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Musculoskeletal Disorders and Asymmetric

Playing Postures of the Upper Extremity and
Back in Music Teachers A Pilot...

Article in Medical problems of performing artists · September 2009


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2 authors:

Cecilia Wahlström Edling Anncristine Fjellman Wiklund

Umeå University Umeå University


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Musculoskeletal Disorders and Asymmetric Playing
Postures of the Upper Extremity and Back
in Music Teachers
A Pilot Study
Cecilia Wahlström Edling, RPT, Anncristine Fjellman-Wiklund, RPT, PhD

To play a musical instrument, such as the violin or flute, requires had a significantly greater prevalence of symptoms in the
controlled, adequate movements performed by the arm, hand, and neck, shoulders, and thoracic spine, compared with male
fingers in an asymmetric playing posture. The movements are
music teachers.7 Several studies indicate that bowed string
monotonous and often of long duration, involving static and repet-
itive muscle work of the upper extremity and neck-shoulder muscles. players are more likely to suffer from musculoskeletal disor-
This situation may lead to an increased risk of contracting muscu- ders than players in other instrument groups.3,5,7–9 An inves-
loskeletal problems. The aim of this cross-sectional study was to tigation among guitar players concluded that 81% of its par-
investigate the relationship between physical workload, defined as ticipants reported having musculoskeletal disorders.11
playing posture and playing time per week, and musculoskeletal dis-
Many instruments, such as the bowed strings, flute, guitar,
orders in music teachers. A questionnaire was distributed, with
items based on work-related musculoskeletal disorders and physical and trombone, require the player to work constantly in an
working conditions. The study population consisted of music teach- asymmetric playing posture.6,11–13 The instrument is held with
ers employed at a Swedish municipal music school. Out of 61 music one arm elevated, which demands a static muscle load to sta-
teachers, 47 (77%) agreed to participate, including 28 women and bilize the shoulder blade and shoulder joint. With some instru-
19 men. The study group was divided into two groups depending on
ments, players also have to rotate and bend the head and hold
if they had an asymmetric or symmetric upper extremity/back play-
ing position. Of the total participants, 77% reported musculoskele- their lower back turned to one side, which may lead to unilat-
tal disorders during the preceding 12 months. Female teachers eral, static muscle work. Simultaneously, repetitive movements
reported significantly more symptoms in the neck, shoulders, and with the arm and/or fingers are executed, frequently in high
upper back than male teachers. Music teachers with an asymmetric speed and with extreme demands on precision and timing.2
playing posture had significantly more musculoskeletal disorders
While playing the double bass and cello, great strength of the
than music teachers with a symmetric playing posture. This study
demonstrates that an asymmetric playing position may affect the left hand and lower arm is needed to press the strings down on
amount of musculoskeletal disorders in the upper extremity and to the fingerboard.14 Altogether this makes for asymmetric
back. Med Probl Perform Art 2009; 24:113–118. playing postures, with demands of simultaneous static and
repetitive muscle work for long hours.11,13

M usculoskeletal disorders related to playing occur fre-

quently among musicians,1–3 music students,4,5 and
music teachers.6,7 Prior investigations concerning physical
Other instruments are held in a more symmetric position
with arms closer to the body and the head directed frontally.
This is the case with, for instance, the clarinet, oboe,
and psychosocial working conditions, as well as muscu- recorder, piano, and percussion. Playing these instruments
loskeletal disorders, among music teachers in municipal still involves static and repetitive muscle work of the upper
music schools in northern Sweden concluded that about extremity and neck- shoulder muscles.
80% of the participants reported having such disorders Due to high levels of static contraction or extreme work
during the preceding 12 months. Disorders tended to be postures involving neck and shoulder muscles, certain occu-
long-lasting and to progress over time.6,7 pations are exposed to a higher risk of neck/shoulder mus-
Work-related musculoskeletal disorders among musicians culoskeletal disorders.15,16 Working with elevated arms leads
seem to be most frequent in the neck, shoulders, upper to a high intramuscular pressure which impedes local muscle
extremities, and lower back1,3,5 and more frequent among blood flow in the infraspinatus and supraspinatus mus-
female than male musicians.3,5,8–10 Female music teachers cles.17–20 Furthermore, work tasks including repetitive work
with the hands and arms demand an added amount of static
load of the stabilizing scapular muscles, which could also lead
Ms. Wahlström Edling is physical therapist in the Department of Paramed-
icine, Brommageriatriken AB, Bromma, Sweden; and Dr. Fjellman-Wik- to neck/shoulder musculoskeletal disorders if executed
lund is senior lecturer in the Department of Community Medicine and during the majority of working time.16
Rehabilitation, Physiotherapy, Umeå University, Umeå, Sweden The aim of the current study was to investigate the rela-
tionship between physical workload, defined as playing pos-
Address correspondence to: Ms. Cecilia Wahlström Edling, Department of ture and playing time per week, and musculoskeletal disor-
Paramedicine, Brommageriatriken AB, Box 3084, S-168 56 Bromma,
Sweden. Tel 0046(0)86875088; e-mail: cecilia.wahlstrom-edling@bromma ders in music teachers employed at a Swedish municipality
geriatriken.se. music school.

September 2009 113

METHODS TABLE 1. Numbers of Teachers of Each Instrument in the
Asymmetric and Symmetric Playing Position Groups*
Study Population Asymmetric Playing Position Symmetric Playing Position
(n = 22) (n = 20)
The investigation was performed in a Swedish municipality Violin 8 Clarinet 3
music school in the Stockholm region. All 61 employed Cello 5 Oboe 1
music teachers who had been working during the preceding Double bass 1 Bassoon 1
12 months were invited to participate in the study. Prior to Trombone 1 Trumpet 2
the investigation, the employees were informed about the Flute 3 Recorder 3
purpose of the study and that participation was voluntary; Guitar 4 Keyboard/piano 8
they were informed that the data were confidential and that Percussion 2
they could withdraw from the investigation at any time *Teachers of voice and eurhythmics (n = 4) and unspecified wind
without reason. Each employee gave an oral consent before instrument (n = 1) are not included.
participating. Forty-seven teachers (77%) agreed to partici-
pate, with 28 women (60%) and 19 men (40%). An analysis
of the non-participants (23%) showed that they did not
differ from the respondents with regard to sex, age and The asymmetric posture group included bowed string instru-
main instrument played. ments, flute, trombone, and guitar. The symmetric playing
posture group included the clarinet, oboe, bassoon, trumpet,
Questionnaire recorder, keyboard, and percussion (Table 1).
Playing time per week was assessed by a self-evaluated
A self-administered questionnaire was used to assess work- question from the MCQ-West,3 asking “How many hours per
related musculoskeletal disorders and working conditions. week, on average, do you play your main instrument?” The
The basic premise was to use established, validated, and reli- answering options were: 0, 1–10, 11–20, 21–30, 31–40, or
able questions. Data therefore were collected with the Stan- >40 hours.
dardized Nordic Questionnaire (SNQ) on work-related mus-
culoskeletal disorders.21 The SNQ is recommended for Procedure
screening of musculoskeletal disorders and evaluations of
ergonomic workplace programs and has acceptable reliability The questionnaire, together with written and oral informa-
and validity.21,22 In the SNQ, disorders were defined as pain tion about the study, was distributed at a meeting at the
and aches occurring during the preceding 12 months and music school. The music teachers were given opportunity to
focused on six body regions (neck, shoulders, elbows, ask questions to the main researcher. During the meeting, 32
hands/wrists, thoracic spine, and lower back). The body music teachers answered the questionnaire. The remaining
regions were shown on a drawing, and response options were 23 music teachers received the questionnaire by mail. Data
yes or no. Previous research has shown that aches and pains collection ended following two reminders.
in the lower extremities are rare in music teachers and musi-
cians, and therefore these body regions were excluded in the Data Analysis
Data on the amount of playing time per week on the Data were analyzed with the statistical program Minitab 15
teachers’ main instrument were collected with the Musical (Minitab, Inc., State College, PA). Demographic data were
Cohort Health Questionnaire–West (MCQ-West).3 The presented with mean value, minimum/maximum (range),
MCQ-West was constructed for a retrospective cohort study and standard deviation (SD). Due to low frequency of mus-
on work-related musculoskeletal disorders and hearing prob- culoskeletal disorders in elbows and hands/wrists, data on
lems among (former) university music students in Sweden.3 these areas are presented descriptively (n, %). The relation-
In addition, there were questions on sex, age, height, weight, ship between musculoskeletal disorders and sex and
music education, years of employment in the profession, and between musculoskeletal disorders and asymmetric/sym-
main instrument. metric playing posture were investigated with Kruskal-Wallis
test and based on disorders in the upper extremity and back
Physical Workload combined. χ2 tests were used to investigate the relationships
between musculoskeletal disorders per body region (neck,
In the current cross-sectional study, physical workload was shoulders, upper back, and lower back separately) and the
defined as playing posture and amount of playing time per relationships between sex and disorders by body regions
week on the main instrument. The music teachers were and asymmetric/symmetric playing position. The Kruskal-
divided into two groups depending on whether they had an Wallis test was used to investigate the relationship between
asymmetric or a symmetric upper extremity/back playing amount of playing time per week and musculoskeletal dis-
position. The definition of playing posture was based on the orders per body region. A significance level for all tests was
researchers’ personal knowledge of musicians’ work postures. set to p <0.05.

114 Medical Problems of Performing Artists

TABLE 2. Demographic Data of the Music Teachers * problems in the lower back, shoulders, neck, and elbows
Women Men Total (Table 4).
(n = 28) (n = 19) (n = 47)
Physical Workload
Age 44 52 47.5
(28–64) (10.6) (36–67)(9.0) (28–67)(10.7)
Music teachers with asymmetric playing postures (bowed
Height, cm 168 179 — strings, flute, trombone, and guitar) had a significantly
(160–180)(5.7) (165–191)(5.8)
greater number of disorders (upper extremity and back com-
Weight, kg 66 78 — bined) compared with music teachers with a symmetric play-
(51–90)(9.2) (65–90)(7.6) ing posture (clarinet, oboe, recorder, bassoon, trumpet,
* Data expressed as mean, (range), and (SD). piano, and percussion) (p = 0.042). There was no significant
difference between playing position and musculoskeletal
disorders in the neck (p = 0.059), shoulders (p = 0.172),
RESULTS upper back (p = 0.081), or lower back (p = 0.537) separately
(Table 5).
Demographic data for the music teachers are presented in About half of the music teachers reported that they played
Table 2. The music teachers had worked on average 20 yrs 1 to 10 hrs/wk on their main instrument, while the other
(SD 11.33 yrs; range, 3–41 yrs) in the profession. half played 11 hrs or more per week (Table 6). Significant dif-
ferences between disorders of the neck (p = 0.241), shoulders
Musculoskeletal Disorders (p = 0.715), upper back (p = 0.607), or lower back (p = 0.566)
in relation to the playing time per week on the main instru-
Of the total 47 participants, 36 (77%) music teachers ment could not be found.
reported experiencing musculoskeletal disorders during the
preceding 12 months. Most common were complaints involv- DISCUSSION
ing the lower back (49%), neck (47%), upper back (32%), and
shoulders (28%) (Table 3). Only 11 people (23%) reported The aim of this study was to investigate the relationship
having no musculoskeletal problems. between physical workload, defined as playing posture and
Female music teachers reported musculoskeletal disorders playing time per week, and musculoskeletal disorders in music
mostly of the neck (61%), lower back (57%), and upper back teachers at a municipal music school in Sweden. The results
(46%), while male music teachers reported mostly having showed that music teachers with asymmetric playing postures
problems of the lower back (37%) and neck (37%) (Figure 1). had a significantly greater amount of neck, shoulder, and back
Female music teachers reported a significantly greater disorders (combined) compared with music teachers with a
number of problems than male teachers in the neck (p = symmetric playing posture. The group of musicians with an
0.020), upper back (p = 0.010), shoulders (p = 0.025), and a asymmetrical playing position included players of bowed
combination of these body areas (p = 0.010). There was no string instruments, the guitar, trombone, and flute, while the
significant difference between female and male music teach- group of those with a symmetric playing position included the
ers in frequency of low back problems (p = 0.172). piano, clarinet, bassoon, oboe, recorder, trumpet, and percus-
String teachers reported musculoskeletal disorders mostly sion. The number of people in each instrumental group was
in the neck (71%), lower back (64%), and upper back (50%). small, and so the results of this study should be interpreted
Teachers of wind instruments reported musculoskeletal dis- with caution. It is, however, interesting that there was an
orders in the same body regions, but to a lesser extent. Piano, apparent difference between the two groups.
guitar, and percussion teachers reported mostly lower back It is possible that the issue of asymmetry per se is less
problems. Voice and eurhythmics teachers (n = 4) reported important than the fact that several of the instruments

TABLE 3. Prevalence of Musculoskeletal Discomfort in the Previous 12 Months by Gender

Women Men Total
(n = 28)
___________________ (n = 19)
___________________ (n = 47)
Body Region n (%) n (%) n (%) p-Value*
Neck 17 (61) 5 (26) 22 (47) 0.020*
Shoulders 11 (39) 2 (10) 13 (28) 0.025*
Elbows 7 (25) 2 (10) 9 (19) ns
Hands 5 (18) 2 (10) 7 (15) ns
Upper back 13 (46) 2 (10) 15 (32) 0.010*
Lower back 16 (57) 7 (37) 23 (49) ns
*Comparing female vs male teachers. Significance p < 0.05; ns = nonsignificant.

September 2009 115


FIGURE 1. Prevalence of musculoskeletal disorders by body region among male and female music teachers.

belonging to the asymmetric group also involved working nation with mechanical stress and a pinched muscular
with one or both arms lifted or elevated more than 40°. In a tendon could lead to degeneration, which causes pain,
study of orchestral musicians, Nyman et al.23 found that aching, and discomfort.17–20 Sustained elevated intramuscu-
musicians who played with the arms lifted more than 40° lar pressures also cause a repression of local muscle fatigue
degrees (violin, viola, flute, trumpet, and trombone) reported recovery.17–20
greater neck/shoulder disorders than those who played with In the present study, almost half of the participants
a more neutral arm position (cello, double bass, oboe, clar- reported neck disorders, and one third reported shoulder dis-
inet, bassoon, French horn, tuba). The arm position when orders. Musculoskeletal problems in neck and shoulders are
playing string instruments can exceed 40°.6 A study measur- common in music teachers and among other professional
ing upper-limb movements in the bowing arm of string play- musicians. Female music teachers experienced a significantly
ers showed that, while playing, the right arm angle varied greater amount of disorders in the neck, shoulders, and tho-
from 38 to 80° among cellists and between 27 and 64° racic spine than male music teachers. This gender difference
among violinists.24 is in accordance with results of other studies involving music
Studies have shown that working with elevated arms leads teachers6,7 as well as a multitude of studies in professional
to a high intramuscular pressure in the muscle bellies in the musicians3,5,8–10 and the general working population. Among
shoulder muscles infra- and supraspinatus.17–20 The intra- the working population in Sweden, data from 2006 showed
muscular pressure in both these muscles increases in associa- that 25% suffered from musculoskeletal disorders in the
tion with increased upper arm elevation. For the supraspina- upper body during the preceding 12 months.25
tus muscle, the intramuscular pressure also increases with an In the current study string teachers reported a greater
increased abducted position of the arm. A high intramuscu- number of musculoskeletal disorders of the neck and
lar pressure causes reduced local blood flow in the muscles, shoulders than teachers of the other instrumental groups;
which also affects the circulation in the muscle tendons, this is in agreement with earlier studies among musi-
since blood perfusion in the tendon originates partly from cians.1–3 This could indicate that an uncomfortable work
the muscle. Impingement of the supraspinatus tendon posture has a negative impact on the neck and shoulder
between the humeral head and the coracoacromial arch muscles. The result could also be influenced by the fact
during humeral abduction compresses the tendon and fur- that the string teachers in this study had many years of
ther impairs the circulation. A reduced blood flow in combi- experience in the profession (20 years on average) and

TABLE 4. Prevalence of Musculoskeletal Discomfort in the Previous 12 Months by Instrument Group

Bowed Strings Wind Instruments Piano, Guitar, Percussion Voice, Eurhythmics
(n = 14)
__________________ (n = 15)
__________________ (n = 14)
__________________ (n = 4)
Body Region n (%) n (%) n (%) n (%)
Neck 10 (71) 7 (47) 3 (21) 2 (50)
Shoulders 5 (36) 4 (27) 2 (14) 2 (50)
Elbows 2 (14) 5 (33) — – 2 (50)
Hands 2 (14) 3 (20) 2 (14) — —
Upper back 7 (50) 6 (40) 1 (7) 1 (25)
Lower back 9 (64) 6 (40) 6 (43) 2 (50)

116 Medical Problems of Performing Artists

TABLE 5. Prevalence of Musculoskeletal Discomfort in the Previous 12 Months by Playing Position
Asymmetric Playing Position Symmetric Playing Position
(n = 22)
__________________________ (n = 20)
Body Region n (%) n (%) p-Value*
Neck 13 (59) 6 (30) ns
Shoulders 7 (32) 3 (15) ns
Elbows 3 (14) 3 (15) ns
Hands 3 (14) 4 (20) ns
Upper back 10 (45) 4 (20) ns
Lower back 12 (55) 9 (45) ns
Neck, shoulders, upper back, and lower back combined 16 (63) 6 (30) 0.042*
*Comparisons between asymmetric and symmetric playing positions. (Teachers of voice and eurhythmics [n=4] and unspecified wind instru-
ment [n=1] were not included.) Significance p < 0.05; ns, nonsignificant.

could therefore have been thoroughly exposed to strained CONCLUSION

working conditions.
In this study, no difference was found between neck, This study demonstrates that an asymmetric playing position
shoulder, or back disorders and playing time per week. In may affect the degree of musculoskeletal disorders in the upper
contrast, Hagberg et al.3 found an increased prevalence of dis- extremity and back. Music teachers with an asymmetric playing
orders in the elbow and hands/wrist among those who posture had a significantly greater amount of disorders (upper
played for 20 hrs or more per week compared to those who extremity and back combined) compared with music teachers
had a shorter playing time. Nyman et al.23 concluded that with a symmetric playing posture. Female teachers reported a
those musicians who worked with lifted arms had a higher significantly higher prevalence of symptoms in the neck, shoul-
prevalence of neck/shoulder pain than those who had a ders, and upper back than their male counterparts. Because
more neutral working posture, even for musicians playing less this is a pilot study with a small group of music teachers, fur-
than 2 hrs/work day. For those with a neutral work position, ther studies involving larger groups of musicians are warranted
the playing time was less important. 23 in order to verify the conclusions of the current study. Further
In addition to physical factors at the workplace, psy- studies including larger populations should also evaluate the
chosocial factors such as influence over decisions at work, combination of symmetric/ asymmetric playing position and
professional demands, and social support also are impor- playing time by using regression analysis.
tant for developing work-related musculoskeletal disor-
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118 Medical Problems of Performing Artists

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