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ORIGINAL ARTICLE

Occupational injuries suffered by classicalmusicians through overuse

M.J.E. Heming*

Back2Health, 52 Anstey Road, Alton, Hampshire GU34 3RE, UK

Received 30 May 2001; received in revised form 15 February 2004; accepted 27 February 2004

Introduction

Classical musicians are required to dedicate largeamounts of time to reach a high level of perfor-mance, yet there is little support for them whenthey become injured and are unable to play. Thegeneral public perceive musicians to be ‘‘doingwhat they want to do’’ and feel, therefore, thatthey should ‘‘put up with their problems’’. As aresult, little has been done to help musicians pre-vent and rehabilitate from injury.1

The size and weight of the instrument adds topostural effort, as there is often the need to providesupport against gravity in an unnatural, often asym-metric, position. The length of a practice sessionalso contributes to injury, as musicians who want totake their playing to a high standard will rehearsefor a minimum of 3 h a day with few (if any)breaks.2,3 This causes the body to be held in oneposition for some time, usually seated.2 Most instru-ments are taken up during childhood and thereforethe body is still developing and strengthening. Withinstruments that are played asymmetrically, mus-culoskeletal imbalances can arise that may causeproblems for the musician later in life if notaddressed. With this in mind, a skilled teacher

Clinical Chiropractic (2004) 7, 55—66

KEYWORDS

Adult humans;

Chiropractic;

Classical musicians;

Musculoskeletal injury;

Overuse syndrome;

Repetitive strain injury

Abstract Objective: To establish the types of injuries suffered by musicians. Datawere analysed with descriptive statistics and displayed using graphs and tables.Methodology : An anonymous, retrospective questionnaire covering aspects of lifestyleand musical habits was distributed to 107 musicians. Sixty-two questionnaires werereturned (58% response rate). Results: Of the returned questionnaires, 59 were usable.There was an age range of 16—72 years. Thirty-one were teachers, with all but 1 usingeither verbal or visual postural advice. Of the total population, 70% had suffered aninstrument-related injury, with one third of these unable to play for a period of time.Females (72%) and string players (77%) showed a higher preponderance. Professionalteachers (57%) harboured the majority of injuries. There were no injured amateurs.The homunculi drawing revealed the posterior left shoulder and upper thoracic spine tobe the most prevalent site for pain and discomfort during and after playing. Handsand wrists were relatively unaffected. Conclusion: There is a high rate of injury to

professional classical musicians and teachers that can be disruptive to practice andpotentially threatening top careers. Females and string players were discovered to beof particular risk. The majority of injuries were to the shoulder and proximal thoracicspine and the absence of injuries in amateur players suggests a relationship to overuse.The author suggests that the incorporation of postural and ergonomic into musicaleducation and chiropractic treatment programmes for classical musicians and teacherscould be of benefit. 2004 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.

*Tel.: þ44-1420-80007; fax: þ44-1420-80045.E-mail address: [email protected](M.J.E. Heming).

1479-2354/$30.00 2004 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.clch.2004.02.008

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should try to match body build and size of the pupil

to the instrument, taking into account the physical

build of the parents if necessary.4 If the match is

done correctly, the child should be able to reach a

fuller potential and have fewer problems adapting

to the instrument.

Overuse injury

There have been many different definitions of over-

use syndrome (OS). Putting them together, the

author has concluded OS to be:

‘‘A clinical entity in its own right, caused by

overload or repetition of some movements giv-

ing episodes of micro-trauma to muscle and

joint ligaments, resulting in chronic inflamma-

tion and fibrosis as connective tissue is slowly

taken beyond its biomechanical and physiolo-gical limits’’.5—11

The onset of OS in musicians often begins with

pain, discomfort, functional loss and, occasionally,

paraesthesia in the affected part, usually after

intensive hand activity. This can be precipitated

by a change in technique or increase in playing time.

Gradually, the intensity of the activity and/or the

length of time required to trigger symptoms

decreases until the problem is present constantly.

Without treatment, the problem will progress, giv-

ing a reduction in grip strength, muscle wasting and,

possibly, tenosynovitis.4,5

OS is difficult to diagnose as it may present as a

neuropathy, tendinitis, tenosynovitis, peritendoni-

tis crepitans, arthritis, spondylosis, reflex sympa-

thetic dystrophy or repetitive strain injury (RSI).7,12

No matter which diagnosis is given, rest is the usual

treatment. This will alleviate pain but, unless the

causative factors are either changed or removed,

not the problem.9

Evidence as far back as the 19th century6,13

suggests the most useful treatment for OS is rest.

‘‘Rest’’, however, means different things to differ-

ent people and the physician should explain how

they expect the patient to interpret this. It may be a

decrease in playing time, a change in technique, or

complete cessation of playing and, possibly, other

activities regarded as contributory.5,6,12,14 How-

ever, the muscle atrophy and bone wasting that

occurs with enforced rest may create additional

problems.4 Other proactive treatments, such as

cryotherapy and non-steroidal anti-inflammatory

drugs (NSAIDs), should be considered by the physi-

cian to accelerate the repair of the tissue.15 Manip-

ulation can be used once the acute stage is over

along with strengthening and stretching exercises.15

It has been demonstrated that players of stringed

instruments, including the piano, are more likely to

suffer injury than are players of wind instruments by

a ratio of 3:1.16 There are two different mechanisms

for OS and RSI that have been theorised17 and go

some way to explaining why string players are more

at risk. The first considers injury to muscle understatic (low-level repetition) low-level loads. This is

common in the proximal joints of the upper limb as

they work as essential fixators, holding the hands,

fingers and instrument in the correct position. For

the majority of string instrumentalists, the weight

of the instrument is supported in whole or part

by their shoulder, whereas the majority of wind

players need to support the weight of their instru-

ment with their fingers or thumbs only.

The second proposed mechanism is injury to

other structures, such as tendon sheaths, under

high repetition activities. This occurs directly in

the fingers and the muscles that move them. Playing

stringed instruments requires strength and force to

hold down the string, followed by rapid release to

move to the next note position. This may involve a

change in wrist position as well as movement up and

down the neck of the instrument. Comparatively,

less force is required to hold the key of a wind

instrument and generally only the fingers need to

move as the hand is statically maintained in the

correct position.

A study performed in 2000 by Chan et al.18 used

surface electromyography to record the fatigue

level of the upper trapezius muscle of 14 orchestralmusicians before and after a practice session and

compared results to a subjective rating scale. They

found that 11 of the subjects reported a playing-

related musculoskeletal complaint, with all but 5 of

these being in the neck and shoulder region. After a

training session, there was a significant (P ¼ 0:003)

increase in perceived exertion using a visual analo-

gue rating scale. However, there was no significant

difference in the surface electromyography on the

trapezius muscle before and after training. The

study concluded that ergonomic factors needed

to be taken into account as a risk factor. The author

suggests this should include playing posture and that

concert halls and other playing venues should

review their facilities with respect to chairs and

stands provided for the musician.

There has been much discussion regarding the

description of an injury as ‘‘over-use’’ rather than

‘‘mis-use’’. Rathbourne19 and Dickson20 feel that

‘‘over-use’’ is a misdiagnosis and it would be more

accurate to diagnose a ‘‘mis-use’’ injury. This clas-

sification needs to be carefully thought out, due to

the psychological effects of labelling patients.

‘‘Mis-use’’ to the professional musician may be

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incorrectly interpreted as a slight or insult and cause

embarrassment, whereas ‘‘over-use’’ is more accep-

table psychologically, as it suggests the player is

conscientious in their practicing and does not imply

faulty technique. For an amateur or student, a diag-

nosis of ‘‘mis-use’’ would be more workable as the

musician realises the need for greater understandingof what they are trying to achieve. ‘‘Over-use’’ could

put them off playing, or stop them playing until the

pain eases. Thinking the problem has cured itself;

they may then start to play again before the involved

structures have a chance to fully heal. In general, it

seems that awareness is the key to prevention of

overuse and other musculoskeletal injuries.With this

in mind, the author supports Fry,5 who would like to

see teaching institutions implement courses and lec-

tures on prevention of overuse–—after all, ‘‘preven-

tion of overuse, is the control of use’’.6

The literature reviewed revealed a lack of first-

hand information from musicians with regard to

their knowledge of injury, treatment and support

groups. This survey was compiled to aid in gaining

some of this information.

Methodology

An anonymous, retrospective questionnaire was dis-

tributed to musicians of all standards who lived in

Bristol or Bournemouth, England.

The questionnaire was in three parts and was

based on previously validated work by Arnarson.21

The first part covered demographic, teaching and

postural information; the second, instrumental

habits and the third used an homunculus to elicit

information regarding the nature and location of

the musicians’ pain.

The questionnaire divided the standard to which

the musician played (Table 1). The results were

analysed using a database and descriptive statistics,

and shown in graph or table form.

Results

One hundred and seven questionnaires were distrib-

uted by hand or post with 62 (58%) being returned.

One did not indicate the instrument played and two

others were incompletely filled out, leaving 59

(55%) to be analysed.

Demographic data

The respondents to the 59 questionnaires comprised

30 (51%) male and 29 (49%) female subjects. The age

range was 16—72 years with a mean age of 40 and

mode of 32.

The relative numbers of males to females in each

of the categories of musicianship standard is shown

in Fig. 1. The distribution showed more men reach-

ing higher professional standards, whilst women

played more socially. Thirty-seven (63%) subjects

featured in the professional and/or teaching cate-

gory. This is representative of the main target areas

being professional or from schools.

The 31 teachers (51%) in the study were asked

how they monitored posture. Over half (53%) mon-

itored verbally, 34% used a mirror and verbal cor-

rection and there were two who used photographs.

One teacher did not monitor at all.

Of the musicians questioned, 55 (93%) felt they

were aware of their posture. Twenty (34%) learnt

some form of relaxation therapy with 16 of these

studying the Alexander technique.

Injury data

Sixty-seven percent of men, compared to 72% of

women, suffered an injury, giving an overall injury

rate of 70%.

Fig. 2 shows all the 26—30 and 31—35 age groups

having a lower prevalence of injury. This figure

omits the 66—70 and 70—75 age groups, as there

was only one candidate per sample size and there-

fore no comparison.

The prevalence of injury by instrument played

showed the piano has the lowest injury rate whilst

playing the oboe, double bass or viola gave a 100%

injury rate (Table 2). These results are, however,

unreliable considering the large number of pianists

surveyed compared to the small number of the

latter instruments and the response bias that this

may well reflect.

The largest subset (41%) of those surveyed prac-

ticed for 1 h or less per day. Only 1 practised for 6 h

or more per day. From the Professional-teacher

group, 2 indicated their schedule changed depend-

ing on whether or not it was term time. Their results

have been omitted from Fig. 3 (n ¼ 57), which

Table 1 Division of standards of musicianship.

Type Description

Professional Playing the instrument as a

profession

Professional-teacher Teaches and plays the

instrument professionally

Teacher Only teaches the instrument

and is not paid for orchestral/

solo work undertaken

Paid amateur Earns money from playing

periodically

Amateur Plays for fun, not paid

Student Still learning

Occupational injuries suffered by classical musicians through overuse 57

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shows those practising for 1 h or less per day are lesslikely to suffer an injury, supporting the theory that

increasing practice time increases the chance of

injury.

Forty-one musicians (70%) had or had had a play-ing-related injury. Of these, 30 (73%) had sought

help and 16 of those that sort help were forced to

stop playing for some time. Eleven of the group of

injured musicians that were seeking help at the time

of the study were suffering from a playing-related

musculoskeletal injury preventing them playing at

their optimum level. Most commonly, the musician

would contact their GP leading, in some cases, to

referrals to specialists (Fig. 4). The most common

self-prescribed form of therapy was ice (30%). Other

therapies included strapping (13%), stretching (17%)

and adaptive devices (13%).

Of the 30 musicians who admitted to seeking help

for their problem, 18 said they would play while

suffering pain; only 4 would not. There were 8 who

qualified their answer with their continuation of

practice depending on what they were doing at

the time the pain came on.

Of the 59 musicians responding, 44 (75%) were

reluctant to take time-off from playing. This group

contained 100% of the Teacher and 92% of the

Professional-teacher category. Of the Professional

grouping, 63% felt reluctant to take time-off. The

reasons for this are shown in Fig. 5.

Figure 1 Number of males and females by musicianship standard.

Table 2 Prevalence of injury depending on instru-

ment played.

Total

(n ¼ 59)

Percentage

who suffer

an injury

Percentage

who do not

suffer an

injury

Bassoon 3 67 33

Cello 4 50 50

Clarinet 4 50 50

Double bass 2 100 0

Flute 8 50 50

Guitar 2 50 50

Oboe 2 100 0

Organ 2 50 50

Percussion 3 33 66

Piano 13 31 69

Trumpet 2 50 50

Viola 4 100 0

Violin 10 80 20

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Whilst 43% of injured musicians questioned con-

sidered themselves injured because they were in

pain, it was interesting to note that, of the Profes-

sional musicians, 3 out of 7 only considered them-

selves injured when they were actually unable to

play. By contrast, the majority of ‘‘Professional-

teachers’’ (9 of 17) felt injured because they were

experiencing pain (Table 3).

Awareness of injury

Musicians’ knowledge of target sites for injury was

also investigated (Fig. 6). The majority realised that

musicians are prone to suffer from more than one of

the examples given. Only 6 (10%) were unaware of

this, with 2 of these not aware of any potential

injury sites. However, there were only 4 (7%)

respondents who were aware that musicians could

suffer from all the injuries given. The most common

injury recognised by the musicians was that of

muscle tension, followed by wrist problems. Aware-

ness of dystonia was lowest.

The two main organisations that help musicians’injuries are the British Performing Arts Medicine

Trust (BPAMT) and the International Society of

Study of Tension in Performance (ISSTIP). However,

only 19 (32%) of the respondents were aware of the

existence of one or other of these groups. Of these,

84% had only heard of BPAMT, 5% only knew of ISSTIP

only and 11% had heard of both.

Figure 2 Prevalence of injury with age.


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Pain and discomfort homunculi

The homunculi (Fig. 7) revealed that 3% of the

respondents’ problem sites were identified ante-

riorly on the head, neck and torso compared to

64% posteriorly over the same area (Fig. 8). The

most frequently identified site was the left poster-

ior shoulder and upper thoracic spine.

The remaining 33% of problem sites were on the

arms and legs. There were no markings on either the

anterior or posterior right wrist (Fig. 9a), although

the left wrist was indicated as a site of pain bothposteriorly and anteriorly by one respondent

(Fig. 9b).

Discussion

Although the questionnaires were anonymous,

there was a higher percentage of questionnaires

returned by post compared to those distributed

during rehearsals. This could be because the musi-

Figure 3 Prevalence of injury related to daily hours of practice.

Figure 4 Treatment received for playing-related physical problems.

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cian was unable to spend the time during a busy

rehearsal to fill in the questionnaire. It may also be

because they did not want to admit to problems,

or risk the possibility of colleagues finding out

‘‘weaknesses’’ they may have if the questionnaire

was filled in whilst other orchestral members were

present. However, despite a moderate response

rate, the number provided a good basis to pilot

the questionnaire and identify areas within it that

could be focused more closely in future studies.

Injury

Over half of the musicians questioned for this study

suffered from some form of injury with a higher

female predominance. This is consistent with the

Figure 5 Reasons why musicians are reluctant to take time-off playing when injured.

Table 3 Why injured musicians consider themselves injured.

In pain Injury prevents

playing to potential

Injury prevents

playing

Total

(n ¼ 30)

Professional 2 2 3 7

Professional-teacher 9 5 3 17

Teacher 2 1 1 4

Paid amateur — 1 — 1

Amateur — — — —Student — 1 — 1

Total (n ¼ 30) 13 10 7


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study carried out on the International Conference of

Symphony and Opera Musicians.22 The data pre-

sented here strongly suggest that string instrumen-

talists are most at risk, particularly the upper

strings, such as the violin and viola. This finding is

supported by the work of Dawson23 and Zaza and

Farewell.24

The results showed that the basics of most instru-

ments are taught before the age of skeletal maturity

when there is incomplete fusion of the growth

plates. This increases the risk that an injury may

lead to dysplasticity, deformity or malalignment.25

It is possible to get smaller versions of stringed

instruments to fit the young child. Although this is

not the case with wind instruments, it is sometimes

possible to start of a higher register member of the

same family. However, frequently young students

may have to support the weight of an adult-sized

instrument as well as master fingering with small

hands. With the bones of the wrist and hand not

being completely ossified until around the age of 20,

supporting this kind of weight and stretching over

long distances is likely to increase muscle bulk at

the expense of their bony attachments.

Figure 6 Musicians awareness of injuries.

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Two clarinettists in the survey demonstrated an

example of the type of problem that may result

from this. They noted on the homunculi drawing

that the base of the right thumb was a site of pain.

The thumb is the only support for the weight of the

instrument (830 g for full size orchestral clarinet),

thus predisposing it to osteoarthritis.6

Fishbein et al.22 analysed data referring to the

current age of the musician and the likelihood of a

future problem. Their results showed that classical

musicians aged 35—45 were most likely to report a

problem. This is in agreement with the results

achieved by this survey, which found that all

responding musicians aged between 36 and 40

reported an injury. Most musicians will be settling

into their career by this time. Professional musi-

cians and teachers will be established in an orches-

tra or school and auditions will not be as prevalent

as they were in previous decades. Due to a heigh-

tened family life for the majority, warm-up and

practice time may not be considered as necessary

or easy to achieve as in previous years leading to

increased stress on the muscles and joints. When

rehearsal time is heightened before a performance

they may then rely on intense practice for a short

while and familiarity with repertoire rather than

regular practice. However, in a recent study3 of 22

pianists of varying skill levels, it was found that the

quantity of their practice time, measured using

cassette recording tapes, was not related to the

comparative quality of their performance in a reci-

tal setting.

Awareness

The author feels it is important for the clinician to

visualise how an instrument is held. This allows the

clinician and musician to work together to identify

areas within the body that could be targeted by

injury. Few of the musicians in the survey were

Figure 7 Homunculus: body region by number.


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aware of all the sites or type of injury suggested and

the overall results do indicate a lack of knowledge

on the part of the musician. It has been noted that,

as musicians play long movements or pieces, their

posture gets progressively worse as the muscles

fatigue.6 The therapist should therefore explain

to the musician the benefits of good posture and

ergonomics along with postural and stamina exer-

cises to help avoid further problems and give the

musician a better awareness of possible problemareas.

Breathing is affected by posture, with the latter

being learnt at a young age. However, this survey

shows that posture is not considered an important

issue to address when it comes to teaching. Existing

teachers, players and students need to be educated

as to why posture is such an important issue and

every opportunity should be taken by their clinician

to emphasise this. Ideas the clinician could imple-

ment include viewing the patient playing with his

eyes closed, thus removing the visual influence from

proprioceptive feedback2 or to ask the patient to

video themselves playing so they can review their

own posture. The body is good at compensating for

its own weakness by using incorrect movement

patterns and, if these become the norm, they will

become more difficult to correct later in life.26

A stable foundation is required to play as the

lower limbs, pelvis and abdominal musculature pro-

vide support for respiration and stability to the

upper back, arms, head and neck. Many singers

and musicians who perform standing are encour-

aged to do so with one foot slightly in front of the

other. However, it is important that staging be

taken into consideration whether sitting or stand-

ing. Many Concert Halls have a raked stage and thus

tilting chairs and stands. The musician must be able

and prepared to accommodate this. Ideas to correct

for these types of problem include wooden struts

under the legs of the chair and ‘‘bubble-wrap’’ that

can be folded and sat on (Andrews E, personal

communication, 1999).

Research has found anterior head carriage and

scapular protraction and rotation were morecommon when reviewing the relationship between

posture and OS. The location and extent of the

problem was not detailed.27 These and other pos-

tural defects are common in playing instruments.

Whilst it must be remembered that every instru-

ment requires a different posture, some general

tips can be applied. Stretching after playing and

adopting a mirror image posture to force the body

to re-centre have been proposed as the basis for a

warm-down after playing (Andrews E, personal com-

munication, 1999).

The homunculi

This survey found both the right and left shoulders

to be the greatest cause of pain and discomfort with

the latter being slightly more prevalent. However,

Fry12 rates the shoulder third on his list of preva-

lence after hand/wrist and neck regions. He does

not indicate whether the left or the right side is

more prevalent. Neither Fry’s study nor this one

took into account laterality.

Despite musicians being aware that the wrist is at

risk of injury, it is observed from these results and a

Figure 8 Anterior and posterior head, neck and torso pain/discomfort.

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previous study that it is not a common injury site.22

Two reasons are suggested for this. Firstly, due to

heightened awareness, the musician is constantly

reviewing the wrist posture or, secondly, wrist pro-

blems are perceived to be more common than they

really are. The survey emphasised the need for an

increase in the musicians’ injury prevention educa-

tion and the awareness of their physical well being.

In all, the findings demonstrated the need for

further work in the area of musicians and their

instruments, as well as ways instruments can be

adapted to avoid injury.

Figure 9 (a) Right arm pain. (b) Left arm pain.


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Conclusion

This is a large subject area, but one that remains

relatively untouched in research papers. The clas-

sical musician needs to be more informed on the

benefits of posture and be educated in basic anat-

omy and muscle movement. This would alert thosemost at risk to injury whether it be precipitated by

the instrument they play, such as the strings, or

their build and body type and also give them a basis

for treatment should the need arise.

This study and questionnaire focused on the

attitude and awareness of musicians. The author

suggests that the survey could also be adapted

and distributed to clinicians to discover their aware-

ness of the musculoskeletal problems suffered by

musicians.

Acknowledgements

This article was originally based on an undergrad-

uate research project at the Anglo-European

College of Chiropractic and I would like to offer

my appreciation to my research supervisor, Mike

Kondracki.

References

1. Zyporyn T. Pianist’s cramp to stage fright: the medical side

of music making. J Am Med Assoc 1984;252:985—9.2. Ibsen NL. Chiropractic and the performing arts: symphony.

Int Rev Chiropractic 1986;42(4):28—31.

3. Williamon A, Valentine E. Quantity and quality of musical

practice as predictors of performance quality. Br J Psychol

2000;91:353—76.

4. Bird H. Musculoskeletal problems encountered in musicians.

Int Soc Study Tension Performance J 1992;7:4—5.

5. Fry HJ. Overuse syndrome in musicians: prevention and

management. Lancet 1986;2:728—31.

6. Fry HJ. Overuse syndrome in instrumental musicians. Semin

Neurol 1989;9(2):136—45.

7. Lockwood AH. Medical problems of musicians. New Engl J

Med 1989;320:221—7.

8. Hackney RG. Nature, prevention, and management of injury

in sports. Br Med J 1994;308:1356—9.9. Byl N, Merzenich M, Jenkins W, Learning-induced dediffer-

entiation of the representation of the hand in the primary

somatosensory cortex in adult monkeys I. Neurology 1996;

47:508—19.

10. Bejjani FJ. Musicians occupational disorders. In: Proceed-

ings of the International Conference for Health and the

Musician. University of York; 1997.

11. Sheon RP. Repetitive strain injury. 2. Diagnostic and

treatment tips on six common problems. Postgrad Med

1997;102(4):72—8.

12. Fry HJ. Incidence of overuse syndrome in the symphony

orchestra. Med Probl Performing Artists 1986;1:51—5.

13. Fry HJ. Overuse syndrome in musicians: 100 years ago. Med

J Aust 1986;145:620—5.

14. Altenmuller E. Causes and cures of focal limb dystonia in

musicians. In: Proceedings of the International Conference

for Health and the Musician. University of York; 1997.

15. Souza T. General approach to musculoskeletal complaints.

In: Differential diagnosis for the chiropractor, 1st ed.

Maryland, USA: Aspen Publishers, Inc.; 1998. p. 15—7

[chapter 1].

16. Potter JP, Jones IC. Medical problems affecting musicians.

Can Fam Physician 1995;41:2121—8.

17. Moore A, Wells R, Ranney D. Quantifying exposure in

occupational manual tasks with cumulative trauma disorder

potential. Ergonomics 1991;34(12):1433—53.

18. Chan RF, Chow C, Lee GP, To L, Tsang XY, Yeung SS, et al.

Self-perceived exertion level and objective evaluation of

neuromuscular fatigue in a training session of orchestral

violin players. Appl Ergon 2000;31(4):335—41.

19. Rathbourne J. Letter to the Editor–—overuse syndrome in

musicians. Lancet 1986;2:916.

20. Dickson J. Correspondence: overuse injuries in musicians. Br

Med J 1989;298:1517.

21. Arnarson G. Incidence and pattern of pain in a group of

musicians. D.C. Project. England: Anglo-European College

of Chiropractic; 1989.

22. Fishbein M, Middlestadt SE, Ottai V, Strauss S, Ellis A.

Medical problems among ICSOM musicians: overview

of a national survey. Med Probl Performing Artists 1988;3:1—8.

23. Dawson WJ. Hands and upper extremity problems in

musicians: epidemiology and diagnosis. Med Probl Perform-

ing Artists 1988;3:19—22.

24. Zaza C, Farewell VT. Musicians’ playing-related musculos-

keletal disorders: an examination of risk factors. Am J Ind

Med 1997;32(3):292—300.

25. Andrews E. Ossification. In: Healthy practice for musicians,

1st ed. London, UK: Rhinegold Publishing Limited; 1997.

p. 31—5 [chapter 2].

26. Tubiana R. Prevention of musculoskeletal disorders in

musicians. In: Proceedings of the International Conference

for Health and the Musician. University of York; 1997.

27. Greenfield B, Catlin PA, Coats PW, Green E, McDonald JJ.

Posture in patients with shoulder overuse injuries andhealthy individuals. J Orthop Sports Phys Ther 1995;21(5):

287—95.

66 M.J.E. Heming

1-s2.0-S1479235404000185-main

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