Playing-Related Musculoskeletal Disorders Among Icelandic Music Students. Differences Between Students Playing Classical vs Rhythmic Music

Playing-Related Musculoskeletal Disorders Among Icelandic Music Students Differences Between Students Playing Classical vs Rhythmic Music Kári Árnason, PT, BSc, Árni Árnason, PT, PhD, and Kristín Briem, PT, PhD Mr. Kári Árnason is a physical therapist at the National University Hospital and at MT stofan, Reykjavik, Iceland; and Dr. Árni Árnason and Dr. Kristín Briem are associate professors at the Department of Physical Therapy at the University of Iceland School of Health Sciences, Research Center of Movement Science, Reykjavik, Iceland. Address correspondence to: Mr. Kári Árnason, The University of Iceland, Sæmundargata 2, 101 Reykjavik, Iceland. Tel +354 697 8114, fax +354 525 4008. kariarna@gmail.com. 2014 Science & Medicine. www.sciandmed.com/mppa. Most research studies investigating the prevalence of musculoskeletal disorders affecting musicians and music students have focused on classical music, while less is known about their prevalence in other music genres. The purpose of this study was to document cumulative and point prevalence of playing-related musculoskeletal disorders (PRMD) among music students in Iceland and, specifically, to identify differences between those studying classical vs rhythmic music. We hypothesized that students of classical music would report more frequent and more severe musculoskeletal disorders than students involved in rhythmic music, as classical instruments and composition typically require more demanding, sustained postures during practice and performance. A total of 74 students from two classical music schools (schools A and B) and 1 rhythmic school (school C) participated in the study by answering a questionnaire assessing PRMDs. The results showed that 62% of participants had, at some point in their musical career, suffered a PRMD. The cumulative prevalence was highest in music school A (71.4%) and lowest in music school C (38.9%). A statistically significant difference was identified between the cumulative prevalence of PRMD from schools A and B combined compared to music school C (p=0.019). Over 40% of participants reported a current PRMD, and a significant difference was identified between the three schools (p=0.011), with the highest point prevalence being registered in music school A (66.6%) and the lowest in music school C (22.2%). The prevalence of PRMDs among Icelandic music students was high. The difference found between students who play classical vs rhythmic music may be explained by different demands of the instruments and composition on playing posture. Med Probl Perform Art 2014; 29(2):74 79. Musical performance, whether it is in the form of singing or playing a musical instrument, is a physically demanding activity, and musculoskeletal problems often affect a musician s ability to perform. 1 Playingrelated musculoskeletal disorders (PRMDs) have been defined as any pain, weakness, numbness, or other physical symptom that interferes with one s ability to play a musical instrument in the manner one is accustomed to. 1 Studies documenting the cumulative prevalence (suffering from a PRMD at some point in the career) of PRMDs among musicians indicate that up to 87% of participants have, at some point in their career, dealt with a PRMD, 2,3 and nowadays studies have included both professional musicians and music students. A study by Ranelli et al. included students between 7 and 17 years of age and showed a PRMD cumulative prevalence of 67%, 4 while 79% of 330 music university freshmen reported having suffered from a PRMD at some point in their musical career in a study by Brandfonbrener. 5 These numbers are quite high considering that participants were generally young and healthy, but now several studies have been published showing that the cumulative prevalence of PRMDs among music students is between 32 and 93%. 5 7 Numerous physical and mental factors may contribute to this high cumulative prevalence of PRMDs among musicians. 8,9 Factors like repeated movements, age, gender, static loading in muscles, and poor posture are all identified risk factors. 10 Studies have also shown that poor physical fitness can be a risk factor, especially for young musicians. 8 Although some studies indicate that the cumulative prevalence for PRMDs is higher among women, 1,10,11 others have shown similar results for the two genders. 5 Musicians, especially music students, often continue playing their instrument despite experiencing symptoms of pain. A study by Britsch showed that 35% of participants thought this was acceptable, 8 while a recent study by Ackermann and Driscoll showed that 50% of participating parents of children from a musically selective school seemed to accept that feeling pain while playing an instrument was normal. 12 Music students, parents, teachers, and professional musicians must be aware that suffering, whether it is physically or mentally, is not acceptable when it comes to playing music. 13 This may, in part, be due to insufficient health promotion and injury prevention awareness as part of students curricula, although some music schools now offer specific PRMD-prevention courses. Zander et al. investigated the efficacy of a PRMD-prevention and health promotion course on students physical and mental health. 14 The results indicated that the course had a positive influence and the authors concluded, as did Chesky et al., 15 that these kind of courses should be a part of the cur- 74 Medical Problems of Performing Artists

riculum in all music schools. Another recently published study by López and Martínez evaluated the effectiveness of a course on health and the prevention of PRMDs for superior-grade students at the High Conservatory of Music of Salamanca, Spain. 16 The results indicated that 91% of the participants in the experimental group thought that the course had a positive influence on their body awareness, and the injury frequency decreased by 78% compared to no improvements in the control group. 16 These authors also concluded that these kind of courses should be an integrated part of the curriculum in music schools. The great majority of studies that have documented the cumulative prevalence of PRMDs have focused on classical musicians, and a search of the literature revealed no studies comparing the cumulative prevalence of PRMDs between those who play classical music and those who play rhythmic music (jazz, pop, rock, etc.) Therefore, the overall purpose of the study was to document the prevalence, both cumulative and current (present for the last 7 days), of PRMDs among music students in Iceland, and specifically, our aim was to identify differences between those studying classical vs rhythmic music. We hypothesized that due to the stringent and demanding postures typically required for performance of classical composition, these students would report more frequent and more severe musculoskeletal disorders than students involved in rhythmic music, who may have greater possibility for postural variability. METHODS The total number of participants was 74 music students drawn from 3 music schools in Reykjavik (2 classical, called music schools A and B, and 1 rhythmic, called music school C). Prior to participation, the students received information about the purpose of the study and what participation involved, after which a formal consent form was presented for them to sign. The study was assessed and approved by the National Bioethics Committee and reported to the National Data Protection Authority. The participants voluntarily answered a questionnaire, specially designed to document both the cumulative and current prevalence, as well as the severity, of PRMD among musicians. 17 The questionnaire had previously been published in the original and slightly changed versions. 17,18 Prior to recruiting participants for the study, the questionnaire was translated into Icelandic by two individuals fluent in both languages, and a consensus reached where discrepancies occurred. The Icelandic version was then translated back to English by another two individuals and compared to the original English version. The finalized Icelandic version of the questionnaire was then pretested by asking 6 musicians, who did not participate in the study, to answer it and indicate whether they felt the questions were clear. Some final changes were then made to improve clarity. A few questions from the original version were altered with the authors permission in order to better suit music students, as the original questions were designed for professional musicians, not students. In addition to general information (age, gender, physical activity, and years of musical education), the questionnaire is designed to acquire more specific information about frequency of injuries and their severity. The variables of interest for the present study related to frequency and severity of symptoms and what affected them, in addition to information regarding education relating to injury prevention. Participants were asked to rate on a 100-mm visual analog scale (VAS) 19 their perceived frequency of PRMDs and the severity of the worst PRMD they suffered. Participants were also asked to choose one or more items from a list of factors that could in their view potentially have influenced the development of their PRMD. Each chosen factor was given a number from 0 to 10 on a numeric rating scale (NRS) 20 in regard to how much influence they felt it had. The NRS was also used when participants were asked rate the impact that the PRMD had on their daily activities. Statistical Analysis Data analysis was done with SAS Enterprise Guide 4.3 and Microsoft Excel. Chi-square tests were used to identify differences in the distribution of individuals with and without PRMD between groups based on gender, school, classical vs rhythmic music, regarding practice time and regarding gender distribution between the schools. Independent t-tests were used to identify differences between the schools in how often the participants suffered from PRMDs and how severe the worst PRMDs were. Statistically significant differences were identified as p < 0.05. RESULTS Demographic Information Seventy-four music students, 57% male and 43% female, took part in the study, and their age ranged from 16 to 36 years (Table 1). Music school A (57% male vs 43% female) and music school C (67% male vs 33% female) included a greater number of male participants, but in music school B there was more equal gender distribution (48% male vs 52% female) (p=0.488). The mean age in each music school was quite similar, between 20 to 23 years. The mean (SD) time of musical education was 11.6 (4.7) years, and the participants had played their main instrument for on average 11.2 (4.9) years. A number of participants (13.5%) also worked as music teachers, with a mean (SD) weekly workload of 6.5 (4.2) hours. Participants practiced on their instrument on average 6 days/week, twice a day, for 74 minutes per session, and the minimum rest between sessions was 39 minutes. The largest proportion, or 32%, of participants, played a string instrument (viola, cello, acoustic and electric guitar, double and electric bass), while 23% played woodwind and brasswind, 23% were pianists, 19% vocalists, and 4% percussionists. June 2014 75

TABLE 1. Demographic Information Cumulative Prevalence of PRMD At some point of their careers, 62% of the participants had dealt with a PRMD. No statistically significant difference was identified between the 3 schools (p=0.063). However, when the 69.9% combined cumulative prevalence of PRMD among participants from music schools A and B (both classical) was compared to the 38.9% found among participants from music school C (rhythmic), a statistically significant difference was identified (p=0.019, Fig. 1). The cumulative prevalence of PRMDs was significantly higher among female participants, 61% compared to 39% among male participants (p<0.001). Frequency of PRMD occurrence was rated on a VAS from 0 (never) to 100 (all the time), and a significant difference of scores was identified between schools A and C (p=0.02). The mean (SD) frequency score from music school A was 50 (26), from music school B 38 (23), and from music school C 23 (17). Magnitude of the worst PRMD that musicians had suffered from was rated on a 0- to 100-mm VAS, and a significant difference of scores was identified between schools A and C (p=0.01) and B and C (p=0.048). The mean (SD) magnitude ratings from music schools A, B, and C were 56 (24), 51 (29), and 27 (17), respectively. Point Prevalence PRMD Male (n=42) Female (n=32) All (n=74) Age (yrs) 22.6 (4.7) 22.2 (3.5) 22.4 (4.2) Height (cm) 180 (6.3) 170 (6.7) 176 (9.6) Weight (kg) 76.9 (13.8) 61.5 (8.8) 70.2 (14.1) Body mass index (BMI) 23.2 (4) 21.8 (3.1) 22.6 (3.7) Data given as mean (SD). A current PRMD was defined as a PRMD that had been present for at least the last 7 days, and this was reported in 40% of participants. A statistically significant difference was identified between the three schools (p=0.011). The point prevalence of PRMD was highest in music school A (66.6%) and lowest in music school C (22.2%), while the prevalence in music school B was 34.4%. When combined reports of current PRMD from the classical music schools were compared to those from the rhythmic school, however, no statistically significant difference was identified between the two groups (p=0.069). The participants were also asked to evaluate the magnitude of the current PRMD on the VAS, and the mean (SD) overall score for the current PRMD was 38.2 (30). Of those participants reporting a current PRMD, 73% had dealt with this for at least 3 months, 27% for 4 to 12 weeks, and 17% for <4 weeks. Some participants reported more than 1 PRMD, and in those cases some PRMDs had been present more at least 3 months, another for 4 to 12 weeks, and etc. Therefore the total score is higher than 100%. PRMD Cumulative Prevalence Between Instrument Groups The cumulative prevalence of PRMDs was similar between most of the instrument groups, although none of the 3 participating percussionists had any history of PRMD (Table 2). The mean score for how often participants suffered from PRMDs ranged from 33 (vocal) to 47 (piano), and the mean magnitude of the worst and current PRMD was similarly rated between groups, as rated on the VAS (Table 3). Practice Time Participants were asked to document how often per week they practiced, how many practice sessions there were per day, and how long each session was. The results regarding sessions per week, sessions per day, and length of each session were similar between the three schools and no significant statistically difference was found between the schools regarding any factor (Table 4). Health and PRMD Prevention Education Participants were asked if they had received any formal health and PRMD prevention education. Most of them had FIGURE 1. Cumulative prevalence of PRMD: A, classical music schools A and B combined; B, rhythmic music school (music school C). 76 Medical Problems of Performing Artists

TABLE 2. Cumulative Prevalence of PRMDs between Different Instrument Groups Instrument Group No.* Rate of PRMD Vocal 9/14 64% Woodwind and brass 10/17 59% Strings 16/24 67% Piano 11/16 69% Percussion 0/3 0% TOTAL 46/74 *Number of participants out of the total number in each category. TABLE 3. Frequency (How Often) of PRMDs, Magnitude of the Worst PRMD, and Magnitude of Current PRMD of Different Instrument Groups Mean Mean Mean Magnitude Magnitude Instrument Frequency of Worst of Current Group of PRMD PRMD PRMD Vocal (n=9) 33 (20.7) 46 (31.5) 40 (21.9) Woodwind and brass (n=10) 40 (28.7) 48 (27.4) 33 (23.5) Strings (n=16) 39 (23.7) 49 (25.1) 40 (23.8) Piano (n=11) 47 (21.9) 50 (28.7) 40 (25.2) Evaluated on the VAS (0 100). Data given as mean (SD). received either none or little health and PRMD prevention education, while very few had received a lot of it (Fig. 2), and the results were similar across music schools (Fig. 3). Potential Risk Factors Participants were asked to choose one or more items from a list of risk factors that in their view could potentially have influenced the development of their PRMD. Each chosen factor was given a number from 0 to 10 on the NRS (0 = no influence, 10 = greatest influence) in regard to how much influence they felt it had on the development of their PRMD. Poor posture was the factor that received the highest rating (Table 5). TABLE 4. Mean Practice Time for Instrument Sessions Music Music Music School A School B School C p-value Days/week 5.1 (2.0) 5.9 (1.3) 6 (1.1) 0.09 Minutes/session 69 (54) 84 (48) 72 (31) 0.50 Sessions/day 2 (1.4) 1.7 (0.9) 2.4 (1.4) 0.32 Data given as mean (SD). aim. We hypothesized that due to vulnerability of students of classical music, regarding, for example, demanding postures typically required for classical instruments and stringent composition, classical music students would report more frequent and more severe musculoskeletal disorders than students involved in rhythmic music. Overall, 62% of the participants had at some point in their career dealt with a PRMD, and 40% reported disorders that had been present for the last 7 days, and this is consistent with previous findings. 4 7 Music school C (rhythmic) compared favorably when the cumulative prevalence of PRMD was contrasted to the combined rate of the classical music schools, and furthermore, the point prevalence of PRMDs was lowest in music school C. These results, combined with the fact that the mean scores for frequency and magnitude of PRMD were also lowest in music school C, support our apriori hypothesis. One of the differences between the performance of classical and rhythmic music is that in rhythmic music there is more musical freedom regarding performance, composition, and interpretation. The music does not have to be played exactly as it is written, and so there is more freedom to choose what notes to play, when to play them, and how to play them. Rhythmic musicians are also in a better position to move while playing compared to classical musicians, who typically sit for long periods while playing, sometimes in very crowded places. More musical freedom may involve less physical stress due to more breaks, tempo changes, etc., and this may, in part, explain the disparity found between schools in both the cumulative and current prevalence of PRMDs. Effects of PRMD on Daily Activities Participants were asked to evaluate the effect that the PRMD they had suffered had on their daily activities on the NRS (0 = no effect at all, 10 = greatest effect). The mean score for all three music schools was 2.1 (2.3). DISCUSSION The purpose of this study was to document both the cumulative and point prevalence of PRMD among Icelandic music students. As noted earlier, contrasting PRMD between musicians of classical vs rhythmic music genres is an understudied area, and therefore, this was our primary FIGURE 2. The amount of formal education participants had received on health and PRMD prevention. June 2014 77

FIGURE 3. The amount of formal health and PRMD prevention education participants from each music school had received (music schools A, B, and C). The demands of technical excellence are great in the classical music world, and students who are determined to succeed have to spend a great amount of time practicing to have a possibility to reach their goal. Surprisingly, no difference was found between the classical vs rhythmic music students regarding practice time. The ergonomic environment that classical music students practice in, however, may be considered more physically stressful due to the required body posture and the shape of the instruments. There were also a higher number of female participants from the classical schools, and our results are consistent with other reports that indicate higher PRMD prevalence among females. 1,10,11 These factors may contribute to the high cumulative prevalence of PRMD found among classical musicians. Some participants from music school B reported that their main study was music composition, not instrument playing. As they had a background in music and played a musical instrument on a regular basis, they were included in the study. This may, however, have led to a slightly lower rate of PRMD for that school, as music composition students probably spend less time playing their instruments than other music students. Notably, vocalists in the present study recorded the same PRMD prevalence as the instrumentalists. This is consistent with a previous report by Eller et al. 21 whose results indicated that disorders reported by singers were predominantly from the mouth, lips, and throat, while instrumentalists reported problems in other body regions. The large number of participants reporting a current PRMD and who had suffered from these symptoms for over 3 months is worrisome considering that the participants were generally young and healthy. A possible explanation for this high point prevalence of PRMDs is limited health promotion within the school system. Greater awareness in this area might lead to a decrease in reported symptoms, as indicated by the results reported by López and Martínez, where injury frequency decreased by 78% after students attended of a course on health and the prevention of PRMD. 16 The high cumulative prevalence of disorders reported in the present and other studies is hardly acceptable in light of the fact that some, if not many, of them are preventable. A large amount of physical and mental stress comes with being a music student, and this will likely increase as the students further their music careers and education, in particular if they will have the opportunity to work as professional musicians. Special health education and PRMD prevention courses have been established in some music schools, and studies have shown that these courses can be very effective. 14 16 PRMD prevention and health promotion should start in the very beginning of musical training, so that the students will be prepared for the physical and mental stress which comes with being a music student and a professional musician. 14 Physical problems that arise early on can develop into chronic problems and have very serious consequences if they are ignored. Taking regular breaks, being aware of good body posture, warming up appropriately, gradually increasing the time spent on instrumental playing, and monitoring physical and mental health are factors that should therefore never be underestimated. Although students from music school C reported the highest frequency of getting no preventive education yet at the same time had the lowest prevalence of PRMD, the authors believe that health promotion and PRMD prevention are important. The relatively low prevalence of PRMDs reported by the rhythmic music students may have lead to a lower priority of preventive education within that school and funds being allocated toward other projects. Health promotion and PRMD prevention may be particularly important for classical musicians, as they may be more vulnerable for developing PRMD for reasons previously noted. All musicians, classical and rhythmic alike, may have a tendency to adapt their body posture to the instrument but not vice versa. Classical instruments like the violin or cello, however, were hardly designed with the best ergonomics in mind, while rhythmic musicians are notably less bound to demanding postures when playing their instruments. The risk factors that participants in this study reported as influencing their PRMD could possibly be addressed by improving body awareness and by promoting good physical and mental health. Musculoskeletal problems associated with playing a musical instrument are nonetheless as 78 Medical Problems of Performing Artists

TABLE 5. Risk Factors that Participants Thought Had Influenced the Development of their PRMD How Often Mean Each Factor Risk Factor Score (SD) Was Chosen (46) Poor posture 7.7 (2.5) 40 Long practice sessions 7.4 (2.3) 41 Excess muscle tension 7.4 (2.2) 41 Instrument set up issue 7.1 (2.5) 35 Sudden playing increase 7 (2.4) 35 Insufficient rest 6.8 (2.5) 37 Stress 6.6 (2.4) 35 Evaluated on NRS (0 = no effect at all, 10 = greatest effect at all). inevitable as musculoskeletal problems are in the sports world. The results demonstrated that over 50% of students had received little or no formal health education and PRMD prevention and thereby strongly indicate that there is room for improvement. Traditionally, musicians tend to adhere to their schedules and play their instruments despite experiencing pain. 22 This tendency may be countered by improving awareness of professional musicians, as well as students and their parents, as to the importance of good physical and mental health. 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