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OBJECTIVE: CANS (complaints of arm, neck, and/or
shoulder not caused by a systemic disease or acute trauma) are
a recognized problem in specific occupational groups such as
musicians. This study aimed to compare the prevalence, char-
acteristics, and consequences of CANS between music acad-
emy students and a control group of peer-age medical stu-
dents. METHODS: A cross-sectional study among music
academy students and medical students. Data were collected
using a web-based questionnaire on musculoskeletal condi-
tions of the upper extremity in the two cohorts. RESULTS:
Students of three music academies (n=345) and one medical
university (n=2,870) received the questionnaire, of which 25%
(n=87) and 18% (n=503) responded, respectively. The 12-month
prevalence of CANS was nearly twice as high among music
academy students as the control group (80.7% vs 41.5%,
p<0.001). Music academy students reported 2.6 times the point
prevalence as medical students (47.0% vs 18.2%, p<0.001).
Chronic CANS was present in 36.1% of the music students,
compared to 10.3% of the medical students (p<0.001). Music
academy students presented more complaints per anatomic
localization and a higher number of involved anatomic local-
izations. Music students rated the influence of CANS on
daily functioning as more severe (5.0 vs 3.1, p<0.001). Of all
subjects with CANS during the last year, more music academy
students (46.3%) visited a healthcare professional compared to
medical students (29.8%, p=0.013). CONCLUSION: The
prevalence of CANS is high in music academy students com-
pared to medical students. This emphasizes the necessity of
effective (preventive) interventions in these high-demanding
professionals. Med Probl Perform Art 2015; 30(3):163–168.
Musculoskeletal problems among musicians are
frequent, with reported 12-month prevalence
among music academy students and profes-
sional musicians ranging from 39 to 90%,1–8 while these
numbers vary between 2 and 60% in the general working
population.9,10 These prevalence estimates are often
focused on the occurrence of musculoskeletal complaints
in the whole body.2–5,11 However, playing an instrument
mainly involves overuse at the upper extremity and neck
area. The latter is in accordance with studies showing a
high prevalence of musculoskeletal complaints among
musicians at the upper extremities, neck, and mouth.11,12
Since some studies showed that nearly half of professional
musicians discontinued practicing their instrument at
home during 1 year due to musculoskeletal complaints,
evaluation is necessary.2
The extent of upper extremity musculoskeletal com-
plaints can be described within the CANS (Complaints of
Arm, Neck, and/or Shoulder) model.13 In the CANS
model, complaints due to systemic disease or acute trauma
are excluded. This model was developed to support and
compare scientific research and to increase multidiscipli-
nary cooperation, using a delphi consensus strategy. One
of the advantages of using this model is the possibility of
comparing different populations. Systematically describ-
ing the scope of CANS experienced by musicians is not
only an important step in recognizing the extent of the
problem in that specific group in comparison to other pro-
fessions, but it will also give clues for addressing preven-
tive interventions. Thus, the primary aim of this study was
to evaluate the prevalence of CANS among music acad-
emy students compared to a control group of medical stu-
dents; secondly, the impact of CANS symptoms experi-
enced by music academy students compared to medical
students was evaluated.
METHODS
Study Design
A cross-sectional study on musculoskeletal conditions of
the upper extremity in music academy students was per-
formed. A group of medical school students was consid-
ered as a control group. Data were collected from a web-
based questionnaire among 3,215 students of three music
academies and 2,870 students at one medical university in
the Netherlands, extensively described in a previous arti-
cle.11 Data were collected between February and May 2011.
All Dutch-speaking students of three music academies
(n=345)—the Royal Conservatoire, The Hague;
CODARTS University for the Arts, Rotterdam; the Ams-
terdam School of the Arts, Amsterdam, with a classical
instrument as main subject (singers and conductors were
excluded)—received an invitation, as did medical students
(studying to be physicians) from Leiden University
Prevalence and Consequences of Arm, Neck, and/or
Shoulder Complaints Among Music Academy Students
A Comparative Study
Laura M. Kok, MA, MD, Rob G.H.H. Nelissen, MD, PhD, and Bionka M.A. Huisstede, PhD, PT
From the Department of Orthopedics (LMK, RGHHN, BMAH),
Leiden University Medical Center, Leiden, and Department of Rehabil-
itation, Nursing Science, and Sports (BMAH), University Medical
Center Utrecht, Utrecht, The Netherlands.
The authors declare no funding or conflicts of interest.
Address correspondence to: Dr. Laura M. Kok, Department of Orthope-
dics, Leiden University Medical Center, Postzone J11R, Postbus 9600,
2300 RC Leiden, The Netherlands. Tel +31-(0)71-5263606, fax +31-(0)71-
5266743. laura.m.kok@gmail. com.
© 2015 Science & Medicine. www.sciandmed.com/mppa.
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164 Medical Problems of Performing Artists
(n=2,870). The student registries of the four centers were
used to select the subjects. Exclusion criteria were age
below 18 yrs and above 30 yrs. All eligible students
received an e-mail with an invitation to complete the web-
based questionnaire. A reminder e-mail was send 3 weeks
after the first e-mail. The Leiden University Medical Ethi-
cal Committee approved the protocol (11/003b).
Questionnaire
The electronic questionnaire included items on sociode-
mographic characteristics, general health and muscu-
loskeletal complaints (age, gender, height, weight,
right/left-hand dominance), study-year (bachelor year 1–
4, master year 1–2), instrument playing (average time play-
ing per week and years of experience) and study (music
academy student/medical student), and main instrument.
For students playing an instrument, information on the
number of years already spent playing the instrument and
the average number of hours per week devoted to practice
were collected. In addition, the questionnaire included
questions concerning smoking, alcohol, sports, and
comorbidities.
The existence of musculoskeletal complaints during the
last year, current musculoskeletal complaints, and chronic
musculoskeletal complaints (complaints during at least 3
months) were scored for six anatomic regions: 1) elbow,
wrist, and hand; 2) neck, shoulder, and upper back; 3) lower
back; 4) hips and knees; 5) ankles and feet; 6) jaw and
mouth. Since this study focused on CANS, only the upper
extremity data were used. The body region “elbows, wrists,
and hands” was subdivided in six localizations (elbow left
and right, wrist left and right, and hand left and right). The
region “neck, shoulders, and upper back” was subdivided
in four localizations (shoulders left and right, neck and
upper back). For all complaints, information was collected
concerning the type of the complaint (pain, loss of gross
motor skills, loss of fine motor skills, power loss, loss of
control, cramp, loss of speed, loss of endurance, swelling,
redness, other), the duration of the complaint, cause of the
complaint according to the subject, the effect on daily life
functioning (scored on a scale from 0–10), and medical con-
sultation (general practitioner, specialist, physiotherapist,
alternative medicine). Also the cause(s) for the complaint
was questioned (e.g., trauma, repetitive use, etc.).
Statistical Analysis
Statistical analyses were performed with SPSS 20.0 (IBM
SPSS, Armonk, NY, USA). Mean and standard deviation
(SD) were calculated for each continuous normally distrib-
uted variable. Median and range were computed in case of
a non-normal distribution. Comparisons of gender, study,
smoking, hand preference, and healthcare usage between
music academy and medical students were done using chi-
square and t-tests.
Prevalence estimates for CANS were calculated by
adding all subjects with at least one complaint in one of
the six relevant anatomic regions. In case of complaints at
multiple sites (e.g., elbow and shoulder), the complaint
with the longest duration and the most severe score on
daily functioning was used to calculate duration and sever-
ity of CANS. Following the definition of CANS com-
plaints due to acute trauma (using the question on causal-
ity) and systemic disease (using the questions on causality
and comorbidity) were excluded. The following non-exclu-
sive prevalence estimates were calculated: point prevalence
of CANS (defined as current CANS); 12-month preva-
lence of CANS (defined as CANS during the last 12
months); and chronic CANS (defined as CANS present at
the time of completing the questionnaire and present for at
least 3 months).13 Prevalence rates, symptoms, occurrence
TABLE 1. Sociodemographic Characteristics of the Study Populations
Music Academy Students Medical Students
(n=83) (n=494) p-Value
Age 21.5 (SD 2.2) 22.1 (SD 2.6) 0.062
Gender
Male 22 (26.2%) 120 (24.3%) 0.843
Female 62 (73.8%) 374 (75.7%)
Grade
Bachelor’s 72(86.7%) 248 (50.2%) < 0.001
Master’s 11 (13.3%) 246 (49.8%)
Smoking 10 (11.9%) 26 (5.3%) 0.019
Sport (hrs/wk) 2.2 (SD 2.4) 3.0 (SD 2.8) 0.005
Alcohol consumption (glasses/wk) 3.9 (SD 4.5) 5.5 (SD 6.9) 0.090
Body mass index (kg/m2) 21.2 (SD 3.0) 22.0 (SD 2.5) 0.001
Practice time (hrs/wk) 20.7 (SD 8.7)
Experience (no. of playing years) 13.0 (SD 3.3)
Hand preference
Right 71 (85.5%) 43(87.7%) 0.593
Left 12 (14.5%) 61 (12.3%)
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September 2015 165
of complaints at multiple sites, and healthcare usage were
compared using chi-square tests. The occurrence of com-
plaints at multiple sites was compared using t-tests.
RESULTS
A total of 590 students completed the questionnaire: 87
music academy students (25%) and 503 (18%) medical stu-
dents. After exclusion of subjects exceeding the age limits,
577 students were included: 83 from the music academies
and 494 from the medical school. Table 1 illustrates the
characteristics of the responders.
Prevalence: The 12-month prevalence of CANS among
music academy students was nearly twice as high as in
medical students (80.7% vs 41.5%, p<0.001, Table 2). The
point-prevalence of CANS was 2.6 times higher in music
academy students than in medical students (47.0% vs
18.2%, p<0.001, Table 2). Differences between both groups
were highest for those with chronic CANS. Chronic
CANS was more than 3 times as frequent in music acad-
emy students (36.1%) as in medical students (10.3%,
p<0.001).
Symptoms: For those with CANS at present, during the
last 12 months, or with chronic CANS, Table 2 reports the
symptoms (e.g., pain, loss of gross motor skills, and pres-
ence of muscle cramp). Within both the music academy
and medical students groups, at least 90% of the subjects
reported pain. However, music academy students pre-
sented more severe symptoms compared to medical stu-
dents; music students with CANS reported more joint
swelling (p=0.042) and more motor skill problems (fine
motor skills p=0.024, loss of speed p<0.001, loss of control
p=0.012, cramp p=0.046, power loss p=0.043, and loss of
endurance p<0.001) than medical students.
Localization of CANS:The localizations of CANS
among music academy and medical students are presented
in Table 3. The neck was the most frequently affected area,
with 46% and 27% of the music academy students and med-
ical students reporting complaints of the neck (p=0.001).
Among all subjects with CANS during the last 12 months,
a higher percentage of music academy students compared
to medical students report complaints of the shoulders.
The right shoulder was affected in 30% and 9% (p<0.001)
and the left shoulder in 28% and 7% (p<0.001) of the music
and medical students, respectively.
Number of involved anatomic localizations:More music
academy students reported CANS in a higher number of
anatomic localizations: 32.8% of the music academy students
reported complaints in one, 38.8% in two, and 28.4% in three
or more anatomic localizations. In medical students, 58.8%
reported complaints in one, 31.7% in two, and 9.8% in three
or more localizations. Table 4 shows the number of anatomic
localizations in which complaints were reported in those
reporting CANS during the last 12 months.
Impact on functioning: Music academy students rated
the impact of CANS on activities of daily living as more
severe than did medical students (VAS 5.0 vs 3.1; p<0.001,
Table 2).
Health care usage: Of all students reporting CANS
during the last 12 months, significantly more music acad-
TABLE 2. Characteristics and Duration in Music Academy and Medical Students with CANS
12-months-prevalence of CANS Point prevalence of CANS Chronic CANS
_______________________________ _______________________________ _______________________________
Music Music Music
Academy Medical Academy Medical Academy Medical
Students Students Students Students Students Students
(n=83) (n=494) p-Value (n=83) (n=494) p-Value (n=83) (n=494) p-Value
Prevalence of CANS 80.7% 41.5% 0.001 47.0% 18.2% <0.001 36.1% 10.3% <0.001
Influence of CANS
on functioning* 5.0 (2.8) 3.1 (2.4) <0.001 5.0 (2.7) 3.7 (2.4) 0.013 5.4 (2.6) 4.4 (2.3) 0.122
Symptoms
Pain 91.0% 91.2% 0.965 92.3% 91.1% 0.329 90.0% 90.2% 0.623
Motor problems
Gross motor skills 23.9% 25.4% 0.807 25.6% 23.3% 0.823 30.0% 35.3% 0.897
Fine motor skills 10.4% 3.4% 0.024 2.6% 1.1% 0.013 13.3% 2.0% 0.701
Loss of speed 13.4% 1.0% <0.001 5.1% 0 0.001 20.0% 0 0.062
Loss of control 7.5% 1.5% 0.012 5.1% 1.1% 0.164 13.3% 0 0.062
Cramp 35.8% 23.4% 0.046 25.6% 23.3% 0.016 40.0% 35.3% 0.422
Power loss 14.9% 6.8% 0.043 7.7% 1.1% 0.365 23.3% 5.9% 0.107
Loss of endurance 29.9% 5.4% <0.001 23.1% 6.7% 0.001 36.7% 9.8% 0.021
Other
Swelling 10.4% 3.9% 0.042 10.3% 0 0.455 20.0% 0 0.007
Redness 3.0% 2.9% 0.980 2.6% 0 0.181 3.3% 2.0% 0.190
Other 0.0% 5.4% 0.053 0 5.6% 0.644 0 13.7% 0.371
*Measured on VAS 1–10. SD given in parentheses. Significant p-values are shown in boldfaced type.
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166 Medical Problems of Performing Artists
emy students than the medical students visited a health-
care professional (46.3% vs 29.8%, p=0.013, Table 5).
Gender and school grade: Among the music academy
students, a higher prevalence of CANS was present among
female students compared to male students (84% vs 71%,
p=0.212, Table 6). A higher prevalence of CANS was
reported among bachelor’s students than master’s students
(85% vs 55%, p=0.018, Table 6).
DISCUSSION
This study showed high prevalence rates of CANS among
music academy students, which were two to three times
higher than in medical students. Prevalence rates of
CANS in music academy students were 80.7% for 12-
month prevalence of CANS, 47.0% for point prevalence,
and 36.1% for prevalence of chronic CANS. Furthermore,
music academy students with CANS presented with a
higher number of symptoms for each of the anatomic
localizations. Complaints were present at a higher number
of anatomic localizations among music academy students
than in medical students, and they rated the influence of
CANS on daily functioning as more severe compared to
the control group of medical students. Music academy stu-
dents also reported more healthcare use compared to med-
ical students due to these musculoskeletal complaints.
In this study we choose not to account work-related-
ness, although we focused on a specific occupational
group. The reason for this was that the advantage of using
the definition of CANS, a universal term allowing ade-
quate comparison of results, would thereby be lost. Also
the term playing-related musculoskeletal complaints
(PRMDs)15 was not used in the present study, due to the
limitation to work/music-related complaints in that defi-
nition. Furthermore, PRMDs would not have been scored
properly in the non-musicians control group, which would
make comparison of these groups impossible.
Computer office workers are one of the occupational
groups known to have a high risk of upper extremity mus-
culoskeletal complaints. Research on CANS among com-
puter office workers showed 1-year prevalences between 54
and 64%.9,16,17 This prevalence is higher than the preva-
lence in the general Dutch population (36.8%).14 However,
this prevalence of CANS among computer office workers
is still low compared to the 12-month prevalence in our
music academy students (80.7%), underscoring even more
the high prevalence of CANS in this specific group of stu-
dents. Thus, focusing on preventive measures to counter-
act the occurrence of these musculoskeletal complaints is
of importance.
An unexpected outcome of this study was the use of
healthcare of music academy students compared with med-
ical students with CANS. Previous research showed a cul-
ture among musicians acknowledging musculoskeletal pain
as “a normal consequence of playing” and in which talking
about these complaints is considered a taboo, the latter
potentially causing a healthcare-avoiding behavior.15,18
This was in contrast to our findings, since we found more
healthcare use among Dutch music academy students than
in medical students. These results are comparable to a
Danish study2which also showed a high healthcare use
among musicians (64%); on the contrary, in the USA,
TABLE 3. Affected Anatomic Localizations in Music Academy and Medical Students with CANS During the Last 12 Months
No. of Music Academy No. of Medical Students
Students with CANS with CANS During
During Last 12 Months Last 12 Months p-Value
Hand Right 13 (16%) 21 (4%) 0.005
Left 7 (8%) 16 (3%) 0.123
Wrist Right 13 (16%) 30 (6%) <0.001
Left 6 (7%) 17 (3%) 0.001
Elbow Right 1 (1%) 4 (1%) 0.541
Left 5 (6%) 6 (1%) 0.012
Shoulder Right 25 (30%) 42 (9%) <0.001
Left 23 (28%) 32 (7%) <0.001
Neck 38 (46%) 135 (27%) 0.001
Significant p-values are shown in boldfaced type.
TABLE 4. Overlap of Complaints in Anatomic Localizations in Subjects with CANS During the Last Year
No. of Anatomic Sites
_______________________________________________________________________________________
1234567
Music academy students (n=67) 22 (32.8%) 26 (38.8%) 13 (19.4%) 5 (7.5%) 0 1 (1.5%) 0
Medical students (n=205) 120 (58.5%) 65 (31.7%) 17 (8.3%) 2 (1.0%) 0 0 1 (0.5%)
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September 2015 167
healthcare use among musicians is reported at only 21%.19
Musicians in general have low economic resources and
often no permanent contract, with consequently no health-
care insurance for these complaints in a US-based system.20
The differences found between the above-mentioned stud-
ies and countries may be caused by financial reasons due to
national differences in both accessibility of healthcare sys-
tems as well as funding of healthcare use, which are both
easily accessible and rather cheap in the Netherlands.
Limitations
The present study has some limitations. First, the response
rate was low, which can be due to the fact that the invita-
tion for the questionnaire was sent by e-mail (instead of
telephone/mail), and only one reminder was send to the
participants. Second, selection bias may be present as a
consequence of this low response rate and may have
resulted in an over- or underestimation of the results. In
general it has been found, that those who sought medical
care are more likely to respond to a postal survey,21 and
thus an overestimation of musculoskeletal complaints
might be present in this study.
Third, selection bias may be present by the use of med-
ical students as a control group. It is unknown whether
medical students with CANS will under- or over-report
their complaints compared to those with CANS in the gen-
eral population. The “medical students disease,”
hypochondria, might result in a higher amount of health-
care use; on the other hand, medical students can easily
access medical literature and informally consult a physi-
cian, which might result in a less “official” healthcare
usage.22 The largest study measuring the prevalence of
CANS in the general population reported a 1-year preva-
lence of 36.8%.14 This prevalence, in a population aged over
25 yrs of age, is comparable to our outcome data among
medical students (41.5%). Also, the overall healthcare usage
due to CANS between these studies is comparable: 59% in
our control population compared to 58% in the study of
Huisstede et al.14 This comparability of the control group
with a study performed in the general population under-
lines the representativeness of our control group.
There is a lack of literature comparing musicians with
non-musicians.4,11,12,23 Comparative research has a higher
level of evidence compared to a non-controlled cross-sec-
tional study. This study has, despite the presence of bias by
using medical students, an important additional value to
the existing literature on musculoskeletal problems among
musicians.
Future research on musculoskeletal complaints among
musicians should aim at two important domains: 1) pre-
vention, and 2) treatment of specific and non-specific
CANS. One of the options for prevention could be a pre-
vention training program; In all types of professional
sports, there are specific strength training programs, in
addition to the technical sport-specific training, which
have proved to reduce the risk of injuries, also in non-con-
tact sports.24 A comparable preventive training program
should be developed for musicians; a study on a physical
training program for musicians or music academy students
with a focus on the upper extremity would be very interest-
ing. Khalsa and Cope,25 for example, studied the effect of
yoga training on a small group of music students, which
seemed to relieve performance anxiety but not muscu-
loskeletal problems. Recently, in Australia, a trial was
started to study the effects of a training program on
orchestral musicians.26 In addition to physical efforts pre-
venting musculoskeletal complaints, the mental aspects
also should be addressed.27 These studies are examples of
the next steps in preventing musculoskeletal complaints
among musicians. However, much work has to be done,
TABLE 5. Health Care Usage of Music Academy and Medical Students with CANS
CANS During the Last Year Current CANS Chronic CANS
_______________________________ _______________________________ _______________________________
Music Music Music
Academy Medical Academy Medical Academy Medical
Students Students Students Students Students Students
(n=67) (n=205) p-Value (n=39) (n=90) p-Value (n=30) (n=51) p-Value
Any medical care 46.3% 29.8% 0.013 53.8% 52.2% 0.865 63.3% 66.7% 0.761
General practitioner 14.9% 12.7% 0.638 15.4% 23.3% 0.308 16.7% 31.4% 0.145
Specialist 16.4% 4.4% 0.001 20.5% 8.9% 0.066 26.7% 7.8% 0.021
Physiotherapist 34.3% 18.5% 0.007 41.0% 34.4% 0.476 53.3% 49.0% 0.708
Alternative medicine 16.4% 3.4% <0.001 23.1% 6.7% 0.008 26.7% 9.8% 0.046
Significant p-values are shown in boldfaced type.
TABLE 6. Occurrence of CANS (12-Month Prevalence)
Among Music Students, by Gender and Grade
CANS No CANS
(n=67) (n=16) p-Value
Gender 0.212
Male (n=21) 15 (71%) 6 (29%)
Female (n=62) 52 (84%) 10 (16%)
Grade 0.018
Bachelor’s (n=72) 61 (85%) 11 (15%)
Master’s (n=11) 6 (55%) 5 (45%)
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especially among music academy students, in which mus-
culoskeletal problems are highly prevalent and changes in
health habits and attitude can be made.
A second important future study domain should focus
on describing the occurrence, clinical presentation, and
treatment options and outcomes of specific syndromes
and diseases among musicians. For example, studies
describing the presentation of “normal diseases” such as
neuropathy of the median or ulnar nerve among musi-
cians28,29 should focus on specific complaints among musi-
cians that are probably different compared to the general
population. Also, the outcome of regular and musicians-
specific conservative treatment options (e.g., adaptive
instruments, playing technique) and operative treatment
options should be evaluated in order to optimize health-
care for musicians.30 This could lead to a field of knowl-
edge, comparable to sports medicine, in which the choice
of treatment for musicians possibly differs compared to
non-musicians. The results of this study may help to give
directions to both of the above-mentioned study domains.
CONCLUSION
In conclusion, this study emphasized the striking preva-
lence rates and serious consequences on daily functioning
and healthcare usage of CANS among music academy stu-
dents. Awareness of this health condition among this spe-
cific profession is a first step, which may be helpful to
develop preventive intervention programs aimed at reduc-
ing the extent and consequences of CANS among music
academy students and musicians.
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