This short review article tries to identify the most effective methods to prevent the occurrence of performance related musculoskeletal disorders (PRMD) of the upper body in professional string players like classically trained violin, viola, violoncello, and bass players. PRMDs are musculoskeletal disorders which are defined as conditions that interfere with the ability to play and to perform on a given instrument. Previous research has shown that musicians in general have a higher prevalence of these conditions when compared to an employed non-musician cohort (Vastamäki et al., 2020). Some of the few higher quality studies have shown a 12-month prevalence of PRMD among orchestral musicians of 82% to 86%. But it is noteworthy that generally the prevalence of PRMD remains hard to quantify because of methodological heterogeny within the literature, lack of uniform definitions and measuring tools (Rotter et al., 2020). It seems that particularly upper string players (Violin and Viola) are at increased risk to suffer from PRMDs for reasons like their sustained asymmetrical playing posture, and the longer playing time relative to other orchestral instrumentalists (Mizrahi, 2020; Vastamäki et al., 2020). They are more likely to experience reduced cervical extension range of motion, cervical strength, and scapular dyskinesia as a result of sustained asymmetrical posture when holding and playing their instrument (Tawde et al., 2016). These imbalances could lead to problems in string players as it has been shown to be the case in athletic populations like volleyball players (Wang & Cochrane, 2001). Lower string players are at risk of developing PRMDs to a slightly lower extent, due to the fact that their playing position is seated, the asymmetric playing position is only affecting the arms, and the weight of the instrument is supported by the spike of the instrument (Brandfonbrener, 2003). However, the need for proximal shoulder strength and prolonged asymmetric arm positions when playing leads to muscle tightness and muscle imbalances in lower string players as well (Brandfonbrener, 2003). Additionally, the higher bridge height, string thickness, and greater fingerboard travel distances lead to more finger, wrist and forearm pathologies (Jacobs et al., 2013). Contrary to popular belief string players do produce lower overall grip strength and are less balanced between left and right hand when compared to non-musicians, likely because of the overuse of extrinsic flexor muscles caused by the demand of playing technique of the instrument (Gorniak et al., 2019). Both, upper string and lower string players can experience shoulder and neck pain and increased fatigue caused by the asymmetric upper body and arm position (Rensing et al., 2018), with women, musicians experiencing low mood, and those with high somatic scores being affected more frequently (Rotter et al., 2020).
Obvious strategies in preventing the occurrence of PRMDs are the appropriate setup of the instrument i.e., the shoulder rest of a violin or viola or the ergonomic seat setup and spike length of a violoncello or bass (Leder Horina et al., 2010). Furthermore, the appropriate use of playing technique seems to be an intuitive tool, even though maintaining that appropriate technique over hours of daily playing is dependent on the musician’s physical capacity. Therefore, a targeted strength and conditioning programme could contribute to reduce PRMDs. The rationale for the application of strength and conditioning for the prevention of PRMDs in string players is that the resulting improvements in physical and functional capacity will help to reduce the relative impact (strain) of the given work task (Pronk et al., 2004). This could further result in a reduction of the perceived effort of playing (Chan et al., 2014).
As in other cohorts (L. L. Andersen et al., 2008), strength and conditioning could contribute to the attempts to reduce the risk and prevalence of PRMDs among string players. Unfortunately, high quality intervention studies in this cohort of professional string players are very rare (Rotter et al., 2020). Ackermann et al. (2002) has investigated the effect of strength training versus endurance training on perceived rating of exhaustion (RPE) in young undergraduate music majors at a university, and found that PRMD were significantly improved mainly for the group that focused on endurance. Unfortunately, this was only a small size study (N=19 of which 10 were string players) with a two arms design without control, and the age of the participants was significantly lower (between 18 years and 28 years) than the average age of professional string players (46 Years +/- 9.4) working in symphonic orchestras (Ackermann et al., 2002; Gembris & Heye, 2014). Much closer to that age bracket, a study by Andersen (2017) was investigating the different effects of a targeted 9 week strength exercise programme for the shoulders and upper body, and a lower body endurance exercise programme. He showed improvements of self-reported playing satisfaction among participants of both groups, but reduced pain levels only in the group that was part of the targeted strength intervention. However, the targeted strength intervention had a slightly higher count of participants who reported that the training was interfering with their playing, which could be explained by the occurrence of post workout muscle aches (DOMs) (L. N. Andersen et al., 2017). Interestingly, the majority of participants of both groups reported a perceived positive effect on their instrumental performance (L. N. Andersen et al., 2017). The above findings are in alignment with previous investigations of Chan et al. (2014) who found that tailored exercise programmes are associated with a reduction in PRMDs and thus having positive effects on performance in orchestral musicians including string players. All these findings are very promising, but in the attempt to prevent or resolve PRMDs, more research must be conducted to find the most affective strength and conditioning interventions tailored to the category of string player (upper vs lower), the specific string instrument or even the individual player. Because of the higher average age of professional string players additional factors like the effect of the conditions of the STAR triad (Follow this link to learn more) should be considered as well. The prevalence of these conditions among older string players and their specific needs could confound the results of future interventional studies that try to evaluate the effect of strength training on string players.
Ackermann, B., Adams, R., & Marshall, E. (2002). Strength or endurance training for undergraduate music majors at a university? Medical Problems of Performing Artists, 17, 33–41.
Andersen, L. L., Kjaer, M., SØgaard, K., Hansen, L., Kryger, A. I., & Sjögaard, G. (2008). Effect of two contrasting types of physical exercise on chronic neck muscle pain. Arthritis Care & Research: Official Journal of the American College of Rheumatology, 59, 84–91.
Andersen, L. N., Mann, S., Juul-Kristensen, B., & Søgaard, K. (2017). Comparing the impact of specific strength training vs general fitness training on professional symphony orchestra musicians: A feasibility study. Medical Problems of Performing Artists, 32, 94–100.
Brandfonbrener, A. G. (2003). Musculoskeletal problems of instrumental musicians. Hand Clinics, 19, 231–239.
Chan, C., Driscoll, T., & Ackermann, B. J. (2014). Effect of a musicians’ exercise intervention on performance-related musculoskeletal disorders. Medical Problems of Performing Artists, 29, 181–188.
Gembris, H., & Heye, A. (2014). Growing older in a symphony orchestra: The development of the age-related self-concept and the self-estimated performance of professional musicians in a lifespan perspective. Musicae Scientiae, 18, 371–391.
Gorniak, S. L., Evan D. Collins, Collins, E. D., Staines, K. G., Brooks, F. A., & Young, R. V. (2019). The Impact of Musical Training on Hand Biomechanics in String Musicians. Hand, 14, 823–829.
Jacobs, M. A., Austin, N. M., & Austin, N. M. (2013). Orthotic intervention for the hand and upper extremity: Splinting principles and process. Lippincott Williams & Wilkins.
Leder Horina, J., Jurčević Lulić, T., & Sušić, A. (2010). Ergonomic aspect of violin playing. Proceedings of 4th International Ergonomics Conference, Ergonomics 2010., 119–130.
Mizrahi, J. (2020). Neuro-mechanical aspects of playing-related mobility disorders in orchestra violinists and upper strings players: A review. European Journal of Translational Myology, 30, 9095.
Pronk, N. P., Martinson, B., Kessler, R. C., Beck, A. L., Simon, G. E., & Wang, P. (2004). The association between work performance and physical activity, cardiorespiratory fitness, and obesity. Journal of Occupational and Environmental Medicine, 46, 19–25.
Rensing, N., Schemmann, H., & Zalpour, C. (2018). Musculoskeletal Demands in Violin and Viola Playing: A Literature Review. Medical Problems of Performing Artists, 33, 265–274.
Rotter, G., Noeres, K., Fernholz, I., Willich, S. N., Schmidt, A., & Berghöfer, A. (2020). Musculoskeletal disorders and complaints in professional musicians: A systematic review of prevalence, risk factors, and clinical treatment effects. International Archives of Occupational and Environmental Health, 93, 149–187.
Tawde, P., Dabadghav, R., Bedekar, N., Shyam, A., & Sancheti, P. (2016). Assessment of cervical range of motion, cervical core strength and scapular dyskinesia in violin players. International Journal of Occupational Safety and Ergonomics, 22, 572–576.
Vastamäki, M., Ristolainen, L., Heliövaara, M., & Vastamäki, H. (2020). Musculoskeletal pain among Finnish orchestra musicians versus core workforce. Occupational Medicine, 70, 507–513.
Vastamäki, M., Vastamäki, H., Ristolainen, L., Laimi, K., & Saltychev, M. (2020). Violists and Violinists Report More Intense Hand Pain on NRS Than Other Orchestra Musicians. Medical Problems of Performing Artists, 35, 162–166.
Wang, H. K., & Cochrane, T. (2001). Mobility impairment, muscle imbalance, muscle weakness, scapular asymmetry and shoulder injury in elite volleyball athletes. Journal of Sports Medicine and Physical Fitness, 41, 403–410.
mer during a family hike in the Appalachians.
Thormann Personal Training 