Advertisement

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

Published:April 13, 2021DOI:https://doi.org/10.1016/j.jht.2021.04.006

      Highlights

      • Different instruments have specific demands and injuries from unique ergonomics.
      • Treatment plans for of overuse injuries should be musician-centered.
      • A framework helps customize patient-centered approaches to prevention and treatment.

      Abstract

      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.
      • Brandfonbrener A.G.
      Musculoskeletal problems of instrumental musicians.
      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.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Hand Therapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Brandfonbrener A.G.
        Musculoskeletal problems of instrumental musicians.
        Hand Clin. 2003; 19 (v): 231-239
        • Zaza C.
        Research-based prevention for musicians.
        Med Probl Perform Art. 1994; 9: 3
        • Ackerman B.
        • Driscoll T.
        • Kenny D.T.
        Muscolosketel pain and injury in professional orchestral musician in Australia.
        Med Probl Perform Art. 2012; 27(4): 181-187
        • Narducci D.M.
        Musculoskeletal and associated conditions in the instrumental musician. In: Perspectives in performing arts medicine practice.
        Springer, 2020: 197-239
        • Norris R.N.
        Return to play after injury: Strategies to support a musician's recovery.
        Work. 1996; 7: 89-93
        • Norris R.N.
        5th ed. Upper extremity difficulties of instrumental musicians. Rehabilitation of the Hand and Upper Extremity. 2. Elsevier, St.Louis, Mosby2002: 2043-2052
        • Zander M.F.
        • Voltmer E.
        • Spahn C.
        Health promotion and prevention in higher music education: Results of a longitudinal study.
        Med Probl Perform Art. 2010; 25: 54-65
        • Matei R.
        • Broad S.
        • Goldbart J.
        • Ginsborg J.
        Health education for musicians.
        Frontiers in psychol. 2018; 9: 1137
        • Chan C.
        • Driscoll T.
        • Ackermann B.
        Exercise DVD effect on musculoskeletal disorders in professional orchestral musicians.
        Occup Med. 2014; 64: 23-30
        • Chan C.
        • Ackermann B.
        Evidence-informed physical therapy management of performance-related musculoskeletal disorders in musicians.
        Frontiers in psychol. 2014; 5: 706
        • Chan C.
        • Driscoll T.
        • Ackermann B.J.
        Effect of a musicians’ exercise intervention on performance-related musculoskeletal disorders.
        Med Probl Perform Art. 2014; 29: 181-188
        • Azar N.R.
        Rates and patterns of playing-related musculoskeletal disorders in drummers.
        Med Probl Perform Art. 2020; 35: 153-161
        • Zaza C.
        • Farewell V.T.
        Musicians' playing-related musculoskeletal disorders: An examination of risk factors.
        Am J Ind Med. 1997; 32: 292-300
        • Bragge P.
        • Bialocerkowski A.
        • McMeeken J.
        A systematic review of prevalence and risk factors associated with playing-related musculoskeletal disorders in pianists.
        Occup Med. 2006; 56: 28-38
        • Frucht S.J.
        Focal task-specific dystonia of the musicians’ hand—a practical approach for the clinician.
        J Hand Ther. 2009; 22 (doi:): 136-143https://doi.org/10.1016/j.jht.2008.11.006
        • Ting A.
        • Rocker J.
        Evaluation and treatment of musicians from a holistic perspective.
        The Open Jour of Occup Ther. 2019; 7 (doi:): 1-10https://doi.org/10.15453/2168-6408.1581
        • Berque P.
        • Gray H.
        • McFadyen A.
        Development and psychometric evaluation of the musculoskeletal pain intensity and interference questionnaire for professional orchestra musicians.
        Man Ther. 2014; 19: 575-588
        • McCrary J.M.
        • Ackermann B.J.
        • Halaki M.
        A systematic review of the effects of upper body warm-up on performance and injury.
        Br J Sports Med. 2015; 49 (doi:): 935-942https://doi.org/10.1136/bjsports-2014-094228
        • Foxman I.
        • Burgel B.J.
        Musician health and safety: Preventing playing-related musculoskeletal disorders.
        AAOHN J. 2006; 54: 309-316
        • Boyette J.
        Splinting for adaptation of musical instruments.
        Work. 2005; 25: 99-106
        • Kaufman-Cohen Y.
        • Portnoy S.
        • Sopher R.
        • Mashiach L.
        • Baruch-Halaf L.
        • Ratzon N.Z.
        The correlation between upper extremity musculoskeletal symptoms and joint kinematics, playing habits and hand span during playing among piano students.
        PLoS One. 2018; 13e0208788
        • Lee S.
        Hand biomechanics in skilled pianists playing a scale in thirds.
        Med Probl Perform Art. 2010; 25: 167-174
        • Dounskaia N.V.
        • Swinnen S.P.
        • Walter C.B.
        • Spaepen A.J.
        • Verschueren S.
        Hierarchical control of different elbow-wrist coordination patterns.
        Exp Brain Res. 1998; 121: 239-254
        • Chi J.
        • Halaki M.
        • Ackermann B.J.
        Ergonomics in violin and piano playing: a systematic review.
        Appl Ergon. 2020; 88103143
      1. Ciurana Moñino M.R., Rosset-Llobet J., Cibanal Juan L., García Manzanares M.D., Ramos-Pichardo J.D. Musculoskeletal problems in pianists and their influence on professional activity. Med Probl Perform Art. 2017;32:118-122. doi: 10.21091/mppa.2017.2019.

        • Dawson W.J.
        Upper-extremity problems caused by playing specific instruments.
        Med Probl Perform Art. 2002; 17: 135-140
        • Guptill C.
        Musicians’ health: a developing role for occupational therapists.
        Occup Ther Now. 2014; 16: 29-31
        • Mizrahi J.
        Neuro-mechanical aspects of playing-related mobility disorders in orchestra violinists and upper strings players: a review.
        European J of Translat Myol. 2020; 30
        • Vastamäki M.
        • Ristolainen L.
        • Heliövaara M.
        • Vastamäki H.
        Musculoskeletal pain among Finnish orchestra musicians versus core workforce.
        Occup Med. 2020; 70: 507-513
        • Vastamäki M.
        • Vastamäki H.
        • Ristolainen L.
        • Laimi K.
        • Saltychev M.
        Violists and violinists report more intense hand pain on NRS than other orchestra musicians.
        Med Probl Perform Art. 2020; 35: 162-166
      2. Wales J. 3D movement and muscle activity patterns in a violin bowing task. 2007.

        • Visentin P.
        • Li S.
        • Tardif G.
        • Shan G.
        Unraveling mysteries of personal performance style; biomechanics of left-hand position changes (shifting) in violin performance.
        PeerJ. 2015; 3 (doi:): e1299https://doi.org/10.7717/peerj.1299
        • Gorniak S.L.
        • Collins E.D.
        • Goldie Staines K.
        • Brooks F.A.
        • Young R.V.
        The impact of musical training on hand biomechanics in string musicians.
        Hand. 2019; 14 (doi:): 823-829https://doi.org/10.1177/1558944718772388
        • Rensing N.
        • Schemmann H.
        • Zalpour C.
        Musculoskeletal demands in violin and viola playing: a literature review.
        Med Probl Perform Art. 2018; 33 (doi:): 265-274https://doi.org/10.21091/mppa.2018.4040
        • Tawde P.
        • Dabadghav R.
        • Bedekar N.
        • Shyam A.
        • Sancheti P.
        Assessment of cervical range of motion, cervical core strength and scapular dyskinesia in violin players.
        Int J Occup Saf Ergon. 2016; 22 (doi:): 572-576https://doi.org/10.1080/10803548.2016.1181892
        • Leder Horina J.
        • Jurčević Lulić T.
        • Sušić A.
        Ergonomic aspect of violin playing. 2010; : 119-130
        • Butler K.
        • Norris R.
        Assessment and treatment principles for the upper extremities of instrumental musicians.
        in: Skirven TM Osterman AL Fedorczyk JM Amadio PC Rehabilitation of the hand and upper extremity.elsevier health sciences. eds. Elsevier Health Sciences, Philadelphia, PA2011: 1859-1861
        • Turner-Stokes L.
        • Reid K.
        Three-dimensional motion analysis of upper limb movement in the bowing arm of string-playing musicians.
        Clin Biomech (Bristol, Avon). 1999; 14 (doi:): 426-433https://doi.org/10.1016/S0268-0033(98)00110-7
        • Wolff A.L.
        The musician.
        in: Jacobs MA Austin NM Orthotic intervention for the hand and upper extremity. eds. Wolters Kluwer, 2021
        • Johnson C.D.
        Splinting the injured musician.
        J Hand Ther. 1992; 5: 107-110
        • Chong J.
        • Lynden M.
        • Harvey D.
        • Peebles M.
        Occupational health problems of musicians.
        Canadian family physician. 1989; 35: 2341
        • Yokogawa N.
        • Schumacher Jr H.R.
        Percussionists' wrist: Overuse syndrome with an enlarging tenosynovitis and scapholunate advanced collapse.
        JCR: J of Clin Rheumatol. 2010; 16: 250
        • Lederman R.J.
        Neuromuscular and musculoskeletal problems in instrumental musicians.
        Muscle Nerve. 2003; 27 (doi:): 549-561https://doi.org/10.1002/mus.10380
        • Cebriá i Iranzo M.À.
        • Pérez-Soriano P.
        • Igual Camacho C.
        • Llana Belloch S.
        • Cortell-Tormo J.M.
        Playing-related musculoskeletal disorders in woodwind, brass and percussion players: A review.
        J of Human Sport and Exercise. 2010; 5 (doi:): 94-100https://doi.org/10.4100/jhse.2010.51.10
        • Sandell C.
        • Frykman M.
        • Chesky K.
        • Fjellman-Wiklund A.
        Playing-related musculoskeletal disorders and stress-related health problems among percussionists.
        Med Probl Perform Art. 2009; 24: 175-180
        • Dawson W.J.
        Bassoonists' medical Problems—Current state of knowledge.
        Med Probl Perform Art. 2012; 27: 107
        • Dawson W.J.
        The motions of wind instrument performance.
        Dawson. 2006; 2: 1-4
        • Dawson W.
        Hand and upper extremity problems in American instrumentalists.
        in: Sixth Congress of Federation of European Societies for Surgery of the Hand, Bonn, Germany1999
        • Thrasher M.
        • Chesky K.S.
        Prevalence of medical problems among double reed performers.
        Med Probl Perform Art. 2001; 16: 157-161
      3. Shafer S.W., Koreerat N.R., Gordon L.B., Santillo D.R., Moore J.H., Greathouse D.G. Median and ulnar neuropathies in US army medical command band members. Medical problems of performing artists. 2013;28:188-194.

      4. Smith J.C., Smith J.S., Greathouse D.G. 2020 Median & ulnar neuropathies in university brass players. Available at: https://www.hornsociety.org/publications/horn-call/horn-call-archive/147-median-a-ulnar-neuropathies-in-university-brass-players. Accessed 06.20.

      JHT Read for Credit

      Quiz: # 761

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to JHTReadforCredit.com. There is only one best answer for each question.
      • # 1.
        Unfortunately on occasion a PRMD may result in
        • a.
          surgery to relieve TOS
        • b.
          the premature end to a musician's career
        • c.
          litigation against the orchestra company
        • d.
          missing an important concert engagement
      • # 2.
        The authors recommend taking into consideration
        • a.
          prevention strategies
        • b.
          musician-centered interventions
        • c.
          risk factors
        • d.
          all of the above
      • # 3.
        The patient management strategy was developed in part on
        • a.
          ASHT guidelines for treating PRMD
        • b.
          the Philadelphia Hand Rehabilitation Center program for musician performance
        • c.
          evidence-bases data
        • d.
          the London Symphony experience
      • # 4.
        The authors’ team model often includes the musician, a surgeon, a therapist, the music teacher, and
        • a.
          an insurance company representative (case coordinator)
        • b.
          a physiatrist
        • c.
          the patient's spouse
        • d.
          an engineer who designs instruments
      • # 5.
        The authors suggest use of the MPHQM
        • a.
          true
        • b.
          false
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.