The Effects of Stretching Exercises During Rehearsals on String Students’ Self-Reported Perceptions of Discomfort

Music Medicine/Terminology

Musicians have recognized that physical problems often accompany playing, yet examinations of performance-related injuries and medical problems remain relatively new. In contrast, terminology used in describing “. . . pain syndromes has been a source of controversy for many years, engendering a debate not limited to performing arts medicine (Dawson, Charness, Goode, Lederman, & Newmark, 1998, as cited in Brandfonbrener & Lederman, 2002, p. 1014). Multiple factors contribute to pain syndromes, and just as there is no single approach to management, there appears within the field no single term used to define it. Terminology includes—but is not limited to—tendinitis, overuse, cumulative trauma disorder, and repetitive stress or strain injury. With regard to orchestral players, music medicine has used the term overuse syndrome when categorizing a common string player’s affliction (Winberg & Salus, 1990, p. 9). Musicians who experience pain from overuse may compensate in ways that compromise posture and technique (J. Horvath, 2003, p. 28).

Physical Stature and String Players

The type of instrument played can be a factor in musicians’ pain-related problems as well as body shape. Teachers should regard a child’s body size when recommending instruments as it may “predispose him or her to injury” (J. Horvath, 2003, p. 38). A musician’s stature “may impose limits on musicians’ technique by determining how they must adapt with their own physical limitations to the instrument’s requirements” (Brandfonbrener & Lederman, 2002, p. 1012).

Winberg and Salus (1990) noted that string instruments were “not designed with body ergonomics in mind” (p. 11) and prolonged use can cause problems. Researchers have identified that “instruments requiring the greatest number of repetitive finger/hand actions are associated with the highest incidence of musculoskeletal problems in all classes of musicians—students, professionals, and amateurs” (Brandfonbrener & Lederman, 2002, p. 1012). Studies conducted by Cayea and Manchester (1998), Fishbein, Middlestadt, Ottati, Straus, and Ellis (1988), and Lederman (1994) indicate that keyboard and string players—plucked and bowed—have the highest incidence of injuries.

Individuals have varying hand sizes, arm lengths, and height that can affect playing ability, technique, and performance levels. The violin—with its virtuosic demands—requires great flexibility. Additionally, the manner in which violin players hold and play the instrument are “basically non-anatomical or contrary” to the body, which can result in left shoulder and neck discomfort (Winberg & Salus, 1990, p. 12). Brandfonbrener and Lederman (2002) also identified pain localization in violinists’ and violists’ left arms and hands. Irvine (1991) posits that most injuries to the bow arm or hand are caused by “excessive squeezing of the thumb and the fingers against the bow” (p. 65). He states that a relaxed bow hand should be the first priority for string players because a tight hand can result in injury and restricted tone production (Irvine, 1991).

Cailliet (1990) identified problems with string players related to the support required to play the instrument. Data reveal a positive correlation between instrument size and injury: the larger the instrument, the higher the rate of injury (Middlestadt & Fishbein, 1989). Lower strings have localized pain areas; cellists have the highest rate of back injury followed by harpists, pianists, and then double bass players (J. Horvath, 2003, p. 152). Double bass players—because of their instruments’ weight and size—often report lower back problems, whereas cellists have increased risk of strain and hypertension because of their extended hand positions (Winberg & Salus, 1990, p. 33).

Adolescent Musicians

Musicians of all ages remain vulnerable to injury. With young musicians, “[o]verpractice by overeager students appears to be a contributing factor” (Winberg & Salus, 1990, pp. 9-10). When studying adolescent musicians, causes of injury remain more difficult to define because of adolescents’ unique characteristics (Brown, 1997; Fry, Ross, & Rutherford, 1988; Shoup, 1995). These characteristics may consist of “. . . underlying physical conditions such as asthma; lack of time management skills that lead to overuse in proximity to an important musical event; or poor basic training” (K. A. Horvath, 2003, p. 69). Manchester (1997) identified other possible causal factors such as rapid growth, peer relationships, and limited thought process and impulse control.

Lockwood (1988), in examining 14- to 18-year-old students, found that the students’ perceptions of pain could contribute to injury, as noted by 79% of the students indicating playing with pain as acceptable. Lockwood posits that if students assume pain is normal or a requisite, they may be less inclined to acknowledge the need for rest. He asserts the need for “pain-free pedagogy,” and for music educators to anticipate students’ risk factors to prevent injury. K. A. Horvath (2003) supports the need for the teacher to take an active role in injury prevention. “If we as teachers begin to think of ourselves as trainers and utilize some very important information about muscle development, muscle mapping, and stamina building, we can help raise healthy musicians who have a reduced risk of injury” (p. 69).

Injury Preventions

When considering performance-related injuries, preventative techniques—such as warm-ups and stretching exercises—would seem an obvious place to start. “The behavior modification efforts that appear to be advisable seem rather common-sense and minimal, including the pacing of playing with frequent rests, participating in some form of regular exercise, watching one’s posture, and so forth” (Brandfonbrener & Lederman, 2002, pp. 1020-1021). Yet with regard to avoiding performance-related medical problems, few studies have shown the effectiveness of specific preventative techniques (Brandfonbrener & Lederman, 2002).

Incorporating and combining warm-ups and stretches in the daily routine is touted as most important to realize their “multiple benefits” (Winberg & Salus, 1990, p. 6). Knowledge of the individual’s fatigue, flexibility, and general health remains crucial when incorporating warm-ups and stretching exercises. Winberg and Salus (1990) also endorse constant self-monitoring. Smith (1994) promotes handclapping exercises to improve finger strength and agility, rotating the wrists for bow-hold preparation, and a “basketball shot” motion to improve wrist flexibility and strength. Irvine (1991) posits the Alexander technique as useful for addressing upper torso injuries. Brandfonbrener and Lederman (2002) promote weight training and resistance exercises and repetitions to increase endurance and also recognize the importance of a “physiologic point of view” in discussions about technique and music pedagogy (p. 1020).

Method

The focus of this study was to determine whether physical intervention—easily performed stretches for the hands, arms, and shoulders of a brief duration—administered during rehearsals at approximately 10-minute intervals would affect orchestra students’ perceptions of physical discomfort. The two research questions were as follows:

This quasi-experimentally designed study, included two high school (HS) classes, taught by the same instructor, and two junior high school (JHS) classes taught by the same instructor. Participants for the study comprised N = 126 HS and JHS string orchestra students from four schools in the Northwestern United States ranging in age from 14 to 18. Only students who completed all four reporting sessions were used in the study for a resultant N of 100. There were 35 male (35%) and 65 female (65%) participants in the sample with 66% of the participants in JHS and 34% in HS. There were 68 (68%) upper string students (violin and viola) and 32 (32%) lower string students (cello and double bass).

The groups were assigned by grade level at the beginning of the school year. An independent adjudicator selected the groups for study participation based on their performance ability. Thus, the groups at the JHS were determined to be equivalent in performance ability as were the HS groups and thus were chosen for study participation. Participants were assigned by class to the treatment or control group, resulting in one JHS and one HS class per group. Fifty-seven students were in the treatment group (37 JHS and 20 HS), whereas 43 (18 JHS and 25 HS) were in the control group. All participants, regardless of group assignment, completed the Perception of Discomfort (POD) survey and provided demographic information, which included gender, age, grade in school, and instrument played. They also responded to a five-part question using a Likert-type scale to report any experienced discomfort in the following: hands, wrists, arms, shoulders, and neck. Participants indicated discomfort levels—or lack thereof—using a five-point scale prior to and immediately following four rehearsals over a 2-week period. The scale degrees were as follows: 1 = no discomfort, 2 = slight discomfort, 3 = moderate discomfort, 4 = high discomfort, and 5 = extreme discomfort.

In the control group participants’ methodology protocol, students were requested to report any experienced discomfort in their hands, wrists, arms, shoulders, or neck prior to the beginning of rehearsal using the POD survey. After the rehearsal, participants completed the POD’s reverse side to indicate any experienced discomfort within the five body areas. On each rehearsal’s conclusion, forms were collected. Students completed the POD four times over a 2-week period.

Treatment group participants completed the POD survey in the same manner as control group participants; however, at various intervals throughout the rehearsal (approximately 10 minutes apart), the instructor directed students to complete stretches/exercises designed to reduce fatigue and/or stress or discomfort. Exercises were taken from Stretching for Strings (Winberg & Salus, 1990). Each instructor was provided specific directions for administering the stretches to the treatment group participants and diagrams of each exercise (see Table 1 and Figure 1).

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Table 1.

String Students’ Self-Reported Perceptions of Pain Methodology Protocol

Control group

1. Prior to rehearsal, have each student complete a “Perception of Discomfort” (POD) survey

2. At the completion of the rehearsal have each student complete the opposite side of the POD survey

Experimental group

1. Prior to rehearsal, have each student complete a “Perception of Discomfort” (POD) survey

2. At various intervals throughout the rehearsal (approximately 10 minutes apart), teacher will direct students to complete stretches/exercises designed to reduce fatigue and/or stress/pain. The following four sets of stretches/exercises may be administered in any order as long as all are used

Set 1: Wrist rotations, shoulder–deltoid, forward neck roll

Set 2: Oppositional finger–wrist press, hand–finger extensions, fist clench and unclench

Set 3: Hand wringing, arms–bicep curls, shoulder–deltoid variation (ear to shoulder)

Set 4: Hand shakes, arms–triceps extension, and fingers clenched and unclenched (overhead)

3. At the completion of the rehearsal have each student complete the opposite side of the POD survey

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Figure 1.

Diagram of Set 1 Stretches

The following four sets of stretches/exercises could be administered in any order, as long as all were used within each rehearsal.

POD survey reports, from all four sessions, were organized by participants. Each participant was requested to provide pretest and posttest responses on one questionnaire per session. One side of the survey was used for pretest responses, and then at the conclusion of the session or class, the opposite side was used for posttest responses. The administrator instructed students not to view or refer to their pretest responses when completing posttest responses. Students from each class were asked to return their surveys with their name on it. Each survey was prepared so that the group and session were recorded on the form. All responses of one student were kept together by class/group/session (i.e., Fred, Group 1, Session 1). Once the testing was completed for all study sessions, the forms were clipped together and data were recorded. If a student was absent during any sessions, he or she was eliminated from the study for data analyses purposes. Each form was identified according to the POD administration (1, 2, 3, or 4) to track survey administration/completion order during data analysis.

Results

Data were scored/compiled as follows for analyses purposes: A grand mean score was computed for each participant’s before- and after-rehearsal scores. A combined score was calculated by computing the mean of the aggregate hands, wrists, arms, shoulders, and neck scores for each participant. This resulted in a grand mean before-rehearsal score and a grand mean after-rehearsal score for each participant.

Data were analyzed using a two-way multivariate analysis of variance (MANOVA).

Discussion

“Among teachers, doctors and therapists there is a concern that developing muscles and bones may be damaged by repetitive activities” (J. Horvath, 2003, p. 117). Are teachers inadvertently promoting “playing through pain,” which can ultimately lead to long-term physical issues. Chesky, Kondraske, Henoch, Hipple, and Rubin (2002) assert that educators need to acknowledge problems and be involved in “music education-based prevention programs” (p. 1023). Based on findings in this study, participants who were administered periodic stretching exercises had significantly lower perceptions of discomfort than control group participants. It would appear, at least initially, that some discomfort issues could be reduced through such exercises. Thus, teachers need to be proactive in guarding against injury. Our students should experience music education program without experiencing performance-related injuries.

J. Horvath (2003) notes that the Medical Problems of Performing Artists (MPPA) reported that when teacher’s were asked to disclose amount of time teaching injury-prevention techniques, 68% responded as “spending less than five minutes . . . during a 30-minute lesson” (pp. 119-120). If musicians and teachers become more cognizant of new evidence related to musicians’ health issues and music performance–related injuries and provide instruction on injury-prevention techniques, is there a way to perform music without the accompaniment of pain? It is time to relinquish the clichés of “no pain, no gain,” as muscle strain can result in loss of function and dexterity. Students should be able to report physical discomfort to their teachers without fears of repercussions.

Future research could incorporate the Alexander technique or the Feldenkrais method of somatic education to determine whether these approaches would also reduce the perception of discomfort when playing. Both of these techniques are designed to refine movement and reduce tension and therefore improve everyday activities.

“Each instrument presents unique requirements” (Winberg & Salus, 1990, p. 11). In this study, instrument scores—both lower and upper strings—showed a significant difference in before- and after-rehearsal scores. Therefore, another study could focus on which exercises affect specific instruments. Existing research appears to identify that upper strings tend to have “more issues” (Brandfonbrener & Lederman, 2002; K. A. Horvath, 2003; Winberg & Salus, 1990). Also interesting was the significant disordinal interaction that existed between group and instrument in before- and after-rehearsal scores. Treatment group participants’ after-rehearsal discomfort scores decreased as compared with their before-rehearsal scores—in contrast to control group participants’ after-rehearsal scores, which increased. Replicating this study in the band area could be informative as some band instruments are associated with overuse problems.

Summary

Informed and trained educators can prevent student injuries. “[T]he most distinguishing feature of all diseases and injuries related to music is that they are preventable” (Chesky et al., 2002, p. 1035). They also recognize music educators as in “an ideal position to help prevent problems because they dictate the sequence and set the pace for musical learning and are in everyday contact with students before and during skill and potential problem development” (p. 1035).

Results from this study revealed significant differences in discomfort perception by treatment and instrument. Brandfonbrener and Lederman (2002) note that musicians’ injuries are often cumulative over time. Therefore, a music educators’ role is important in being proactive about preventative and/or rehabilitative measures. Music educators should have the information available to “. . . limit the impact of these problems on musicians and especially attempt their prevention” (p. 1009). Being cognizant of the continued interface between musician and instrument and knowledgeable about strategies to reduce or alleviate discomfort and injury remains paramount for musicians and educators. The time has come to dispel the “common misperception that pain is a necessary accompaniment of playing an instrument” (Brandfonbrener & Lederman, 2002, p. 1014). Perhaps, the first step for teachers is to give their students permission to acknowledge discomfort or pain and then to provide solutions to alleviate and/or decrease the level of such discomfort during rehearsals.