Physical health status of music students in a post-secondary institution: A cross-sectional study

1 Introduction

Musicians’ health and well-being encompasses their physical and psychological health, including but not limited to musicians’ injuries, their use of prescription medications, performance anxiety, depression, etc. The limited literature available is restricted by narrow scope, poor experimental design, or outdated data [1–3]. Due to the nature of a musician’s training, it is common for many to sustain physical injuries [4–6]. In prior literature, these injuries are referred to as playing-related musculoskeletal disorders (PRMDs) [7], a term which we will use synonymously with physical injuries which impact playing. Previous research demonstrates the importance of screening music students early in their education [8], and to make appropriate changes to their long term-training [9, 10].

Though practice methods such as the Alexander Technique [11, 12] have been utilized with varying success [13], we seek to understand the exact factors [14], modifiable or unmodifiable, which predispose musicians to PRMDs. Previous studies have found that further investigations should be longitudinal and should include the physical injuries of populations beyond professional, or classically trained post-secondary institution-based musicians [15]. By understanding these risk factors, physicians and educators can identify musicians who are predisposed to PRMDs and work with them on preventing and managing injuries. Only by understanding the severity and shortcomings in the current state of health among musicians can we truly begin to make changes and provide musicians with an environment which fosters open discussions on health with the hopes of advancing the culture of musicians’ health. The first step in working towards this is to gather information on musicians’ physical health and injury rates in order to understand how to better support musicians throughout all levels of their career.

2 Methods

2.4 Analysis

All survey entries were verified twice by researchers and processed using a pre-specified protocol (Fig. 1). Non-music students who play an instrument served as the control. Fisher’s exact test was used to analyze all nominal data (Fisher’s exact test was used because some categories had fewer than 5 participants due to the criteria of the categories). One-way ANOVA tests were used to analyze all ordinal data, and the Tukey HSD test was performed for all post hoc comparisons. Not all participants answered all the questions; those jeopardizing the accuracy of the survey were excluded based on protocol (< 1%). As well, questions answered with the option “Prefer not answer”, or those left blank, were excluded from the analysis of the given question. The significance level was set at 0.05 and the statistical analysis was performed using GraphPad Prism, version 8.0.2.

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Fig. 1

Protocol used to analyze usability and completion of the survey, as well as when individual questions were left empty.

Physical injuries are detrimental to any musician’s career. There has been a trend to refer injured musicians to sports medicine specialists, due to the popular belief that the mechanisms of injury share a common cause [25]. Educators, who often have the most exposure with musicians and music students, should play an essential role in prevention and management [26]. Unfortunately, the institutional barriers that prevent musicians from accessing preventative medicine, or taking time off for injuries when they need, only accentuates this problem [27, 28].

This study found music students to not only have a higher prevalence of performance-related injuries, but also to have more locations of PRMDs compared to non-music students who play an instrument. It also found professional musicians to have a higher prevalence and more locations of PRMDs than those of music students. The results did not find age, practice durations, or consulting healthcare professionals to correlate with these findings. Furthermore, these findings address the specific lack of data regarding playing duration, different instrument groups, and longitudinal components as noted in a recent systematic review [2].

Surprisingly, we found no correlation within the music student population between practice duration and PRMDs, which had been indirectly suggested in previous studies [29–31]. With no prior standardized studies to serve as comparison [2], it is unclear why the observations differ. However, we believe that due to our larger sample size, our findings were less likely influenced by additional biases. It is possible that as musicians become injured, they opt to practice less, resulting in artificially elevated rates of PRMD prevalence. We also could not exclude the possibility that with shorter practice durations, music may have a therapeutic effect in non-music students. Nevertheless, we see a similar trend within the professional musician group where no correlation was found between practice duration and PRMDs. This leads us to believe that practice duration does not contribute towards PRMDs, but may in fact be limited by PRMDs themselves.

We observed music students within the age of 20–22-year-old to have a high prevalence of PRMDs. This age range corresponds well to being enrolled in Years 2 and 3 of study, in which we also observe a higher prevalence and number of PRMDs. Given that a similar trend was not observed within our other cohorts, we concluded here that age does not have a significant contribution towards playing-related injuries. We do, however, note a significant rise in PRMD prevalence between music students in their last year of study and professional musicians. No prior literature has investigated the longitudinal trend of PRMDs [2], making this a novel observation which requires additional exploration regarding the accumulation of injuries during the transition to becoming a music student, as well as the transition from being a music student to a professional musician.

This study observed participants of the female gender to have an increased likelihood of PRMDs. The literature in sports medicine found no differences in the incidence of injury between genders [32], though this had been previously observed by other researchers studying musicians [13, 19]. Here, we can simply postulate that there may be some contributing physiological [33], societal, or environment differences associated with the female gender, and that the types of musculoskeletal activity performed by a musician induces injury through mechanisms which are different from those in sports.

The study also found that the number of PRMDs and the prevalence associated with playing certain instruments did not correspond to the subspecialty program in which the music student participants are enrolled. While studies have investigated the role of playing certain instruments in developing PRMDs [34], our findings highlight the need to investigate further into psychological and environmental factors [35].

We do believe our physical health questions adapted from the NMQ demonstrates the need for a standardized and validated assessment tool to assess for physical injuries. The 3 major improvements we had made upon the questions addressed injuries that would otherwise not have been picked up by the NMQ, because it was never designed for the purpose of assessing for PRMDs [18]. It neglects or fails to elucidate injuries such as those to the ears or vocal cords. Furthermore, as highlighted in the lack of longitudinal assessment of physical injury of musicians [2], there is a need to investigate beyond the scope of 12 months constrained by the NMQ. Lastly, the inclusion criteria of the NMQ are inconsistent with the definition of PRMDs, a definition which is commonplace in literature regarding the physical health of musicians. Therefore, we believe our physical health survey questions based upon the NMQ framework is better suited for future studies of PRMDs of musicians and music students.

5 Conclusions

To our knowledge, this is the first study to investigate the health of music students and musicians in a comprehensive manner which encompasses multiple facets of health, as well as to try to identify unmodifiable and modifiable factors that may predispose musicians to physical injury. Moreover, we believe this to be the first study to investigate differences between professional musicians, post-secondary music students, and non-music students. It also fulfills a gap previously identified in literature [2] regarding the impact of practice duration on PRMDs and progressions longitudinally. While we may have identified risk factors which predispose a musician or music student to PRMDs, additional research is required to truly clarify the mechanisms behind how they result in injury. The findings also suggest that musicians’ PRMDs are perhaps unique and should be managed within the healthcare system differently from what is done in sports medicine, particularly regarding the impact of practicing on injury; it is essential not to generalize physical injuries as simply occupational hazards and suggest the avoidance of practicing and/or performing. We have also adapted the NMQ into a survey which we believe is more tailored for future research of PRMDs. Our findings on physical health are only one component of our research to understand musicians’ health as a whole, and it is likely that additional factors such as the presence of mental health issues and medication usage may be contributory as well. Most importantly, we hope the findings encourage educators and healthcare professionals alike to foster an environment for musicians and music students in which discussions of injuries are no longer discouraged, and where personalized treatments allow for long and successful careers [10, 37].