785000

research-article2018
CRE0010.1177/0269215518785000Clinical RehabilitationRoos and Roy

CLINICAL
Article REHABILITATION

Clinical Rehabilitation

Effect of a rehabilitation program on 2018, Vol. 32(12) 1656­–1665

© The Author(s) 2018
Article reuse guidelines:
performance-related musculoskeletal sagepub.com/journals-permissions
DOI: 10.1177/0269215518785000
https://doi.org/10.1177/0269215518785000

disorders in student and professional journals.sagepub.com/home/cre

orchestral musicians: a randomized

controlled trial

Marianne Roos1 and Jean-Sébastien Roy1,2

Abstract
Objective: To explore the feasibility of a rehabilitation program and its effect on the performance-
related musculoskeletal symptoms and functional limitations of orchestral musicians.
Design: Single-blind pilot randomized controlled trial with exercise group and control group.
Setting: Workplace of professional symphony orchestra and tertiary-level conservatory orchestral
musicians.
Participants: Professional and student orchestral musicians with or without performance-related
musculoskeletal disorders.
Interventions: A rehabilitation program including an educational presentation, an 11-week home
exercise program and three supervised exercise sessions, versus no intervention.
Measures: Feasibility measures included adherence and drop-out rate. The Musculoskeletal Pain Intensity
and Interference Questionnaire for professional orchestra Musicians (MPIIQM) measured symptom
intensity and functional limitations, while the Nordic Musculoskeletal Questionnaire (NMQ) measured
symptom prevalence and frequency.
Results: A total of 30 participants were recruited (n = 15 per group). Exercise group adherence was
97.7% for the supervised sessions and 89% for the home exercise program. There were no drop-outs.
Significant group-time interactions were obtained for both the pain intensity (partial η2 = 0.166; P = 0.025)
and pain interference (partial η2 = 0.186; P = 0.017) sections of the MPIIQM. Mean (standard deviation)
pain intensity score changes from baseline to 11 weeks were control group: 0.40 (5.04); P = 0.763; partial
η2 = 0.007; and exercise group: –4.07 (5.31); P = 0.010; partial η2 = 0.386. For pain interference, mean score
changes were control group: 0.20 (9.10); P = 0.933; partial η2 = 0.001; and exercise group: –9.00 (10.73);
P = 0.006; partial η2 = 0.430. NMQ analyses revealed no significant interaction (P > 0.05).
Conclusion: Results suggest that the studied program is feasible and effective in decreasing the intensity
and functional impact of musicians’ symptoms. However, no significant medium-term effect on the
prevalence and frequency of symptoms was shown.

1Department of Rehabilitation, Faculty of Medicine, Laval Corresponding author:

University, Québec, QC, Canada
2Centre for Interdisciplinary Research in Rehabilitation and
Social Integration (CIRRIS), Québec, QC, Canada
Jean-Sébastien Roy, Centre for Interdisciplinary Research in
Rehabilitation and Social Integration (CIRRIS)Õ25, boulevard
Wilfrid-Hamel, office H-1706, Québec G1M 2S8, Canada.
Email: jean-sebastien.roy@rea.ulaval.ca
Roos and Roy 1657
Keywords
Exercise program, musculoskeletal pain intensity and interference questionnaire for professional
orchestra musicians, orchestral musician, performance-related musculoskeletal disorder, rehabilitation
program
Date received: 1 December 2017; accepted: 2 June 2018
Introduction
The nature of the classical musician’s work, which
comprises numerous daily hours of precise and fre-
quently strenuous repetitive movements in asym-
metrical postures, renders them vulnerable to
performance-related musculoskeletal injury.1
Performance-related musculoskeletal disorders
have been defined as “any pain, weakness, numb-
ness, tingling or other physical symptoms that inter-
fere with your ability to play your instrument at the
level to which you are accustomed.”2–4 The lifetime
prevalence of these disorders in professional instru-
mental musicians ranges from 62% to 93%.3 These
high prevalence rates indicate the need for preven-
tive and intervention strategies. Furthermore, typi-
cal musical instruction does not include education
pertaining to general physical well-being, load
management, and injury prevention,5,6 and this is
thought to be an important factor in musicians’
development of pain problems and injuries.6–8
An exercise program created by Chan et al.9
aimed to tailor specifically to the needs of orches-
tral musicians. The exercises were designed to
strengthen and improve the recruitment of key pos-
tural muscles and then to apply this heightened
muscle activation to movements used regularly by
musicians. Studies evaluating the effects of the
program both in face-to-face10 and DVD11 form
demonstrated its ability to significantly decrease
the frequency and intensity of performance-related
musculoskeletal symptoms. Neither of these stud-
ies was, however, a randomized controlled trial.
While randomized controlled trials have looked at
the effect of strength, general fitness, and endur-
ance training in orchestral musicians,12,13 to our
knowledge, the effect of this musician-specific
exercise program has yet to be evaluated with this
study design. Furthermore, the combination of this
form of exercise with health education geared
toward the orchestral musician’s lifestyle and work
could increase the impact on physical health and
well-being.
The objective of this pilot randomized con-
trolled trial was to evaluate the feasibility and the
effect of a rehabilitation program including an edu-
cational presentation and a series of musician-spe-
cific home exercise videos on the intensity and
frequency of performance-related musculoskeletal
symptoms and resulting functional limitations in
orchestral musicians. The hypotheses were that the
compliance with the rehabilitation program would
be high (>80%) and that the intensity and fre-
quency of performance-related musculoskeletal
symptoms and functional limitations would
decrease as a result of the program.
Methods
This study was approved by the Laval University
research ethics committee (2016-355/31-01-2017)
and was registered on ClinicalTrials.gov
(NCT03288688). Orchestral musicians from three
musical establishments, namely one symphony
orchestra, one string orchestra, and the conserva-
tory of music, were invited to participate in this ran-
domized controlled trial, regardless of the presence
or absence of musculoskeletal injuries related to
playing their instrument. Interested musicians were
included if they met the following criteria: aged 18
and above; a professional or freelance orchestral
musician, or tertiary-level full-time music student
majoring in an orchestral instrument; able to com-
mit to performing exercises two times per week
over an 11-week period. Exclusion criteria were:
the presence of musculoskeletal injuries non-related
to musical practice or performance; fewer than
15 hours per week playing their instrument; corti-
costeroid injection in the six weeks preceding
recruitment; prescribed anti-inflammatory drugs or
1658 Clinical Rehabilitation 32(12)
gabapentin in the three weeks preceding recruit-
ment. Informed consent forms were signed by all
participants.
Random allocation to the exercise group or to
the control group proceeded as follows: a block
randomization list was generated by a member of
the research team using a random number genera-
tor (block sizes of 2 and 4). Due to the impact of
the instrument played on the development and
nature of performance-related musculoskeletal dis-
orders, as well as the influence of the type of
orchestra on the nature and schedule of playing,
randomization was stratified by instrument group
and musical establishment to ensure balance of the
treatment groups with respect to these variables.
Instrument groups used for stratification were
upper strings (violin and viola), lower strings (cello
and double bass), winds (clarinet, bassoon, oboe,
and flute), brass (trombone, French horn, and trum-
pet), and percussion. Allocation was concealed in
sealed and opaque envelopes that were sequentially
numbered. The envelopes were opened by a mem-
ber of the research team following baseline assess-
ment. As it was impossible to blind the treating
therapist and the musicians, a single-blind design
was used, in which the evaluator was blinded.
Precautions were taken to ensure that participants
in the control group were unaware of the treatment
of the exercise group, and participants were
instructed not to reveal their group to their col-
leagues or to the evaluator.
All participants were evaluated once at baseline
(T0) and once at the end of the 11-week rehabilita-
tion program (T1), which coincided with the mid-
dle and the end of the orchestra season, respectively.
The baseline evaluation consisted of questionnaires
on demographics, performance-related musculo-
skeletal symptoms, and functional limitations. All
questionnaires were available in both French and
English. The same performance-related musculo-
skeletal symptoms and functional limitations ques-
tionnaires were completed by all participants at the
final, 11-week evaluation, with the addition of a
question on global perceived change of their condi-
tion since the initial evaluation. A research assis-
tant who was unaware of group assignment
supervised the evaluations. All meetings with the
participants were held in the shared workplace of
the symphony orchestra and the conservatory.
The Musculoskeletal Pain Intensity and
Interference Questionnaire for professional orches-
tra Musicians (MPIIQM) was used as the primary
outcome to document performance-related muscu-
loskeletal disorder symptoms and functional limi-
tations. This tool is a biopsychosocial self-report
questionnaire developed and validated14 specifi-
cally for orchestral musicians. It comprises a sec-
tion on demographics and two sections of questions
scored on scales from 0 to 10: the pain intensity
and pain interference sections, with possible totals
of 40 and 50 points, respectively.
The Nordic Musculoskeletal Questionnaire
(NMQ) was used to determine the regions of the
body in which the participants had experienced
pain or other symptoms and at what frequency.
They were asked to indicate the prevalence and fre-
quency of symptoms in the neck, shoulders, upper
back, elbows, wrists or hands, lower back, hips or
thighs, knees, and ankles or feet. Its psychometric
properties have been demonstrated.15,16
Global rating of change (GRC) questions are
designed to quantify a patient’s perceived improve-
ment or deterioration over time.17 Using a 15-point
Likert-type scale ranging from −7 (a very great
deal worse) to 0 (about the same) to +7 (a very
great deal better), participants reported their per-
ceived global change since the initial evaluation.
The validity, reliability, and responsiveness of this
scale have been established.18
The intervention offered to the exercise group
consisted, first, of a 40-minute educational presen-
tation on topics such as the roles of postural and
dynamic muscles, the importance of physical activ-
ity in preparing their bodies for the demands of
their work, gradual adaptation of the body to work-
load and physical stressors, load management, rest,
injury management, and instructions pertaining to
the exercise program.6,19–25 The presentation was
offered one week after the baseline evaluation and
marked the beginning of the 11-week intervention
period. In addition, three short informative emails
on healthy practice habits,20 risk factors to musi-
cians’ injuries and how they are addressed by the
exercise program being studied,9,23 as well as
Roos and Roy 1659
exercise recommendations (based on questions
asked in the group exercise sessions), dosage, and
health benefits,6,26 were sent to all exercise group
members over the course of the study.
The second component of the intervention was
an exercise program inspired by that of Chan et al.,9
offered to the musicians in the form of homemade
exercise videos. Universal serial bus (USB) mem-
ory sticks containing the videos and exercise mate-
rials (one pool noodle and two resistance bands,
one red and one green) were distributed to the exer-
cise group on the day of the educational presenta-
tion, and participants were instructed to commence
the program directly. One week later, participants
met with the treating therapist in groups of four to
five for a 45-minute exercise session including
explanations, demonstrations, and corrections of
exercise execution. Two more group exercise ses-
sions, about 1 hour in length, were offered over the
course of the 11-week intervention, approximately
one month apart.
The exercise program comprises warm-ups,
exercises, and cool-downs and aims to improve
recruitment, strength, and endurance of postural
muscle groups that are key to the work of a musi-
cian. Basic activation exercises progress to
dynamic and resisted exercises as well as gross
motor movements that imitate those used by musi-
cians. Exercise group participants were asked to
perform a minimum of two 35- to 40-minute exer-
cise sessions per week, including 5 minutes each of
warm-ups and cool-downs. Exercises were
arranged as proposed by Chan et al.:9 there is one
series of exercises for each of five bodily regions,
namely the neck, shoulders, abdominals, back, and
hips. Each series includes six exercises of increas-
ing difficulty. Subjects were asked to start at the
first exercise of each series and to progress to the
following exercise upon mastery of the first. All
shoulder exercises were performed with a red
resistance band, as the less resistant yellow band
used by Chan et al.9 was not believed to be chal-
lenging enough for the average musician, consider-
ing the physical demands intrinsic to their work.
Control group members were asked to continue
their normal activities and received no intervention
for the duration of the study.
Due to the following two factors, no sample size
calculations were used: (1) this is a pilot study of
an exploratory nature, and (2) only professional
orchestral musicians and seriously trained perfor-
mance-oriented orchestral music students were
included; accessibility of such a population in
Québec City is limited, as there is only one small
conservatory, one symphony orchestra, and one
string orchestra.
All data were tested to check the distributional
assumptions for inferential statistical analyses.
Baseline demographic data were compared using
independent sample t-tests and chi-square tests.
Principles underlying “intention-to-treat” analysis
were followed, meaning that each participant was
analyzed according to the randomized treatment
assignment. Two-way mixed-model analyses of
variance (ANOVA) (groups (exercise, con-
trol) 
× evaluations (baseline, week 11)) were
employed to determine the effect of the rehabilita-
tion program on the primary outcome (the
MPIIQM), using SPSS Software (IBM Corporation
in Armonk, NY). Bonferroni adjustments for mul-
tiple comparisons were used, and effect sizes were
reported (partial η2 and Glass’ Δ). NMQ and GRC
data, on the other hand, were analyzed using R
Software, (Version 3.3.2), with non-parametric
analysis of longitudinal data in factorial experi-
ments (nparLD),27 and a two-sample test for equal-
ity of proportions with continuity correction,
respectively. The level of significance was set at
P < 0.05 for all statistical analyses.
Results
The trial spanned from February 2017 (start of
recruitment) to July 2017 (completion of follow-
up). A total of 31 musicians manifested their
interest in participating in the project. As one
subsequently decided to focus on other physical
activity (running) rather than an exercise pro-
gram, 30 were included and randomly allocated
to the exercise group (n = 15) or the control group
(n = 15). There were no drop-outs (Figure 1). No
between-group differences (P > 0.05) were found
for any of the participant characteristics at base-
line (Table 1).
1660 Clinical Rehabilitation 32(12)

Figure 1.  Flow diagram for participant recruitment, allocation, 11-week follow-up, and analysis.

One of the exercise group members attended
only two of the three supervised exercise sessions,
and the others (n = 14) had a 100% attendance rate.
Four exercise group members were unavailable
for the educational presentation and listened
instead to a narrated Powerpoint version sent to
them via email. Adherence tables in which exer-
cise group participants indicated the time and
number of exercise sessions per week showed an
average self-reported compliance of 89%
(12.46/14) for 14 of the exercise group members
(the 15th omitted to indicate the time spent on
each session, but carried out 2 to 3 sessions per
week for all but one week).
One exercise participant consulted a physiother-
apist three times over the course of the study and
had been consulting the same therapist occasion-
ally for a number of years. Another exercise group
subject received treatments from a previously con-
sulted chiropractor once a week from weeks 5 to
11. In the control group, one participant started
consulting a physiotherapist during the study and
received a total of seven treatments before the final
evaluation (frequency of once a week followed by
once every two weeks). Another control group
member had two acupuncture treatments in the two
weeks preceding the final evaluation, while a third
visited an osteopath twice during the study. No
Roos and Roy 1661

Table 1.  Participant characteristics at baseline (n = 30).

Control (n = 15) Exercise (n = 15) P-value

Demographics  
  Sex (F/M) 8/7 8/7  
  Age (years; mean ± SD) 39.3 ± 12.7 36.8 ± 11.5 P = 0.58
  Regular physical activity (n) 7 7  
Musical characteristics (mean ± SD)  
  Years playing the instrument 29.8 ± 11.5 27.7 ± 10.6 P = 0.60
  Years professional playing in orchestra 14.2 ± 12.7 11.4 ± 10.3 P = 0.51
  Hours played in orchestra per week 15.7 ± 6.1 12.9 ± 7.6 P = 0.26
  Hours played outside orchestra per week 20.7 ± 11.4 21.5 ± 12.2 P = 0.85
  Total hours played per week 36.4 ± 8.4 34.3 ± 10.6 P = 0.56
Occupation (n)  
  Full-time orchestral musician 8 9  
  Freelance orchestral musician 4 2  
 Student 3 4  
Instrument group (n)  
  Upper strings 5 4  
  Lower strings 5 5  
 Woodwinds 3 3  
 Brass 2 2  
 Percussion 0 1  
PRMD prevalence (MPIIQM), n (%)  
  Lifetime prevalence 10 (66.7) 13 (86.7)  
  One-year prevalence 8 (53.3) 8 (53.3)  
  One-month prevalence 4 (26.7) 6 (40)  
  Point prevalence 2 (13.3) 4 (26.7)  
PRMD prevalence (MPIIQM) (%) All participants (n = 30)  
  Lifetime prevalence 76.7 (23/30)  
  One-year prevalence 53.3 (16/30)  
  One-month prevalence 33.3 (10/30)  
  Point prevalence 20 (6/30)  

F: female; M: male; PRMD: performance-related musculoskeletal disorder; MPIIQM: Musculoskeletal Pain Intensity and Interfer-
ence Questionnaire for professional orchestra Musicians.

further consultation and no prescribed medications
were reported, and no injuries were developed.
Slight increases in pain in three subjects during
home exercise sessions were alleviated upon cor-
rection of their technique during the following
supervised session.
Analysis of the primary outcome (MPIIQM)
revealed significant group-time interactions for
both the pain intensity (partial η2 = 0.166; P = 0.025)
and pain interference (partial η2 = 0.186; P = 0.017)
scales. Post hoc analysis confirmed significant
improvement in the exercise group following the
rehabilitation program and stability in the control
group (Table 2). When analyzing change scores,
Glass’ Δ effect sizes were: –0.89 (P = 0.025) for
pain intensity and −1.01 (P = 0.017) for pain
interference.
Participants’ perceived change is presented in
Table 2. Two-sample tests for equality of propor-
tions with continuity correction showed that
improvement scores of “moderately better” (+4)
and higher were indicated by a significantly greater
1662 Clinical Rehabilitation 32(12)
Table 2.  Group scores and treatment effects: symptoms, functional limitations, and perceived change.
MPIIQM pain intensity
  T0 (mean ± SD)
  T1 (mean ± SD)
  Mean score change from baseline to T1
  Effect size (partial η2)
MPIIQM pain interference
  T0 (mean ± SD)
  T1 (mean ± SD)
  Mean score change from baseline to T1
  Effect size (partial η2)
GRC: change in condition at T1 (n)
 Improved
 Same
 Deteriorated
MPIIQM: Musculoskeletal Pain Intensity and Interference Questionnaire for professional orchestra Musicians; GRC: global rating of
change; T0: baseline; T1: 11-week evaluation.
Mean score change data presented as mean ± SD.
*Statistically significant change in mean score from baseline to T1 (P < 0.05).
proportion of exercise group participants (73.3%)
compared to the control group (26.7%; P = 0.028).
Data from the NMQ showed that the shoulders
were the most commonly painful area in the last
week (n = 21 at baseline), followed by the neck
(n = 16 at baseline). These regions were conse-
quently chosen for statistical analysis. The “Global”
prevalence and frequency were also analyzed,
where the former refers to the prevalence of symp-
toms in the last week for all regions of the body
combined, and the latter is each participant’s maxi-
mal frequency of symptoms anywhere in the body.
The nparLD analyses for the neck, shoulder, and
global prevalence and frequency demonstrated no
statistically significant difference between the
groups and no significant changes from baseline
(P > 0.05; Table 3).
Discussion
In this pilot randomized controlled trial, the effect of a
musician-specific rehabilitation program comprising
exercises combined with education on healthy prac-
tice habits and injury prevention was evaluated in
professional and conservatory orchestral musicians.
Control (n = 15) Exercise (n = 15)
 
8.60 ± 4.75 9.33 ± 5.89
9.00 ± 6.47 5.27 ± 5.04
0.40 ± 5.04, P = 0.763 −4.07 ± 5.31*, P = 0.010
0.007   0.386
 
7.47 ± 6.79 12.00 ± 10.56
7.67 ± 11.60 3.00 ± 4.66
0.20 ± 9.10, P = 0.933 −9.00 ± 10.73*, P = 0.006
0.001   0.430
 
5  15
6   0
4   0
Analyses suggest that the studied program is effective
in decreasing performance-related musculoskeletal
symptom intensity and functional limitations, as well
as allowing improvement to be perceived by the
musicians, but symptoms remained present, with no
significant effect on symptom prevalence or fre-
quency over an 11-week period. The high adherence,
0% drop-out rate and lack of injury indicate that the
program is feasible for use in other orchestral popula-
tions, and may realistically be evaluated with a larger-
scale clinical trial.
Due to the cyclical nature of this population’s
musculoskeletal symptoms, which tend to increase
during busy periods and decrease when the work-
load is lighter, the program may be considered both
preventive and interventive, which explains the
inclusion of musicians with and without perfor-
mance-related musculoskeletal disorders in this
study. Similarly, the project was effectuated from
the first third to the very end of the orchestral sea-
son, to consider the effect of the program when
symptoms are usually at their most intense. The
inclusion of pain-free participants may, however,
have increased the variability of our data, making it
more difficult to see significant changes.
Roos and Roy 1663

Table 3.  Group scores for symptom prevalence and variables, and results of these studies are highly
frequency (NMQ). heterogeneous, yet there does seem to be a trend in
Prevalenceb Frequencya which postural strengthening and musician-spe-
cific exercises are more effective in decreasing
  3 2 1 0 performance-related musculoskeletal symptoms
Exercise (n)   than other forms of exercise. Although a larger-
  Global T0c 14/14 10 3 1 0 scale trial is still needed, our results support the
  Global T1 14/15 10 1 3 1 idea that clinicians working with this population
  Shoulder T0 12/14 6 3 2 3 should consider focusing on postural strengthen-
  Shoulder T1 7/15 6 2 4 3 ing, control, and endurance exercises, with particu-
  Neck T0 9/14 4 3 2 3 lar emphasis on training in dynamic postures
  Neck T1 6/15 4 3 3 5 specific to the instrument, adding resistance to
  Low back T0 3/14 3 0 6 5 emulate its weight.
  Low back T1 5/15 1 2 4 8 A growing awareness that musicians lack and
Control (n)   need education pertaining to physical health has
  Global T0 13/15 8 6 0 1 seen the implementation of injury prevention and
  Global T1 13/15 9 2 4 0 general health courses in a number of undergradu-
  Shoulder T0 9/15 4 4 3 4 ate and conservatory programs, with positive
  Shoulder T1 8/15 6 0 5 4 results on physical and psychological health.28,30,31
  Neck T0 7/15 4 3 3 5 The combination of exercise and education, how-
  Neck T1 7/15 6 2 2 5 ever, has rarely been studied. The role of the educa-
  Low back T0 8/15 6 2 3 4 tional aspect of this study in the decrease in
  Low back T1 5/15 5 1 1 8 symptom severity and functional limitations is
NMQ: Nordic Musculoskeletal Questionnaire; T0: baseline; unknown, but education per se is believed to be of
T1: 11-week evaluation. great importance in the prevention and manage-
Symptoms in other regions of the body were not prevalent ment of playing-related problems.6,32
and thus were not included in the table.
aNMQ frequency legend: 0 = never, 1 = once/a few times This study population was heterogeneous,
over the past three months, 2 = once/a few times per month, which is an intrinsic characteristic of all orchestral
3 = once/a few times per week. communities. Different instruments require not
bPrevalence in the last week.
cOne exercise group participant did not complete the NMQ
only varying postures and playing techniques, but
at baseline. also greatly contrasting hours of playing, both in
terms of individual practice hours and hours play-
ing in the orchestra. We aimed to limit the negative
The significant improvement in symptom inten- effects of the heterogeneity of the subjects by strat-
sity seen in the exercise group is consistent with ifying the groups according to establishment and
Chan et al.’s10,11 findings when testing their exer- instrument category. We believe that this approach
cise program in group session and DVD forms, allowed us to maximize the positive aspect of the
which demonstrated a significant decrease in heterogeneity, which is its external validity, and
symptom frequency and intensity immediately fol- hence its pertinence and flexibility for use in a vari-
lowing the intervention. Another study in profes- ety of musical populations.
sional orchestra musicians evaluating an A limitation of this study is the follow-up period
intervention that included some musician-specific of only 11 weeks, as the retention of study effects
movement principles also demonstrated a decrease was not evaluated and as a change in symptom
in symptoms.28 Further studies evaluating the prevalence and frequency may have required more
effect of exercises in musicians used forms of exer- time to be detected. Although no studies evaluating
cise less specific to this population, with variable the effect of exercise interventions on performance-
results.12,13,29 The populations, interventions, related musculoskeletal disorder prevalence in
1664 Clinical Rehabilitation 32(12)
musicians were found, a similar study in helicopter
pilots demonstrated a significant decrease in fre-
quency and prevalence of symptoms (measured by
the NMQ) 12 months after baseline, as opposed to
directly following the intervention.33 A third evalu-
ation session, 6–12  months following baseline,
may have revealed such an effect.
Our results support the need and feasibility of a
larger clinical trial to further evaluate the effects of
the studied rehabilitation program. Such a trial
would require a sample size of 30 participants per
group (total of 60) at 95% power (alpha = 0.05) for
similar results to this study (G*Power software).34
The trial should have a follow-up of at least six
months, preserve the education and exercise com-
ponents of the program, and its timing in relation
to the orchestral season should be carefully con-
sidered (e.g. in the northern hemisphere: interven-
tion period from October to December and
follow-up until May). Still, the results of this trial
combined with those of previous studies already
justify the use of education as well as postural and
musician-specific exercises in the clinical
approach to performance-related musculoskeletal
disorders.
Clinical messages
•• A rehabilitation program comprising
education and postural exercise decreased
the intensity and functional impact of
performance-related musculoskeletal
disorders in orchestral musicians.
•• A large-scale randomized controlled trial
of 30 participants per group with long-
term follow-up is warranted in order to
further evaluate the effects of the
program.
Acknowledgements
The authors would like to thank all the musicians who
participated in the study, as well as Jean Leblond for his
assistance in the statistical analysis. M.R. and J.-S.R.
both played integral roles in the initiation, design, and
realization of the study, as well as in writing the article.
M.R. prepared the intervention and was the treating ther-
apist, while J.-S.R. played the role of director and is the
guarantor of the project.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publica-
tion of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
References
1. Paarup HM, Baelum J, Manniche C, et al. Occurrence
and co-existence of localized musculoskeletal symptoms
and findings in work-attending orchestra musicians—an
exploratory cross-sectional study. BMC Res Notes 2012;
5: 541.
2. Ackermann B, Driscoll T and Kenny DT.
Musculoskeletal pain and injury in professional orches-
tral musicians in Australia. Med Probl Perform Art
2012; 27(4): 181–187.
3. Kok LM, Huisstede BMA, Voorn VMA, et al. The occur-
rence of musculoskeletal complaints among professional
musicians: a systematic review. Int Arch Occup Environ
Health 2016; 89(3): 373–396.
4. Zaza C. Playing-related musculoskeletal disorders in
musicians: a systematic review of incidence and preva-
lence. CMAJ 1998; 158(8): 1019–1025.
5. Hoppmann RA and Patrone NA. A review of muscu-
loskeletal problems in instrumental musicians. Semin
Arthritis Rheum 1989; 19(2): 117–126.
6. Chan C and Ackermann B. Evidence-informed physical
therapy management of performance-related musculo-
skeletal disorders in musicians. Front Psychol 2014; 5:
706.
7. Rennie-Salonen B and De Villiers F. Towards a model for
musicians’ occupational health education at tertiary level
in South Africa. Muziki 2016; 13(2): 130–151.
8. Chesky K, Dawson W and Manchester R. Health promo-
tion in schools of music: initial recommendations. ITG J
2007; 31(2): 55–59.
9. Chan C, Driscoll T and Ackermann B. Development of
a specific exercise programme for professional orchestral
musicians. Inj Prev 2013; 19(4): 257–263.
10. Chan C, Driscoll T and Ackermann BJ. Effect of a musi-
cians’ exercise intervention on performance-related mus-
culoskeletal disorders. Med Probl Perform Art 2014;
29(4): 181–188.
11. Chan C, Driscoll T and Ackermann B. Exercise DVD
effect on musculoskeletal disorders in professional
orchestral musicians. Occup Med 2014; 64(1): 23–30.
12. Nygaard Andersen L, Mann S, Juul-Kristensen B, et al.
Comparing the impact of specific strength training vs gen-
eral fitness training on professional symphony orchestra
musicians: a feasibility study. Med Probl Perform Art
2017; 32(2): 94–100.
Roos and Roy 1665
13. Ackermann B, Adams R and Marshall E. Strength or
endurance training for undergraduate music majors at a
university? Med Probl Perform Ar 2002; 17: 33–41.
14. Berque P, Gray H and McFadyen A. Development and
psychometric evaluation of the musculoskeletal pain
intensity and interference questionnaire for profes-
sional orchestra musicians. Man Ther 2014; 19(6):
575–588.
15. Kuorinka I, Jonsson B, Kilbom A, et al. Standardised
Nordic questionnaires for the analysis of musculoskeletal
symptoms. Appl Ergon 1987; 18(3): 233–237.
16. Baron S, Hales T and Hurrell J. Evaluation of symptom
surveys for occupational musculoskeletal disorders. Am J
Ind Med 1996; 29(6): 609–617.
17. Jaeschke R, Singer J and Guyatt GH. Measurement
of health status. Ascertaining the minimal clinically
important difference. Control Clin Trials 1989; 10(4):
407–415.
18. Kamper SJ, Maher CG and Mackay G. Global rating of
change scales: a review of strengths and weaknesses and
considerations for design. J Man Manip Ther 2009; 17(3):
163–170.
19. Rietveld ABMB. Dancers’ and musicians’ injuries. Clin
Rheumatol 2013; 32(4): 425–434.
20. Quarrier NF. Performing arts medicine: the musical ath-
lete. J Orthop Sports Phys Ther 1993; 17(2): 90–95.
21. Lethem J, Slade PD, Troup JD, et al. Outline of a fear-
avoidance model of exaggerated pain perception–I. Behav
Res Ther 1983; 21(4): 401–408.
22. Lederman RJ. Neuromuscular and musculoskeletal prob-
lems in instrumental musicians. Muscle Nerve 2003;
27(5): 549–561.
23. Dommerholt J. Performing arts medicine—instrumental-
ist musicians: part III—case histories. J Bodyw Mov Ther
2010; 14(2): 127–138.
24. Toledo SD, Nadler SF, Norris RN, et al. Sports and
performing arts medicine. 5. Issues relating to musi-
cians. Arch Phys Med Rehabil 2004; 85(3 Suppl. 1):
S72-S74.
25. The Running Clinic. Mechanical stress quantification,
2017, https://therunningclinic.com/mechanical-stress-
quantification/
26. Canadian Society for Exercise Physiology. Canadian
physical activity guidelines for adults 18–64 years, 2017,
http://csepguidelines.ca/wp-content/themes/csep2017/
pdf/CSEP_PAGuidelines_adults_en.pdf
27. Noguchi K, Gel YR, Brunner E, et al. nparLD: an R soft-
ware package for the nonparametric analysis of longitu-
dinal data in factorial experiments. J Stat Software 2012;
1(12): 1–23.
28. Spahn C, Hildebrandt H and Seidenglanz K. Effectiveness
of a prophylactic course to prevent playing-related health
problems of music students. Med Probl Perform Ar 2001;
16(1): 24–31.
29. Kava KS, Larson CA, Stiller CH, et al. Trunk endurance
exercise and the effect on instrumental performance: a
preliminary study comparing Pilates exercise and a trunk
and proximal upper extremity endurance exercise pro-
gram. Music Perform Res 2010; 3: 1–30.
30. Martín López T and Farías Martínez J. Strategies to pro-
mote health and prevent musculoskeletal injuries in stu-
dents from the high conservatory of music of Salamanca,
Spain. Med Probl Perform Art 2013; 28(2): 100–106.
31. Barton R and Feinberg JR. Effectiveness of an educa-
tional program in health promotion and injury prevention
for freshman music majors. Med Probl Perform Art 2008;
23(2): 47–53.
32. Gasenzer ER, Klumpp MJ, Pieper D, et al. The prevalence
of chronic pain in orchestra musicians. Ger Med Sci 2017;
15: Doc01.
33. Ang BO, Monnier A and Harms-Ringdahl K. Neck/
shoulder exercise for neck pain in air force helicopter
pilots: a randomized controlled trial. Spine 2009; 34(16):
E544–E551.
34. Faul F, Erdfelder E, Lang A-G, et al. G*Power 3: A flex-
ible statistical power analysis program for the social,
behavioral, and biomedical sciences. Behav Res Methods
2007; 39: 175–191.