This study primarily focused on the exploration of patterns of pain location empirically identified in a cohort of music students enrolled in different pan-European music institutions.
Consistent with previous research (1, 4–10, 34), our findings showed that the anatomical areas most affected by MSK pain among participants were the neck (59.1%) and shoulders (43.2% on the right and 40.3% on the left), as well as the back (37.7% in the upper part and 37.1% in the lower part).
Cluster analysis identified five homogeneous patterns of pain location amongst the 340 participants (see Table 5). The WP cluster was characterised by MSK pain in the wrists and the WSP one by widespread pain (i.e. MSK pain in all the locations considered). In addition, the RSP and LSP clusters were characterised by MSK pain in the shoulders, with the RSP including participants with MSK pain only in the right shoulder and the LSP cluster in both shoulders but with a tendency in the left side. Participants included in the NBP cluster reported focal MSK pain in the neck, upper and lower back.
Amongst the identified patterns of pain location, the largest number of associated variables in the bivariate analysis emerged in the WSP cluster, which contained the most heterogeneous dispersal of location variables (i.e. widespread pain). This group identified a significant differential of MSK pain in women (79%) compared to men (18%; χ2(df, 8) = 18.05 p < 0.05; Table 6], which is in line with previous studies (4, 7, 10). Similarly, participants included in the WSP cluster were more likely to report a lower level of self-efficacy, where the median for the PSEQ-2 score was 9.0 in this group and 10.0 in the other clusters [see Table 6; χ2(df, 4) = 17.9; p < 0.01] and a higher level of perceived exertion after 45 minutes of practice without breaks [see Table 6; χ2(df, 4) = 13.99], where the median of the WSP cluster (i.e. 6.0) was the highest amongst all the groups. Interestingly, the median reported by participants in the WSP cluster was fairly high if we consider that this measure refers to musicians practicing in private and it is likely that during performance this rating potentially increase (35).
Furthermore, widespread pain is often associated with psychological distress (36), and this was confirmed in our study. The median of the K-10 score was significantly higher in the WSP cluster, presenting the highest figure among the clusters [see Table 6; χ2(df, 4) = 22.6 p < 0.001]. This finding is consistent with a previous study by Kenny and Ackermann (37) showing a positive relationship between both pain and depression, and pain and the tendency to somatisation. In addition, another study by Wristen and Fountain (38) indicated a significant association between depression and pain as well as between anxiety and pain.
The aetiology of MSK pain in music students was further implicated within this study’s bivariate analyses, where the positive association between perceiving the playing activity as the cause of MSK pain and belonging to the WSP cluster [see Table 6; representing reports from 95% of participants in the WSP cluster vs. 82% of the total sample; χ2(df, 8) = 23.66; p < 0.01; 95%], suggested a possible relationship between reporting widespread pain and a student’s playing activity. Nonetheless, the percentage of participants perceived their playing activity as the main cause of their MSK pain was remarkably high among all groups (82.3%) and this is in line with previous research (35).
Additionally, the use of clustering also reveals substantial variation in the reporting of disability in regard to plating-related activities and the pattern of pain location. When compared to the total sample, a higher rate of disability in relation to playing-related activities was reported by participants included in the WP and WSP clusters and a much lower level was shown in the LSP and NBP clusters [see Table 6; χ2(df, 4) = 22.2; p < 0.001]. Indeed, PAS-DASH scores of 37.5 recorded for both WP and WSP clusters, and 25.0 for both LSP and NBP clusters (Table 6) showed a wide range of scores compared to the median of the total sample (31.3). Overall, reported disability levels were high in comparison to other studies using this outcome measure among music students (39–41), professional orchestra musicians (6, 42) or among other populations (43). Even though this difference could be attributed to the fact that participants included in our sample were all music students with current MSK pain, the mechanisms regarding the impact of MSK pain on their functional and the relevant implications on their playing ability deserve to be explored further. For instance, future focal research involving selected played-instruments may reveal even more critical insights about MSK pain. Indeed, depending on the instrument played, musicians are exposed to rather uncomfortable, ergonomically incorrect positions and postures that often require static and prolonged use of the neck and shoulders as well as a repetitive use of the joints of the upper limb, or a combination of both.
In order to analyse differences in terms of MSK pain in different instrumental groups, the present study used the classification of risk associated with an elevated arm position (30, 31), which has been adapted according to a previous study (3). Bivariate analysis regarding clusters’ membership and instruments’ classification revealed noteworthy associations [see table 6; χ2(df, 20) = 49.53; p < 0.001]. Participants playing an instrument with “both arms elevated in a frontal position” were more likely to be included in the WSP cluster and participants playing an instrument with both arms elevated in the left quadrant position showed a statistically significant association with MSK pain in the shoulders – left concentrated, as expected. Moreover, participants playing instruments in a neutral position were more likely to be included in the RSP cluster and less in the WSP cluster. Ultimately, the category of singers, consistent with previous research (4), was more likely to be included in the NBP cluster and thus to report MSK pain more in the neck and in the back in comparison with the total sample. These findings could be clearly observed also in the distribution of MSK pain in the various anatomic regions of the upper body among the six groups (see Fig. 4).
Elevated both frontal (n = 28): Music students playing musical instruments with both arms elevated in a frontal position; Elevated both left (n = 65): Music students playing musical instruments with both arms elevated in the left quadrant position; Elevated left (n = 28): Music students playing musical instruments with only the left arm elevated; Elevated right (n = 50): Music students playing instruments with only the right arm elevated; Neutral (n = 132): Music students playing instruments in a neutral position, without the elevation of arms; Singers (n = 37).
The prevalence of MSK pain in the neck and back is prominent in the category of singers, probably due to the overuse of both the vocal tract and the standing position singers have to maintain for many hours during performance or rehearsals that may possibly lead to MSK pain especially in the back (4). As might have been expected, the highest prevalence of MSK pain in the left shoulder were reported by participants playing with both arms elevated and in the left quadrant, whereas reports of MSK pain among participants playing an instrument with both arms elevated in a frontal position were more likely to cover almost the entire upper part of the body, especially the neck and shoulders, as well as the back for the harp players, and the left elbow, and wrist/hand for the trombone players. Asymmetry, which involves playing with one or both arms elevated, is a recognised issue in ergonomics for biomechanical risk assessment (31) and previous studies have demonstrated that working with elevated arms may lead to the degeneration of muscles and tendons, causing discomfort and distress (4, 31, 44–48).
Consequently, this study's approach of statistically clustering musicians according to pain location patterns might have implications potentially for further research. The multivariate clustering approach based on homogeneity of patterning might be offering a more precise and empirical representation of the population’s burden and capable of providing distinctive information on trajectories of MSK pain among musicians, with a new interpretation that is different in its nature compared to antecedents within the literature view of evidence. This type of novel interpretation might reasonably form the basis for even more sophisticated and comprehensive long term-research to quantify the impact trajectories of patterns of MSK pain affecting musicians at specific anatomical sites, and the efficacy of standardised interventions for both primary and secondary prevention. For example, prophylactic strategies for the management of pain before its escalation to a chronic levels have been advocated (49), together with approaches offering greater insights into the exploration of different aetiologies and personal significance of pain amongst musicians.
Importantly, the technique, eliciting five empirically-derived pain patterns suggests that musicians with MSK pain shouldn't be considered as a homogeneous group as this sub-optimal approach could be problematic and lead to inaccurate treatments. For example, principles of treatment specificity for optimal responses, might reasonably dictate that musicians with widespread pain should benefit most from a congruent array of treatment strategies. The latter might include appropriate multicomponent approaches emphasising integrated care for decreasing psychological distress and disability, as well as perceived exertion during practising. Future studies will be able to address whether the prevalence of MSK pain would be reduced when adopting such specific treatments when compared to contemporary practices.
There are limitations to be aware of when considering our findings. Firstly, although the location of MSK pain was determined according to a well-known and validated questionnaire - NMQ by Kuorinka et al. (23) - in order to obtain standardised results which could be compared to other groups (12), specific localised areas of the body such as fingers, were not contemplated as defined by other methods (e.g. anatomical regions according to the Margolis rating or according to pain drawings). This approach, in turn, was directly connected with the lack of a specific diagnosis for the MSK pain due to the self-reported nature of the study without any physical examination or objective measures. Nonetheless, the self-reported data was used in the best way possible to minimise potential heterogeneity amongst participants that had affected studies in the contemporary literature. Similarly, the use of validated measures in this context may contribute to and facilitate meta-analytical synthesis and further understanding of the study’s results. A more comprehensive investigation considering specific diagnosis may yield additional results capable of furthering our understanding of the relevance of studying MSK pain.
Limitations associated with the clustering analyses used in this study include the need for replication of the patterns of belonging observed in this study amongst other populations, for example within an even broader range of music students and amongst professional musicians or including external validation within independent populations. The current study reflects selected sub-sample' responses of a relatively large (n = 997) group of music students from amongst those enrolled in 55 pan-European music institutions at baseline of the RISMUS project (3). Nevertheless, altered heterogeneity amongst intra-individual and inter-individual characteristics associated with larger or different populations of musicians, might provoke incongruence with the findings of the exploratory models of this study. Future validation studies should evaluate the advantages of clustering as an adjunct to current diagnostic and treatment approaches. It is plausible that the latter approach might contribute to a wider understanding of musicians’ MSK pain as well as to the development of more effective treatment strategies for each kind of cluster.