Perceptual and Motor Skills, 2004,99,669-678.

O Perceptual and Motor Slulls 2004

PERCEPTIONS OF CAUSES OF PERFORMANCE-RELATED

INJURIES BY MUSIC HEALTH EXPERTS
AND INJURED VIOLINISTS '

BRONWEN J. ACKERMANN AND ROGER D. ADAMS

School of Physiotherapy
University of Sydney

Summary.-Skilled violin and viola players, all of whom had a current perfor-
mance-related musculoskeletal injury, were asked to report their perceptions of con-
tributing risk factors, consistent with a participatory ergonomics approach. The 26
players, age 18 to 60 years, had been playing for a minimum of 10 years and averaged
three hours of practice per day. In addition, 7 music health experts, all with more
than 10 years of clinical experience in treating musicians, were asked to report on the
risk factors for musicians' performance-related injuries. A high correlation between
the perceptions of these two groups was found, with the same top five factors in terms
of severity indicated by both groups. Factors rated as high risk were primarily intrin-
sic and related to the manner in which respondents practiced, to playing posture, and
to flaws in skill technique.

Producing music at an elite level may place skdled players at risk of

injury, even when the physical loads involved are relatively low, as they strive
to perform complex and highly repetitive movements over prolonged peri-
ods of time (Tubiana, 2000). The precise and highly specific physical actions
associated with mahng music can lead to performance-related musculoskele-
tal injuries, with playing groups reporting problems characteristic to the spe-
cific physical demands of the instrument (Bejjani, 2000). Further, the com-
plexity of the skds demanded of performers has increased over time (Zukof-
sky, 1992). For example, when Tcharkovsky (1840-1893) wrote his violin
concerto, which is now considered standard repertoire for elite violinists, vir-
tuoso violinists at the time refused to play it, deeming the score unplayable
(Ericsson, Krampe, & Tesch-Romer, 1993).
Recent research in music medicine has reported incidence rates of over-
use-type injuries at approximately 70% for occurrence in instrumentalist
musicians at some time in their careers and rates from 65% to 88% in vio-
linists (see Table l ) . Some of the cited factors for injuries occurring in vio-
linists given in the music medicine literature include a high frequency of re-
petitive movement patterns, awkward postures, poor technique, poor physical
condition, predisposing anatomical variations, sudden increases in practice
time, an increase in absolute amounts of practice, poor practice habits, in-

'Please address correspondence to Dr. Bronwen J. Ackermann, P.O. Box 192, Civic Square,
ACT 2608, Australia or e-mail (ackerman@netspeed.com.au).
670 B. J. ACKERMANN & R. D. ADAMS

strument changes, performance anxiety, and environmental factors (Fry,

1986; Hiner, Brandt, Katz, French, & Beczkiewicz, 1987; Norris, 1993; Zaza
& Farewell, 1997; Brandfonbrener, 2000).

TABLE 1
SUMMARY
OF SURVEYS
ASSESSING
INCIDENCEOF PERFORMANCE-RELATED
MUSCULOSKELETAL
INJURIES
OF MUSICIANS

Study Sample % Injury % Response

Survey in Ohio 1986
Caldron, Calabrese, Clough,
Lederman, Williams, &
Leatherman
Survey in Australia 1986
Fry
Survey in Indiana 1987
Hiner, Brandt, Katz, French, &
Beczkiewicz
Survey in USA 1989
Middlestadt & Fishbein
Survey in USA 1993
Larsson, Baum, Mudholkar, &
Kollia
Survey in Sweden 1998
Zetterberg, Backlund, Karlsson,
Werner, & Olsson
Survey in Australia 2002
Davies & Mangion
Survey in Australia 2003
Ackermann & Adams
"Overall.
Prevalence Rate
1,245 professional orchestral
musicians and music teachers
485 professional orchestral
musicians
55 surveys distributed by mail to
a group of elite violinists (also
international)
USA symphony orchestras
660 university music staff and
students
227 university music students
240 music teachers and profes-
sional musicians
32 violinists from professional
orchestras and tertiary music
institutions

Expert musicians spend approximately four hours a day in deliberate

practice on their instrument (Ericsson, et al., 1993), which is comparable to
the time spent during daily training by elite sports athletes (Weldon & Rich-
ardson, 2001). Hence, the physical condition of the performer may affect the
development of injuries in musicians (Ackermann, Adams, & Marshall,
2OO2b), as has been reported elsewhere in overuse literature for athletes
(Weldon & Richardson, 2001). The motor skills required to play a violin rep-
resent one of the more complex and demanding skilled activities using the
upper limbs, with both arms having to perform different actions in perfect
synchrony and intermittently at an extremely fast pace over many hours
(Horvath, 2002). These movements not only serve a functional role in play-
 VIOLINISTS: PERFORMANCE-RELATED INJURY 67 1

ing the music, but also an expressive one, whereby gestures and flourishes
add emotion and vibrancy to the performance (Ruggieri & Katsnelson, 1996;
De Poli, Roda, & Vidolin, 1998), so individual differences might be expect-
ed, Furthermore, diverse methods of playing the violin and viola have devel-
oped over centuries from different cultures and countries, and hence there
are considerable variations in playing styles (Dilworth, 1992). Pedagogical
books and papers on both posture and technical aspects of playing written
by violinists and violists tend to reflect their personal views and experiences
(Flesch, 1939; Galamian, 1962; Weilerstein & Neal, 2000) without using sci-
entific or injury data about associations with particular movement patterns.
Eales (1992) noted that the available range of teaching and playing styles
would bewilder the aspiring violin player, with no consensus providing per-
spective on different styles and their relation to performer physical character-
istics or potential injury risk. The importance of recognising players' percep-
tions of risk factors for musculoskeletal injury is a key concept in the field of
participatory ergonomics (Noro & Imada, 1991; Vink, Peeters, Grundemann,
Smulders, Kompier, & Dul, 1995; Kuorinka, 1997; Zalk, 2001). Information
provided by equipment users has been beneficial in implementing programs
to manage risks in several occupational domains, e.g., with steelworkers, man-
ual handling jobs, meat processing workers, and office workers (Kuorinka &
Patry, 1995; Vink, et al., 1995). To date, identification of risk factors among
musicians has been obtained from separate surveys given either to musicians
or to the medical professionals who provide their h d t h care.
The purpose of the current study was to investigate the relative impor-
tance of commonly cited risk factors from both the perspective of the violin-
ist and the music health professional. Information obtained can then be ex-
amined for agreement on the perceived relevant risk factors between these
groups.

Subjects
Highly skilled musicians (N= 28), comprising 26 violinists and 2 violists
who were from three different university music schools and two different or-
chestras and who were currently suffering performance-related musculoskele-
tal disorders volunteered to participate. Subjects were 21 women and seven
men with an age range of 18 to 60 years. Their mean daily practice time was
3 hr. (with a range between 1.5 to 6 hours per day). No subjects were un-
able to practice or perform at their normal capacity due to severity of their
pain. The music health experts group consisted of four medical specialists
and three physiotherapists (three women and four men) all of whom had
worked clinically with musicians for more than 10 years. Musician volunteers
were recruited by notices placed in several university music institutions and
 B. J. ACKERMANN & R. D. ADAMS

orchestral backstage areas, and music health professionals were recruited by

sending written information about the study and asking for volunteers to fill
out the questionnaire.
Protocol
The term "performance-related musculoskeletal disorder" was used in
this study in a way consistent with a definition based on previous testing
with musicians. The definition was responding affirmatively to the question,
"do you have a performance-related musculoskeletal problem, i.e., any pain,
weakness, numbness, tingling, or other symptoms, that interferes with your
ability to play your instrument at the level you are accustomed to?" (Zaza &
Farewell, 1997). For the current study, risk factors listed were identified from
both reported causes in the literature and from previous interviews with
professional musicians and music teachers. Subjects completed a short ques-
tionnaire on the risk factors they perceived as contributing to the perfor-
mance-related injuries and were asked to grade each contributing factor in
terms of significance using a numbering system in which "1" represented
the most significant factor. The same number could be used to represent
equivalent contributions of different risk factors. An open-ended category
was included to allow identification of any other factors by the musicians.
Analysis
The relative significance of each factor was examined by giving each
number assigned to a factor a value that reflected the weighting of that fac-
tor as recorded by the violinist and the music health professional. As the
highest number used was 10, the equation "Relative severity = 11 - x" was
used to give numerical values for each factor. These assigned numbers were
analysed in two ways. The relationship between summed severity values for
each risk factor between groups was examined by Pearson correlation and
the agreement between the severity ranking by Spearman rho.
RESULTSAND DISCUSSION
All subjects completed and returned the questionnaires, representing a
100% response rate in the chosen samples of violinists, violists, and music
health professionals. The responses are summarised in Table 2. The ranked
perceived severity scores were correlated between groups (rho = .75, p = .003)
as were the summed severity scores (r = .77, p = .002). The scatter plot for
the summed severity scores is shown in Fig. 1.
A significant correlation was found between the rankings of perceived
causes of performance-related injury by injured violinists and violists versus
health care providers working with this population. Concurrence as to the
causes of players' injury was high.
One of the most important risk factors reported by the musicians and
the music health experts was poor posture. There are current recommenda-
 VIOLINISTS: PERFORMANCE-RELATED INJURY

TABLE 2

Factor Musicians Health Experts

Rank C Severity Rank E Severity
Long hours of practice
Sudden increases in playing time
Poor posture
Technique flaws
Insufficient rest breaks
Lack of understanding of physical strain
Insufficient warm-up
Inadequate chairs
Travel strains
Performance anxiety
Poor physical condition/fitness
Inadequate instrument set-up
Poor flexibility
Cold environment*
Difficult programs"
Highly repetitive studies"
Excessive muscle tension"
Long orchestra rehearsals" 9
"Additional risk factors added and rated as important in causing injuries by the musicians.

tions in the sports literature that postural considerations should be applied

to sports performance for optimal performance of these elite athletes (Bloom-
field, Ackland, & Elliott, 1994). Similarly, guidelines are ldsely identifiable
for these performers. However, in several attempts by health professionals to
identify such optimal postures for violinists, proposed ideals vary (Brock-
man, Tubiana, & Chamagne, 1992; Norris, 1993; Dommerholdt , 2000).
Whilst this may perhaps reflect a range of approaches that suit natural varia-
tions which occur within individual postures, it does make such applications
confusing. Further research in this area may identify which particular pos-
tures, even of individual segments, places these performers at a higher injury
risk.
While some attempts to define technical aspects of playing have been
performed (Hodgson , 1958; Tulchinsky & h o l o , 1994; Turner-Stokes &
Reid, 1999), there has not been biomechanical analysis of playing styles in
depth such as occurs in the sports literature (Bloomfield, et al., 1994). Un-
derstanding the basis of normal movement patterns may be important for
violinists and violists in injury prevention (Medoff, 1999; Tubiana, 2000),
and such concepts could be applied within the framework of current tech-
niques. As expressed by one violin pedagogue, the general principles of the
techniques of violin playing need to cover all areas broadly, yet be flexible
 B. J. ACKERMANN & R. D. ADAMS

-
In
([I
C
.-0
In
V)

2
2
a
6
-
([I
Q)
I

Musicians

FIG. 1. Scatter plot of summed severity scores for different factors made by the injured
violinists and violists and the music health experts. The five factors on the right are intrinsic
and difficult to define. The point of maximum discrepancy between the two groups was the
perceived severity of touring as a risk factor for injuries.

enough to take into account the individual physical and mental characteris-
tics of each performer (Galamian, 1962). In the past, there have been some
attempts to understand the physiological processes involved in playing the
violin as a basis for suggesting ways in which playing stresses may be altered
(Polnauer & Marks, 1964; Szende & Nemessuri, 1971). If necessary it seems
possible that technique could be modified successfully even in these elite vio-
linists as was achieved with elite swimmers (Sanders, 1995), and indeed this
happens commonly when violin or viola students change teachers. However,
the effect of altering the physical movements within a technique on musical
performance is not known, and some interventions may actually have detri-
mental effects (Ackermann, Adams, & Marshall, 2002a). That musicians per-
ceive poor technique to be a relatively critical risk factor indicates the neces-
sity for further research and education to identify whether particular tech-
niques, as with postures, are in fact identifiable and consistently linked to an
increased risk of injuries.
Out of the five risk factors rated as most likely to cause an injury re-
lated to playing an instrument, poor practice habits could account for three
out of the top five. Long hours of practice and sudden increases in practice
time were reported consistently despite the variability in practice hours be-
 VIOLINISTS: PERFORMANCE-RELATED INJURY 675

tween the performers and the lack of practice information given to the mu-
sic health professionals. Hence, this may be considered to be a relative phe-
nomenon rather than an absolute one. That there is a risk from a sudden in-
crease in hours of practice or long hours of practice may partiaUy reflect in-
adequate preparatory muscle endurance conditioning (Ackermann, et al.,
2002b). Insufficient rest breaks was also considered important and may act
by increasing tissue injury as a result of not dowing sufficient time for tis-
sue recovery (Hagberg, 1997)) creating similar types of tissue overload to the
highest ranking two factors.
This poor management of practice scheduling suggests musicians' inade-
quate understanding of the physiology of muscle recovery and basic training
principles. To approach the management of these problems, musicians and
music teachers may need to evaluate how they manage practice and perfor-
mance schedules and be involved in suggesting how more appropriate sched-
ules can be introduced into their practice regimes. Increasingly emphasised
is that musicians should ideally be given adequate training in these areas
while studying at music conservatories (Tubiana, 2000; Spahn, Hildebrandt,
& Seidenglanz , 2001). Graduated schedules of increasing practice when com-
mencing playing after holidays or an injury, such as the return to play strat-
egies suggested by Norris (1996)) do not appear to be commonly used. Lit-
erature in pedagogical books on this topic is sparse, with one famous violin
pedagogue recommending rest breaks of 15 min. after every hour of practice
(Flesch, 1939). However, it is likely that such a time frame would need to be
adjustable depending on the familiarity and musical demands of the piece to
be played, as muscle fatigability alters according to differing physical require-
ments (Gandevia, 2001; Visentin & Shan, 2003). In professional situations,
rest breaks may be partly set by conductors who can reduce the control the
professional musician has over this aspect of their performance (Horvath,
2002). In the orchestral situation, a participatory ergonomics team approach
with orchestral management bodies, musicians and specialised health practi-
tioners may be helpful in scheduling so the risk of injury to players is re-
duced.
Risk factors below the top five identified above showed overall good
agreement, with some differences which may reflect a result of the training
differences between the two groups. For example, the music health profes-
sionals rated poor physical condition far more highly than the violinists,
which may mean condition is not an apparent problem to the musicians who
are less likely to be aware of the benefits of good physical condition. Extrin-
sic risk factors showed more variability in perceived importance and were
overall rated lower than intrinsic risk factors by both groups.
Interestingly, in one area there was little agreement. The injured violin-
ists identified touring as influential in developing injuries, a viewpoint not
676 B. J. ACKERMANN & R. D. ADAMS

shared by the music health experts. This may partially reflect relatively little
experience of touring amongst these health practitioners working predomi-
nantly in a clinical practice. Injuries whilst touring do occur, and those sus-
tained by musicians have been previously documented (Ackermann , 2002).
From these data, part of the solution to reducing injury in violinists and
violists may be better provision of health education to the music teachers
and musicians (Spahn, et al., 2001). Understanding the interface between the
performer and the instrument in relation to different individual physical
characteristics may help early troubleshooting (Ackermann & Adams, 2003).
This may allow musicians and teachers to develop a "repertoire" of knowl-
edge to fit differing physical and musical requirements.
Conclusion
Intrinsic factors related to both performance characteristics and dura-
tion were suggested by both musicians and music health experts as of great-
er importance in injury than extrinsic or environmental demands. The five
factors rated by both health professionals and skilled violinists as the most
likely to cause injury are essentially difficult to define. The ideal practice
structure, posture, and technique could arguably be only judged after detail-
ed consideration of an individual's anthropometrics, style of playing, and the
relevant requirements of repertoire. Further research may indicate whether
more widespread health education could assist more teachers when fitting
pedagogical viewpoints and ideas about playing styles with physical charac-
teristics of individual violinists or violists.
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Accepted July 29, 2004.