The prevalence of performance-related musculoskeletal disorders in fine arts faculty students and academics

Abstract

BACKGROUND:

While professional musicians may have a high incidence of musculoskeletal pain, there are few studies on the performance-related musculoskeletal disorders (PRMD) in visual artists.

OBJECTIVE:

To assess the prevalence and probable risk factors of PRMD in visual artists.

METHODS:

The study population comprised the students and academics of fine arts faculty. The Rapid Entire Body Assessment (REBA) and the Cornell Musculoskeletal Discomfort Questionnaires were used to evaluate posture and pain, respectively.

RESULTS:

The study included 197 participants (140 women, 57 men). The mean REBA score was 5.2. The sculptors who worked in marble sculpting had the highest REBA scores. Of the participants, 88.8% reported musculoskeletal pain. The pain severity of 64.0% of the participants was 3 (very uncomfortable with a reduction in activity) and/or 4 (pain interferes with the ability to work). The PRMD prevalence was 64.0%, and significantly higher in women than in men (p < 0.05).

CONCLUSIONS:

Musculoskeletal pain in visual artists is extremely prevalent. Mean REBA score of 5.2 corresponds to a medium risk assessment accompanied by guidance to “further investigate, change soon.” The policy makers in fine arts faculties who are responsible for student and employee health should prioritize strategies to prevent and manage musculoskeletal pain.

Keywords

Ergonomics visual arts musculoskeletal pain occupational medicine epidemiology

1 Introduction

Musculoskeletal complications are the most prevalent occupational disease [1], comprising 50% of new onset occupational diseases in Europe [2]. Among artists, occupational diseases are generally referred to as performance-related musculoskeletal disorders (PRMD) or, in musicians, playing-related musculoskeletal disorders [3 –5]. Previously, PRMD studies have primarily focused on orchestral musicians and dancers, but many visual artists perform their art as vigorously as musicians and dancers. Notably, visual artists are often admitted to hospitals due to pain in several parts of their body. When we came across to these visual artists who admitted to our outpatient clinic, they had opined that their musculoskeletal complaints likely developed from working for long sessions in precise positions that required either standing or sitting. The frequency of these complaints increased during periods when the artists had to work intensely (i.e., during final exam week for students and exhibition periods for academics).

A review of the occupational disease literature on visual arts such as painting, sculpture, ceramics and miniature revealed two studies by Chang et al. and Sahu et al. [6, 7]. The first one of these two studies, which is by Chang et al., involved a study population of painters and sculptors, 70% of whom reported lower back pain. Age, hours worked per day and length of employment (but not gender) were determined to be risk factors for musculoskeletal pain [6]. The second study which is by Sahu et al. focused on potters and clay sculptors and demonstrated that awkward postures caused pain [7]. Whether artists from different branches of the visual arts differ in the frequency and severity of musculoskeletal pain remains unanswered. Therefore, we aimed to determine the prevalence and probable risk factors of PRMD in the students and academics at the Marmara University Faculty of Fine Arts.

2 Methods

2.1 Study design

This cross-sectional study was conducted at the Marmara University Faculty of Fine Arts Acibadem Campus between November 2015 and April 2016. The study was approved by the Marmara University School of Medicine Ethics Committee with the protocol code of 09.2015.213 on the date of 04.09.2015. The volunteer participants provided written informed consent.

2.2 Study population

The Rapid Entire Body Assessment (REBA) [8, 9], used as one of the data collection tools in this study, is performed by observation. The following visual art departments were selected for inclusion in the study: painting, sculpture, traditional Turkish arts, interior design, ceramic-glass and textiles. The students and academics of these departments constituted the population of the study. Throughout the course of this study, three days a week during the workshop’s working hours, the researcher observed the artists while they performed their art activities. All the observations were performed by a single researcher. The students who were in their first year at school were excluded, as it was assumed that these students had not yet developed significant musculoskeletal pains. There were two types of students in the faculty: regular and irregular students. A regular student was expected to finish school within the prescribed number of semesters/years, based on the effective curriculum upon admission, and therefore, attended school regularly. An irregular student was unable to follow the program due to failure, dropping out, leave of absence and/or shifting. In the six selected departments, there were 950 students in the second-, third- or fourth-year classes and 75 academics. Of these 950 students, 700 were regular students, and 250 were irregular students. Assuming a PRMD prevalence of 50% and factoring in 700 students and 75 academics, we estimated that 201 participants would be needed to achieve a 90% confidence interval with 5% type I error [10]. But, in the preliminary study, we observed that the regular students were not all routinely present at the school. To reach the required number of participants, all the artists in the classes who worked during the time that the researcher was present at the relevant workshops were invited to participate in the study. Except for two artists, all the students and academics who performed their art during that timeframe agreed to participate in the study. The academics and the students in the second-, third- and fourth-year classes were included; the first-year class students and any artists with inflammatory rheumatologic diseases were excluded.

2.3 Data collection tools

Data were collected according to the schedule and working hours of the students and academics. The researcher observed the artists while the artists performed their art. The data collection tools included a participant follow up form, which surveyed the artists’ demographical data, comorbidities, drug utilization, body mass index (BMI) and body surface area (BSA) as well as the REBA for posture evaluation [8, 9] and the Cornell Musculoskeletal Discomfort Questionnaires (CMDQ) for pain assessment [11]. First, the participant was interviewed to fill in the participant follow-up form and the CMDQ. Then, the participant was asked to continue his/her work; while he/she worked, the researcher performed the REBA. The data collection sessions took place after approximately 60–90 minutes of artwork that each participant started to perform and took 15 minutes for each participant.

After reviewing the students’ class information on the participant follow-up form, the number of years that the students had spent in school was taken into consideration. The students who were in their first year of school were excluded; the students who were taking their first-year class again were included. The comorbidities identified on the form were grouped as respiratory tract, gastrointestinal system (GIS), neurological, psychiatric, musculoskeletal, dermatological, hematological, endocrinological, cardiovascular diseases and others. Drug utilization was classified according to the Anatomical Therapeutic Chemical classification. The self-reported weight and height data were used to calculate BMIs and BSAs.

The REBA, which was used for posture assessment, is composed of two parts. Part A analyzes the positioning of the neck, trunk and legs. Part B analyzes the positioning of the arms and wrists [8]. During the observation, points are assessed based on posture and range of motion, resulting in a summed REBA score for the observed activity. The REBA score interpretations are listed below.

1 ⟶ Negligible risk.

2–3 ⟶ Low risk. Change may be needed.

4–7 ⟶ Medium risk. Further investigate. Change soon.

8–10 ⟶ High risk. Investigate and implement change.

11+⟶ Very high risk. Implement change.

The researcher received training to perform the REBA and practiced with a physiotherapist before performing the REBA for the study. A practice guideline on how to perform the REBA is also available [9].

Because the validity and reliability of the CMDQ have been extensively tested in Turkey with good results, the CMDQ was chosen as the study’s pain assessment tool [12]. The CMDQ surveys musculoskeletal pain during the previous week. However, a PRMD assessment cannot be limited to musculoskeletal pain caused by art activity within a single week, so we modified this question to ask about musculoskeletal pain during previous year (last 12 months) like in included studies in a systematic review of Kok et al. in evaluation of PRMD [5]. The left side of the CMDQ contains a body figure that has been separated into parts. The participants were asked to identify on that figure the body parts where they felt pain. They were also asked about the frequency and severity of their pain, and the researcher noted these data on the right side of the questionnaire. The pain frequency, severity and if pain interferes with work, the level of pain interfering with work were recorded using a Likert scale. For the frequency assessment, the scale was as follows: 1 = 1–2 times per year, 2 = 1–2 times per month, 3 = 1–2 times per week and 4 = every day. For the severity assessment, the scale was as follows: 1 = slightly uncomfortable, 2 = moderately uncomfortable, 3 = very uncomfortable. For the pain interfering with work assessment, the scale was as follows: 1 = not at all, 2 = slightly interfered, 3 = substantially interfered.

2.4 Statistical analysis

The SPSS version 21.0 was used to perform the study’s statistical analyses. To measure central tendency, mean values were used; except for the parameters of age and year of employment. For these two parameters, median values were used because they showed extreme variation in a population that was consisted of both students and academics. Standard deviation (SD) was used to measure dispersion when mean values and ranges were used. After the descriptive analyses were calculated, for categorical variables, such as relationships between the REBA score and pain frequency and severity the chi-square test was used; to compare constant variables the student-t test was used. When parametric test assumptions were not met, non-parametric equivalents were used. The level of p, which denoted a statistically significant result, was < 0.05.

In order to strengthen the analysis due to the fact that there was less number of participants who reported level 2 of pain interfering with work (slightly interfered); we combined “pain severity part” and “pain interfering with work part” of CMDQ and renamed it “pain severity part” while performing the statistical analysis. Level 1 and 2 of pain severity part remained. Besides, we combined level 3 of pain severity (very uncomfortable) with level 2 of pain interfering with work (slightly interfered) and renamed it “very uncomfortable with a reduction in activity” as “level 3 of pain severity”. We renamed “level 3 of pain interfering with work” as “level 4 of pain severity”.

2.5 PRMD definition

In this study, PRMD was defined in accordance with Ackerman et al. (i.e., any musculoskeletal pain that interferes with any art activity) [13]. It is determined that this definition corresponded to pain severity of 3 (very uncomfortable with a reduction in activity) and/or 4 (the pain interferes with the ability to work). The PRMD prevalence was assessed according to this definition.

3 Results

3.1 General characteristics

The study included 197 participants. Of these, 183 (92.9%) were students, and 14 (7.1%) were academics (7 were faculty members, and 7 were research assistants). The study included 140 (71.1%) women and 57 (28.9%) men. The departmental distribution of the participants is shown in Fig. 1.

Fig. 1

Flowchart of allocation of the participants. 1 Total number of academics and students who were at 2nd, 3rd and 4th classes in these departments. 2 Total number of academics and regular students. 3 Number of academics and students who were asked to participate in the study. 4 Number of academics and students who accepted to participate in the study. RR: response rate.

The median age of the study participants was 22 years (quartiles: 20, 22 and 25 years; min-max: 18–66 years). The mean height, weight, BMI and BSA values were 168.9 cm (±8.4), 60.7 kg (±11.7), 21.2 kg/m² (±3.3) and 1.7 m² (±0.2), respectively. Comorbidities were identified by 70 (35.5%) participants, and 10 participants had 2 comorbidities. The three most frequent comorbidities were gastritis (n = 9; 11.3%), asthma (n = 9; 11.3%) and migraine (n = 9; 11.3%). The three most frequent disease groups were respiratory tract (n = 19; 23.8%), musculoskeletal (n = 16; 20%) and GIS (n = 10; 12.5%) diseases.

Out of all the study participants, 49 (24.9%) used at least one drug. The most frequently used drug group was the musculoskeletal system drug group (group M, n = 17; 25%); flurbiprofen (M01AE09, n = 8; 11.6%) was the most frequently used drug. The participants expressed that they used this group of drugs for musculoskeletal pain relief.

3.2 Pain assessment and PRMD prevalence

Participant pain was assessed using the CMDQ. Of the studied population, 96% (n = 189) expressed having musculoskeletal pain in at least one location, and 42% (n = 76) expressed having musculoskeletal pain in at least two locations. Of the participants, 126 reported a pain severity of 3 (very uncomfortable with a reduction in activity) and/or 4 (the pain interferes with the ability to work). According to these data, the PRMD prevalence was 64%.

There was a significant difference in PRMD prevalence between women and men (Table 1). There was no significant difference in PRMD prevalence between students and academics, but there was a significant difference in musculoskeletal pain prevalence (Table 2).

Table 1
The difference of PRMD, neck and knee pain prevalence within women-men

Women Men Total

n n n

No pain and pain severity 1–2* 44 (31.4%) 27 (41.4%) 71

Pain severity 3–4 (PRMD)* 96 (68.6%) 30 (52.6%) 126

Neck pain (+) 62 (44.3%) 10 (17.5%) 72

Neck pain (–) 78 (55.7%) 47 (82.5%) 125

Knee pain (+)^† 12 (8.6%) 11 (19.3%) 23

Knee pain (–)^† 128 (91.4%) 46 (80.7%) 174

Total 140 57

	Women	Men	Total
No pain and pain severity 1–2*	44 (31.4%)	27 (41.4%)	71
Pain severity 3–4 (PRMD)*	96 (68.6%)	30 (52.6%)	126
Neck pain (+)**	62 (44.3%)	10 (17.5%)	72
Neck pain (–)**	78 (55.7%)	47 (82.5%)	125
Knee pain (+)^†	12 (8.6%)	11 (19.3%)	23
Knee pain (–)^†	128 (91.4%)	46 (80.7%)	174
Total	140	57

*chi-square = 4.465; p < 0.05. **chi-square = 12.5; p < 0.01. ^†chi-square = 4.520; p < 0.05. Knee pain (+): participants who reported knee pain; Knee pain (–): participants who did not report knee pain; Neck pain (+): participants who reported neck pain; Neck pain (–): participants who did not report neck pain; Pain severity: 1 = slightly uncomfortable, 2 = moderately uncomfortable, 3 = very uncomfortable with a reduction in activity and 4 = pain interfere with the ability to work; PRMD: Performance-related musculoskeletal disorders.

Table 2

The difference in musculoskeletal pain prevalence within students and academics

	Students	Academics	Total
	n	n	n
Pain (+)*	165 (90.2%)	10 (71.4%)	175
Pain (–)*	18 (9.8%)	4 (28.6%)	22
No pain and pain severity 1–2**	66 (36.1%)	5 (35.7%)	71
Pain severity 3–4 (PRMD) **	117 (63.9%)	9 (64.3%)	126
Total	183	14

*chi-square = 4.632; p < 0.05. **chi-square = 0.001; p > 0.05. Pain (+): participants who reported pain; Pain (–): participants who did not report pain; Pain severity: 1 = slightly uncomfortable, 2 = moderately uncomfortable, 3 = very uncomfortable with a reduction in activity and 4 = pain interfere with the ability to work; PRMD: Performance-related musculoskeletal disorders.

Among the cases of musculoskeletal pain, the ceramic-glass department had the highest ratio with 97%. The number of pain locations expressed was 389, and the most frequently expressed pain location was the lower back (n = 101; 26%), followed by the upper back (n = 90; 23.1%) and the neck (n = 72; 18.5%) (Fig. 2). Lower back pain was primarily seen 1–2 times per week and was ranked “very uncomfortable with a reduction in activity” (n = 25). There was no significant difference between women and men in the most frequent pain location. Neck pain prevalence in women was higher than in men (44.3% and 17.5%, respectively; p < 0.01); knee pain prevalence was higher in men than in women (19.3% and 8.6%, respectively; p < 0.05) (Table 1). In terms of departmental distribution, the most frequent lower back pains were found in the painting, sculpture, textile and ceramic-glass departments, while the most frequent upper back pains were found in the interior design and traditional Turkish art departments.

Fig. 2

The prevalence of musculoskeletal pain as a function of body location in fine arts faculty students and academics in the last 12-months.

3.3 REBA scores

The overall mean REBA score was 5.2 (SD: 1.5; quartiles 4, 5 and 6). The sculpture department had the highest mean REBA score (Fig. 3). The three art activities with the highest mean REBA score were marble sculpting (mean REBA score 11), clay sculpting (mean REBA score 10) and torso sculpting (mean REBA score 8.6), all of which were located in the sculpture department. The activity with the lowest mean REBA score was drawing on the computer (mean REBA score 2.6).

Fig. 3

Boxplot demonstration of distribution of participants’ REBA scores among departments.

Relationships between pain and the REBA score were calculated, and analyses on the relationships between the REBA score and the frequency and severity of each pain location were performed. There was no linear relationship between the REBA score, the pain frequency and severity, and PRMD.

Relationships between pain and age, pain and the participants’ year of school/employment, pain and BMI, pain and BSA, and pain and drug utilization were calculated; no significant difference was found except for the relationship between pain and drug utilization. The frequency of drug utilization was higher in participants who had received a PRMD diagnosis (Table 3).

Table 3

The relation between PRMD and drug utilization

Pain severity	Drug utilization (+)	Drug utilization (-)	Total
	n	n	n
No pain and pain severity 1–2	10 (20.4%)	61 (41.2%)	71
Pain severity 3–4 (PRMD)	39 (79.6%)	87 (58.8%)	126
Total	49	148	197

Chi-square = 6.914; p < 0.01. Drug utilization (+): participants who reported drug utilization; Drug utilization (–): participants who did not report drug utilization; Pain severity: 1 = slightly uncomfortable, 2 = moderately uncomfortable, 3 = very uncomfortable with a reduction in activity and 4 = pain interfere with the ability to work; PRMD: Performance-related musculoskeletal disorders.

4 Discussion

This study revealed that the musculoskeletal pain prevalence in the Marmara University Faculty of Fine Arts was 88.8%, the PRMD prevalence was 64% and the overall mean REBA score was 5.2, the last of which corresponds to a medium risk assessment that is accompanied by guidance to “further investigate, change soon.”

Because the literature does not provide a precise definition of PRMD, it was difficult to decide how to define PRMD and its prevalence. Previous studies have used different PRMD definitions. The studies of Kaufman-Cohen and Ratzon [4], Kaneko et al. [14] and Kok et al. [15] defined PRMD as any musculoskeletal pain at any frequency and severity that appeared during the previous 12 months. When PRMD is defined in this manner, the PRMD prevalence is said to be 88.8%. But if PRMD is defined according to Zaza et al. 1 or Ackerman et al. 2 [13], the PRMD prevalence is said to be 64%. The latter definition was preferred in this study, and we determined that PRMD was equal to a pain severity of 3 and/or 4 in the CMDQ, concluding that the PRMD prevalence is 64%. Regardless of which PRMD definition was chosen, PRMD is a self-reported musculoskeletal pain and, therefore, not an objective diagnosis. This is a limitation of both our study and the other relevant studies in the literature.

To our knowledge, the only previous comparable studies on visual artists are those of Chang et al. [6] and Sahu et al. [7]. Chang et al.’s study group consisted of painters and sculptors, and the most frequently expressed pain locations were in the lower back (70%), neck (64%) and shoulders (58%) [6]. In Sahu et al.’s study, the population consisted of potters and clay sculptors, and the most frequent pain locations were the neck and lower back [7]. In our study, the lower back was the most frequent pain location for artists in the painting, sculpture and ceramic-glass departments. The expressed pain locations were closely related to the activities performed by the artists [17].

The PRMD prevalence was higher in women than in men. In the general population, being a woman is a known risk factor for musculoskeletal complaints [18, 19]. However, the specific mechanisms underlying this gender difference are not clear [20, 21]. Biological (anthropometric) and psychosocial factors are thought to play a role [20, 22]. Testosterone’s anti-nociceptive effects toward estrogen and progesterone [23], testosterone’s inducing effect on the pain-inhibiting brain regions and differences in the endogenous opioid system are some of the biological factors that are thought to underlie gender differences in feeling and reporting pain [20]. Several psychosocial factors have also been mentioned in previous studies, including sociocultural beliefs, pain-coping strategies and gender role expectations. In our study, the prevalence of upper extremity complaints in women was higher than in men. These results are in concordance with Chang et al.’s study, where the prevalences of neck and shoulder pain were higher in women than in men [6].

The literature has indicated that physicians generally have a lack of knowledge regarding musician health problems [16 , 24]. It is said that there are few health professionals with knowledge of how to approach performing artists [25]. Musicians’ low rates of hospital admissions have also been attributed to musicians being afraid of stigmatization and losing their jobs if a doctor advises them not to play their instruments [16, 24]. Also, artists are known to underestimate their musculoskeletal complaints; they assume that it is something with which they have to live [17, 24]. It is determined that another reason why they underestimate their pain was because of the low pay they earned and the lack of financial support of occupational therapy in some certain countries [24]. The populations of these studies have primarily comprised professional musicians, unlike our study population, which was mainly composed of students. Of the students in our study, 90.2% expressed that they had pain, while 9.8% did not. Of the academics in our study, 71.4% expressed that they had pain, while 28.6% of them did not (Table 2). Students seemed to report musculoskeletal pain more than academics. There are no studies in the literature to explain this significant difference. So to our knowledge, this is the first study to find such a prevalence difference between students and academics of fine arts to report musculoskeletal pain. Besides Zaza et al. reported that classical music students emphasized bad technique whereas professionals cited lack of warm up as a cause of PRMD [16]. We do not know if the power of bad technique is greater than the power of lack of warm up exercise to cause PRMD. On the other hand, the high musculoskeletal pain prevalence of the students address lack of prevention of musculoskeletal pain. So education of the educators, here academics, such as being aware of basic ergonomic principles, risk and prevention of PRMD, would be welcomed for prevention of musculoskeletal pain of students [24, 25].

A list of probable PRMD risk factors includes inappropriate techniques, posture, work load, repetitive movements, lack of rest breaks, lack of physical conditioning and psychosocial factors [3]. In this study, technique and posture were evaluated using the REBA, and the REBA score of each art activity performed by each participant was calculated. The mean REBA score was 5.2. The REBA scores of the population were concentrated in the 4 to 5 range. In the studied population, 88.8% expressed having musculoskeletal pain. In a population with close REBA scores, as in our study, the relationship between pain and the PRMD-REBA score did not show a statistically significant linear relationship. We could not demonstrate the probability of PRMD and musculoskeletal pain based on the postures of the artists while they performed their art activities in non-ergonomic positions.

In the Chang et al. study, the pain locations were compared with the variables of age, gender, daily working hours and years of employment. There were direct correlations between the following factors: lower back pain and age; shoulder pain and year of employment; and neck and shoulder pain and daily working hours [6]. In our study, in addition to the relationship between pain and the REBA score, we searched for relationships between the following: pain and age; pain and year of class/employment; pain and BMI; pain and BSA; and pain and drug utilization. The pain severity and the number of pain locations were used to compare the pain assessments with the other variables. Although previous reports in the literature have found these relationships, the relationships may not have been found in this study due to similarities in age, year of class/employment, and the BMI and BSA of the participants. Musculoskeletal pain prevalence in overweight and obese persons is higher than in normal weighted persons [26, 27]. Accordingly, we assumed that higher BMI and BSA values would be a risk factor for pain. This comparison could not be performed in our study because the mean BMI value corresponded to normal weight; there was no overweight or obese person in our study population. In contrast to the Chang et al. study, the participants in our study were not questioned about their daily working hours. The daily working hours of the students were similar to the daily lesson hours, so this parameter would not have varied among the participants. A commonly expressed theme among the participants was that their musculoskeletal complaints were more frequent during their final exam periods.

This study revealed a correlation between PRMD and drug use. Notably, the musculoskeletal system drugs were the most frequently used drug group, and flurbiprofen, a musculoskeletal system drug, was the most frequently used drug. The participants might have taken painkillers as a form of self-treatment so that they could avoid seeing a doctor. In the performing arts, medicine is commonly used for musculoskeletal pain management; analgesics and especially nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used by performers [28]. As mentioned in Hoppman’s review, NSAIDs are the most commonly used medications for the control of mild to moderate pain [29]. In a study of Norwegian musicians, higher proportions used analgesic medication compared to the general workforce [30]. To our knowledge, our study is the first to reveal the prevalence of drug use in visual artists. This information provides important insights into the numbers of visual artists who seek solutions for their musculoskeletal pain and whose musculoskeletal pain results in the use of analgesic medications.

To our knowledge, this is the first PRMD study on visual artists specializing in painting, sculpture, ceramic-glass, textile, interior architecture and traditional Turkish arts. The literature instructs that to understand PRMD in artists and the associated problems, it is important to observe artists while they perform their art [17]. A strength of our study is that the artists were observed while they performed their art.

The main limitation of this study was the subjectivity of the PRMD definition, as discussed above. This self-reported pain could have resulted from performing art or from other causes. Another limitation was that the distribution of the participants was not homogenous within the student and academic groups. This prevented the study from making comparisons between indicated pain and the years of employment. Another limitation was the lack of a population of artists with low REBA scores, which affected the ability to make comparisons between pain and technique/posture. If a low REBA score population could have been included in this study, a correlation might have been revealed. In addition, there was no randomization in the allocation of the study participants. However, all the students and academics who performed their art activities during the observation period were invited to join the study, and all were included except for two artists who decided not to participate in the study.

5 Conclusion

The PRMD prevalence in visual artists was found to be as high as previous reports have demonstrated in musicians. Technique and posture, both PRMD and ergonomic risk factors, are at the forefront of PRMD prevention as these can be easily modified using the appropriate approaches [1, 31]. The interpretation of each REBA score provides insights into the ergonomics of the studied posture or activity. Although a relationship between PRMD and REBA score could not be shown in this study, increasing REBA scores are accompanied by advice to modify the activity’s technique to more ergonomic conditions. As we are not artists, we cannot say how art activities should be performed; we can only assess the ergonomics of each art activity according to the REBA. Therefore, if the technique or posture cannot be modified to prevent PRMD, warm-up exercises, daily exercises, taking breaks, reasonable working hours and education of healthcare professionals and performing artists about risk and prevention of PRMD are particularly important [17, 24]. Routine exercises have been shown to prevent PRMD in musicians [32]. Future studies should focus on interventions, such as the exercises discussed in Chan et al.’s study, and other means of preventing PRMD in visual artists.

Conflict of interest

None to report.

Footnotes

Acknowledgments

We confirm that this manuscript has not been published elsewhere and is not under consideration by another journal. Any organization or community did not fund this study. The authors have no conflicts of interest to declare. This study was presented as a poster presentation in 10th Family Medicine Autumn School, 28 September–2 October 2016, Antalya, Turkey.

Personal, chronic and disabling health problems that affect the whole person, physically, emotionally, occupationally and socially.

Any pain, weakness, numbness, tingling, or other symptoms that interfere with the ability to play the instrument at the level being accustomed to.

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