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Kelsey Sims ’18 has played the violin since she was four years old. “It’s an excellent way to express myself,” she says. “Music can reach a wide array of people and spread happiness and joy to others.”

Sims, a music and environmental studies major from Columbus, Ohio, takes private lessons at St. Olaf College and practices 12–14 hours a week on her own and as a member of the St. Olaf Orchestra’s second violin section. While she loves the violin, she doesn’t love the extensive pain in her arms, wrists, and back she experiences while playing it.

“The entire left side of my body is in almost constant pain,” she says. “No one ever teaches you how to relax and stretch your body before you play. You just sit down, start playing, and push through the pain.”

It’s not surprising, then, that Sims was eager to join a new research study that assesses functional movement in violinists and dancers. The study is being conducted by Jennifer Holbein, an exercise science instructor at St. Olaf, and six student researchers. Holbein hopes to determine whether a regular, simple warm-up routine (whole body exercises and stretches that differ from playing scales or doing pliés) can relax muscle tension, reduce pain, and prevent injury in performing artists.

“Very little research has been done assessing the outcome of injury-preventative measures in performing artists,” says Holbein, who developed the study, which includes several six-weeks-long assessments of St. Olaf dancers and violinists, for a two-semester Directed Undergraduate Research (DUR) course she offered to students this year. DURs generally consist of a topic determined or guided by a faculty member, often based on his or her research interests. By exposing students to the rigors of research, a DUR course is one of the ways that St. Olaf provides undergraduate students with a high-impact educational experience.

Holbein, who marched in drum corps for many years, has long been intrigued by the idea of including performing artists in the same category as athletes: both groups put their bodies through punishing, repetitive use — whether in rehearsal and performance or athletic training and competition.

“Athletes receive so much education about preventing and treating injuries that isn’t yet available to performing artists,” Holbein says. “We know that musicians and dancers have injuries similar to those in sports, caused by muscle tension, overuse, and not warming up their bodies properly. This study is really driven by one question: how do we prevent those injuries in performing artists?”

Connecting Art to Science

Nina Lautz ’18, the lead student researcher on the functional movement study, is an exercise science and biology major from Milwaukee, Wisconsin. Like Sims, she is a violinst, having played the instrument for 15 years. She was a member of the St. Olaf Philharmonia for three years and also has danced competitively for nine years.

During a fall 2016 biomechanics class taught by Holbein, Lautz and three classmates were tasked with conducting a small research project from concept to completion. The group chose to conduct a four-week study on how warming up the body might affect 10 violinists in the St. Olaf Philharmonia.

“We were told to choose something we are passionate about, and for me that’s violin,” Lautz says. “Musicians, even though they use their body as much as an athlete does, don’t really warm up their joints or muscles. They tend to fiddle around on their instruments, tuning or running through difficult passages in the music.”

Ann Dahl, an occupational therapist who works part-time at St. Olaf treating musicians’ injuries or stresses related to their hands, wrists, and upper bodies, worked with the student researchers to develop a series of warm-up stretches and exercises for the violinists to do twice a week before rehearsal, easily completed in less than 10 minutes.

“It was a short study, but the results were very good,” Lautz says, noting that after four weeks, the violinists reported experiencing a decrease in pain levels in the head, neck, shoulders, and wrist. “All of them said they enjoyed the exercises and would consider using them long-term,” says Lautz.

That 2016 class project, combined with Holbein’s interest in researching injury prevention in performing artists, became the pilot for the more in-depth, yearlong study currently underway by Holbein, Lautz, and five other students in the DUR course: Abby Carpenter ’18, Eric Bakken ’18, Kyle Leemon ’18, Andrew Thao ’18, and Emil Hiiri ’19.

String Theory

Holbein expanded the pilot study to include research with both dancers and violinists. She also incorporated a new element — a before-and-after assessment of the participants in the study. Using a variety of methods, the study assessed the performers’ functional movement prior to running them through warm-up exercises for six weeks and then reassessed them to see if their functional movement improved.

The current research — the focus of the yearlong DUR course — began last fall with 14 St. Olaf Orchestra violinists, who completed several evaluations, both before using the warm-ups and after: the String Instrumentalist Pain Survey, the DASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire, and the Kenny Music Performance Anxiety Inventory assessment. Northfield chiropractor Daniel Corbett also conducted electromyography (EMG) and thermography scans on the violinists to measure resting tension in specific muscles of the hand.

“The scans helped us see if the violin players had muscle spasms in their arms and back — while at rest — that we couldn’t detect or they couldn’t feel during playing,” says Carpenter, an exercise science major from Northfield who facilitated the collaboration with Corbett.

In Sims’s case, the EMG scan showed that she had a range of mild, moderate, and bad muscle tension in her left hip and throughout her upper back and neck.

“My results confirmed why I felt so awful,” Sims says. “It was eye-opening to see the tension we have from playing the violin, even when we’re not actually playing.”

The exercise science students also conducted what’s known as a functional movement screen (FMS), an assessment tool that’s commonly applied to athletes rather than performing artists. A standard FMS involves a set of seven movements that assess range of motion and help to identify areas of the body that need to be targeted for improved strength or mobility.

“Essentially, an FMS breaks down a body from head-to-toe to see what parts work well and what parts don’t work well,” says Holbein, noting that FMS is typically taught to physical and occupational therapists at the residency level but rarely taught to students at the undergraduate level.

To help her students learn FMS and modify it to fit the specialized needs of violinists, Holbein turned to Dahl and her colleague Dave Wieber, a physical therapist who partners with Dahl in the treatment of musicians and non-varsity athletes at St. Olaf. Wieber helped Holbein’s students adapt the Titleist Performance Institute’s functional movement screening developed for golfers so that it could be applied to violinists. He also taught the students how to demonstrate and assess the movements they’d be asking the violinists to perform.

“FMS assessment works sort of like a flow chart,” Wieber says. “If you pass a movement — say, touch your toes — you go on to perform the next movement. If you fail, additional movement tests are done to see where the problem lies before moving on.”

The 14 violinists participating in the study were divided into two groups, with seven forming an experimental group and seven forming a control group. After the initial evaluations of the 14 participants, which exposed common upper body problems such as with spinal and shoulder rotation, the seven violinists in the experimental group met with Lautz and her fellow students three times a week for six weeks before rehearsals to warm up their bodies. They worked through simple stretches such as arm circles, bear hugs with a head roll, and pushing their palms flat against a wall. Those in the control group did no warm-up exercises.

At the end of the six weeks, all 14 repeated the surveys, the scans, and the FMS assessment. The experimental group’s average FMS score improved from 81 to 87 percent. Their EMG scans decreased from an average of 145 microvolts (the amount of electrical activity or firing within a muscle at rest) to an average of 136 microvolts. A normal scan is about 115.6 microvolts, indicating that the violinists had higher resting muscle tension than the average person might have.

“It was a small study in a short time frame, so in order to get statistical significance, we’d need a much larger group of subjects,” Lautz says. “Even still, we were pleased with the improvement we saw and with the fact that we didn’t make anyone’s pain worse.”

Like the other student researchers, Kyle Leemon, an exercise science major from Lander, Wyoming, who has played soccer for many years, has a newfound appreciation for the athleticism involved in playing a string instrument.

“This study takes artists in the performance arts sector and treats them as athletes, which is really cool,” Leemon says. “It gives them the tools to properly warm their muscles.”

The work Holbein’s group did with the violinists has almost put Wieber and Dahl out of the business of treating string players, Wieber says. “Our patients have dropped off by 70 to 80 percent,” he says. “We were seeing a lot of students with wrist, hand, elbow, shoulder, and neck strain, and now we hardly see any string instrument students.”

“For our students to have training in functional movement screening — a tool often used in physical or occupational therapy — and to have used it in a research setting at the undergraduate level is extraordinary.” — Cindy Book

For Sims, the St. Olaf Orchestra violin player, the warm-up exercises changed the way she treats her body and have reduced her pain while playing. Her post-test EMG showed improved results, with her left hip tension now in normal range and the tension in her neck and upper back greatly reduced.

“The study helped me become aware of my body and to learn to not push through the tension or pain,” says Sims, who continues to use the warm-up stretches in her daily practice routine. “Now, whenever I notice my wrist starting to cramp up, I stop and stretch it out and do some deep breathing before I’m ready to jump back in. It has helped me gain control over my body while I’m playing and helped my muscles last longer throughout rehearsals and performances.”

She hopes more violinists are exposed to the benefits of warming-up. “There should be more focus on ways that violinists can maintain well-being in their bodies and prevent injuries, from a young age.”

Lautz agrees. She thinks that the research study has the potential to influence the development of young musicians.

“It is heartbreaking to hear my musician friends say they aren’t able to play certain repertoire or perform solo recitals due to their chronic pain,” Lautz says. “Wouldn’t it be amazing if through education and proper training, injuries in musicians could be prevented altogether?”

Dance Moves

While the exercise science students were working with the violinists last fall, they were also assessing functional movement in 10 students in Artist in Residence Anthony Roberts’s Modern Dance II class.

Those 10 students were assessed only with the functional movement screen, both at the start and end of the study, and not with EMG scans or surveys. The student research team observed and scored the dancers while they performed specific movements — again, a set created by Wieber and the students specifically for dancers. The FMS tested such things as hip rotation, rotator cuff strength, and isolation of the neck musculature. The dancers earned higher FMS scores (an average of 97 percent) than the violinists, which wasn’t surprising to the research team.

“In general, dancers are hypermobile and very flexible because of their art,” Lautz says.

Roberts led all 10 dancers (there was no control group) in a 10-minute full-body warm-up routine twice a week before the start of his class. The routine was based on one developed at the University of Louisiana, which was customized for the St. Olaf dancers by the exercise science students and demonstrated on tape by Lautz and Leemon.

Even though the dancers’ initial FMS scores were high, their scores still improved at the post-test assessment after the six weeks of participating in the study’s warm-up techniques.

“It was encouraging to see positive results, with scores of 98 or 99 percent improving to 100 percent,” Leemon says. “Even those who scored 100 were able to maintain that score.”

Study participant Julianne Eckert ’20, a dance and women and gender studies major from Flagstaff, Arizona, estimates that she dances for more than 10 hours a week, either in class or in rehearsal for Companydance, St. Olaf’s modern dance company. Sitting on the floor, with her legs extended in front of her, Eckert has the uncanny ability to touch her toes to the floor when pointing them.

“I’ve always been told that my point is really nice for lines,” she says. “But during the FMS, I failed the ‘point your toes’ movement, because I was told it wasn’t normal to touch my toes to the floor. What I thought was good from a dancing perspective isn’t necessarily good from a healthy body perspective.”

Eckert says the warm-ups the dancers did as part of the study were different from a typical dance warm-up, focusing more on strength movements such as planks, lunges, and hamstring stretches, instead of cardio movements like running or leaping or genre-specific techniques like pliés or tendus.

“I found it interesting that my body was warm and ready to dance without doing much cardio,” she says, noting that she felt an overall “strengthening” of her body.

Roberts has long been interested in the intersection of dance and science. As early as 2014, he was investigating ways the Dance Department could collaborate with the Exercise Science Department, and so when this study was proposed, he was eager to have his dance students participate. He says that it’s not yet common for dance students to have a fundamental grasp on how to take care of their bodies, which includes warming up properly. Roberts also recognizes the importance of having dancers study anatomy and kinesiology.

“It’s crucial that they embrace dance science and learn the anatomically safe and sound structure and function of the body,” he says.

Holbein and her students have continued assessing dancers during spring semester in order to collect a wider-ranging data set. They’re working with 30 students — evenly divided into control and experimental groups — in three dance courses. As with the studies last fall, all the dancers will undergo a pre- and post-test FMS. The experimental group of dancers will complete the twice-weekly, six-week warm-up routine to test if it impacts their functional movement.

“My goal is for our dancers to learn the warm-up and then encourage them to do it consistently before every rehearsal and to become more mindful of treating their bodies well,” says Roberts, who has completed the warm-ups alongside his students. He has noticed a “weight drop,” or improved body alignment that allows him to feel more of his muscles engaging as he dances.

“In some ways, it’s like after you’ve had a good yoga class and you feel a different presence in the world as an embodied being,” he says.

Training Lessons

Exercise science is a relatively new major at St. Olaf, having been first offered in 2002 after the department — previously physical education, then sports science — was revamped. Most students interested in becoming physical or occupational therapists choose to major in either exercise science, which graduates about 25 students each year, or biology or psychology.

“For our students to have training in functional movement screening — a tool often used in physical or occupational therapy — and to have used it in a research setting at the undergraduate level is extraordinary,” says Cindy Book, chair and associate professor of exercise science. “It’s also exciting to extend our department’s reach beyond Skoglund, as we’re often associated with only working in the sports realm. Bringing together the worlds of music, dance, and exercise science has been fabulous.”

“My goal is for our dancers to learn the warm-up and then encourage them to do it consistently before every rehearsal and to become more mindful of treating their bodies well.” — Anthony Roberts

Book noted that assessing functional movement in violinists and dancers isn’t the only research being conducted in the Exercise Science Department. She and Holbein are among the 2017–18 recipients of a Magnus the Good Collaborative Fellowship, which is supported by an endowed fund established in 2003 by friends of St. Olaf’s former Paracollege (the forerunner of the current Center for Integrative Studies). The fund supports projects that provide opportunities for collaborative work between students and faculty members.

Together with students Jordan Lutz ’18 and Randall Rude ’18, Book and Holbein are conducting research to develop strategies that may help people with Parkinson’s disease multitask while walking. Their study is using electroencephalogram (EEG) and EMG machines and video analysis to examine walking gait in human subjects at various levels of weight load while performing a cognitive task. Essentially, the study’s subjects mimic the gait of a Parkinson’s patient on a treadmill while attempting to complete a small task. At the same time, the student researchers measure their brain waves and muscle activity.

“Research shows that Parkinson’s patients cannot multitask while walking because they’re fixated on their gait,” Book says, “whereas you and I just walk, and if we see a rug, step, or dog, we just walk around it without having to think about it.”

So far, the group has found that if a Parkinson’s patient is harnessed while walking, he or she feels safe. When a task is introduced, such as a math problem or coin sorting, the person is able to multitask because he or she isn’t focusing as much on walking. Additionally, the harness’s ability to “un-weight” the patient — remove 10, 20, or 30 pounds of body weight — is also proving beneficial.

Other research projects in the Exercise Science Department are student led. For example, Carpenter, one of the students working on the violinist/dancer study, is completing an independent research project as part of her senior seminar, a requirement for students in the department who want to earn distinction in the major. For her project, Carpenter is examining the effects of caffeine on endurance athletes.

Her participants — St. Olaf varsity athletes with an endurance background — chew a piece of caffeinated gum for about 20 minutes, allowing the caffeine to enter their bloodstream. She then puts them through a running endurance test, recording their time to failure (exhaustion) and testing the level of caffeine left in their system.

“With each caffeine dosage level, I compare it to the athlete’s baseline to see if their time to failure increased or not,” says Carpenter, who plans to work in cardiac rehabilitation after graduation.

Leemon, another student conducting the violinist/dancer study, plans to earn a master’s degree in exercise physiology. He has completed a literature review of the effects of altitude training on the maximal oxygen uptake in elite endurance cyclists. “I looked at whether a body increases the amount of oxygen it can use during a race at higher elevations,” he says.

Lautz, the lead student for the violinist/dancer study, is using the violin portion as her distinction project, which requires her to write a detailed account of the research, from literature review and methods to results and analysis. She has been accepted into the doctorate of physical therapy program at Mayo Clinic.

“I’ve been pleased with how driven these students are,” Holbein says. “They’ve been involved in every step of the research, and they understand the importance of bringing awareness about injury prevention to performing artists around the world.”

In late June, Holbein and the student researchers will present their data in a poster session at the international conference of the Performing Arts Medicine Association in Orange, California.

“I’ve been pleased with how driven these students are. They’ve been involved in every step of the research, and they understand the importance of bringing awareness about injury prevention to performing artists around the world.” — Jennifer Holbein

“The much broader question the performing arts world needs to address is whether these exercises and stretches to warm your body should be taught to children so that they become second nature, like warming up their instrument is,” Holbein says.

Holbein already has her eye on continuing the project in the fall of 2018. She and her students next fall, including Emil Hiiri, who joined the project in February to learn from the graduating seniors, will continue assessing functional movement in groups of violinists and dancers. Rather than assigning the same warm-up routine to everyone, Holbein hopes to implement individualized injury prevention strategies — in other words, create targeted therapies for an imbalance indicated in each participant’s FMS score. Eventually, Holbein would like to expand the music portion of the study to include players of all instruments.

“Wouldn’t it be fabulous if we could screen an entire orchestra and create individual therapies for each player?” Holbein asks. “I’m not kidding when I say this could be a 10-year project.”