Relationship between playing-related factors and occupational balance in professional violinists

1 Introduction

Occupational balance has been described in different ways, as the balance between different roles or the rhythm of daily life occupations, an individual’s satisfaction with their daily patterns or the balance between what the individual is supposed to do and what he/she wants to do [1, 2]. Occupational balance, in terms of occupational therapy, includes the performance of individuals in three main areas of activity (work - productive, self - care, and leisure time), together with participation, and satisfaction[1].

Playing an instrument as an occupation requires the body to take a variety of positions depending on the type of instrument to be played [3]. Performing instruments with an asymmetrical structure, like the violin, can subject musicians to some health problems [4, 5]. The violin is positioned almost horizontally, supported by the left clavicula and slightly pressed by the chin. The left arm can only make limited movements in the sagittal plane. The right arm makes large movements to direct the arch. To balance the violin, the center of gravity of the body is shifted forward and the head is bent to the left [3, 6]. It is important to maintain an aesthetic body posture while playing the instrument. Playing the violin for long periods of time and frequent repetitive movements in an inappropriate position exposes musicians to an insignificant health risk and, where present, a worsening of posture [5, 7]. Factors such as anatomical differences between individual violinists may also cause health problems [5, 8].

Common disorders amongst musicians are lateral epicondylitis, thoracic outlet syndrome, shoulder impingement syndrome, tendinitis, cervical and lumbar disc herniations, allergic reaction (Fiddler’s neck), and temporomandibular joint dysfunction [5, 9]. Lee et al. [3] reported that health problems specific to string players are overuse syndrome, focal dystonia, hypermobility syndrome, and compressive neuropathy. Those problems related to playing posture may affect the occupational balance of musicians. However, there is no practical description of what occupational balance is in the life of a musician.

Violinists will practice playing while standing or sitting. In concert, solo performances are in a standing position, while in orchestras or chamber music ensembles, the violin is often played in a sitting position. Practicing and training are mostly undertaken in a standing position [5, 10]. If a music stand is used, it is placed in front of each musician. However, when playing in an orchestra, generally two musicians share one music stand. This results in two additional playing directions, to the right and left of the music stand [10]. When sitting and standing performing postures of violinists were examined, it was found that the posture was riskier while sitting than standing [5]. There appears to be a general consensus that there is a need for studies to help identify the effect of non-optimal posture with related factors causing health impairment in musicians[3, 8].

It is important to note that musicians generally complain about posture [11]. Of 148 conservatory students in Milano, 66.2% had a postural disorder and 73.4% had a non-optimal posture [12]. Approximately 84.4% of musicians experience pain at least once during their career [3]. Although pain mostly occurs after a performance, if the problem deteriorates, it may continue when a musician rests [13]. Thus, the symptoms of pain may disrupt the occupational balance of affected individuals [14]. On the other hand, the striving for occupational balance serve a pain free life.

In occupational therapy, studies have been performed concerning occupational balance [14]. Occupational imbalance among musicians may negatively affect their playing performance, health, and quality of life. Although we could not find a single relevant study on musicians for occupational balance, in a study involving occupational therapists in Sweden, it seemed important to consider not only socio-demographic conditions, but also occupational balance to prevent health problems[14].

Occupational therapy is a rapidly developing field in Turkey. The most commonly taught instrument in music schools in Turkey is the violin. In this study, because it is both the most preferred and the riskiest string instrument, it was decided to study violinists. The effects of playing posture, playing duration, and postural pain on playing performance have been studied in previous studies [4, 15]. However, there is a lack of research into the association between playing-related factors and occupational balance of the musicians. No researchers have studied that violinists have occupational disruption and we want to find out if those violinists who do not have risk factors have a better occupational balance. Therefore, the aim of this study was to investigate the relationship between posture, pain, functionality and occupational balance in violinists. Our hypothesis was that good playing posture, lack of pain, and functionality affect occupational balance positively.

2 Methods

This correlational study was conducted at six different symphony orchestras and conservatories in Istanbul. The data collection was performed between the 15th of June and the 30th of July, 2022. Ethical approval was obtained from the Hamidiye Scientific Research Ethics Committee of the University of Health Sciences (22/286-14/03, 05/27/2022). The study was conducted in accordance with the Declaration of Helsinki and was registered in the Clinical Trials Registry (NCT05664997, 12/16/2022). Participants gave written informed consent. Inclusion criteria were to play the violin in a conservatory or orchestra, to be at least 18 years old, and to volunteer to participate in this study. Those who played any other instrument professionally were excluded.

Power analysis was used to identify the smallest sample size and demonstrate that the results obtained are really significant or not [16]. The impact size was taken as 0.40. The target number of the participants was 44 with a 95% confidence level and 80% power. All violinists who met the criteria that were present at the evaluation day were included in the study by using simple random sampling method. Fifty violinists were initially recruited but five of them were excluded due to having missing information in their forms. Therefore, the final study population was 45 violinists, made up of twelve from Cemal Resit Rey Symphony Orchestra, seven from Maltepe University Conservatory, 11 from Istanbul University State Conservatory, seven from Okan University Conservatory, two from Cemal Resit Rey Jazz Orchestra, and six from Cemal Resit Rey Orchestra.

The Personal Information Form, the Edinburgh Handedness Inventory, the Wong-Baker Faces Pain Rating Scale, the Disability of Arm, Shoulder and Hand-Sports/Musicians (DASH-SM), the Rapid Upper Limb Assessment (RULA), and the Turkish language version of the 11-item revised version of the Occupational Balance Questionnaire (OBQ11-T) were used. Assessments of each violinist took approximately 25 minutes. Participants were asked to mark the most suitable option for them for the questionnaires.

Factors such as gender and weight are intrinsic, while the instrument group, instrument size, repertoire, playing technique, playing duration, practice habits, and posture are extrinsic factors that may affect occupational performances of musicians [5, 11]. We assessed some of these factors in this study. Factors that affect the playing performance of individuals, such as demographic characteristics, hand preference, and physical activity level may indirectly change the playing posture [3, 15]. Therefore, a personal information form was created by the researcher to collect data relating to socio-demographic and musical characteristics. This form included the musician’s age, gender, height (cm), weight (kg) (body mass index (BMI) was calculated by dividing the weight to the square of the height), how long he/she has been playing the violin (years), how many hours a day he/she plays the violin, with which hand he/she plays the violin (the hand he/she holds the arch), whether he/she takes a break while playing the violin, whether he/she does a warm-up exercise before playing the violin, whether he/she has diagnosed problems related to playing the instrument (including diagnosis, if any), whether he/she has diagnosed systemic diseases, whether he/she had a habit of exercising regularly (type of exercise, if any), and in which position (standing or sitting) he/she practiced playing. All these questions were asked violinists one-to-one through a survey.

The Edinburgh Handedness Inventory was used to determine the participants’ dominant hand. This records which hand or hands are used while performing ten different hand activities related to activities of daily living; writing, drawing, throwing something, brushing teeth, using scissors, striking a match, using a spoon, using a broom, opening jar lids, and using a knife. The validity and reliability of the Turkish version of this scale was confirmed by Atasavun Uysal et al. [17].

The Wong-Baker Faces Pain Rating Scale was used to assess playing-related pain symptoms before, during, and after the performance while asking violinists to answer according to their practices in general. This scale is graded from 0 to 10, with 0 indicating no pain while 10 indicates the most severe pain. There is the representation of a facial expression for each point on the scale and the pain is self-reported according to these facial expressions [18].

In high-performance musicians, such as violinists, especially those who practice for hours a day, and the associated repetitive movements create exhausting musculoskeletal tension in the upper extremities and spine [8]. Therefore, we specialized on upper extremities and spine while assessing in this study.

The DASH–SM was used to evaluate the effect of violinists’ complaints-related playing on functionality. The DASH was developed to assess upper extremity physical functional status, symptoms, disability, and limitations of the activity and participation. In the literature, there are studies that evaluate upper extremity functionality and disability using the DASH in musicians who play different musical instruments [19, 20]. The validity and reliability of the Turkish version of the questionnaire was performed by Duger et al. [19]. The DASH consists of three parts. These are: functional/symptom; business model; and high-performance sports-musicians model. The sports-musicians (SM) model is optional. The DASH-SM is frequently preferred by occupational therapists. Although the validity and reliability of this music part has not been demonstrated, it is preferred because its questions were appropriate to measure the inability of the musicians to play an instrument [20].

The DASH-SM consists of four questions, and in all questions, the individual marks the appropriate answer on a 5-point Likert scale (1: no difficulty, 2: mild difficulty, 3: moderate difficulty, 4: extreme difficulty, and 5: not able to do at all). A total score between 0–100 (0: no disability, 100: maximum disability) is obtained and is further modified by the formula [(n/4)-1]×25 where “n” is the score obtained. The closer the result is to zero, the less the risk of disability. The American Academy of Orthopedic Surgeons (AAOS) determined the normative value of DASH-SM as less than or equal to9.75 [20].

The RULA was used to determine the ergonomic risk levels of the participants while playing the violin by evaluating posture and repetitive movements. The RULA was developed by Mc Atamney and Corlett [21]. This is a frequently preferred method to evaluate the ergonomic status of the upper trunk, including the head and neck, during occupational performance. In this scale, which has Turkish validity and high reliability, the position of the hands, wrists, elbows, shoulders, arms and forearms, neck, trunk and legs, and their relative positions are scored through the relevant tables [22]. The final score takes a value between 1 and 7, with scores of 1 and 2 indicating an acceptable (safe) ergonomic posture, scores of 3 and 4 indicating an ergonomic posture that may require research and modification (low risk), scores of 5 and 6 indicating an ergonomic posture requiring further investigation and urgent changes (moderate risk) and scores of 7 indicating an ergonomic posture (serious risk) needing investigation and definite changes [21, 22].

The violinists’ ergonomic risk analyses were done while observing them during their practical performances. They drew attention to certain postural attitudes and movements, which appear in sequences of a violinist’s rendition of the Concerto for Violin in D Major by Mozart. The researchers took photos and videos, then calculated the RULA scoring based on these data, taking into account the static left arm. Because the left arm is affected more frequently in violinists [7].

The OBQ, that measures self-rated occupational balance, was developed by Wagman et al. [1] in Sweden. The original version consisted of 14 questions. The 11-item, revised version of the scale (OBQ11-T), which has validity and reliability in its Turkish form, was used in the present study [2]. Each item in the questionnaire is scored on a 4-point Likert scale from “strongly disagree” to “strongly agree”. The total score may range from 0 to 33, with higher scores indicating greater occupational balance.

3 Results

The mean±SD age of the violinists was 29.1±10.6 years with a range of 18–52 years, and 31 (68.9%) of them were women. The mean±SD BMI was 22.01±3.2 kg/m², ranging from 15.4–29 kg/m². Socio-demographic characteristics of the participants are shown in Table 1. Thirty-seven (82.2%) were right-handed and 43 (95.6%) played the violin holding the arch with their right hands. Sixteen (35.6%) had been diagnosed with playing-related problems, including tendinitis, cervical lordosis, cervical disc herniation, sciatalgia, carpal tunnel syndrome, impingement syndrome, 5th finger injury, and back pain. Reported systemic diagnoses were “thyroid” (n = 1), hypothyroidism (n = 1), high cholesterol (n = 1), and anemia (n = 1). Twenty (44.4%) reported doing regular exercise, which included Pilates (n = 5), walking (n = 5), keep fit (n = 4), playing soccer (n = 2), playing basketball (n = 2), cycling (n = 1) and qigong (n = 1). All had differing degrees of pain at different times, before, during and after performing.

The results of the pain, functionality, and occupational balance scores of the participants are shown in Table 2. Their reported mean pain score increased from before performing to a post-performance mean of 3.91±2.4, although the maximum reported pain score of 10 was reported during performance, while the maximum score after performing fell to 8, which matched the maximum pre-performance pain score reported.

The mean RULA score was 6, indicating the need for further investigation and urgent changes. The correlations between the factors and the OBQ11-T are shown in Table 3. Doing regular exercise was moderate correlated with occupational balance (r = 0.539, p < 0.001). No correlation was found between the scores of the DASH-SM and the OBQ11-T (r = –0.191, p = 0.209).

This is the first study to evaluate the effects of many playing-related factors on occupational balance in a cohort of professional violinists, excluding players of other instruments. There was no relationship found between pain, functionality and occupational balance as assessed by scores on the OBQ11-T, with the exception of musicians who took regular exercise who reported better occupational balance scores than those who did not take regular exercise. Therefore, our hypothesis was rejected.

In a study investigating differences in occupational balance among adults in Sweden, the OBQ was positively correlated to self-rated health and life satisfaction, supporting the relationship between occupational balance and health [23]. It was interesting that no relationship was found between many health-related factors, such as having a known medical diagnosis and even older age and occupational balance in the present study.

Musicians need to develop good working habits, especially posture-related, during their education and maintain this throughout their professional careers in order to avoid potential chronic health complaints, such as pain [5, 24]. It is important to gain and maintain good habits, such as doing exercises at early ages, while studying. If excessive practice hours and repetitive movements are inevitable, based on the results of our study, we recommend adopting a habit of doing regular exercise as part of the balanced life of a professional violinist. On the other hand, Usgu et al. [25] have been highlighted that physical needs specific to the instrument and performance should be taken into account when prescribing exercises to string musicians having pain. Especially, Prada et al. [26] say that rehabilitation of a violinist’s hand should be aimed at enhancing motor performance of the left hand and should be focused to maximize dexterity of both hands.

In the present study, the mean pain reported during the performance was twice as high as pre-performance and increased further post-performance. The results support the literature [13]. Gasenzer et al. have been reported that more than half of the musicians in German orchestras had chronic pain [27]. The variation in reported pain in our study was also notable with some performers reporting no pain at any of the three time points while others reported high levels of pain, even before performing and a maximum score of 10 was reported during performance. We thought that the playing-related pain might affect the occupational balance. However, no significant relationship was found between pain and occupational balance. The pain experienced by violinists appears to be important and requires further investigation.

Posture-related pain is one of the most common complaints in musicians with a high BMI who play string instruments [9]. In our study, most violinists were within normal limits for BMI, but some were underweighted and some were overweighted. Different results may have been found if subjects were divided into groupings based on low, normal or high BMI categories. Given the results of the earlier research and the findings of our study, it seems intuitive that maintaining a normal BMI would be as important for professional musicians, as it is for others.

Violin playing in a sitting position carries greater risk than playing standing [10]. Most of the violinists in our study stated that they practiced playing while standing. We did not have sufficient sample size to compare occupational balance scores of violinists in standing and sitting positions. Future studies should include sufficient numbers to investigate this issue.

In a study of 4025 musicians the injury rates of musicians by instrument group and gender were found to be the highest among string players (66%) and women (70%) [28]. Occupational balance should be investigated further in an appropriate sample size, taking into account different instruments so that factors such as gender, instrument and BMI can be more comprehensively researched. Are there other factors, besides those we assessed that affect occupational balance in violinists?

In our study, the daily violin playing duration was longer than stated as 1–3 hours in the literature [5] and this was not found to affect occupational balance scores.

Sixteen of the violinists in our cohort reported playing-related musculoskeletal problems. We believe these problems adversely affect their playing performance and occupational balance. However, there is a lack of evidence in the literature on this subject.

It would be beneficial for musicians to take appropriate breaks during playing if possible, depending on the piece being performed, do warm-up exercises, be aware of the effects of their bodies, choose an appropriate instrument, adopt safe handling techniques for equipment, choose suitable practicing environments, and use ergonomic practicing habits [7, 11]. Educational programs to improve and maintain good occupational balance may be important as part of health promotion in professional violinists. The present study might provide an impetus for health professionals to work in this field and develop such educational programs.

Our study is the first to investigate the relationship between DASH-SM and the OBQ11-T scores in professional violinists. The DASH-SM scores of the violinists were relatively high in our study, with a mean more than twice that of the recommended limit proposed by the AAOS but this did not appear to impact the OBQ11-T scores.

Kaufman-Cohen and Ratzon [29] assessed ergonomic risk analysis of musicians using the RULA and found the right extremities of string musicians were at more risk than the left. In our study, the risk was high even in the static left arm, the only extremity we evaluated. More objective tests are required to assess the moving right arm. Three-dimensional analyses may be more valuable, especially during playing, due to the complex activities performed by musicians [22].

The young age range of the study group might be effective in the absence of a relationship between such various assessment parameters and the occupational balance. It is predicted that chronic effects may occur in later ages. The fact that this study only investigated violinists made this a unique study. In Turkey, both the discipline of occupational therapy and the topic of musicians’ health are developing rapidly. Therefore, we believe more studies are needed in these fields.

5 Conclusion

In the study which examined the relationship between occupational balance and playing posture, pain, and functionality in 45 violinists, only doing regular exercise was moderately correlated with occupational balance. We evaluated variables like exercise with a self-reported survey that was a methodological limitation.

The DASH-SM scores were high, but this did not appear to impact the OBQ11-T scores. We believe that appropriate playing postures and exercises in breaks will contribute positively to the occupational balance in this group.

Sixteen participants had been diagnosed with playing-related problems. There was a degree of pain present in the violinists even before performing. The mean RULA score for posture was suggestive of the need for further investigation and urgent changes. The present study may help and stimulate further research among health professionals who work in this field.

Ethical approval

Hamidiye Scientific Research Ethics Committee of the University of Health Sciences (22/286-14/03, 05/27/2022).

Informed consent

Participants gave written informed consent.