Perceived Musculoskeletal Discomfort Among Elementary,Middle,and High School String Players

Abstract

The purposes of this study were to identify the body regions where young string players report experiencing musculoskeletal discomfort and explore factors that may impact their perceived discomfort. A purposive yet nonprobability sample of elementary (n = 101), middle school (n = 97), and high school (n = 159) students participated in the study by completing a questionnaire developed from previous research. Participants responded to items designed to collect data regarding the extent and location of discomfort, warm-up activities, physical activities, and psychological issues thought to impact perceived discomfort. Participants reported experiencing little musculoskeletal discomfort, and no relationship was found between discomfort and warm-up or physical activities. Participants’ school level, instrument, and gender were not related to musculoskeletal discomfort. On the basis of participants’ responses, we were able to identify five regions of the body where young string players experience varying levels of discomfort. We found significant relationships between string class frequency, stress about playing the instrument, and enjoyment of the instrument and reported musculoskeletal discomfort.

Keywords

musculoskeletal pain string injury

Playing a string instrument is a rewarding and challenging experience both cognitively and physically. It is unlike many other physical activities in that it requires highly developed fine motor control and complex, repetitive motions (Ackermann, Adams, & Marshall, 2002; Rardin, 2007). Athletes spend a great deal of time honing their physical skills, but they focus most of their efforts on large muscle groups. String players spend many hours refining the small muscle groups that control the fingers, hands, and wrists (Ackermann et al, 2002; Rardin, 2007). Athletes also spend much of their practice time in the presence of a trainer who is there to develop the athlete’s physical skills and help the athlete avoid injury. In contrast, young or developing string players do most of their practicing alone and may not have sufficient self-regulation skills to identify or solve the problems they experience without a teacher’s help (Austin & Berg, 2006; Leon-Guerrero, 2008; McPherson & Renwick, 2000; Miksza, 2006, 2007; Paull & Harrison, 1997).

If left unchecked, young string players may develop unhealthy practice habits that could lead to discomfort, pain, and, over time, injury (Ackermann et al., 2002). Brandfonbrener (2009) claimed that music students often encountered music-induced pain as high school students or younger. It is imperative that young string players develop healthy practice habits from the beginning of their study so that they may become lifelong music makers unencumbered by pain. Moreover, teachers must take an active role in preventing student pain. Due to the increased reported incidence and severity of many musician injuries, members of the National Association of Schools of Music (2012), the accrediting agency for music schools in the United States, added language to its accreditation manual stipulating that schools, in order to be accredited, must educate their students about healthy practices and injury prevention:

It is the obligation of the institution that all students in music programs be fully apprised of health and safety issues, hazards, and procedures inherent in practice, performance, teaching, and listening both in general and as applicable to their specific specializations. This includes but is not limited to information regarding hearing, vocal, and musculoskeletal health and injury prevention. (p. 67)

If it is the responsibility of the institution to educate future music teachers in injury prevention, it follows that those music teachers are responsible for using their expertise to help their students develop healthy practice habits, prevent pain, and avoid injury. In this endeavor, a teacher’s first step may be to identify and better understand what pain his or her students experience and what practices may best mitigate pain.

Rardin (2007) identified physical and musical warm-ups as means to injury prevention that warrant further study. Musicians, teachers, and authors alike tend to agree that physical warm-ups may help reduce injuries in string players and should be an essential part of healthy, daily practice (Ackermann et al., 2002; Frederickson, 2002; Klickstein, 2003). Practitioner journals are replete with articles on the importance of warm-ups. Klickstein (2003) acknowledged that warming up may be the last thing on young musicians’ minds, but neglecting to do so poses a serious health risk. Froese (2002) believed physical warm-ups are necessary to prepare the body of the student, especially if the student was using his or her body in a non-ergonomic way prior to a rehearsal. Perlmutter (2009) recommended warm-ups as a way to “stay loose” and avoid injury (p. 38).

Professional musicians, rather than young students, served as the target population of several seminal studies. There is a body of research on the impact of warm-ups on the health of professional musicians (Brandfonbrener, 1997a, 1997b; Fishbein & Middlestadt, 1988; West, 2003). These researchers suggested that warm-ups might alleviate pain and reduce the risk of injury. More recently, however, Rardin (2007) investigated the effects of an injury prevention program that included physical warm-ups on the reported pain and tension of high school string students. The researcher found that students who participated in the program reported less pain after treatment. While most of the data collected for these studies were from string players, none of the studies addressed warm-ups among middle or elementary school string students.

Researchers have found a burgeoning amount of evidence that the use of systematic warm-ups may have music-related (not just physical) benefits for students, but the majority of these researchers have focused on students in wind ensembles rather than orchestras. Researchers have found that the use of warm-ups can improve an ensemble’s intonation and tone quality (Millsap, 1999), harmonic recognition and attitude toward the overall ensemble performance (Grugin, 1999), and student understanding of music concepts (Henry, 1992).

Researchers have addressed whether and how secondary public school music educators incorporate warm-ups into their rehearsals but most often examined warm-ups in band and choral ensemble settings (Brendell, 1996; Fiocca, 1986; Grimes, 1988; Sherril, 1986; Szabo, 1992). Generally, these researchers found that secondary band and choral directors devote some time at the beginning of rehearsals to warming up and that, for the most part, warm-ups were musical in nature. Less often, directors incorporated physical warm-ups into their rehearsal routines.

Although articles on warm-ups abound in the practitioner literature, few researchers have explored the benefits of physical warm-ups on young or developing string players. Moreover, relatively few researchers have sought to examine the impact of factors other than warm-ups on experienced musculoskeletal pain. Brandfonbrener (2009) examined the impact of instrument played, gender, sleep duration, exercise habits, years of study, and performance anxiety on university freshmen’s reported pain. Generally, string players reported experiencing the most pain. Although the difference was not significant, more females (81%) reported having a history of pain than men (76%). The number of years of study was not significantly related to reported pain. Brandfonbrener found that exercise neither increased nor decreased the likelihood of experienced pain. Although a greater proportion of participants who reported experiencing performance anxiety (81%) reported a history of pain than those who did not experience performance anxiety (77%), the difference was not significant. Despite the nonsignificant findings in this study, researchers should continue to examine these factors for different populations, including elementary and secondary string players as the impact of playing string instruments may be different for younger players or musicians who experience musical performance differently.

Russell (2006) focused only on sixth-, seventh-, and eighth-grade students in a single school district and found that neither warm-up frequency nor duration nor type of warm-up activity impacted students’ perceived pain. Interestingly, grade level was the only factor that related significantly to students’ discomfort: Sixth-grade students reported more discomfort than did seventh- or eighth-grade students. Brandfonbrener (2009) postulated that string players, as well as pianists, may be more prone to experience musculoskeletal pain because they often start playing their instrument at a younger age than other instrumentalists and often are encouraged to avoid other physical exercise in which they may be injured in a manner that would deter them from playing their instrument. Moreover, the repetitive use of small muscle groups in a manner that requires fluidity and relaxation (e.g., vibrato, shifting, finger patterns) often not yet achieved by younger string players may exacerbate discomfort. More research is needed on physical pain experienced by younger as well as more experienced string players.

Purpose and Research Questions

The purposes of this study were to build upon previous research (i.e., Brandfonbrener, 2009; Russell; 2006), identify the regions of the body where young string players report experiencing musculoskeletal discomfort, and explore factors that may impact their perceived discomfort. More specifically, we sought to answer the following research questions: (1) What is the reported discomfort of school-age string players, and can it be logically mapped? (2) Are any types of or frequency and duration of warm-up activities related to the reported discomfort? (3) Are other physical activities or instrumental experiences related to students’ reported discomfort? (4) Is there a relationship between psychological issues and reported discomfort? (5) Are any individual difference variables related to perceived physical discomfort?

Method and Data Source

Following approval from a university human subjects committee, we contacted music teachers to elicit participants. Participants attended a public school in one of three school districts in a northeastern state. String educators from one elementary school, two middle schools, and two high schools agreed to administer our questionnaire to their string students. We selected these schools due to purpose (each school offered orchestral sting instruction) and convenience. The reader should note that the nonprobability sampling employed in this study is a limitation and should be wary of generalizing the data.

Instrument

We used The Physical Discomfort Questionnaire II (PDQ2), a researcher-designed measure, which was developed from previous research (Russell, 2006). We altered the original PDQ to include language that would be intelligible to elementary through high school students (wording of the questions was examined by a graduate music education research course with graduate students with years of teaching experience in multiple levels). For example, we changed the wording of one question from “How much stress or anxiety do you feel about performing on your primary instrument?” to “How much stress or worry do you feel about performing on your primary instrument in public or in concerts?” We added items regarding psychological issues (enjoyment of playing and stress about performing) and items about other non-music-related physical activities in which students may participate.

Participants responded to items designed to assess the location and intensity of any musculoskeletal discomfort experienced when playing their instrument. Participants responded to a series of 32 items arranged in pairs (representing left and right sides of the body) and encompassing various joints and muscle regions. For each item or body region, students rated the degree of physical discomfort they typically experience on a 5-point scale ranging from no discomfort to severe discomfort. Participants also responded to a series of items that addressed warm-up habits (frequency of warming up prior to playing their instrument, length of typical warm-up period, and type of warm-up activities) and additional items that focus on music background and demographics.

Russell (2006) found that this instrument was highly reliable (Cronbach’s α = .96). In the original study, participants completed the questionnaire in 7.5 to 15 min on average. In order to further investigate the validity of the questionnaire, we examined patterns of association using factorial analysis, compared responses to data collected from previous studies (i.e., Russell, 2006), and examined the predictive validity of responses (Fowler, 1995). We examined patterns of associations of the five regions of musculoskeletal pain using the factorial analysis. The regions of the body found in the questionnaire are logical. Fowler (1995) argued that one method of evaluating the validity of data collected in survey research is to compare results against some other data source. We compared data from the PDQ2 to similar items found in the original PDQ (Russell, 2006) and found a high average correlation (r = |.91|) between items, suggesting high reliability as well as construct validity. Overall, participants in each study reported experiencing relatively little pain.

Procedure

We mailed all five teachers who agreed to participate in the study the requisite number of questionnaires for their students as well as return postage. We included the directions for completing the questionnaires at the top of each copy. Participating teachers then administered the questionnaires to each of their students and mailed the completed questionnaires to us. We then entered data into the statistical software package SPSS (Version 16.0 for Mac). We employed the one-shot cross-sectional survey method (Creswell, 2009). The major threat to the internal validity of this research design is the selection process (Gall, Borg, & Gall, 2006) as mentioned above.

Findings

School Context and Teacher Experience

String teachers from one elementary school, two middle schools, and two high schools agreed to administer the questionnaire to their students. At the elementary school, 170 students participated in the string program. The teacher in this program was a cellist, taught for 4 years, held a bachelor’s degree in music education, and was in the 1st year of a master’s degree. In this school, string instruction began in the third grade, while band and chorus began in fourth grade. Students could take an instrumental class and chorus simultaneously but not two instrumental classes. Approximately 17% of the students in the school participated in strings. This teacher did not assign a specific number of minutes for students to practice but asked that students practice five times per week. In this district, 70% of students participated in the free or reduced lunch program, and a large English-as-a-second-language (ESL) population existed.

At the first middle school, 75 students enrolled in strings. Fifty-two (69%) of those students completed usable questionnaires. The teacher at this school played the viola in college, earned a bachelor’s and a master’s degree in music education, and also taught band during a 5-year career as a music educator. Students in this school could take one instrumental class in each grade (sixth, seventh, and eighth), but it was not required. Approximately 10% of the school participated in the string program. This teacher required 100 min of practice each week from sixth-grade students and 125 min per week from seventh- and eighth-grade students. Similar to the elementary school, this teacher reported about 75% of students on free and reduced lunch, with a racially diverse student population (40% African American, 30% Hispanic, 30% White).

All 45 students at the second middle school returned usable questionnaires. The teacher at this school was a violinist with 3 years of string teaching experience. The teacher earned a bachelor’s degree in music education and had started coursework on a master’s degree in music education. Students in this school could take one instrumental class in each grade (sixth, seventh, and eighth), but none were required. Approximately 5% of the school participated in the string program. This teacher required 100 min of practice each week from each student. This teacher also reported a high proportion of students who received free and reduced lunch (70%) as well as a large ESL population.

Forty-four of the 60 students at one high school completed usable questionnaires (73%). The teacher at this high school was a violinist with 11 years of teaching experience and a master’s degree. Students at this school did not practice for a set number of minutes each week. Instead, the teacher assigned goals with specific metronome markings for the students to practice. Roughly 8% of the school population participated in the string program, in which they usually met twice a week. At this high school, participation in the string program was completely voluntary, while string instruction began in the fourth grade in the district. The teacher reported very little diversity in the school (98.52% White) and few students in free or reduced lunch programs.

At the final high school, 115 students of 190 completed the questionnaire (61%). Two different teachers taught the string classes at this school. One teacher was a cellist, earned a master’s degree in performance, and taught for 2 years. The other teacher earned a master’s degree and taught for 22 years. These teachers did not require set amounts of practice time each week. Like the other high school, they set practice goals for students and expected students to regulate their own practice time. Just under 12% of the 1,630 students in the school participated in the string program. Students in this program met every day for orchestra as well as one additional time for chamber group instruction. The teachers at this school reported relatively little racial diversity (88% White).

Participant Demographics

Participants in this study were elementary (n = 101), middle school (n = 97), and high school (n = 159) string students from a northeastern state. Of these 357 students, the majority (52.8%) played the violin, while relatively equal proportions of participants played the viola (23.4%) and cello (17.5%). Only 6.2% of participants reported playing the bass in their school orchestra. The majority of participants (67.3%) were female. These proportions of gender (e.g., Hamann, Gillespie, & Bergonzi, 2002) and instruments (e.g., Russell, 2006) are similar to those found by previous researchers.

Descriptive Statistics

Musculoskeletal Discomfort

Although we asked participants to indicate the amount of discomfort they experienced while playing their instrument in 32 specific regions of the body from head to toe, researchers have found that instrumentalists experience discomfort primarily in the upper body (e.g., Roach, Martinez, & Anderson, 1994). Given this research, we focused on 20 areas of the body above and including the lower back (see Table 1). Although participants reported relatively little physical discomfort when playing (no average discomfort was greater than 2 on the 5-point scale ranging from none to severe discomfort), respondents indicated experiencing the most discomfort in the shoulders and neck. Few experienced any discomfort in their elbows.

Table 1.

Reported Physical Pain.

Body Area	M	SD
Left shoulder	1.87	1.11
Right shoulder	1.83	1.09
Left side of the neck	1.80	1.13
Left fingers	1.79	0.94
Right side of the neck	1.65	1.03
Left upper back	1.61	1.03
Left hand	1.59	0.85
Left lower back	1.58	0.96
Right upper back	1.58	0.99
Right lower back	1.58	0.95
Right middle back	1.58	0.92
Right hand	1.53	0.86
Right forearm	1.53	0.93
Left wrist	1.52	0.83
Lower middle back	1.51	0.91
Right wrist	1.50	0.82
Right fingers	1.46	0.76
Left forearm	1.43	0.78
Right elbow	1.27	0.71
Left elbow	1.26	0.67

Note. 1 = none, 2 = little, 3 = moderate, 4 = considerable, 5 = severe.

Warm-Up Practices

Participants responded to a series of questions regarding their usual warm-up activities. The participants most commonly reported warming up only “sometimes” (33.4%) or “usually” (25%) while relatively equal proportions reported warming up “almost each time” (17.4%) or “always” (18.3%). Only 21 participants (5.9%) indicated that they “never” warmed up before playing their instrument. In addition to warm-up frequency, participants responded to an item designed to elicit information about how much time they spend warming up when they do warm up. The majority (62.8%) reported usually warming up between 1 and 5 min. Fewer than one fifth of the participants (19%) reported warming up for less than 1 min, while slightly more than one tenth (12.6%) indicated spending an average of 6 to 10 min warming up. Only 20 participants (5.7%) warm up for more than 10 min.

Participants responded to a series of items designed to examine the types of warm-up activities they use when warming up. Participants most commonly warmed up by playing scales (82%) and playing a favorite tune or exploration (58%). Roughly half of the participants warm up using finger patterns (49%) or long tones (44%). Fewer reported employing string-crossing warm-ups (31%) or position exercises (24%). Participants were least likely to engage in physical warm-ups without their instrument, such as stretching (20%).

Participant Physical Activities

In order to examine any possible impact of other physical activities on the discomfort of young string players, we asked participants to respond to a series of questions designed to explore the various physical activities in which the participants engaged. Respondents indicated that the most common physical activity was running (62%), which is congruent with previous research (Branfonbrener, 2009). Roughly half of the participants indicated playing team sports (48%), playing individual sports (45%), biking (43%), and swimming (40%). Fewer participants indicated participating in dancing (31%), weight lifting (28%), hiking (23%), martial arts (20%), or yoga (20%).

Instrumental Experience

To account for instrumental experience and any cumulative impact of many experiences, we asked participants to respond to items eliciting information regarding how long they have played their instrument, how many ensembles they play in, how often they play in orchestra (days per week), and if they play additional instruments. The majority of participants did not play an additional instrument (53.5%). The average elementary participant played an instrument for 1.77 years. The average middle school participant played his or her instrument for 3.82 years, while the average high school participant played his or her instrument for 7.35 years. The average elementary participant reported playing in orchestra an average of 2.11 days per week, while the secondary participants played more often (middle school, 2.51 days per week; high school, 4.17 days per week). These averages are similar to previous research in which scholars found that the average elementary string student participated in orchestra twice weekly (Hamann et al., 2002). The majority of participants reported playing in at least one additional ensemble (68.2%), while 29% indicated playing in at least two additional ensembles.

Psychological Issues

In order to examine the impact of some common psychological issues on physical discomfort experienced by young string players, we collected information about the amount of stress participants feel about playing their instrument publicly, how much they enjoy playing their instrument, and the average amount of sleep they get each night. Elementary participants reported getting the greatest amount of sleep per night (9.01 hr), while middle school students received 7.74 hr and high schools students received 7.14 hr. Based on a 5-point scale ranging from not at all to very much, elementary participants enjoyed playing their instruments the most (M = 4.69, SD = 0.81), followed by high school students (M = 4.45, SD = 0.70) and middle school students (M = 4.21, SD = 0.90). The reader should note, however, that all of these averages were high, indicating overall enjoyment at each level. High school participants, however, reported the highest experienced stress about playing their instrument on a 5-point scale ranging from none to a great deal (M = 3.14, SD = 1.22), followed by elementary participants (M = 2.86, SD = 1.63) and middle school students (M = 2.60, SD = 1.31).

Data Reduction and Discomfort Body Mapping

In order to examine if the discomfort experienced and reported by the participants could be logically mapped to facilitate a more nuanced set of analyses, we conducted a factor analysis. We employed an orthogonal varimax rotation in order to minimize any correlation between components. This rotation required seven iterations to converge. Using a minimum eigenvalue of 1.0, five distinct factors emerged, accounting for roughly 68% of the variance in responses. The factor structure was clear, logical, and interpretable; all but one loading exceeded .55, and few cross-loadings exceeded .30 (see Table 2). We established sampling adequacy using the Kaiser-Meyer-Olkin measure (.84) and met the assumption of sphericity as evidenced in the Bartlett Test of Sphericity (χ² = 3830.96, p < .001).

Table 2.

Rotated Component Matrix.

	Component
Body Area	1 Cronbach’s α = .92	2 Cronbach’s α = .74	3 Cronbach’s α = .79	4 Cronbach’s α = .76	5 Cronbach’s α = .80
Right middle back	.833
Lower middle back	.826
Right lower back	.824
Left lower back	.798
Right upper back	.757		.310
Left upper back	.748		.410
Right forearm		.780
Right wrist		.696
Left forearm		.612			.349
Left shoulder			.762
Left side of neck			.736
Right side of neck	.357		.629
Right shoulder		.530	.562
Left hand				.744	.329
Left finger				.714	.317
Right finger				.712
Right hand		.539		.579
Left wrist		.327	.349	.410
Left elbow					.735
Right elbow					.733

Note. Cross-loadings under .30 have been eliminated to improve clarity. Items are in boldface under the component on which they loaded.

Component 1 (back discomfort) consists of all the items pertaining to the back. Component 2 (forearm discomfort) includes both forearms as well as the right wrist. Component 3 (shoulder discomfort) includes each side of the shoulders and neck. Component 4 (manual discomfort) consists of all the discomfort experienced in the hands and fingers, while Component 5 (elbow discomfort) comprises both elbows (see Figure 1).

Figure 1.

Body mapping of musculoskeletal pain.

Factors Influencing Overall Musculoskeletal Discomfort

To facilitate subsequent analyses, we created an overall discomfort score for each participant. Prior to this step, we examined the internal consistency of the physical discomfort scale and found a very high reliability (Cronbach’s α = .91 including all 20 scale items). We considered this sufficient to create a composite score, which we computed using the arithmetic mean of all 20 discomfort items. Before we conducted any inferential procedure, we decided that the number of intended analyses would increase the threat of Type I error. To mitigate this threat, we established an a priori alpha of .01. We then conducted a 2 × 3 × 4 factorial ANOVA using gender, school level, and instrument as the categorical independent variables and the computed overall discomfort score as the dependent variable. We selected these variables because previous researchers (Brandfonbrener, 2009; Russell, 2006) examined them with different populations (i.e., college students, middle school students only). No significant main effects for gender, F(1, 356) = 0.06, p = .80; school level, F(2, 357) = 0.55, p = .58; or instrument, F(3, 354) = 0.45, p = .71, existed. We found no interaction effect between gender and level, F(2, 353) = 3.56, p = .03; gender and instrument, F(3, 353) = 1.61, p = .19; instrument and level, F(6, 353) = 0.94, p = .47; or the three independent variables, F(6, 353) = 0.61, p = .73.

In order to examine the relationship between different warm-up activities and the overall discomfort reported by participants, we conducted a series of independent-samples t tests. In order to further mitigate Type I error, we utilized a Bonferonni adjustment (.01 / the number of analyses or 7 = .001). Despite the precaution of mitigating a Type I error, no warm-up activity examined in the current study significantly impacted participants’ discomfort. Similarly, we conducted a series of independent-samples t tests to examine the impact of participation in a range of different physical activities on participants’ reported discomfort. Again, we used a Bonferonni adjustment (.01/10 = .001) to mitigate Type I error. Again, no physical activity significantly impacted participants’ reported discomfort. Finally, to examine the impact of warm-up frequency and duration, we conducted a 5 × 4 factorial ANOVA. Because participants responded to these items in ipsative categories (frequency categories included never, sometimes, usually, almost each time, and always; duration categories included less than 1 min, 1 to 5 min, 6 to 10 min, and more than 10 min) rather than scaled or open-ended items, we treated them as categorical variables, thus meeting the assumptions of the ANOVA. We found no significant main effects for either warm-up frequency, F(4, 353) = 1.59, p = .18, or warm-up duration, F(3, 354) = 0.79, p = .53, and no significant interaction, F(9, 347) = 1.00, p = .44.

It is possible that how often and how long a student plays an instrument may impact his or her experienced discomfort. We conducted Pearson correlations to examine the extent to which three variables regarding time playing an instrument and overall discomfort were related. Neither the number of years a student had been playing his or her instrument (r = .096, p = .093) nor playing in additional ensembles (r = .101, p = .085) was related to participants’ reported discomfort. The number of days per week students played in an ensemble, however, was significantly related (r = .15, p = .01) to overall discomfort. Based on the weak nature of the direct relationship, however, little practical significance can be assumed.

Understanding that psychological issues may impact the perceived level of physical discomfort experienced by instrumentalists, we asked participants to respond to items regarding their stress, enjoyment, and average hours of sleep per night. In order to examine any relationships that may exist between these factors, we conducted a Pearson correlation. Although average hours of sleep was not related to the overall discomfort experienced by participants (r = –.12, p = .04; note the a priori adjustment of α), both stress about playing their instrument (r = .20, p = .001) and enjoyment of playing (r = –.14, p = .01) were significantly related to overall discomfort. Those who felt stress were more likely to report discomfort, and those who enjoyed playing their instrument were less likely to report discomfort. Unfortunately, the weak relationships indicate relatively little practical significance.

Finally, in order to examine the impact of individual difference variables on the reported discomfort experienced in the different regions of the upper body, we conducted a factorial MANOVA. Based on the interpretable data and the high internal consistency of the components found in the data reduction procedure (see Cronbach’s α analyses in Table 2), we created five variables by computing the arithmetical mean of each component. We then conducted a 2 × 3 × 4 factorial MANOVA using gender, level, and instrument as the three categorical independent variables and four of the five component variables as dependent variables. We did not include Component 5 (elbow discomfort) despite its high reliability as a dependent variable because only two items loaded in that component. We found no main effect for gender, Wilks’s Λ = .989, F(1, 356) = 0.749, p = .56; level, Wilks’s Λ = .982, F(2, 355) = 0.631, p = .75; or instrument, Wilks’s Λ = .935, F(3, 354) = 1.59, p = .09. Similarly, we found no significant interaction between gender and instrument, Wilks’s Λ = .952, F(12, 738) = 1.16, p = .31; gender and level, Wilks’s Λ = .962, F(8, 558) = 1.38, p = .20; or instrument, level, and gender, Wilks’s Λ = .948, F(24, 974) = 9.63, p = .91. We found a significant interaction, however, for instrument and level, Wilks’s Λ = .855, F(24, 974) = 1.87, p = .01. Despite the statistical significance, this interaction explained minimal variance (partial η² = .04), suggesting little practical significance.

Discussion

Overall, participants reported experiencing little musculoskeletal discomfort (no mean exceeded 2 on a 5-point scale), despite the fact that Branfronbrener (2009) claimed that the majority of incoming university freshmen (86%) had experienced discomfort. Branfronbrener’s participants may have reported greater musculoskeletal discomfort given their music background (i.e., Branfronbrener’s participants were university music students who most likely played their instrument more often and for longer durations than the typical K–12 orchestra student). Nonetheless, our encouraging finding may be due to increasingly improved string pedagogy and skill of string teachers or pedagogies more informed by understanding of physical health (e.g., Palac, 1992). Russell (2006), however, posited that young string players may not play their instruments often enough or for long enough periods of time to experience discomfort. Moreover, we found that warm-up activities, duration of warm-ups, frequency of warm-ups, and any other physical activities had no impact on participants’ reported physical discomfort, which confirms previous research (i.e., Russell, 2006), who found that warm-up activities did not influence physical discomfort.

Rardin (2007) found that students reported less pain after participating in an injury prevention program that included physical warm-ups than before. However, these participants claimed to experience greater tension in their playing after treatment. Rardin posited that this might have been due to greater awareness of or sensitivity to these issues. Branfonbrener (2009) found similar results regarding other physical activities and claimed that “exercise did not appear either to protect musicians or put them at increased risk for playing-related pain” (p. 32). Also supporting our results, Branfonbrener found that gender was not a significant indicator or predictor of physical pain.

Surprisingly, we found that neither school level nor instrument played influenced the musculoskeletal discomfort experienced by participants. Russell (2006) found a significant difference in the reported physical discomfort between sixth-grade students and seventh- and eighth-grade students. Despite claims that pianists and string players are at the greatest risk of experiencing pain (e.g., Fishbein & Middlestatdt, 1988), participants in this study (all string players) reported little discomfort and demonstrated no differences by instrument played.

We uncovered a significant but weak relationship between how often participants had orchestra class and the severity of reported musculoskeletal discomfort. This is an interesting finding because the frequency of orchestra class seems highly related to school level (i.e., high school students have more orchestral class contact time). However, it may be that the scheduling of more time between rehearsals (such as employing rotating block schedules rather than classes that meet daily) may increase recuperation time or diminish the compounding effect of repetitive string playing, leading to less musculoskeletal discomfort. The reader should be wary of this interpretation, however, due to the relatively minimal practical significance of the statistical finding. Moreover, we did not collect data regarding how much participants actually played their instruments outside the school day. We reported the amount of practice time required by each teacher but not individual participant playing time. The primary reason for this omission is the questionable reliability of self-reported practice time. Wagner (1975), for example, found that asking students to report the amount of time they practiced had no impact on the amount of time they actually practiced. Similarly, Geringer and Kostka (1984) found that college-age students would over- or underreport practice time despite being generally accurate. Nonetheless, the impact of out-of-school playing time should be examined in future research. As students participate in youth orchestras, Celtic groups, mariachi groups, fiddling, and other music activities, researchers should consider the impact of time playing in these settings as well as the possible stylistic issues that may lead to varying discomfort. Moreover, researchers may want to consider the use of alternative measurement instruments (i.e., alternative self-report techniques, such as pictorial rating scales) or direct observation of physical discomfort through electronic measures (see Kjelland, 2000).

Branfonbrener (2009) found that the reported performance anxiety of undergraduate musicians was not related to their physical pain. We, however, found significant, yet weak, relationships between stress about playing and physical discomfort. Those who experienced more stress were more likely to report physical discomfort. It is possible that participants who feel stress about playing their instrument are responding to a heightened awareness of discomfort (Rardin, 2007). Some students might be generally prone to stress and therefore more apt to experience discomfort as their body reacts to stress with increased physical tension.

Although we found no relationship between participants’ reported sleep habits and discomfort, other researchers have found a link between sleep disturbance and musculoskeletal discomfort. Spence (2001), for instance, found that flute players who reported more frequent sleep disturbances were more likely to report increased pain. Similarly, Fjellman-Wiklund and Chesky (2006) believed sleep disturbances to be a possible cause of musculoskeletal pain among fretted string players.

Logically, those who enjoyed playing their instrument more were less likely to report physical discomfort. Researchers outside the field of music education have found that students’ enjoyment of a subject is directly related to achievement and self-efficacy (e.g., Wigfield, 1994). Similarly, music education researchers have found that students who enjoy playing are more likely to practice and develop self-regulation (McPherson & Renwick, 2001; Sloboda & Davidson, 1996). We believe that students who experience less discomfort may be better able to enjoy the physical act of playing the instrument. Conversely, it may be that maladaptive students allow their dislike of playing their instrument to manifest in exaggerated reported physical discomfort, be it real or imagined.

We examined the underlying physical loci of participants’ physical discomfort using factor analytic techniques and found that participants’ musculoskeletal discomfort focused on five underlying body regions: the back, forearms, shoulders, hands, and elbows. Poor body alignment is a primary cause of musculoskeletal pain (Zaca, 1998). The muscles in the back are the primary stabilizers for body alignment, which may explain the locus of back pain. The forearms are used regularly in the production of vibrato as well as advanced bowing techniques (Hodgson, 1958). These repetitive motions may lead to discomfort and explain the forearm locus of discomfort.

String players’ shoulders are often responsible for holding instruments or maintaining irregular positions. We found that the shoulders were a distinct area of discomfort. Although researchers have examined the impact of chin rests (Okner, Kernozeck, & Wade, 1997) and their ability to mitigate shoulder pain, more research is needed. String players’ hands are some of the most-used facets of the body. Examination of finger dexterity and hand asymmetry (e.g., Palac & Sogin, 2006) has led to greater understanding of how and why fingers may experience discomfort. Finally, we identified the elbows as the last possible locus of discomfort (although participants reported little to no discomfort in this locus). The elbows may have been grouped together due to their roles in string playing or, unfortunately, to response error as participants may have responded to items with similar prompts in a similar fashion. The right elbow, which is used repetitively for bowing, may experience discomfort. Upper string players (violin and viola) may experience discomfort in the left elbow because the use of wrist and elbow vibrato has become more common.

Unfortunately, as with previous research (Branfonbrener, 2009), our participants were not able to “uncover factors that might be linked to playing-related pain” (p. 35) or readily identify possible solutions to experienced pain. The self-report nature of these data may be obscuring possible causes of discomfort experienced by young string players. It is possible that direct-observation research may be better suited to identifying and ultimately mitigating string players’ discomfort and injury. The implications for practice from this study are limited as we have been unable to identify immediately applicable strategies to alleviate students’ musculoskeletal discomfort. It would behoove music education researchers to continue to directly examine the factors that may influence physical discomfort as a means to keep students healthy, enjoying music instruction, and participating in school programs.

Additional research should be conducted on the instruction of warm-ups as well as a closer and direct examination of the activities, durations, and frequency of those warm-ups. Finally, more research is needed that examines the sociopsychological issues that lead to students’ reported discomfort and the impact of different class scheduling practices on student discomfort. Although we are uncomfortable claiming that warm-ups do not mitigate physical discomfort, our findings add to this claim (Russell, 2006). We do, however, realize that participants in this study may not have been making the most effective use of their warm-up activities or time. In-service music educators, researchers, and music teacher educators should remain committed to the teaching of healthy string pedagogies as well as psychologically healthy classroom environments, which may help ensure student success.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Joshua A. Russell is director of the Music Education Division and associate professor at the Hartt School, University of Hartford. His research interests include education policy, teacher education, string education, and psychological/cognitive development in music learning and teaching.

Rachel L. Benedetto graduated from the Hartt School of the University of Hartford in 2012 with a master’s degree in music education. She lives in the Hudson Valley region of New York with her husband and young son. She currently divides her time between her private studio and raising her toddler.

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