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Musculoskeletal Pain and Injury in Professional Orchestral Musicians in

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 Musculoskeletal Pain and Injury in Professional
Orchestral Musicians in Australia
Bronwen Ackermann, BAppSc(PT), MPH, PhD, DipOHS, Tim Driscoll, BSc(Med), MBBS, MOHS, PhD,
and Dianna T. Kenny, BA(Hons), MA, PhD, ATCL, DipEd
This paper reports on the major findings from the questionnaire
component of a cross-sectional survey of the musicians in Australia’s
eight fulltime professional symphonic and pit orchestras, focusing
on performance-related musculoskeletal disorders (PRMDs).
METHODS: All musician members of the orchestras participating
in this project were invited to complete a self-report survey. The
overall response rate was about 70% (n = 377). In addition to gen-
eral health and experience questions, respondents who reported a
current or previous PRMD were asked to report on a range of asso-
ciated factors. RESULTS: Of the participants, 84% had experi-
enced pain or injuries that had interfered either with playing their
instrument or participating in normal orchestral rehearsals and per-
formances. Fifty percent reported having such pain or injury at the
time of the survey, mostly with disorders perceived by the musicians
to be work-related. Twenty-eight percent had taken at least 1 day off
from work for such pain in the previous 18 months. The most
common broad sites affected were the trunk (primarily the back),
the right upper limb and neck, the left upper limb and neck, and
the neck alone, but the relative proportions varied by instrument.
Of those musicians who reported at least one episode of pain or
injury in the past, less than 50% reported that they had completely
recovered. The most commonly cited performance-related factors
that had contributed to injury or pain all related to training and
playing load (including practice and performance). CONCLU-
SION: This study provides strong evidence that PRMDs are a
common complaint in professional orchestral musicians and identi-
fies a range of factors suggested as contributing to the occurrence or
persistence of these disorders. Med Probl Perform Art 2012;
27(4):181–187.
A ustralia has eight full-time professional symphonic and
pit orchestras located in each of the capital cities in Aus-
tralia. Their musicians represent the country’s most elite
orchestral musician population. With few elite positions
available for a relatively large number of aspiring music stu-
dents, intense competition exists to acquire a position in one
of these professional orchestras.
The act of playing music is a complex one, requiring a
high level of physical and psychological skill to succeed, sim-
Dr. Ackermann is Senior Lecturer in the Discipline of Biomedical Science,
University of Sydney, Dr. Driscoll is Associate Professor in the Sydney School
of Public Health, University of Sydney; Dr. Kenny is Professor in the Faculty
of Arts and Social Sciences, University of Sydney, Sydney, Australia.
This paper forms part of the Sound Practice research project, which is
funded by the Australia Research Council and The Australia Council for
the Arts, and receives in-kind support from the eight major symphony and
pit orchestras of Australia.
Address correspondence to: Dr. Bronwen Ackermann, Discipline of Bio-
medical Science, PO Box 170, Lidcombe, NSW 1825, Australia. Tel 02
9351 9472, fax 02 9351 9715. bronwen.ackermann@sydney.edu.au.
© 2012 Science & Medicine. www.sciandmed.com/mppa.
ilar to many elite sports. Yet there has traditionally been little
or no health education or services to support this popula-
tion, in great contrast to the sporting population.1 Perhaps
unsurprisingly, international surveys report high rates of per-
formance-related injury in orchestral populations with fig-
ures typically around 70% to 80%.2–20
In 2005, a comprehensive review was conducted of the
Orchestras of Australia. This review noted soaring insurance
premiums related to health issues and, inter alia, issued a key
recommendation to study and develop specific occupational
guidelines for orchestral musicians.21 In a unique research
effort, a national collaborative team was funded to address
these major health concerns of this population. The team
includes researchers from the University of Sydney and the
eight major symphony and pit orchestras of Australia with
funding support from two Australian government depart-
ments (the Australia Council for the Arts and the Australia
Research Council).
The first major phase of the study was to undertake a
cross-sectional survey of the musicians. The survey involved a
detailed questionnaire and a physical examination. The aim
of this paper is to report on the major findings identified
from the questionnaire in relation to physical health issues,
and the reported causes, within this population.
METHODS
Participants
All musician members of the orchestras were invited to par-
ticipate. Those who agreed completed a self-report survey.
Response Rate
Response rate varied from 50 and 98% between the eight
orchestras. In the orchestras that returned a lower response
rate, participating musicians were asked if they were aware of
a reason for the reduced uptake in the study. The most
common issues were concerns about the career implications
of reporting symptoms despite assurances of anonymity and
perceived variable levels of encouragement from musicians in
senior orchestral positions and, in some cases, orchestral
management.
Survey Design
The survey was divided into three main sections. The design
of the first section containing physical and demographic data
December 2012 181
 TABLE 1. Musicians’ Age TABLE 2. Instrument Group and Instrument Played
Age (yrs) No.* % Instrument No. %

15–24 7 1.9 Upper strings

25–29 49 13.1 Violin 115 30.5
30–34 45 12.0 Viola 54 14.3
35–39 52 13.9 Total 169 44.8
40–40 59 15.8 Lower strings
45–49 70 18.7 Cello 46 12.2
50–50 45 12.0 Double bass 22 5.8
55–59 31 8.3 Total 68 18.0
60–69 16 4.3 Woodwind
Total 374 100.0 Flute 21 5.6
*Age was missing for 3 musicians. Oboe 18 4.8
Bassoon 15 4.0
Clarinet 13 3.4
has been described previously.22 The second section con- Total 67 17.8
sisted of questions pertaining to psychological symptoms and Brass
stressors, while the third section used previously validated French horn 28 7.4
tests against which the results from the first two sections Trombone 16 4.2
could be compared. This paper reports only on the physical Trumpet 10 2.7
and demographic section. Tuba 4 1.1
Performance-related musculoskeletal disorders (PRMDs) Total 58 15.4
were defined as “any pain, weakness, numbness, tingling or Percussion and tympani
other physical symptoms that interfere with your ability to Percussion 7 1.9
play your instrument at the level to which you are accus- Tympani 5 1.3
Total 12 3.2
tomed. This definition does not include mild transient
aches or pains.” Respondents who reported a current or pre- Other
Harp 3 0.8
vious PRMD were asked to identify which, if any, perform-
Total 3 0.8
ance-related factors had contributed to the occurrence of the
Total 377 100.0
disorder and the extent to which the factor contributed to
any injury or pain. Respondents had a choice of 17 nomi-
nated potential causes and could nominate their own cause
as well. They were also asked to rate how important the Most musicians did not appear to consume alcohol at high-
factor was, on a scale from 0 (“no effect at all”) to 10 (“great- risk levels, with 70% drinking <5 days per week, 70% drink-
est effect of all”). The Borg scale of perceived exertion or ing 1 to 2 standard drinks in an episode of drinking, and
Ratings of Perceived Exertion (RPE), which has been sug- 56% drinking <7 standard drinks per week.
gested to indicate levels of physical strain23 and muscle The mean time played as a professional was 20.6 years (SD
fatigue,24 was also used. 10.7); only 17.8% had played for <10 years. The vast majority
This study was approved by The University of Sydney (93.0% of the 301 who answered the question) were
Human Research Ethics Committee. employed on a fulltime basis—the rest were part time (3.4%)
or casual (3.3%).
RESULTS
Ratings of Perceived Exertion
Of the eligible musicians questioned, 377 provided useable
data (70%). The age of the musicians ranged from 18 to 68 Performance, either in the pit or on stage, was rated as requir-
years (mean 42.1, SD 10.2), with most aged between 25 and ing significantly more exertion than rehearsing and practis-
54 (Table 1). There were slightly more women (51%) than ing, and practising privately required significantly less exer-
men and their age distribution was similar. tion than any of the other assessed activities. The RPE was
The most common instrument group played by the musi- related more to the type of performance situation than the
cians was upper strings (violin and viola, 44.8%), with most location of the performance (i.e., pit or stage) (Table 3).
of the remainder evenly spread between lower strings, wood-
wind, and brass (Table 2). Past or Current Pain Symptoms
Of the respondents, 62% had a normal body mass index
(BMI) (18.5 to <25), with 30.4% overweight (BMI 25 to <30) The vast majority of musicians (84.4%) had at some time in
and 7.1% obese (BMI >30). Three players were underweight their career experienced pain or injuries that had interfered
based on their BMI. About two thirds (68.9%) of musicians either with playing their instrument or participating in
had never smoked and only 5.9% were current smokers. normal orchestral rehearsals and performances. This was

182 Medical Problems of Performing Artists

 TABLE 3. Rating of Perceived Exertion for Playing,
Rehearsing and Practising Privately*
Rating
________________________
Playing Situation Mean SD
Playing in the pit 14.8 2.6†
Rehearsing in the pit 13.8 2.5†
Playing on stage 14.9 2.4‡
Rehearsing on stage 13.4 2.1‡§
Private practice 12.9 2.1§
* Measured using Rating of Perceived Exertion scale.23 SD, standard devia-
tion; CI, confidence interval.
† Mean difference = 1.0 (95%CI = 0.8–1.2, p<0.0001).
‡ Mean difference = 1.4 (95%CI = 1.3–1.6, p<0.0001) (the numbers in the
table suggest the difference is 1.5, but this is due to rounding).
§ Mean difference = 0.6 (95%CI = 0.4–0.8, p<0.0001) (the numbers in the
table suggest the difference is 0.5, but this is due to rounding).
similar for all musician types, ranging from 70 to 90%. Fifty
percent of musicians reported having such pain or injury at
the time of the survey. Of these, 79% (39% of all musi-
cians) reported that the pain or injury was caused by work,
11% reported that it was not due to work, and 11% were
unsure. The percentage with current pain or injury was con-
siderable across all musician types (ranging from 37 to 67%)
except for the 13 bassoonists, only two (13%) of whom
reported current pain or injury. For most instrument
groups, more than 50% of those with current pain reported
that the pain had been present for more than 12 weeks
(Table 4).
Asked to rate how often they had a PRMD, 70% of the
musicians rated this as three or less on a scale from 0
(“never”) to 10 (“constantly”). The mean pain frequency
rating of 2.8 (SD 2.9) was similar across instrument groups.
For those who reported at least some pain, the mean pain
severity on a 10-point scale was 4.8 (SD 2.5). This was similar
across instrument groups, with the exception of tympani and
percussionists who had a lower mean severity (3.0; SD 2.2),
but one based on only six musicians.
Of the respondents, 28% had missed at least 1 day of
work in the previous 18 months because of pain or injury.
This percentage was similar for all instrument groups except
tympani and percussion, for which only 1 of 12 musicians
(8.3%) had missed at least 1 day of work in the previous 18
months because of pain or injury.
Musicians who reported current presence of pain or
injury were asked to indicate on a body chart where they were
currently experiencing pain or injury. The most common
broad sites were the trunk (primarily the back), the right
upper limb and neck, the left upper limb and neck, and the
neck alone. The predominant sites varied between instru-
ment groups: back, neck and both shoulders for brass; right
upper limb for woodwind; back and right shoulder for lower
strings; back and both upper limbs for upper strings; back,
neck and right shoulder for percussion and tympani. The
sites of pain or injury considered not, or possibly not, work-
related were similar to the sites for those considered work-
related, except for injuries to the trunk, which were a little
more common (Table 5).
Musicians were also asked to indicate whether they had
ever had pain or injury at each of a range of nominated
anatomical sites. The most common broad sites were the
trunk (primarily the back), the right upper limb and neck,
the left upper limb and neck, and the neck alone. As for
reported current pain, the predominant sites varied between
instrument groups, and even more so when the anatomical
site was examined in more detail. This variation was similar
to that seen for current injuries, although there were some
differences (Table 6).
Of those musicians who reported at least one episode of
pain or injury in the past, less than 50% reported that they
had completely recovered. This was true for pain and injury
at most anatomical sites (Table 6).
Respondents who reported current or previous PRMDs
were asked to identify which, if any, performance-related fac-
tors had contributed to the pain and the extent to which the
factor to contributed to any injury or pain. The most com-
monly nominated performance-related factors that had con-
tributed to the occurrence of the injury or pain (nominated
by more than 75% of respondents) all related to training and
playing load (including practice and performance). These fac-
tors were also commonly rated as being important. Excess
muscle tension, muscle fatigue, insufficient rest, and long
practice sessions were the four factors most commonly nom-
inated as making a high contribution to the occurrence of
the pain or injury and were among the top six most com-
monly identified factors (Table 7).
Of those musicians who reported previous PRMDs, for
most anatomical areas less than half of respondents reported
that they were fully recovered (Table 6).

TABLE 4. Chronicity of Current Pain or Injury

Instrument Type
______________________________________________________________________________________________
Weeks of Pain Brass Woodwind Lower Strings Upper Strings Percussion Harp Total
or Injury (n = 50*) (n = 58) (n = 56) (n = 126) (n = 10) (n = 6) (n = 306)

<4 wks 26.0 20.7 28.6 42.9 10.0 16.7 31.7

4–12 wks 8.0 12.1 16.1 5.6 50.0 16.7 10.8
>12 wks 66.0 67.2 55.4 51.6 40.0 66.7 57.5
Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0
*Number of current injuries in brass musicians. Data given are percentages.

December 2012 183

 TABLE 5. Reported Current Pain or Injury, by Anatomical Site and Instrument Type
Tympani and
Brass Woodwind Lower Strings Upper Strings Percussion Total*
(n = 58) (n = 67) (n = 68) (n = 169) (n = 12) (n = 377)

Body Part
Head, face, lips 8.6 4.5 2.9 1.2 — 3.2
Neck 17.2 9.0 16.2 12.4 16.7 13.5
Upper limb and neck, left 15.5 6.0 11.8 18.9 8.3 14.6
Upper limb and neck, right 13.8 29.9 25.0 21.3 25.0 22.3
Trunk 32.8 17.9 30.9 23.1 16.7 24.9
Any 55.2 49.3 54.4 45.0 50.0 49.6
More detailed classification
Neck and shoulder, left 3.4 1.5 1.5 2.4 — 2.1
Neck and shoulder, right — 9.0 1.5 3.0 — 3.2
Shoulder and upper arm, left 8.6 — 1.5 8.9 8.3 6.1
Shoulder and upper arm, right 10.3 10.4 11.8 10.1 16.7 11.1
Elbow and forearm, left 3.5 3.0 2.9 3.0 — 2.9
Elbow and forearm, right 3.5 11.9 4.4 6.5 — 6.4
Wrist and hand, left 3.5 1.5 4.4 5.9 — 4.2
Wrist and hand, right 1.7 1.5 2.9 4.1 — 2.9
Fingers, left — — 1.5 1.2 — 0.8
Fingers, right — 3.0 — — — 0.5
Thumb, left — 1.5 — — — 0.3
Thumb, right — 4.5 4.4 — 8.3 1.9
Upper limb, left — — — 1.8 — 0.8
Upper limb, right — — 1.5 — — 0.3
Upper limb, both 6.9 — 10.3 2.4 8.3 4.5
Chest and abdomen 1.7 1.5 1.5 1.8 — 1.6
Back, upper 12.1 10.4 13.2 11.2 8.3 11.7
Back, lower 17.2 7.5 16.2 15.4 8.3 14.1
Back, general 1.7 3.0 4.4 — — 1.6
Lower limb, left 1.7 1.5 — — 8.3 1.1
Lower limb, right 1.7 1.5 — 1.2 — 1.3
Lower limb, both — — 1.5 — — 0.3
Multiple — — 1.5 — — 0.3

* Includes 3 harpists not included in the rest of the table. Data given are percentages.

DISCUSSION issues related to occupational overuse that 25 years ago were

This study identified a high prevalence of current and past
occupationally related pain and injury that adversely affected
the musicians’ ability to play to their optimum level. Whilst
elite performers may be assumed to be pushing the bound-
aries of performance, and therefore expect to occasionally
overload their system in some way, the presence of current
performance-related pain in approximately 50% of musicians
is a concern, especially given that about 80% of the cases
were considered to be related to playing. This has important
implications both in terms of the ability of the musicians to
play to their ability and for their health. The results suggest
that the orchestra population have lower rates of smoking
and obesity than the Australian population.25,26 However,
approximately 30% of musicians appeared to be drinking at
a level considered “risky” based on Australian guidelines.27
The characteristic pattern of low levels of pain in the
majority of the musicians reporting symptoms appears con-
sistent with the range of musculoskeletal injuries or pain
suggested to be prevalent in Australia’s professional orches-
tral musicians.7 The current study builds on that study by
providing current, fully national and detailed data on this
population of musicians. A similar picture is provided by
other studies that have looked at the issue in orchestras in
other countries, although few of these studies have had the
required number of subjects or detailed data collection
required to provide a comprehensive description.2–20 In the
original large-scale ICSOM survey, the overall prevalence of
musculoskeletal problems was not reported.6 However, the
regions with the highest prevalence of musculoskeletal symp-
toms were reported as the shoulder, neck, and back, which is
consistent with the findings in the current study.
The analysis of pain by body region suggests a relationship
between the physical demands of the instrument and where
symptoms occur. For example, in most woodwind instru-
ments, the reported higher incidence of neck, shoulder, right
elbow, and forearm pain is understandable given that the
right arm carries a major component of the load of the

184 Medical Problems of Performing Artists

 TABLE 6. Reported Past or Current Pain or Injury, by Anatomical Site and Instrument Type
Tympani and
Brass Woodwind Lower Strings Upper Strings Percussion Total * Recovery †
Body Part (n = 58) (n = 67) (n = 68) (n = 169) (n = 12) (n = 377) (n = 377)

Body Part
Head, face, lips 31.3 16.4 4.4 1.8 — 9.3 60.0
Neck 39.7 41.8 42.7 50.9 16.7 44.8 35.5
Upper limb, left 51.7 43.3 73.5 56.2 66.7 57.0 43.4
Upper limb, right 39.7 67.2 72.1 49.7 66.7 56.2 40.3
Back 55.2 40.3 47.1 47.9 75.0 48.3 37.0
Any 86.2 88.1 92.7 90.5 91.7 89.9 39.9
More detailed classification
Jaw 8.6 6.0 7.4 7.1 8.3 7.2 40.7
Back, mid 17.2 20.9 20.6 20.7 16.7 20.2 40.8
Back, lower 50.0 31.3 39.7 38.5 66.7 40.1 35.1
Shoulder, left 36.2 23.4 30.9 29.6 16.7 29.4 18.9
Shoulder, right 22.4 41.8 44.1 31.4 33.3 34.2 26.4
Elbow, left 5.2 6.0 16.2 11.2 25.0 10.6 45.0
Elbow, right 3.5 7.5 16.2 15.4 16.7 12.5 48.9
Forearm, left 6.9 10.5 25.0 10.1 8.3 12.2 43.5
Forearm, right 5.2 16.4 19.1 10.7 8.3 12.5 40.4
Wrist, left 17.2 19.4 25.0 14.8 — 17.8 52.2
Wrist, right 12.1 11.9 22.1 14.2 8.3 14.6 47.3
Hand, left 6.9 11.9 29.4 11.2 16.7 14.3 48.2
Hand, right 1.7 11.9 19.1 6.5 8.3 9.3 57.1
Fingers, left 6.9 17.9 27.9 18.3 33.3 18.6 67.1
Fingers, right 5.2 26.9 16.2 7.1 25.0 12.5 48.9
Hip, left 1.7 6.0 7.4 3.6 8.3 4.5 23.5
Hip, right 1.7 7.5 7.4 4.1 — 4.8 11.1
Knee, left 8.6 11.9 8.8 5.9 16.7 8.2 29.0
Knee, right 10.3 7.5 8.8 11.8 25.0 10.6 27.5
Foot/ankle, left 6.9 10.5 14.7 11.2 25.0 11.7 54.6
Foot/ankle, right 8.6 6.0 14.7 7.7 16.7 9.3 48.6

* Includes 3 harpists not included in the rest of the table. Data given as percentages.
† Percentage of respondents with a particular problem who reported that they had fully recovered from that problem.

instrument and requires sustained relatively static position-
ing while still needing to operate keys repetitively with the
fingers. In addition to the demands of playing particular
instruments, the perception and reporting of pain can poten-
tially be influenced by many physical, psychological, and
organisational factors, as suggested in a recent study by
Leaver and colleagues on a sample of British musicians.10
This will be explored in depth in the current study popula-
tion in a future analysis.
Perceived exertion has been previously reported to be sen-
sitive to both physiological and psychological variables asso-
ciated with exercise or activity.24 It is interesting to note the
increase in ratings of perceived exertion in the performance
situation compared to rehearsal and practice rankings, which
may have implications for rehabilitation of injured perform-
ers. A musician’s ability to return to orchestral performance
may not be able to be determined by their ability to return to
private practice as the performance exertion ranking was
13% higher. The RPE measure has been correlated with
fatigue levels previously24 and may also warn of impending
fatigue in the orchestral situation.28
It is difficult to identify data from other working popula-
tions that allow direct comparison. In this study, 28% of
musicians had missed at least one day of work in the previous
18 months because of pain or injury. As a comparison, in a
population survey in New South Wales, 16% of employed
persons reported suffering an injury or illness in the previous
12 months.13
The strengths of this study are the national coverage,
detailed information collected, and the high response rate.
There was no detailed information about eligible musicians
who did not participate, but the information that was avail-
able suggested the gender proportions and proportions play-
ing various instruments were similar for those who partici-
pated and those who did not. In addition, a separate analysis
of each orchestra was undertaken, and the orchestra with the
highest rate of participation was compared to the two with
the lowest participation (around 50%). This analysis showed
a slightly lower proportion of reported pain and injury in the
orchestras with lower participation rates, but a similar distri-
bution of the nature and severity of the disorders and the
suggested contributing factors. This suggests the study results

December 2012 185

 TABLE 7. Identification and Nominated Importance of conductor approaches were also identified. The results will
Perceived Causative Factors for Pain or Injury be used to plan trials of general prevention initiatives for all
Factor Identified* Importance† musicians and initiatives tailored for those playing particular
types of instruments.
Excess muscle tension 82.4 73.5
Muscle fatigue 76.8 70.8 Funding Statement: This project was supported as part of an ongoing 5-year
Insufficient rest 80.5 70.3 occupational health study of Australian Orchestras funded by the Australia
Long practice sessions 82.0 66.9 Research Council Linkage Grant Scheme (grant no. LP0989486), the Aus-
Sudden increase in playing 75.5 65.6 tralia Council for the Arts, and in-kind support from The Sydney Symphony
Repertoire scheduling 71.7 63.8 Orchestra, the Melbourne Symphony Orchestra, the Adelaide Symphony
Orchestra, the Queensland Symphony Orchestra, the West Australian Sym-
Poor posture 77.9 63.3
phony Orchestra, the Tasmanian Symphony Orchestra, the Australian
Stress 69.6 58.5
Opera and Ballet Orchestra, and Orchestra Victoria.
Poor injury management 62.8 47.9
Performance anxiety 62.0 47.6
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