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74 Medical Problems of Performing Artists
Most research studies investigating the prevalence of muscu-
loskeletal disorders affecting musicians and music students
have focused on classical music, while less is known about
their prevalence in other music genres. The purpose of this
study was to document cumulative and point prevalence of
playing-related musculoskeletal disorders (PRMD) among
music students in Iceland and, specifically, to identify differ-
ences between those studying classical vs rhythmic music. We
hypothesized that students of classical music would report
more frequent and more severe musculoskeletal disorders
than students involved in rhythmic music, as classical instru-
ments and composition typically require more demanding,
sustained postures during practice and performance. A total
of 74 students from two classical music schools (schools A
and B) and 1 rhythmic school (school C) participated in the
study by answering a questionnaire assessing PRMDs. The
results showed that 62% of participants had, at some point in
their musical career, suffered a PRMD. The cumulative preva-
lence was highest in music school A (71.4%) and lowest in
music school C (38.9%). A statistically significant difference
was identified between the cumulative prevalence of PRMD
from schools A and B combined compared to music school C
(p=0.019). Over 40% of participants reported a “current
PRMD,” and a significant difference was identified between
the three schools (p=0.011), with the highest point prevalence
being registered in music school A (66.6%) and the lowest in
music school C (22.2%). The prevalence of PRMDs among Ice-
landic music students was high. The difference found between
students who play classical vs rhythmic music may be
explained by different demands of the instruments and com-
position on playing posture. Med Probl Perform Art 2014;
29(2):74–79.
Musical performance, whether it is in the form of
singing or playing a musical instrument, is a physi-
cally demanding activity, and musculoskeletal problems
often affect a musician‘s ability to perform.1Playing-
related musculoskeletal disorders (PRMDs) have been
defined as any pain, weakness, numbness, or other physi-
cal symptom that interferes with one’s ability to play a
musical instrument in the manner one is accustomed to.1
Studies documenting the cumulative prevalence (suffer-
ing from a PRMD at some point in the career) of PRMDs
among musicians indicate that up to 87% of participants
have, at some point in their career, dealt with a PRMD,2,3
and nowadays studies have included both professional
musicians and music students. A study by Ranelli et al.
included students between 7 and 17 years of age and
showed a PRMD cumulative prevalence of 67%,4while
79% of 330 music university freshmen reported having suf-
fered from a PRMD at some point in their musical career
in a study by Brandfonbrener.5These numbers are quite
high considering that participants were generally young
and healthy, but now several studies have been published
showing that the cumulative prevalence of PRMDs among
music students is between 32 and 93%.5–7 Numerous phys-
ical and mental factors may contribute to this high cumu-
lative prevalence of PRMDs among musicians.8,9 Factors
like repeated movements, age, gender, static loading in
muscles, and poor posture are all identified risk factors.10
Studies have also shown that poor physical fitness can be
a risk factor, especially for young musicians.8Although
some studies indicate that the cumulative prevalence for
PRMDs is higher among women,1,10,11 others have shown
similar results for the two genders.5
Musicians, especially music students, often continue
playing their instrument despite experiencing symptoms of
pain. A study by Britsch showed that 35% of participants
thought this was acceptable,8while a recent study by Ack-
ermann and Driscoll showed that 50% of participating par-
ents of children from a musically selective school seemed
to accept that feeling pain while playing an instrument was
normal.12 Music students, parents, teachers, and profes-
sional musicians must be aware that suffering, whether it
is physically or mentally, is not acceptable when it comes
to playing music.13 This may, in part, be due to insufficient
health promotion and injury prevention awareness as part
of students‘ curricula, although some music schools now
offer specific PRMD-prevention courses. Zander et al.
investigated the efficacy of a PRMD-prevention and
health promotion course on students‘ physical and mental
health.14 The results indicated that the course had a posi-
tive influence and the authors concluded, as did Chesky et
al.,15 that these kind of courses should be a part of the cur-
Playing-Related Musculoskeletal Disorders
Among Icelandic Music Students
Differences Between Students Playing Classical
vs Rhythmic Music
Kári Árnason, PT, BSc, Árni Árnason, PT, PhD, and Kristín Briem, PT, PhD
Mr. Kári Árnason is a physical therapist at the National University
Hospital and at MT–stofan, Reykjavik, Iceland; and Dr. Árni Árnason
and Dr. Kristín Briem are associate professors at the Department of
Physical Therapy at the University of Iceland School of Health Sciences,
Research Center of Movement Science, Reykjavik, Iceland.
Address correspondence to: Mr. Kári Árnason, The University of Ice-
land, Sæmundargata 2, 101 Reykjavik, Iceland. Tel +354 697 8114, fax
+354 525 4008. kariarna@gmail.com.
© 2014 Science & Medicine. www.sciandmed.com/mppa.
riculum in all music schools. Another recently published
study by López and Martínez evaluated the effectiveness of
a course on health and the prevention of PRMDs for supe-
rior-grade students at the High Conservatory of Music of
Salamanca, Spain.16 The results indicated that 91% of the
participants in the experimental group thought that the
course had a positive influence on their body awareness,
and the injury frequency decreased by 78% compared to no
improvements in the control group.16 These authors also
concluded that these kind of courses should be an inte-
grated part of the curriculum in music schools.
The great majority of studies that have documented the
cumulative prevalence of PRMDs have focused on classical
musicians, and a search of the literature revealed no studies
comparing the cumulative prevalence of PRMDs between
those who play classical music and those who play rhyth-
mic music (jazz, pop, rock, etc.) Therefore, the overall pur-
pose of the study was to document the prevalence, both
cumulative and current (present for the last 7 days), of
PRMDs among music students in Iceland, and specifically,
our aim was to identify differences between those studying
classical vs rhythmic music. We hypothesized that due to
the stringent and demanding postures typically required for
performance of classical composition, these students would
report more frequent and more severe musculoskeletal dis-
orders than students involved in rhythmic music, who may
have greater possibility for postural variability.
METHODS
The total number of participants was 74 music students
drawn from 3 music schools in Reykjavik (2 classical,
called music schools A and B, and 1 rhythmic, called music
school C). Prior to participation, the students received
information about the purpose of the study and what par-
ticipation involved, after which a formal consent form was
presented for them to sign. The study was assessed and
approved by the National Bioethics Committee and
reported to the National Data Protection Authority.
The participants voluntarily answered a questionnaire,
specially designed to document both the cumulative and
current prevalence, as well as the severity, of PRMD
among musicians.17 The questionnaire had previously
been published in the original and slightly changed ver-
sions.17,18 Prior to recruiting participants for the study, the
questionnaire was translated into Icelandic by two individ-
uals fluent in both languages, and a consensus reached
where discrepancies occurred. The Icelandic version was
then translated back to English by another two individuals
and compared to the original English version. The final-
ized Icelandic version of the questionnaire was then pre-
tested by asking 6 musicians, who did not participate in
the study, to answer it and indicate whether they felt the
questions were clear. Some final changes were then made
to improve clarity. A few questions from the original ver-
sion were altered with the authors’ permission in order to
better suit music students, as the original questions were
designed for professional musicians, not students. In addi-
tion to general information (age, gender, physical activity,
and years of musical education), the questionnaire is
designed to acquire more specific information about fre-
quency of injuries and their severity.
The variables of interest for the present study related to
frequency and severity of symptoms and what affected
them, in addition to information regarding education
relating to injury prevention. Participants were asked to
rate on a 100-mm visual analog scale (VAS)19 their per-
ceived frequency of PRMDs and the severity of the worst
PRMD they suffered. Participants were also asked to
choose one or more items from a list of factors that could
in their view potentially have influenced the development
of their PRMD. Each chosen factor was given a number
from 0 to 10 on a numeric rating scale (NRS)20 in regard to
how much influence they felt it had. The NRS was also
used when participants were asked rate the impact that the
PRMD had on their daily activities.
Statistical Analysis
Data analysis was done with SAS Enterprise Guide 4.3
and Microsoft Excel. Chi-square tests were used to identify
differences in the distribution of individuals with and
without PRMD between groups based on gender, school,
classical vs rhythmic music, regarding practice time and
regarding gender distribution between the schools. Inde-
pendent t-tests were used to identify differences between
the schools in how often the participants suffered from
PRMDs and how severe the worst PRMDs were. Statisti-
cally significant differences were identified as p< 0.05.
RESULTS
Demographic Information
Seventy-four music students, 57% male and 43% female,
took part in the study, and their age ranged from 16 to 36
years (Table 1). Music school A (57% male vs 43% female)
and music school C (67% male vs 33% female) included a
greater number of male participants, but in music school B
there was more equal gender distribution (48% male vs 52%
female) (p=0.488). The mean age in each music school was
quite similar, between 20 to 23 years. The mean (SD) time
of musical education was 11.6 (4.7) years, and the partici-
pants had played their main instrument for on average
11.2 (4.9) years. A number of participants (13.5%) also
worked as music teachers, with a mean (SD) weekly work-
load of 6.5 (4.2) hours. Participants practiced on their
instrument on average 6 days/week, twice a day, for 74
minutes per session, and the minimum rest between ses-
sions was 39 minutes. The largest proportion, or 32%, of
participants, played a string instrument (viola, cello,
acoustic and electric guitar, double and electric bass), while
23% played woodwind and brasswind, 23% were pianists,
19% vocalists, and 4% percussionists.
June 2014 75
76 Medical Problems of Performing Artists
Cumulative Prevalence of PRMD
At some point of their careers, 62% of the participants had
dealt with a PRMD. No statistically significant difference
was identified between the 3 schools (p=0.063). However,
when the 69.9% combined cumulative prevalence of
PRMD among participants from music schools A and B
(both classical) was compared to the 38.9% found among
participants from music school C (rhythmic), a statistically
significant difference was identified (p=0.019, Fig. 1). The
cumulative prevalence of PRMDs was significantly higher
among female participants, 61% compared to 39% among
male participants (p<0.001).
Frequency of PRMD occurrence was rated on a VAS
from 0 (never) to 100 (all the time), and a significant differ-
ence of scores was identified between schools A and C
(p=0.02). The mean (SD) frequency score from music
school A was 50 (26), from music school B 38 (23), and
from music school C 23 (17).
Magnitude of the worst PRMD that musicians had suf-
fered from was rated on a 0- to 100-mm VAS, and a signif-
icant difference of scores was identified between schools A
and C (p=0.01) and B and C (p=0.048). The mean (SD) mag-
nitude ratings from music schools A, B, and C were 56 (24),
51 (29), and 27 (17), respectively.
Point Prevalence PRMD
A “current PRMD“ was defined as a PRMD that had been
present for at least the last 7 days, and this was reported in
40% of participants. A statistically significant difference
was identified between the three schools (p=0.011). The
point prevalence of PRMD was highest in music school A
(66.6%) and lowest in music school C (22.2%), while the
prevalence in music school B was 34.4%. When combined
reports of current PRMD from the classical music schools
were compared to those from the rhythmic school, how-
ever, no statistically significant difference was identified
between the two groups (p=0.069).
The participants were also asked to evaluate the magni-
tude of the current PRMD on the VAS, and the mean (SD)
overall score for the current PRMD was 38.2 (30). Of those
participants reporting a current PRMD, 73% had dealt
with this for at least 3 months, 27% for 4 to 12 weeks, and
17% for <4 weeks. Some participants reported more than 1
PRMD, and in those cases some PRMDs had been present
more at least 3 months, another for 4 to 12 weeks, and etc.
Therefore the total score is higher than 100%.
PRMD Cumulative Prevalence Between Instrument
Groups
The cumulative prevalence of PRMDs was similar
between most of the instrument groups, although none of
the 3 participating percussionists had any history of
PRMD (Table 2). The mean score for how often partici-
pants suffered from PRMDs ranged from 33 (vocal) to 47
(piano), and the mean magnitude of the worst and current
PRMD was similarly rated between groups, as rated on the
VAS (Table 3).
Practice Time
Participants were asked to document how often per week
they practiced, how many practice sessions there were per
day, and how long each session was. The results regarding
sessions per week, sessions per day, and length of each ses-
sion were similar between the three schools and no signif-
icant statistically difference was found between the
schools regarding any factor (Table 4).
Health and PRMD Prevention Education
Participants were asked if they had received any formal
health and PRMD prevention education. Most of them had
TABLE 1. Demographic Information
Male (n=42) Female (n=32) All (n=74)
Age (yrs) 22.6 (4.7) 22.2 (3.5) 22.4 (4.2)
Height (cm) 180 (6.3) 170 (6.7) 176 (9.6)
Weight (kg) 76.9 (13.8) 61.5 (8.8) 70.2 (14.1)
Body mass index
(BMI) 23.2 (4) 21.8 (3.1) 22.6 (3.7)
Data given as mean (SD).
FIGURE 1. Cumulative prevalence of PRMD: A, classical music schools A and B combined; B, rhythmic music school (music
school C).
June 2014 77
received either none or little health and PRMD prevention
education, while very few had received a lot of it (Fig. 2), and
the results were similar across music schools (Fig. 3).
Potential Risk Factors
Participants were asked to choose one or more items from
a list of risk factors that in their view could potentially
have influenced the development of their PRMD. Each
chosen factor was given a number from 0 to 10 on the
NRS (0 = no influence, 10 = greatest influence) in regard to
how much influence they felt it had on the development of
their PRMD. Poor posture was the factor that received the
highest rating (Table 5).
Effects of PRMD on Daily Activities
Participants were asked to evaluate the effect that the
PRMD they had suffered had on their daily activities on
the NRS (0 = no effect at all, 10 = greatest effect). The mean
score for all three music schools was 2.1 (2.3).
DISCUSSION
The purpose of this study was to document both the cumu-
lative and point prevalence of PRMD among Icelandic
music students. As noted earlier, contrasting PRMD
between musicians of classical vs rhythmic music genres is
an understudied area, and therefore, this was our primary
aim. We hypothesized that due to vulnerability of students
of classical music, regarding, for example, demanding pos-
tures typically required for classical instruments and strin-
gent composition, classical music students would report
more frequent and more severe musculoskeletal disorders
than students involved in rhythmic music.
Overall, 62% of the participants had at some point in
their career dealt with a PRMD, and 40% reported disor-
ders that had been present for the last 7 days, and this is
consistent with previous findings.4–7 Music school C
(rhythmic) compared favorably when the cumulative
prevalence of PRMD was contrasted to the combined rate
of the classical music schools, and furthermore, the point
prevalence of PRMDs was lowest in music school C. These
results, combined with the fact that the mean scores for
frequency and magnitude of PRMD were also lowest in
music school C, support our “apriori” hypothesis.
One of the differences between the performance of clas-
sical and rhythmic music is that in rhythmic music there is
more “musical freedom” regarding performance, composi-
tion, and interpretation. The music does not have to be
played exactly as it is written, and so there is more freedom
to choose what notes to play, when to play them, and how
to play them. Rhythmic musicians are also in a better posi-
tion to move while playing compared to classical musi-
cians, who typically sit for long periods while playing,
sometimes in very crowded places. More “musical free-
dom” may involve less physical stress due to more breaks,
tempo changes, etc., and this may, in part, explain the dis-
parity found between schools in both the cumulative and
current prevalence of PRMDs.
FIGURE 2. The amount of formal education participants had
received on health and PRMD prevention.
TABLE 2. Cumulative Prevalence of PRMDs between
Different Instrument Groups
Instrument Group No.* Rate of PRMD
Vocal 9/14 64%
Woodwind and brass 10/17 59%
Strings 16/24 67%
Piano 11/16 69%
Percussion 0/3 0%
TOTAL 46/74 —
*Number of participants out of the total number in each
category.
TABLE 3. Frequency (How Often) of PRMDs, Magnitude
of the Worst PRMD, and Magnitude of “Current PRMD”
of Different Instrument Groups
Mean Mean
Mean Magnitude Magnitude
Instrument Frequency of Worst of “Current
Group of PRMD PRMD PRMD”
Vocal (n=9) 33 (20.7) 46 (31.5) 40 (21.9)
Woodwind and brass
(n=10) 40 (28.7) 48 (27.4) 33 (23.5)
Strings (n=16) 39 (23.7) 49 (25.1) 40 (23.8)
Piano (n=11) 47 (21.9) 50 (28.7) 40 (25.2)
Evaluated on the VAS (0–100). Data given as mean (SD).
TABLE 4. Mean Practice Time for Instrument Sessions
Music Music Music
School A School B School C p-Value
Days/week 5.1 (2.0) 5.9 (1.3) 6 (1.1) 0.09
Minutes/session 69 (54) 84 (48) 72 (31) 0.50
Sessions/day 2 (1.4) 1.7 (0.9) 2.4 (1.4) 0.32
Data given as mean (SD).
78 Medical Problems of Performing Artists
The demands of technical excellence are great in the
classical music world, and students who are determined to
succeed have to spend a great amount of time practicing to
have a possibility to reach their goal. Surprisingly, no dif-
ference was found between the classical vs rhythmic music
students regarding practice time. The ergonomic environ-
ment that classical music students practice in, however,
may be considered more physically stressful due to the
required body posture and the shape of the instruments.
There were also a higher number of female participants
from the classical schools, and our results are consistent
with other reports that indicate higher PRMD prevalence
among females.1,10,11 These factors may contribute to the
high cumulative prevalence of PRMD found among classi-
cal musicians.
Some participants from music school B reported that
their main study was music composition, not instrument
playing. As they had a background in music and played a
musical instrument on a regular basis, they were included
in the study. This may, however, have led to a slightly
lower rate of PRMD for that school, as music composition
students probably spend less time playing their instru-
ments than other music students. Notably, vocalists in the
present study recorded the same PRMD prevalence as the
instrumentalists. This is consistent with a previous report
by Eller et al.21 whose results indicated that disorders
reported by singers were predominantly from the mouth,
lips, and throat, while instrumentalists reported problems
in other body regions.
The large number of participants reporting a current
PRMD and who had suffered from these symptoms for
over 3 months is worrisome considering that the partici-
pants were generally young and healthy. A possible expla-
nation for this high point prevalence of PRMDs is limited
health promotion within the school system. Greater
awareness in this area might lead to a decrease in reported
symptoms, as indicated by the results reported by López
and Martínez, where injury frequency decreased by 78%
after students attended of a course on health and the pre-
vention of PRMD.16 The high cumulative prevalence of
disorders reported in the present and other studies is
hardly acceptable in light of the fact that some, if not
many, of them are preventable. A large amount of physical
and mental stress comes with being a music student, and
this will likely increase as the students further their music
careers and education, in particular if they will have the
opportunity to work as professional musicians.
Special health education and PRMD prevention
courses have been established in some music schools, and
studies have shown that these courses can be very effec-
tive.14–16 PRMD prevention and health promotion should
start in the very beginning of musical training, so that the
students will be prepared for the physical and mental stress
which comes with being a music student and a profes-
sional musician.14 Physical problems that arise early on
can develop into chronic problems and have very serious
consequences if they are ignored. Taking regular breaks,
being aware of good body posture, warming up appropri-
ately, gradually increasing the time spent on instrumental
playing, and monitoring physical and mental health are
factors that should therefore never be underestimated.
Although students from music school C reported the
highest frequency of getting no preventive education yet at
the same time had the lowest prevalence of PRMD, the
authors believe that health promotion and PRMD preven-
tion are important. The relatively low prevalence of
PRMDs reported by the rhythmic music students may have
lead to a lower priority of preventive education within that
school and funds being allocated toward other projects.
Health promotion and PRMD prevention may be par-
ticularly important for classical musicians, as they may be
more vulnerable for developing PRMD for reasons previ-
ously noted. All musicians, classical and rhythmic alike,
may have a tendency to adapt their body posture to the
instrument but not vice versa. Classical instruments like
the violin or cello, however, were hardly designed with the
best ergonomics in mind, while rhythmic musicians are
notably less bound to demanding postures when playing
their instruments.
The risk factors that participants in this study reported
as influencing their PRMD could possibly be addressed by
improving body awareness and by promoting good physi-
cal and mental health. Musculoskeletal problems associ-
ated with playing a musical instrument are nonetheless as
FIGURE 3. The amount of formal health and PRMD prevention education participants from each music school had received
(music schools A, B, and C).
June 2014 79
inevitable as musculoskeletal problems are in the sports
world. The results demonstrated that over 50% of students
had received little or no formal health education and
PRMD prevention and thereby strongly indicate that
there is room for improvement. Traditionally, musicians
tend to adhere to their schedules and play their instru-
ments despite experiencing pain.22 This tendency may be
countered by improving awareness of professional musi-
cians, as well as students and their parents, as to the
importance of good physical and mental health. Musicians
and music students must also know how to react to
PRMDs and where to seek assistance if needed.
A limitation to this study includes the fact that all of the
data are self-reported, which render them susceptible to
recall bias. Furthermore, respondents may have misinter-
preted some questions and some answers may therefore be
inaccurate. Due to the relatively small sample size, subgroup
analyses were not feasible, and as participants all came from
a single city, the study‘s external validity is reduced.
In conclusion, the results of the study demonstrated
that rates of PRMDs reported by music students were high,
although a clear disparity was found between schools
teaching classical vs rhythmic music, indicating a vulnera-
bility of students of classical music. Improving education
may increase awareness in the area of physical and mental
health and thereby lower the risk of injury and thereby
lower the risk of PRMDs and improve recovery.
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TABLE 5. Risk Factors that Participants Thought Had
Influenced the Development of their PRMD
How Often
Mean Each Factor
Risk Factor Score (SD) Was Chosen (46)
Poor posture 7.7 (2.5) 40
Long practice sessions 7.4 (2.3) 41
Excess muscle tension 7.4 (2.2) 41
Instrument set up issue 7.1 (2.5) 35
Sudden playing increase 7 (2.4) 35
Insufficient rest 6.8 (2.5) 37
Stress 6.6 (2.4) 35
Evaluated on NRS (0 = no effect at all, 10 = greatest effect at
all).
