REVIEW ARTICLE
published: 08 July 2014
doi: 10.3389/fpsyg.2014.00706
Evidence-informed physical therapy management of
performance-related musculoskeletal disorders in
musicians
Cliffton Chan* and Bronwen Ackermann
Discipline of Biomedical Science, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
Edited by:
David Wasley, Cardiff Metropolitan
University, UK
Reviewed by:
Lutz Jäncke, University of Zurich,
Switzerland
Christoff Zalpour, University of Applied
Sciences Osnabrueck, Germany
*Correspondence:
Cliffton Chan, Discipline of Biomedical
Science, Sydney Medical School, The
University of Sydney, 75 East Street,
Lidcombe, Sydney, NSW 1825,
Australia
e-mail: cliffton.chan@sydney.edu.au
Playing a musical instrument at an elite level is a highly complex motor skill. The regular daily
training loads resulting from practice, rehearsals and performances place great demands
on the neuromusculoskeletal systems of the body. As a consequence, performance-related
musculoskeletal disorders (PRMDs) are globally recognized as common phenomena
amongst professional orchestral musicians. These disorders create a significant financial
burden to individuals and orchestras as well as lead to serious consequences to the
musicians’ performance and ultimately their career. Physical therapists are experts in
treating musculoskeletal injuries and are ideally placed to apply their skills to manage
PRMDs in this hyper-functioning population, but there is little available evidence to
guide specific injury management approaches. An Australia-wide survey of professional
orchestral musicians revealed that the musicians attributed excessively high or sudden
increase in playing-load as major contributors to their PRMDs. Therefore, facilitating
musicians to better manage these loads should be a cornerstone of physical therapy
management. The Sound Practice orchestral musicians work health and safety project used
formative and process evaluation approaches to develop evidence-informed and clinically
applicable physical therapy interventions, ultimately resulting in favorable outcomes. After
these methodologies were employed, the intervention studies were conducted with
a national cohort of professional musicians including: health education, onsite injury
management, cross-training exercise regimes, performance postural analysis, and music
performance biomechanics feedback. The outcomes of all these interventions will be
discussed alongside a focussed review on the existing literature of these management
strategies. Finally, a framework for best-practice physical therapy management of PRMDs
in musicians will be provided.
Keywords: physical therapy, playing-related musculoskeletal disorders, work-related musculoskeletal disorders,
overuse, performing arts medicine, injury management, formative evaluation, process evaluation
INTRODUCTION
Performing music at an elite level requires greatly developed and
integrated sensorimotor and neuromuscular body systems. These
are honed by long daily hours of practicing highly complex movements over many years of intensive training (Watson, 2006; Hyde
et al., 2009; Krause et al., 2010; Hoenig et al., 2011). As the musician
progresses in their skills, the repertoire becomes increasingly challenging requiring more practice time. To then reach the epiphany
of the music profession, these meticulous and artistic athletes persist with practice and work at a heightened level of physical stress,
making them highly susceptible to neuromusculoskeletal injuries
(Brandfonbrener, 2010).
Injury rates are globally reported to be high in this profession (Middlestadt and Fishbein, 1989; Leaver et al., 2011;
Paarup et al., 2011; Ackermann et al., 2012), and are thought
to relate to the repetitive physical loads reflecting the particular demands of the instrument played. For example, shoulder
injuries occur frequently in violin and viola players (Leaver et al.,
2011; Paarup et al., 2011; Ackermann et al., 2012), while orofacial
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and embouchure problems are common in brass players (Iltis
and Givens, 2005; Fletcher, 2008; Frucht, 2009). The same phenomenon is observed in sport, whereby the injury region reflects
the physical demands of the sport played. For example, shoulder problems are extremely common in swimmers, and knee
and ankle problems frequently occur in soccer players (Pink and
Tibone, 2000; Drawer and Fuller, 2001; Waivenhaus et al., 2012).
Despite this similarity between the task-specific type of injury
risks faced by musicians and athletes, there are clear differences
in the provision of health education and injury management
services.
Sports Medicine has made substantial progress in the monitoring of their athletes for the vigorous demands of their sport and
early injury management through strong networks with sports
medical and allied health professionals. In contrast, musicians
usually have minimal connections with specialized performing arts
healthcare professionals (Tubiana, 2000; Guptill, 2011). Throughout their training and professional life, musicians do not receive
specialized health education and advice to aid in injury recovery
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Chan and Ackermann
or to minimize potential injury risks (Hoppmann and Patrone,
1989). Furthermore, musicians typically do not participate in
other supplementary training activities to support their performance like the athletes. Upon reaching a professional level of
performance, musicians usually cease to attend lessons or receive
any technical feedback or instruction. This is unlike other elite
performance domains, such as sports and dance, where this
is maintained throughout their career. Increasing knowledge of
healthy practice strategies and implementing tailored injury prevention measures specifically for musicians, following approaches
similar to Sports Medicine, may reduce the susceptibility of musicians to a range of musculoskeletal disorders (Zaza, 1993, 1994;
Tubiana, 2000).
In addition to exposure to physical injury risks, musicians,
like other athletes, face intense psychological pressures arising
from performing under public scrutiny. Unlike sports communities, however, negative cultural perceptions regarding injury
within the musical community can provide a challenge to implementing a best practice model of healthcare (Rickert et al.,
2013). Negative connotations of inferior technical competency are
commonly directed at musicians suffering performance-related
injuries by their peers (Guptill, 2011, 2012; Raymond et al.,
2012). Injuries can thus be associated with feelings of professional inadequacy or shame (Bragge et al., 2006; Guptill, 2011;
Chimenti et al., 2013), tending to lead to injury concealment
behaviors that delay the implementation of appropriate healthcare management. Such stigmas associated with playing-related
injuries, as well as the lack of specialized health services and
education, have led to professional orchestral musicians’ often
playing through the pain until they can no longer manage
(Schoeb and Zosso, 2012). Additionally, there is increasing awareness of the complex relationship between performance-related
musculoskeletal disorders (PRMDs), performance-related pain
and a range of psychosocial factors (Altenmüller and Jabusch,
2010; Kenny and Ackermann, 2013). Hence effective rehabilitation of musicians’ injuries requires healthcare professionals to
manage both the physical and psychological aspects of PRMDs
(see Table 1). Healthcare practitioners should be aware of
their potential contribution to psychosocial and cultural factors in the performing arts field, however, it is beyond the
scope of this paper to explore the psychosocial interventions for
PRMDs.
Physical therapists are trained to use scientific and evidencebased assessments and treatments to prevent musculoskeletal
disease and disability, and are experts in optimizing function
and performance (Kolt and Snyder-Mackler, 2007). As a profession trained to treat a wide range of neurological, respiratory
and musculoskeletal conditions, they are well-positioned to apply
their manual therapy, exercise and biomechanics skills to managing PRMDs in musicians (World Confederation for Physical
Therapy, 2011). However, the pool of physical therapists treating musicians as a specialty is very small compared to sports
physical therapy although this specialty appears to be growing.
One of the challenges to current physical therapy management approaches is the lack of specialized training programs
and available evidence on effective intervention strategies for
musicians.
Frontiers in Psychology | Cognitive Science
Evidence-informed physical therapy for musicians
USE OF FORMATIVE AND PROCESS EVALUATION
METHODOLOGY
The use of rigorous epidemiological approaches in the design and
implementation stages of developing an occupation-specific prevention and management program may increase the likelihood of
intervention outcomes being successful (Viera and Kumar, 2004;
Stetler et al., 2006; Boocock et al., 2007; Jurg et al., 2008; Bell and
Burnett, 2009; Harding et al., 2009). This was found to be the case
in our studies with professional orchestral musicians (Chan et al.,
2013b,c). All stakeholders including researchers, expert clinicians,
orchestral management and musician employee representatives
should contribute. Including all relevant parties in the development of prevention and management programs can help to avoid
organizational or work barriers that may otherwise hinder trial
compliance and participation rates (Dehar et al., 1993). Formative and process evaluation methodologies are increasingly being
employed to ensure interventions are researched, designed and
pilot tested prior to implementation (Stetler et al., 2006; Jurg et al.,
2008; Baranowski et al., 2009), and suit the needs of designing
interventions for the musician population.
In the first stage, formative evaluation strategies were utilized in the development of specific interventions for professional
orchestral musicians to optimize likely positive outcomes (Chan
et al., 2013b,c). A comprehensive literature review of musicians’
health, as well as a review of relevant literature from occupational and sports medicine was undertaken and information
synthesized to draft a preliminary program. A panel of experienced physical therapists reviewed the proposed intervention
programs and were asked for their evaluation and comments.
Musicians and their management teams were also asked to give
feedback about the proposal. In instances where there was a
lack of consensus, the program was revised, and subsequently
sent out for feedback. Working closely with orchestra management staff was necessary for the programs to be designed
in a way that was compatible with the context and practicalities of the orchestral environment and schedules. This
formative evaluation process was vital in ensuring the interventions were highly credible and likely to optimize desired
results.
In the pilot testing or process evaluation phase, interventions
were trialed and modified as necessary based on evaluation of
the intervention by the researchers, feedback from the physical
therapists involved in the study as well as feedback from a small
number of musicians that had volunteered for the pilot trial. While
these physical therapists were highly experienced and qualified
in sports and occupational physical therapy, most did not have
musician-specific injury management expertise. This stage of the
program development had the additional benefit of allowing participating physical therapists to familiarize themselves with the
research protocol and intervention delivery. The piloting process
was also useful in refining the intricacies of implementing the
intervention and identifying potential impracticalities or errors
that may occur when implementing the program on a larger
nationwide scale. Therefore, formative and process evaluation
provided an effective means to develop intervention trials that
had good support from all relevant stakeholders at the outset of
the project.
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Chan and Ackermann
Evidence-informed physical therapy for musicians
Table 1 | Physical and psychosocial factors influencing the development and perpetuation of performance-related musculoskeletal disorders
(based on Wu, 2007; Altenmüller and Jabusch, 2010; Brandfonbrener, 2010; Leaver et al., 2011; Ackermann et al., 2012; Kenny and Ackermann,
2013).
Physical risk factors
Psychosocial risk factors
Non-modifiable
Minimally modifiable or modifiable
• Instrument played
• Overload – sustained high levels of
• General and/or performance anxiety
• Anthropometrics
playing or sudden increases in playing
• Depression
• Gender
load
• Pressures from self, peers, educational
• Playing conditions – temperature, length
of rehearsals and performances
• Lack of rest breaks in rehearsals and
institution or work organization
• Work and/or non-work Related stress
private practice
• Joint laxity - past trauma or generalized
• Poor posture
• Social phobia
• Challenging repertoire
• Poor biomechanics
• Personality traits – e.g., somatization
• Joint hypomobility
tendencies, extreme perfectionism
• Instrumental technique and pedagogical
style
• Lack of physical conditioning
• Poor injury management
The purpose of this review is to inform physical therapists of
evidence-based management strategies for PRMDs in the musician population that can be readily implemented in the clinic
environment and introduced into music institutions and organizations. The outcomes of a series of formative and process evaluated
intervention strategies, undertaken as part of the “Sound Practice”
project, along with their clinical and research implications will be
presented. These include: health education and advice provided to
musicians, specialized onsite injury and recovery services, exercise
regimes, and postural and biomechanics analysis.
specialized and relevant healthcare advice to promote optimal
injury prevention strategies and management enabling musicians to safely sustain their necessarily highly repetitive playing
loads.
Throughout the duration of the “Sound Practice” project each
of the Australian state orchestras received regular delivery of
healthcare education, covering physical, psychological, nutritional
and auditory health topics. Informal feedback following these
sessions indicated the musicians felt they had a high need for
this education, and should have received it much earlier in their
musical careers.
RESULTS
MUSICIAN’S HEALTH EDUCATION AND ADVICE
Private practice scheduling
It is generally accepted that a vital component in the prevention and management of work-related musculoskeletal disorders
is appropriate health education and medical advice (Bohr, 2002;
Silverstein and Clark, 2004). Since professional musicians often
endure long rehearsals and performances that involve extremely
repetitive activities, it is only sensible to educate them about potential risks to which they may be exposed; since these could lead to
them sustaining a work-related injury (Pascarelli and Hsu, 2001;
Baldwin, 2004; da Costa and Viera, 2010). For example, some
modifiable risk factors associated with PRMDs on which physical therapists could provide advice are: scheduling of private
practice sessions, rest and relative rest after injury, basic nutrition and hydration, general fitness and early injury identification
and management. However, at present there is a lack of formal health and fitness education during musical training as well
as within the orchestral workplace (Barrowcliffe, 1999; Tubiana,
2000; Dommerholt, 2009). Musicians’ lack of understanding of
injury causes or best management approaches may lead to musicians using unreliable sources for health advice, and therefore
poor or inadequate management of injuries. Physical therapists
working with professional musicians should be able to provide
The importance of planning out private practice for the prevention of PRMDs is suggested by various authors (Zaza, 1994;
Green et al., 2000). Even professional musicians may not consider
that challenging and higher intensity repertoire should be practiced in shorter durations with frequent rest breaks or with easier
repertoire in between (Fry, 2000) to avoid muscle fatigue. While
professional orchestral musicians often have limited flexibility in
their private practice schedule, wherever possible, distributing the
total private practice schedule through the day (Green et al., 2000)
will ensure that there is adequate rest and recovery for the body,
and allows for better skill refinement and consolidation (Donovan
and Radosevich, 1999; Robertson et al., 2004; Lee and Wishart,
2005).
When the amount of playing hours fluctuate due to performances, auditions and other playing demands, musicians should
be made aware of the potential overload on musculoskeletal structures. Such a problem is often caused by sudden increases of
overall playing load and musicians should adjust their practice
schedules accordingly (Newmark and Lederman, 1987; Davies
and Mangion, 2002; Ackermann and Adams, 2004). During periods of increased load, a higher number of performances and
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Chan and Ackermann
rehearsals, musicians may need to reduce physical practice and
employ the use of practice strategies such as shadow-playing or
mental practice (Menuhim, 1986; Keller, 2012). In the opposite
situation, after periods of minimal playing (i.e., during holidays),
musicians should build up their intensity and duration of private practice prior to returning to full playing workloads (Green
et al., 2000). In summary, orchestral musicians should carefully
plan their private practice schedules as well as monitor their overall playing load to minimize the potential for development of
PRMDs.
Evidence-informed physical therapy for musicians
As symptoms subside and the injury heals, the number of playing sessions and their duration can be progressively increased
to match ability. Rehabilitation should be directed toward functional recovery from the outset as in other specialized domains,
aiming for graduated return to work from about week six following the injury, depending on the injury severity (Järvinen
et al., 2007). Orchestral musicians may otherwise return to performance prior to adequate healing and thereby risk ongoing health
issues.
Nutrition and hydration
Rest and relative rest after injury
Rest breaks to prevent work-related musculoskeletal disorders,
especially injuries relating to overuse as is typical in professional
musicians, are important in all occupations involving long periods
of repetitive work (Huang and Feuerstein, 2004). In occupational medicine literature, it is recommended that regular breaks
be taken, a minimum of 5 min every hour, to prevent excessive physical stress and allow energy stores in the muscles to be
replenished (Westgaard and Winkel, 1996; Silverstein and Clark,
2004; Kennedy et al., 2010). For musicians, frequent and regular breaks assist in reducing the constant strain and load-bearing
on the joints, as well as allowing recovery of supporting musculature and fine-control muscles of the fingers and lips (Zaza,
1994). While musicians may have little control over rest breaks
during orchestral rehearsal and performance, they should be
able to appropriately implement these in their private practice
sessions.
There is evidence to suggest that taking regular breaks during private practice has a protective effect on recurrent PRMDs
in musicians (Zaza and Farewell, 1997). As a general recommendation, a 5-min rest break should be taken for every 25 min of
playing (Zaza, 1994; Robinson and Zander, 2002; Ackermann,
2010). Musicians should also take into consideration more frequent breaks when practicing repertoire with higher intensity and
increased difficulty. If practice sessions are longer, 10–15 min
rest should be taken after 45–60 min (Robinson and Zander,
2002; Ackermann, 2010). Musicians should be acutely aware that
working at sustained elevated physical-stress levels is damaging
to musculoskeletal structures and without adequate rest the tissue breakdown process will exceed the speed of repair ultimately
leading to injury (Kumar, 2001).
Following an injury, it is important that the musician understand the basic healing characteristics of the relevant body
tissues to ensure good compliance in rehabilitation protocols
(Ackermann, 2010; Hoppmann, 2010). In the event of acute
musculoskeletal injury, it is recommended that tissues should
be given a rest period of between 3 and 7 days to optimize the
initial inflammatory phase (Kannus et al., 2003; Järvinen et al.,
2007). To facilitate optimal tissue healing and integrity and prevent further tissue atrophy the rest period should be followed
by gentle and graduated range of movement exercises depending
on the severity of tissue damage (Popovich et al., 2000; Orchard
and Best, 2002; Kannus et al., 2003; Nash et al., 2004). For the
injured musician, shorter practice sessions with more regular
breaks may be necessary in the early injury recovery phase (Norris, 1993), for example 5 min playing followed by 5 min rest.
Frontiers in Psychology | Cognitive Science
It would seem logical that nutrition and hydration are important
considerations in a musicians’ preparation before their long practice sessions and performances much like the athletic population.
A musician’s nutritional needs are likely to be above that of the
general population due to the physical nature of their work over
long periods suggesting nutritional education should be included
in the prevention and management of PRMDs (Robinson and
Zander, 2002; Shafer-Crane, 2006).
In low intensity endurance activities, approximately 60% of the
energy expended comes from carbohydrate sources (Holt, 1993;
Manore et al., 2009). This would suggest that before rehearsals
and performances, a musician’s diet should include carbohydrates, then fats and proteins. Low to medium glycemic index
(GI) carbohydrates, i.e., energy sources that produce a slow to
moderate rise in blood glucose and insulin, would be likely to
be the most ideal to enable the energy to be sustained over long
rehearsals and performances (Manore et al., 2009). Fat and protein sources provide approximately 25 and 15% respectively of
the energy supplies during low intensity endurance activity (Holt,
1993; Manore et al., 2009). Following long performances, consuming a more rapid release carbohydrate food source (medium
to high GI) as well as proteins are suitable to optimally replenish depleted fuel reserves and to facilitate repair of any muscle
fiber breakdown that may have occurred (Phillips, 2006; Campbell
et al., 2007; Kumar et al., 2009; Manore et al., 2009). Sports science
research indicates it is important to consume these carbohydrate
and protein food sources within one hour after the activity (Campbell et al., 2007). Therefore, an adequate nutritional intake before
and after strenuous rehearsals and performances may be important in potentially reducing the risk of PRMDs (Phillips, 2006;
Campbell et al., 2007).
Another important component of nutritional consideration is
water intake, with these needs varying from approximately 2 l
of water per day for a sedentary adult male under normal environmental conditions up to approximately 3 l with the addition
of modest physical activity (Kenefick and Sawka, 2007; Jéquier
and Constant, 2010; Popkin et al., 2010). To maintain hydration in a warmer environment, water intake may need to be
further increased to account for the greater fluid loss through
sweat. If musicians become too dehydrated prior to performances, this could lead to tiredness, muscular weakness, dry
and sticky mouth and tongue, headaches, dizziness or lightheadedness (Jéquier and Constant, 2010), which could potentially
affect playing. Musicians who regularly perform under different
environmental conditions both indoors and outdoors should be
mindful of their water intake; replenishing before, during and
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Chan and Ackermann
after playing as required (Kenefick and Sawka, 2007; Montain,
2008). Even a small degree of dehydration can affect cognitive and physical function (Shirreffs, 2009; Popkin et al., 2010),
and as such musicians needing to perform at their peak and
reduce the likelihood of injury should be aware of their water
intake.
General fitness
Participation in cardiovascular fitness and resistance training has
been suggested to be an important element in maintaining a
healthy and long career in the performing arts (Shafer-Crane,
2006). There are many physical and psychological benefits associated with appropriate levels of regular physical activity, such
as significant increases in cardiovascular fitness, skeletal muscle
endurance, reaction time, and decreased incidence of osteoarthritis, depression and anxiety (Booth et al., 2012). In one previous
survey, musicians who performed physical activity regularly rated
their perceived exertion level during rehearsal to be significantly
lower than musicians that did little or no physical activity (Wilke
et al., 2011).
Musicians, like other hyper-functioning performers such as
dancers and athletes, should undertake both cardiovascular and
resistance exercises each week to best achieve and maintain optimal physical conditioning. Based on recommendations from the
American College of Sports Medicine (Medicine ACoS, 2010)
and expert music health practitioners (Ackermann et al., 2002;
Ackermann, 2010; Wilke et al., 2011), an example of a potential
best-practice exercise guideline for musicians is included in Table 2
below including the type, frequency, and duration of exercises.
Specialized and tailored musician exercise programs may further enhance physical condition of performers without overloading already heavily worked structures, and these will be discussed
in Section “Cross-Training Exercise Regimes” below.
Early injury identification and management
Early identification of injury and commencement of rehabilitation
is key to optimizing prognosis of most neuromusculoskeletal problems (Linton, 2002; Gatchel et al., 2003; Stucki et al., 2005), with
potential benefits to professional orchestral musicians (Milanese,
2000). Not only can the best healthcare management be immediately implemented when injury presents (Orchard and Best, 2002;
Dommerholt, 2010; Pemoff et al., 2012), but secondary problems can also be prevented (Laisné et al., 2012). For musicians,
early injury identification or triage by an onsite physical therapist
could minimize the effect of the injury on playing/performance
by immediately implementing a plan for best injury management (Chan et al., 2013c), thus aiding a more rapid return to
work or play (Shafer-Crane, 2006). Musicians should be educated on the principles of first aid that can be applied prior
to a healthcare consultation for acute injury management. The
principles of first aid could include: resting the injured area,
icing the injured area, and applying compression with elevation in the presence of swelling and seeking a diagnosis if
symptoms persist (Australia SJsA, 2012; Bruckner and Khan,
2012).
For musicians, receiving immediate and specific advice when
to simply rest and self-manage a mild strain or when to consult
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Evidence-informed physical therapy for musicians
a health professional for an injury is likely to be important for
optimizing recovery.
SPECIALIZED ONSITE INJURY AND RECOVERY SERVICES
A brief intensive physical therapy-led triage service for professional orchestral musicians was successful in managing musicians’
injuries during a busy playing period (Milanese, 2000). This author
concluded that the availability of a regular triage service may
allow earlier identification and management of PRMDs occurring throughout the usual playing schedule. Such an acute injury
management advice service, led by physical therapists, was developed and implemented for 12-weeks for each state orchestra
Australia-wide (Chan et al., 2013c). In consultation with orchestral management, clinics were held for one hour every fortnight,
usually during the lunch hour between rehearsal calls, with both
an anonymous appointment booking system or drop-in services
available.
This onsite triage service was well-received by the musicians,
and was evidenced by consistent feedback of the musicians’ gratitude toward having such an easily available injury management
service. Most of the consultations at these triage services were classified as PRMDs, and services were more likely to be utilized by
females and string players. Most musicians who presented with
PRMDs reported that these affect their normal playing, and the
physical therapists considered that the majority of conditions seen
may have been preventable. These encouraging results support
the regular accessibility of a triage clinic at orchestral premises; if
this is achievable in the longer term it may be possible that many
PRMDs could be better managed or prevented altogether.
Following on from the injury advisory service, an intensive
trial providing both injury advice and short treatments (usually recovery massage) were undertaken with one orchestra. This
orchestra’s management team forecasted a possible increase in
playing-related injury due to a heavier than normal orchestral
cycle immediately following a holiday period. In this study of short
recovery treatments and injury advice, 10 to 15 min consultations
with a qualified massage therapist and/or physical therapist were
made available throughout the duration of the orchestral season.
Feedback from musicians and orchestra management indicated
that most musicians benefited from these sessions. Additionally,
shorter sessions of lighter “effleurage and petrissage” style massage
(Weerapong and Kolt, 2005) were preferred over the occasional
more intensive massage or treatment approaches as the latter
tended to leave some soreness effects in the next playing session.
Management reported far less absences than they had anticipated
over the course of the trial. These quick recovery treatments may
be greatly beneficial to musicians during busy playing periods, or
during intensive touring programs (Ackermann, 2002).
CROSS-TRAINING EXERCISE REGIMES
Despite suggestions that purpose-designed exercise regimes may
play a major preventative role in avoiding PRMDs (Zaza, 1994;
Brandfonbrener, 1997; Foxman and Burgel, 2006), there is a lack
of clinical trials in this area for professional orchestral musicians.
In other occupational health literature, there is a strong body
of literature indicating the efficacy of exercise therapy in targeting work-related musculoskeletal disorders, especially in the
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Evidence-informed physical therapy for musicians
Table 2 | An exercise guideline for musicians to improve cardiovascular fitness and muscular conditioning.
Type of exercise
Frequency and duration
Example exercises
Cardiovascular (aerobic) fitness exercise
Five sessions of moderate intensity exercise per
Brisk walking, cycling at an easy pace, swimming
week, at least 30 min per session or three
leisurely, or jogging, cycling with a slight incline or
sessions of high intensity exercise per week, at
low resistance, swimming with a moderate effort
least 20 min per session
Resistive (muscular endurance) exercise
Two sessions per week, 2–3 sets of 10–20
• Scapular retractors (seated rows, reverse flyes)
repetitions, with 90 s rests in between sets
• Shoulder external rotators
Aim to target 8–10 major muscle groups each
• Low back extensions
week
• Hip extensions (bridging in supine lying)
• Leg press, squats, or lunges
• Tricep extensions
• Bicep curls, push ups, chest press*
*Should be performed less regularly as the muscles used in these exercises are commonly tight and overused from instrumental playing.
neck, lower back and upper body regions (Boocock et al., 2007;
Blangsted et al., 2008; Gerg and Smith, 2008; Äng et al., 2009; Bell
and Burnett, 2009; Machotka et al., 2009; Andersen et al., 2010a,b;
Lysaght et al., 2010). Purpose-designed exercise programs appear
to be equally effective or better at reducing pain and improving functional outcomes in a cost-effective manner than a wide
range of manual therapy or ergonomic interventions (Verhagen
et al., 2007; van Eijsden et al., 2009). For these reasons, it is
worth thoroughly investigating the efficacy of participation in tailored exercise programs for the professional orchestral musician
population.
To guide the development of a specific exercise program for
professional orchestral musicians a review of the existing literature
was performed. Only one intervention trial was found that investigated the effects of a 15-week exercise program on PRMD levels
and associated risk factors in a small sample of 17 professional
orchestral musicians (de Greef et al., 2003). The intervention did
not specifically evaluate exercise, but it was part of an intervention package of musician-specific education, some specific
exercises and a traditional general strengthening exercise program.
These authors found significant reductions in PRMD levels and
self-reported improvements in playing-related posture, strength,
fatigue, anxiety and ability to cope with work-related stress.
Three other studies investigated the effect of exercise programs on
university music students. Exercise interventions included resistance, core stability or aerobic exercises and were reported to
reduce the presence, frequency and intensity of PRMDs and to
improve instrumental playing posture (Spahn et al., 2001; Ackermann et al., 2002; Kava et al., 2010). It appears that simply
participating in generic aerobic and strengthening fitness programs that provide overall cardiovascular and strength benefits
are insufficient to prevent PRMDs or improve instrumental performance in musicians (Van Hees, 1997; Zetterberg et al., 1998).
These findings from the four exercise trials suggest that there is
a key role for developing exercise programs to target and potentially prevent PRMDs in professional musicians (Andersen et al.,
2008).
Frontiers in Psychology | Cognitive Science
The intervention groups participating in an exercise program
targeting specific body regions susceptible to injury in musicians
reported positive benefits in relation to PRMDs, exertion and a
range of playing-related factors (Chan et al., 2013b). The literature
on common body regions of PRMDs experienced by musicians
was used to identify target regions for strengthening (Roset-Llobet
et al., 2000; Wu, 2007; Leaver et al., 2011; Paarup et al., 2011; Ackermann et al., 2012). Existing evidence from sports and occupational
health literature and well-accepted clinical practice was integrated
to produce a progressive exercise program aimed to increase
the endurance of supportive musculature in the shoulder, neck,
abdominal, lower back, and lumbo-pelvic regions (Chan et al.,
2013b). In addition, the exercises incorporated improving motor
control and movement patterning of the body region. Participants
were taught how to activate weakened stability muscles and then
incorporate these muscles in a task-specific and functional manner
for musicians.
Exercise programs targeted toward strengthening the supportive musculature of commonly injured areas in musicians
were effective in reducing PRMDs and improved numerous
other playing-related factors. The evaluation of survey results
from the DVD exercise trial was greatly encouraging. A statistically significant reduction in PRMD frequency and severity
occurred immediately after the 12-week intervention (Chan et al.,
2014a). In the face-to-face exercise intervention study similar positive benefits were seen. Additionally, the opposite was
observed in the control group’s PRMD frequency and severity
scores, which increased over the time of two standard orchestral cycles despite most of them undertaking regular physical
activity (Chan et al., 2014b). After the cessation of the intervention at six-month follow-up, the beneficial effect seen in
the intervention group slowly declined. This slight decline in
positive effects of exercise is consistent with other literature documenting that exercise levels must be maintained for ongoing
benefits (Kay et al., 2005; Fransen and McConnnell, 2008; Macedo
et al., 2009; Vina et al., 2012). Participants of the interventions also reported moderate to high perceived improvements
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Chan and Ackermann
in the strength of the muscles that support their playing, flexibility, posture and ease of movement after the interventions,
with most of these benefits maintained at similar levels at
follow-up. The program appeared to be safe, with no injuries
incurred as a direct consequence of the exercises. Therefore, it
appears that musicians benefit from undertaking targeted exercises for muscles that support their instrumental playing demands
and then to maintain such a program to prevent or manage
PRMDs.
The ability of musicians to consistently participate in exercise
programs was identified as a challenge by both orchestral management and musicians due to the continued variability in their
work schedule. Programming of such sessions was an important
and often complicated component that has to be factored into
the successful implementation of such an intervention. By undertaking face-to-face exercise classes immediately before or after
orchestral rehearsals and ensuring exercises focused on supporting rather than playing musculature, participants were still able to
begin their rehearsal without any complaints of muscular fatigue
affecting performance (Chan et al., 2014a). An additional solution suggested in the sports and rehabilitation medicine domains
was to deliver an exercise program via the use of digital media
(Hupperets et al., 2009; Vandelanotte and Mummery, 2011; Khalil
et al., 2012). Such a flexible delivery method may increase accessibility, and allow more self-conscious musicians to participate
without the scrutiny of their peers. Consequently, with the assistance of a professional film crew, the authors (CC and BA)
produced an exercise DVD based on the program outlined in
Chan et al. (2013b). The DVD study had a much higher initial
uptake across all orchestras, although tended to be more popular with the musicians who had an existing physical activity
regime (Chan et al., 2014a), suggesting that face-to-face classes
are still also useful for musicians who perhaps feel they need
more guidance and supervision. Through careful scheduling of
the exercise class around rehearsal times and different forms
of intervention delivery modes, barriers to attendance could be
overcome.
PERFORMANCE POSTURE ANALYSIS
Correct posture has been defined as the body position adopted
that loads the joints safely, helps conserve energy and allows
freedom of movement (Kendall et al., 1952). Throughout instrumental playing, such a correct posture needs to also allow
supportive muscles to sustain efficient static or dynamic movements and stability of the joints during performance actions.
However, achieving optimal posture while performing can challenge basic concepts of “ideal” posture as playing most musical instruments requires maintaining asymmetrical postures in
either sitting or standing over prolonged periods of time (Cailliet, 1990; Haslegrave, 1994; Nyman et al., 2007; Claus et al.,
2009; Edling and Fjellman-Wiklund, 2009; O’Sullivan et al.,
2012). Non-ideal postures requiring higher levels of muscle
activation to support the musician and their instrument while
compensating for reduced balance and control, may increase
static loading and stress of neuromusculoskeletal structures,
leading to earlier muscular fatigue and excessive muscular tension, creating a higher risk of developing PRMDs (Magnusson
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Evidence-informed physical therapy for musicians
and Pope, 1998; Medoff, 1999; Kapandji, 2000; Tubiana, 2000;
Kumar, 2001; Quarrier and Stenback, 2002; Price and Watson,
2011).
When maintaining postures for extended periods of time, such
as sitting which is common to all orchestral musicians, spinal
structures may be in non-ideal positions and muscles may become
overloaded (Hedman and Fernie, 1997; Briggs et al., 2007). The
effect of these postures on loading is further compounded by
the added dynamic and asymmetrical stressors of playing their
instrument (Hides, 2004; Briggs et al., 2007). The accumulation
of these factors may accelerate degenerative processes in spinal
motion segments and contribute to the development of dysfunction and pain (Kendall et al., 1952; Eijsden-Besseling et al., 1993;
Hoogendoorn et al., 2000; Briggs et al., 2007; Price and Watson,
2011). Hence, maintaining as neutral and yet supported posture
as possible may be important to prevent PRMDs in professional
orchestral musicians.
Not only are sustained and poor postures a potential cause
of injury to musculoskeletal structures, such postures could also
potentially affect the neuromuscular system leading to an inferior musical performance. Posture also plays a crucial part in
breathing mechanics, suggested to influence the volume and quality of sound produced by woodwind and brass instrumentalists
(Quarrier and Stenback, 2002; Gaunt, 2004; Ackermann, 2010).
In the general population, slouched posture has been shown to
increase respiratory effort, and significantly decrease breathing
capacity and control (O’Sullivan et al., 2002; Landers et al., 2003),
with likely altered abdominal and accessory respiratory muscle
recruitment patterns, as well as non-optimal biomechanical positioning of these muscles (Roussos, 1985; Kera and Maruyama,
2005; Ainscough-Potts et al., 2006; Ratnovsky et al., 2008). Such
changes may have a negative impact on breathing endurance and
control for musicians, although more research is needed in this
area.
In order to test the impact of postural changes on instrumental playing, it was important to first ascertain whether clinically
utilized methods of assessment were a reliable way of measuring and monitoring postural change. A postural trial was
undertaken to determine whether experienced observers, including healthcare professionals and music educators with Alexander
Technique/Body Mapping training, were able to detect postural
changes in musicians from photographs following a 10-week exercise intervention program. This qualitative approach was tested
because health professionals commonly use anterior and lateral
photographic views of posture as part of their re-assessment of
intervention effectiveness. Our results suggest that both health
professionals and music educators were statistically significantly
better (p < 0.001 and p = 0.002 respectively) than chance at selecting the true post-intervention photograph (Chan et al., 2013a).
Although the health professionals (66%) were slightly better than
the music educators (60%) at selecting the true post-intervention
as having better posture, this result was not statistically different.
Interestingly, 97% of the musician participants (n = 57) in this
trial reported a noticeable improvement in their playing-related
posture, which may reflect the limited ability for static photographs to evaluate dynamic postural changes and underlying
muscular tension changes perceived by the professional orchestral
July 2014 | Volume 5 | Article 706 | 7
Chan and Ackermann
musicians. While the use of static photographs may be useful in observing large scale abnormal skeletal postures, such as
spinal deviations, forward head postures and shoulder angles
(O’Sullivan et al., 2012), more subtle changes in a musician’s
technique and posture may suit other assessment methods such
as videography. Nonetheless, the use of photographs may still
provide a useful component of the re-assessment of a musician’s posture by experienced health practitioners and music
educators.
MUSIC PERFORMANCE BIOMECHANICS FEEDBACK
The term “biomechanics” refers to the study of internal and external forces acting on the human body and the effects produced
by these forces (Freivalds, 2011). In occupational biomechanics, the physiological loads and stresses placed on the human
body as a result of work-related tasks are analyzed (Chaffin
et al., 1991). This can provide useful insights for physical therapists to help musicians optimize playing-related posture, maximize playing technique efficiencies, understand the importance
of ergonomics and use of equipment, and potentially minimize unnecessary load on body preventing injury (McGinnis,
2013). Biomechanical analysis has also been applied extensively
to sports performance, and in collaboration with coaches has
led to new advances and insights into performance optimization
and injury prevention. The term “Music Performance Biomechanics” is used here to extend this concept to the study of
the mechanics of human movement applied to musical performance.
Whilst laboratory based quantitative research on music performance biomechanics is continuously emerging (Visentin et al.,
2008; Chadefaux et al., 2012; Fernandes and de Barros, 2012; Kelleher et al., 2013; Sung et al., 2013), music teachers still rely almost
entirely on qualitative approaches to performance technique feedback. This is mostly based on the outcome goal of the quality of
sound output rather than observing how the musician is moving and reacting to achieve the desired sound. Even with the
far greater amount of technological data regarding the athletic
performer, there is little evidence as yet on how to best utilize
such information to provide effective feedback in performance
situations (Phillips et al., 2013). A qualitative approach is typically used in the practical sport setting, whereby movements and
elements of technique are analyzed and then remediation occurs
through feedback to address any identified flaws that may detrimentally affect performance or increase the risk of injury (Lees,
2002). Experts consider that observing the movements of the performer with their instrument is a key part of health assessment
of the musician (Blum, 2003). Despite this, developing reliable
rating scales for observing musicians playing their instrument has
provided only limited success, with complicated systems showing poor inter-rater reliability (Ackermann and Adams, 2004),
and simpler analyses showing better reliability (Driscoll and Ackermann, 2012). In such a domain where sound quality is the
primary goal and playing styles can be diverse, it seems sensible to take a collaborative approach incorporating the expertise
of the musician and the healthcare professional in achieving the
goal of improving both sound and movement quality during
performance.
Frontiers in Psychology | Cognitive Science
Evidence-informed physical therapy for musicians
The aim of the biomechanics feedback study as part of the
“Sound Practice” project was to videograph performers in their
usual rehearsal situations, identify those actions that may create
a higher risk of physical strain within an individual musicians’
technique, and then discuss the footage and analysis with the performer. The approach of providing individualized biomechanics
feedback aimed to incorporate strategies is suggested by current
research, whereby feedback needs to be task and person specific
and the key elements that may benefit from remediation being
readily modifiable (Phillips et al., 2013). The use of observation
offers a chance to process performance information that could
not occur simultaneously with physical practice, facilitating refinement (or maintenance) of complex motor skills (Wulf et al., 2010).
In sports medicine literature, immediate feedback has been shown
to enhance athletic task performance (Argus et al., 2011). By providing immediate feedback of the musician’s performing as well
as using the experience and skills of the musician themselves in
the process, may then further improve the ability to adapt recommendations into an individual technique and optimizing musical
performance.
. This biomechanics feedback procedure was further refined
using process evaluation by piloting methods of feedback with
an orchestra not involved in the “Sound Practice” project. Semistructured interviews post-feedback were used to further refine the
amount of feedback given and presentation of footage and other
information. 60 musicians volunteered to participate in this trial
from the five orchestras who responded to the research invitation.
Four out of these five orchestras requested a repeat of the trial in
response to positive feedback from the musicians. A simple postfeedback survey was used to evaluate the trial, ranging from −5
for negative impact to +5 for positive impact. Of the 50% of musicians who responded to the survey, every response was neutral or
positive in terms of impact on performance. The self-report factors
included: ease of playing; effect on pain; muscle tension; understanding playing actions; impact on playing posture; impact on
muscle fatigue; and impact on playing biomechanics. A narrative
section allowed musicians’ to write any additional responses, and
these reinforced the positive outcome of this intervention and the
strong engagement by the musicians in the process. Overall, this
final biomechanics feedback trial was welcomed and supported
by the orchestra management and the musicians themselves, and
appeared to be a proactive way of monitoring performance and
preventing injury.
While more research is needed in this field, along with exploring methods of integrating qualitative and quantitative data,
preliminary results are encouraging and reinforce the need for
physical therapists to consider music performance biomechanics
as a component of their health management of the musician.
RECOMMENDATIONS FOR EFFECTIVE PHYSICAL THERAPY
MANAGEMENT OF PERFORMANCE-RELATED
MUSCULOSKELETAL DISORDERS IN MUSICIANS
Current approaches to the management of PRMDs have been
based on expert opinion (Zaza, 1993; Shafer-Crane, 2006; Dommerholt, 2009, 2010) and translational research adapted from
other fields of medicine. However, as guidelines for practice
emerge based on new research findings (Altenmüller and Jabusch,
July 2014 | Volume 5 | Article 706 | 8
Chan and Ackermann
2010; Driscoll and Ackermann, 2012) physical therapists should
aim to adapt and modify their practice using such guidelines to
enhance their management of PRMDs in musicians.
At all stages of physical therapy interventions for musicians’
injuries, from prevention to assessment and onto rehabilitation, the performer must be regarded as a highly trained and
skilled individual. Our own approaches to management need
to be expanded and specialized to better meet the needs of
the musician population. During history taking, the musician’s
background of years of playing, stage of skill, practice habits,
teacher and “school of playing” should be recorded as these may
influence their playing technique and posture. This information
can add valuable perspectives for why the musician is adapting
Evidence-informed physical therapy for musicians
postures that may place them at a biomechanical disadvantage
or provide indications to the mechanism of injury. During the
physical examination, musicians must be examined with their
instrument and with attention to the extreme ranges of motion
related to performance requirements (Driscoll and Ackermann,
2012). A summary of some of these important information
specifics to assessment and treatment of musicians is illustrated
in Table 3.
Physical therapists should carefully structure the musicians’
rehabilitation program to include musician specific education
and advice, targeted exercise regimes and any other intervention strategies to achieve better functional outcomes. After an
injury, musicians should be informed of the need to implement
Table 3 | Management of the injured musician.
Assessment
Treatment
History
Education and advice
• Years of playing on primary instrument
• Private practice scheduling
• Stage of skill on primary instrument
• Rest and relative rest after injury
• Increased switches between instruments or recent change of primary
• Nutrition and hydration
instrument
• General fitness
• Current and past teacher/s
• Early injury identification and management
• “School of playing”
Specialized onsite injury and recovery services
• Total playing hours (the sum of private practice, rehearsals and
• Music organizations and music educational institutions should
performances)
consider implementing such a service to ensure musicians received
• Preparation routine
specialized advice on the best course of action for any concerns and
• Practice schedule (e.g., 1 h, twice per day) and the duration and frequency
injuries, as well as immediate management by suitably experienced
of rest breaks
healthcare professionals.
• Changes to repertoire (e.g., style, difficulty)
Cross-training exercise regimes
• Any recent modifications to instrument (e.g., ergonomic devices) or playing
• Musicians should undertake a targeted exercise program for any
technique
• Impact of pain on current playing capacity
existing postural concerns or identified problems, and for
strengthening supportive musculature required for their instrument.
• Other relevant work-related psychosocial risk factors
Music performance biomechanics feedback
Physical examination
• This tool could be used as a monitoring system to track progress or
• Observation of static posture (with and without instrument) and playing
posture
• A “Performance Postural Analysis” of the musician with and without
instrument in sitting and standing should be performed. Poor postural habits
provide feedback to the musician, student or teacher.
Ergonomic considerations
• Sourcing instrument-specific ergonomic modifications to aid the
adaptation of the instrument to the musician.
are often missed if not performed under playing conditions (e.g., forward
head posture when trying to seal their embouchure with the interface of the
woodwind/brass instrument). Ideally this should be done with videography
but photographs can also be used for more gross postural issues.
• Measure available range of movement at the injured joint to ensure there is
sufficient range for the instrumentalist (e.g., 99◦ of supination at left elbow
in violin players, left hand span larger than right hand span in cello and
double bass players).
• Test muscle strength and control of supporting muscles relevant to their
instrumental playing and problem (e.g., string player with shoulder issue –
test external rotator cuff versus internal rotator cuff strength)
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July 2014 | Volume 5 | Article 706 | 9
Chan and Ackermann
a graduated return to playing and/or return-to-work plan such
that sufficient rest and recovery for any damaged neuromusculoskeletal structures. A practice diary could be used to
record and monitor timing of playing and rest breaks, Additional strengthening, movement or flexibility regimes off the
instrument into relevant ranges of motion, and muscle activation patterns specific for the instrumentalist (e.g., consider
whether the strengthening needs to occur in inner/middle/outer
range for the muscle/s with a which type of muscle contraction). Consideration of playing-related demands created by the
instrument and the workplace may require additional management strategies (e.g., reduced rest week between multiple
orchestral cycles with increased performances and difficulty of
repertoire may require an onsite physical therapy recovery service to aid recovery and promptly manage any playing-related
injuries).
In summary, emerging evidence in the field of music medicine
has lead to useful insights and clinically applicable strategies for
the management of PRMDs in musicians. Beyond a thorough
understanding of current models of management of work-related
musculoskeletal disorder, physical therapists should further tailor their history taking and physical assessment to treat musicians
as a highly specialized and hyper-functioning population. Relevant education and advice should be provided to musicians
early in their injury whilst preventative information needs to
be delivered early and throughout their careers. Specific training and workplace demands must also be carefully considered in
the comprehensive management of the musician’s injuries. Finally,
proactive steps at music institutions and organizations should be
taken, such as implementing onsite health prevention and management services for musicians, as playing-related problems in
this population is not only highly prevalent and persistent but can
also become greatly debilitating ultimately jeopardize a musicians’
career.
AUTHOR CONTRIBUTIONS
Cliffton Chan and Bronwen Ackermann made substantial contributions to the conception and design of this work, drafting
the work and revising it critically for important intellectual
content. We give permission for this paper to be published
and agree to be accountable for all aspects of the work in
ensuring that questions related to the accuracy or integrity
of any part of the work are appropriately investigated and
resolved.
ACKNOWLEDGMENTS
Cliffton Chan and Bronwen Ackermann would like to thank
the Australian Research Council, Australian Council of the
Arts and the eight participating orchestras (Australian Opera
and Ballet Orchestra, Sydney Symphony, Melbourne Symphony
Orchestra, Orchestra Victoria, Adelaide Symphony Orchestra, Queensland Symphony Orchestra, Tasmanian Symphony
Orchestra, West Australian Symphony Orchestra; LP0989486)
for funding and supporting the “Sound Practice” project. The
authors would also like to acknowledge the useful feedback
provided by Dr. Debra Shirley during the write-up of this
paper.
Frontiers in Psychology | Cognitive Science
Evidence-informed physical therapy for musicians
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Conflict of Interest Statement: The authors declare that the research was conducted
in the absence of any commercial or financial relationships that could be construed
as a potential conflict of interest.
Frontiers in Psychology | Cognitive Science
Evidence-informed physical therapy for musicians
Received: 28 February 2014; accepted: 19 June 2014; published online: 08 July 2014.
Citation: Chan C and Ackermann B (2014) Evidence-informed physical therapy management of performance-related musculoskeletal disorders in musicians. Front. Psychol.
5:706. doi: 10.3389/fpsyg.2014.00706
This article was submitted to Cognitive Science, a section of the journal Frontiers in
Psychology.
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