Introduction
In public health, a sentinel health event is the occurrence of a preventable disease, disability, or death whose very existence signals a failure of prevention. When Leon Fleisher’s right hand began to fail in 1964, and he spent twenty years searching for answers that did not exist, his case was not simply a personal tragedy. It was a sentinel event for an entire occupational population — a signal that the health infrastructure serving performing artists was fundamentally absent.
Fleisher’s case was not isolated. Surveys of professional orchestral musicians revealed injury rates that would trigger public health intervention in any other workforce. Yet performing artists had no dedicated medical specialty, no occupational health framework, and no scholarly literature to guide their care. Four decades later, that discipline exists. What began as a response to injuries among musicians now spans six continents and serves dancers, actors, vocalists, circus artists, and the entire ecosystem of creative workers. What it has lacked — until now — is a scholarly publication owned by its own community, open to all who need it, and governed by the people who generate its evidence.
This article traces the arc of performing arts medicine from sentinel event to the launch of the Journal of Performing Arts Medicine — structured as four movements of a symphony in which each movement builds the case for why this journal, at this moment, is the necessary resolution.
Movement I: Symptoms — The Evidence That Needed a Home
The story begins with Dr. Alice Brandfonbrener.1 In 1983, she began gathering colleagues at the Aspen Music Festival and School. Dr. Richard Lederman attended that first meeting and became instrumental in shaping the gatherings that followed. The epidemiological data was staggering: International Conference of Symphony and Opera Musicians surveys revealed extraordinary rates of playing-related injury among professional orchestral musicians,2 and when these findings reached the New England Journal of Medicine in 1989, the scale of the problem entered mainstream medical consciousness.3 Yet injuries remained hidden and stigmatized — complex constellations of physical and psychological symptoms whose relationship to the demands of performance was not understood. What Brandfonbrener created at Aspen was the first space where these injuries could be discussed without shame and examined with scientific rigour.
Brandfonbrener understood that evidence without a publication platform would remain invisible. In the 1980s, she created Medical Problems of Performing Artists (MPPA), giving the field its first dedicated scholarly voice.1 For decades, MPPA served as the intellectual home of performing arts medicine — a remarkable achievement for a small, specialized publication navigating the pressures of a rapidly expanding discipline.
When the Performing Arts Medicine Association (PAMA) incorporated in 1988, it formalized Brandfonbrener’s international vision. The British, German, Dutch, and Australian performing arts medicine associations each emerged independently — adapted to local contexts but united by a shared recognition that performing artists’ health demanded specialized attention. As the evidence base grew and the community generating it became increasingly international, the question of who controlled the field’s scholarly infrastructure would take on growing significance.
Already the field was uncovering its defining paradox: the qualities rewarded in performing arts cultures — perfectionism, persistence, and an intense identification with one’s craft — were the same qualities that are associated with increased injury risk. This was a systems problem demanding rigorous, accessible scholarship. The gap between the field’s expanding scope and its lack of ownership over its scholarly platform was quietly widening.
Movement II: Synapse — A Field That Outgrew Its Infrastructure
Through the late 1980s and 1990s, the annual symposium at Aspen became the space in which performing arts medicine took shape as a field. Several developments converged simultaneously, each amplifying the others.
The neuroscience deepened. Research was revealing that intensive artistic training was not simply skill acquisition but neurobiological transformation4 — neurons that fire together wire together,5 with neuroplasticity reshaping the brain, expanding cortical representations, and building mastery through structural changes in white matter pathways.67 But the same plastic mechanisms that enabled artistry could, under certain conditions, produce focal dystonia and other movement disorders.6 A pianist whose hand cramped on rapid passages that had once been automatic; a singer whose voice broke on sustained notes that had once been effortless. Not from lack of preparation, but from neural pathways that had reorganized against the very skills they were built to serve. Understanding them required a kind of science that performing arts medicine had not yet developed.
At the same time, a parallel body of research was establishing performing artists as a true occupational health population. The pioneering work on muscular overuse in musicians — influenced by the broader awareness of repetitive strain injury in the workplace — made it clear that the physical demands of performance carried measurable biomechanical consequences.7 The emergence of the term “playing-related musculoskeletal disorders” formalized what clinicians had been observing: these were not incidental injuries but occupational conditions arising from specific performance-related stressors including sustained postures, repetitive movements, and excessive force.8 Alongside the neurological contributions that were illuminating conditions like focal dystonia and nerve entrapment syndromes, the musculoskeletal research established the epidemiological foundation on which the entire field would build.
Secondly, the populations served expanded far beyond instrumental musicians. The International Association of Dance Medicine and Science introduced the world of dance injuries to the PAMA community, revealing parallel patterns of overuse, psychological distress, and training cultures that normalized suffering. The integration of laryngology and voice science brought an entirely new domain into the field. Actors, circus artists, and eventually the entire ecosystem of creative industry workers followed, each population bringing its own injury patterns and its own version of the same underlying paradox.9
Finally, and no less significant, was the transformation of who constituted the community itself. The original vision was physician-centred — understandably so, given the clinical urgency that had brought the founders together. But the complexity of what clinicians were encountering at Aspen — focal dystonia intertwined with performance anxiety, musculoskeletal injury compounded by chronic stress, biomechanical problems inseparable from psychological ones — demanded expertise that no single discipline could provide. The push to open PAMA to health professionals of all disciplines, educators, and performers themselves fundamentally changed the character of the organization. What had been a medical subspecialty became an interdisciplinary field, and the quality of care available to performers was transformed as a result.
What emerged from this convergence — deeper neuroscience, broader populations, and a truly multidisciplinary community — was an evidence-based field that none of the three could have produced alone. Mental practice, attention training, real-time biofeedback techniques and strategic rest periods proved not just more efficient but neurologically safer.10 Neuroplasticity could enable recovery as well as injury — the same mechanisms that created problems could solve them, if guided by the interdisciplinary science that the PAMA community was now generating. A field this broad deserved a scholarly home where it could flourish.
Movement III: Salience — The Global Turn
By 2010, PAMA’s international engagement was deepening from collegial exchange to structured collaboration. The sister societies — British, German, Dutch, and Australian — became active partners in a growing global network. Performing arts medicine communities around the world found in PAMA a home where the work could flourish together. The field’s reach now extended to six continents, with new organizations emerging wherever performing artists gathered and the same patterns of injury, stress, and institutional neglect were recognized.
What was striking was not the differences between these communities but the similarities. Everywhere PAMA’s network reached, the same constellation appeared: performers whose bodies bore the cumulative toll of chronic evaluative stress, whose autonomic nervous systems showed disrupted balance, whose cortisol responses persisted long after the performance was over.1314 The science emerging within the PAMA community was beginning to explain why. Psychophysiology research revealed that performance environments don’t just shape behaviour — they shape biology. Every audition and jury entangles artistic success with identity, social standing, and economic security. Under these conditions, the nervous system may stop distinguishing between performance and survival.
The advancing science and accumulating clinical experience pointed toward a unifying construct: Performance Traumatic Stress Disorder — capturing how repeated exposure to high-stakes evaluative environments reshapes the nervous system through mechanisms paralleling post-traumatic stress.11 The evidence base was deep. Landmark research on Adverse Childhood Experiences had already demonstrated dose-response relationships between cumulative adversity and long-term health outcomes.12 Advances in epigenetics were revealing that chronic stress produces lasting alterations in gene expression — changes that persist beyond the stressor and can be transmitted intergenerationally.1718 One year of chronic stress can equal six years of biological aging.13 Yet the same research showed that mindfulness, physical activity, and psychotherapy can reverse these modifications.14 The implication was profound: the damage was real, but it was not permanent — if the right interventions reached the right people in time.
PAMA clinicians working across multiple disciplines and artistic populations were demonstrating exactly that — high artistic standards and nervous system resilience could coexist.15 If the nervous system can learn to associate performance with threat, it can also learn to associate it with safety, connection, and joy.
PAMA had become what Brandfonbrener envisioned: a truly international collective generating evidence that spanned continents and disciplines. Throughout this expansion, MPPA’s editors worked tirelessly to produce a stellar publication in the face of an explosion of research spurred by the growth of performing arts medicine as a field. Working within the capacity of a small publishing company, they maintained scientific rigour and editorial independence with tenacity, integrity, and no small measure of personal sacrifice. Their dedication sustained the field’s scholarly voice for decades — and their example set the standard that any future publication would need to meet.
Movement IV: Structure — Building What Was Missing
The first three movements of this symphony traced the growth of evidence, populations, and community. The fourth traces the institutional infrastructure built to sustain them — and the structural gap that remained until now.
The Symposium
From 1983 through 2015, the PAMA symposium convened alongside the Aspen Music Festival — allowing clinicians and researchers to immerse themselves in the performing arts culture they were working to protect. The 2016 move to Weill Cornell in New York marked a watershed — PAMA’s first International Congress and its first symposium away from Aspen. Since then, an “academic footprint philosophy” has partnered PAMA with leading universities: Chapman, UCLA, Shirley Ryan AbilityLab, and Johns Hopkins — expanding the community with each meeting.
The COVID-19 pandemic, which shut down live performance and meetings worldwide, forced the symposium online — and created a breakthrough. For the first time, PAMA’s annual gathering was accessible to anyone with an internet connection. International membership surged. The shift online also catalyzed PAMA’s Young Professionals movement, empowering members to take the lead on developing webinars, networking sessions, journal clubs, social media engagement, and community resource development. This created a natural entry point for students and early-career professionals who found meaningful belonging through hands-on involvement — and who would go on to shape the future of our field. The lesson was clear: the future of performing arts medicine is hybrid, global, and radically inclusive. In 2024, University College London hosted the first symposium outside North America.
This year’s 2026 return to New York marks the tenth anniversary of that first move away from Aspen. The programme includes the screening of the Dear Lara documentary16 — a film that confronts the sexual abuse experienced by concert violinist Lara St. John, and that embodies the field’s growing recognition that the health of performing artists cannot be separated from the institutional cultures of power, silence, and complicity in which they train and work. In 2027, the symposium moves to the Royal Northern College of Music in Manchester — for the first time embedding PAMA directly within a conservatory, the very environment where the next generation of performers is being shaped and where the evidence reviewed in this article is most urgently needed.
Education
Education has been central to PAMA’s mission from the beginning, but the means to deliver it globally are new.
In 2006, a joint initiative on Health Promotion in Schools of Music17 brought PAMA into collaboration with the National Association of Schools of Music — the accrediting body for music programs across the United States. That collaboration produced advisory papers on hearing loss, musculoskeletal disorders, and psychological health18 intended to guide institutional policy. The impact has been limited. Too often, performer health is framed as individual student resilience rather than institutional responsibility. Health and safety in artistic training is an occupational health imperative, and PAMA’s educators have made this a defining priority.
That priority drove what followed. In 2015, PAMA launched its first formal educational credential: the Essentials of Performing Arts Medicine (EPAM) certificate course, developed through the Athletes and the Arts collaboration with the American College of Sports Medicine.19 A complete overhaul for 2026 brings the course in line with the field’s advances and PAMA’s expanded scope across all performing arts populations.
The PAMA Learning Hub, also launched in 2026, creates a permanent digital repository for the educational resources the PAMA community has been generating since 2021. It includes webinars, presentations, and the recordings of the PAMA-thon — a 24-hour continuous virtual event hosted by PAMA’s Education Committee in 2023 that circled the globe across every time zone: 111 contributors from 23 countries, 704 registrants from 53 countries. The knowledge is, and will continue to be, preserved, curated, and accessible to learners worldwide.
The Financial Foundation
Growth without financial infrastructure creates its own bottleneck. A discipline that generates evidence across six continents, serves all performing arts populations, and aspires to publish an open-access journal cannot sustain itself on membership dues alone. Without a dedicated philanthropic engine, the very initiatives that define PAMA’s future — above all, the launch and long-term viability of JPAM — would stall.
The Foundation for Performing Arts Medicine (FPAM) addresses this structural need. FPAM is not a separate entity but a foundation established under the auspices of PAMA — an integrated model in which the philanthropic arm and the professional organization share governance, mission, and accountability. Its vision and bylaws have been shaped by a group of PAMA Past Presidents who bring the lived experience of having led this community through its most formative years. Generous contributions to PAMA’s Legacy Fund have provided the seed capital, and the scholarly groundwork laid by the Research Committee — whose membership includes many of the younger investigators who represent the field’s future — has ensured that the foundation’s priorities are grounded in the evidence base rather than institutional inertia.
FPAM will be formally established in time for the 2026 New York symposium. Its first and most urgent priority is to support the establishment and sustainability of JPAM — ensuring that the journal has the financial backing to maintain open access, waive article processing charges for PAMA members, and invest in the editorial infrastructure that rigorous peer review demands. Beyond the journal, FPAM’s vision includes supporting the scholarly development of the PAMA community — research grants, early-career investigator support, and the translational work that carries evidence from publication into the studios, clinics, and classrooms where it is needed most. The logic is straightforward: the evidence base that will improve the health of performing artists around the world requires a publication platform to disseminate it and a financial foundation to sustain it. FPAM provides the latter so that JPAM can deliver the former.
JPAM: The Resolution
Every development in this article — the expanding evidence, the growing scope, the multidisciplinary transformation, the international collaborations, the educational innovations — has been building toward a single structural need: a scholarly publication belonging to the performing arts medicine community itself.
The Journal of Performing Arts Medicine is that publication. It is not a replacement for what came before — the debt to Brandfonbrener for creating MPPA is permanent, and the editors who sustained scholarly publishing through decades of growth and change deserve lasting recognition for their tenacity and sacrifice. JPAM is the next expression of the same impulse that moved Brandfonbrener to create a dedicated journal in the 1980s: the conviction that this field’s research deserves a home whose editorial governance, peer review, and strategic direction are shaped by the community that generates the evidence.
But JPAM is also something new. It is open access — meaning that every clinician, educator, student, and performing artist in the world can read the research without a paywall. It is owned by PAMA — meaning that the organization’s members govern the journal’s direction and editorial standards. PAMA members can submit up to two manuscripts per year as first author without article processing charges — removing a financial barrier that has historically limited who can publish. And its scope encompasses all performing arts populations — musicians, dancers, actors, vocalists, circus artists, visual artists, and the entire creative ecosystem — reflecting the field as it actually exists today, not as it existed when the first journal was founded.
JPAM’s editorial leadership represents a new generation bridging the full lineage of performing arts medicine scholarship — trained under, shaped by, and now building upon the work of each editor who preceded them. This is not a journal that starts from zero. It starts from everything its predecessors built, with the structural independence to take the work where it needs to go.
This is what four decades of evidence, institution-building, and international collaboration have been leading to: a scholarly home that is accessible to all, accountable to its community, and attuned to the discipline it serves.
Coda: The Art of What Comes Next
To those who have carried this work for decades: none of this existed before you. Every study cited in this article exists because people in this community refused to accept that artists should suffer in silence. JPAM exists because you kept this field alive.
To those arriving now: you are inheriting not just evidence but a moral commitment. The creative economy is one of the fastest-growing sectors of the global workforce. Hundreds of millions earn their living through performing and creative work. Their occupational health challenges are public health imperatives spanning every country and culture. The evidence in this article applies to all of them — and now, for the first time, it will be published in a journal that all of them can read.
Imagine every conservatory, dance academy, theater school, and performing arts faculty on earth embedding evidence-based health and safety into its accreditation standards — not as an elective but as a non-negotiable condition of training artists. Imagine performing arts medicine recognized worldwide as a legitimate occupational health specialty. Imagine the epigenetic damage of Performance Traumatic Stress Disorder understood as clearly as the damage of asbestos exposure — and prevented with the same seriousness. That world is not utopian. Every element is supported by the evidence that already exists. What has been missing is the publication infrastructure to make that evidence universally accessible and the institutional ownership to ensure it remains so. JPAM provides both.
Leon Fleisher’s sentinel event exposed the absence of a discipline. Today that discipline spans six continents, has transformed the way performing artists are understood and cared for — and now publishes in its own open-access journal. The question that animated this field — What do we owe the people who dedicate their lives to artistic excellence? — has an answer: everything that science, medicine, education, and institutional courage can provide.
The symphony is not yet complete. But the score is being written, the orchestra is assembled, and for the first time in the history of this discipline, we hold the baton.
Far better an appropriate answer to the right question, which is often vague, than an exact answer to the wrong question, which can always be made precise. — John Tukey20
Competing Interests
The author is Past President and current Treasurer of the Performing Arts Medicine Association. No other competing interests are declared.
Funding
No financial assistance was received in support of this work.
Acknowledgments
The author acknowledges with gratitude the founding vision of Dr. Alice Brandfonbrener, the dedication of the editors who sustained scholarly publishing in performing arts medicine through decades of growth and change, and the global community of clinicians, researchers, educators, and performers whose collective work is the subject of this article.
AI Statement
Artificial intelligence tools (Claude, Anthropic) were used to assist with drafting, editing, and formatting this manuscript. The author is solely responsible for all manuscript content.
Author Contributions
JC conceived the article, provided all source material and clinical experience, directed all editorial decisions, and approved the final manuscript.