hand in comparison to the data of professional musicians in the corresponding instrument group, i.e. the relative advantages or limitations of the individual hand. From this, practical consequences for practicing, training, playing technique and choice of literature, ergonomic solutions and so on can be derived. The unique instruments and the comparative possibilities with instrument-specific data from more than 50 years make the BHM a unique scientific procedure to this day.

... to the practice

The interdisciplinary musician's consultation hour, which is accessible at the music academies, records a particular accumulation of pain and tension in the area of the upper extremities during the several hundred consultation hours per year. In this initially laboratory-independent context, a form of examination derived from the BHM is also suitable for use in music education: The Pragmatic Hand Evaluation according to Christoph Wagner (PHE). This provides an overview of 25 individual hand characteristics. The hand laboratory can then be used for more detailed clarifications.

At the music academies in Zurich, Basel and Stuttgart as well as at the Vorarlberg State Conservatory, the objective assessment of hand characteristics is regularly referred to in seminars and further training courses in music education. The individual requirements of the upper extremities are also increasingly being taken into account in music medicine consultations. Ongoing basic research complements the activity profile of the ZZM. This also contributes to the training of musicians at all levels, as has long been a matter of course in sport in the context of performance diagnostics and prevention.

Professional singers often only seek help when concerts have to be canceled or recording dates postponed and the existential pressure increases. However, pressure further detunes the body instrument that most directly influences the sound of singers. Above all, the control circuit of breathing - posture - laryngeal suspension becomes confused, incorrect and compensatory tensions are the rule, which can lead to vicious circles.

The voice of 24-year-old B., a student at a jazz school, repeatedly breaks away uncontrollably in the upper range, and the pitch is associated with great effort. The specialist diagnosis: hyperfunctional dysphonia, incipient nodule formation. B. has a clear idea of sound, she wants to have a soulful, full chest voice even in the high register. She tries to achieve this by pulling up the chest register and provides too little support. First, a vocal relief program is put together so that the voice can vibrate freely with little pressure. Then we work "classically" on developing the head register sound and B. discovers that this can also be very full and direct, but with less pressure. Now it's all about mixing the different timbres in the high register, as well as improving the support technique, a singing program and vocal hygiene measures. In the second half of the therapy, the exchange with B.'s singing teacher is lively and fruitful.

In the case of 51-year-old freelance opera singer M., many factors come together: Back problems after an accident, pre-existing asthma, major weight loss in a short space of time and the onset of hormonal changes. The voice suddenly breaks completely or detonates in the middle and higher registers, the vibrato sounds flabby, sustained notes are not possible, nor is legato or piano singing. Is the voice part adequate? The speaking voice is hardly affected. Some engagements are unsatisfactory, the pressure is great. Specialist diagnosis: functional dyspho-nia/dysodia. The therapy is as varied as the causes in M.'s case. In addition to consistent fitness training to rebuild postural muscles and physical therapy work, M. works with a singing teacher and with me. Initially, the aim is to find out why her voice is breaking. In some cases, the support and voice position have to be significantly adapted to the new physical conditions.

Once the basics are working reasonably reliably again, the decision about the focus of each lesson lies more and more with M. Is it about pelvic floor involvement, edge shifting, vocal approach in the high register, vowel equalization, specific examples from the upcoming literature? We listen to tapes of engagements and exchange ideas with the vocal coach and the specialist. In the beginning we see each other frequently, but over time the intervals between the sessions become longer and are more like supervision sessions.

With professional singers - as with amateurs at a different level - it is always about the same basis: adjusting the instrument. This means the interaction of the state of tension and the cooperation of the transverse structures pelvic floor - diaphragm - vocal folds - base of tongue - soft palate, i.e. the erection and the "inner posture". In addition, there is work on the "outer posture", the torso and breathing muscles as well as the head posture, which determines the suspension of the larynx. In addition, economizing the pressure balance at the vocal cord level and optimizing the sound space (the "embouchure tube") and articulation. Strengthening self-awareness and (re)building confidence in one's own competence in dealing with the voice are central towards the end of the joint journey.

For years, the promotion of gifted and talented children, integration and inclusion have been part of the mission of music schools throughout Europe. In Germany, the projects "Jedem Kind ein Instrument" ("An instrument for every child") and "Klingende Kindertagesstätte" ("Musical day-care centers for children") marked the beginning of music-making for children of all ages and in large groups. In Switzerland, basic musical training, classroom music-making and projects with a wide variety of focuses have been expanded.

Publications and modules in training and further education have developed basic principles for structuring lessons that allow every child to experience and learn music. In order to create equal opportunities for all children in group music lessons, accompanying measures have been defined in addition to the actual music didactics. These make it possible to design integrative music lessons in a variety of ways and in accordance with new pedagogical findings. Based on the didactics of music and movement, theories on the promotion of perception and various learning theories, the following structuring theories can be helpful.

Integrative music lessons are designed to be diverse - different types of learners are also important in music lessons. Rhythmization, which designs the lessons in a variety of ways at different levels, makes it possible for everyone to participate in the lessons according to their abilities.

Integrative teaching is designed to be perceptible and tangible - playing an instrument requires the whole body to be aware of the surface of the body as well as internal organs, especially respiratory functions. Differentiation of movement, including balance structures, is also required. For music lessons, it has proven useful to differentiate between near and far senses. Near senses are all senses that are directly related to the perception of the body and its differentiated use. The ear and eye are distant senses. Musical experiences, for example in the form of body percussion sequences, become tangible and perceptible.

Integrative music lessons are designed with movement - musical creation is also movement and requires coordination and dexterity. Clearly designed pulse and rhythm movements alternating with making music on the instrument support learning and concentration. Movement and sitting on the chair are designed in a lively alternation. With this focus, the physiologically relevant use of chairs for music should also be considered.

Integrative music lessons are designed to be audible and visible - visual and auditory structures in the classroom create orientation and deeper opportunities for concentration. This creates an aesthetic of lesson design that conveys redundancy with the dynamics of artistic processes in general. The quality of the auditory structure means music lessons in which phases of joint music-making and experimentation alternate with sequences of silence. A clear visual focus takes into account aspects of the design of musical material, the arrangement of the teaching setting in the room as well as the specific type of instruction and conducting.

The score of integrative music lessons has different voices - children learn in different rhythms. For the composition of the music lesson, this is a phenomenon that can be used artistically. Just as each piece of music is created with different voices, the lessons are also structured in a differentiated way. In arrangements made especially for the group, there are basic elements that are played by everyone, more differentiated parts and even solos, as well as parts for simple grooves and individual accents.

Literature

Long version of the article:

By far the most common and also the most serious movement disorder in musicians is musician's dystonia. In its full form, it is characterized by the loss of fine motor control of complex movements on the instrument. Pain is not a primary symptom of dystonia. However, it can occur as a result of excessive muscle tension. The most common symptoms of advanced hand dystonia are involuntary curling or stretching of individual fingers and/or abnormal wrist postures. Occasionally, short-lasting muscle contractions (myoclonic dystonia) or involuntary trembling (dystonic tremor) can also dominate the symptoms.

Those affected often report a strong feeling of tension in the forearm while playing music. This is due to the simultaneous activation (cocontraction) of antagonistic flexor and extensor muscles. Patients only report a feeling of weakness in less than 5 percent of cases. It is difficult to diagnose hand dystonia in the early stages of the disease, and it remains particularly difficult to differentiate it from overuse injuries. In this case, patients often only report subtle difficulties with fast, regular movements on the instrument. There is obviously a "gray area" between this and disorders that should rather be described as "over-exercising" or "muscular fatigue". It is important to distinguish such very common movement problems from incipient dystonia, as the former responds very well to retraining, and anti-inflammatory and muscle relaxant drugs are also effective. Overall, the chances of recovery seem much better with this form of movement difficulties, which is why we do not refer to it as "incipient focal dystonia", but prefer the diagnosis "dynamic stereotype". This term comes from sports science and stands for incorrectly practiced movement habits which, in contrast to focal dystonia, can be corrected more easily and enable a correct movement sequence by consciously directing attention.

A particularly interesting area is embouchure dystonia in wind players. In the early stages, it often manifests itself in subtle inadequacies of intonation, predominantly in a particular register or playing style or in a clearly defined dynamic range. In advanced stages, the problem usually extends to the entire range of the instrument and to all dynamic ranges; control over embouchure, articulation and breathing is then no longer guaranteed in any playing style. However, the diagnostic spectrum for embouchure dystonia is also much broader. In a new study by Dr. Steinmetz and ourselves, 1817 questionnaires on embouchure difficulties were distributed to all brass players in German orchestras. The response rate was 32 percent. Of the 585 brass players, 60 percent reported embouchure problems at the time of the study, with around 30 percent reporting tongue stoppers and difficulties in the high register and 26 percent cramping of the embouchure muscles. Surprisingly for us, 10 percent reported that they had already had such difficulties with their embouchure during their orchestral work that they were unable to work. It was also interesting to note that 40 percent of those who had embouchure problems had already successfully overcome an embouchure crisis in the past. It would certainly be medically unjustified and psychologically very clumsy to classify this high percentage of wind players as "affected by dystonia", especially as, fortunately, many of them successfully overcome these crises. We are therefore in the process of drawing up new classification guidelines. The trigger factors (overload or not), the severity and manifestation of the symptoms, the presence of "islands of well-being", the family history (are there relatives with neurological movement disorders) and the presence of psychological symptoms (anxiety problems or not) all play a role. The prognosis for recovery through retraining is good for musicians who develop movement problems after overuse, who have mild symptoms, who are able to make music repeatedly without major complaints, who have no relatives with dystonia and who tend to suffer from stage fright.

Children and young people face particular physical and psychological challenges. On the one hand, their bodies change considerably while they are learning to play an instrument, to which they have to react with constant ergonomic adjustments. On the other hand, they find themselves in complex areas of tension between their own, as yet unresolved life plans and the expectations of parents, schools and friends. On October 26 in Zurich, renowned experts discussed these issues - expertly and knowledgeably moderated by Ticino doctor Adrian Sury.

Elisabeth Danuser, Head of Continuing Education at the ZHdK, pointed out another challenge in the first presentation of the day at the symposium led by SMM founder Pia Bucher: "School classes and music-making classes are becoming increasingly heterogeneous in terms of attention and previous training. It is therefore important to develop individual strategies for teaching and practicing music. ZHdK music physiologist Horst Hildebrandt then offered an overview of the initiatives and institutionalization of health care at music schools and colleges in German-speaking countries. With the Lahr Music Physiological Counseling Center, which he founded in 1993, he was a pioneer in Germany in providing services for music schools. Whereas musicians with such problems previously had to turn to doctors who were unable to recognize their professional or activity-specific problems as such, today they are supported by specially trained experts in their training and everyday working life, now also at the conservatoires themselves.

Christine Bouvard Marty, President of the Swiss Association of Music Schools (VMS), formulated rules for inclusive music lessons. In view of the increasingly complex tasks, this faces special challenges. In addition to the variety of teaching methods, the speaker emphasized the multiple sensory aspects: Making music with children and young people must involve all the senses and, above all, the adolescents' desire to move, so that they can constantly harmonize their musical practice and body image anew.

In workshops, music physiologist Oliver Margulies, who works in Zurich, and Frankfurt-based physiotherapist Alexandra Türk discussed the anatomical and physiological characteristics of young musicians. Margulies presented the diagnostic possibilities for musicians' hands, which were developed in Hanover in pioneering work by Christoph Wagner. His Hannover Hand Competence Center has since been taken over by the ZHdK. Alexandra Türk used the example of an adolescent graduate of the Zurich Conservatory to illustrate the effects of physical changes on instrumental playing. Girls in particular, who are growing rapidly at a certain stage, have to pay attention to phenomena such as a "hunched back" and a recalibration of their sense of balance.

Lucerne rheumatologist Urs Schlumpf pointed out that instrument-specific complaints tend to increase in children and young people. However, the increased demands in an increasingly competitive society can be met with child-friendly instrument variations, consistent warm-up programs and clever division of overtime and playing time. Finally, Zurich child and adolescent psychiatrist Dominique Simon put some of the increasingly inflationary psychological and social disorder diagnoses of children into perspective and pleaded for a more relaxed approach to so-called "difficult" music students.

Depending on the study, between 40 and 75 percent of professional musicians struggle with pain in muscles, tendons and nerves, the so-called RSI syndrome (repetitive strain injury). However, there are very few detailed findings in the specialist literature on the epidemiological, biomechanical and ergonomic aspects of such ailments. The rare studies are hardly comparable or generalizable in terms of study design, methodology or the size of the groups studied. Recommendations are usually limited to references to stretching exercises and breaks.

In order to gain differentiated insights into the syndrome, teams from the Royal Conservatory in Brussels, the Accademia Vivaldi in Ticino, the Free University of Brussels and the Thim van der Laan University of Applied Sciences for Physiotherapy in Landquart, among others, have collaborated on the MoReMu (MOtor learning and REpetitive strain injuries in Musicians) project. The aim of the project is to investigate the influence of local muscular fatigue and performance stress on muscle coordination.

Among other things, ultrasound examinations, complex audiovisual observations, but also surveys on everyday life, general health, eating habits and ergonomic conditions have been carried out. Students in Brussels and Ladquarter, for example, have drawn up questionnaires as part of their Bachelor's and Master's theses, which are intended to provide meaningful information about the corresponding stresses and strains in musicians' everyday lives. The SMM recruited doctor Adrian Sury and two physiotherapists from Ticino from among its members, who took part in the study free of charge.

For the first time, spatial data on the biomechanics of instrumental playing has also been collected for MoReMu using sophisticated technical methods - combined with so-called electromyographic methods. This involves using needle electrodes to measure potential fluctuations in individual muscle activities. The role of different playing techniques, such as vibrato, spiccato or legato in the case of strings, can also be delineated in this way. The Swiss contributions to the study also include investigations into the ergonomic effects of different shoulder rests for violinists.

The interdisciplinary cooperation between different institutes and disciplines could be groundbreaking and help to develop complex, holistic strategies to prevent RSI and other health problems. The various partners in the project are concentrating on individual aspects such as exercise strategies and ergonomic considerations, but also the importance of sporting activity and nutrition in strengthening RSI-preventing music-making.

Initial methodological discussions have shown that various factors are important for the success of the studies. For example, the measurement methods must be able to register subtle variations in technical execution on the instrument. Moreover, the three-dimensional measurement of movements on the instrument has shown that it is not easy to determine which micro-movements can be assigned to which notes played. The researchers are therefore also experimenting with software instruments that have been developed for speech recognition.

The first results of a pilot study were presented at the 6th International Conference on Sport, Leisure and Ergonomics in Liverpool in 2007 and at the 3rd World Congress of Musicians' Medicine in Milan in 2008. In Switzerland, the first measurements were carried out in November 2009 and April 2010 with pupils from the Accademia Vivaldi Muralto and students from the Conservatorio di Musica di Lugano - with the approval of the Ticino Ethics Committee.

However, it has not yet been possible to achieve robust, definitive results from this pioneering project. Problems with funding, which is not secured for the continuation of the project, are currently having an inhibiting effect.

Like adults, children also have limits that they cannot simply cross. For some, it is a lack of fine motor skills; for others, a crisis at school puts limits on their musical enthusiasm; still others come from a non-musical family and have to assert their will to practise at home. How can professionals deal with the different children and their needs?

It is useful to structure and rhythmize (!) the lessons with a varied but predictable sequence. Lesson topics such as colors, seasons, certain composers or musical styles can be used to integrate the child's interests. It makes sense to keep the lessons simple but varied and to appeal to the children's different senses.

The basis for successful and enjoyable teaching is a good relationship with the child. This includes knowing their preferences, family and sibling structure, strengths and weaknesses, at least to some extent. The basis for this is a binding contact with the parental home. Young children in particular are often still somewhat unsure of how to move between the poles of "home - instrument - music teacher". The teacher's relationship with the parents should not be limited to giving practice tips. Parents can tell from the child's mood whether the teacher values the child and whether they, the parents, are welcome as partners in the music education process.

The "fidgety" child with ADHD (Attention Deficit Hyperactivity Disorder) often shows daytime fluctuations with increased distractibility towards the evening. They benefit best from lessons in the early afternoon. Some, but by no means all, children with ADHD are also rather clumsy when it comes to fine motor skills. They are very aware of whether the teacher has confidence in them. The stressed child may have worries that they would like to discuss. If a relationship is sustainable, it should be possible to motivate the child to seek solutions with parents or other adult caregivers, or even to seek professional help. The temptation to be the child's only confidant or even to take on the role of a therapist must be resisted.

Music teachers are challenged in many ways every day. However, regular communication with class teachers or parents - also by telephone - prevents conflicts and disappointed expectations on both sides.

Dr. med. Dominique Simon

Child and adolescent psychiatrist and systemic psychotherapist

Supervisor in her own practice in Zurich.

> dr.simon@hin.ch

> www.ausbildungsinstitut.ch