British Association for PERFORMING Arts Medicine

Returning to Playing and Performance for Instrumental Musicians

A high proportion of musicians will encounter an injury or symptoms (most commonly pain) which interfere with normal playing. This can require total or relative rest from playing for a period of time. Aside from injury, there may be other circumstances such as illness, unemployment, or extended leave where there is a significant break in the normal practice and performing schedule.

Research has shown that a common trigger for injury in musicians is a sudden increase in playing load. This can also apply if a musician returns to their normal playing schedule following a period of rest or recovery, as their capacity will have reduced during time spent away. Therefore, it is important to return to playing in a gradual way, to allow time for the muscles, tendons and other structures to adapt and rebuild tolerance. The following Return to Play Schedule provides an outline for musicians to follow when structuring their practice.

A printable pdf version of this resource is available here: BAPAM Returning to Playing and Performance for Instrumental Musicians

How to use the schedule

Start at Level 1 and work to this schedule for 3-7 days. If playing is comfortable, with no pain or other symptoms during or after the play period – progress to the next level.
If you progress to a new level, but start to experience symptoms, then revert to the previous level for a further period until you can progress.
Keep to the schedule timings as even if you feel fine during the practice, you may experience symptoms later or even the following day if you do too much too soon. Use a timer if needed.
Keep a record of your progress and seek advice from a health professional if you are still experiencing symptoms.

Return to Play Schedule (minutes per day)

Level	Play	Rest	Play	Rest	Play	Rest	Play	Rest	Play
1	5	60	5
2	10	50	10
3	15	40	15	60	5
4	20	30	20	50	10
5	30	20	25	40	15	45	5
6	35	15	35	30	20	35	10
7	40	10	40	20	25	25	15	50	10
8	50	10	45	10	40	10	35	30	20
9	50	10	50	10	40	10	35	30	20
10	50	10	50	10	50	10	45	20	30

Adapted from Norris (1996)

As well as progressing the time spent playing, the musician also needs to consider the intensity and technical difficulty of the repertoire.

Start with repertoire that is slow, simple and soft to begin with – you can use a metronome to ensure the required pace.
Initially, if injury has been severe, playing related movements may be started without the instrument (shadow playing) as tolerated.
It can be frustrating to limit playing time but there are ways of making good use of this period such as: using mental practice techniques, analysing recordings, or studying other aspects of music theory.

Consider these three factors when returning to playing

Duration

Intensity

Difficulty

Gradually increasing the duration and frequency as shown in the return to play schedule

Gradually increasing the tempo and volume

Return to performance

Gradually moving from easier pieces to more technically demanding repertoire

The Return to Play Schedule shown is designed to be used for guideline purposes only. It should be modified according to the musicians’ injury, type of instrument and current level of symptoms vs function. Activities of daily living which require use of the injured area (e.g., computer use, driving etc) should also be evaluated. Ideally, the schedule should be tailored to suit the musician by a suitably experienced Performing Arts Health Professional, offering guidance and support during the return to play process.

If you are experiencing any symptoms such as pain, weakness, swelling, pins & needles, excessive fatigue, reduced dexterity, increased muscle tension or reduced range of movement, please seek help from a qualified health professional. BAPAM offer free online or in-person health assessments with GPs, physios and osteopaths for support and guidance. Contact the BAPAM helpline on 020 8167 4774 for more information.

Consider additional Healthy Practice Habits (see below) with emphasis on warm-ups and cool-downs during the return to play period and beyond.

Healthy Practice Habits for Musicians

Environment	Instrumental Supports
Ensure the practice room is a comfortable temperature with good lighting Seating and music stand should be set up for a supported posture.	The loads imposed by ‘held’ instruments can be spread or reduced by neck straps, instrument posts, thumb stops, customised shoulder and chin rests etc
Warm-Ups	Concentration and Fatigue
Warm-up physically away from the instrument before playing (see BAPAM’s Don’t Cramp My Style Factsheet). Then warm up at the instrument starting with gentle playing.	Ensure ‘deliberate practice’ (with a goal in mind), maintaining concentration. Pause or stop at any sign of reduced concentration, fatigue, or discomfort. Drink water – even minimal dehydration impairs performance. Practice times can be reduced using mental rehearsal techniques.
Cool-Downs	Recognise Risks
After practice, cool-down at the instrument with some gentle playing Then away from the instrument, with movements and stretches to release muscle tightness and restore range of movement	Be vigilant – seek reasons for awkwardness, difficulty, or discomfort. Do not play with discomfort. For technical problems, find easy postures and movements, release effort – no holding on. Adjustments, with revision of e.g. fingering, articulation, phrasing, can produce a comfortable, even more musical, outcome – and less risk.
Breaks	Carrying and Travelling
Take a 3-5 minute break from playing every 20-25 minutes (e.g., relaxation, water, score reading). Return to neutral body/limb postures aided by gentle stretches to keep the muscles responsive.	When travelling with your instrument, use straps, wheels, or trolleys (pushed not pulled) to reduce load and keep a neutral posture. Backpacks should be placed low and symmetrically
Optimal Postures	Fitness and Relaxation
During playing maintain optimal postures and return to neutral postures as often as possible, including the wrists and thumbs.	Regular moderate aerobic exercise (guidelines indicate 150 minutes per week) and resistance training (two sessions per week) is advised to maintain general fitness, strength and flexibility. Organise schedules to include time for relaxation.

References

Butler K. (2021) Assessment and treatment principles for the upper extremities of instrumental musicians. In: Skirven TM, Osterman AL, Fedorczyk JM, Amadio PC, Feldscher SB, Shin EK (Eds.) Rehabilitation of the Hand and Upper Extremity. Philadelphia, Elsevier. Vol. 2: 1668-1693.
Norris R N. (1996) Return to play after injury: strategies to support a musician’s recovery. Work (Reading, Mass.), 7(2), 89–93. https://doi.org/10.3233/wor-1996-7203
Winspur, I (2018) The Musician’s Hand: A Clinical Guide, 2nd ed. JP Medical Publishers, London. ISBN 978-1-909836-81-5

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