The correlation between upper extremity musculoskeletal symptoms and joint kinematics, playing habits and hand span during playing among piano students

The Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians: Assessment of Patient-Related Outcomes among Professional Orchestra Musicians in Poland-A Cross-Sectional Study

Background: Musculoskeletal pain is one of the reasons for a musician's inability to play an instrument. An assessment of the localization, intensity, and interference of those complaints is important among musicians because of the risk of occupational disease. Assessment by validated tools is especially important and serves as an indicator to take up proper preventive or treatment actions. The aim of the study was to assess the prevalence of playing-related musculoskeletal disorders (PRMDs) and the relationships with PRMDs' impact on playing musical instruments among Polish professional orchestra musicians. Methods: The study was conducted on a group of professional orchestra musicians (age 37.19 ± 9.62 years), 99 (55%) women and 83 (45%) men. Work experience in professional orchestra was 18.3 ± 9.83 years and the reported years of playing musical instrument were 31.4 ± 9.50. The study used the online version of a musician-dedicated questionnaire, Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians of the Polish Population (MPIIQM-P). Results: In the study group, 89.9% of women and 83.1% of men had experienced playing-related pain in their lifetime. The most intense pain among the group with current playing-related musculoskeletal complaints (n = 85) was located in the neck area for 19 (22.4%). Conclusions: The results of the study indicate a high prevalence of playing-related musculoskeletal problems among professional musicians.

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.

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.

Biomechanical comparison of walking with a new, wearable rehabilitation training device to Nordic walking and regular walking in people with chronic low back pain

Physical activity, particularly walking, is commonly used for the treatment of diseases such as low back pain. In this study, the effects of walking wearing the new ToneFit Reha training belt (TFR) were compared to both Nordic walking and regular walking. The TFR is intended to intensify the effects of walking through the integration of two adjustable resistance handles. Ten patients with low back pain performed regular walking, Nordic walking, and walking with the TFR in a movement laboratory. The kinematics of the trunk, upper extremities, and lower extremities were measured, and the activity of the trunk and upper extremity muscles recorded. Data were analyzed by repeated-measures ANOVA and paired t-test. Kinematics indicated that walking with the TFR introduces instability that was mitigated by a delayed peak trunk rotation (peak at 63.3% gait cycle, vs. 52.8% in walking (p = .001) and 51.0% in NW (p = .007)). Upper extremity kinematics (constrained elbow flexion, high peak shoulder abduction) showed movement patterns that need to be considered when training over a longer period. Increased muscle activity was observed especially for upper extremity muscles, when training with TFR. Overall, walking with the TFR was found to be a suitable therapy for use in a rehabilitation setting.

Characterizing the effects of an ergonomic handle on upper limbs kinematics and neuromuscular activity, comfort, and performance during ergometer rowing

Articular stress and discomfort during repetitive movements may impact the risk of injuries of the upper limbs during ergometer rowing, especially when using a regular circular handle. Therefore, the purpose of the study was to propose and evaluate the influence of an ergonomic handle on upper limbs biomechanics, comfort and performance during ergometer rowing. An ergonomic irregular hexagon handle, with a 1:1.25 width/length diameters ratio, has been developed. Left upper limb kinematics and neuromuscular activity, perceived comfort and power production were monitored for 29 expert rowers. The ergonomic handle increased the perceived comfort while maintaining the overall articular stress and performance as the same level compared to the regular handle. We recommend using irregular hexagon handles with 1:1.25 ratio for ergometer rowing. Further improvements of the ergonomic handle such as an individualization based on the user's hand length may further enhance comfort and achieve better performance.

The influence of proximal motor strategies on pianists' upper-limb movement variability

Repetitive movements are considered a risk factor for developing practice-related musculoskeletal disorders. Intra-participant kinematic variability might help musicians reduce the risk of injury during repetitive tasks. No research has studied the effects of proximal motion (i.e., trunk and shoulder movement) on upper-limb movement variability in pianists. The first objective was to determine the effect of proximal movement strategies and performance tempo on both intra-participant joint angle variability of upper-limb joints and endpoint variability. The second objective was to compare joint angle variability between pianist's upper-limb joints. As secondary objectives, we assessed the relationship between intra-participant joint angle variability and task range of motion (ROM) and documented inter-participant joint angle variability. The upper body kinematics of 9 expert pianists were recorded using an optoelectronic system. Participants continuously performed two right-hand chords (lateral leap motions) while changing movements based on trunk motion (with and without) and shoulder motion (counter-clockwise, back-and-forth, and clockwise) at two tempi (slow and fast). Trunk and shoulder movement strategies collectively influenced variability at the shoulder, elbow and, to a lesser extent, the wrist. Slow tempi led to greater variability at wrist and elbow flexion/extension compared to fast tempi. Endpoint variability was influenced only along the anteroposterior axis. When the trunk was static, the shoulder had the lowest joint angle variability. When trunk motion was used, elbow and shoulder variability increased, and became comparable to wrist variability. ROM was correlated with intra-participant joint angle variability, suggesting that increased task ROM might result in increased movement variability during practice. Inter-participant variability was approximately six times greater than intra-participant variability. Pianists should consider incorporating trunk motion and a variety of shoulder movements as performance strategies while performing leap motions at the piano, as they might reduce exposure to risks of injury.

A first step towards a framework for interventions for individual working practice to prevent work-related musculoskeletal disorders: a scoping review

BACKGROUND

Work-related musculoskeletal disorders (WMSDs) are a key topic in occupational health. In the primary prevention of these disorders, interventions to minimize exposure to work-related physical risk factors are widely advocated. Besides interventions aimed at the work organisation and the workplace, interventions are also aimed at the behaviour of workers, the so-called individual working practice (IWP). At the moment, no conceptual framework for interventions for IWP exists. This study is a first step towards such a framework.

METHODS

A scoping review was carried out starting with a systematic search in Ovid Medline, Ovid Embase, Ovid APA PsycInfo, and Web of Science. Intervention studies aimed at reducing exposure to physical ergonomic risk factors involving the worker were included. The content of these interventions for IWP was extracted and coded in order to arrive at distinguishing and overarching categories of these interventions for IWP.

RESULTS

More than 12.000 papers were found and 110 intervention studies were included, describing 810 topics for IWP. Eventually eight overarching categories of interventions for IWP were distinguished: (1) Workplace adjustment, (2) Variation, (3) Exercising, (4) Use of aids, (5) Professional skills, (6) Professional manners, (7) Task content & task organisation and (8) Motoric skills.

CONCLUSION

Eight categories of interventions for IWP are described in the literature. These categories are a starting point for developing and evaluating effective interventions performed by workers to prevent WMSDs. In order to reach consensus on these categories, an international expert consultation is a necessary next step.

The structure of occupational diseases in first-third-year piano students

BACKGROUND

The aim is to analyze the structure of occupational diseases in first-third year piano students studying.

METHODS

A total sample of 300 individuals participating in the research process underwent a complete medical examination at the end of each academic year.

RESULTS

Among piano students, number of those distributed to special medical groups for health reasons grew from 14 to 38% (p ≤ 0.02). The incidence of diseases of the muscular system increased from 58 to 71% (p ≤ 0.05), with the sharpest rise during the transition from the second to the third year of study. Similar tendencies were obtained for the incidence of hand-related diseases-their overall frequency advanced from 17 to 23% (p ≤ 0.05). The surge of morbidity in the transition from the second to the third year of study can be attributed to the increased educational load experienced by students during this period, as they begin to practice music intensively after theoretical classes. Сorresponding measures directed at preventing occupational diseases, bettering physical education, expanding the rest intervals between piano lessons are to be taken.

CONCLUSIONS

The research results indicate that the main occupational diseases of piano students are those related to hands and muscular system.

IMPACT

The obtained data suggest that the range of diseases is likely to progress throughout the musical training. The main diseases of piano students are those related to hands and muscular system. The sharpest rise was during the transition from the 2nd to the 3rd year of study.

The Impact of Piano Styles on Muscle Force in Pianist Students

The study of the consequences of different sonata styles (baroque, classical and romantic piano repertoire) on pianists’ upper limbs represents a research topic for both the musical and medical fields. Twenty piano students were examined using a MicroFet2 dynamometer after playing three sonatas (Scarlatti K. 1 Sonata as a representative of the baroque style, Haydn Sonata no. 60 for the classical style and Chopin second Sonata for the romantic style). The phase sequence was randomised for each subject: firstly, continuous interpretation of 10 bars of a sonata was conducted 10 times, with the metronome tempo set by the investigator; secondly, the subject interpreted 10 bars of a different sonata continuously, standardised by tempo, which was carried out 10 times; finally, the continuous interpretation of 10 bars of the remaining third sonata, standardised by tempo, was carried out 10 times. After each performance of the 10 bars, the elbow extensor’s isometric muscle force was measured. Significant differences were found between the elbow extensor’s isometric muscle force assessed after playing Scarlatti’s sonata and Haydn’s sonata (p = 0.005 for left arm, p = 0.03 for right arm), between Scarlatti’s sonata and Chopin’s sonata (p < 0.0001 for both left and right arms) and between Haydn’s sonata and Chopin’s sonata (p = 0.01 for left arm, p < 0.0001 for right arm). In healthy piano students, the dynamometric assessment of elbow extensors’ isometric muscle force after playing three different sonatas (baroque, classical and romantic) showed that the lowest values were recorded after playing the baroque style. Our results showed bilateral symmetry in the elbow extensor’s isometric muscle force for all three piano styles. The testing of arm muscles, besides that of the fingers, should be considered as a regular evaluation for future professional pianists with regard to the prevention of musculoskeletal complaints.

An Examination of Trunk and Right-Hand Coordination in Piano Performance: A Case Comparison of Three Pianists

Playing the piano at expert levels typically involves significant levels of trial-and-error learning since the majority of practice occurs in isolation. To better optimize musical outcomes, pianists might be well served by emulating some of the practices found in sports, where motor learning strategies are grounded in biomechanics and ergonomics in order to improve performance and reduce risk of performance-related injuries. The purpose of the current study is to examine trunk-hand coordination and preparatory movement strategization in piano performance, while considering the influence of anthropometry, skill level of the performer, and musical context. Using a ten-camera motion capture system, movement of C7 and right-hand distal phalanges was tracked at three different playing speeds during performance of an excerpt from Beethoven’s “Appassionata” Sonata. There were three participants: two males and one female of differing anthropometric characteristics and skill levels. Motor strategization was examined. Expertise influenced starting trunk position: Initiation intervals and trunk range of motion (ROM) both suggested anthropometry to be a performance factor. For the shortest performer, trunk movement appeared to be used as an efficiency measure to compensate for a shorter arm reach. Skill level was revealed by examining right-hand velocity at the fastest tempo. The current study hypothesizes that an examination of proximal-to-distal preparatory strategies in terms of anthropometry and skill level can help to optimize motor learning for pianists. To realize piano performance as a whole-body skill and encourage healthy practice, pedagogy needs to educate learners regarding fundamental biomechanical and ergonomic principles, movement optimization, and movement strategization in the service of artful performance.

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.

Are the forearm muscles excited equally in different, professional piano players?

Background and objectives

Professional pianists tend to develop playing-related musculoskeletal disorders mostly in the forearm. These injuries are often due to overuse, suggesting the existence of a common forearm region where muscles are often excited during piano playing across subjects. Here we use a grid of electrodes to test this hypothesis, assessing where EMGs with greatest amplitude are more likely to be detected when expert pianists perform different excerpts.

Methods

Tasks were separated into two groups: classical excerpts and octaves, performed by eight, healthy, professional pianists. Monopolar electromyograms (EMGs) were sampled with a grid of 96 electrodes, covering the forearm region where hand and wrist muscles reside. Regions providing consistently high EMG amplitude across subjects were assessed with a non-parametric permutation test, designed for the statistical analysis of neuroimaging experiments. Spatial consistency across trials was assessed with the Binomial test.

Results

Spatial consistency of muscle excitation was found across subjects but not across tasks, confining at most 20% of the electrodes in the grid. These local groups of electrodes providing high EMG amplitude were found at the ventral forearm region during classical excerpts and at the dorsal region during octaves, when performed both at preferred and at high, playing speeds.

Discussion

Our results revealed that professional pianists consistently load a specific forearm region, depending on whether performing octaves or classical excerpts. This spatial consistency may help furthering our understanding on the incidence of playing-related muscular disorders and provide an anatomical reference for the study of active muscle loading in piano players using surface EMG.

A musician-centered approach to management of performance-related upper musculoskeletal injuries

STUDY DESIGN

Invited Clinical Commentary BACKGROUND: Performance related musculoskeletal disorders (PRMD) are common in instrumental musicians and often affect the upper extremities. These overuse injuries typically result from inadequate attention to the musculoskeletal demands required for the high-level performance of musician-students and experienced instrumentalists.¹ PRMDs often interfere with career trajectory, and in extreme cases, can be career ending. Many clinicians and healthcare practitioners treating upper extremity injuries are not familiar with the specific demands faced by instrumental musicians and how to tailor treatment and prevention strategies to the specific risks and occupational needs of each instrumental group.

PURPOSE OF THE STUDY

This paper describes an evidenced-based framework for the assessment, prevention, and treatment of musculoskeletal musician injuries to provide clinicians with an instrument-specific, and musician-centered guide for practice. We synthesized available literature on instrumental ergonomics, biomechanical demands, and upper extremity injuries to highlight the risks and common upper-extremity pathologies, focusing on the specific demands of instrumental groups: piano, high strings (violin and viola), low strings (cello and bass), percussion, woodwinds, and brass. Targeted assessment, prevention, and treatment strategies are reviewed in this context to provide healthcare providers with an evidence-based framework to approach the treatment of PRMD to mitigate incidence of injury during practice and performance.

METHODS

A comprehensive search of electronic databases was conducted including all study designs.

RESULTS

This review describes risk factors for PRMD in instrumental musicians, strategies to prevent misuse and performance injury, and musician-centered interventions to allow playing while reducing risk of misuse.

CONCLUSION

The suggested assessment and treatment framework can assist clinicians with a customized patient-centered approach to prevention and treatment by addressing the gap in clinical knowledge with the goal of ultimately reducing the incidence and severity of PRMD in musicians.

Relationship between Information and Communication Device Usage and Development of Hand Disorders

This study examined the association between hand disorders and time spent using information and communication devices. The participants in this study, conducted between January 2017 and 2020, were 150 healthy university students. They were tested for carpal tunnel syndrome and De Quervain’s tenosynovitis. Average daily device usage time was found to be 5.76 ± 3.00 (1.9-16.2) h. Smartphones were used the most, followed by personal computers and gaming consoles. However, usage time did not vary significantly by device type. Intensive users were significantly more likely to have De Quervain’s tenosynovitis (P < .001), while non-intensive users were significantly less likely to have hand disorders (P < .001) and less likely to have De Quervain’s tenosynovitis. These results can form the basis of guidelines for the prevention of information and communication device overuse.

Ergonomics in violin and piano playing: A systematic review

This systematic review aimed to evaluate whether muscle activity and playing-related musculoskeletal disorders are associated with musicians' anthropometrics and their instrument size or set-up during violin and piano performance. Studies were retrieved systematically from six databases on 1 April 2019 combined with hand searching results. The Appraisal tool for Cross-Sectional Studies (AXIS tool) was used to evaluate the methodological quality of the included papers. A total of twenty articles were identified. Most included studies focussed on either the adjustment of the shoulder rest in violinists, or the hand size in pianists. However, methodological quality was inconsistent. The electromyography data reported by the included studies were not appropriately processed and interpreted. Studies generally reported the use of a shoulder rest changes muscle activity and smaller hand size is correlated to increased playing-related musculoskeletal disorders incidence. However, no conclusions can be drawn due to heterogeneity and low quality of methodology in the available literature.

Regional Differences in Mitochondrial Capacity in the Finger Flexors of Piano Players

BACKGROUND

Near-infrared spectroscopy (NIRS) has been used to measure oxidative capacity, but regional differences have not been identified. Piano players are also a novel group of subjects for this lab.

METHODS

Controls (n = 13) and piano players (n = 8) were tested in a seated position on the right forearm. A fatigue test was performed for three minutes at 2, 4 and 6 Hz using electrical stimulation, which created an endurance index (EI) as the forearm fatigued. A six-cuff oxidative capacity test was performed using manual exercise to activate the muscle and allow for regional specificity. A rate constant (Rc) was generated from the mitochondrial capacity data.

RESULTS

Overall, piano players (Rc = 1.76 ± 0.6) and controls (Rc = 1.17 ± 0.3) have significant differences for the last two fingers (p = 0.01). While controls have significant differences between the index (Rc = 1.86 ± 0.5) and last two fingers (Rc = 1.17 ± 0.3) (p = 0.001), this difference was not observed in piano players. Overall, piano players (EI = 75.7 ± 12.3) and controls (EI = 73.0 ± 17.3) had no differences in endurance index values (p = 0.71).

CONCLUSIONS

Piano players have significant differences in the mitochondrial capacity of the finger flexors that control the last two fingers compared to controls. The lack of difference between groups in the index fingers and overall endurance test suggests playing the piano produces training adaptations to the finger flexor muscles of the last two digits, which are rarely used by control subjects.