Article

Playing-Related Musculoskeletal Problems Among

Professional Orchestra Musicians in Scotland
A Prevalence Study Using a Validated Instrument,
The Musculoskeletal Pain Intensity and Interference Questionnaire
for Musicians (MPIIQM)
Patrice Berque, MSc, BSc(Hons), MMACP, MCSP,a,b Heather Gray, Prof D, MSc, BSc,
MCSP,a and Angus McFadyen, PhDc

Many epidemiological surveys on playing-related muscu-

loskeletal problems (PRMPs) have been carried out on
professional musicians, but none have evaluated or con-
firmed the psychometric properties of the instruments
that were used. The aim of the present study was to eval-
uate the prevalence of PRMPs among professional
orchestra musicians and to gather information on pain
intensity and pain interference on function and psychoso-
cial variables, using a self-report instrument developed
and validated specifically for a population of professional
orchestra musicians. METHODS: Out of 183 professional
orchestra players, 101 took part in the study (55%
response rate) and completed the Musculoskeletal Pain
Intensity and Interference Questionnaire for Musicians
(MPIIQM). RESULTS: Lifetime prevalence of PRMPs was
77.2%, 1-year prevalence was 45.5%, and point prevalence
was 36.6%. Of the PRMP group, 43% reported having pain
in three or more locations, most commonly the right
upper limb, neck, and left forearm and elbow. However,
predominant sites of PRMPs varied between instrument
groups. The mean pain intensity score for the PRMP
group was 12.4±7.63 (out of 40). The mean pain interfer-
ence score was 15.2±12.39 (out of 50), increasing signifi-
cantly with the number of reported pain locations
(F=3.009, p=0.044). CONCLUSION: This study confirms
that musculoskeletal complaints are common in elite pro-
fessional musicians and that the use of an operational
definition and a validated self-report instrument allows
for more accurate and meaningful estimates of pain
prevalence. Med Probl Perform Art 2016; 31(2):78–86.
From the aSchool of Health and Life Sciences, Glasgow Cale-
donian University; bDepartment of Physiotherapy, Glasgow
Royal Infirmary; and cAKM-STATS, Glasgow, Scotland, UK.
The authors declare no funding or conflicts of interest.
Address for correspondence: Mr. Patrice Berque, Dep. of
Physiotherapy, Glasgow Royal Infirmary, Alexandra Parade,
Glasgow G31 2ER, Scotland. Tel +44 1360 621896.
patrice.berque@btinternet.com.
http://dx.doi.org/10.21091/mppa.2016.2015.
© 2016 Science & Medicine. www.sciandmed.com/mppa.
T he prevalence of musculoskeletal disorders is high
among workers who require that certain bodily move-
ments and positions be used in a repetitive manner.1-4 Mus-
culoskeletal (MSK) problems among professional musi-
cians are, in most ways, no different from musculoskeletal
problems associated with any other occupation, and a
recent systematic review of pain prevalence in instrumen-
talist musicians5 revealed a high prevalence in the lower
back, neck, shoulder, and hand. Although it can be diffi-
cult to differentiate between MSK problems “caused” by
playing and those “interfering” with playing,6 a recent
study comparing MSK complaints of tertiary music stu-
dents and non-musicians (medical students) in The Nether-
lands7 showed that music students reported a statistically
significant higher prevalence of MSK complaints (89.2% vs
77.9%, p=0.019). Another study in Denmark showed, using
an indirect comparison with the Danish workforce popula-
tion, that symphony orchestra musicians had a higher
prevalence of MSK complaints in both genders.8
Heterogeneity of Studies on
Prevalence of PRMDs
Numerous prevalence studies on playing-related muscu-
loskeletal disorders (PRMDs) affecting musicians have
been carried out worldwide. In 1998, a systematic review
addressed the incidence and prevalence of PRMDs in clas-
sically-trained musicians.3 The author highlighted the
weaknesses of the studies, i.e., the lack of an operational
definition of the observed outcome, low response rates,
measurement bias, reporting errors, and omissions. Never-
theless, the author found that the prevalence of PRMDs
ranged from 39% to 87% in adults. The prevalence estimate
was narrowed (between 39% and 47%) when mild and tran-
sient complaints were excluded, with PRMDs defined as
“pain, weakness, numbness, tingling, or other symptoms
that interfere with (their) ability to play (their) instrument
at the level (they) are accustomed to.”9

78 Medical Problems of Performing Artists


Prevalence of PRMDs Among Professional
Orchestra Musicians
Since the systematic review by Zaza,3 more recent epidemi-
ological surveys have been carried out among professional
orchestra musicians6,8,10–16 in order to ascertain prevalence
rates of, and risk factors associated with, PRMDs: i.e.,
female gender, anthropometrics, age, instrument type,
location of pain, playing conditions, poor playing posture,
lack of physical conditioning, music exposure and over-
load, lack of preventative behaviours, psychosocial stres-
sors (performance anxiety, depression, personality traits,
work-related stress).11,17–20
Two recent systematic reviews5,17 revealed the same lim-
itations and methodological weaknesses noted by Zaza3:
i.e., questionnaires were not validated; inconsistent, poorly
described, and deficient in collecting psychosocial factors;
operational definitions of pain were either absent or incon-
sistent between studies; methodological approaches dif-
fered greatly between studies. Despite this heterogeneity,
Silva et al.5 attempted a meta-analysis, indicating a 1-year
prevalence of “pain in general” of 75% among professional
orchestra musicians. The figure was reduced to 54% when
accounting only for “pain affecting playing capacity.”
Finally, Silva et al.5 concluded that it would be essential
to use validated questionnaires in order to assess pain inten-
sity and its impact on function and psychosocial variables.
Indeed, very few of the prevalence studies on orchestra
musicians conducted to date have used existing validated
instruments to measure MSK pain, and, if used, no attempt
was made to evaluate or confirm the psychometric proper-
ties of these instruments in a population of musicians.
MUSCULOSKELETAL PAIN INTENSITY
AND INTERFERENCE QUESTIONNAIRE
FOR MUSICIANS (MPIIQM)
Structure of the MPIIQM
Following a detailed literature review which revealed a
lack of validated instruments specifically designed for a
population of musicians, the present authors21 developed
and validated a new biopsychosocial self-report instru-
ment for professional orchestra musicians, collecting
demographic data on age, gender, and practice habits;
prevalence of MSK pain and problems; pain location; pain
intensity; impact of pain on function (pain activity inter-
ference) and on psychosocial and affective variables (pain
affective interference). The MPIIQM addressed several of
the biopsychosocial components set out in the International
Classification of Functioning, Disability and Health (ICF)22
and was designed to have evaluative qualities, i.e., the abil-
ity to detect change over time.23
The operational definition of PRMD developed by Zaza
et al.9 was used explicitly for the prevalence questions, with
the wording being slightly modified by using the words
TABLE 1. Factor Structure and Factor Loadings for the 9-Item
Solution of the MPIIQM Following Exploratory Factor Analysis*
Factor 1: Factor 2:
Pain Intensity Pain Interference
Worst pain 0.830
Least pain 0.814
Average pain 0.979
Pain right now 0.783
Mood 0.848
Enjoyment of life 0.818
Using your usual technique 0.797
Playing because of symptoms 0.695
Playing as well as you would like 0.895
* Principal axis factoring with oblique rotation (direct oblimin).
pain/problems instead of pain alone to accommodate most
musculoskeletal conditions,24 including painless syndromes
such as musicians’ dystonia21,25,26 and symptoms for which
a diagnosis cannot be made. The authors will therefore
now refer to playing-related musculoskeletal problems
(PRMPs) rather than PRMDs in the remainder of the text.
Nine items, using 11-point numerical rating scales,
measured pain intensity and pain interference21 (Table 1).
The four pain intensity items were from the Brief Pain
Inventory (BPI).27,28 The pain interference items comprised
two items from the BPI, representing the impact of pain on
psychosocial variables (pain affective interference), and
three items from the optional performing arts and sports
module of the Disabilities of the Arm, Shoulder, and Hand
(DASH) questionnaire,29 representing the impact of pain
on function (pain activity interference). The pain intensity
score was expressed as the sum of the four pain intensity
items (0–40), and the pain interference score as the sum of
the five pain interference items (0–50).
Psychometric Properties of the MPIIQM
The COSMIN checklist was followed at every stage of
instrument development and psychometric testing.30,31
Face and content validity were ascertained by expert
panels who reviewed the relevance, comprehensiveness,
and clarity of the MPIIQM.
The results from exploratory factor analysis demon-
strated that the MPIIQM had a strong and stable two-
factor structure, with high factor loadings (Table 1). The
factorial solution explained 71.3% of the variance in the
data.21 Internal consistency and test-retest reliability of the
MPIIQM were adequate, in keeping with values obtained
by studies investigating the BPI.21
Study Aims
The aim of the present study was to evaluate the preva-
lence of PRMPs among professional orchestra musicians
in Scotland, and to gather information about pain inten-
sity, pain activity interference, and pain affective interfer-
ence using the MPIIQM.
June 2016    79
 TABLE 2. Participants by Orchestra and Instrument Group
Upper Lower
Strings Strings Woodwind
Orchestra 1 25 3 2
Orchestra 2 19 13 8 7
Orchestra 3 8 5 4 2
Total (n) 52 21 14
Total (%) 51.4% 20.8% 13.9%
METHODS
The study was conducted in accordance with the guide-
lines of the Declaration of Helsinki,32 and was approved
by the Research Ethics Committee of the School of Health
and Life Sciences at Glasgow Caledonia University. A
meeting with the musicians was organised by each orches-
tra manager. During the meeting, one of the researchers
(PB) explained the aims of the study, emphasised that par-
ticipation was voluntary and that anonymity was
respected, and an information leaflet was given to all
orchestra players. Participants gave their informed con-
sent prior to their inclusion in the study.
Participants
Of the four professional classical orchestras in Scotland,
three agreed to take part in the study. Only the permanent
members of those three orchestras were eligible to partici-
pate (n=183). Freelance players, who may have very vari-
able timetables and workloads and may perform a wider
type of repertoire, therefore were excluded.33
Questionnaire and Data Collection
The MPIIQM, the psychometric properties of which are
described in detail elsewhere,21 was used to collect all study
data. A second meeting with the musicians was organised
to administer the questionnaire. Return of the question-
naire to the researcher was deemed proof of consent. Data
were collected over a 4-month period.
Statistical Analysis
The data were coded prior to statistical analysis. Classes
regarding musical instruments and anatomical sites were
chosen with reference to recent prevalence studies for con-
sistency.6,15,34 IBM SPSS Statistics for Windows, version
22.0. (IBM SPSS Corp., Armonk, NY, USA), was used for
all analyses.
After testing for normal distribution of the data, differ-
ences between the PRMP and non-PRMP groups were
assessed using either the independent sample t-test or the
Mann-Whitney U-test, with associations being assessed
using the chi-squared test.35 Differences in pain intensity
and pain interference scores according to gender, instru-
80 Medical Problems of Performing Artists
Percussion
Brass & Timpani Total (n) Total (%)
1 2 33 32.7%
2 49 48.5%
0 19 18.8%
10 4 101 100.0%
9.9% 4.0% 100.0%
ment groups, and number of reported pain locations were
assessed using independent sample t-tests and one-way
analysis of variances (ANOVA), respectively. Diagnostics
were performed to confirm normality and homoscedastic-
ity.35 All tests were performed using a 5% level of signifi-
cance (α=0.05).
RESULTS
Participants’ Characteristics
Of the 183 professional orchestra musicians eligible to par-
ticipate in the study, 101 completed the MPIIQM, for a
55% overall response rate. The most common instrument
groups were upper strings (51.4%), followed by lower
strings (20.8%), woodwind (13.9%), brass (9.9%), and percus-
sion (4%) (Table 2). There were no tuba or harp players rep-
resented in the sample.
The sample was almost evenly split between males
(50.5%) and females (49.5%). The mean age of participants
was 47.7±10.4 (SD) yrs (range 25–65 yrs), with the vast
majority (93.1%) of orchestra musicians working full time.
The musicians had played professionally in an orches-
tra for a mean of 23.5±11.1 yrs. On average, orchestra
duties amounted to 24.5±5.0 hrs of playing per week, to
which another 8.4±4.9 hrs of playing per week were added,
representing personal practice, teaching, and any other
engagements outside the orchestra.
Table 3 summarises the characteristics of the partici-
pants, when divided in PRMP and non-PRMP groups.
There was a statistically significant difference in the mean
age (t=2.21, p=0.029) of the two groups, with participants in
the PRMP group being almost 5 yrs older than those in the
non-PRMP group (Table 3). There also was a statistically
significant difference between the two groups in the aver-
age number of years of playing professionally in an orches-
tra (Z=–1.99, p=0.046), with participants in the PRMP group
having played professionally in an orchestra for almost 5
yrs more than those in the non-PRMP group (Table 3).
PRMP Prevalence Rates
The majority of the participants, at some point in their
career, had experienced PRMPs: lifetime prevalence was
77.2% (n=78), with 45.5% of respondents (n=46) experienc-
ing PRMPs in the past 12 months.
 TABLE 3. Participants’ Characteristics According to Presence or Absence of PRMPs
With PRMPs Without PRMPs
(n=37) (n=64) t* Z† χ2 ‡ p-Value

Gender, M:F (n) 16:21 35:29 0.81 0.367

Age 49.6 (8.93) 45.0 (10.83) 2.21 0.029
Years of playing the instrument 38.7 (8.07) 35.6 (10.08) 1.56 0.121
Years of professional playing in an orchestra 26.4 (9.81) 21.9 (11.59) –1.99 0.046
Weekly hours of playing in the orchestra 26.2 (4.90) 23.6 (4.88) –1.77 0.076
Weekly hours of playing outside the orchestra 8.3 (3.99) 8.4 (5.41) –0.36 0.722
Total weekly hours of playing 34.9 (7.07) 32.1 (7.30) –1.43 0.152
Data given as mean (SD), except for gender. Values in bold are statistically significant.
*Independent t-test: data normally distributed.
†Mann Whitney U test: data not normally distributed.
‡Chi-square test for independence with continuity correction.

Of those who responded, 36.6% of musicians (n=37)
reported having PRMPs at the time of the study. This
point prevalence figure consisted of 5% (n=5) reporting
PRMPs in one location, 15.8% (n=16) in two locations, and
15.8% (n=16) in three or more locations. By gender, 68.8%
of males (n=11) reported two or less pain sites, whilst 52.4%
of the females (n=11) reported three or more sites; however,
this relationship was not statistically significant (χ2=2.571,
p=0.463).
The most commonly reported locations for PRMPs
were the right forearm/elbow (14.9%), neck (13.9%), right
shoulder/upper arm (12.9%), right wrist/hand (11.9%),
and left forearm/elbow (11.9%) (Table 4).
When considering the locations of PRMPs with respect
to specific instrument groups, several trends emerged,
which are shown in Table 5. Upper string players reported
most problems in the right and left upper limbs and the
neck. Lower string players reported most problems as
being equally distributed between the left and right upper
limbs. Woodwind players reported most problems in sev-
eral parts of the right upper limb, the upper back, and
mouth. Brass players reported most problems in the neck,
lower back, and left shoulder/upper arm. In this sample,
percussion and timpani players did not complain of any
problems.
p=0.098). There was, however, a slightly statistically signif-
icant difference when considering pain interference across
the reported pain location categories (F=3.009, p=0.044),
with an increase in the mean pain interference score from
6.8 for one reported pain location to 22.0 for four or more
reported pain locations (Table 6).
DISCUSSION
PRMP Prevalence Rates
Lifetime Prevalence of PRMPs
The overall questionnaire response rate (55%) was in keep-
ing with several larger scale studies carried out with profes-
sional orchestra musicians.13,15,16,36 Lifetime prevalence
was 77.2%, indicating that the vast majority of orchestra
musicians had, at some point in their career, experienced
PRMPs that were severe enough to interfere with playing
their instrument at their usual level. This was in agreement
with recent studies on professional orchestra musicians
that reported lifetime prevalence of 81.3%, 84.4%, and
89.5% respectively.6,14,16

Pain Intensity and Pain Interference Scores

TABLE 4. Prevalence of PRMPs by Anatomical Site Expressed
in Numbers and Percentages
Table 6 summarises the mean scores for the PRMP group
Males Females Total Total*
for the two constructs pain intensity and pain interference Anatomical Site (n=51) (n=50) (n=101) (%)
of the MPIIQM. The PRMP group mean pain intensity
score was 12.4±7.63, and the mean pain interference score Right forearm and elbow 4 11 15 14.9
Neck 6 8 14 13.9
was 15.2±12.39. Right shoulder and upper arm 2 11 13 12.9
There were no statistically significant differences Right wrist and hand 5 7 12 11.9
between males and females for the pain intensity and pain Left forearm and elbow 6 6 12 11.9
interference scores (Table 6). Statistical significance was, Left shoulder and upper arm 4 6 10 9.9
however, almost reached for the mean pain interference Left wrist and hand 4 4 8 7.9
Lower back 4 4 8 7.9
score between males (10.9±10.82) and females (18.5±12.75). Upper back 4 3 7 6.9
There were no statistically significant differences between Right lower limb 0 4 4 4.0
instrument groups in either of the two constructs. Left lower limb 0 3 3 3.0
A one-way ANOVA revealed no significant differences Head, face, lips 0 3 3 3.0
in pain intensity across pain location categories (F=2.277, *Results expressed in percentage of the total sample (n=101).

June 2016    81
 TABLE 5. Prevalence of PRMPs by Anatomical Site and Instrument Group*
Upper Strings Lower Strings Woodwind Brass Percussion & Timpani
Anatomical Site (n=52) (n=21) (n=14) (n=10) (n=4)
Right forearm and elbow 19.2 9.5 21.4 – –
Neck 17.3 4.8 7.1 30.0 –
Right shoulder and upper arm 13.5 9.5 21.4 10.0 –
Right wrist and hand 9.6 9.5 28.6 10.0 –
Left forearm and elbow 17.3 9.5 7.1 – –
Left shoulder and upper arm 11.5 9.5 – 20.0 –
Left wrist and hand 9.6 4.8 7.1 10.0 –
Lower back 5.8 4.8 7.1 30.0 –
Upper back 7.7 – 14.3 10.0 –
Right lower limb 5.8 4.8 – – –
Left lower limb 5.8 – – – –
Head, face, lips 1.9 – 14.3 – –
*Results expressed in percentage of each instrument group.

1-Year Prevalence of PRMPs
The 1-year PRMP prevalence rate of 45.5% obtained in the
present study was in keeping with two other studies that
reported prevalence rates of 52% and 41%, respectively,
when a definition of pain encompassing either “pain
affecting playing capacity”12 or “disabling pain”15 was
used. Studies that did not use an operational definition,
with pain being loosely defined as “trouble, ache, pain, or
discomfort,”8 were unable to exclude mild and transient
complaints, resulting in inflated 1-year prevalence rates
exceeding 83%,8 making differences between studies diffi-
cult and often meaningless, especially when trying to carry
out a meta-analysis of pain prevalence.3,5,16
Point Prevalence of PRMPs
Point prevalence for the present study was 36.6%, which is
lower than prevalence rates reported in other studies.
Recent studies on professional orchestra musicians
reported point prevalence rates with large variations and
significant heterogeneity between studies,5 ranging
between 61% and 86%8,12,13 when an operational definition
of PRMPs was not used, in contrast with studies reporting
rates of 50% with a definition of PRMPs excluding mild
and transient complaints.6,11,13
The lower point prevalence rate obtained in the present
study could be partly explained by the wording of the
prevalence questions, which reproduced the full definition
of PRMP in each of the prevalence questions in order to
avoid bias.21 The point prevalence rate obtained (36.6%) is
indeed close to the range of 39% to 47% obtained by Zaza3
in her systematic review, when mild and transient com-
plaints were excluded.
Conflicting Findings Regarding Potential Risk Factors
of PRMPs
When considering potential risk factors of developing
PRMPs, previous studies on adult music students and pro-
fessional orchestra musicians have revealed that females,
string and keyboard players were significantly more likely
to develop PRMPs.8,11–13,16,17,36–39 These findings were
inconsistent with the current study, which found no statis-
tical association between PRMP and non-PRMP groups,
and gender (Table 3). A possible reason could be the small
PRMP group sample size, hence a possible lack of statisti-
cal power.
In addition, in previous studies, it was found that more
years of playing an instrument had a significant protective
effect on PRMPs, whereby musicians who had been play-
ing fewer years showed more pain and symptoms than
older musicians, and the reasons given in the literature
were survivor bias or attrition.10,11,16,17,38 The present study
revealed contrary findings, with a statistically significant
difference between groups for age and the number of years
of professional playing (Table 3) and an increased risk of
having PRMPs with increasing age or increasing number
of years of professional playing. Age and years of profes-
sional playing were, as expected, highly correlated in the
PRMP group (r=0.865, p<0.001).
These findings were, therefore, in contradiction with
previous studies that showed an opposite trend with a pro-
tective effect of age.10,11,16,17,38 The study by Yeung et al.10
had, however, a very low response rate of 23% and a very
small overall sample size (n=39), and the authors warned
that their results should therefore be taken with caution.
In the study by Zaza and Farewell,38 the sample was made
of students, orchestra musicians, and teachers rather than
orchestra musicians only. Moreover, some authors34,40
have argued that there was no consensus with respect to
age as a risk factor, with some studies on orchestra musi-
cians13 and on wider groups of professional musicians41
showing no statistical relationship between age and pres-
ence of pain.
There is significant evidence that the prevalence of
many MSK conditions increases with age (i.e., osteoarthri-
tis,42,43 rotator cuff disease,44,45 tendinopathies,46,47 degener-
ative lumbar disc disease),48 and this could partly explain
the results obtained. This justification would, however,
need to be tempered by mounting evidence suggesting a

82 Medical Problems of Performing Artists

 TABLE 6. Pain Intensity and Pain Interference Summary Statistics for the PRMP Group by Gender, Instrument Groups, and Number of
Reported Pain Locations
Pain Pain
Intensity* p-Value Interference† p-Value
Total PRMP group 12.4 (7.63) 15.2 (12.39)
Gender
Male (n=16) 12.2 (6.52) 10.9 (10.82)
Female (n=21) 12.6 (8.53) t=0.145§ 18.5 (12.75) t=0.434§
p=0.882 p=0.064
Instrument group‡
Upper strings 13.5 (7.07) 17.8 (10.47)
Lower strings 10.5 (7.89) 10.5 (11.91)
Woodwind 10.1 (10.38) 18.0 (18.49)
Brass 13.6 (6.11) F=0.486¶ 7.2 (6.22) F=1.439¶
p=0.694 p=0.249
No. of pain locations
One area (n=5) 11.0 (9.30) 6.8 (9.26)
Two areas (n=16) 9.4 (6.39) 11.7 (12.39)
Three areas (n=4) 13.7 (4.99) 19.7 (3.95)
Four areas or more (n=12) 16.5 (7.99) F=2.277¶ 22.0 (12.25) F=3.009¶
p=0.098 p=0.044
Data given as mean (SD). p-Values in bold are statistically significant.
* Scores expressed as the sum of the four pain intensity items: maximum possible score is 40.
† Scores expressed as the sum of the five pain interference items: maximum possible score is 50.
‡ There were no participants suffering from PRMPs in the percussion and timpani group.
§ Independent t-test: data normally distributed.
¶ One-way analysis of variances (ANOVA): data normally distributed.

poor correlation between the presence or absence of pain
and the extent and degree of pathological and radiological
changes in most MSK pathologies.44,49–55
Playing load, expressed as the weekly number of hours
of playing, has been associated with PRMPs in studies
involving soloists or students who reported sudden
increases in playing time prior to exams or perform-
ances,34,56,57 but not in studies with professional orchestra
musicians.10,11,13 These findings are in keeping with the
present study (Table 3): indeed, orchestra musicians have a
more regimented weekly workload with a compulsory
timetable and therefore are less likely to be subjected to
sudden increases in playing load.
Prevalence by Anatomical Site and Instrument Group
Numerous studies on adults and tertiary-level students that
have explored the location of PRMPs have revealed that
the upper limbs and neck were the most common problem
areas.34 The present study on professional orchestra musi-
cians reported the same trends (Table 4), in agreement with
the systematic review by Silva et al.5 and other prevalence
studies on orchestra musicians,6,8,13–16,36 except for the low
back region which was not one of the main areas of PRMPs
in the present study (Table 4). The small sample size of the
PRMP group (n=36) could explain this discrepancy.
When considering the number of PRMP locations
affected, only two studies on orchestra musicians investi-
gated this variable,13,16 revealing that a large proportion of
musicians suffering from PRMPs were complaining of pain
in several locations: i.e., 55% reported problems in three
locations or more,13 and 43% reported pain in more than
five regions.16 This is in keeping with the present study,
which showed that 43% of the PRMP group had pain in two
anatomical areas and 43% in three or more areas (Table 6).
Although the PRMP group was too small to carry out
statistical tests according to anatomical area, the present
study showed that females were more affected than males
in the right upper limb, left shoulder, and neck (Table 4), in
keeping with several prevalence studies that found higher
odd ratios for females in those body regions.8,15,16 Further-
more, there was a slight predominance of right upper limb
involvement (Table 4), in keeping with some studies,6,8,14
but in contradiction with others.13,16
The predominant sites varied between instrument
groups, and the trends obtained (Table 5) were in agree-
ment with other orchestra studies,6,14–16 although no statis-
tical tests were carried out due to the small PRMP group
size. These trends have been explained by the specific
physical demands of each instrument group, and pain may
result from adaptations associated with asymmetrical pos-
tures and with prolonged static and dynamic loading of
neuromusculoskeletal structures.4,8,10,16,19,34,58
Pain intensity and Pain Interference
This study is the first epidemiological study on professional
orchestra musicians to use a self-report instrument, the
MPIIQM,21 specifically developed and validated to meas-
ure MSK pain and pain interference in musicians in terms
of function and psychosocial or affective constructs. This
study, therefore, echoes recommendations made by Silva et

June 2016    83
al.5 in their systematic review with regard to using validated
questionnaires to measure pain and its impact.
The composite mean pain intensity score (four pain
items) revealed low to moderate pain intensity (12.4±7.63
out of 40, Table 6). The pain intensity scores were obtained
from musicians attending work, which may explain the low
to moderate pain severity levels: i.e., PRMPs were severe
enough to affect playing capacity, but not severe enough to
be off work. Although no direct comparison with a com-
posite score is available in other orchestra studies, this
score is in keeping with pain intensity scores obtained by
four other studies6,13,14,16 with scores ranging between 3.7
and 4.8 (out of 10), although three of those studies failed to
indicate what they were measuring (i.e., “worst pain,”
“average pain,” “pain right now,” or “least pain”).
The paucity of studies on “pain intensity” and “pain
interference” among professional orchestra musicians
highlights the need to explore the relationships between
these constructs and other variables in future orchestra
studies, as has been carried out in studies investigating
MSK pain in the general population. With regard to
gender, for instance, there is overwhelming evidence that
men and women differ in their pain experience and per-
ceptions, and that prevalence rates for many MSK condi-
tions are higher among women.59–61 Various explanations
have been given, including biological differences in the
nociceptive pain pathways with reported lower experimen-
tal pain threshold and tolerance, hormonal influences, dif-
fering psychosocial mechanisms and pain behaviours. 59–61
Stubbs et al.60 used the Brief Pain Inventory (BPI) as
their main outcome measure to investigate sex differences
in a sample of 500 primary care patients suffering from per-
sistent pain in the back, hip, or knee. These authors con-
cluded that women reported significantly worse pain
intensity and greater pain-related disability than men, with
disability being measured by the BPI interference score.
Others have shown that women are also more likely to
experience pain in multiple body areas, a factor which has
been associated with higher levels of disability and psy-
chosocial distress.59,61 The present study did not show a
statistically significant gender difference for the pain
intensity and pain interference scores, but the trend clearly
showed a higher score for pain interference for females
(Table 6). Furthermore, although no statistically significant
relationship was found between gender and the number of
reported pain sites, a greater proportion of females
reported more pain sites, with 52.4% of the females report-
ing three or more pain sites whereas 68.8% of males
reported two or less pain sites.
Pain interference measured the impact of pain and
PRMPs on function (activity interference) and on psy-
chosocial variables (affective interference). The composite
mean pain interference score, combining two affective
interference items and three activity interference items
(Table 1), revealed low to moderate pain interference
(15.2±12.39 out of 50), in keeping with the pain intensity
score (Table 6). Although no direct comparison with a
84 Medical Problems of Performing Artists
composite score is available in other orchestra studies and
given that performance anxiety was not considered in the
MPIIQM, the study by Leaver et al.15 concluded that non-
occupational risk factors including somatising tendency
and low mood were likely to have a greater impact on the
development of PRMPs than performance anxiety or psy-
chosocial aspects related to work environment. These
findings were supported by some,38 but not by others.11,13,16
With regard to activity interference, only one study
directly reported prevalence of the impact of PRMPs on
function, encompassing impaired playing and impaired
function outside work.8 Although the items described and
the statistical approach were not comparable to the pres-
ent study, Paarup et al.8 reported a high prevalence, with
females more affected than males, but found little differ-
ence between instrument groups, in keeping with the pres-
ent study (Table 6). Finally, there was a statistically signifi-
cant increase in the pain interference score with an
increase in the number of reported pain sites (Table 6); this
has not been reported before.
Study Strengths and Limitations
This study is the first prevalence study on professional
orchestra musicians to use a self-report instrument specifi-
cally developed and validated to collect data on preva-
lence of PRMPs in musicians and to measure MSK pain
intensity and pain interference within the biopsychosocial
framework of the ICF.22 Furthermore, the study used a
slightly modified version of the operational definition of
PRMPs developed by Zaza et al.,9 excluding mild and tran-
sient complaints. These qualities would contribute to the
determination of meaningful and more realistic prevalence
data on professional orchestra musicians. Furthermore,
the MPIIQM gives an opportunity to investigate the rela-
tionships between the two constructs “pain intensity” and
“pain interference” and other variables in order to
improve our understanding of PRMPs among musicians.
There were, however, several limitations. The overall
response rate of 55% was adequate with regard to other
studies, but there were variations between the three
orchestras (42%, 56%, and 70% response rates). This could
have led to selection bias and have affected the reported
prevalence rates. Furthermore, the PRMP group was small
(n=37), possibly causing a lack of generalisability compared
to large-scale studies. A lack of statistical power in detect-
ing differences, given the large variation, may explain
some of the conflicting statistical results obtained com-
pared to other studies (Tables 3 and 6).
The MPIIQM was not designed to collect information
on the presence of specific pathology in the PRMP group,
and it is therefore not possible to ascertain whether inter-
fering MSK problems were directly caused by playing the
instrument or the consequence of pre-existing pathology.
As stated in the Introduction, the operational defini-
tion used in this study excludes mild and transient symp-
toms. The non-PRMP group in this study therefore
included both asymptomatic subjects and subjects with
“mild complaints.”
Although several studies have reported a high preva-
lence of music performance anxiety among professional
orchestra musicians,11,13,16,20,36 it was neither considered in
the present study, nor included in the structure of the
MPIIQM.21 Indeed, music performance anxiety is a com-
plex construct, which can only be measured by using a
range of validated and specific psychosocial instruments
in order to capture the occurrence of various anxiety dis-
orders and the co-occurrence of anxiety and depression.20
Finally, owing to the discrepancies noted within the lit-
erature with regard to the wide variation of operational
definitions used, the lack of consensus with regard to the
risk factors of PRMPs, and the fact that mild complaints
had to be clustered with the non-PRMP group for analysis,
future studies could endeavour to clarify and define a more
widely accepted operational definition of PRMPs in order
to have more reliable, meaningful, and comparable esti-
mates of prevalence in the future.
Conclusion
The present study confirms that PRMPs are common in
professional orchestra musicians. Using an operational def-
inition of PRMP and a validated self-report instrument
made it possible to gather prevalence data which are mean-
ingful and realistic. Future studies are required to investi-
gate the interactions of the two constructs of pain intensity
and pain interference with other variables, and to compare
populations of professional musicians to other professions
involving repetitive movements and prolonged static and
dynamic loading of neuromusculoskeletal structures.
The authors thank the orchestra managers and musicians of the three
professional orchestras involved who participated in the study.
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Published online 1-June-2016
http://dx.doi.org/10.21091/mppa.2016.2015