Barriers and facilitators in implementing an exercise-based injury prevention program for string players

Abstract

BACKGROUND:

Musicians are at risk of developing playing-related injuries/musculoskeletal problems - to the extent that several injury-prevention strategies have been employed by them. In order to ensure compliance and improve implementation strategies, this study explores the opinions of musicians and music tutors on the barriers and facilitators in implementing an injury prevention program for string players, and the perceptions of the first mentioned as to the practicality of such an exercise-based injury prevention program.

METHOD:

This study employed a qualitative method (focus group discussion) to explore the opinions of musicians on exercise-based injury-prevention programs for string players and their implementation strategies. Content thematic analysis was used to analyze and interpret the data.

RESULTS:

Two music schools, with 11 musicians, participated in the study. The mean age and the mean years of experience of the participants were 28.2±6 years and 12.4±3.8 years respectively. The results of this study showed willingness in the musicians to adopt an exercise-based injury prevention program. However, the major challenge proved to be the time constraint of including an exercise program in the participants’ normal practice and teaching routines.

CONCLUSION:

There is a willingness to explore possible exercise-based intervention programs to mitigate or prevent instrument-playing-related health problems. However, time constraints proved to be the major barrier to implementation. It was further concluded that consideration should be given to the duration of the intervention program and the mode to adopt in the implementation of the exercise program.

Keywords

Musician injury prevention time constraints

1 Introduction

The organisational culture of musicians supports ‘playing through pain’ which has resulted in poor injury management among musicians [1, 2]. Musicians tend to conceal their injuries, often on account of their fear of the manager’s perception of playing-related health problems [2]. However, in recent years, there has been an increase in health-promotion programs to manage playing-related problems among musicians [3 –6]. Musicians and health professionals have built a sustained relationship to provide solutions to the problems associated with playing a musical instrument. This collaboration has resulted in an understanding of playing-related problems, and possible intervention strategies are being explored. Intervention strategies are focused on improving the psychological and physical well-being of the musician [7]. At the 2008 National Music Teachers’ Meeting in the United States of America, four core areas of playing-related problems were identified and health-promotion programs to mitigate the identified problems were recommended as part of the curriculum in music schools [7].

In South Africa, there has been an increase in the research conducted to understand the nuances in the prevalence of injuries and the injury patterns that arise in performing artists in the African population, with the focus being mainly on musicians [8 –11] and dancers [12]. There is currently no literature on intervention programs in South Africa in spite of the growing body of literature to understand the sequelae of injury while playing an instrument. In countries where intervention programs have been developed, implemented and tested, promising results such as reductions in perceived exertion and in self-reported injuries have been noted [5 , 13].

With the growing evidence of the positive effect of health promotion programs inclusive of exercise-based intervention for injury prevention among musicians, uptake and compliance are still major concerns. An exercise-based intervention program in Australia reported a 25% uptake and 41% compliance [4]. In injury management, adherence to an intervention program is a challenge and a method to ensure adherence to intervention programs is important for good outcomes and reductions in the cost of treatment [14, 15]. The nuances of a health-promotion intervention are population dependent. The interrelationship between the individual, the organisational structure in which he/she works, and the psychological and physical demands made upon him/her, will influence his/her work-related problems in terms of the occurrence and management of injuries [16].

Identifying the barriers to the implementation of an intervention program with the aim of a barrier-specific strategy would ensure the effectiveness of treatment and improve treatment outcomes [17, 18]. Therefore, in order to improve the uptake in and compliance with a health-promotion program for musicians, there needs to be a change in health behaviour on the sides of both the managers and the musicians. This change in health behaviour is often informed by models such as the Health Belief Model [19].

The Health Belief Model informs the process of implementing treatment programs. ‘Conveying the consequences of the health issues associated with risk behaviours’, ‘communicating injury prevention methods and highlighting the benefits’, and ‘providing assistance in identifying barriers’, are important aspects in the implementation of injury prevention programs [19].

As part of a larger study to develop and implement an exercise-based injury prevention program for string players, this study aimed to explore possible barriers in the implementation of the developed exercise program. The opinion of music instructors and musicians on the usefulness of the program and possible implementation strategies to facilitate an exercise-based injury-prevention program for string players, was explored.

In ensuring a successful plan, it was deemed necessary to communicate the health issues associated with work demands and also outline the benefits of an injury-prevention program for string players [19].

2 Materials and methods

2.1 Study design

This study employed a qualitative design approach. Focus Group Discussions (FGD) were conducted using an interview guide, which allowed for different opinions and interactions amongst the participants [20]. The focus group discussion generally has the potential to be used as a research design to explore predetermined themes and emerging themes in a specific area of interest [21, 22]. In this study, we used the focus group discussion to explore both pre-determined themes and emerging themes. This study constitutes part of an overall study for a doctorate degree that is aimed at developing an exercise-based injury-prevention program for string players. As such, this stage of the research focuses on exploring the barriers and facilitators that could affect the implementation of the developed exercise program in question.

2.2 Recruitment and sampling

Two music schools in Johannesburg, South Africa, participated in the study. The participants, including musicians and music tutors, were approached via the telephone, face-to-face, or by email. Important to note is that all the participants reported to have had experience in playing at least one musical instrument. The sample consisted of those musical performers who had agreed to participate. A total of 11 participants were included in two focus group discussions at the two music schools. The mean age and the mean years of experience of the participants were 28.2±6 years and 12.4±3.8 years respectively. The participants comprised of two females and nine males (Table 1).

Table 1
Demographic attributes of the participants

FGD Participant Age (years) Gender Profession Playing experience (years)

Group 1 1 26 Female Violinist and music tutor 15

2 22 Male Violinist 12

3 26 Female Violinist 15

4 35 Male Violinist 07

5 19 Male Bassist 06

6 30 Male Violinist 15

7 20 Male Violinist 09

Group 2 1 31 Male Cellist – player and teacher 16

2 34 Male Violinist, Trombonist, Music researcher and music tutor 17

3 36 Male Pianist and music tutor 15

4 31 Male Guitarist and Music tutor 12

FGD	Participant	Age (years)	Gender	Profession	Playing experience (years)
Group 1	1	26	Female	Violinist and music tutor	15
	2	22	Male	Violinist	12
	3	26	Female	Violinist	15
	4	35	Male	Violinist	07
	5	19	Male	Bassist	06
	6	30	Male	Violinist	15
	7	20	Male	Violinist	09
Group 2	1	31	Male	Cellist – player and teacher	16
	2	34	Male	Violinist, Trombonist, Music researcher and music tutor	17
	3	36	Male	Pianist and music tutor	15
	4	31	Male	Guitarist and Music tutor	12

2.3 Procedure

The participants were familiar with the aim of the research, and relationship was developed between the participants and the interviewer. The components of the exercise program and the potential effects were explained to them. The questions posed in the discussions explored the opinions of the musicians about the practical applicability and the method of implementing an exercise-based injury-prevention program for string players.

The developed exercise program comprised of core stabilisation programs, stretching and strengthening exercises of the upper extremity and neck, as well as warming-up and cooling-down exercises [23]. The exercises were developed specifically for violin/viola players and could be easily adapted for other string players (cellists and double bassists) [23].

Familiarity was fostered by involving participants who were willing to genuinely participate in the FGD. Probes to generate further explanation from the participants were used during questioning to ensure that the participants were being honest [24]. The FGD was conducted at the music school of the participants and the discussion was facilitated using an interview guide.

The FGDs were conducted in December 2016 and January 2017 at the workplace of the participants (the two music schools). With the researcher acting as facilitator, the discussions continued until no more emerging themes were apparent. The discussions were audio-taped and field notes taken.

To ensure data credibility, participants’ responses were validated during the group discussions; the comments of the participants were summarised; and the accuracy of opinions offered was confirmed with the participants during the discussions; and finally, peer debriefing was conducted at the end of the session.

2.4 Ethical considerations

Ethical approval was granted by the Human Research Ethical Committee at the University of the Witwatersrand, South Africa (M130836). Written informed consent was obtained from all the participants to participate in the study and for the group discussions to be audio-taped. After a clear explanation of the study, a copy of the research information sheet was handed to each of the participants. It was explained that confidentiality in a qualitative research study cannot be entirely guaranteed, but that the researcher would ensure that identifying details relating to the participants would be removed from the transcribed document.

2.5 Data analysis

SPSS statistics 24 was used to analyse the descriptive statistics (age, years of experience, gender) of the participants. The interview was recorded and thematic content analysis [25] was applied to analyse the data. The transcribed data were then categorised into themes. In their turn, themes were derived from the comments/quotations of the participants and grouped together into predetermined and emerging categories that were based on similarities in the context of the comments/quotations made by the participants.

3 Results

3.1 Themes

The transcribed report was encoded into themes and subsequently categorised into broader themes that were based on the objectives of the study (Table 2).

Table 2
Thematic analysis of the study

Themes Sub-themes Code Direct quotes

Benefits of the exercise program Perceived effect on pain The perceived positive benefits of the exercise program. I think with this it deals with pain, it is beneficial to everyone in the music school

Experiential effect of injury on performance The adverse effect of the injury on performance. My injury affects my playing and performance

Implementation strategy Time factor Need to make time for the implementation of the program We can make time….we will have to arrange something.

Fixed teaching duration Our groups are an hour long.

Time constraints in teaching the program I have only 30 minutes to teach my student.

Willingness to make time to teach the intervention program We have groups here, like big groups, with many of the children, and if we have like five minutes or ten minutes before or after, I show them the exercises and tell them to do them before and after the practice.

Teaching and training Small group teaching and implementation of the exercise program If we don’t put everybody on the same da, we can put them into groups and that way everybody gets a chance to do it….Before they start playing, we can do exercises to start and after that, we do some exercises as well.

Need for a workshop to teach the program I think the workshop is best, if we have you guys come to the school where we have a class of beginners and the beginners get it from you straight up and then we will stay with them for the rest of the time but first time it was your being here so that everyone understood.

Teaching of the program from seniors to juniors in the music schools Or we can organise a teacher’s workshop and you guys show up what you came up with. When you teach us, we take it back to the kids because we also have young trainees who are still in high school and they also learn and pass it down.

Willingness of the teachers/instructors to follow up on compliance and adherence to the program …….Teachers’ follow-up.

Health promotion and education Need for knowledge on injury prevention I would like to know how other players manage their injuries or how it comes about that they make themselves feel better by playing

Willingness to learn and adopt the program and teach the intervention program to young learners. I definitely will be open to learning the exercises. Also, because I’m also teaching here…. We teach from the very little ones, the very new beginners to some of the grown up ones. So I think as a teacher it will also benefit the young ones if I know the exercises that need to be done, I can do it with them from a young age to help them grow and play without pain.

Themes	Sub-themes	Code	Direct quotes
Benefits of the exercise program	Perceived effect on pain	The perceived positive benefits of the exercise program.	I think with this it deals with pain, it is beneficial to everyone in the music school
	Experiential effect of injury on performance	The adverse effect of the injury on performance.	My injury affects my playing and performance
Implementation strategy	Time factor	Need to make time for the implementation of the program	We can make time….we will have to arrange something.
		Fixed teaching duration	Our groups are an hour long.
		Time constraints in teaching the program	I have only 30 minutes to teach my student.
		Willingness to make time to teach the intervention program	We have groups here, like big groups, with many of the children, and if we have like five minutes or ten minutes before or after, I show them the exercises and tell them to do them before and after the practice.
	Teaching and training	Small group teaching and implementation of the exercise program	If we don’t put everybody on the same da, we can put them into groups and that way everybody gets a chance to do it….Before they start playing, we can do exercises to start and after that, we do some exercises as well.
		Need for a workshop to teach the program	I think the workshop is best, if we have you guys come to the school where we have a class of beginners and the beginners get it from you straight up and then we will stay with them for the rest of the time but first time it was your being here so that everyone understood.
		Teaching of the program from seniors to juniors in the music schools	Or we can organise a teacher’s workshop and you guys show up what you came up with. When you teach us, we take it back to the kids because we also have young trainees who are still in high school and they also learn and pass it down.
		Willingness of the teachers/instructors to follow up on compliance and adherence to the program	…….Teachers’ follow-up.
	Health promotion and education	Need for knowledge on injury prevention	I would like to know how other players manage their injuries or how it comes about that they make themselves feel better by playing
		Willingness to learn and adopt the program and teach the intervention program to young learners.	I definitely will be open to learning the exercises. Also, because I’m also teaching here…. We teach from the very little ones, the very new beginners to some of the grown up ones. So I think as a teacher it will also benefit the young ones if I know the exercises that need to be done, I can do it with them from a young age to help them grow and play without pain.

4 Discussion

The aim of the study was to explore the perceived barriers and facilitators involved in the implementation of an exercise-based intervention program for musicians. Such perceived barriers and facilitators are often influenced by the individual, the organisation, and the social and policy context [26]. Our study showed both individual and organisational factors that could act as barriers and facilitators in the implementation of an exercise-based intervention program for musicians. The perceived barriers identified were time constraints, inadequate knowledge/information, and organisational structures.

The participants considered the time constraint as a barrier in implementing the program. They suggested that the teaching of the program would meet with greater success if it were to be implemented in a music school rather than through one-on-one tutor encounters on account of the relatively short period for teaching which is usually of the order of only 30 minutes.

As mentioned above, time is a major constraining factor in the implementation of an intervention program [15]. On the other hand, the duration and frequency of the exercise program within the organisational structure could affect the participants’ adherence to the program and eventually the effect of the program on injuries [27].

In our study, the participants suggested possible implementation strategies to encourage them to adopt the exercise program and overcome the time constraints, as well as a follow-up session to test the compliance of the music teachers and their uptake. The following quotations by participants convey their impressions of the exercise program:

“It is beneficial to everyone, we might have to make arrangements and probably teach the students in batches and that way everybody gets a chance to learn the exercises. We can createtime.”

“We can organise workshops…. I think the workshop is best even if it’s not for the teachers alone….you teach everybody and the teachers can follow up on the monitoring.”

Since the music tutors and management have the authority to ensure compliance and adherence in respect of the exercise program, no major problems were envisaged in the attitudes of the participants. The exercise-based injury-prevention program for string players was generally considered to play an important role in preventing injury among string players, and the participants showed their willingness to understand the components of the exercise program, and also their anticipation in looking forward to implementing the program.

On account of the musculoskeletal problems related to string-instrument performance experienced by a number of the participants, a preventative approach to their injuries was considered to be a good intervention. All of the participants tended to perceive the benefits of the exercise program positively. Thus, the program could be put to good use in facilitating a willingness to adopt the program. As stated by one of the participants, and a view shared by all of the participants in the study,

“I think it is going to benefit us a lot. I suffer from a lot of shoulder and back pain and I’m always going to physio for that…. It was found that my muscles are weak and if there is something that could be found to strengthen my back and shoulders so that I would be able to play without experiencing pain, that would be awesome, because I know for myself personally, it is a huge struggle for me to play, especially when we’ve got a lot of work, when we’ve got a concert coming up, or when on tour, because there’s a lot of pain happening…. It becomes a struggle, because I then get muscular spasms, with my back not wanting to work. It’s a struggle to walk; it’s a struggle to play. I would definitely be open to learning and teaching the exercises”.

The quotation above is not surprising as there is evidence that musicians with a history of debilitating injuries tend to report their injuries and seek medical help [28]. In fact, music students generally have poor health behaviours [29, 30], with female students showing much better health behaviour than males [30].

Difficulty in expressing injury-related concerns by musicians on account of the fear of job loss and subsequent unemployment has been reported as one of the major reasons [31] for poor health behaviour among musicians. Nevertheless, the debilitating effect of the injuries on playing and performance tends to motivate the musicians to learn about health problems related to string-instrument playing and to adopt injury-prevention strategies to prevent or mitigate injuries.

The willingness of the participants to discuss their problems, to explore the exercise-based intervention program for their own personal use, and to teach their students, could facilitate willing attitudes to facilitate the adoption of the program. In recent years, health-promotion strategies and injury-prevention programs have been developed for music-performance-related injuries. The health-promotion programs are focused on identifying common health problems and risk factors, as well as on teaching injury-prevention strategies [32]. In settings where various health-promotion programs have been tested, positive outcomes have been recorded.

Barton and Feinberg [33] evaluated the effect of a health-promotion course for music students that focused on teaching common health problems, physical and psychological risk factors, as well as injury-prevention strategies. The health-promotion program showed an increase in the knowledge about playing-related injuries and a change in the behaviour of the music students through the adoption of injury-prevention strategies [33]. A better understanding of injuries related to instrument playing and injury-prevention strategies could increase the adoption by musicians of such programs at the individual level, as well as their compliance to them. Nevertheless, it bears thinking of that apart from acting as facilitators; organisational factors could also negatively affect the implementation of an exercise program.

The organisational culture of the musical performance industry does not encourage disclosure of injuries and this often results in musicians concealing their injuries from the orchestral managers [2]. Owing to the secrecy around injuries among musicians, it is not surprising for musicians to be reticent about disclosing their injury challenges amongst their peer performing group. This makes the ‘injured’ musician feel he or she is suffering alone. As one of the participants commented,

“I’d like to know how other players manage their injuries or how they go about making us feel better by playing!”

The ability of musicians and their managers to understand the effect of injury on performance is improving. However, there needs to be an institutional approach to manage performance-related injuries. In fact, some institutions have health clinics that are dedicated to conducting research and managing the health problems of music students [34]. This has resulted in better access to specialised treatment for music students.

In our study, aspects such as the adoption of the exercise program, compliance, adherence, and time constraints, were considered to be the three major sub-themes of intervention that were dealt with in the focus group discussions. The participants were willing to adopt the exercise program. It was suggested that the exercise program should in fact be introduced to musicians at an early stage in their profession when they are still acquiring the motor skills necessary for playing a string instrument.

Chesky, Dawson [35], believe that providing information to music teachers and young music students concerning injury prevention is important in the implementation of health-promotion programs. A health-promotion program that comprises education on risk behaviours, pathophysiology of injury, and the implementation of intervention programs would be effective in ensuring compliance and adherence [19].

An educational course in health promotion and injury prevention directed at college music majors showed that students understand and retain the information concerning injury-prevention strategies. However, it deserves mention that the application of the injury-prevention methods does not necessarily prove to be consistent with the relevant information [33].

Health preventative methods have been shown to improve the attitude of musicians towards health matters. However, the educational program does not cater for a significant improvement in pre-existing symptoms [36], the inconsistencies in the implementation of intervention strategies possibly being one of the explanatory factors [33]. The reinforcement of injury-prevention programs [33] and specific therapeutic interventions [36] for young musicians have been suggested as strategies to improve adherence. The quotation below reflects this viewpoint:

“As a teacher, it will also benefit the young ones at an early age to help them grow and prevent injuries when they are still young.”

The major barrier to implementing an exercise-based intervention program in this population lies in the time constraints. Musicians have limited times in which to practise, and to implement an exercise program during this short period appears to be difficult. However, the participants showed their willingness to explore possible ways of integrating the exercise program into their practice period. Furthermore, the willingness of the music tutors to implement an appropriate health-promotion program and subsequently to follow up on it with the students could facilitate the successful adoption of an exercise program.

5 Conclusion and recommendations

Intervention strategies to reduce and prevent playing-related health problems among musicians are a current trend, and in order to attain the goal of preventing injuries among musicians, the challenges and fears of the musicians are important considerations in the implementation of an injury-prevention program. The participants in this study showed their willingness to adopt such a program that would be beneficial to them. Furthermore, the time constraints that they were faced with proved to be an important factor influencing their adherence and compliance to the program. It was found that it would be more effective to implement the program at the more formal music institutions (schools) than in a more informal setting. Music students could be taught at an early age about pathophysiology of injury and possible intervention strategies. Furthermore, music institutions could include injury prevention as part of their music-training curriculum. These strategies could help in the adoption and implementation of exercise-based injury-prevention programs for musicians.

Conflict of interest

None to report.

Footnotes

Acknowledgments

We would like to acknowledge the music schools that participated in this research, the sponsor/s of the FRC individual grant, the Faculty of Health Sciences, and the Financial Aid Office at the University of the Witwatersrand, South Africa.

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