University of Groningen
Musculoskeletal pain & dysfunction in musicians
Woldendorp, Kees Hein
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Woldendorp, K. H. (2019). Musculoskeletal pain & dysfunction in musicians. Rijksuniversiteit Groningen.
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Chapter 8
Embouchure:
Assessment of Embouchure
(‘CODE of Embouchure’)
Puplished as:
Kees H. Woldendorp, Elise Ploos van Amstel, Hans Boschma,
Anne M. Boonstra, Hans J. Arendzen, Michiel F. Reneman.
Towards consensus on clinical assessment of embouchure
in brass players: a Delphi study.
(Med Probl Perform Art. 2019:3(1):6-13)
Towards consensus on clinical assessment of embouchure in
brass players: a Delphi study.
Objective:
The objective of this study was to determine the content validity of an assessment
instrument for embouchure (the ‘CODE of Embouchure’) which covers the main
aspects of the construct of embouchure in brass players.
Method:
Design: Delphi technique. A selected panel of 35 international experts gave their
opinion via a three-round digital Delphi survey as to whether the instrument as a
whole, and its items, adequately measure the construct of embouchure. Criteria for
consensus and whether items should go through to the next Delphi round were
pre-determined. Data were independently analysed by two researchers. The CREDES
guidelines were used for conducting and reporting of the study.
Results:
Consensus was reached over 64% and 73% of the closed questions in the first and
third rounds respectively. A second round was necessary to resolve intra- and
inter-expert contradicting information. Finally, 5 items were added to the instrument, 3
items were removed and 23 items were adjusted. Consensus was reached in 63 Items
(98%). The final multi-item assessment instrument consists of 4 domains and 64
items.
Conclusion:
Content validity of most aspects of the ‘CODE of embouchure’ instrument was
established.
Introduction
Sixty percent of brass players (1) experience embouchure-related or other problems
when producing an optimal sound or an optimal range of sounds in their instrument.
Teachers, physicians and therapists consulted by wind players would benefit from
a systematic approach to the assessment of embouchure. So far, no integrated
systematic approach is available for routine practice, despite the fact that there are
several dynamic methods to observe elements of embouchure (e.g. stroboscopy
(2-6), high-speed real-time MRI (7-9), electromyography (9,10), and fluoroscopic video
imaging (10,11)), and that some simple classification systems have been developed
(2-4). There is also no structured and agreed way to interpret the findings in terms of
functional or dysfunctional embouchure (12). Moreover, evaluation and comparison
of various educational methods and therapeutic treatments of dysfunctional
embouchure are not possible either. This is hampering the evaluation of teaching
methods and treatment results and/or the right diagnostic approach to establish the
cause of embouchure problems. For this reason a new measurement instrument has
been developed to assess embouchure in brass players.
In the development process of an assessment instrument it is necessary to know what
is relevant to measure in order to correctly reflect the construct (13). A definition of
the construct of embouchure and its main principles has recently been developed
(12). Based upon this, we have developed an assessment instrument called the
‘CODE of Embouchure’ (‘Classification, Observation, Diagnosis and Evaluation
of Embouchure’). Embouchure was defined as the process needed to adjust the
amount, pressure and direction of the air flow (generated by the breath support) as
it travels through the mouth cavity and between the lips, by means of the position
and/or movements of the tongue, teeth, jaws, cheeks and lips, to produce a tone in
a wind instrument (12). Since the construct of embouchure should be regarded as
a multidimensional construct, the assessment instrument that was constructed to
enable assessment of the whole construct consisted of 4 domains (Appendix I). Since
not all aspects relating to tone production or movement can be explained in detail
in writing, we produced an instruction video also called the ‘CODE of Embouchure’,
which forms an integrated part of the present paper (https://www. Youtube.com/
watch?v=Vr-FLpTcX7g).
Optimizing the content of the ‘CODE of Embouchure’ required a study to test and
improve the validity of the instrument. Validity is defined as the degree to which an
instrument truly measures the construct(s) it purports to measure (13). One of the
types of validity that can be distinguished is content validity. Content validity focuses
on whether the content of a measurement instrument corresponds with the construct
that one intends to measure, in terms of relevance and comprehensiveness (14). The
aim of the present study was to determine and improve the content validity of the
‘CODE of Embouchure’ instrument.
Methods
Study design
In order to determine and improve the content validity of the ‘CODE of Embouchure’,
we asked an expert panel to what extent they agreed with the content. This was done
using a web-based Delphi survey among a selected international expert panel. The
Delphi technique is a systematic method consisting of multiple question rounds
(15). The experts gave their opinion anonymously and independently, unaware of
each other’s identity (16). During the question rounds, experts were informed by a
summary of the group response of the previous round, to enable them to reconsider
their answers (17). The CREDES guidelines were used for conducting and reporting
of the study (15). Figure 1 shows the structure of the Delphi procedure used in the
present study. Ethical approval was received from the Ethical Committee of the Hanze
University of Applied Sciences Groningen. Prior to the Delphi rounds, all experts were
informed about anonymity towards other participants and reporting of results. They
also consented to semi-anonymous processing of all questionnaires; one researcher
(EP) depersonalized the responses to ensure that all experts and the coauthors were
blinded to the names of the experts and their corresponding responses.
Participants: the expert panel
A minimum sample size of 10-15 for a homogeneous group of experts has been
suggested in the literature (18). The validation of the ‘CODE of Embouchure’, however,
required input from different kinds of experts on embouchure. We thus aimed to
classify a variety of experts in the field of functional and dysfunctional embouchure
into four categories: (A) scientists in the field of embouchure/wind playing, (B)
physicians and therapists, (C) brass/wind players, and (D) other experts (e.g. dentists)
assumed to possess relevant knowledge on specific groups of items within the ‘CODE
of Embouchure’ (Table 1). Since our sample thus consisted of four different disciplines,
and several of the invited experts had expertise in more than one discipline, we
intended to have an expert panel of at least 30 independently working experts to
Figure 1. Structure of the Delphi procedure used in the present study
ensure sufficient power for the study. To limit the potential impact of the input by
the group of ‘other experts’, because of their limited knowledge about
embouchure-specific elements, the percentage of this group was intended to be a maximum of 25%
of the total number of experts. Experts were invited if they had published in the field
of music medicine, and/or if they were known to be professional brass players and/or
well-known brass pedagogues. People from different parts of the world were invited.
They remained anonymous to each other and to the authors, except for one of the
co-authors (EP). The authors did not participate in the expert panel. To minimize the
risk of introducing conflicts of interest, the main coordination of the Delphi study
(including the communication) was entrusted to an independent researcher in the
field of embouchure (EP) as recommended by the CREDES guidelines (15).
Category A and some of the category B experts were identified via a search in
PubMed, Research Gate, Google Scholar, Medical Problems of Performing Artists,
Journal of Musicological Research and Journal of Music Teacher Education (search
terms: Embouchure; Embouchure AND/OR Brass player(s); Embouchure AND/OR
Wind player(s); Embouchure AND/OR Brass instrumentalist(s); Embouchure AND/
OR Wind instrumentalist(s); Embouchure AND musicians). Category B experts
were mostly identified in an unstructured way via our network in music medicine
and snowball sampling. Since there is no international standard to search for brass
players, the category C experts were also found via the network of the authors, via
snowball sampling, and via a search on the internet for authors of brass pedagogy
books or websites. Category D experts were found via the authors’ networks or via
snowball sampling. All identified experts were invited via e-mail to participate in the
study.
Figure 2. Flow chart of Delphi Survey.
Procedure
A flow chart showing the Delphi survey process is presented in Figure 2. The
panel members were sent a paper we had published about the Fundamentals of
Embouchure (12) by e-mail, to ensure a shared level of knowledge about the construct
of embouchure. They also received a short questionnaire with questions about their
characteristics as experts in one or more domains of embouchure, such as numbers
of years of experience, domain of expertise and self-reported level of expertise.
In the first Delphi round the experts were asked to report, on a seven-point scale (from
‘strongly disagree’ to ‘strongly agree’, or ‘undecided’), whether or not they agreed with
the content of the ‘CODE of Embouchure’. Agreement for the items of the ‘CODE of
Embouchure’ was rated on a seven-point visual analogue scale (score ranging 0-100)
or dichotomous scale (‘yes/no’; sometimes in combination with the option ‘maybe’
or in the case of the seven-point scale with ‘undecided’). The panel members could
provide comments or alternatives as feedback. The first round consisted of 47 closed
and 48 open-ended questions.
The feedback from the first round necessitated essential alterations of the text. The
research group also felt a need to clarify intra- and inter-expert contradictions in
answers, which could not be resolved in one final round. Therefore an extra round
was added to share this information among the panel members and to determine the
level of agreement for the adjustments made to the ‘CODE of Embouchure’ after the
first round. The second round consisted of 24 closed and 4 open-ended questions.
Furthermore, because of problems with interpreting the ‘undecided’ answering
option in the first round, we changed this answering option to ‘insufficient expertise’
and ‘partly agree/partly disagree’.
Based on the items for which no consensus was reached, and on relevant suggestions
(on the open-ended questions) from the second round, adjustments to the ‘CODE
of Embouchure’ were made, which were tested in the third round. The third round
consisted of 22 closed and 23 open-ended questions.
Consensus criteria
Consensus in this study was defined as:
• ≥75% gave the same answer (‘no’ or ‘yes’). ‘Maybe’ was counted as ‘yes’ in the
calculation, or
• ≥75% of all experts agree (‘agree somewhat’ to ‘strongly agree’), or
• a score ≥75 on the Visual Analogue Scale.
Data analysis
The quantitative analysis involved descriptive statistics. For this purpose, data were
entered in SPSS version 24 (Armonk, NY: IBM Corp.) to calculate the percentages
of answers to closed questions and to determine consensus according to our criteria.
Central tendency, dispersion and distribution of the variable were determined for
two closed questions with ratio measurement level measures. The qualitative part of
the analysis involved processing the answers to the open-ended questions, providing
suggestions and comments about the ‘CODE of Embouchure’ instrument. These
suggestions and comments were evaluated in two ways to decide if they were to be
entered into the next Delphi rounds. Firstly, the research group qualitatively analysed
the assumed relevancy of the comment. Secondly, a quantitative analysis assessed
whether ≥5 of the same comments had been made on a particular question. Experts
who had answered only the question ‘To what degree does the content of the ‘CODE
of Embouchure’ adequately reflect the construct of Embouchure’ were excluded from
the analysis. Percentages were calculated over the available data; missing data were
not included in the per-item analysis.
Participants
One hundred and thirty-five (135) experts were asked to participate. Fifty-six
respondents (41%) from 12 countries were willing to participate in the Delphi
procedure, while 36 (27%) were not, and we received no reaction from 43 e-mail
addresses (32%), for unclear reasons. The main reason given for non-participation
was unavailability during the study period. Of the 56 respondents indicating their
willingness to participate, 6 experts withdrew at a late stage because of illness, not
regarding themselves as experts, or because they were too busy. Forty-one of the
remaining 50 experts responded to the questionnaires (response rate 82%).
Thirty-five respondents participated in the first Delphi round, (response rate 70%, of which
1 incomplete). For the second Delphi round, 43 experts were sent the survey, of
which 33 responded (response rate 77%, of which 1 incomplete). For the third round,
38 experts were approached, of which 35 experts responded (response rate 92%, of
which 1 incomplete). The majority (94%) of the experts participating in the first
round also took part in the third round (Figure 2).
The questionnaire about the expert characteristics was not completed by all experts
(83%). The researchers (KHW and EP) then determined the categorization of the
respondents (Table 2). Category D, that of ‘Other’ experts, accounted for 17% of the
total panel.
First round
In the first round, the experts were asked whether they generally agreed with the
content of the first draft of the ‘CODE of Embouchure’ as developed by the authors.
In addition, they were asked to indicate for each item whether it should be included
in the ‘CODE of Embouchure’. Consensus was assessed for 47 closed questions:
consensus was reached for 30 of these questions (64%) (Table 3). For the closed
questions, the highest level of agreement (93%) was found for the question about
the relevance of items. The lowest level of agreement (43%) was found for the cut-off
scores, with a large number of ‘undecided’ answers (32%).
In the version of the ‘CODE of Embouchure’ tested in the first round, the items on
asymmetry and size of features (items 1-4, 8-10, 14, 19, 20, 28-30, 32, 38 and 39) in
Domains 1, 2 and 3 (Domain 4 included no such items), were assessed using
pre-specified quantitative thresholds (in degrees or millimetres) to improve the quality of
assessment, as suggested in the QUADAS (19). Under the influence of the first Delphi
round the items on asymmetry and size of features were adjusted into ordinal scales.
Appendix II summarizes the results of the closed questions. Seventeen (36%) of the
closed-ended questions were identified as suitable to be entered in the next Delphi
round after adjustments had been made in response to the feedback on the
open-ended question (see next paragraph).
Ten of the 48 open questions elicited at least 5 similar suggestions by the experts.
These suggestions were categorized into 9 topics: asymmetry, images (pictures) of
the various items, presence of non-relevant items, muscle function examination,
instrument detail and length of the ‘CODE of Embouchure’ instrument, pitches
and volume used during playing, red flags and cut-off points, the terminology of
dysfunctional / functional embouchure, and subjectivity in measuring with the
instrument. There were also 7 separate comments in the answers to other questions
which the research group considered to be relevant. These comments regarded
the topics of ‘positioning of the measurement instrument’, ‘adjustment of items of
the measurement instrument’, ‘classification’, ‘diagnosis’, ‘evaluation’, ‘whether the
measurement instrument actually measures the construct’, and ‘whether or not to add
history-taking’. The above topics were categorized into 17 subtopics (Appendix III)
and included in the further Delphi-procedure. On the whole, we found substantial
numbers of contradicting answers within and between the individual experts.
Second round
Consensus was reached about 6 of the 24 statements (Table 4). No consensus
was reached on the removal of the terms ‘embouchure motion’ and ‘pivoting’,
and about altering the terms ‘functional and dysfunctional embouchure’,
which meant that all these terms were retained. As regards the open questions,
there was only consensus among the experts about the inclusion of an item
about the mouth piece pressure on the lips.
Third round
Consensus on the closed questions was reached for 16 questions (73%) (Table 5).
At the 23 open-ended questions, 5 respondents gave similar suggestions about the
‘subjectivity of measuring the level of mouthpiece pressure on lips’. Comments
perceived to be relevant regarded using the term ‘orange flags’ instead of ‘red flags’,
ambiguity of pictures (items 1, 4, 29, 60 and 61), the explanation of the method to
determine the range of tones and the pitch categories, palpation of the tongue bone
(hyoid bone), using ‘obviously’ instead of ‘significantly’, using ‘different’ instead of
‘paradoxical’, and positioning of descriptions prior to instead of after the response
ratings.
No consensus was reached on the method for determining mouthpiece pressure on
the lips (without extra equipment), despite the fact that the earlier Delphi rounds
had yielded consensus among the experts that this aspect might be relevant for the
assessment of embouchure. We have adopted the suggestions of some experts to add
a visual screening item, to see if the lips show white discolouration after playing some
notes as a direct consequence of high pressure by the mouth piece on the lips. The
item on discoloration of the lips was not tested further for consensus.
Discussion
Despite an initially substantial number of intra- and inter-expert contradictions
in the answers, the participants reached consensus about the majority of the items
(98%). The results support the construct validity of the final draft of the ‘CODE of
Embouchure’ as the first assessment instrument of embouchure in brass playing,
enabling physicians, therapists and brass musicians to describe embouchure-related
aspects in brass players without the use of complex or expensive equipment. The
‘CODE of Embouchure’ has potential to be used for classification, observation,
diagnosis and evaluation of embouchure in individual players. Moreover, it might
in the future enable the identification of risk factors for embouchure problems and
comparisons of the effectiveness of pedagogic and therapeutic strategies for brass
players.
No consensus was reached about the way mouthpiece pressure on the lips should
be determined (without extra equipment), despite the fact that the experts agreed
that this aspect might be relevant in the assessment of embouchure. The suggestion
of some experts, to add a visual screening item checking whether the lips whitened
after playing some notes due to high pressure of the mouthpiece on the lips, was
adopted, but could not be tested for consensus. If discoloration is observed, additional
quantitative testing with force registration equipment in the brass instrument might
be used in future studies, to assess whether excessive pressure of the mouthpiece on
the lips is the cause of the discoloration (and dysfunctional embouchure).
Application of a Delphi technique, including a worldwide and highly heterogeneous
expert panel of sufficient size, the substantial response rates of the experts, the high
cut-off levels for consensus and the active encouragement of open discussions, which
were held anonymously and were coordinated by an independent researcher, are
regarded as strengths of this study. The use of a Delphi method has the benefit of
avoiding group dynamics and hierarchical structures, which are often seen in focus
meetings (15). The risk of introducing bias might have been substantial if we had used
focus meetings to reach consensus among the strong and sometimes contradicting
expert-based opinions which are found in the field of embouchure. We stress the
importance of this group consensus, because there is no other common platform of
information exchange between the four categories of experts included in our panel.
Potential limitations of this study might be related to selection bias in our recruitment
of the experts, questionnaire fatigue, the use of non-validated English translations of
the questionnaires, the obligation to read a specific article about embouchure at the
start of the study participation, the subjectivity of item interpretation and the fact that
consensus is not a guarantee for ‘finding the truth’. In a Delphi study, the process of
questioning should normally be continued until consensus is reached (mostly in 2 or
3 rounds) (15,16). Because of the risk of questionnaire fatigue among the participants,
it is recommended not to use more than 3 rounds (16). In our study, questionnaire
fatigue was a potentially serious problem, in view of the many comments by the
panel experts about their work load and the efforts it them took to complete the
first Delphi round. We assume that the impact of limiting the Delphi procedure to a
maximum of 3 rounds is negligible, in view of the high level of consensus among the
experts at the end of the third round.
Selection bias: this potential source of bias was reduced by using different ways to
approach the experts. Fifty-one percent of the expert panel consisted of Dutch experts.
As far as the authors know, the variety of opinions among Dutch embouchure experts
does not differ from that across other countries. Some of the Dutch experts were invited
to participate because of their knowledge of subjects not related to embouchure (e.g.
dentist / audiologist / speech therapists and music therapist). Moreover, the authors
were not previously acquainted with several of the Dutch experts. No substantial or
consistent differences in answers were observed between the Dutch and other experts.
Therefore, we regard it as unlikely that the over-representation of the Dutch has
introduced bias in the study. Another limitation might be that we chose to perform
the study in English with non-validated questionnaires, as we had no alternative.
We received some comments from both English and non-English speaking experts
about difficulties in the interpretation of the exact meaning of some text parts, which
increased the percentage of ‘no opinion’ answers, thereby reducing consensus.
In the questionnaire of the first Delphi round questions with the answering options
‘yes/no/maybe’ were applied. In the calculation ‘maybe’ was considered as ‘yes’, because
‘maybe’ refers to at least some level of doubt of the expert about the content of that
particular question or item. In this way, the option ‘maybe’ has led to adjustment or
removal of the item as was the case in 4 out of the 5 questions (e.g. ‘Presence of
non-relevant items concerning embouchure’). Overall, the addition of ‘maybe’ resulted
in a more conservative estimation of the construct validity.
A potential limitation of the ‘CODE of Embouchure’ itself is the subjective nature
of the interpretation of several items. This is a common issue in the assessment of
body structures, body functions and physical functioning. For example, the existing
grading systems for determining facial asymmetries, as known from the literature
about peripheral facial nerve paralysis, are also all subjective in their assessment. As a
consequence, such grading systems have limited psychometric value (20). We tried to
reduce this potential limitation by quantifying features (e.g. millimetres of difference
in asymmetries or differences in degrees of deviations). During the first Delphi round
this approach was much criticized, because it was unclear how to measure these
features. The relevance of the magnitude of these differences is unknown.
Knowledge bias may have been introduced in the study because of the obligation
to read a paper about the fundamentals of embouchure to ensure a shared level of
knowledge. Although it was not our intention to test the level of consensus about
the content of that paper, which had been published in a peer-reviewed journal, it
is possible that some potential experts did not participate in the panel because they
disagreed with the views on embouchure presented in it. We did not receive any
comments suggesting this, although some experts severely criticized some aspects.
All of these experts remained included during the whole study and agreement was
ultimately reached for most items. It is important to stress that consensus reached
via a Delphi method among a group of experts is not a guarantee for ‘finding the
truth’ (21). Further research with different designs is necessary to study other
psychometrics and the relevance of items of the ‘CODE of Embouchure’, including
reliability, item relevance, (causal) relations between features of embouchure and
embouchure problems. Additionally, several experts in this study stressed that there
are many ways to play a brass instrument, and this has to be taken into account when
judging individual embouchure features of brass players. Although we agree with
this aspect of inter-individual variation, we assume that there are also general rules,
characteristics and physical laws underlying embouchure, which enable consistent
assessment of potential ‘at risk’ embouchure (12).
Conclusion
Participants in this Delphi study reached consensus on almost all of the finally
included items of the ‘CODE of Embouchure’, thus confirming its content validity.
The ‘CODE of Embouchure’ may in the future enable clinicians, scientists and brass
players to assess embouchure in brass players without the use of expensive or complex
equipment.
Acknowledgments
The authors thank the experts who took part in the Delphi panels for their
participation, and Mr. Antoine de Schipper for preparation of the figures.
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333679.
Instructions
fo
r
the
assessment
of
embouchur
e
in
br
ass
pla
yers
usin
g
“C
ODE
of
embouchur
e”
K.H.Woldendorp
, H.B. Boschma
& E. Ploos
van Amstel
©
1
Instructions
fo
r
the
assessment
of
embouchur
e
in
br
ass
pla
yers
using
“C
ODE
of
embouchur
e”
Chapt
er
1:
Gener
al
instructions
The CODE of em bouchur e consists of 4 d om ai ns wi th 64 items: 1. Inspection of the brass player i n r esting position (wi thout i ns trument), items 1‐21. 2. Inspection of the bra ss player durin g pl aying, ite ms 22‐34. 3. Inspection of the posi tioni ng of the instrumen t/rim v isualizer (duri ng playi ng ), items 35‐42. 4. Aspects of so und‐prod ucti on, items 43‐ 64. It is re comm ended to re cord th e brass pl ayer’s playing on video (wi th sound ). Thi s enables re peated i nspe ction of th e diff eren t it ems of the C ODE of Embou chu re by the observer after wa rds. It also ser ves as a reco rd to enable comparison o f the various items over time. In ea ch i tem there is an ans wering op tion: ‘ Don’t know’ (e. g. i n case of un certai nty abou t ho w to ju dge th e ite m). T he option ‘Don’t know’ is i ndi cated in domains 2, 3 and 4 by the l etter ‘Z’. Be fo re starti ng to fill in D omai n 1 : The brass playe r should not have p layed for at least one hour to avoid visible marks of previou s pl ay ing in the fa cial are a. The brass player may sit or stand a nd sh ould be in a c omfortabl e po sit io n. The i nspectio n should be in day lig ht or with sui table artificia l li ghti ng. Requir eme nt s: a goniome ter, a pen and a paper versi on of the CO DE of Embou chure . Before starti ng to fill in D omai n 2 : The brass player should s tart wi th a sho rt warmin g u p on his/he r instrument to feel comfortable about pl aying the diff erent ite m s of the CODE of embouchure . The brass player may sit or stand w hile playing. Fi g. 1 : R im v isu al izer .
2 Fi lli ng in D om ai ns 2 ‐4: The assessme nts for Domai ns 2‐4 should be performe d using the i ns trumen t i n combination with a rim vis ualizer (Fig. 1 ) or tra nsparent mouthpiece . The diame ter /size of the ri m vis ualizer should b e as si milar as possible to th e mo uthpi ece (Th e rim visualiz er is available vi a www.thomann.de/). Us in g th e rim v isu al ize r: af te r playi ng th e ‘test tone’ (at th e pi tc h l evel to be assessed) on th e brass instru ment, each m out h position should be assessed with the rim visualizer. Th e m ou th sh ou ld b e kept in th e same position whil e switching f rom th e in st rum en t t o t he rim vi su al ize r. In individual cases the position of the ri m visualizer on the l ip s can be sli ghtly di fferent from the position of the real mou thpi ece: this should be noted i n the cell marked “Miscella neou s” or “Techni cal aspects” i n Domain 4 . The observati ons of playin g th e i nstrum ent are th e m ost releva nt a nd ta ke priority whe n filling i n the form. The s coring o f all ite m s is e xpla ine d in C hapter 2 and the i nte rp ret ation of all sc ores is indica ted a t t he en d of Chapt er 3. Additi on al i nf orma tio n: Instruction m ovie (1;49 hr ) “The C OD E of E m bo uc hu re ” o n Yo uT ub e: https://www.youtube.co m /watch?v=Vr‐FLpTcX7g. List of terms & abbrevi ati ons : This symbol u sed in the Cla ssification Ta ble m eans m ultiple opt ion s can be chosen in an i te m MC: Mo uth co rn er (s) MP: Mo uth pie ce NLF: Nasolabial Fold(s) TMJ: Temporoman dibular join t (jaw joint) TMP: Tongue bone Movemen t P attern Righ t: The brass player’s right si de Left : The brass player’s left side Orange fla gs: Indica te ab normal/ deviant feat ur es , signs and sy mp to ms in the em bouchur e‐rel ated body str uctures and/ or functio ns of a brass pla yer. Atten tion sho uld b e giv en to the poten tial negative im pact of t he se ‘orange fla gs’ on th e bra ss players’ embouchure.
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Scoring met hod: Step 1: Circl e the a ppropria te op tions in the cells. If a pplica ble, cir cle right (R) or left (L ). Step 2: I ndica te for ea ch i tem if an oran ge flag is scor ed. Step 3: After comple ting D omain 1, cou nt the nu m be r of orange f la gs and e nter at the botto m of the tabl e for Domain 1. MOUTH/ LIPS /TONGUE (items 1‐6) Item 1 Sy m m et ry o f mo ut h co rn er s ( M Cs ) a t R ES T: If one M C is l ower, circle w hich MC is l ower, right (R ) or lef t ( L). (An MC is low er when it is below t he ho riz on ta l l in e) . If one M C is pulled out in a forward direction, cir cle w hich MC is pu lled ou t more , R or L . If one MC is more lateral than t he ot her , circle whi ch M C is mo re la teral, R or L. Mul tiple opti ons can be chosen. Item 2 Degre e of asym metry o f MCs in item 1 This it em is u sed to deter mine the de gr ee of t he asy mme try repo rted i n i tem 1 . This is en ter ed usin g an ordinal scale: ‘no’ ‐ ‘light’ ‐ ‘severe’ asymmetry . An orange flag is s core d if the asymmetr y is ‘seve re’. In case of diff erent cate gories of asymm etry in ite m 1 : choose the most promin ent cate gory. Item 3 Scar(s) in/ ar ound the mouth/li ps : A scar should only be scor ed as ‘yes’ if i t is loca ted in the a rea of the mouthpiece. A scar is non‐relevant if it ca n be assume d to have no i nfluen ce on the e mbouc hure. A scar is rel evant if it can be assumed to affect th e loc al cha racteris tics of the lip tissue to such exte nt that a n influ en ce o n th e e mbou chure is lik ely , this is s cored as an orang e flag. Scar tissue el asticity can b e differe nt fr om tha t of t he surrou ndi ng tissue. Circle R or L. Multipl e opti ons can be ch osen (a maxi m um of 1 o range flag for t his ite m ). Item 2: Sever e a symmetry Item 1: Lower MC right (li gh t a sy m m et ry ) Item 2: No asym m etry Item 1: Lower MC right (sever e asymmetry)
4 Item 4 Miscellaneous/Disor ders : ‘Yes’ is scored as an orang e fla g: If e.g. extre mely thi n lips (=i .e. li p is di ffi cul t t o ob se rv e a t r es t) o r e xtr em el y th ick and weak lips. Thi s should be e ntered in this cell . Red, swollen lips, blisters, pain or small w ounds shou ld also be entered in this cell. Item 5 To ng ue a no m al ie s w hi le a t R ES T: A tong ue ano maly should be score d as ‘Yes’ (= orang e flag) if the tongue is asy m me trical a t RES T, if ther e is pain, wound (s) i n/a round the tongu e or if the ton gu e (h yoid) bon e d oes no t change position (‘fixed’ tongu e bone ). This can be test ed by p alp at ing th e t on gu e bo ne d ur ing sw al lo w in g. T he h yo id b on e is ro ug hl y aligned with the chin in the nor mal upright posture (see dotted line in the figure). During swallowing t he tongue bone should move upwards and forwards. Circle R or L if appli cable a nd in dica te o bservation. Item 5: Thin lips Item 5: Thick li ps Ite m 5 : S w ol le n up pe r l ip Item 5: Normal tongue Item 5: Tongue bone Item 5: Palpati ng the to ngu e b on e Item 4: Non‐r elevant scar up per li p Item 4: Relevant scar upper lip
5 Item 6 Tongue anomalies when STICKING OUT the tong ue : A tong ue ano maly should be score d as ‘yes’ if a perso n can not l ift th e ti p of his/h er ton gue u p to the upper alveolar edge (e.g. b ecause the li ngual fre nulu m is too s hort ) or if they cannot sti ck th eir tong ue straight ou t. This is scored as an orange flag. If asym m etry is pres ent: circ le de viation towards R or L and in di ca te o bs er va tio n. (Source: Jansonius‐Schultheiss, K ., Coppenolle, L. Van & Beya er t, E. (2012). Afwijk ende mondgewo onte n. Inleiding, onderzoek en beha ndeling. Den Haag/Leuv en: Acco.) CHE EKS & MI DFACE (item 7‐10) Item 7 Sy m m et ry o f t he n as ol ab ia l f ol ds (N LF s) a t R ES T: The recording of diffe re nces in symmetries of the mi dfacial are a (the main characteristi c b ei ng the nasolabial fold) is subjective i n nature. If asymme try is visible, cir cle whi ch NLF i s longes t, R or L. If th e asy mme try is ‘m ore pronounc ed’, this is sc ored as an orange flag. ‘No, absent’ m eans NL F is not vi sible on one side . T hi s is scor ed as an orange fla g: cir cle whi ch NLF is abse nt, R or L. ‘Yes, but bot h absen t’ me ans the NLFs are not visibl e on ei ther side. This is s cored as an ora nge flag . Item 8 Midfacial ac tivity Di ffere nces are best observed w hen show ing teeth. If there is asymmetry of lip opening when showing teeth (=dista nce between the upper and l ower l ips at the level of Item 7: Normal Item 7: ‘Abs ent ’ r ight Ite m 7: ‘More p ron ou nc ed ’ righ t Item 6: Lingual f renul um to o sh or t Item 6: Normal the canin es on th e rig ht an d left side ), c ircle R or L . Item 8/9: Sever e asymmetry left Item 8/9 : No as ymmetry
6 Item 9 Degree of asymmetry i n i tem 8 In this item the d egree of asymme try n oted at ite m 8 is quan tif ie d and en tere d using an or dinal scale: ‘n o’ ‐ ‘light’ ‐ ‘s ever e’ asymmetry. An orange flag is scored if th e as ym m et ry is ‘se ve re ’. Item 10 Misce llaneous/ Disorder s: ‘Yes’ if e.g. s cars of the cheek s ham per p roper movem ents of th e midfacial area, this is scored as an orange fla g: In di cate ob serv ation. DENTAL ARC H (I tems 11‐1 7) Item 11 Den tal Arch ‘Gothic’ dental arch of the max illa: If the incisors stand at a n ang le relative to th e adjace nt te eth a nd the canines are pl ac ed too far backw ards, this is s core d as an orange flag. It can b e assum ed that a gothic den tal arch in terferes with a proper posi tioning of the mouthp iece. ‘Miscellaneo us’: If you ob serve a shape of the de ntal arch (oth er than a go thic dental arch ) which can be assumed to i nterfere negatively wi th the positioning of the m outhpie ce, th is is scor ed as an orange fla g, ent er your observation. Item 12 Den tal Arch ‘Irregular’: If the den tal ar ch is irregular with parts of the incis ors missin g, den tal elem en ts incline d backwa rds, or turn ed arou nd their axis, th is is scored as an orange flag. Item 8/9 : Sever e asymmetry right Ite m 1 1: ‘G ot hi c’ (a bo ve ) an d normal/round denta l ar ch (be lo w) . Ite m 12: Irre gu lar d en tal row mandi ble
7 Item 13 De nt al ar ch The i ncisors of the maxilla are s cored as ‘split’ (ce ntra l dias tema ) if o ne can ex hale air t hrough it, this is scor ed as an or ange flag. Item 14 De nt al A rc h The den tal ar ch is not i nta ct if ele men ts are missing li ke in ci sors or canin es of lo wer (= oran ge flag) and/or upp er jaw (= or ange flag). Mul tiple opti ons can be ch osen (a maxi mum of 1 orange flag for this ite m). Item 15 Teeth 1 Teeth are s cored as ‘promi nent’ if they protrude forward, this is s cored as an orange flag. A n addi tional a rgume nt to s core ‘p rominent’ is when a change in t he mucosal layer can be observed on the in side of the corresponding lip area, due to pressure be tween the prominen t tooth and th e mouthp ie ce. A protrudi ng tooth outsid e the im medi at e ar ea o f t he mo ut hpi ec e sho ul d be sc or ed as ‘no prominen t te eth’. Mu ltiple opt ions c an be chosen ( a maximum of 1 orange flag for this item). 1 ‘ Te eth’: also in case of a single tooth. Item 14: Missin g elem ent in de nt al ro w o f u pp er ja w Ite m 1 5: P rom in en t i nc iso r i n up pe r (circle) and low er jaw (arrow) Item 13: Incis ors spli t
8 Item 16 Inc lina tio n an gle o f t ee th An in clination angle ca n b e consider ed to be normal if betw een 1 25 and 180 degrees. ‘B ackward inc lination’: If the i nc lin at ion an gl e of the t eeth (the angl e betwee n the upper and lower i ncisor s) i s ≥ 180 degrees, th is is s co red a s a n or ang e f lag. ‘Extre me for ward inclinati on’: If the i ncl in atio n an gle is ≤ 12 5 degr ees, thi s i s s cored as an or ange fl ag. Item 17 De nt al b ra ce s/ pr os th es is( es ) Braces or prosthesis(es) in upper jaw (= orange flag) a nd/or lo wer j aw (= orange flag). Mul tiple opti ons can be ch osen (a maxi mum of 1 orange flag for this ite m). JAWS (Items 18‐21) Ite m 1 8 Relation between dental arches – sagittal view ‘Underbite’: If the incisors of the lo wer jaw are positio ned fu rther forward than the incisors of the upper jaw, this is score d as an orange flag. Item 16: Backward incli na tio n an gl e Item 16: Extreme forward incli nat ion an gl e Item 18: Underbite Item 16: Prin cip le of angl e assessm ent Item 16: Normal in cli na tio n an gl e ‘Rel ative underbite’: If the inci sors of both dental arches or incisors of the l ower jaw are pos iti oned di rectl y behi nd t he inc isors of the upper jaw, thi s i s scored as an orange flag. Item 1 8: R elativ e un de rb ite
9 ‘Overbite’ : If the incisors of the upper jaw are positioned further forwa rd than the incisors o f the lower jaw, this is scored as an orange fl ag. Item 19 Rela tio n b etwee n d en tal arches – f ron tal view ‘Mild asym m etry’: If the u pper an d low er jaws show a small devi ation from the midline. ‘Pronounced asymmetry’: If asy mmetry of uppe r and l ower jaws and/or deviation from midline is obvious, thi s i s scored as an orange flag. ‘Open bite’: If the in cisors of the upp er and lower ja ws do not m ee t, t his is scor ed as an orange flag. Mul tiple opti ons can be ch osen (a maxi mum of 1 orange flag for this ite m). Item 20 Jaw opening ‐ vertic al direction Item 18: Overbi te Item 19: Pronounced asymmetr y Item 19: Mild asymmetry (ci rc le )a nd open bite Item 20: Limited m outh op en in g (two fingers)
10 ‘Normal’: If t he brass play er can open h is/her mouth to an e xte nt that the tips o f the ind ex, middle and ri ng fin ger tog ether can be positioned i n the mouth opening be tween the ce ntral in cisors of the lower a nd u pper jaw . ‘Limited’: If the brass player c an not p ut the ti ps of hi s/her i nde x, middle and ri ng fin ger tog ether in the mouth openi ng b etw ee n t he centra l incisor s of the lower and th e up per jaw, this is score d as an orange flag. (Source: Zawawi, K.H., Al‐Badaw i,E.A., Lobo Lobo , S., Me lis, M .& Mehta, N.R. (20 03). An Index fo r the Measurement of Normal Ma ximum Mouth Opening. J Can Dent Assoc 2003; 69(11):737 –4 1) Item 21 Misce llaneous/ Disorder s: ‘Yes’ if e.g. lo osening teeth, p ain, ab normal lip move m ents and /o r s w ol le n temporoman dibular Joint (TMJ) tha t hi nders proper movements of jaw, this is s cored as an orange flag. In dicate observation.
Domain 2: Body Structures & functions wh
ile playing
NOTE: The following steps shoul d be p er forme d to deter m in e the pitch‐ categories fr om ‘extre mel y low’ to ‘extr emely high’. Step 1: Det er m ine the hi ghest and low est pi tch ed tones the brass player ca n p lay (=ran ge of tones): The brass player starts with pla ying a tone from the middle reg ister and the n g oing in to do w nw ard pi tch direction until th e lo west pitched tone what c an be played i n t he same way as the mid dle re gister ton e. Th is tone is the lowest pitched tone. As a next ste p fo llow the sam e proce dure in th e opposit e way to deter m ine th e tone with the hi ghest pi tch. This is th e high est pitch ed ton e. Step 2: T his r ange should be div id ed into 5 cate gorie s, first b y d eterminin g the central tone . Next, the range of tones on eac h side o f the central tone should be divi ded into three parts. The mi ddle third par ts are take n t og eth er as the m ed ium pitch are a; see fig ure and e xample . Ask th e playe r to play one tone wi thin e ach category. Indi cate th is tone on the d otted lines of the ‘playing tones’ in t he tab le . Ite m 2 1: T em po rom an di bu la r J oi nt (T M J)11 Examp le: Lowest to ne = a1 and high est ton e = c is4 ; rang e of to nes = 3 .2 (c o r cis = the sa me d ecimal ) octaves. The central tone i s (th e m iddle) : 3.2/2 = 1.6 octave: a1 + 1 .6 o ctave giv es f2 . Each 1/3 of 1.6 octave is 0.5 octav e. Extr emely lo w pitc h i s: a1 ‐e1. Lo w pi tc h is e1‐b2 etc . Playing tones of different pi tches means: Medi um pitch = the ton es in the cen tral part (≤ 1/3 below and ≤ 1/ 3 above th e central tone o f the range of tones), E xtremely low pit ch= in th e lowest 1/3 below the ce ntral tone, Low pit ch = i n th e ne xt hi gher 1/3 b elow the tone s of t he me diu m pitch, High pitch = i n th e n ext 1/ 3 abov e th e tones o f the me dium p itc h, Extre mely hig h pi tch = in th e hig hest 1/3 above the ce ntral ton e. In some items of Domain 2 ( item 22, 25, 26, 27 and 31) one can indicate ’diffe rent patter ns’. ‘Different p atterns’ shou ld be cir cled if the way of p erforming over the diffe rent pitch l evels for that e mbouchure item is i n the opposite way as describe d i n th e F unda mentals of Embouchure ( Woldendorp et al. (2016) ); e.g. playing low ton es with a s mall lip o pe ni ng a nd te nse d th in li ps. Scori ng met hod: Step 1: Fill in all cells for th e differe nt pi tches using the o ptions pr ovided in col umn 3. Step 2: For each row, identify i f there is an orange fla g patte rn or symptom . T he se miscella ne ou s symptom s or differen t patter ns are describe d in the expla nati on section be low. Step 3: If an orange flag is ide ntified in one cel l/row, enter this in column 5 (‘orange flag sco re’). Step 4: After comple ting D omain 2, cou nt the nu m be r of orange f la gs for this d omain and en ter a t t he bott om of the t able for Domain 2. Cent ra l to ne Up pe r t on e Lo w pitch Medium pitch High pitch Extremely High pitch Extremely low pitch Lowe st tone 1/3 1/3 1/3 1/3 1/3 1/3
12 Lip opening ( relative width) A, B, C, D = ‘Relative width’ of the lip opening is the widt h of the lip opening while playing tones of the pitch/intensity cat egory to be tested, i n comparison wi th pl ayi ng tones i n the other pi tch/i ntensi ty categori es. An orange flag is scored if a different pattern is visible while pl aying tones of different pitches, in whi ch the l ip opening becomes sm aller while playing lower pitch ed tones (and vice versa). Item 23 Lip op ening A = If asymmetry of the l ip opening is vi sible. B = If th e lip opening is ou tsid e the MP/ rim visualize r, this is s cored as an orange flag. Item 24 Degree of asymmetry i n i tem 23 This item determines the degree of asymme try in de lip opening assessed by ite m 23; i t is ent ered usi ng an ordinal scale : A = no asym m etry B = lig ht asymme try C = severe as ymmetry . A n orange f lag is scored if the asymmetry is ‘s ev er e’ . Item 23: Sever e asymmetr y Ite m 2 3: Li p op en in g ou ts id e rim visuali zer Item 24: Sever e asymmetr y Mouth & Lips (items 22‐30) Item 22
13 A, B, C = ‘ Relative thickness’ of the lip is the thickness of the l ips whi le pl ayi ng tones of t he pi tch/i ntensi ty category to be tested, in comparison with playing t ones in the other pitch/intensity categories. An orange flag is scored if a different pattern is visible while playing tone s of different pitches, in which the upper and/or lower l ip becomes relati vel y thinner while playing lower pitched tones (and vice versa). Item 27 Lip s r ol le d in w ar ds /o ut w ar ds Lower lip roll s inwards to cr eate hi gher lip te ns ion for the pr odu cti on of hig her t ones and vi ce versa. A = If lips are curved aroun d th e i ncisors B = If lips are rolled out an d in side muco sa is vi sible An orange flag is scored if a differen t pa ttern is visibl e whil e playi ng ton es of di fferent pitche s, with li ps rolle d inwards a t l ow p itches or rolled outwards at h igh pi tches. Item 28 Mou th co rn er s ( MC s) (h or izo nt al d ire ct io n) A = If diffe re nces between rig ht and l eft si de of the mouth are absent or small. B = If differences in changes between right and left side of th e mouth are clearly visible, more to the ri ght and left, respectivel y. Thi s is scored as an orange f lag. C = If on e MC deviates sev ere ly in l ater al directi on, thi s i s s cored as an orange flag. D = If one MC is pull ed ou t severe ly in frontal dire ctio n, this is scored as an orange flag. If appli cabl e, indi ca te R or L i n the ce ll(s ). Mul tipl e opti ons can be ch osen ( a maxi mum of 1 orange fl ag for this ite m). Ite m 2 7: R ol le d in li ps fro nt al view Ite m 2 7: R ol le d in li ps la te ra l view Ite m 2 7: R oll ed o ut lips lat er al view Ite m 2 7: R oll ed o ut lips fro nt al view Item 28: MC (righ t) severely deviati on to l ateral directio n Item 28: MC (left) of small deviati on to l ateral directio n Item 28: MC ( right) pulled out severe in frontal direction Ite m s 2 5 an d 26 Lower / Upper lip (rel ativ e thickness)
Item 29 Mouth corners (MCs) (vertical direction) Observed rel ati ve to the mi ddl e of the li p cl osure whi le pl ayi ng the di fferent tones as i ndi cated in Domain 2. A = If b ot h M Cs a re at equal levels (in middle and low pitched r egister) B = If one MC i s obvi ousl y l ower . Indi cate R or L i n the cel l(s ). C = If one MC i s obvi ousl y hi ghe r. Indicate R or L i n the cel l(s) . D = If both MCs are at equal levels in high position and the li ps kept tensed, while playing a me dium or (extreme ly) lo w tone ( e.g. smile & press: this means if the brass player plays with lips spread wi de (= MCs shift to lateral in a slight up w ar d po sit io n) . This pheno meno n is func tio nal duri ng high/extremely high playin g, but some brass pla yers also apply thi s tec hniq ue when play ing medi um and/or l ow pi tched tones. The corre spo nding tone s sound squeezed. Item 30 Abnormal lip movem en ts: features l ike vibrations, tr emors, twitching, shaki ng. A = No B = Yes. T his i s scored as a n orange fla g. Jaw (item 31) Item 31 Ja w p os iti on Th e po sition of the jaws s hou ld b e con sider ed rela tive to ea ch other. Opt io ns A an d D a re th e m os t ex tre me positions in which the man dibl e can be ac tively posi tioned. Orange fla g is scored if one of the fol lowi ng mi scel laneous sym pto m s or dif fere nt pa tter ns is visible w hile pla ying tones of different pi tches; movi ng the jaw posi tion back ward when pl ayi ng l ow an d/or forward when pl ayi ng hi gh (n ot extreme ly hi gh ). Ite m 29 : M C le ft ob vi ou sly lo w er and MC right o bviously hig her Ite m 29 : B ot h M C hi gh p os iti on 14
15 Cheeks (items 32 & 33) Item 32 Cheeks Recordi ng dif ferences in sy mme tries of t he mi dfacial area (main ch aracteristic b eing the nasola bial fold) is subjective in nat ure. B = If asym m etry in the NL Fs leng th is vi sible, indi cate R or L in t he cell (s), fo r t he longes t N LF. C = If ‘miscell aneous’, this is scored as a n orange fla g. Indi cate o bservatio n, e .g. puffed cheeks. Mul tiple opti ons can be chosen. Item 33 Degree of asymmetry i n i tem 32 This it em det ermines the d egree of asymme try of t he ph enomen a i n i tem 32; this is re cord ed usin g an ordinal scale: A = no a sy m m et ry B = lig ht asymme try C = severe as ymmetry . A n orange f lag is scored if the asymmetry is ‘s ev er e’ . Tong ue (Items 34 & 35) Item 34 Visual aspects of Tong ue A = No abnor m alities (no tongue v isibl e), or tones are con tinuo usl y ende d by p utti ng the tip of the tongu e in the lip open ing (this phe nom enon should be in dicated i n Domain 4, i tem 47 (‘ ton gu e stoppi ng’)). B = If the ton gue is visib le during playin g, this is scored as an orange flag. Item 32/33: NLF severe asymmetry left
