Leveraging implementation science to prevent and reduce musculoskeletal overuse injury in musicians: A proposal for the study of a conceptual framework


      • Proposal for an implementation science conceptual framework to study the factors that influence adoption of musician health education programs to prevent performance related injury.
      • Application of the Consolidated Framework for Investigative Research (CFIR) to study implementation of musician injury prevention programs.
      • Methodology to identify determinants of implementation by engaging key stakeholders, developing strategies for adoption of injury prevention programs and generation of hypotheses for future studies.



      Musician health and wellness, a fundamental requirement for safe, effective and optimal musical performance, is not guaranteed. Performance related musculoskeletal disorders (PRMD) affect between 60% and 90% of all musicians, and have serious consequences on musculoskeletal health, performance ability and the overall healthcare burden of musculoskeletal injury. The high prevalence of PRMD in musicians can be prevented and reduced via health-education programs designed to address risk factors and practice habits. Multiple studies demonstrate the efficacy of education and instructional exercises in reducing PRMD symptoms in musicians. Despite the awareness of risk and the substantial consequence of non-adherence, implementation of health-education programs is complex and challenging and is rarely offered in music institutions. For successful adoption of musculoskeletal health programs, it is important to identify system level barriers and facilitators and it is important to develop and pilot effective strategies to guide successful implementation of musculoskeletal health programs for musicians.


      This paper proposes a conceptual framework using implementation science methodology to study the factors that influence adoption of musician health education programs to prevent performance related injury. The overall goal of this methodology is to identify determinants of implementation by engaging key stakeholders, developing strategies for adoption of injury prevention programs and generate hypotheses for future studies.


      The research plan is designed to accomplish the specific aims of this study. Through a mixed-method study we will use qualitative and quantitative methods to address potential barriers, and design and test implementation feasibility of health-education programs for musicians.


      Our findings will inform the development of a large-scale participant randomized hybrid trial to assess effectiveness and implementation outcomes of health education programs and ultimately reduce injury and promote musculoskeletal longevity and performance in musicians


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        • Ackermann B.
        • Driscoll T.
        • Kenny D.T.
        Musculoskeletal pain and injury in professional orchestral musicians in Australia.
        Med Probl Perform Art. 2012; 27: 181-187
        • Steinmetz A.
        • Möller H.
        • Seidel W.
        • Rigotti T.
        Playing-related musculoskeletal disorders in music students-associated musculoskeletal signs.
        Eur J Phys Rehabil Med. 2012; 48: 625-633
        • Stanek J.L.
        • Komes K.D.
        • Murdock F.A.
        A Cross-Sectional Study of Pain Among U.S. College Music Students and Faculty.
        Med Probl Perform Art. 2017; 32: 20-26
        • Zaza C.
        • Farewell V.T.
        Musicians’ playing-related musculoskeletal disorders: an examination of risk factors.
        Am J Ind Med. 1997; 32: 292-300
        • 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
        • Paarup H.M.
        • Baelum J.
        • Manniche C.
        • Holm J.W.
        • Wedderkopp N.
        Occurrence and co-existence of localized musculoskeletal symptoms and findings in work-attending orchestra musicians - an exploratory cross-sectional study.
        BMC Res Notes. 2012; 5: 541
        • Paarup H.M.
        • Baelum J.
        • Holm J.W.
        • Manniche C.
        • Wedderkopp N.
        Prevalence and consequences of musculoskeletal symptoms in symphony orchestra musicians vary by gender: a cross-sectional study.
        BMC Musculoskelet Disord. 2011; 12: 223
      1. Yellin, E.H. W.-C. SI. BMUS: The Burden of Musculoskeletal Diseases in the United States. BMUS: The Burden of Musculoskeletal Diseases in the United States. Accessed February 1, 2021.

        • Brandfonbrener A.G.
        Musculoskeletal problems of instrumental musicians.
        Hand Clin. 2003; 19 (, v-vi): 231-239
        • Rensing N.
        • Schemmann H.
        • Zalpour C.
        Musculoskeletal Demands in Violin and Viola Playing: A Literature Review.
        Med Probl Perform Art. 2018; 33: 265-274
        • 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
        • Chan C.
        • Ackermann B.
        Evidence-informed physical therapy management of performance-related musculoskeletal disorders in musicians.
        Front Psychol. 2014; 5: 706
        • Chan C.
        • Driscoll T.
        • Ackermann B.
        Development of a specific exercise programme for professional orchestral musicians.
        Inj Prev. 2013; 19: 257-263
        • Matei R.
        • Broad S.
        • Goldbart J.
        • Ginsborg J.
        Health Education for Musicians.
        Front Psychol. 2018; 9: 1137
        • Arnason K.
        • Arnason A.
        • Briem K.
        Playing-related musculoskeletal disorders among icelandic music students: differences between students playing classical vs rhythmic music.
        Med Probl Perform Art. 2014; 29: 74-79
        • Roos M.
        • Roy J.-S.
        Effect of a rehabilitation program on performance-related musculoskeletal disorders in student and professional orchestral musicians: a randomized controlled trial.
        Clin Rehabil. 2018; 32: 1656-1665
        • 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: 935-942
        • Spahn C.
        • Nusseck M.
        • Zander M.
        Long-term analysis of health status and preventive behavior in music students across an entire university program.
        Med Probl Perform Art. 2014; 29: 8-15
        • Chan C.
        • Driscoll T.
        • Ackermann B.
        Exercise DVD effect on musculoskeletal disorders in professional orchestral musicians.
        Occup Med (Lond). 2014; 64: 23-30
      2. Chesky K., Dawson W.J., Manchester R. Health PRomotion in Schools of Music: Initial REcommendations for Schools of Music. Medical Problems of Performing Artists 21(3):142-144.

        • NASM
        Facilities and Equipment, Health and Safety: Guidelines and Recommendations.
        National Association of Schools of Music, 2012
        • Emery C.A.
        • van den Berg C.
        • Richmond S.A.
        • et al.
        Implementing a junior high school-based programme to reduce sports injuries through neuromuscular training (iSPRINT): a cluster randomised controlled trial (RCT).
        Br J Sports Med. December 10, 2019; (Published online)
        • Richmond S.A.
        • Donaldson A.
        • Macpherson A.
        • et al.
        Facilitators and Barriers to the Implementation of iSPRINT: A Sport Injury Prevention Program in Junior High Schools.
        Clin J Sport Med. March 26, 2018; (Published online)
      3. Formative Evaluation: Fostering Real-Time Adaptions and Refinements to Improve the Effectiveness of Patient-Centered Medical Home Interventions | PCMH Resource Center. Accessed January 14, 2021.

        • Ajidahun A.T.
        • Myezwa H.
        • Mudzi W.
        • Wood W.-A.
        Barriers and facilitators in implementing an exercise-based injury prevention program for string players.
        Work. December 3, 2019; (Published online)
        • Laursen A.
        • Chesky K.
        Addressing the NASM health and safety standard through curricular changes in a brass methods course: an outcome study.
        Med Probl Perform Art. 2014; 29: 136-143
        • Árnason K.
        • Briem K.
        • Árnason Á.
        Effects of an Education and Prevention Course for University Music Students on Their Body Awareness and Attitude Toward Health and Prevention.
        Med Probl Perform Art. 2018; 33: 131-136
        • Yang N.
        • Fufa D.T.
        • Wolff A.
        A Musician-Centered Approach to Management of Performance-related Upper Musculoskeletal Injuries.
        Journal of Hand Therapy. 2021; 0
        • Berque P.
        • Gray H.
        • McFadyen A.
        Playing-Related Musculoskeletal Problems Among Professional Orchestra Musicians in Scotland: A Prevalence Study Using a Validated Instrument, the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians (MPIIQM).
        Med Probl Perform Art. 2016; 31: 78-86
        • 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
        • Wolff A.L.
        • Ling D.I.
        • Casey E.K.
        • Toresdahl B.G.
        • Gellhorn A.C.
        Feasibility and impact of a musculoskeletal health for musicians (MHM) program for musician students: A randomized controlled pilot study.
        J Hand Ther. April 15, 2021; (Published online)
        • Morris Z.S.
        • Wooding S.
        • Grant J.
        The answer is 17 years, what is the question: understanding time lags in translational research.
        J R Soc Med. 2011; 104: 510-520
        • Sriphanlop P.
        • Jandorf L.
        • Thompson H.
        • Valdimarsdottir H.
        • Redd W.
        • Shelton R.C.
        Preventive Health Behaviors Among Low-Income African American and Hispanic Populations: Can Colonoscopy Screening Serve as a Teachable Moment?.
        J Racial Ethn Health Disparities. 2018; 5: 179-186
        • Goldsmith S.
        • Friedman D.
        • Horton R.
        • Seehaus M.
        • Robbins L.
        Creating musculoskeletal programs for culturally diverse, underserved communities: a community-based participatory research survey.
        HSS J. 2014; 10: 266-275
        • Waltz T.J.
        • Powell B.J.
        • Fernández M.E.
        • Abadie B.
        • Damschroder L.J.
        Choosing implementation strategies to address contextual barriers: diversity in recommendations and future directions.
        Implement Sci. 2019; 14: 42
        • Proctor E.
        • Silmere H.
        • Raghavan R.
        • et al.
        Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda.
        Adm Policy Ment Health. 2011; 38: 65-76
        • Damschroder L.J.
        • Aron D.C.
        • Keith R.E.
        • Kirsh S.R.
        • Alexander J.A.
        • Lowery J.C.
        Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science.
        Implement Sci. 2009; 4: 50
        • Weiner B.J.
        • Lewis C.C.
        • Stanick C.
        • et al.
        Psychometric assessment of three newly developed implementation outcome measures.
        Implement Sci. 2017; 12: 108
        • Keith R.
        • Hopp F.
        • Subramanian U.
        • Wiitala W.
        • Lowery J.
        Fidelity of implementation: Development and testing of a measure.
        Implementation science: IS. 2010; 5: 99

      JHT Read for Credit

      Quiz: # 758

      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 There is only one best answer for each question.
      • # 1.
        One important assumption underlying this thesis is that
        • a.
          PRMD is a serious concern in approximately 15% of professional musicians
        • b.
          hand therapists are well trained in the management of PRMD
        • c.
          PRMD may be positively mitigated by an appropriate program of education and exercise
        • d.
          improper shoulder posture is the primary cause of PRMD
      • # 2.
        The author propose using ______________________ to address hurdles which musicians must overcome to lessen the incidence of PRMD
        • a.
          implementation science methodology
        • b.
          wrist stabilizing orthotics
        • c.
          transcendental meditation
        • d.
      • # 3.
        Historically musicians created barriers to dealing successfully with PRMD by falling back on
        • a.
          playing through the pain
        • b.
          injury concealment
        • c.
          denial of their problem
        • d.
          all of the above
      • # 4.
        The article is
        • a.
        • b.
        • c.
          both qualitative and quantitative
        • d.
          a case series
      • # 5.
        This study sets the table for a randomized investigation into the effectiveness of their proposed intervention
        • a.
          not true
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.