Are Factors of Posture and Balance Integrated in Research Studies on Upper Extremity Musculoskeletal Pain in Instrumental Musicians?: A Scoping Review.

It is widely believed that posture and balance stressors are factors in playing-related pain for musicians using hand-held musical instruments. This purpose of this scoping review was to assess the available literature relative to the effects of posture and balance in musicians with neuromusculoskeletal injuries. A search of Medline, Web of Science, and SportDiscus seeking articles combining posture and balance considerations with pain in performing artists was performed. From 1,403 articles initially identified by the search parameters, the further abstract/title review for relevance and inclusiveness of pain and posture/balance variables in performing artists resulted in the retention of 29 articles for this full-text scoping review. The full-text analysis assessed publication type, study design, participant population, methodology, statistical methods, main results, and whether the study evaluated the relationship between posture/balance and pain in musicians. Overall, most of the studies including musicians were observational or descriptive. Although, in recent years, there has been an increase in the number of interventional studies regarding posture, balance and pain in musicians, there is still minimal evidence about the contribution of posture and balance characteristics to pain in musician performers. To reliably establish a predictable relationship with injury symptomatology experienced by musicians, it is essential to integrate standardized, validated measurements of posture and balance in the evaluation of all musicians who report to a health professional with neuromusculoskeletal pain. This will not only allow researchers to determine the effect of postural righting dysfunction on neuromusculoskeletal injuries in musicians, but also may provide a foundation for clinicians to develop effective interventions.

Validity and reliability of the Musicians' Health Literacy Questionnaire, MHL-Q19.

High prevalence of musicians' physical and mental performance-related health issues (PRHI) has been demonstrated over the last 30 years. To address this, health promotion strategies have been implemented at some post-secondary music institutions around the world, yet the high prevalence of PRHI has persisted. In 2018, an international group of researchers formed the Musicians' Health Literacy Consortium to determine how best to decrease PRHI, and to examine the relationship between PRHI and health literacy. An outcome of the Consortium was the development of a new health literacy tool for musicians, the MHL-Q19, which drew from the theoretical framework of the European health literacy suite of tools, HLS-EU. The aim of the current study was to evaluate the validity and reliability of the MHL-Q19. Participants completed a battery of questionnaires, including the HLS-EU-Q16 for the assessment of general health literacy; the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians (MPIIQM); the RAND-12 quality of life questionnaire; and the General Self-Efficacy scale (GSE). We hypothesized that the MHL-Q19 would have a weak correlation with the HLS-EU-Q16; moderate correlation with the physical component scale and weak correlation with the mental component scale of the RAND-12; moderate correlation with the GSE; and finally, moderate correlation with pain interference and weak correlation with pain intensity of the MPIIQM. A total of 549 post-secondary music students from six English-speaking countries completed the battery of questionnaires, and 328 of these participants provided valid responses to the MHL-Q19 alone 2 weeks later. The tool showed acceptable internal consistency and test-retest reliability. Three of our hypotheses were supported, although the strength of the correlations varied from what we had predicted. The fourth hypothesis was not supported; our findings indicate that lower health literacy scores were weakly related to higher MPIIQM pain intensity and interference scores. The results of this study support the notion that musicians' health literacy is a distinct construct that cannot be fully evaluated with existing health literacy tools. Given that this is a new instrument, the evidence presented is positive and promising. Further studies will be needed to refine the tool.

An Examination of Trunk and Right-Hand Coordination in Piano Performance: A Case Comparison of Three Pianists.

Playing the piano at expert levels typically involves significant levels of trial-and-error learning since the majority of practice occurs in isolation. To better optimize musical outcomes, pianists might be well served by emulating some of the practices found in sports, where motor learning strategies are grounded in biomechanics and ergonomics in order to improve performance and reduce risk of performance-related injuries. The purpose of the current study is to examine trunk-hand coordination and preparatory movement strategization in piano performance, while considering the influence of anthropometry, skill level of the performer, and musical context. Using a ten-camera motion capture system, movement of C7 and right-hand distal phalanges was tracked at three different playing speeds during performance of an excerpt from Beethoven's "Appassionata" Sonata. There were three participants: two males and one female of differing anthropometric characteristics and skill levels. Motor strategization was examined. Expertise influenced starting trunk position: Initiation intervals and trunk range of motion (ROM) both suggested anthropometry to be a performance factor. For the shortest performer, trunk movement appeared to be used as an efficiency measure to compensate for a shorter arm reach. Skill level was revealed by examining right-hand velocity at the fastest tempo. The current study hypothesizes that an examination of proximal-to-distal preparatory strategies in terms of anthropometry and skill level can help to optimize motor learning for pianists. To realize piano performance as a whole-body skill and encourage healthy practice, pedagogy needs to educate learners regarding fundamental biomechanical and ergonomic principles, movement optimization, and movement strategization in the service of artful performance.

Wrist Internal Loading and Tempo-Dependent, Effort-Reducing Motor Behaviour Strategies for Two Elite Pianists.

One of the greatest challenges in reducing high rates of performance injuries among musicians is in providing them usable tools to address playing-related musculoskeletal problems (PRMP) before they become disorders. Studies in biomechanics have the potential to provide such tools. In order to better understand the mechanisms through which PRMP manifest in pianists, especially in the distal segments of the upper limbs, the current study quantifies wrist internal loading (WIL) and wrist impact loading frequency. It does so while discussing pianists' motor behaviours and observed effort-reduction strategies in the wrists as a function of anthropometry. This concept has great utility for performers. A VICON 3D motion capture system documented two expert pianists performing a B major scale, hands together, at 4, 6, 8, 9, and 10 notes/sec. Biomechanical modeling quantified WIL. Changes in motor behaviour were observed at 8 notes/sec. Individualized anthropometry influenced the range of motor strategies available to each pianist. The pianist with the larger hand span employed a flexion/extension wrist strategy as a compensatory means for effort reduction, while the pianist with the smaller hand span employed a radial/ ulnar deviation strategy. The current study provides a new perspective in addressing PRMP among pianists by rationalizing anthropometric potentials in terms of ergonomic parameters and documenting the availability and utility of effort-reduction strategies in the wrists during piano performance as performers consider PRMP risk and avoidance.

Pursuing Artful Movement Science in Music Performance: Single Subject Motor Analysis With Two Elite Pianists.

Piano performance motor learning research requires more "artful" methodologies if it is to meaningfully address music performance as a corporeal art. To date, research has been sparse and it has typically constrained multiple performance variables in order to isolate specific phenomena. This approach has denied the fundamental ethos of music performance which, for elite performers, is an act of interpretation, not mere reproduction. Piano performances are intentionally manipulated for artistic expression. We documented motor movements in the complex task of performance of the first six measures of Chopin's "Revolutionary" Etude by two anthropometrically different elite pianists. We then discussed their motor strategy selections as influenced by anthropometry and the composer's musical directives. To quantify the joint angles of the trunk, shoulders, elbows, and wrists, we used a VICON 3 D motion capture system and biomechanical modeling. A Kistler force plate (1 N, Swiss) quantified center of gravity (COG) shifts. Changes in COG and trunk angles had considerable influence on the distal segments of the upper limbs. The shorter pianist used an anticipatory strategy, employing larger shifts in COG and trunk angles to produce dynamic stability as compensation for a smaller stature. Both pianists took advantage of low inertial left shoulder internal rotation and adduction to accommodate large leaps in the music. For the right arm, motor strategizing was confounded by rests in the music. These two cases illustrated, in principle, that expert pianists' individualized motor behaviors can be explained as compensatory efforts to accommodate both musical goals and anthropometric constraints. Motor learning among piano students can benefit from systematic attention to motor strategies that consider both of these factors.

Health Education Literacy and Accessibility for Musicians: A Global Approach. Report from the Worldwide Universities Network Project.

OBJECTIVE: To address the need for accessible health education and improved health literacy for musicians throughout their lifespan. METHODS: Formation of a multicultural, international, and interdisciplinary collaborative research team, funded by the Worldwide Universities Network. The goal is to design a multi-strand research program to develop flexible and accessible approaches to health education for musicians, thus improving their health literacy. RESULTS: Two team meetings took place in 2018. The first was held 11 to 15 April 2018 in Perth, Australia, and involved a review of existing literature and interventions on health education in music schools, intensive development of research topics, aims, and methodologies, and identification of potential funding sources to support future large-scale research programs. This resulted in the draft design of three research projects, finalized during a second meeting in Maastricht, the Netherlands, 27 to 31 August 2018. DISCUSSION: These intensive meetings identified the need for both cultural change in music education settings as well as improved health literacy in musicians across global geographical regions. A global project to address health literacy and health education accessibility for musicians has commenced.

Torso and Bowing Arm Three-Dimensional Joint Kinematics of Elite Cellists: Clinical and Pedagogical Implications for Practice.

BACKGROUND: Elite cello playing requires complex and refined motor control. Cellists are prone to right shoulder and thoracolumbar injuries. Research informing injury management of cellists and cello pedagogy is limited. The aims of this study were to quantify the torso, right shoulder, and elbow joint movement used by elite cellists while performing a fundamental playing task, a C major scale, under two volume conditions. METHODS: An eight degrees of freedom upper limb biomechanical model was applied to 3D motion capture data of the torso, upper arm, and forearm for 31 cellists with a mean experience of 19.4 yrs (SD 9.1). Two-factor ANOVA compared the joint positions between the four cello strings and two volume conditions. FINDINGS: Significant (p<0.05) effects were found for either the string and/or volume conditions across all torso, shoulder, and elbow joint degrees of freedom. The torso was consistently positioned in left rotation from 5.0° (SD 5.6) at the beginning of the scale, increasing to 16.3° (5.5) at its apogee. The greatest mean shoulder flexion, internal rotation, and abduction joint angles were observed when playing at the tip of the bow on the top string (A): 107.2° (11.6), 59.1° (7.1), and -76.9° (15.7), respectively, during loud playing. INTERPRETATION: Elite cellists use specific movement patterns to achieve string crossings and volume regulation during fundamental playing tasks. Implications of the static left-rotated torso posture and high degrees of combined shoulder flexion and internal rotation can be used to inform clinical and pedagogical practices.

The Influence of X-Factor (Trunk Rotation) and Experience on the Quality of the Badminton Forehand Smash.

No existing studies of badminton technique have used full-body biomechanical modeling based on three-dimensional (3D) motion capture to quantify the kinematics of the sport. The purposes of the current study were to: 1) quantitatively describe kinematic characteristics of the forehand smash using a 15-segment, full-body biomechanical model, 2) examine and compare kinematic differences between novice and skilled players with a focus on trunk rotation (the X-factor), and 3) through this comparison, identify principal parameters that contributed to the quality of the skill. Together, these findings have the potential to assist coaches and players in the teaching and learning of the forehand smash. Twenty-four participants were divided into two groups (novice, n = 10 and skilled, n = 14). A 10-camera VICON MX40 motion capture system (200 frames/s) was used to quantify full-body kinematics, racket movement and the flight of the shuttlecock. Results confirmed that skilled players utilized more trunk rotation than novices. In two ways, trunk rotation (the X-factor) was shown to be vital for maximizing the release speed of the shuttlecock - an important measure of the quality of the forehand smash. First, more trunk rotation invoked greater lengthening in the pectoralis major (PM) during the preparation phase of the stroke which helped generate an explosive muscle contraction. Second, larger range of motion (ROM) induced by trunk rotation facilitated a whip-like (proximal to distal) control sequence among the body segments responsible for increasing racket speed. These results suggest that training intended to increase the efficacy of this skill needs to focus on how the X-factor is incorporated into the kinematic chain of the arm and the racket.

Unraveling mysteries of personal performance style; biomechanics of left-hand position changes (shifting) in violin performance.

Instrumental music performance ranks among the most complex of learned human behaviors, requiring development of highly nuanced powers of sensory and neural discrimination, intricate motor skills, and adaptive abilities in a temporal activity. Teaching, learning and performing on the violin generally occur within musico-cultural parameters most often transmitted through aural traditions that include both verbal instruction and performance modeling. In most parts of the world, violin is taught in a manner virtually indistinguishable from that used 200 years ago. The current study uses methods from movement science to examine the "how" and "what" of left-hand position changes (shifting), a movement skill essential during violin performance. In doing so, it begins a discussion of artistic individualization in terms of anthropometry, the performer-instrument interface, and the strategic use of motor behaviors. Results based on 540 shifting samples, a case series of 6 professional-level violinists, showed that some elements of the skill were individualized in surprising ways while others were explainable by anthropometry, ergonomics and entrainment. Remarkably, results demonstrated each violinist to have developed an individualized pacing for shifts, a feature that should influence timing effects and prove foundational to aesthetic outcomes during performance. Such results underpin the potential for scientific methodologies to unravel mysteries of performance that are associated with a performer's personal artistic style.

A prisoner's dilemma with asymmetrical payoffs: revealing the challenges faced by performing arts health and wellness practitioners.

In a prisoner's dilemma, constructed narratives are used to demonstrate problems within individual rationality and decision-making. Performing artists can be seen as facing a type of prisoner's dilemma in their careers: they must practice repeated movements for long periods in order to improve, yet despite the short-term perception of gained artistic benefit, the long-term consequences may be playing-related musculoskeletal disorders and injury. To help avoid such an outcome, educators and health and wellness practitioners must function as negotiators, engaging in discussions of artistry as part of establishing credibility and encouraging behaviors that keep artists in efficient, healthy behaviors. By setting practice time limits that are considerate of the intensity of each specific task, performers can improve their performance on a daily basis and become more skilled at planning their future training.

A pilot study on the efficacy of line-of-sight gestural compensation while conducting music.

Music ensemble playing relies heavily on a conductor's gestural cues. Visibility of those cues varies within the ensemble, so conductors typically use compensation strategies selectively to improve the clarity of their gestures for different players. Currently, there are no quantitative studies evaluating the efficacy of such compensatory strategies. The present pilot study examined the effectiveness of one typical strategy, namely, twisting or turning to address different sections of an ensemble. The method used three-dimensional motion capture and biomechanical modeling to quantify line-of-sight visibility of the conductor from the viewpoint of ensemble players. Results established a visually advantaged quadrant within the ensemble. They further showed that optimizing visual communication may require less turning than commonly believed.

A frequency-based characterization of spiccato bowing in violin performance.

Performance of instrumental music requires high precision and the automisation of motor control to free the performer to focus on the artistic outcome. To acquire this high skill, training is experience-based, involves one-on-one instruction, and requires long hours of repetitive practice. This approach is consistent with a traditional model of vocational apprenticeship. Practice habits and long hours associated with training have been identified as sometimes contributing to high rates of vocational injury among musicians. This study explores violin performance, identifying generalizable perceptual markers to bridge the gap between science and experience in pedagogical methodology. Kinematic data were collected using 3-D motion capture. Dynamic modeling was used to specify internal loads. Eleven professional-level musicians were tested, ranging in age from 21 to 47 years (M = 36 yr., SD = 6). The study identified several motor-learning markers, speed-dependent motor control phases (increasing effort, optimization, and approaching physiological limits), string-dependent motor control, and an unexpected sympathetic resonance between the two arms, notwithstanding their very different functions. This study suggests that instrumental performance could be aided by identifying markers related to musical outcomes, performers' perceptions, and motor skill acquisition.