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December 2006 169
Abstract—The aim of this cross-sectional study was to describe self-
reported problems among guitarists and to examine differences
associated with type of guitar played. Data for the study were
extracted from the University of North Texas Musician Health
Survey (UNT-MHS) data set. Subjects for the present study (n =
520) were included if they identified acoustic guitar, electric guitar,
electric bass or banjo as their primary instrument. Prevalences for
musculoskeletal problems were determined for the total group, by
guitar-specific groups, and by gender. Prevalences for nonmuscu-
loskeletal, overall health problems were established for the whole
guitar group and by instrument. Of the total subjects, 81% reported
one or more musculoskeletal problems. The acoustic guitar group
reported the highest prevalence (83%), followed by the banjo (78%),
electric bass (77%), and electric guitar groups (74%). The highest
site-specific prevalences for the whole group were the left fingers
(32.9%), left wrist (29.8%), and left hand (24.7%). Regarding non-
musculoskeletal problems, 66% of the total group perceived stress
due to work environment as a moderate to high problem. The total
group reported mostly problems with fatigue, depression, headache,
and eye strain. The overall findings of the study show that muscu-
loskeletal problems as well as stress-related health problems are a
major concern for the guitar community. Med Probl Perform Art
Guitarists represent one of the largest and fastest growing
groups of musicians. According to the Music Trades
Magazine industry census,1guitar is the number one selling
instrument. In the year 2000, 1.6 million guitars were sold,
which has more than doubled since 1992. Total piano sales
were second to guitar at about 107,000 with guitar outnum-
bering piano with more than 15 to 1. The American Federa-
tion of Musicians (AFM), who represents union musicians in
the U.S. and Canada, reported that in the year 2002, over
16,000 out of approximately 100,000 union members were
Similar to musicians playing other instruments, guitarists
experience work-related musculoskeletal problems that affect
the upper extremity and back. One study included a random
sample of 1000 U.S. residents and found the highest preva-
lence of upper-extremity pain in keyboardists (33%) and gui-
tarists (30 %)2. A cross-sectional study on work-related mus-
culoskeletal and psychosocial health among music teachers
indicated that teachers who reported guitar as their primary
and most played instrument had an increased risk for having
neck and shoulder disorders.3A report from a hand surgical
practice that included 167 instrumentalists showed that gui-
tarists presented mostly left-sided or bilateral strains distal to
the elbow, inflammatory conditions, and nerve problems
such as focal dystonia in the hand and fingers, and carpal
tunnel syndrome.4Medical problems of guitarists have been
highlighted in case studies and included guitar-string der-
matitis and other skin conditions,5–7 tuft finger fractures8,
and acro-osteolysis as evidenced by shortening of the distal
phalangeal finger bones due to mechanical stress on the fin-
gers while playing the guitar.9,10
Some reports indicate that classical guitarists are among
the guitarists most likely to suffer from musculoskeletal prob-
lems related to playing.11,12 However, a study of muscu-
loskeletal problems in guitarists playing popular music
showed that many of these musicans also experience playing-
related pain in the left hand and wrist, back, and neck.13 The
musculoskeletal problems of banjo players also have to some
extent been reported, showing cases of overuse syndrome and
focal dystonia.14,1 5 The prevalence of nonmusculoskeletal
problems in musicians, relevant to guitarists, reflect concerns
for stress, fatigue, sleeping problems, depression, anxiety,
stage fright, and substance abuse.16 ,17
The reasons for work-related musculoskeletal problems
among guitarists are not fully understood. Physical demands
such as non-neutral postures while working, repetitive arm
and finger movements, and required force for performing any
work task have been proposed.18–20 Extreme working postures
and working techniques that include repetitive movements
and static muscle work are easily found in guitar playing.21,22
However, research is needed to better understand the relative
importance of these factors.
Guitars come in many shapes and sizes and involve vari-
ous performance techniques. General categories include
Musculoskeletal and General Health
Problems of Acoustic Guitar,
Electric Guitar, Electric Bass,
and Banjo Players
Anncristine Fjellman-Wiklund, R.P.T., Ph.D., and Kris Chesky, Ph.D.
Dr. Fjellman-Wiklund is Senior Lecturer at the Department of Community
Medicine and Rehabilitation, Physiotherapy, Umeå University, Umeå,
Sweden, and is a Visiting Scholar at the Texas Center for Music & Medi-
cine, University of North Texas, College of Music, Denton, TX. Dr. Chesky
is Director of the Texas Center for Music & Medicine, University of North
Texas, College of Music, Denton, TX.
Address correspondence and reprint requests to: Dr. Anncristine Fjellman-
Wiklund, Department of Community Medicine and Rehabilitation, Phys-
iotherapy, Umeå University, Umeå, Sweden. Tel 46.90786-9756; email
170 Medical Problems of Performing Artists
acoustic guitar, electric guitar, and electric bass. In addition
to the obvious differences due to sizes and shapes, character-
istics of string size and strength may influence levels of force
to depress, pluck, pull, or bend strings. Influences also may
include the number of strings used and the overall weight of
Another instrument in the guitar family is the banjo,
widely used in folk, bluegrass, and early jazz, this instrument
includes challenging technique that can involve a high fre-
quency of finger movements for extended periods of time
under certain conditions that require great precision.15 There
are different types of banjos, including those with different
sizes and number of strings. Greene21 suggested that the
shape of the banjo and the positions necessary to support it
are important factors that may lead to nerve compressions.
Clearly, guitarists are at risk for medical problems. How-
ever, past reports have grouped guitarists into one homoge-
nous population. To our knowledge, no study has described
patterns or types of medical problems across subgroups. The
aim of this study was to describe self-reported problems
among guitarists and to examine differences associated with
type of guitar played. The study was approved by the Univer-
sity of North Texas Institutional Review Board.
The University of North Texas Health Survey
Data for this study were extracted from the University of
North Texas Musician Health Survey (UNT-MHS) data set.
The Survey was created to examine medical problems among
a large heterogeneous group of musicians (n= 4017).23 It was
developed to recruit subjects and to collect information over
the Internet and involved discussion groups, advertisements
in professional publications, and notices by professional soci-
eties and organizations. Several research articles have resulted
from this effort and suggest that the respondents to the UNT-
MHS compared well to the U.S. population regarding demo-
graphic and socioeconomic profiles.23 The online aspect of
the survey has been addressed in one study comparing two
samples of flautists, which showed similar demographics and
responses to questions about musculoskeletal problems.24
Study Population and Assessments
Subjects for the present study were included if they iden-
tified acoustic guitar, electric guitar, electric bass, or banjo as
their primary instrument. Data were coded, entered, and
analyzed using the Statistical Package for the Social Science
(SPSS) for Windows (version 13.0, SPSS Inc., Chicago, IL).
Descriptive statistics for both the total and guitar-specific
groups included questions regarding age, gender, height,
weight, marital status, primary instrument, years of formal
college music instruction, hours of practice per day, smoking
status, and hours of weekly physical exercise.
The survey list of bilateral body locations was used to deter-
mine musculoskeletal problems.25 Prevalence rates for one or
more musculoskeletal problem were calculated for the total
group and by guitar-specific groups. Site-specific prevalence
rates were calculated for the whole guitar group, by instrument-
specific groups, and by gender and for comparisons, between
classical and nonclassical guitarists. For guitarists who reported
problems at specific sites, average pain severity levels were cal-
culated from responses to a five point scale by Fry.26
Nonmusculoskeletal questions included several health
problems common in musicians. Prevalence rates for these
problems were calculated for the whole guitar group and by
instrument-specific groups. The Pearson chi-square test (95%
significant level) was used for testing group differences in
Out of the total UNT-MHS sample, 520 subjects (62
women, 458 men) reported guitar as their primary instru-
ment. Table 1 shows the demographic data for the total
TABLE 1. Demographics for the Total Guitar Group
Acoustic Guitar Electric Guitar Electric Bass Banjo Total Guitar
Demographics* (n= 213) (n= 185) (n= 108) (n= 14) (n= 520)
Age, yrs 37.12 (11.62) 31.11 (11.21) 33.14 (10.58) 48.14 (9.67) 33.04 (13.05)
Gender, % male 78 97 91 78 88
Height, in 69.9 (3.7) 70.4 (3.6) 70.4 (3.2) 68.5 (2.9) 69.8 (3.4)
Weight, lbs 183.4 (37.1) 178.7(36.4) 184.8 (40.3) 206 (68.8) 188.2 (45.7)
Marital, % married 51 38 45 71 51
Yrs of music college instruction 1.7 (2.3) 4.1 (2.9) 1.8 (2.6) 0.3 (0.8) 1.2 (2.2)
Practice per day, hrs 2.2 (1.6) 2.6 (1.7) 2.1 (1.4) 1.6 (1.1) 2.1 (1.4)
Earning ≥50% of income from music
performance, % 19 21 13 7 18
Classical guitarist in group, % 9 0.5 3.7 — 6
Smoker, % 13 21 18 14 16.5
Physical exercise, hrs/wk 3.3 (3.4) 4.4 (5.5) 3.7 (5.2) 3.8 (4.2) 3.8 (4.6)
*Data, where appropriate, are expressed as mean (SD)
December 2006 171
guitar group and for guitar-specific instrument groups.
Gender distribution was significantly male dominated for all
guitar groups (p= 0.01). Classical guitar was played by 6% of
the total group. The mean number of years of college music
instruction was 1.2 (SD 2.2) for the total group. The gui-
tarists reported a mean practice time of 2.1 hrs/day (SD 1.4)
and a mean physical exercise time of 3.8 hrs/wk (SD 4.6).
Eighteen percent of the total group reported that 50% or
more of their total income came from music performance.
Total Guitar Group
Of the total group, 81% reported having musculoskeletal
problems in one site or more. The highest site-specific preva-
lence rates for the whole group were for the left fingers
(32.9%), left wrist (29.8%), and left hand (24.7%) (Table 2).
Comparisons of prevalence rates by gender for the guitar
group and subgroups showed consistently higher prevalence
rates for female guitarists than males (Table 2). In some cases,
the prevalence was twice or three times as high for female gui-
tarists. Severity levels in many cases were higher for sites with
higher prevalence rates (Table 3).
Acoustic guitar represented the largest subgroup (n=
213) (Table 1), with 83% reported having musculoskeletal
problems in one site or more. Acoustic guitarists reported
most problems in the left fingers (34.9%), left wrist (34%),
and left hand (27.4%) (Table 2). About one forth of the
group were females, reporting problems especially in the
left fingers (46.5%) (Table 2). Specific severity levels showed
that for the acoustic guitar group, the highest severity levels
were found in the right shoulder (2.63) and left lower back
(2.65) (Table 3). Comparisons between classical and non-
classical guitarists showed that classical guitarists reported
significantly more musculoskeletal problems (p= 0.027).
Electric guitarists were the second largest subgroup (n=
185) (Table 1) with the lowest total prevalence (74%) of mus-
culoskeletal complaints of the guitar groups. Highest preva-
lence sites for electric guitarists included the left wrist
(28.7%) and left hand (23.4%) (Table 2). Representing a
small group (3%), female electric guitarists reported prob-
lems at the left hand (66.7%), left wrist (50%), and right
wrist (50%). The electric guitar group reported highest sever-
ity levels in the left shoulder (2.92), right lower back (2.88),
and left lower back (2.83) (Table 3).
Electric bass players represented about a fifth of the total
guitar group (n= 108) (Table 1). The total prevalence of mus-
culoskeletal complaints for the group was 77%. Electric bass
players reported problems at the left finger (31.2%), right
lower back (25.7%), left lower back (23.9%), and right fingers
TABLE 2. Prevalence Rates (%) for Musculoskeletal Problems across Gender, Specific Guitar Groups, and the Total Guitar Group
Acoustic Guitar Electric Guitar Electric Bass Banjo Total Guitar
Body Region Female/Male/Total Female/Male/Total Female/Male/Total Female/Male/Total Female/Male/Total
Right finger 30.2 / 24.7 / 26 33.3 / 22.2 / 22.3 30.0 / 23.5 / 23.9 0 / 27.3 / 21.4 29.0 / 23.5 / 24.1
Left finger 46.5 / 31.9 / 34.9 33.3 / 32.8 / 33 50.0 / 29.6 / 31.2 0 / 18.2 / 14.3 43.5 / 31.4 / 32.9
Right hand 18.6 / 18.7 / 18.1 50.0 /14.4 / 15.4 40.0 / 17.3 /19.3 0 / 9.1 / 7.1 24.2 / 16.5 / 17.1
Left hand 30.2 / 27.1 / 27.4 66.7 / 21.7 / 23.4 50.0 / 21.4 / 23.9 0 / 9.8 / 7.1 35.5 / 23.3 / 24.7
Right wrist 23.3 / 22.3 / 21.9 0 / 22.2 / 21.8 30.0 / 19.4 / 20.2 33.3 / 27.3 / 28.6 22.6 / 21.8 / 21.7
Left wrist 25.6/ 37.3 / 34 50.0 / 28.3 / 28.7 50.0 / 22.4 / 24.8 33.3 / 18.2 / 21.4 32.3 / 30.1 / 29.8
Right forearm 4.7 / 8.4 / 8.4 16.7 / 16.7 / 16.5 30.0 / 12.2 / 13.8 0 / 18.2 / 14.3 9.7 / 12.7 / 12.5
Left forearm 9.3 / 15.1 / 14.4 16.7 / 14.4 / 14.4 40.0 / 11.2 / 13.8 0 / 18.2 / 14.3 14.5 / 14.1 / 14.3
Right elbow 14.0 / 7.8 / 8.8 0 / 13.3 / 12.8 0 / 8.2 / 7.3 0 / 0 / 0 9.7 / 9.9 / 9.7
Left elbow 11.6 / 9.6 / 9.8 0 / 7.2 / 6.9 10.0 / 9.2 / 9.2 0 / 0 / 0 9.7 / 8.4 / 8.4
Right shoulder 27.9 / 16.9 / 20.0 16.7 / 14.4 / 14.9 40.0 / 15.3 / 17.4 0 / 18.2 / 14.3 27.4 / 15.6 / 17.5
Left shoulder 32.6 / 15.7 / 20.0 33.3 / 16.1 / 16.5 30.0/ 23.5 / 23.9 33.3 / 36.4 / 35.7 32.3 / 18.0 / 20.0
Right side of neck 27.9 / 12.0 / 15.8 33.3 / 13.3 / 13.8 40.0 / 12.2 / 14.7 0 / 18.2 / 14.3 29.0 / 12.7 / 14.8
Left side of neck 23.3 / 10.2 / 13.5 33.3 / 10.0 / 10.6 40.0 / 9.2 / 11.9 33.3 / 9.1 / 14.3 27.4 / 9.9 / 12.2
Right upper back 14.0 / 6.6 / 8.8 0 / 13.3 / 12.8 20.0 / 13.3 / 13.8 33.3 / 27.3 / 28.6 14.5 / 11.2 / 11.8
Left upper back 14.0 / 6.6 / 8.8 0 / 9.4 / 9.0 30.0/11.2/12.8 0/18.2/14.3 14.5 /9.0 / 9.9
Right middle back 9.3 / 10.2 / 9.8 0 / 8.9 / 8.5 20.0/11.2/11.9 0 / 9.1 / 7.1 9.7 / 9.9 / 9.7
Left middle back 4.7 / 8.4 / 7.4 0 / 7.8 / 7.4 20.0/9.2/10.1 0 / 9.1 / 7.1 6.5 / 8.4 / 8.0
Right lower back 25.5 / 15.1 / 17.7 33.3 / 22.2 / 22.3 30.0/25.5/25.7 0 / 36.4 / 28.6 25.8 / 20.7 / 21.3
Left lower back 14.0 / 10.8 / 12.1 16.7 / 22.8 / 22.3 30.0/23.5/23.9 0 / 27.3 / 21.4 16.1 / 18.7 / 18.4
172 Medical Problems of Performing Artists
(23.9%) (Table 2). Females represented about 10% of the
group and reported problems at the left fingers (50.2%), left
hand (50.2%), left forearm (40.2%), right hand (40.2%),
right shoulder (40.2%), and left shoulder (40.2%), and right
side of the neck (40.2%) (Table 2). The highest severity levels
reported by the group were left elbow (2.90) and right lower
back (2.57) (Table 3).
Banjo players was the smallest group (n= 14) (Table 1),
and they had a total prevalence about the same as electric
bass players (78%). Banjoists reported most problems in the
left shoulder (35.7%), right wrist (28.6%), and right upper
and lower back (28.6%) (Table 2). The highest prevalence
rates for female banjo players included the right wrist
(33.3%), left wrist (33.3%), left shoulder (33.3 %), left side of
the neck (33.3 %), and right upper back (33.3 %) (Table 2).
The highest severity levels included the right hand (4.0), left
wrist (3.0), and right fingers (2.67) (Table 3).
Regarding nonmusculoskeletal problems, 66.2% of the
total guitar group perceived stress due to work environ-
ment as a moderate to high problem. The total guitar
group reported problems with fatigue (39.7%), depression
(36.1%), headache (32.1%), and eye strain (31.2%) (Table
4). Acoustic guitarists reported most problems with fatigue
(36.7%), headache (34%), and stage fright (33%), which
was significantly greater than other guitar groups (p=
0.006). Problems with highest prevalence rates by electric
guitarists included fatigue (44.7%), depression (39.4%),
and eye strain (30.9%). Electric bass players reported prob-
lems with fatigue (40.4%), depression (36.7%), hearing
loss (34.9%), and headache (33.0%). Banjo players
reported problems with depression (42.9%), weight
(42.9%), sleep disturbance (35.7%), eye strain (35.7%),
and hearing loss (35.7%).
The aim of the present study was to examine and compare
medical problems of musicians who play the guitar. The results
indicated that many guitarists experience musculoskeletal
problems. Compared to other instrument-specific results from
the UNT-MHS data, the prevalence rates for musculoskeletal
TABLE 3. Severity Levels by Musculoskeletal Body Regions across Guitar Groups and for the Total Guitar Group*
Body Region Acoustic Guitar Electric Guitar Electric Bass Banjo Total Guitar
Right finger 2.0 (1.19) 1.86 (1.14) 1.58 (0.90) 2.67 (1.53) 1.96 (1.10)
Left finger 2.07 (1.14) 2.02 (1.12) 1.88 (1.07) 2.50 (0.70) 1.98 (1.30)
Right hand 2.08 (1.31) 2.03 (1.24) 1.62 (0.86) 4.00 (–) 2.15 (1.14)
Left hand 2.27 91.11) 2.05 (2.0) 1.92 (0.89) 3.00 (–) 2.11 (1.17)
Right wrist 2.15 (1.10) 2.30 (1.21) 2.32 (1.25) 1.75 (0.96) 2.29 (1.20)
Left wrist 2.37 (1.15) 2.54 (1.34) 2.26 (1.10) 1.67 (1.15) 2.23 (1.17)
Right forearm 2.22 (1.35) 2.10 (1.19) 1.67 (1.11) 1.50 (0.71) 2.11 (1.11)
Left forearm 2.06 (1.18) 2.52 (1.12) 2.13 (1.25) 1.00 (0.00) 2.00 (1.10)
Right elbow 2.11 (1.15) 2.29 (1.33) 2.00 (1.20) — 2.27 (1.23)
Left elbow 2.33 (1.0) 2.38 (1.39) 2.90 (1.45) — 2.34 (1.27)
Right shoulder 2.63 (1.18) 2.25 (1.27) 2.47 (1.39) 2.50 (0.71) 2.30 (1.17)
Left shoulder 2.40 (1.05) 2.92 (1.14) 1.92 (1.16) 1.60 (1.34) 2.23 (1.15)
Right side of neck 2.24 (1.21) 2.19 (1.13) 2.06 (1.29) 2.00 (1.41) 2.23 (1.13)
Left side of neck 2.24 (1.18) 2.35 (1.09) 1.15 (1.14) 1.00 (0.00) 2.25 (1.14)
Right upper back 2.26 (0.87) 2.00 (1.18) 2.07 (1.22) 2.50 (1.29) 2.13 (1.10)
Left upper back 2.05 (1.03) 2.41 (1.23) 2.29 (1.14) 2.50 (0.71) 2.19 (1.10)
Right middle back 2.33 (0.91) 2.25 (1.06) 2.08 91.32) 2.00 (0.00) 2.10 (1.10)
Left middle back 2.56 (0.89) 2.57 (0.85) 2.27 (1.35) 2.00 (0.00) 2.11 (1.09)
Right lower back 2.47 (1.20) 2.88 (1.17) 2.57 (1.43) 2.25 (1.26) 2.45 (1.22)
Left lower back 2.65 (1.29) 2.83 (1.12) 2.19 (1.36) 2.33 (1.53) 2.45 (1.22)
*Pain severity levels, from 1-5, were calculated for subjects who reported having pain in one site or more.=
Grade 1: Pain while playing; should be consistent rather than occasional: pain ceases when not playing.
Grade 2: Pain while playing; slightly physical signs of tenderness; may have transient weakness or loss of control: no interference with
other uses of this location.
Grade 3: Pain while playing; pain persists away from instrument; some other uses of this location cause pain; may have weakness, loss of
control; loss of muscular response or dexterity.
Grade 4: As for Grade 3; all common uses of the location cause pain (housework, driving, writing, turning knobs, dressing, washing,
etc.) but these are possible as pain is tolerated.
Grade 5: As for Grade 4; including loss of use of location due to disabling pain.
December 2006 173
problems for guitarists were similar to those reported for bas-
soon players27 and higher than those for oboists,27 brass play-
ers,28 and pianists.29 Prevalence rates of guitarists in this study
compared well to those reported in other studies of muscu-
loskeletal problems of guitar-specific groups12 and in general
music populations that included guitarists.2,3
The present study did show a distinct trend for left-sided
problems for guitarists. Acoustic guitarists, electric guitarists,
and electric bass players all reported highest prevalence rates
for the left fingers and left hand (Fig. 1–3) while banjo play-
ers reported left shoulder problems (Fig. 4). Guitarists
reported highest pain severity levels in the left wrist and fin-
gers, and banjoists reported highest pain severity levels in the
Upper-extremity musculoskeletal problems reported by gui-
tarists do seem to reflect the general biomechanics, postural,
and other playing demands including repetitive movements
together with static muscle work. Certain playing techniques
have been discussed to address poor posture, especially exces-
sive wrist deviation and wrist flexion.21 The importance of
keeping the finger joints in a neutral position for timing and
for controlling the sound was stressed in one study.30 Other
studies have discussed how the fingers of the left hand may
perform repetitive movements at extreme flexion and depend-
ing on playing posture, together with ulnar or radial devia-
tion, while at the same time forearms, elbows and shoulders
at both sides are stabilizing and positioning the hands.12,13,22
When left wrist is held in maximum flexion, the maximal
strength used in the flexor muscles may be decreased, possibly
creating repetitive and static strain and maximum carpal
tunnel pressure. Brandfonbrener31 has found from clinical
practice that it is largely the hyper-flexed wrist positions that
TABLE 4. Prevalence Rates (%) for Nonmusculoskeletal Problems across Specific Guitar Groups and the Total Guitar Group*
Nonmusculoskeletal Problem Acoustic Guitar Electric Guitar Electric Bass Banjo Total Guitar
Fatigue 36.7 44.7 40.4 14.3 39.7
Depression 32.6 39.4 36.7 42.9 36.1
Headache 34.0 29.8 33.0 28.6 32.1
Eye strain 33.0 30.9 27.5 35.7 31.2
Weight problems 30.2 29.8 27.5 42.9 29.8
Sleep disturbances 31.2 26.1 27.5 35.7 28.7
Stage fright 33.0 23.4 16.5 14.3 25.7
Hearing loss 14.9 28.2 34.9 35.7 24.3
Acute anxiety 18.1 19.7 19.3 21.4 19.0
Respiratory allergy 17.7 20.2 14.7 21.4 18.1
Earaches 12.1 17.6 22.0 21.4 16.1
Asthma 16.3 11.7 15.6 0 14.1
Blackout/dizziness 10.7 16.5 14.7 7.1 13.5
Chest discomfort 12.1 14.4 9.2 14.3 12.4
Hemorrhoids 12.6 9.6 15.6 14.3 12.2
High blood pressure 9.3 8.0 6.4 7.1 8.2
TMJ syndrome 8.8 5.3 9.2 0 7.4
*Prevalence is in ranked order from highest to lowest rate for the total group.
FIGURE 1. Musculoskeletal problems in left versus right side for acoustic guitar (n= 213).
174 Medical Problems of Performing Artists
generate musculoskeletal disorders and that playing with neu-
tral wrist position generates fewer problems.
Another interesting trend was that banjo and electric bass
players reported musculoskeletal problems in the right fin-
gers and right wrist. Perhaps this finding is associated with
the demands associated with plucking. Plucking may increase
muscle effort in the right hand and fingers. Finger flexion
seems to be necessary for the plucking of the strings, but
there seems to be no reason for moving the wrist in extreme
flexion at the same time, provoking carpal tunnel syn-
drome.21 A playing technique that includes bringing the
hand closer to the strings through adjustments at the elbow
and shoulder might decrease the wrist flexion during pluck-
ing, which could prevent wrist problems. Plucking the strings
via a small and very thin plectrum includes a precision grip,
which also may increase the muscle tension in the fingers and
hand. Motion analysis of banjo finger-picking suggested that
extreme flexion of the distal interphalangeal joint and abduc-
tion of the index finger joint may be risk factors for finger
problems in banjo players.15
Prevalence rates for back problems found in the present
study may be related to holding the instrument’s consider-
able weight, sometimes for hours in a slightly flexed and
twisted position. Musicians routinely lift and move their
instrument(s) and other music equipment from one place to
another. Although the epidemiology literature is limited,
cumulative physical loading of the spine tissues, particularly
with high peak forces and adverse trunk postures and move-
ments, is an assumed risk factor for low back pain.32 In recent
epidemiologic reviews, lifting and carrying, as well as bending
and twisting, were found to be risk factors for back pain.18,19,33
Manual handling as a work task is common in working
life.18–20 It is regarded as a complex task requiring strength,
endurance, balance, and experience. Studies on manual han-
dling have found that men lift more than women in working
life, under experimental conditions, and during leisure
FIGURE 2. Musculoskeletal problems in left versus right side for electric guitar (n= 185).
FIGURE 3. Musculoskeletal problems in left versus right side for electric bass (n= 108).
December 2006 175
time.34 Men often handle heavier loads, while women do
lighter, more repetitive lifting. It seems plausible that manual
material handling, which causes high loads on the body, may
lead to musculoskeletal disorders.19
The prevalence rates for musculoskeletal problems were
higher for female guitarists compared with males. Although
consistent with rates reported in studies of other instrumen-
tal groups,27–29 occupations, and populations,18,19,33 these
findings must be considered with caution because of the
small percentage of female guitarists in this study.
Classical guitarists in our study reported significantly
more musculoskeletal problems than nonclassical guitarists.
One previous study of classical and flamenco guitarists
reported that musculoskeletal disorders are a frequent health
problem and suggested that hand and arm problems were
more frequent in flamenco guitarists and possibly attributa-
ble to a plucking technique (i.e., plucking requires greater
muscle effort and a need to produce high volumes when play-
ing in groups).12 Sounds from a classical guitar are typically
more exposed and not combined with other instruments.
Mistakes are easily recognized. Additional research is needed
to help explain why classical guitarists report more muscu-
loskeletal problems than nonclassical guitarists. Research
should include both the physical demands and the psy-
chosocial working conditions as potential determinants.
More than 60% of the total guitar group in the present
study perceived stress due to work environment as a problem.
The highest prevalence rates for nonmusculoskeletal prob-
lems included fatigue, depression, headache, eye strain, and
sleep disturbance. A high level of these general health prob-
lems could be regarded as symptoms reflecting elevated levels
of stress and poor psychosocial work environment. A study of
orchestral musicians has shown that overall health symptoms
(similar to the nonmusculoskeletal symptoms reported in
this study) and musculoskeletal problems were associated
with psychosocial work factors such as work content35: the
more satisfied a musician was with the work content, the
lower level of musculoskeletal and nonmusculoskeletal symp-
toms. Further, a high influence over work conditions and
good social support from colleagues and supervisors led to
less overall health problems.
Psychosocial work factors and hearing disorders have been
investigated in rock and jazz musicians, showing that the
musicians did not generally experience themselves as stressed
at work.36 However, they often felt tired and had difficulties
relaxing after work, and the job was often psychologically
demanding. A difficulty to relax after work was associated
with tinnitus and hyper-acusis.
The strength of the present study is that the data are part
of a large epidemiologic survey that included a large sample of
professional and educated guitarists. Limitations associated
with the cross-sectional and convenience sampling preclude
the possibility of assessing cause-effect relationships and could
have introduced recall bias. Guitarists with medical problems
may have been more likely to report exposure in terms of prac-
tice and performance time, in an attempt to explain or under-
stand the symptoms, while guitarists without problems were
less likely to remember an exposure because of less meaning
or importance of the symptoms to them. The use of the Inter-
net for recruitment of the sample may have introduced self-
selection bias that could affect the validity and reliability of
the responses. However, as mentioned earlier in this article,
two studies23,24 that have compared data from the UNT-MHS
with other samples have suggested that the UNT-MHS respon-
dents compared well to other samples regarding demographic
profiles as well as socioeconomic data reported.
FIGURE 4. Musculoskeletal problems in left versus right side for banjo (n= 14).
176 Medical Problems of Performing Artists
The results of the present study show that the prevalence
rates of musculoskeletal and general health problems in
musicians playing acoustic guitar, electric guitar, electric bass,
and banjo are at a high level, which calls for further investi-
gations. Differences found in the results across the guitar sub-
groups could reflect the specific demands, including biome-
chanics, force, and ergonomics of playing the guitar, as well
as psychological demands. Together with the fact that gui-
tarists represent one of the largest group of musicians, impli-
cations from this research indicate that additional study is
warranted and suggest a need for targeting risk factors impor-
tant to both physical demands and psychosocial work envi-
ronment for a more holistic health approach.
1. The Annual Census of the Music Industries. Music Trades Mag 2002.
Available at: http://www.musictrades.com/census.html; accessed Jun,
2. Morse T, Ro J, Cherniack M, Pelletier S: A pilot population study of
musculoskeletal disorders in musicians. Med Probl Perform Art 2000;
3. Fjellman-Wiklund A, Brulin C, Sundelin G: Physical and psychosocial
work-related risk factors associated with neck-shoulder discomfort in
male and female music teachers. Med Probl Perform Art 2003;
4. Dawson W: Upper-extremity problems caused by playing specific
instruments. Med Probl Perform Art 2002; 17:135–140.
5. Marshman G, Kennedy CTC: Guitar-string dermatitis. Contact Der-
matitis 1992; 26:134.
6. Lombardi C, Bottello M, Caruso A, et al: Allergy and skin diseases in
musicians. Allerg Immunol 2003; 35:52–55.
7. Gambichler T, Boms S, Freitag M: Contact dermatitis and other skin
conditions in instrumental musicians. BMC Dermatol 2004; 4:3.
8. Young RS, Bryk D, Ratner H: Selective phalangeal tuft fractures in a
guitar player. Br J Radiol 1977; 50:147–148.
9. Destouet JM, Murphy WA: Guitar player acro-osteolysis. Skel Radiol
1981 ; 6:275–277.
10. Baran R, Tosti A: Occupational acroosteolytis in a guitar player. Acta
Derm Venereo 1993; 73:64–65.
11.Cayea D, Manchester R: Instrument-specific rates of upper-extremity
injuries in music students. Med Probl Perform Art 1998; 13:19–25.
12. Marques DN, Rosset-Llobet J, Marques F, et al: Flamenco guitar as a
risk factor for overuse syndrome. Med Probl Perform Art 2003;
13. Rigg J, Marrinan R, Thomas M: Playing-related injury in guitarists play-
ing popular music. Med Probl Perform Art 2003; 18:150–152.
14. Brandfonbrener A: Musicians with focal dystonia: a report of 58 cases
seen during a ten-year period at a performing arts clinic. Med Probl
Perform Art 1995; 10:121–127.
15. Kenyon G, Thaut M: Analysis of index finger trajectory in banjo finger
picking: proposed correlates to movement disorder. Med Probl Per-
form Art 1998; 13:127–135.
16. Raeburn S: Psychological issues and treatment strategies in popular
musicians: a review, pt 2. Med Probl Perform Art 2000; 15:6–16.
17. Chesky K, Hipple J: Musicians perceptions of widespread drug use
among musicians. Med Probl Perform Art 1999; 14:187–195.
18. Bernard BP (ed): Musculoskeletal Disorders and Work Place Factors:
A Critical Review of Epidemiological Evidence for Work-related Mus-
culoskeletal Disorders of the Neck, Upper Extremity, and Low Back.
publication no. 97-141. DHHS (NIOSH) Cincinnati, OH, National
Institute for Occupational Safety and Health, July, 1997.
19. Kuorinka I, Forcier L (eds): Work Related Musculoskeletal Disorders:
A Reference Book for Prevention. London, Taylor & Francis, 1995.
20. Buckle PW, Devereux JJ: The nature of work-related neck and upper
limb musculoskeletal disorders. Appl Ergon 2002; 33:207–217.
21. Greene D: Performance-related medical problems and the guitarist: an
overview. GFA Soundboard 1994; 20(3):31–35.
22. Cameron J, McCutcheon J: Experiences of guitar students who begin
to study the piano as a second instrument. Med Probl Perform Art
23. Chesky K, Corns J, Devroop K: Population characteristics of an Inter-
net-based musician survey. In Laufer D, Chesky K, Ellis P (eds): Kölner
Studien Zur Musik in Erziehung und Therapie. Köln, Verlag
Christoph Dohr, 2000, pp 39–51.
24. Spence C: Prevalence rates for medical problems among flautists: A
comparison of the UNT-Musician Health Survey and the Flute Health
Survey. Med Probl Perform Art 2001; 16:99–101.
25. Fishbein M, Middlestadt S, Ottati V, et al: Medical problems among
ICSOM musicians: overview of a national survey. Med Probl Perform
Art 1988; 3:1–8.
26. Fry HJH: Patterns of overuse syndrome seen in 685 affected instru-
mental musicians. Int J Music Educ 1988; 11:3–16.
27. Thrasher M, Chesky K: Medical problems of clarinetists: results from
the UNT-Musician Health Survey. The Clarinet 1998; 25(4):24–27.
28. Chesky K, Devroop K, Ford, J III: Medical problems of brass instru-
mentalists: prevalence rates for trumpet, trombone, French horn, and
low brass. Med Probl Perform Art 2002; 17:93–98.
29. Pak C, Chesky K: Prevalence of hand, finger, and wrist musculoskele-
tal problems in keyboard instrumentalists: the University of North
Tex as Health Survey. Med Probl Perform Art 2001; 16:17–23.
30. Heijink H, Meulenbroek RG: On the complexity of classical guitar
playing: functional adaptations to task constraints. J Mot Behav 2002;
31. Brandfonbrener A: Epidemiology and risk factors. In Tubiana R,
Amadio P (eds): Medical Problems of the Instrumentalist Musician.
London, Marin Dunitz, 2000.
32. Norman R, Wells R, The Ontario Universities Back Pain Study Group:
A comparison of peak vs cumulative physical work exposure risk fac-
tors for the reporting of low back pain in the automotive industry. Clin
Biomech 1998; 13:561–573.
33. Hoogendoorn WE, van Poppel MN, Bongers PM, et al: Physical load
during work and leisure time as risk factors for back pain. Scand J
Work Environ Health 1999; 25:387–403.
34. Kilbom Å, Messing K, Bildt Torbjörnsson C (eds): Women’s Health at
Work. Stockholm, National Institute for Working Life, 1998.
35. Liljeholm Johansson Y, Theorell T: Satisfaction with work task quality
correlates with employee health. Med Probl Perform Art 2003;
36. Kähäri K, Eklöf M, Sandsjö L: Associations between hearing and psy-
chosocial working conditions in rock/jazz musicians. Med Probl Per-
form Art 2003;18: 98–105.