Journal of Bodywork & Movement Therapies (2017) 21, 157e172

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REVIEW: LITERATURE REVIEW

Musicians, postural quality and

musculoskeletal health: A literature’s
review
Patricia Blanco-Piñeiro, PhD a,*, M. Pino Dı́az-Pereira, PhD b,
Aurora Martı́nez, PhD b

a
Conservatorio Superior de Música of Vigo, Manuel Olivié, no 23, Vigo, 36203, Spain
b
Department of Special Teaching, Area of Physical Education and Sports, University of Vigo, Ourense,
32004, Spain

Received 8 March 2016; received in revised form 10 June 2016; accepted 28 June 2016

KEYWORDS Summary Objective: An analysis of the salient characteristics of research papers published
Review; between 1989 and 2015 that evaluate the relationship between postural quality during musical
Musician; performance and various performance quality and health factors, with emphasis on musculo-
Postural quality; skeletal health variables.
Musculoskeletal Methods: Searches of Medline, Scopus and Google Scholar for papers that analysed the subject
disorders; of the study objective. The following MeSH descriptors were used: posture; postural balance;
Efficiency muscle, skeletal; task performance and analysis; back; and spine and music. A descriptive sta-
tistical analysis of their methodology (sample types, temporal design, and postural, health and

REVIEW: LITERATURE REVIEW

other variables analysed) and findings has been made. The inclusion criterion was that the
body postural quality of the musicians during performance was included among the target
study variables.
Results: Forty-one relevant empirical studies were found, written in English. Comparison and
analysis of their results was hampered by great disparities in measuring instruments and oper-
ationalization of variables.
Conclusions: Despite the growing interest in the relationships among these variables, the
empirical knowledge base still has many limitations, making rigorous comparative analysis
difficult.
ª 2016 Elsevier Ltd. All rights reserved.

* Corresponding author.
E-mail addresses: patricia.blanco@edu.xunta.es, pinod@uvigo.es (P. Blanco-Piñeiro).

http://dx.doi.org/10.1016/j.jbmt.2016.06.018
1360-8592/ª 2016 Elsevier Ltd. All rights reserved.
 158
Introduction
The quality of body posture in musical performers has been
investigated for its impact on their health and their inter-
pretive performance. The stress experienced by a musi-
cian’s heart during a concert performance has been likened
to that experienced by an elite athlete’s (Iñesta Mena,
2006). The psychophysical burden borne by musicians
throughout their career is frequently a source of health
problems, mostly involving the musculoskeletal system,
which can affect both quality of life and musical perfor-
mance. The prevalence of which among musicians has
variously been reported as between 25% and 93% (Viaño
Santasmarinas et al., 2010). According to some studies, a
significant percentage (37%) of musicians suffer musculo-
skeletal disorders that are sufficiently serious to affect
performance (Roset-Llobet et al., 2000).
A frequently cited risk factor for musculoskeletal disor-
ders among musicians is poor posture (Queiroz de Andrade
and Marques Fonseca, 2000; Pascarelli and Hsu, 2001; Byl
et al., 2003; Lederman, 2003; Nyman et al., 2007;
Dommerholt, 2009; Kruta De Araújo et al., 2009; Granda
Vera et al., 2011; Barczyk-Pawelec et al., 2012), which
has been studied from a medical standpoint (Pascarelli &
Hsu, 2001; Nyman et al., 2007; Bittner-Czapin
ska and
Janiszewski, 2004; Buckley and Manchester, 2006; Edling
and Fjellman-Wiklund, 2009; Johnson and Skinner, 2009;
Husseini et al., 2011) (with a view to treatment), but also
from an educational perspective (Rabuffetti et al., 2007;
Kruta De Araújo et al., 2009; McKenzie et al., 2009; Staes
et al., 2011; Akel et al., 2010a, 2010b; Steinmetz et al.,
2010; Baadjou et al., 2011; Barczyk-Pawelec et al., 2012;
Blanco-Piñeiro et al., 2015), in regard to its influence on the
quality of performance (Staes et al., 2011; Blanco and
Garcı́a Soidán, 2011; Van Der Linden et al., 2011; Lee
et al., 2012). Several authors have emphasized the need
for medical professionals and music teachers to collaborate
in postural training programmes in order to instil postural
habits that minimize risk and favour optimal performance
(Barczyk-Pawelec et al., 2012; Edling and Fjellman-
REVIEW: LITERATURE REVIEW
Wiklund, 2009).
Figure 1 Flowchart of the study selection process.
P. Blanco-Piñeiro et al.
In spite of the considerable number of studies in this
field, we know of no review papers surveying its current
situation (Lederman, 2003). To remedy this deficit, in this
paper we analyse the objectives, design and main results of
published research into the relationships among musculo-
skeletal health, the quality of performance, and postural
quality during musical performance (or interventions aimed
at improving postural quality).
Methods
Search strategy
Searches in Medline and Scopus were supplemented by
others in Cinahl, the CSIC databases IME and ISOC, Redinet,
Teseo, Proquest Dissertations, Dialnet, ERIC and Google
Scholar. We used the MeSH descriptors posture; postural
balance; muscle, skeletal; task performance and analysis;
back; and spine and music. The Medline search strings were
as follows:
(MH “Posture”) AND (MH “Music”);
(MH “Muscle, Skeletal/PH”) AND (MH “Music”);
(MH “Task Performance and Analysis”) AND (MH “Music”)
AND Posture;
(MH “Back”) AND (MH “Music”);
(MH “Spine”) AND (MH “Music”);
(MH “Postural balance”) AND (MH “Music”); and
(MH “Spine”) AND (MH “Music”) AND (MH “Posture”).
The period spanned by the search was January 1989 to
February 2015.
Study selection
The criterion for including a study in the present analysis
was that it should aim to analyse relationships between the
quality of musicians’ body posture during performance on
the one hand, and, on the other, measures of health or
physical or musical performance. Theoretical studies,
Musicians, postural quality and musculoskeletal health
reviews, articles of a popular or educational nature, and
articles not published in English were excluded. After a first
step in which some papers found by the database searches
were excluded on the basis of their titles and abstracts, the
inclusion or exclusion of the remaining candidates was
decided on the basis of a complete reading (Fig. 1).
Study characteristics recorded
Studies were characterized in terms of five categories of
feature, as follows.
1. Sample: the number, age and gender of the participants,
their musical level, and their instruments.
2. Temporal design: prospective or retrospective, and the
period covered by the study.
3. Variables of postural quality and musculoskeletal
health: the types of variable studied, the evaluation
instruments, and the body region studied.
4. Risk factors: sociodemographic, musical activity habits
or other variables considered as possibly related to
musculoskeletal health or postural quality.
5. The main results and conclusions concerning inter-
relationships among posture, musculoskeletal health,
and physical or musical performance.
Descriptive statistics were calculated using SPSS 20.0.
Results
The 41 papers satisfying the criterion for inclusion in the study
fell naturally into two groups: a) analyses of the relationships
among performing postural quality, performance-related
musculoskeletal disorders (PRMDs) and/or performance var-
iables such as instrument, practice time, or musical quality
(27 papers; Table 1); and b) studies evaluating intervention
programmes involving postural re-education or rehabilitation
(14 papers; Table 2). In the remainder of this section we report
our findings regarding each of the five categories of charac-
teristics listed in Methods.
Samples
The results presented below provide information about the
type of samples studied.
Descriptive Studies: study size ranged from 1 to 485
participating musicians (mean was 83, 11). Of the 17 studies
that reported data on participant gender, 15 included both
men and women, but among the 15 there tended to be more
women (range 0e306, mean 45.29) than men (range 0e179,
mean 39.65). Overall mean participant age in the 16 studies
in which mean age was specified was 30.53 years (SD 9.6)
years but in 6 (37.5% of these 16) mean age was greater than
35 years; the oldest reported mean age was 47.50 years. The
youngest participant in any of the 12 studies that mentioned
the range of participant ages was aged 10 years, and the
oldest 79 years. Almost all studies, 26, specified the musical
level of the participants: 12 (44, 4%) evaluated only stu-
dents; 7 (26%) musicians of various levels, from students or
amateurs to professional concert soloists; 4 (14, 8%) only
performing professionals; 2 (7, 4%) only amateurs; and 1 (3,
159
7%) music teachers. Of the 24 studies specifying the types of
instrument played by the participants, 10 (37% of all studies)
concerned a variety of types, 7 (25, 9%) only string in-
struments, 3 (11%) only brass or woodwind, 3 (11%) only sing,
and 1 (3, 7%) only piano. 6 studies including control group.
Interventional Studies: study size ranged from 1 to 150
participating musicians (mean was 45, 64). Of the 9 studies
that reported data on participant gender, 7 included both
men and women. The range of men (0e74, mean 14.88) and
women (1e75, mean 15.38) was similar. Overall mean
participant age in the 5 studies in which mean age was
specified was 32.7 years (SD 7.5); the oldest reported mean
age was 48 years. The youngest participant in any of the 5
studies that mentioned the range of participant ages was
aged 14 years, and the oldest 72 years. Almost all studies,
13, specified the musical level of the participants: 7 (50%)
musicians of various levels, from students or amateurs to
professional concert soloists; 4 (28, 6%) evaluated only
students; 1 (7%) only performing professionals; and 1 (7%)
only amateurs. Of the 13 studies specifying the types of
instrument played by the participants, 7 (50% of all studies)
concerned a variety of types, 4 (28, 6%) only string in-
struments, 1 (7%) only brass or woodwind, and 1 (7%) only
sing. 8 studies including control group but 6 not.
Temporal design
Twenty of the 27 descriptive studies (74%) evaluated the
variables they considered at only a single point in time; 3
were retrospective studies and 3 combined retrospective
data with either a prospective or a transverse study, only 1
was purely prospective. Twelve of the 14 interventional
studies were prospective, and 2 were retrospective. Of the
12 purely prospective studies (85, 7%), 6 followed partici-
pants up for between 4 and 12 weeks, only 3 specified
longer periods (15 weekse9 months), and 1 followed up two
years. Of the 2 purely retrospective studies, 1 concerned
periods of between 6 months and 3 years, and 1 period
longer than 15 years.
REVIEW: LITERATURE REVIEW
Postural and musculoskeletal health variables
Apart from postural quality, the most widely studied vari-
ables were the prevalence of PRMDs and physical compe-
tence during musical performance (Table 3). Table 4 lists
the types of procedure employed to measure postural,
physical and specifically musculoskeletal variables, and
Table 5 the body regions studied.
Risk factors
Table 6 lists variables that have been studied in any of the
27 descriptive or correlational studies of Table 1 in regard
to their possible influence on the postures and/or health
and performance of musicians. Six (22.2%) of these studies
include sociodemographic variables as possible risk factors
for PRMDs or performing posture. Twenty-three considered
variables characterizing musical activity, while 11 (40.7%)
evaluated a variety of other potential risk factors, including
ergonomic conditions during practice or rehearsals, and
physical exercise or sports involvement.
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160
Table 1 Sample size, relevant musical instruments, variables, evaluation procedures and results of the descriptive and correlational studies included in the review.
Paper Sample size, EG- Health and Other variables Evaluation Results
CGa and posture variables procedure
instrument
Bejjani and 16 trumpet players Standing postural Playing 3 notes in Expert analysis of
Data showed notable differences between the neutral posture and the
Halpern (1989) quality anthropometric photographs note-related playing postures. Anthropometric variables, mainly neck
and normal poses. length, explain the changes in playing posture. Horn angle is determined
by the dental overbite. The importance of the anthropometric variables
in playing the more demanding notes indicate that anthropometry may
act to constrain trumpeters’ performance.
Hartsell and Tata 122 music students Presence of Type of instrument Self-report Qa 66 students reported having had PRMDsa. Piano, violin, cello and “other”
(1991) Various PRMDsa. Affected Cause attributed accounted for the majority of injuries although variations were noted
instruments region. Whether between the sexes. Body regions frequently injured were representative
medical help was of the static and dynamic loading requirements of the various
sought. Posture instruments but, generally, were the hands, wrists, and lumbar regions.
required by each Prevalent causes were listed as technique, fatigue, and posture. Over
instrument half the respondents sought medical attention.
Scotto Di Carlo 36 professional Cervical spinal Vocal range X-rays Each of the three vocal pitch ranges has it own specific posture. For all
(1998) singers anomalies subjects, the craniocervical angle increased as pitch increased. This
phenomenon is due to the raised head and the backwards shift of the
cervical spine, both of which are determined by jaw opening. In the
singers, the posterior position of the spine during singing in the upper
pitch range was accompanied by a relatively large inversion of the
cervical curvature. Jaw opening in the upper pitch range varied as a
function of the singer’s vocal technique and performance level. For
singers with generally wide buccal openings, shifts of de 6th cervical
vertebral as large as 4 cm were observed. At rest, these subjects
exhibited either hypokyphosis or cervical rectitude. Singers with smaller
jaw openings exhibited hypolordosis.
Ueno et al. (1998) 1 cello player Patterns of Sound quality Electromyograms The performance is more efficient and the sound quality is better in the
muscular activity Phonetograms and straight spine posture than in bent spine posture. The arms need a
in tasks performed other clinical certain amount of power, while the back muscles do not need as much
with the spine diagnostics power, and in fact, too much back power may have a harmful effect.
curved and
straight.
Pascarelli and Hsu 485; EG: 134 Upper limb Occupation Clinical Significant findings included postural misalignment with protracted

P. Blanco-Piñeiro et al.
(2001) musicians disorders. Posture diagnostics shoulders (78%), head forward position (71%), neurogenic TOSa (70%),
CG: 339 computer quality while cervical radiculopathy (0.03%), evidence of sympathetic dysfunction
users; 12 playing. (20%), and complex regional pain syndrome (0.6%). Hyperlaxity of fingers
repetitive workers and elbows was found in over 50%, carpal tunnel syndrome in 8%, radial
tunnel syndrome (7%), cubital tunnel (64%), shoulder impingement (13%)
medial epicondylitis (60%), lateral epicondylitis (33%) and peripheral
muscle weakness (70%).
 Musicians, postural quality and musculoskeletal health

Crnivec (2004) 207; EG: 70 Types of PRMDsa. Type of Not stated We identified PRMDs (inflammatory and degenerative skeletal disorders
musicians CG: 109 Postural quality, occupation. and minor occupational hearing impairments) that were most frequent.
musicians and 28 playing position. Repetitive A significant proportion of musicians had overuse syndrome, caused by
marketing workers movements. excessive use of the extremities and characterized by cumulative
Various Instrument. Age. microtrauma exceeding human physiologic limits, and dermatologic
instruments Experience. problems, such as finger calluses and “fiddler’s neck. “The most
Playing time. frequent PRMDs were due to repetitive motion, unphysiologic postures
(isometric strain on the affected muscles), and prolonged sitting position
during performances. The highest level of PRMDs was noted in the
double bass and cello, followed by violin, viola, woodwind, and brass
players. The severity of physical impairments and restricted ability to
perform music were correlated with age, duration of classical music
performance, and total length of service. In EG, the incidence of health
problems in general was twice as high as in the CG, whereas the
incidence of PRMDs was six times as high as that in the CG.
Buckley and 47 amateur Presence of Technical quality. Self-report Qa Lifetime prevalence is 54% for a previous injury attributed to playing a
Manchester musicians PRMDs. Postural Practice time. Postural analysis musical instrument and point prevalence is 19%. Following the camp,
(2006) quality. Intensive practice. prevalence increased to 44% (p Z 0.001), and incidence of new injury
was 31%, including individuals with more than one active injury. A higher
rate of injury correlated with a greater increase in absolute playing
time, relative playing time above baseline, and absolute time above
baseline during the camp, although these did not reach statistical
significance. The limited technical analysis qualitatively correlated a
technical deficit to an injury at the same anatomical location in 15 of 47
cases.
Abreu-Ramos and 75 musicians Presence of upper Age, gender, Self-report Qa 81.3% reported having had PRMDs that affected their ability to play. Of
Micheo (2007) various body PRMDs. instrument, these, 83.6% reported their PRMDs was directly associated to playing.
instruments Posture. technique. Females were more commonly affected, 87.5% vs. 79.7% for males.
Lower-body strings (cello, bass) players and percussionists (93.3% and
100%, respectively) and younger (22e29 yrs) and older (50e61 yrs)
populations (83.3% and 90.9%, respectively) reported more PRMDs.
These age groups played more hours per week (28.7 and 32.0 h,
respectively). In all groups, low back pain was the most common
complaint, present in 75.4% of those with PRMDs. Upper body strings
(violin, viola) players also reported neck and left shoulder problems.
Contributing factors include hours of exposure and technical expertise.
Female gender, age, and instrument played were found to be risk factors
for developing PRMDs in this population.
Nyman et al. 235 musicians Neck and shoulder Daily practice Self-report Qa A higher prevalence of neck-shoulder pain were found in the groups
(2007) various pain. Arm position time. Observation by “elevated arm position, <2 h/workday” [OR 4.15 (1.30e13.22)], and
instruments (>40 vs <40
experts. “elevated arm position, >3 h/workday” [OR 5.35 (1.96e14.62)]
elevation). compared to the group “neutral arm position, <2 h/workday”.
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162
Table 1 (continued )
Paper Sample size, EG- Health and Other variables Evaluation Results
CGa and posture variables procedure
instrument
Rabuffetti et al. 15 violin players Posture, kinematic Shoulder rest Optoelectronic The results demonstrate that a skilled player is able to adapt to any
(2007) analysis of position. motion capture shoulder rest setup and can maintain the quality of sound, and that the
movement system adaptations are primarily those of the anatomical systems involved in
holding the violin and not in holding the bow. Moreover, adjustment of
the shoulder rest setup appears to be the individual’s search for a
tradeoff position, which possibly may be alleviated by adopting
objective assessment and innovative shoulder rests.
Kreutz et al. 273 music students Symptoms. Health Performance Not stated Regression analysis showed that musculoskeletal and non-
(2008) Various behaviour. quality. musculoskeletal symptoms reliably predicted perceived practice and
instruments Posture. performance quality, such that fewer symptoms predicted better
quality; the strongest predictors were pain along the spine and fatigue.
These results suggest that significant proportions of health problems
among students emerge from general dispositions, such as posture and
fatigue, and thus are not specific to the instrument played. Healthy
lifestyles appear not to affect perceived practice and performance
quality.
Nawrocka and 61 EG: 42 music Symmetric vs Kasperczyk Scale, Common abnormalities among pianist were: head protrusión (90%),
Wołynska- students; CG: 19 asymmetric cervical mobility hyperlordosis (70%) and hyperkyphosis (65%), often with chest

Sle
ska
˛zyn students of school loading while measurements, a deformities (45%) and abdominal protrusion (50%). Asymmetric shoulder
(2008) various playing. Body self-report Qa position (50%), right shoulder elevation (40%), asymmetric scapular
instruments deformities. position (40%), foot (45%) and knee deformities (25%) were observed,
too. Among violinists: asymmetry in shoulder and scapula placement,
left shoulder elevation (87%) and left scapula elevation (81%), head
protrusion (67%) and left-sided scoliosis (58%). Faulty postures were
significantly more frequent among the violinists and pianists than in the
CG. Any statistically significant associations between body posture and
the number of years of play or the weekly number of hours of instrument
practice were found.
Edling and 47 music teachers Presence of Gender Self-report Female teachers reported significantly more symptoms in the neck,
Fjellman- various PRMDs, affected (Standardized shoulders, and upper back than male teachers (p Z 0.042). Music
Wiklund (2009) instruments body region. Nordic Qa). teachers with an asymmetric playing posture had significantly more
Workload in Musical Cohort PRMDs than music teachers with a symmetric playing posture. String

P. Blanco-Piñeiro et al.
asymmetric Health Q-West. teachers reported PRMDs in the neck (71%), lower back (64%) and upper
posture. Weekly Expert observation back (50%). Teachers of wind instruments reported PRMDs in the same
practice time. body regions, but to a lesser extent. Piano, guitar, and percussion
teachers reported mostly lower back problems. Voice and eurhythmics
teachers reported problems in the lower back, shoulders, neck, and
elbows.
 Musicians, postural quality and musculoskeletal health
Johnson and 18 opera singers Postural Gender, vocal task Roentgen No differences between male and female singers in the craniocervical
Skinner (2009) parameters of the status (performing cephalograms postural variables were found. In singing, the position of the atlas with
cranio-cervical vs repose). respect to the true vertical (Py0.001), the axis (Py0.001) and the C4
region. vertebra both with respect to the horizontal (Py0.001), and the axis
with respect to the cranium (Py0.001), were all significantly different
to those at rest. Of the craniocervical postural variables in the singing
registration, the angles measuring positional change of the atlas and C4
relative to the true horizontal were shown be significantly related to an
increased pharyngeal airway space at the C3 level (Py0.01). An
appreciation of the requirement for the cervical spine to undergo
postural change during professional opera singing has relevance to the
potential impact on voice quality in professional singers should they
undergo cervical spine surgery.
Kruta De Araújo 4 violin students Postural flaws of Bowing of each Expert observation 100% of the violinists presented postural flaws, with excessive flexion of
et al. (2009) the right arm and string (midpart vs by the radiocarpal joint during bowing with the middle and nut areas of the
head. frog). physiotherapists bow and with left lateral deviations of the head.
Akel et al. (2010b) 26 flute students Musculoskeletal Demographic Expert observation 100% had posture and PRMDs where posture analysis reflected the
problems. Static characteristics. by problems. Neck, back, chin, thumb, little and index finger is found to be
and moving Performing habits. physiotherapists the worst positioned regions of the body. 69% of the students were
posture with two and a flautist playing the flute with body rotation. The most common risk factor of
different playing fingers seen in the study was excessive extension of the fingers. Thumb
positions. was in adduction in 39% of the students and they mentioned about
fatigue in thenar area. In general it was noticed that students’ physical
fitness was not well enough to position the flute well and play for hours.
Steinmetz et al. 84 musicians Upper crossed Instrument Various clinical 93% of subjects presented dysfunctions of the PSSa: impairments of
(2010) various syndrome. Gender diagnostics scapular (85%), of lumbopelvic stabilization system (71%), and upper
instruments Dysfunctions of crossed syndrome (57%). Subgroup analysis (upper strings, lower strings,
the lumbopelvic, wind and keyboard instruments) showed significantly more impairment
cervical and of the lumbopelvic stabilization system for upper and lower strings
scapular (p Z 0.008), whereas similar rates for disturbances of scapular
stabilization stabilizers and upper crossed syndrome was seen across subgroups.
systems. Furthermore, significant sex differences with a higher frequency of
scapular stabilizers (p Z 0.14), and upper crossed syndrome (p < 0.001)
in women were present.
Husseini et al. 42 singers Arytenoid Glottal attack Laryngeal analysis Only 28.6% of the subjects had good posture, and close to two thirds had
(2011) asymmetry during by two moderate alignment in their posture. The majority (74%), had mild neck
adduction. Neck independent ear, tension, and less than one third had no tension. The glottal attack was
tension. Posture. nose and throat rated as normal in two thirds of the subjects and as aspirate in 31%. The
specialists total prevalence of arytenoid asymmetry was 50%, with a major
predominance on the right side in 70% of the cases. The asymmetries
were more common in males compared to females. There was no
correlation between arytenoid asymmetry and either posture, neck
tension or glottal attack (p Z 0.343, 0.489 and 0.945, respectively).
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164
Table 1 (continued )
Paper Sample size, EG- Health and Other variables Evaluation Results
CGa and posture variables procedure
instrument
Barczyk-Pawelec 67 students; EG: Performance of Height, weight Expert The spinal curvatures of the EG in the sagittal plane differ from the CG
et al. (2012) 32 violinists; CG: physical therapy. observation. Moiré mainly in terms of length and depth parameters. Compared with the CG,
35 physiotherapy Spinal curvatures photogrammetry the musicians were characterized by statistically more significantly
students and asymmetries longer and deeper thoracic kyphosis (p < 0.01) and shallower lumbar
Violin of the trunk. lordosis (p < 0.05), a greater angle of thoracic kyphosis (p < 0.005), and
a smaller inclination angle of the thoracolumbar and lumbosacral section
of the spine (p < 0.01).
Chadefaux et al. 3 harp players Gesture strategies Playing the first VICON 460 motion The investigation shows that while each musician uses their own specific
(2013) during three chords of capture system and repeatable upper-limb movements, the global sound-producing
performance Debussy’s Danse gesture is mostly controlled by the shoulders. Sound-facilitating hand
profane. gestures are highlighted for their supporting role to the musician
throughout the musical piece.
Savino et al. 12 violin students Clinical profile of Daily practice Clinical tests 100% of the student-worker population analysed had painful symptoms
(2013) the time. (Yocum, Hawkins, related to the vertebral spine; corporal areas affected by painful
musculoskeletal Uninterrupted Napoleon, Jobe, symptoms were: upper limbs (83%); lower limbs (33%); jaw (16%)
system. practice time. Phalen). shoulders (16%); right elbow (33%); first finger of the right hand or in the
Occupational Heterometry. Qa fifth finger of the left hand (16%); knee and ankle (16%). 66% presented
stress. Posture. on posture asymmetry of the shoulders, shoulder blades and a lower limb
(Standard Nordic, hererometria. 16% hyperkyphosis; lumbar hyperlordosis (66%). 33% flat
DASH and NIOSH) back and 50% showed a noticeable muscle contracture at the trapezoid.
and stress (ISPESL- 83% showed finger hyperkeratosis. 16% had hyperkeratosis at the
HSE) proximal third of the clavicle.
Teixeira et al. 36 musicians; EG: Symmetry of Years of flute Goniometer and Significant differences were found between groups concerning forward
(2013) 27 Flute students shoulder muscle playing tape measure (for head posture only; developing flutists showed a higher forward head
in 3 groups strength. Postures posture) posture compared to the other two groups (p < 0.05). No significant
according to of head and Isokinetic differences were found for scapular posture or muscle strength.
experience CG: 9 shoulder blade. dynamometer (for
singers strength)
Clemente et al. 17 piano players Posture of head Use of a score Motion recording It is possible to study the kinematics of the CCMCa during pianist
(2014) and neck while while playing. via goggles with a performance using a 3D wireless accelerometer. Experienced classical
playing 3D accelerometer piano players had higher amplitude in the movements of the CCMC
connected to a compared to jazz players. All of the subjects had greater flexion of the

P. Blanco-Piñeiro et al.
computer. neck relative to a desired posture when asked to look at an upright
position. Increased coactivation of the postural muscles was found in
some piano players who had hyperextension of the neck when looking
forward in an upright position, indicating the possibility of compensatory
neuromuscular mechanisms. With this technique, we found that the
players tilt their heads to the right while playing piano, and most adopt
this position while standing up.
 Musicians, postural quality and musculoskeletal health
Price et al. (2014) 58 brass students Respiratory Spirometry, Only sitting in a reclining position produced statistically significantly
function electromyography,
lower values for VC, FVC, FEV1 and PEF than standing. When players
parameters (VC, inductive produced a note of maximum duration, only a downward sloping seat
FVC, FEV1, PEF)a, plethysmography
caused a significant change (an 11% reduction) compared to standing.
muscle activity, When seated, the abdominal component of respiratory movement was
and respiratory significantly higher during these long notes than when standing, though
movements. maximum activity in abdominal wall muscles was significantly reduced
Performing (32e44%). On a downward sloping seat, muscle activity was significantly
posture higher (9%) than on a flat seat. Tongued and untongued sforzando notes
recruited significantly less abdominal muscle activity (33e67%) when
sitting than when standing. In the trumpet study, abdominal muscle
activity was significantly reduced on a downward sloping seat (by 32%)
and on a flat seat (by 40%) in comparison to standing. Muscle activity in
the two sitting positions was not significantly different.
Ramella et al. 148 music students Posture without Symmetry/ Expert observation 66.2% had a postural disorder; 73, 4% had a non-optimal posture. Playing
(2014) Various instrument, with asymmetry of using a plumb line. an asymmetric instrument was the only variable associated (p Z 0.01).
instruments instrument but not posture required Physiotherapeutic While playing, the postural disorder was increased in 59, 2%; playing an
playing, and by the instrument. test asymmetric instrument (p Z 0.01) and years of practice (p Z 0.007)
playing. Years playing. measurements were the significantly associated variables.
Sports activity.
Spahn et al. (2014) 19 violin players Distribution of Expert observation Results showed unbalanced weight distributions while sitting in front of
bodyweight. using an or oriented to the right of the music stand compared to the almost even
Movement orthopaedic distributions while standing or oriented to the left of the stand. Analyses
patterns when posturography of movement patterns showed significant differences between standing
standing or sitting platform and a 3D and sitting, mainly in the upper body parts with less mobility while
to right, left or motion capture sitting. While sitting in front of or oriented to the right of music stand,
centre of a music device. the right bowing arm showed more restricted movements compared to
stand. other positions.
Blanco-Piñeiro 100 music students 11 variables Performance Expert observation Most advanced music students tend to adopt incorrect postures when
et al. (2015) Various reflecting aspects musical standing using videotape they perform, whether standing or seated. Bad posture is most common
instruments postural quality and seated and photographs, during seated performance. Students tend to exhibit: excessive
and Postural kyphosis, excessive lordosis (standing), backward pelvic tilt (seated),
Observation head pushed forward, shoulders elevated and pushed forward.
Instrument
a
EG: Experimental group; CG: Control group; PRMDs: Performance-related musculoskeletal disorders; Q: Questionnaire; TOS: Thoracic
Outlet Syndrome; PSS: postural stabilization systems; CCMC: Cranio-cervical-mandibular complex; VC: Vital capacity; FVC: Forced vital
capacity; FEV1: Forced expiratory volume in the first second; PEF: Peak expiratory flow.

165
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REVIEW: LITERATURE REVIEW

166
Table 2 Sample size, relevant musical instruments, variables, intervention, evaluation procedures and results of the interventional studies included in the review.
Paper Sample size, EG- Health and posture Evaluation Intervention Results
CGa and variables procedure
instrument
Medoff (1999) 23 musicians Evolution of overuse Expert observation A technique for re- 100% of musicians returned to their pre-injury levels of playing
Various lesions (physiotherapists) education in regard to after an average of 8 visits. Not all were free of symptoms, but
instruments posture and everybody was able to manage through the strategies learned in
movement. physical therapy.
Ackermann 8 violin players Use of scapular Electromyography Scapular taping while Compared with the control condition, scapula taping increased
et al. (2002) stabilization muscles Expert observation playing. electromyographic activity in the left upper trapezius muscle
while playing, with Self-report Qa during playing by 49% (ie 0.83 SD units, F (1, 7) Z 7.91, p Z 0.026)
and without as an overall effect, with a 60% increase in the most physically
intervention demanding piece played (F (1, 7) Z 7.04, p Z 0.033). Lower music
quality was detected in the same piece (Rater 1 F (1, 7) Z 8.29,
p Z 0.02, and Rater 2 F (1, 7) Z 7.25, p Z 0.03). Taping also had
significant negative effects on subjects’ reports of concentration
(t7 Z 2.95, p Z 0.022) and comfort (t7 Z 2.96, p Z 0.021).
Byl et al. (2003) 43; EG: 3 Somatosensory hand Clinical A rehabilitation On the affected side, EG improved an average of: somatosensory
musicians with representation, diagnostics programme (aerobics hand representation (86.8%), target-specific performance (117%);
focal dystonia; target-specific hand and postural fine motor skills (23.9%), sensory discrimination (22.7%), on
CG: 10 healthy control, and exercises, training in musculoskeletal skills (31.9%), and independence (32.3%). EG
musicians and 30 musculoskeletal sensorimotor improved 10% or more on 90% of the subtests with 20%
healthy subjects. function (posture, activities) improvement on 50% of the subtests, except posture and forearm
Various neural tension, etc.). rotation.
instruments Independence
De Greef et al. 45 musicians; EG: Perceived physical Self-report GETSOM exercise Participation in the program has shown a statistically significant
(2003) 17; CG: 28 various competence. therapy programme (p < 0.05) and clinically relevant (d > 0.20) increase in perceived
instruments Evolution of PRMDs physical competence and a decrease in PRMDs in the EG,
compared with the CG. 45% of the decrease in PRMDs was
explained by an increase in physical competence.
Fjellman- 14 violin players Trapezius activity Bilateral 8 weeks of training No significant differences were found in the trapezius muscle
Wiklund EG: 5; CG: 9 while playing electromyography. (Basic Body activation between the Basic BAT EG and the CG. The EG
et al. (2004) Exposure variation Awareness Therapy) perceived positive changes in breathing, muscular tension,
analysis. Principal postural control and concentration mainly during practice
components sessions.
analysis. Expert

P. Blanco-Piñeiro et al.
observation.
Hildebrandt 98 musicians, 26 Music teaching style Self-report Qa Training in music The teachers (EG) noted that they had become more responsible
and Nubling teachers and 66 Pupils’ playing habits physioloy (1 for instructions and more precise related to playing movements
(2004) students semester) than the teachers (CG). The students (EG) noted a change in the
Various teaching style, in verbal instructions and in guidance of posture
instruments and playing-related movements than the students (CG).
 Musicians, postural quality and musculoskeletal health
Schuele and 21 string players Symptoms of focal Self-report and Nerve Information on long-term outcome was available on average 13.8
Lederman with focal dystonia expert observation decompression, years after onset of symptoms. Main complaints were playing-
(2004) dystonia. Violin physical therapy, re- related loss of control and involuntary movements affecting the
and viola training, fingering hand in 16 and the bow arm in 5 patients. In 18 patients
anticholinergic (86%), signs of abnormal posture could be detected by watching
medication, them play their instrument. Only 38% of the performing artists
botulinum toxin, and/ were able to maintain their professional careers, among them
or splints. none with bow arm dystonia.
McKenzie et al. 27 Musculo-skeletal, 4 physical tests, 4 8 weeks’ supervised Musicians with cramps had a higher level of functional
(2009) EG Z 14 musicians sensory and motor sensory tests, 3 sensorimotor training independence and better range of motion, but less strength in the
CG Z 13 writers performance motor tests. affected upper limb than writers. Musicians demonstrated greater
accuracy on graphesthesia, kinesthesia, and localization at
baseline. No between-group differences in motor performance
were noted at baseline or post-intervention. Following
individually adapted learning-based sensorimotor training, both
groups improved in musculoskeletal (physical) parameters,
sensory processing, and motor control; however, improvements on
certain subtests differed by group. At follow-up, differences in
posture, strength, graphesthesia, and kinesthesia persisted
between the groups.
Baadjou et al. 18 musicians Basal metabolic rate Indirect Postural training (8 Mean metabolic (MET) equivalents for playing a wind instrument in
(2011) Brass and (Schofield’s formula) calorimetry in a sessions). the sitting position in a nonoptimized posture. Percent change
woodwind while playing in respiration Mensendieck method between resting metabolic rate and total energy expenditure
unoptimized posture chamber of postural re- while playing was 32% (95% CI 25e39%) in optimized posture and
and a Mensendieck education 23% (95% CI 17e30%) in nonoptimized posture (p Z 0.021).
posture Average physical activity while playing approximates 1.8 MET.
Data show an association between energy expenditure and body
posture while playing a brass or woodwind instrument: playing a
musical instrument in a posture according to postural exercise
therapy leads to higher energy expenditure as compared to a
nonoptimized body posture.
Staes et al. 1 classic singing Postural and vocal Phonetograms Rehabilitation to After program postural alignment, shoulder and neck stress were
(2011) student parameters Clinical optimize joint improved. The patient showed breath support, except for the high
examination and mobility, muscular tones.
video/photo stability and posture.
analysis using
Dartfish Prosuite
(continued on next page)

167
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168
Table 2 (continued )
Paper Sample size, EG- Health and posture Evaluation Intervention Results
CGa and variables procedure
instrument
Van Der Linden 8 musicians Orientation and Animazoo IGS-190- 6 training sessions We found no significant differences between the EG and the CG
et al. (2011) EG: 4; CG: 4 inclination of the bow M motion capture using a MusicJacket to comparing pre and post-test. The data showed no consistent
Violin trajectory system provide vibrotactile learning effect for both groups. However, some trends could be
Orientation of the feedback on bowing observed. EG showed a gradual progress during the subsequent
violin and violin position. sessions, indicated by a decrease of the proximal-distal deviation.
All participants in the feedback group showed a smaller deviation
during the between measurements compared to the before
measurements, and the lowest deviations were obtained during
feedback. In contrast, the general trend for the participants in the
CG was less clear.
Lee et al. 15 music students Physical efficiency Physical & Musical- 8 weeks’ yogic Post-intervention data showed that the program improved
(2012) Various (awareness of Performance breathing and physical efficacy by increased awareness of posture and tension.
posture, tension, Efficacy muscle-strengthening
movement Assessment and flexibility
flexibility). Survey. Expert exercises.
Kinematics while observation of
playing (1 cellist, 1 kinematics.
flautist).
López and 149 music students Body awareness. Qa Course on musicians’ While the students in the experimental group improved their body
Martı́nez EG: 90; CG Z 59 Frequency of PRMDs. health problems, awareness by 91% and the frequency of their injuries decreased by
(2013) Various treatment and 78%, there was no improvement in the students from the control
instruments prevention, including group at the end of the experiment.
warm-up and postural
hygiene.
Baadjou et al. 150 music students Disabilities Qa A biopsychosocial Not stated
(2014) EG: 75; CG: 75 (shoulders, arms, intervention including
Various hands). postural exercises
instruments Pain, quality of life, (Mensendieck or
and changes in health Cesar methods)
behaviour
a
EG: Experimental group; CG: Control group; PRMDs: Performance-related musculoskeletal disorders; Q: Questionnaire.

P. Blanco-Piñeiro et al.
Musicians, postural quality and musculoskeletal health 169

differences found weren’t statistically significant. Of the 14

Table 3 Numbers of studies, by study type and study
studies that evaluated intervention programmes, 6 found
variables.
clear evidence of positive effects, 5 observed positive ef-
Variable Descriptive or Interventional fects on some of the target variables but not on others, and
correlational study study another 2 no positive effects on any of the target variables
Posture 11 2 studied. In particular (and bearing in mind that these
PRMDsa þ posture 12 5 studies generally differed in the specific objectives pur-
Physical performance 4 6 sued), 3 reported positive effects of intervention on the
þ posture course of PRMDs, 7 on physical competence, and 5 on
PRMDsa þ Performance 1 performing posture.
Total 27 14
a
PRMDs: Performance-related musculoskeletal disorders. Summary

The above findings reflect the growing interest in research

Table 4 Number of studies, by study type and measure- on posture during musical performance and its relationship
ment procedures. to musicians’ vulnerability to PRMDs and to their physical
Procedure Descriptive or Interventional competence while performing. Between 2001 and 2015
correlational study there were three times as many publications in this field as
study in the 1990s, while the pre-1990 literature is almost inex-
Postural quality measurement
istent. No reviews or theoretical papers appeared until
Clinical tests 2
about a decade ago, and the few that have appeared since
Self-report 1 1
have concentrated fundamentally on the types of pathology
Expert observation 18 12
that are most common among musicians, without consid-
Clinical tests 4
ering their possible relationships with performing posture,
þ Expert observation
and generally without critical consideration of methodo-
Not stated 2
logical issues. Almost no articles on intervention pro-
Total 27 13
grammes, or of a popular or educational nature, were
Measurement of musculoskeletal disorder
published before 2001.
Clinical tests 2 2
Research evaluating prevention or re-education pro-
Self-report 5 1
grammes has clearly been insufficient. The few studies
Expert observation 1
located differ widely in their objectives, the variables
Clinical tests 3 1
studied, the instruments and measures employed, and the
þ Expert observation
kind of data analysis performed, all of which limits support
Self-report 1
for any conclusions or working protocols. Most published
þ Expert observation
studies were designed with clinical rehabilitation in mind;
Not stated 2
music teachers collaborated in very few.
Total 12 6
Many if not most samples were recruited at teaching
Physical performance measurement
centres or from orchestras, although studies focusing on
Expert observation 1 1
musicians’ pathologies resorted to specialized clinics; these

REVIEW: LITERATURE REVIEW

Clinical tests 1 3
Self-report 1
þ Expert observation
Clinical tests 2 2
þ Expert observation
Total 4 7
Results and conclusions
It is important to emphasize the diversity and heteroge-
neity of operative systems and the measurements of the
variables that are objects of these studies. This makes it
more difficult to establish comparisons between results.
Nevertheless, the following could be inferred: the 81.5% of
the 27 descriptive or correlational studies identified clearly
a relationship between postural quality and some other
variable (physical or musical performance, PRMDs, or
musical activity variables such as instrument type, practice
time, or years of musical activity). The 18.5% (5) didn’t find
a relationship between the variables analyzed, or the
centres obviously favour access to participants. The
absence of studies of first-class concert soloists is attrib-
utable to difficulty of access making it practically impos-
sible to recruit a large enough sample of such musicians.
Most studies used relatively small samples (<50 partici-
pants), with a mean age between 30 and 48 years old.
However, there was no clearly typical participant profile:
participants had a wide variety of musical levels, from
students to concert artists; age varied widely, from 10 to 79
years among the pooled samples of the minority of studies
for which age range was reported; and there was only a
fairly small imbalance between the genders, with on
average somewhat more women than men (in the de-
scriptives or correlational studies). It must be noted that a
considerable number of studies failed to distinguish among
participants of different musical level in presenting and
analysing their data, thus limiting the conclusions that
might be drawn from their results.
Over a third of all studies concerned musicians playing a
variety of instruments (50% of the interventional studies).
Almost another third focused on string players (usually vi-
olinists). There are of course minority instruments, such as
 170 P. Blanco-Piñeiro et al.

Table 5 Number of studies, by study type and body region studied.

Body region Descriptive or correlational study Interventional study
In regard to posture
Whole body 16 8
Head and neck 4
Upper body (head, arms, shoulders, shoulder blades) 3
Upper limbs 1 3
Hand 2
Not stated 3
Total 27 13
In regard to the region affected by PRMDs (performance-related musculoskeletal disorders)
Whole body 8 5
Head and neck 2
Upper body (head, arms, shoulders, shoulder blades) 1
Upper limbs 1
Hand 1
Total 12 6

Table 6 Risk factors.

Sociodemographic risk factor Playing-related risk factor Others risk factors
- Gender - Instrument - Ergonomic conditions
- Age - Professional activity - Sports/physical activity/healthy attitude
- Experience - Physical problems/somatic characteristics
- Practice habits - Motor competence variables (coordination, etc.)
- Hours of practice/workload/stress
- Technique
- Musical style
- Instrumental technique

the bassoon or tuba, for which it is difficult to muster a
sizeable sample of practitioners.
Most of the descriptive or correlational studies evalu-
ated their variables at just a single point in time, and most
of the interventional studies were prospective, with vari-
able follow-up periods, the majority between 4 and 12
REVIEW: LITERATURE REVIEW
postural quality only by observation by experts. Surpris-
ingly, in spite of their avowed objective (evaluation of the
effectiveness of a re-education or rehabilitation pro-
gramme), over half of these papers failed to explain the
procedure by which postural quality was assessed.
Also somewhat surprising is the fact that there has been

weeks. practically no research on the influence of poor performing

Most of the descriptive or correlational studies investi-
gated the possible relationships among prevalence of
PRMDs, postural quality, and risk factors such as the in-
strument played or practice habits. Data were mostly
gathered using self-report forms, followed by medical
diagnostic procedures when appropriate. To evaluate
postural quality these studies generally relied essentially on
the subjective impressions of the participants rather than
using a standardized instrument. However, the number of
studies that did evaluate postural quality objectively was
three times greater in the past years than in the previous
decade. Curiously, a number of studies recorded PRMDs,
but failed to investigate their relationship with performing
posture as a possible risk factor for onset or persistence.
Most of the intervention studies concerned postural re-
education, followed by clinical rehabilitation. Most focused
on musicians’ overall physical competence and postural
quality, without concentrating on any particular body re-
gion, though only 44% carried out a complete evaluation of
posture. Physical competence was generally measured by
means of clinical tests and/or observation by experts, and
posture on the quality of musical performance. A possible
cause is the methodological difficulty of evaluating the
latter and controlling the multiple potential confounding
factors.
The factors investigated as possibly increasing the risk
of PRMDs, most of them assessed by self-report, have been
very diverse, as have the measures employed. The di-
versity of measures and instruments may explain the dis-
crepancies and apparent contradictions in conclusions as
to the factors that favour PRMDs (Viaño Santasmarinas
et al., 2010). Even when not clearly contradictory, this
heterogeneity greatly hampers comparison of the results
of different studies.
Finally, it is important to highlight the lack of previous
review articles in the scientific literature about the
present subject, as this lack is the prime motivation for
our own study. We hope that its main contribution will be
its usefulness for researchers interested in the study of
body posture quality and its impact on different health
indicators and/or performance: such researchers might
wish to get as much information as possible concerning
Musicians, postural quality and musculoskeletal health
the available empirical background on the subject.
Likewise, the identification of some of the most impor-
tant methodological limitations in the previous literature
can help with regard to orienting new studies about this
problem.
Conclusions and suggestions
In conclusion, the results of this survey show that in spite of
increasing interest in this field, the empirical data still
exhibit serious limitations. Our findings prompt the
following suggestions for future studies: 1) samples should
be larger than in most previous studies, with greater con-
trol of variables such as age, musical level, or musical in-
strument; 2) there should be more studies of intervention
programmes, preferably prospective studies with lengthy
follow-up; 3) research teams should include music teachers
to assist in planning studies and interpreting results, and
with a view to encouraging them to apply relevant findings
in their teaching; 4) posture should be evaluated in a way
that guarantees the reliability and validity of the observa-
tions; and 5) there should be more studies on the rela-
tionship between performing posture and the quality of the
performance.
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