Frequency, severity and predictors of playing-related musculoskeletal pain in professional orchestral musicians in Germany

Factors Associated with Performance-Related Pain Among Musicians: A Multicenter Study Using Validated Tools

PURPOSE

We aimed to evaluate factors associated with performance-related pain among musicians with different backgrounds, comparing music students and professional musicians.

METHODS

We performed a multicenter cross-sectional study in a stratified random sample consisting of music students (294) and professional musicians (291). The main outcome was performance-related pain (PRP), measured by the Performance-related Pain among Musicians Questionnaire (PPAM). Factors associated with the outcome were measured using PPAM, International Physical Activity Questionnaire, Modified Fatigue Impact Scale, 10-item Kessler Psychological Distress Scale, Frost Multidimensional Perfectionism Scale, and Medical Outcomes Study Short Form 36 Health Survey.

RESULTS

From the 585 musicians included (response rate of 82.4%), 322 (55.0%) reported PRP. Professional musicians presented a significantly higher lifetime prevalence of PRP (57.5%, p < 0.001); however, music students reported higher levels of fatigue, anxiety and depression, and lower quality of life. Multivariate logistic regression defined a model with 16 factors significantly associated with higher probability of PRP. Additionally, we describe 25 self-perceived factors reported by musicians as being associated with PRP.

CONCLUSION

We present the first study thoroughly describing and assessing factors associated with PRP among musicians, using a validated tool, including musicians with different backgrounds, and distinguishing music students and professional musicians. We also explore self-perceived factors associated with PRP. The relevant insights coming from this and future studies on factors associated with PRP will contribute to developing more effective preventive programs and improving evidence-based guidance and management of musicians affected by PRP.

Efficacy of Therapeutic Exercise in Reducing Pain in Instrumental Musicians: Systematic Review and Meta-Analysis

Playing-related pain poses a significant health concern for musicians, often impacting their ability to perform. Therapeutic exercise emerges as a viable approach to alleviate these symptoms, offering a low-cost intervention with minimal side effects. This review seeks to examine and assess the efficacy of therapeutic exercise in reducing pain intensity among instrumental musicians. Three major databases (PubMed, Web of Science, and Scopus) were systematically searched from November 2023 to June 2024. The inclusion criteria required studies to be randomized clinical trials focusing on pain intensity in instrumental musicians, published in the last 10 years. Two independent researchers assessed the characteristics and methodological quality of the selected studies. Out of 305 identified studies, 15 underwent full-text reviews, with 5 ultimately included in the analysis. The total participant count was 273, with an average intervention duration of 32.5 min per session, twice weekly for eight weeks. Overall, therapeutic exercise interventions demonstrated favorable effects, with three studies exhibiting good methodological quality. The meta-analysis revealed significant positive results favoring exercise in reducing pain intensity, with positive responses observed across all clinical populations, so therapeutic exercise appears to be an effective approach for reducing pain intensity in musicians experiencing playing-related pain.

Passion and performance anxiety: How it affects the incidence of musculoskeletal disorders in dancers

OBJECTIVES

This study aimed to examine the association between the incidence of musculoskeletal disorder episodes (MDEs) and obsessive and harmonious passion as well as performance anxiety throughout a dance season, which lasted 38 weeks.

DESIGN

Prospective cohort study.

METHODS

A total of 118 professional and preprofessional dancers were recruited and assessed at baseline, while 88 completed the follow-up. Their levels of passion and performance anxiety were assessed at the beginning of a dance season using the Passion Scale and the Kenny Music Performance Anxiety Inventory, respectively. To monitor the incidence of MDEs throughout a dance season, dancers were asked to complete a weekly electronic diary.

RESULTS

A higher level of obsessive passion was associated with a higher incidence of MDEs causing an interruption of dance activities (β = 0.264, p = 0.022). Harmonious passion and performance anxiety were not associated with MDEs throughout the season.

CONCLUSIONS

Findings of this study support the role of obsessive passion in the development of MDEs in dancers.

Prevalence of musculoskeletal pain and associated factors among professional orchestra musicians in Norway

BACKGROUND

Orchestra musicians have a high risk of experiencing musculoskeletal problems. These problems may lead to sleep and psychological disturbance.

OBJECTIVES

This study investigated the occurrence of musculoskeletal pain (MSP) among orchestra musicians and the coherence between pain and predictors such as gender, age and instrument. Further, the impact of pain on sleep and mental health was analysed to assess pain as a predictor threatening musicians' wellbeing.

METHODS

Some 358 musicians in eight different professional orchestras in Norway completed a questionnaire. Questions about pain experienced within the last 30 days were based on a national survey. Standardised screening tools like the Hopkins Symptom Checklist-25 (HSCL-25) and Bergen Insomnia Scale (BIS) were used to assess psychological distress and sleeping problems. Kruskal-Wallis tests were used to analyse the differences in the pain-related variables: experienced pain severity (EPS), number of pain areas, and work being perceived as the source of pain based on age. Mann-Whitney U tests were conducted to evaluate the statistical significance between gender and the pain-related variables. Spearman's rank correlations were used to examine the relationship between EPS and BIS, HSCL-25 and pain area. Additionally, simple linear regression models were employed to determine whether EPS can predict higher scores on the HSCL-25 and BIS scales.

RESULTS

The prevalence of MSP experienced in the last 30 days among orchestra musicians in Norway was 85%. Musicians experienced frequent pain regardless of their gender, age or instrument group. Neck, shoulders and upper back represented the most reported pain areas. Further, it was observed that increased EPS was correlated with an increase in the number of pain areas and in work being perceived as the source of pain. EPS significantly predicted sleep- and psychological distress.

CONCLUSIONS

Orchestra musicians have a high risk of encountering MSP. Furthermore, their psychological distress and sleeping problems seem to be related to experienced MSP. To deliver optimal health, these problems should be handled simultaneously.

Development and Initial Validation of the First Questionnaire to Evaluate Performance-related Pain Among Musicians with Different Backgrounds: Performance-related Pain Among Musicians Questionnaire (PPAM)

AIM

To develop and perform the expert's content validation and pretesting of the first questionnaire specifically designed to evaluate performance-related pain among musicians with different backgrounds.

METHODS

The development of the Performance-related Pain Among Musicians Questionnaire (PPAM) was carried out in 4 phases: (1) item generation, (2) experts' panel evaluation and content validation (3) pretesting, and (4) conceptualization of the final version. For item generation we conducted two systematic reviews to identify the existing tools evaluating similar constructs and the predictive factors of performance-related pain. Four expert panel meetings and three pilot tests were performed, with a total of 94 musicians.

RESULTS

From the 1154 articles initially found in the literature search, 153 were included (65 related to pain tools and 88 related to predictive factors) and a pool of 115 items were created. After expert panel evaluation and pretesting, a final self-report questionnaire was defined, comprising 33 core items to evaluate 3 constructs (pain intensity, pain interference in general activities and pain interference in performance), as well as 32 additional items (optional module - predictive factors).

CONCLUSIONS

The PPAM Questionnaire is specifically designed and validated for musicians and can be applied for all types of musicians (professional, amateur and music students), allowing the development of comparative studies between musicians. It is a new enriched tool, easy to respond and disseminate to large, multicentre, and international samples. PPAM is suitable for research and clinical practice purposes and will allow the improved assessment and monitoring of pain in this occupational context.

Performance-Related Pain Among Musicians Questionnaire (PPAM): Multicenter Validation of the First Questionnaire to Evaluate Performance-Related Pain Among Musicians With Different Musical Backgrounds

We aim to present the first psychometric evaluation of the Performance-related Pain Among Musicians questionnaire (PPAM), the first questionnaire specifically designed to evaluate performance-related pain among musicians with different musical backgrounds, based on a multicenter validation study. The psychometric evaluation was performed in a validation sample of 458 musicians, at baseline and after seven days. We assessed the applicability, reliability, internal consistency, construct validity, and factor structure of the PPAM. The Cronbach's α coefficients for the 3 subdimensions of PPAM-"pain intensity", "pain interference in general", and "pain interference in performance"-were .834, .864, and .930, respectively, suggesting a high degree of internal consistency. Test-retest reliability coefficients were substantial for all subscales of the PPAM questionnaire. Exploratory factor analysis indicated a three-factor structure (pain intensity, interference in general activities, and interference in performance) that explained 62% of the variance. Both convergent and divergent validity were well demonstrated, confirming more than 95% of the previously defined hypotheses regarding correlations with other measures. PPAM is the first validated questionnaire to evaluate pain among musicians with different musical backgrounds. This online self-reported questionnaire is a valid and reliable tool suitable for both clinical research and clinical practice, with excellent psychometric properties, both in terms of internal consistency, test-retest reliability, factor analysis, and construct validity. It will allow the development of more robust studies on pain and disability among musicians, comparative studies between different subgroups of musicians and the evaluation of predictive factors of pain development. PERSPECTIVE: This article presents the psychometric properties of the first questionnaire to evaluate pain among musicians (in general), the "Performance-related Pain among Musicians Questionnaire" (PPAM). This valid and reliable tool, composed by three constructs (pain intensity, interference in general activities, and interference in performance), will improve the pain assessment among musicians.

Factors associated with increased risk of playing-related disorders among classical music students within the Risk of Music Students (RISMUS) longitudinal study

Playing-related musculoskeletal disorders (PRMDs) are common among musicians but longitudinal data on risk factors are limited. The aim of the study was to longitudinally identify the factors associated with increased risk of PRMD onset among music students enrolled in different pan-European music institutions. A further goal was to assess the occurrence of PRMDs during a 12-month period. A total of 442 students without PRMDs from 56 European music universities completed a web-based questionnaire on lifestyle and practice habits, health history, physical activity, psychological distress, perfectionism, and fatigue. PRMD onset was assessed prospectively at 6 and 12 months. Logistic regression analysis showed that changes in physical activity level (6-month AOR = 2.343, 12-month AOR = 2.346), increased levels of fatigue (6-month AOR = 1.084, 12-month AOR = 1.081) and socially-prescribed perfectionism (6-month AOR = 1.102) were significantly associated with PRMD onset, which had occurred in 49% of participants during 12 months. Musculoskeletal complaints reported at baseline (6-month AOR = 0.145, 12-month AOR = 0.441) and changes to BMI (12-month AOR = 0.663) limited the onset of PRMDs. The study's novel longitudinal findings were appraised critically within the contexts of potential factors for PRMD onset and evidence-based preventive strategies to minimise the impact of PRMDs.

Musculoskeletal pain in musicians: does playing more than one instrument have more effect?

Objectives. Repeated instrumental practice represents a risk factor for the appearance of playing-related musculoskeletal disorders (PRMDs). This study aimed to compare the prevalence and characteristics of PRMDs based on location, pain characteristics and number of hours of instrumental practice, in musicians who play one or more musical instruments.Methods. An observational study was conducted with music university students in Spain using a questionnaire.Results: A total of 178 musicians (41%) played a second instrument. Musicians who played only one instrument had a slightly lower mean number of pain sites (M 3.25, SD 1.93; M 3.44, SD 2.27). On the contrary, pain intensity (M 2.72, SD 2.03; M 2.23, SD 1.78 points), pain interference on mood, quality of life and instrumental practice (M 3.04, SD 2.29; M 2.80, SD 2.24 points) as well as the number of hours devoted to instrumental practice (M 21.18, SD 10.47; M 20.03, SD 12.54 h/week) is slightly higher in musicians playing a single instrument.Conclusions. Pain intensity is the only variable of those analysed that presents statistically significant differences when comparing musicians who play a single instrument with those who play a second instrument, being higher in mono-instrumental musicians.

For Fiddlers on the Roof and in the Pit: Healthcare and Epidemiology of Playing-Related Problems in Violinists

Musicians, specifically violinists, may experience pain or loss of function as a result of poor playing hygiene, environmental factors, and insufficient guidance from teachers, parents, conductors, and physicians. The causal occurrence of these pathologies and the efficacy of general treatment, along with referral to other specialists for adjunct therapies and rehabilitation, were examined in this literature review. A systematic PubMed search was conducted in May 2022 to gain insight into the current state of the published literature. Inclusion criteria were cross-sectional or comparative studies that address relevant pathologies among violinists by specialty. The search resulted in 25 cross-sectional, 5 comparative studies, and 1 case review including a total of 6010 musicians, among them at least 920 violinists. Orthopedists, neurologists, dentists/orthodontists, dermatologists, and audiologists are most commonly consulted to treat violinists' complaints. Other internists and various paramedical specialists can equally be affected and should be sensitive to the complaints of musicians. In conclusion, the field of performing arts medicine is extremely wide and requires multidisciplinary specialist attention. The studies chosen highlight that violinists may suffer great discomfort at the hands of their instrument and merit adequate guidance from physicians in order to be able to continue playing in a safe, ergonomic way.

Effect of manual therapy on music students with playing-related musculoskeletal disorders: a prospective study

Playing Related Musculoskeletal Disorders (PRMD) belong to the most prevalent medical ailments affecting musicians' health and career. This study documents the effect of a physiotherapeutic treatment as well as functional impairments of PRMD on the musculoskeletal system. In total, 32 music students suffering from PRMD were examined in Hanover Medical School (MHH) before and after they received twelve physiotherapeutic treatments, which were carried out over 20 min each over 6 weeks. Additionally, 32 healthy music students, matched by age and gender, were examined at one time point in the MHH to explore which musculoskeletal restrictions are associated with PRMD. The examination included the evaluation of the pain on the Visual Analogue Scale for pain (VAS), a body composition, and body posture measurement, the finger-to-floor distance, the range of motion of the cervical spine, the pressure pain and muscular hypertension examination, the temporomandibular joint-test, the Beighton score screening test, and the testing of the widespread pain score (WSP). After analyzing the data of the patient group (PG) a significant reduction of pain level on the VAS from an average pain of 6.31 to 3.53 was found (large effect). Additionally, a significant reduction of the pressure pain of the M. levator scapulae, the M. rhomboideus, the M. sternocleidomastoideus on the left side and the paravertebral muscles of the cervical spine on the right side after the treatment of the patients could be detected. Regarding the WSP, the positive testing significantly differed, showing a 28% positive testing in the patient group vs. a positive testing of 9% in the control group (CG). As hypermobility is a common phenomenon in musicians, the percentage of those being diagnosed with generalized hypermobility by using the Beighton score in both groups (PG: 37.5%; CG: 25%) was remarkably higher compared to previous studies. In this study, a short course of manual therapy, client tailored for each musician's specific problem, was shown to reduce pain levels in musicians with PRMD.

Musculoskeletal Health Complaints and Associated Risk Factors in Freshmen Music Students

BACKGROUND

Evidence concerning the development of musculoskeletal health complaints (MHCs) among music students is limited due to inappropriate study designs. We aimed to assess the occurrences of MHCs and associated risk factors in freshmen music students compared to students from other disciplines.

METHODS

A prospective cohort study was conducted. Risk factors such as pain-related, physical, and psychosocial variables were measured at baseline. Episodes of MHCs were recorded monthly.

RESULTS

A total of 146 music students and 191 students from other disciplines were analyzed. In the cross-sectional comparison, pain-related, physical, and psychosocial variables were significantly altered in music students compared to students from other disciplines. Furthermore, music students with current MHCs differed significantly from music students without current MHCs with respect to physical health, pain, and history of MHCs. Our longitudinal analysis showed that monthly MHCs were higher in music students compared to students from other disciplines. Independent predictors for monthly MHCs in music students were current MHCs and reduced physical function. Predictors for MHCs in students from other disciplines were a history of MHCs and stress.

CONCLUSIONS

We provided insight into the development of MHCs and risk factors in music students. This may help in the creation of targeted, evidence-based prevention and rehabilitation.

Orofacial Pain, Musical Performance and Associated Coping Behaviors, Psychological Distress and Disability among Asian Young Adults

Musicians often report orofacial pain (OFP) and performance-related psychological distress related to occupational neuromuscular overuse, but to date, no study has been performed in Asian musicians to assess these factors. This study evaluated OFP, psychological distress, coping behaviors, and disability among Asian musical performers. A total of 201 participants in Singaporean music ensembles were surveyed from which 159 met the inclusion criteria for vocalists or instrumentalist musicians (mean age 20.26 ± 2.20 years). Self-administered questionnaires assessed musical practices, jaw/neck pre-conditioning exercises, pain-related temporomandibular disorders (TMD), OFP descriptors, pain chronicity and disability, coping behaviors and psychological distress. Univariate and multi-variate analyses were carried out. OFP, while performing, was more than two-fold higher in instrumentalists when compared to vocalists (41.4-48% vs. 17.2%, p = 0.002). A similar trend occurred for OFP that progresses while playing (p = 0.035) and for persistent OFP that reduces playing (p = 0.001). There were no differences in psychological distress, pain coping and disability between groups. Vocalists were found to practice jaw/neck pre-conditioning exercises more frequently (75% vs. 4-12.9% in instrumentalists, p < 0.0001). While performing, Asian vocalists reported less OFP when compared to instrumentalists. Future prospective studies are needed to confirm if pre-conditioning exercises play a protective role against OFP in vocalists.

[Orofacial and musculoskeletal disorders of professional musicians - Frequency and therapy principles]

Playing-related musculoskeletal disorders are frequently found in the upper extremety and the spine. Moreover, orofacial pain syndromes and craniomandibular dysfunctions are important in upper string players and wind players. The treatment of musicians is based on a diagnostic process including the evaluation of specific musical aspects, a functional manual medicine examination and an evaluation of postural and movement characteristics while playing the musical instrument.

Repeated stage exposure reduces music performance anxiety

Background

High heart rate (HR) and restlessness are two important features of music performance anxiety (MPA). In a case report of a cellist suffering from this condition, we showed that HR and restlessness decreased after repeated live performances of the same musical excerpt, thereby positively modulating objective performance criteria and subjective components. Here, we largely replicate these results in a group of 18 string players reporting MPA.

Methods

Objective measurement devices included a miniaturized electrocardiogram monitor and three 3-axis accelerometer loggers. Subjective measures included the Multidimensional Mental Health Questionnaire (MDBF) and a customized visual analogue scale (VAS) questionnaire for MPA. Non-artistic performance errors were assessed by music experts using a composite score for technical playing errors (i.e., intonation errors, omission of notes, and bowing noise). Data were collected from each study participant during three brief public solo performances of the same musical excerpt, with each performance occurring before a new audience on the same day.

Results

From the 1st to the 3rd performance, HR, VAS, and playing error scores decreased significantly. MDBF (RU scale) showed a significant increase in calmness from the 1st to the 3rd performance on stage. HR and RU, VAS, and RU, as well as bow acceleration and overall duration of playing correlated significantly across participants and performances.

Discussion and conclusion

We conclude that repeated stage exposure significantly reduces HR as well as restlessness and playing errors linked to MPA. Public performances are still successful when HR is significantly higher than during rest periods. These results underscore the importance of stage training to become accustomed to realistic public self-exposure. Musicians - especially students - should consider this component of stage training as an integral part of their practice routine. Therefore, stage training can reduce MPA, promote better live performances and prevent stress-related mental disorders and physical injuries. These result from excessive self-exercise strategies common in musicians experiencing MPA. HR monitoring should be an integral part of evaluating the effectiveness of interventions for better MPA management and efficient performance training.

Assessing Performing Artists in Medical and Health Practice - The Dancers, Instrumentalists, Vocalists, and Actors Screening Protocol

ABSTRACT

Training in the performing arts exposes individuals to often extreme physical and psychological demands, which are linked to high occupational injury rates. The intense demands of performing artists have been likened to those of sport athletes. However, distinct differences in these demands necessitate specialized approaches to the health care of performing artists. Through the Athletes and the Arts collaboration, the American College of Sports Medicine and Performing Arts Medicine Association identified that the creation of a specialized preparticipation screening tool for performing artists would likely enhance health care for performing artists significantly. Based on a thorough review of established assessments and an extensive consultation process with domain experts, a consensus best-practice screening tool was developed: the Dancer, Instrumentalist, Vocalist, Actor (DIVA) Preparticipation Screening. This screening tool is modeled on the athletic preparticipation examination (PPE) in its structure and 30-min target duration. However, DIVA diverges considerably from the PPE in its content to address the specific risks and needs of performing artists. In particular, screening questions and physical examination procedures focus strongly on musculoskeletal injuries and mental health conditions, in response to the preponderance and interactions of these conditions appearing in performing artists. The DIVA tool presented is intended as a "living tool," which can be modified in the future to include new effective assessment techniques as appropriate. Training in the DIVA preparticipation physical examination is included as a core component of the essentials of performing arts medicine continuing education course described in detail in a companion manuscript in this issue.

Load and fatigue monitoring in musicians using an online app: A pilot study

Background/aims

High occupational injury rates are reported in musicians, with a career prevalence of up to 89%. Fatigue and playing (over)load are identified as key risk factors for musicians' injuries. Self-report fatigue management strategies in sport have demonstrated preventive effects. A self-report fatigue management tool for musicians was developed based on a Delphi survey of international experts and hosted in an online app. The aims of this study are to evaluate the content validity and uptake of this new tool, and explore associations between collected performance quality, physical/psychological stress, pain, injury and fatigue data.

Methods

University and professional musicians were asked to provide entries into the online app twice per week for 1-6 months. Entries into the app were designed to take 2-3 min to complete and consisted of the following: 6 questions regarding playing load over the previous 72 h; 5 questions regarding current levels in key physical/psychological stress domains (sleep, recovery, overplaying, pain, fitness); one question self-rating of performance quality over the previous day; one question regarding current musculoskeletal symptoms; a reaction time task to evaluate psychomotor fatigue.

Results

N = 96 participants provided an average of 2 app entries (range 0-43). Increased playing time, rating of perceived exertion (RPE), and feelings of having to "play too much" were consistently associated with increased self-rated performance quality (p ≤ 0.004; 6.7 <| t |< 2148.5). Increased ratings of feeling fit and recovering well were consistently associated with reduced pain severity (p < 0.001; 3.8 <| t |< 20.4). Pain severity was increased (6.5/10 vs. 2.5/10; p < 0.001) in participants reporting playing-related musculoskeletal disorders (PRMDs; symptoms affecting playing).

Conclusion

The prospective value of regular individual self-report playing load, stress, and performance data collection in musicians is clear. However, limited uptake of the online fatigue management app piloted in this study indicates that new approaches to the collection of these data are needed to realize their potential impact.

Validity and reliability of the Musicians’ Health Literacy Questionnaire, MHL-Q19

High prevalence of musicians’ physical and mental performance-related health issues (PRHI) has been demonstrated over the last 30 years. To address this, health promotion strategies have been implemented at some post-secondary music institutions around the world, yet the high prevalence of PRHI has persisted. In 2018, an international group of researchers formed the Musicians’ Health Literacy Consortium to determine how best to decrease PRHI, and to examine the relationship between PRHI and health literacy. An outcome of the Consortium was the development of a new health literacy tool for musicians, the MHL-Q19, which drew from the theoretical framework of the European health literacy suite of tools, HLS-EU. The aim of the current study was to evaluate the validity and reliability of the MHL-Q19. Participants completed a battery of questionnaires, including the HLS-EU-Q16 for the assessment of general health literacy; the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians (MPIIQM); the RAND-12 quality of life questionnaire; and the General Self-Efficacy scale (GSE). We hypothesized that the MHL-Q19 would have a weak correlation with the HLS-EU-Q16; moderate correlation with the physical component scale and weak correlation with the mental component scale of the RAND-12; moderate correlation with the GSE; and finally, moderate correlation with pain interference and weak correlation with pain intensity of the MPIIQM. A total of 549 post-secondary music students from six English-speaking countries completed the battery of questionnaires, and 328 of these participants provided valid responses to the MHL-Q19 alone 2 weeks later. The tool showed acceptable internal consistency and test–retest reliability. Three of our hypotheses were supported, although the strength of the correlations varied from what we had predicted. The fourth hypothesis was not supported; our findings indicate that lower health literacy scores were weakly related to higher MPIIQM pain intensity and interference scores. The results of this study support the notion that musicians’ health literacy is a distinct construct that cannot be fully evaluated with existing health literacy tools. Given that this is a new instrument, the evidence presented is positive and promising. Further studies will be needed to refine the tool.

A Longitudinal Study of Physical and Mental Health and Health-Related Attitudes Among Music Students: Potentials and Challenges for University Health Promotion Programs

Objective

Well-being of music students has been an increasing matter of concern since studies show that up to 50% of beginners suffer from playing-related pain or anxiety. The aim of this longitudinal study was to examine health status, health-related attitudes, behaviors, knowledge, skills, and coping strategies of students at the beginning of their education at a music university and at the end of their second semester.

Methods

Based on a longitudinal online survey conducted among students at a German music university since 2017, we investigated mental and physical health status, health-related attitudes, knowledge, skills, behaviors, and coping strategies of music students at the beginning of their first year (n = 205). We analyzed differences between performance and music education majors and between students playing different main instruments. In a subsample (n = 62), we additionally analyzed changes between the beginning of the music students’ first and the end of their second semester, also depending on whether they attended courses on musicians’ health.

Results

Music students are already in demand when they enter a music university, practicing on average almost 3 h daily. Compared to other body regions, pain in shoulders/back is most prevalent in first-year students, especially in those playing string instruments. Performance majors reported better knowledge about health risks and protective measures for musicians, better coping abilities, and practiced more than music education majors. First-year students assessed their overall and mental health status at the beginning of their first semester mainly as good, but we found a decrease in mental health status at the end of the second semester. After two semesters, students attending courses on musicians’ health showed increased knowledge and skills regarding different aspects of musicians’ health.

Conclusion

The health status of music students when they first enter a music university is still a concern. Information and practical courses enabling students to prevent overuse and cope with performing anxiety and other stressors are important components of a comprehensive study program. Knowledge about music students’ needs can help conservatories better respond to the requirements and develop courses and measures supporting students from the beginning of their education.

Musculoskeletal pain in musicians: prevalence and risk factors. A systematic review

OBJECTIVE

: to determine the prevalence and regions of the body in which musculoskeletal injuries occur in musicians, as well as to identify risk factors related to their occurrence.

METHODOLOGY

: A search was carried out in the Pubmed, Scopus, Web of Science and Cinahl databases for publications between 2006 and 2020. Observational studies on the prevalence of musculoskeletal injuries or their risk factors in musicians aged 18-65 years were eligible for inclusion, and the methodological quality and risk of bias were assessed.

RESULTS

: 31 studies on multiple instruments and 17 on individual instruments were included. Quality was rated as high in 65% of the studies. Lifetime prevalence of injuries ranged from 46-90% and current prevalence from 9-63%. The most common region of pain was the neck, being present in all instrument families. Being female is a predisposing factor to the appearance of musculoskeletal problems in musicians.

CONCLUSIONS

: Musicians suffer frequently musculoskeletal injuries. The most common regions of the body in which these injuries occur are the neck and shoulders. Numerous risk factors were found to be predisposing to musculoskeletal injuries. We note that there are fewer studies on specific instruments.

Correlations between body postures and musculoskeletal pain in guitar players

Background

The guitar-playing community is the largest group at risk of developing playing related musculoskeletal disorders. A thorough investigation of the relationships between the various risk factors and players’ report on musculoskeletal pain using objective and accurate means of assessment has yet to be reported.

Purpose

(a) to explore the correlations between demographic characteristics, anthropometric measurements, playing habits, and personal habits of guitar player and their complaints of musculoskeletal pain, (b) explore the correlations between the upper body kinematics of guitar players during playing the guitar and their complaints of musculoskeletal pain, and (c) compare the upper body kinematics of guitar players during playing the guitar while sitting versus standing.

Methods

Twenty-five guitar players (27.5±4.6 years old) filled out questionnaires regarding their guitar-playing habits, and the Standardized Nordic Questionnaires for the analysis of musculoskeletal symptoms. Kinematics of their torso and upper limbs were tracked while they played a tune twice, once while sitting and once while standing.

Results

We found moderate correlations between the number of painful joints in the last year and factors, such as physical comfort while playing, years of playing, and position during playing. During standing, lower back pain severity correlated with the rotation range of the torso, while during sitting, it moderately correlated with the average radial-ulnar deviation of the right wrist. During sitting, we found higher anterior and right tilt of the torso, combined with greater abduction of the right shoulder, higher flexion in the left shoulder and higher radial deviation in the left wrist.

Conclusion

Our results point to several risk factors, related both to playing habits but also to playing posture, which should be considered by the guitar players in order to prevent playing-related musculoskeletal disorders.

Musculoskeletal and psychological assessments used in quantitatively based studies about musicians' health in brass players: A systematic literature review

OBJECTIVE

Brass players are exposed to high musculoskeletal strains during their instrumental play. Various assessments can be used to measure these strains, whereby a targeted therapy can also be supported. The aim of this study was to review literature concerning assessments used in quantitatively based studies about the analysis of musculoskeletal loads of brass players.

DATA SOURCES

The Cochrane Library, PubMed, CINAHL, PEDro as well as the journal "Medical Problems of Performing Artists" were searched for relevant studies.

STUDY SELECTION

Two reviewers independently applied the inclusion and exclusion criteria to select potential studies. A third reviewer was involved in the case of discrepancies.

DATA EXTRACTION

Two reviewers independently extracted the data.

DATA SYNTHESIS

A total of 73 studies conducted between 2004 and 2019 were included. Within a total of 30 studies, 18 assessments could be found that collect 2-dimensional or 3-dimensional kinematic data using video- or image-based analysis of posture, sonographic, optoelectronic and various electromagnetic systems. In 7 studies kinetic data were measured by force-transducers, pressure platforms, stabilizer and dynamometer. Fifteen studies used clinical examinations and additional assessments to screen individual body regions and 9 studies derived electromyography measurements from a total of 25 muscles. Thirty-one partially validated questionnaires were used to record musculoskeletal pain of brass players.

CONCLUSIONS

A variety of assessments can be used to optimize analysis and treatment procedures in research and clinical work. Future studies should both examine quality criteria of the various assessment methods and validate clinical examinations and questionnaires.

The effectiveness of Kinesio taping on playing-related pain, function and muscle strength in violin players: A randomized controlled clinical trial

OBJECTIVES

This study aimed to investigate the effectiveness of Kinesio taping (KT) on playing-related pain, upper extremity and hand function, grip and pinch strength in violin players.

DESIGN

Randomized controlled trial.

SETTING

Faculty of health sciences.

PARTICIPANTS

One hundred seventeen participants who were professional violinists for at least two years (82 women; mean age, 22.76 ± 3.87 years) were randomized to receive either therapeutic tape application (KT group), a sham tape application (placebo group), or no application (control group) for one week.

OUTCOME MEASURES

The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) in one week. The secondary outcomes were the Visual Analogue Scale (VAS), the Purdue Pegboard Test, grip and pinch strength. Outcome measures were performed at baseline, immediately after the intervention, and one week later (follow-up). Participants were asked to play the "Violin Concerto No.2, Op.35 (Rieding, Oskar)"; pre-and post-performance pain and grip and pinch strength were assessed.

RESULTS

The overall group-by-time interaction was not significant for DASH, but the improvement in the mean VAS-playing was slightly better in the KT group than in others (p < 0.05). The mean post-performance VAS-playing remained similar in the KT group while slightly increasing in the other groups (p < 0.05). In addition, a decrease in the mean post-performance grip strength of the left hand was significantly lower in the KT group than in the other groups (p < 0.05).

CONCLUSIONS

Violin players receiving an application of KT represented minor improvements in playing-related pain, and post-performance pain intensity and grip strength of the left hand slightly remained after 1 week kT application. The possible post-performance effect of the tape on the pain intensity and grip strength must also be considered because KT can be used during the performance.

The development and use of an anatomy-based retraining program (MusAARP) to assess and treat focal hand dystonia in musicians-A pilot study

BACKGROUND

Movement dysfunctions are commonly reported in musicians, and in extreme cases may result in a persisting loss of motor control. This condition, whereby motor control of the hand during previously highly trained movements on the instrument is lost, is termed focal hand dystonia. It is widely considered to be a consequence of prolonged repetitive daily practice, often in combination with exposure to a range of other risk factors. Current literature recommends retraining as a promising treatment intervention, although only scant scientific evidence exists on which components should be included in a retraining program, and how these may be best administered.

METHODS

A progressive muscle activation and movement exercise program was devised by one of the authors applying a series of anatomy-based off-instrument movement tasks. This series of fine motor control exercises, was used to both assess and retrain focal hand dystonia in a population of musicians. The standardized approach aimed to provide a systematic method of retraining musically relevant muscular synergies that could later be applied to the instrument, while still allowing individual modifications. Retraining sessions were mostly run online as a consequence of the coronavirus pandemic, although some early sessions were also able to be undertaken face to face. Both qualitative and quantitative measures were used in this case series to evaluate program efficacy, due to the typical heterogeneity of the focal hand dystonia participants. This included: blinded external neurological evaluation of video footage using the Tubiana grading system, written subjective feedback, exercise progressions, and performance outcomes.

RESULTS

Pilot testing of 4 patients indicated the utility of the program over approximately a 12- month time period. All subjects improved, 2 of whom have returned to pre-dystonia performance levels. These patients reported the importance of patience and persistence with daily exercise sessions in their recovery.

CONCLUSION

Using off-instrument playing-relevant exercises to enhance fine motor control and muscle activation can be effective in retraining focal hand dystonia, regardless of additional treatments or level of performance. They should be regularly practiced and progressed in order for effects to be best progressed to instrumental applications. Further research may elucidate whether there are optimal outcomes with single or particular combinations of treatment approaches.

Musculoskeletal pain in professional symphony orchestra musicians

Background: A musician’s many years of professional experience may contribute to the development of pain and musculoskeletal disorders. There are a few studies in Poland on gender differences in musculoskeletal pain among adult professional musicians. Aim of the study: This study aimed to assess and compare pain in Polish women and men who are professional musicians, as well as to analyze the relationships between the intensity and frequency of pain and the time spent playing each week and the experience of playing the instrument in years. Material and methods: Sixty professional musicians were examined (26 men and 34 women). Pain intensity was assessed using the visual analog scale (VAS). Participants reported the frequency of musculoskeletal system ailments, the location of the pain, the number of hours of playing the instrument per week, and the playing experience in years. In addition, body weight and height were measured and body mass index (BMI) was calculated. Results: Most of the participants (94% of women and 69% of men) reported pain in the musculoskeletal system (p=0.010). Women experienced significantly greater pain in the musculoskeletal system assessed using the VAS (p=0.036), and also declared pain significantly more often compared to men (p=0.002). Significant positive correlations were found between frequency of symptoms per week with the number of hours of playing per week (r=0.28), year of playing the instrument (r=0.38), and pain assessment on the VAS (r=0.57). Moreover, negative correlations were found between frequency of symptoms per week with body height (r=–0.45) and body mass (r=–0.36). Conclusions: Musculoskeletal disorders are very common among professional musicians, especially among women. In general, the greater the number of hours playing per week and the longer the history of playing, the greater the pain intensity. Future research should aim to evaluate the prevalence and risk factors of musculoskeletal disorders associated with playing an instrument in different groups of musicians.

A Physiotherapeutic Approach to Musicians' Health - Data From 614 Patients From a Physiotherapy Clinic for Musicians (INAP/O)

Currently, the treatment of musicians is an interprofessional approach. Playing-related health complaints may impact the performance of a musician. In Germany, a medical consulting hour for musicians exists, but those for athletes in sports medicine are not so common. The diagnosing and treatment procedure within the physiotherapy consultation for musicians follows a specific concept-b and requires knowledge of instruments and musician-specific complaints. Based on the consulting hour in a clinic in Osnabrueck, 614 case reports were part of this sample, of which 558 data sets were complete. The focus of the analysis is the instrument and the primary complaint. Also, the type of therapy is characterized, and the amount is calculated. Primary complaints of musicians, in general, are found most frequently in the spine and upper extremity. Musician complaints are different between instruments. Instrumentalists have a significantly higher chance to suffer from a primary complaint in the area of the upper extremity. Furthermore, the groups without an instrument (e.g., singing or dancing) are developing complaints in the anatomical area which they primarily use. Therefore, these types of therapy were used: physiotherapy, manual therapy, and osteopathy with an average of 5.9 treatment units. This study underpinned the importance of musician-specific physiotherapy as a profession to treat musicians. Also, an interdisciplinary approach is necessary to treat all aspects of complaints.

Patterns of pain location in music students: a cluster analysis

BACKGROUND

According to existing literature, musicians experience high rates of musculoskeletal (MSK) disorders involving different anatomical areas. The aim of the study was to identify patterns of pain location in a sample of music students enrolled in different pan-European music institutions. A further goal was to explore the association between the identified pain patterns and students' characteristics.

METHODS

A total of 340 music students (mean age 23.3 years, 66.2% female) with current MSK pain completed a web-based questionnaire including both background information (i.e. lifestyle and physical activity, practice habits) and clinical features (i.e. pain characteristics, disability, pain self-efficacy, psychological distress, perfectionism and fatigue).

RESULTS

Five patterns of pain location were identified by hierarchical cluster analysis: wrist pain (WP) representing 22.6% of the total sample, widespread pain (WSP) (16.9%), right shoulder pain (RSP) (18.5%), both shoulders pain - left concentrated (LSP) (23.2%), neck and back pain (NBP) (18.8%). Amongst the identified patterns of pain location, bivariate analysis identified the WSP cluster as containing the largest number of associated variables. Participants in this cluster reported a higher percentage of women (p < .05), a higher perceived exertion (p < .01) and psychological distress (p < .001), as well as a lower level of self-efficacy (p < .01). Similarly, a higher percentage of participants included in the WSP cluster perceived their musical activity as the main cause of their MSK pain (p < .01). Additionally, a higher level of disability in relation to playing-related activity was reported by participants included in the WP and WSP clusters (p < .001). The RSP cluster was characterised by a higher percentage of participants playing an instrument in a neutral position (p < .001) and lower levels of socially prescribed perfectionism (p < .01). A higher percentage of participants playing an instrument with both arms elevated in the left quadrant position were included in the LSP cluster and a higher percentage of singers were included in the NBP cluster (p < .001).

CONCLUSIONS

Five distinct patterns of pain location were identified and their associations with the students' characteristics were explored. These findings may be helpful in the exploration of different aetiologies of MSK pain among musicians and in the development of targeted preventive strategies and treatments.

Cross-Cultural Adaptation and Validation of the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians of the Polish Population (MPIIQM-P)

BACKGROUND The aim of the study was the cross-cultural adaptation and validation of the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians. MATERIAL AND METHODS The process consisted of the following stages: forward translation, backward translation, analysis by committee of experts, pretest of Polish-language version of questionnaire, and cross-cultural validation: psychometric evaluation. In the last step, a convenience sample of 31 professional orchestra musicians (professional experience 16.7±9.5 years) was used to validate the new tool. The primary study outcome measurements were construct validity and internal consistency as measured by exploratory factor analysis (EFA) and Cronbach's alpha, respectively. RESULTS A final Polish version of the questionnaire was developed. Using EFA, the 2-factor structure (pain intensity and pain interference) was obtained, taking into account all 9 items, explaining about 76% of the total variance. The pain interference and pain intensity factors were characterized by high internal consistency (Cronbach's alpha 0.923 and 0.784, respectively). The lifetime prevalence of playing-related musculoskeletal disorders was 87%. CONCLUSIONS Translation and a cross-cultural adaptation of the Polish version of the questionnaire was successfully completed. The results obtained show a correctly carried-out validation process, but further testing of the tool is suggested. The Polish-language version of the validated tool can be used in scientific and clinical practice. The next step would be to estimate cutoff values for severity of health status in orchestra musicians.

The effect of osteopathic medicine on pain in musicians with nonspecific chronic neck pain: a randomized controlled trial

Background:

Nonspecific chronic neck pain (cNP) is common in adult violinists and violists and is often treated with osteopathic medicine (OM), although the effectiveness of this treatment has not been determined to date. This study aimed to evaluate the effectiveness and safety of OM in adult violinists and violists with cNP.

Methods:

In a two-armed randomized controlled single-center open trial, adult violinists and violists, including music students, with cNP (⩾12 weeks) were randomized to either five individualized OM sessions (OM group) or to no intervention (control group, CG) in the outpatient clinic for integrative medicine, Charité - Universitätsmedizin Berlin, Germany. All patients received a musicians’ medicine consultation and paracetamol on demand. The primary outcome parameter was the neck pain intensity on a visual analog scale (VAS, 0–100 mm, 0 = no pain, 100 = worst imaginable pain) after 12 weeks. Secondary outcomes included neck pain disability (Neck Disability Index, NDI, 0–100%) after 12 weeks. The last follow-up visit was after 52 weeks. Statistical analysis included analysis of covariance adjusted for respective baseline value.

Results:

Altogether, 62 outpatients were included [OM group (n = 28), CG (n = 34); 81% female; mean age, 41.6 ± 11.1 years; mean baseline neck pain, 55.9 ± 11.6 mm]. After 12 weeks, OM was associated with an improvement in the OM group versus the CG in neck pain on the VAS [14.6 mm (95% confidence interval 8.0; 21.2) versus 40.8 mm (34.7; 46.9), p < 0.001, Cohen’s d = 1.4], and neck pain disability as determined by the NDI [8.8% (6.7; 10.8) versus 17.2% (15.3; 19.1), p < 0.001]. Some improvements were maintained until 52 weeks of follow-up. No serious adverse events were observed.

Conclusions:

The results of this study suggest that OM might be effective in reducing pain intensity in adult violinists and violists with nonspecific cNP. Further studies should investigate the efficacy of OM in comparison with a sham procedure and with other effective therapy methods in high-quality multicenter trials.

Trial registration:

WHO Trial Registration https://apps.who.int/trialsearch/NoAccess.aspx?aspxerrorpath=/trialsearch/Trial2.aspx by German Clinical Trials Register DRKS00009258, Universal Trial Number (UTN): U1111-1173-5943.

Prevalence and associated factors of playing-related musculoskeletal disorders among music students in Europe. Baseline findings from the Risk of Music Students (RISMUS) longitudinal multicentre study

Musculoskeletal (MSK) conditions among professional musicians and music students are frequent and may have significant physical and psychosocial consequences on their lives and/or on their playing abilities. The Risk of Music Students (RISMUS) research project was set up in 2018 to longitudinally identify factors associated with increased risk of playing-related musculoskeletal disorders (PRMDs) in a large sample of music students enrolled in pan-European institutions. The aim of this cross-sectional study was to describe the prevalence of playing-related musculoskeletal disorders (PRMDs) in this novel population at baseline of the RISMUS project. A further goal was to begin to identify variables that might be associated with the self-reported presence of PRMDs among music students. Eight hundred and fifty students from fifty-six conservatories and music universities in Europe completed a web-based questionnaire on lifestyle and physical activity participation levels, musical practice habits, health history and PRMDs, psychological distress, perfectionism and fatigue. A total of 560 (65%) out of 850 participants self-reported a positive history of painful MSK conditions in the last 12 months, 408 (48%) of whom self-reported PRMDs. Results showed that coming from West Europe, being a first- or a second-year Masters student, having more years of experience and higher rates of perceived exertion after 45 minutes of practice without breaks were factors significantly associated with self-reported presence of PRMDs. According to the authors’ knowledge, a large-scale multicentre study investigating prevalence and associated factors for PRMDs among music students at different stages of their education (from Pre-college to Masters levels) has not been conducted before. The high prevalence of PRMDs among music students, especially those studying at university-level, has been confirmed in this study and associated factors have been identified, highlighting the need for relevant targeted interventions as well as effective prevention and treatment strategies.

Self-reported sleep bruxism among Finnish symphony orchestra musicians: Associations with perceived sleep-related problems and psychological stress

Objective: This study aimed to evaluate whether self-reported sleep bruxism among musicians is associated with sleep-related problems and/or psychological stress.Methods: Eight hundred-thirty-one Finnish orchestra musicians completed a questionnaire that covered, among others, indicators of sleep-related problems, possible sleep bruxism, and stress.Results: In total, 488 questionnaires were completed. The single variable ordinal logistic regression models revealed at least moderate associations between frequency of sleep bruxism and female gender, shorter sleep duration, longer sleep latency, problems in sleeping during concert season, feeling more often tired during the daytime, restless legs, a poor self-rated sleep quality, and more stress experience. The variables that remained in the final model were sleep duration, gender, and stress.Conclusion: Musicians who sleep 7 hours or less per night report more sleep bruxism, as compared to those who sleep 8 hours or more. Female gender and high-stress experience were associated with more sleep bruxism.

Musculoskeletal pain among Finnish orchestra musicians versus core workforce

Background

Professional musicians show a high prevalence of musculoskeletal pain, but information is limited about prevalence of pain compared to the general populations.

Aims

Our cross-sectional epidemiological study compared the prevalence of musculoskeletal pain between professional orchestra musicians and the working population in Finland.

Methods

Musicians with a permanent contract with all domestic professional symphony and philharmonic orchestras and a population sample of the workforce in Finland completed questionnaires including the same questions on musculoskeletal pain and on various other issues. Cross-sectional data from two population-based and two orchestra-musician studies were analysed by logistic regression model adjusting for confounding factors.

Results

In 2002, 345 musicians completed questionnaires (40% response rate), and in 2010, 195 (23%). The Health 2000 study sample comprised 5956 employed participants and in 2011, 5942. Musicians reported, in 2002 and in 2010, back pain during the past 30 days more often than did controls, 39% versus 27%, adjusted odds ratio (95% confidence interval, CI) 1.5 (1.2–1.9); shoulder pain, 21% versus 9%, 2.6 (1.9–2.5); elbow pain, 14% versus 5%, 2.9 (2.0–4.2); wrist pain 14% versus 7%, 2.2 (1.5–3.1); and finger pain 13% versus 9%, 2.8 (2.0–3.9). Prevalence of musculoskeletal pain increased with age in controls but not in musicians.

Conclusions

Professional orchestra musicians reported more pain in the back and upper extremity than other working people. Future research should focus on explaining differences in the occurrence of musculoskeletal disorders between musicians and the general population.

Comparison of Postural Stability and Balance Between Musicians and Non-musicians

Good postural stability and balance provide a basis for optimal movement. For instrumental musicians, particular postures are demanded during long periods of playing and practicing. These postures can potentially also affect the postural control system even in situations when the musician is not playing the instrument. The goal of this exploratory study was to measure the postural stability and balance of instrument musicians in non-instrumental situations. By comparing these measures with a control group of non-musicians, postural differences were identified which can be ascribed to certain playing positions arising from playing the instrument. The measurement technique used was a pressure platform (Zebris force plate) to record static posturography. The postural sway of the center of pressure (COP) and the postural balance (body weight distribution) in a standing position were measured in 390 students including music students (n = 346) and a control group (n = 44). The analyses revealed significant differences for specific instrumental groups. Around 23% of the pianists, 25% of the upper strings players, and 33% of the guitar players showed a weight distribution significantly shifted more to the left compared to the control group (9%). In contrast, 23% of the lower strings players and 33% of the percussionists were found to stand more to the right side than the control group (5%). The results indicate that there are certain unbalanced postural patterns in musicians, outside of the music performance situation, which can be provoked by instrumental playing postures. As postural misalignments can lead to severe postural disorders in older age, preventive activities to improve postural stability and balance should be considered in instrumental education, not only during, but also outside of instrumental playing situations.

Prevalence, Disability and Associated Factors of Playing-Related Musculoskeletal Pain among Musicians: A Population-Based Cross-Sectional Descriptive Study

Background: Playing-related musculoskeletal disorders are the most frequent complaints among instrumental musicians. The aims of this study were: to assess the prevalence of musculoskeletal pain; to evaluate neck, shoulder, and lower back disability; and to determine the associated factors with the presence of musculoskeletal pain among musicians. Methods: A population-based, cross-sectional descriptive study was conducted. We selected Spaniard musicians over 16 years old who played a musical instrument for at least five hours per week. They answered the Spanish versions of the Standardised Nordic Questionnaire, the Oswestry Disability Index, Neck Disability Index and Shoulder Pain and Disability Index. Results: We found 94.8% of musicians presented at least one symptomatic region in the last 12 months, and 72.3% in the last seven days. Female musicians (OR 4.38, CI 2.11-9.12), musicians with overweight or obesity (OR 5.32, CI 2.18-12.97), and musicians who play more than 14 h per week (OR 3.86, CI 1.80-8.29)were shown to be a higher risk of suffering musculoskeletal pain. Conclusions: Musculoskeletal disorders symptoms are highly prevalent in musicians. The main risk factors related to musculoskeletal disorders symptoms were gender (being female), overweight, obesity, and spending playing more than 14 h a week practicing. This study highlights the need to provide strategies to prevent occupational disabilities among musicians. Further studies are needed to analyse the prevalence of pain in the musician using other sampling methods.

Should musicians play in pain?

Musculoskeletal symptoms, including pain, are often experienced by musicians at all levels. These symptoms may have a detrimental impact on musicians' personal and work lives, and may also impact upon the ensembles they work within. Providing musicians with appropriate, evidence-based advice regarding pain management is therefore paramount. In this review, we aim to improve the advice given to musicians regarding playing when in pain, by answering the question 'should musicians play in pain?'. This multidisciplinary narrative review draws upon contemporary pain science, including factors associated with poorer prognoses for those in pain, as well as the reported experiences of musicians with pain (including those who have taken time off from playing). Our current understanding of pain science provides further support for the potential for consequences related to avoiding activities due to pain. Pain is modulated by a number of neuro-immunological processes and is influenced by a range of psychosocial factors. Taking time off from playing might therefore not have any benefit. Importantly, one of the leading causes of a transition from acute to chronic pain is fear-avoidance behaviour (e.g. not playing when in pain); hence, encouraging such behaviour cannot be supported. Musicians who have taken time off from playing due to pain have experienced a range of consequences, including emotional and financial consequences. These experiences indicate that there are potential negative consequences related to taking time off from playing which need to be weighed against any benefits. We conclude that musicians should not necessarily be advised to take time off from playing to manage their pain, in keeping with current best practice for pain management. Instead, we recommend that musicians be educated on contemporary pain science and when to seek treatment from a health professional for individualised advice to reduce the burden of musicians' pain.

Musculoskeletal disorders and complaints in professional musicians: a systematic review of prevalence, risk factors, and clinical treatment effects

PURPOSE

Musicians' practice and performance routines reportedly lead to musculoskeletal complaints and disorders (MCD) that impact their wellbeing and performance abilities. This systematic review aims to assess the prevalence, risk factors, prevention and effectiveness of treatments for MCD in professional musicians and consider the methodological quality of the included studies.

METHODS

A systematic literature search was performed in December 2017 using electronic databases and supplemented by a hand search. Case-control studies, cohort studies, cross-sectional studies, interventional studies and case reports investigating the prevalence, risk factors, prevention or treatment effects of MCD in professional musicians or music students (age ≥ 16 years) were included. Quality assessments of the included studies were performed using an adapted version of the "Study Quality Assessment Tools" from the National Heart, Lung, and Blood Institute.

RESULTS

One case-control study, 6 cohort studies, 62 cross-sectional studies, 12 interventional studies and 28 case reports were included and assessed for methodological quality. The study designs, terminology, and outcomes were heterogeneous, as the analyses mostly did not control for major confounders, and the definition of exposure was often vague. Therefore, evidence that being a professional musician is a risk factor for MCD as well as the causal relationship between these factors remains low despite the fact that a large number of studies have been performed.

CONCLUSIONS

Studies with high internal and external validity regarding the prevalence, risk factors and effectiveness of the prevention or treatment of MCD in professional musicians are still missing. Further high-quality observational and interventional studies are required.

Educating Australian musicians: are we playing it safe?

The effectiveness of health promotion through arts engagement, and the health benefits and social importance of music in particular, are becoming increasingly recognized. However, like sport, music-making is an athletic endeavour, one that often involves high physiological and psychological loadings on the bodies and minds of musicians. Research over the past 30 years has revealed alarming rates of injury among musicians, and has identified health risk factors associated with music performance faced by professional and student musicians. Australia lacks consistent provision of essential health education for musicians, and research shows an unacceptably high prevalence of performance-related health problems among musicians of all ages. This article advocates for effective health promotion to be embraced in the policies and practices of Australian music performance organizations and educational bodies. It argues that a cultural shift is required, recognizing that a settings-based approach to health literacy is as fundamentally important for musicians as it is for any other occupation or athletic activity. Embedding health education into the delivery of music education will not only help to prevent injury over the lifespan of Australian musicians, it will support and sustain their capacity to contribute towards societal wellbeing and public health outcomes.

Not all imagery is created equal: A functional Magnetic resonance imaging study of internally driven and symbol driven musical performance imagery

Playing a musical instrument requires fast multimodal sensory-motor processing which can be activated by voluntary access to performance imagery. Musicians use different methods to activate imagery for the purpose of "mental practice". The aim of the present study was to investigate cortical activation patterns in different methods of mental practice of musical performance. While undergoing functional magnetic resonance imaging (fMRI), 7 male oud (fretless lute) players engaged in performance imagery of a pre-memorized short excerpt from mainstream oud repertoire using three common imagery methods (task conditions): From memory (internally driven) 1)eyes closed, 2)eyes open, and while following the musical score (symbol driven). The study design consisted of a four-task 16-epoch block design where the 4th task was an eyes-open rest tasks (EOR) included as a control condition. Each task was repeated four times in a pseudorandomized sequence. The superior temporal gyrus and transvers temporal gyrus (Heschl) were active in the left and right hemispheres in all imagery conditions. The occipital cortex, specifically the fusiform gyrus was active in all three conditions. Symbol driven imagery resulted in less prominent activations in frontal and parietal lobes. The findings suggest that not all imagery modalities activate sensory and motor areas similarly.

Temporomandibular disorders, pain in the neck and shoulder area, and headache among musicians

Background

Uncertainties still exist about the role of playing musical instruments on the report of musculoskeletal complaints and headache.

Objectives

To evaluate the prevalence of and risk indicators for symptoms of temporomandibular disorders, pain in the neck or shoulder, and headache among musicians.

Methods

A questionnaire was distributed among 50 Dutch music ensembles.

Results

The questionnaire was completed by 1470 musicians (response rate 77.0%). Of these, 371 musicians were categorised as woodwind players, 300 as brass players, 276 as upper strings players, 306 as vocalists and 208 as controls; nine musicians had not noted their main instrument. The mean age was 41.6 years (standard deviation [SD] 17.2), and 46.5% were male. Irrespective of instrumentalist group, 18.3% of the musicians reported TMD pain, 52.5% reported pain in the neck and shoulder area, and 42.5% reported headache. Of the functional complaints, 18.3% of the musicians reported TMJ sounds, whereas a jaw lock or catch on opening or on closing was reported by 7.1% and 2.4%, respectively. TMD pain was associated with playing a woodwind instrument, whereas pain in the neck and shoulder was associated with playing the violin or viola. For each complaint, oral behaviours were found as risk indicator, supplemented by specific risk indicators for the various complaints.

Conclusions

The current finding that pain‐related symptoms varied widely between instrumentalist groups seems to reflect the impact of different instrument playing techniques. Playing a musical instrument appears not the primary aetiologic factor in precipitating a functional temporomandibular joint problem.

Experience-dependent neuroplasticity in trained musicians modulates the effects of chronic pain on insula-based networks - A resting-state fMRI study

Recent resting-state fMRI studies associated extensive musical training with increased insula-based connectivity in large-scale networks involved in salience, emotion, and higher-order cognitive processes. Similar changes have also been found in chronic pain patients, suggesting that both types of experiences can have comparable effects on insula circuitries. Based on these observations, the current study asked the question whether, and if so in what way, different forms of experience-dependent neuroplasticity may interact. Here we assessed insula-based connectivity during fMRI resting-state between musicians and non-musicians both with and without chronic pain, and correlated the results with clinical pain duration and intensity. As expected, insula connectivity was increased in chronic pain non-musicians relative to healthy non-musicians (with cingulate cortex and supplementary motor area), yet no differences were found between chronic pain non-musicians and healthy musicians. In contrast, musicians with chronic pain showed decreased insula connectivity relative to both healthy musicians (with sensorimotor and memory regions) and chronic pain non-musicians (with the hippocampus, inferior temporal gyrus, and orbitofrontal cortex), as well as lower pain-related inferences with daily activities. Pain duration correlated positively with insula connectivity only in non-musicians, whereas pain intensity exhibited distinct relationships across groups. We conclude that although music-related sensorimotor training and chronic pain, taken in isolation, can lead to increased insula-based connectivity, their combination may lead to higher-order plasticity (metaplasticity) in chronic pain musicians, engaging brain mechanisms that can modulate the consequences of maladaptive experience-dependent neural reorganization (i.e., pain chronification).

How do we assess musicians' musculoskeletal symptoms?: a review of outcomes and tools used

Recent reviews of musicians' musculoskeletal symptoms (MSS) have reported heterogeneity in the outcomes reported and data collection tools used, making it difficult to compare and synthesise findings. The purpose of this present review was to improve the consistency of future research, by documenting the outcomes reported in recent studies of musicians' MSS and the data collection tools used. All English language, peer-reviewed studies, published 2007-2016 that reported musicians' self-reported MSS outcomes were identified. Details of the types of outcomes reported and the tools used were extracted, and synthesised descriptively. A range of MSS outcomes were reported, including MSS with a temporal relationship to activities performed, and the consequences of symptoms. Only 24% of studies used standardised questionnaires, with the Nordic Musculoskeletal Questionnaire (NMQ) being the most commonly used. To improve the homogeneity of outcomes and data collection tools when investigating musicians' MSS, we recommend using the NMQ, where appropriate. Recall periods of 12-months and 7-d are the most appropriate for prevalence, and 7-d recall periods for ratings. Importantly, outcomes and the tools used to collect data should be reported in sufficient detail to ensure that the study can be replicated, critiqued, and accurately interpreted.

Motor imagery as a method of maintaining performance in pianists during forced non-practice: a single case study

Background: Musicians suffer from upper limb playing-related musculoskeletal disorders that often oblige them to periodic inactivity. Objectives: To assess the effectiveness of motor imagery as a means of practice when the physical piano practice is restricted. Methods: A 17-year-old healthy pianist participated in a single subject case study with a multiple baseline design (ABC design). Performance ability was assessed during a period of the no practice, then a period of performing motor imagery and again during a period of another no practice. Assessments were performed subjectively by a professional piano teacher and objectively by the Synthesia software. Three visual analog scales were used to record stress, fatigue, and general psychological state. The participant's motor imagery ability was recorded by the use of the Movement Imagery Questionnaire. Results: There was a statistically significant reduction in performance after no practice. There was no change in performance during motor imagery intervention. The pianist's scores moderately correlated with the general psychological state. The Synthesia scoring presented high correlations with professional piano teacher scoring. Conclusions: Motor imagery seemed to have a positive effect in maintaining the musician's performance level. Synthesia shows promise as an outcome measure for assessing music performance, although further research is needed.

Influence of ergonomic layout of musician chairs on posture and seat pressure in musicians of different playing levels

INTRODUCTION

Musicians often perform in forced postures over a long period of time, which in the worst case may lead to playing-related musculoskeletal disorders. In this context, the ergonomics of the musician's chair (construction and surface quality) can be an influencing factor, with impact on the seating position of the upper body and the pressure distribution of the bottom. Therefore, the relationship between different musician chairs and musicians of different playing levels (professional, amateur or student) was analyzed in order to gain useful insights whether playing experience, playing level, playing style (symmetrical or asymmetrical) or gender have an impact.

METHOD

The total dataset of 47 musicians (3 playing levels: professional, amateur, student) were analysed on six musician chairs with different ergonomic layout. Sitting on each chair without instrument (condition 1) and with instrument (condition 2), the upper body posture (videorasterstereography) and the seat pressure (load distribution) were recorded.as Also, a subjective assessment concerning constitutional data, sitting behaviour, prevailing pain in the musculoskeletal system, sport activity and chair comfort rating, was completed using a questionnaire.

RESULTS

There were significant differences shown in 6 of 17 variables, where all between and within factors were accounted for with a MANOVA. Two measurements of the upper body posture (scapular distance and scapular height) differentiated between playing level. Four of the pressure measurements (pressure under the sit bone and the thigh for the left and the right side) differentiated between chairs and the two conditions (with and without instrument). Chairs with soft cushioning had a mean pressure reduction of about 30%. The pressure was increased by about 10% while playing an instrument. Subjective rating was correlated to age for some of the chairs.

DISCUSSION

Differences between chairs are mainly associated with the pressure distribution under the sitting surface. Playing with an instrument puts an additional force onto the surface of the chair that is more than the weight of the instrument. No relationship between pressure data and upper body posture data could be found. Therefore, it can be speculated that the intersubject variability is larger than systematic differences introduced by the chair or instrument.

The German version of the musculoskeletal pain intensity and interference questionnaire for musicians (MPIIQM-G): Translation and validation in professional orchestral musicians

Many musicians suffer from playing-related musculoskeletal disorders (PRMDs) however many of the epidemiological surveys on PRMD do not utilize evaluated self-report instruments, especially as a tool to assess musculoskeletal pain intensity and pain interference in terms of function and psychosocial constructs. The aim of this study was to translate and cross-culturally adapt the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians (MPIIQM) into German, and validate it among a population of professional orchestral musicians. The translated and cross-culturally adapted German version of the questionnaire was sent to a total of 367 professional orchestral musicians in Germany who were eligible for the study. Of this total, 124 musicians responded to the questionnaire. The psychometric evaluation showed a clear two dimensionality namely "pain intensity" and "pain interference". Internal consistency was very high for both the "pain intensity" and "pain interference" dimensions as well as for the complete scale. The values for the Intraclass Correlation Coefficient for the test-retest reliability indicated good to excellent repeatability. The subscales of MPIIQM showed strong correlation with the Brief Pain Inventory (BPI) and the shorter version of Disabilities of the Arm, Shoulder and Hand (QuickDash) and low correlation with the Fatigue Severity Scale (FSS). These results were as expected, confirming the good construct validity of the MPIIQM. The German Version of the MPIIQM (MPIIQM-G) and the original version have similarly high qualities and thus the MPIIQM-G represents a useful self-report instrument for the measurement and evaluation of musculoskeletal pain intensity and pain interference for professional orchestral musicians.

Electromyography of neck and shoulder muscles in instrumental musicians with musculoskeletal pain compared to asymptomatic controls: A systematic review and meta-analysis

Musicians report a high prevalence of annual musculoskeletal pain (86-89%), attributed to prolonged playing times consisting of repetitive static and dynamic muscle activity. The aim of this study was to explore, compare and synthesise evidence on electromyographic (EMG) muscle activity in neck, shoulder and spinal musculature between painful and asymptomatic instrumental musicians. Ovid, Wiley, Web of Science and Scopus databases were searched in August 2016 for cross-sectional studies that compared EMG activity of neck, shoulder and spinal musculature between musicians with musculoskeletal pain and asymptomatic comparisons. An updated search was performed in May 2017, adding a further study. Two authors independently assessed papers for inclusion and then quality, determined using a modified Downs and Black Checklist. Means and standard deviations were extracted from each study to calculate effect sizes and compare results. Six studies were found to fulfil inclusion criteria. Five studies were deemed high-quality with one being low-quality. Conflicting evidence was found supporting increases in upper trapezius EMG muscle activity in musicians reporting of pain. Moderate-quality evidence indicates increased SCM activity in musicians reporting pain. There was limited evidence supporting increased activity of deltoids, lower trapezius and the upper cervical extensors in musicians reporting of musculoskeletal pain. Meta-analysis of results of three studies assessing upper trapezius activity were conflicting with these not being statistically significant. Further studies with prospective designs, larger population sizes and on broader instrumental groups are warranted.

Health Education for Musicians

Context and aims: Many musicians suffer for their art, and health is often compromised during training. The Health Promotion in Schools of Music (HPSM) project has recommended that health education should be included in core curricula, although few such courses have been evaluated to date. The aim of the study was to design, implement and evaluate a compulsory health education course at a UK conservatoire of music. Methods: The course design was informed by a critical appraisal of the literature on musicians' health problems and their management, existing health education courses for musicians, and the HPSM recommendations. It was delivered by a team of appropriately-qualified tutors over 5 months to 104 first-year undergraduate students, and evaluated by means of questionnaires at the beginning and end of the course. Thirty-three students who had been in their first year the year before the course was introduced served as a control group, completing the questionnaire on one occasion only. Items concerned: hearing and use of hearing protection; primary outcomes including perceived knowledge and importance of the topics taught on the course; and secondary outcomes including physical and psychological health and health-promoting behaviors. The content of the essays written by the first-year students as part of their course assessment served as a guide to the topics they found most interesting and relevant. Results: Comparatively few respondents reported using hearing protection when practicing alone, although there was some evidence of hearing loss, tinnitus, and hyperacusis. Perceived knowledge of the topics on the course, and awareness of the risks to health associated with performing music, increased, as did self-efficacy; otherwise, there were negative effects on secondary outcomes, and few differences between the intervention and control groups. The topics most frequently covered in students' essays were managing music performance anxiety, and life skills and behavior change techniques. Conclusion: There is considerable scope for improving music students' physical and psychological health and health-related behaviors through health education, and persuading senior managers, educators and students themselves that health education can contribute to performance enhancement.

[Musculoskeletal pain among bus drivers and fare collectors in the Metropolitan Region of Belo Horizonte, Brazil]

Musculoskeletal pain among professionals in the transport sector has been linked to working conditions. The scope of this study was to assess the prevalence of cervical musculoskeletal pain and its relation to pain in other areas (arms, hands and shoulders). The association between neck pain, related to pain in other areas or otherwise, was checked against occupational factors. A cross-sectional, descriptive and analytical study was conducted with 799 bus drivers and 708 fare collectors of the Metropolitan Region of Belo Horizonte, Brazil. The outcome was characterized according to the positive answer to the question about musculoskeletal pain in the anatomical areas studied. The prevalence of neck pain in the sample was highest at 16.3%, followed by pain in the shoulders 15.4%, arms 13.3% and hands 6.3%. The factors associated with musculoskeletal pain in the sample were being female, complaints of disability, perception of threat to safety, vibration, excessive or unbearable noise and sitting in an uncomfortable posture. The results provide clues to transformation of the workplace, thereby contributing to the enhancement of occupational health.