A proposed Rapid Upper Limb Assessment for Pianists (RULA-p) 1

Abstract

BACKGROUND:

Pianists often suffer from postural related problems due to prolonged sitting and awkward postures. Despite the fact that postural related problems are common among pianists, there is only one study found by the authors, which applied RULA to assess pianists’ postures, without any modification to the original RULA worksheet. None of the other existing literature has applied this postural assessment tool to assess the pianists’ overall posture. There is no existing Rapid Upper Limb Assessment (RULA) checklist that exactly fits into the context of piano playing, at least not without some modifications.

OBJECTIVE:

To propose a Rapid Upper Limb Assessment for Pianists (RULA-p) for postural assessment, which will allow pianists to identify awkward postures (if any) during piano playing, thus, achieving healthful playing for injury prevention.

METHOD:

This study modified (i) the muscle use score; and (ii) the force/load score, from the existing RULA as a rapid assessment for pianists’ posture.

RESULTS:

We proposed the modified RULA for pianists (RULA-p) in the worksheet format.

CONCLUSION:

Overall, this study is intended to further expand the existing literature on the early prevention of pianists’ PRMDs.

Keywords

Occupational health occupational injuries posture ergonomics observation checklist pianists modified RULA for pianists (RULA-p)

1 Introduction

Musculoskeletal disorders are injuries that affect the human body, including muscles, tendons, ligaments, nerves and blood vessels [1 –4]. Musculoskeletal disorders also include injuries to the bones, joints, cartilage and spinal discs [2, 4]. Musculoskeletal disorders can result from a single or cumulative injury that causes pain in any part of the human body, such as the neck, shoulders, upper and lower back, arms, wrists, hands, hips, knees and feet [4].

Injuries caused by work that affect the human body are known as work-related musculoskeletal disorders (WRMDs) [1]. A musician is an occupation that involves playing musical instruments [5 –8]. It is worth noting that musicians are susceptible to occupational disorders [9, 10]. Similar to other occupations, a musician is at risk of suffering from WRMDs [9, 11 –13]. Therefore, in the context of music, work-related musculoskeletal disorders (WRMDs) are referred to as playing-related musculoskeletal disorders [14]. The term ‘Playing-related Musculoskeletal Disorders’, abbreviated to ‘PRMDs’, is used in this study as a generic term for a range of musculoskeletal problems. Common PRMDs include carpal tunnel syndrome, tendinitis, focal dystonia and other conditions [12].

Musicians are high-powered athletes [10], and piano playing is similar to athletic activity [15]. Piano playing at an elite level (i.e. tertiary, college, conservatory or professional) [5, 14] requires agility and physical strength [16] to achieve high-intensity practice, speed and accuracy, and to cope with the stress of competition [14]. While pianists (i.e. professional and non-professional) are at risk of developing PRMDs [17], pianists are also among the musicians with a high occurrence of PRMDs [3, 5, 13]. Over-practice [18], incorrect piano technique [19], and physical limitations such as small hands [20, 21] and insufficient stamina [19] are some of the factors that lead to pianists’ PRMDs [15, 22].

Young musicians are willing to endure the pain they suffer from playing [3]. Mark [23] and Rosety-Rodriguez et al. [24] claimed that the majority of injuries do not end a musician’s professional career. However, these injuries can restrict repertoire choices or even lead to the cancellation of concerts and tours [23, 24]. Musicians’ injuries may not be life-threatening [25], but they can be career-threatening if they are severe enough [26]. In addition, Rozmaryn [10] claimed that minor injuries could potentially end a musician’s career because these injuries can cause permanent damage [24], especially if they are left untreated [24]. However, this tragic situation is avoidable as the injuries are preventable [23].

2 Literature review

According to Bruno et al. [27], musicians who play at a professional level are similar to athletes. Performing artists, such as musicians, are often compared to athletes [6, 28]. It is common for musicians to perform at high speed for a long duration [29, 30], requiring physical endurance [30]. Because both musicians and athletes perform activities that require strength, flexibility, coordination and agility [29], they are susceptible to musculoskeletal injuries [27]. Therefore, PRMDs are common among musicians [8, 12, 17, 31].

Pianists are one of the musicians with a high occurrence of PRMDs [3, 5, 13]. Piano playing requires agility and physical strength [16] to achieve high-intensity practice, speed and accuracy, and the stress of competition [14, 15], all of which are similar to athletic activity [15]. This is particularly true for piano playing at an elite level (i.e. tertiary, college, conservatory or professional) [5, 14]. Therefore, pianists are among the musicians with a high occurrence of PRMDs [3, 5, 13].

Both professional and non-professional pianists are at risk of developing PRMDs [28]. PRMDs are caused by a myriad of factors. Various risk factors that lead to pianists’ PRMDs include: (i) long hours of practice; (ii) sudden increase in practice time; (iii) excessive muscle tension; (iv) improper playing techniques; (v) physical limitations (e.g. hand size and small build); and (vi) awkward postures.

2.1 Long hours of practice

Pianists spend long hours in practising [32, 33]. According to Kreutz et al. [34], musicians who spend long hours practicing to develop and maintain their skills often put heavy strain on their musculoskeletal system. While Pak and Chesky [35] and de Smet et al. [21] found no correlation between practice hours and pianists’ PRMDs, Fry et al. [36] and Shields and Dockrell [37] claimed otherwise. Shields and Dockrell’s study [37] suggested a positive correlation between practice time and pianists’ PRMDs and Fry et al. [36] concurred that there was a strong correlation between practice duration and the symptoms of PRMDs. As longer practice hours are associated with a high risk of PRMDs in musicians [37], long hours of practice is one of the risk factors contributing to pianists’ PRMDs [17, 19, 38].

2.2 Piano techniques

Improper piano playing technique, such as pressing the fingers too hard on the keyboard [15], playing loudly with high force [39], using an excessive muscle force to press the keys [40] and exaggerated technique (i.e. an overly percussive approach to the keyboard) [19] can lead to pianists’ PRMDs. In addition, the repetitive application of dynamic force from practising chords with fortissimo⁴ will also lead to pianists’ PRMDs, particularly in the hand/finger, wrist, forearm and elbow [42]. Shields and Dockrell [37] showed that 73% of the subjects experienced pain with at least one of the piano techniques, which include chords, fortissimo, double octaves or presto⁴. Piano techniques, such as octaves, chords [20, 39, 43] and fortissimo [7], are therefore some of the technical demands that not only increase the risk but are also responsible for pianists’ PRMDs, particularly in the hand and forearm area.

2.3 Physical limitations

Pianists’ anthropometric characteristics [44], physical size and strength [38, 45, 46], muscular structure [44] and physical condition [45, 46] are risk factors for pianists’ PRMDs [44 –46]. According to Grieco et al. [44], pianists with smaller build and lower muscle strength require more effort from the shoulder and trunk to sustain the movement of the fingers. In addition, pianists with a smaller hands size [22] require a larger abduction in between the fingers to perform certain piano techniques [21]. Stretching the finger span of a small hand can potentially cause severe or even permanent damage to the joints and soft tissues [38]. Therefore, a larger abduction angle between the thumb and the little finger puts more stress on the hand of a small-handed pianist compared to a large-handed pianist [7, 15, 20, 43].

2.4 Awkward postures

‘Posture’ is a term used to define the position of different parts of the body [47] at rest or during activity [46]. Musicians often suffered from postural related problems [48]. Postural stress in musicians originated from prolonged sitting [11] and awkward postures when playing an instrument [11, 40]. According to Ranelli et al. [49], musicians adopted awkward postures due to the influence of the physical characteristics of musical instruments. In addition, Winspur et al. [48] added that the most common problems related to playing technique for string and keyboard instruments are also related to postures.

Awkward posture generally leads to musculoskeletal disorders [50]. Excessive bending or twisting of any joint in the body out of a comfortable range of motion is the cause of awkward posture [47]. Faulty alignment [51], poor alignment [46] or awkward posture [47] will inflict excessive stress and strain on bones, joints, ligaments and muscles [51], causing them to work harder [47]. Therefore, awkward posture is one of the risk factors for PRMDs in musicians [11, 49] and pianists [19, 23, 46].

The overall posture position at the piano can reveal some problems that can lead to pianists’ PRMDs [32]. Pianists with long hours of practice often adopt a forward head position and elevated shoulders, causing fatigue and pain in the neck and the entire back [38]. The neck, shoulders, upper back, wrists and hands are the anatomical areas most affected by PRMDs during piano playing [44, 52]. This is mainly due to the fact that pianists tend to have relatively poor posture compared to other musicians [33]. Poor posture commonly found in pianists that leads to PRMDs include: (i) (excessive) kyphotic posture [19, 32, 44, 48, 53 –56]; (ii) elevated shoulders [15, 19, 38, 56]; (iii) forearm is not parallel to the floor [15, 19]; (iv) elbow too close or too far from the body [15, 19]; (v) curving of the wrist that is not in line with the fifth finger [15, 19]; and (vi) a lock stiff wrist [15, 19].

Excessive kyphotic posture, which causes discomfort in the neck and shoulders [19, 48, 54], is a classic problem for pianists [19, 32, 44, 48, 53–55]. According to Brandfonbrener [38] and Brown [56], another awkward posture adopted by pianists is elevated shoulders. Pianists, especially those who practise for long hours will develop fatigue and pain in the neck and the entire back [38]. Parry [19] also asserted that elevated shoulders cause pain in the neck and shoulders area.

Past studies of pianists’ PRMDs have mainly focused on prevalence [12, 14, 37, 42, 52], risk factors [14, 52], piano technique [17, 57], hand size [20, 21], wrist position [7], playing time [27], psychological stress [58], injury prevention [57] and awareness [22].

There is only one study found by the authors that was conducted by Lima et al. [59], which applied Rapid Upper Limb Assessment (RULA) to assess two pianists’ postures, without any modification to the original RULA worksheet. None of the other existing literature has applied this postural assessment tool to assess the pianists’ overall posture. The study that applied postural assessment tools (i.e. RULA) in the context of music was conducted by Kaufman-Cohen et al. [60], which focused on orchestral musicians. The subjects of Kaufman-Cohen et al. [60]’s study involved 39 strings and 20 winds (including woodwind and brass) players from three orchestras. The other study by Islan et al. [61] has also applied RULA to assess a violinist’s posture.

Although the RULA assessment checklist is widely used in various industries, there is no existing checklist that exactly fits into the context of piano playing, at least not without some modifications. Therefore, the novelty of this study is to propose a modified Rapid Upper Limb Assessment for pianists (RULA-p). This study is intended to further expand the existing literature on the early prevention of pianists’ PRMDs. This study is the first to propose a modified Rapid Upper Limb Assessment for pianists (RULA-p). The checklist will allow pianists to identify awkward postures (if any) during piano playing, thus, achieving healthful playing for injury prevention.

3 RULA

According to Brandfonbrener [62], one can learn a lot by observing musicians. Musicians’ awkward positions and ergonomically questionable postures are some of the issues that can be learned from careful and repeated observation [62]. In addition, observing the musician while playing the instrument is necessary to understand musicians’ complaints [31], as symptoms may only appear during a performance [10]. Problems are often obvious from observation of the way the musician holds and plays the instrument [28]. For example, when observing keyboard musicians, the observation can be done by watching them play in a convenient venue [28]. Therefore, a mismatch between the musician and the instrument can be shown by observing the musician playing the instrument [63].

According to Karhu et al. [64] and McAtamney et al. [65], observational methods are used to assess working posture and are widely used in industry [66, 67] to assess the risk of improper work postures [67]. Ergonomic risk assessments can be conducted by assigning scores based on body posture using observational methods [68]. RULA is one of the observational posture-assessment tools [69]. In 1993, McAtamney et al. [65] designed and presented the RULA as an observational posture-assessment tool. The main objective for the development of the RULA is to investigate whether workers are exposed to the risk factors for work-related upper limb disorders [65, 70, 71]. The literature study conducted by [70] provided a comprehensive review on RULA, showing its extensive use in ergonomic studies [72] in a variety of settings [68].

RULA uses a series of diagrams of different body postures and three numerical scoring tables to assess the exposure to postural risk factors [65, 73]. Table A and Table B focus on the analysis of two different groups of body regions. The analysis in Table A focuses on the upper and lower arm positions, wrist position, and wrist twist. Table B, on the other hand, focuses on the positions of neck, trunk, and leg. Table C indicates the final score of the level of action required. There are three stages to adopting RULA on working posture [65, 70]. The first stage is to observe the worker’s posture while performing the task. Subsequently, the posture scores for each body area are then identified from Table A and Table B by comparing the illustration from the RULA worksheet and the posture observation. The muscle use score (i.e. static posture or repetitive action) and the force/load score are added to each posture score according to the task performance to obtain the final score from Table C. Finally, the final score obtained will indicate the level of action required. There are four action levels [65]:

•
Action level 1 (score 1 or 2) – posture is acceptable.
•
Action level 2 (score 3 or 4) – further investigation is needed, changes may be required.
•
Action level 3 (score 5 or 6) – further investigation is needed and changes are required soon.
•
Action level 4 (score 7) – investigation and changes are required immediately.

3.1 Strengths and limitations of RULA

RULA serves as an initial tool that is appropriate for ergonomic assessment [69] due to its quick observational method [73] for the rapid assessment of postural risks [65, 68, 72]. RULA uses a coding system that generates an action list indicating the level of intervention required to reduce the postural risk [65]. While RULA can assess the risks of overall posture and/or a specific segment of the body [72], including the lower body, the main focus of RULA is on the upper body [73].

The following are RULA’s strengths:

•
RULA can be used in a wide range of work situations [67, 70, 72].
•
RULA is easy to learn [73], use and implement [68, 70].
•
RULA users require no special training [65, 68], skills [73], or experience [65, 70].
•
RULA requires minimal or no special equipment [65, 68, 69, 71, 73].
•
RULA requires minimal administration time [65, 69, 71 –73].
•
RULA uses a non-intrusive method of observation [65, 67, 68, 73].
•
The information obtained via RULA is sufficient enough as an initial screening tool [65].
Despite the strengths listed above, RULA also has the following limitations: •
Some detailed posture information (i.e. fingers and thumb positions) is not included in RULA [65, 69].
•
RULA assesses one side at a time (i.e. either the left side or the right side) [70].
•
The duration of the work is not taken into consideration in RULA [70].
•
RULA should be used in conjunction with other assessment tools for detailed ergonomic assessment [69, 73].

3.2 Comparison among RULA, REBA and OWAS

Many observational techniques have been developed to assess postural risk factors associated with musculoskeletal disorders [74]. To list but a few, Rapid Upper Limb Assessment (RULA) [65], Rapid Entire Body Assessment (REBA) [75], and Ovako Working Posture Analysing System (OWAS) [64] are among the few most widely used approaches in various industries to assess postural risk factors [67, 76]. Based on the analyses of working postural data from different industries, Kee [74] compared the three representative observational approaches to assessing musculoskeletal loadings. Despite the advantages and disadvantages, as well as the differences in the postural categories and analysis, these three observation techniques (i.e. RULA, REBA, and OWAS) have been developed and widely adopted in various industries because they provide a quick and simple assessment method [66] that allows workers to identify physical effort exerted from various aspects, such as posture, force, and static or repetitive load [74].

According to Kee [74] and Kee [76], RULA is the best approach for estimating postural loads and work-related musculoskeletal disorders. As mentioned previously, work-related musculoskeletal disorders are also known as PRMDs in the context of musicians. Compared to REBA and OWAS, which focus on the whole body of the subject, RULA focuses only on the assessment of the upper body (including the trunk) [76], which further justifies the relevance of this study to adopt RULA to assess postural risks in pianists. In addition, REBA and OWAS tend to underestimate postural-related risks compared to RULA, regardless of industry, work tasks and the balanced state of body postures [67]. Such an underestimation of postural risks may hinder efforts to cultivate the awareness of PRMDs among pianists, especially those who have little or no knowledge of the risks that are associated with PRMDs.

Whilst each approach has its own advantages and is more appropriate to certain industries than any others [67], RULA is the most appropriate approach to analysing the postural risks in pianists. RULA is also appropriate for analysing sedentary tasks where the worker is seated (e.g. screen-based or computer work) [69, 72]. Pianists playing on piano can also be classified as a sedentary task. Although the RULA evaluation checklist is widely used in various industries, there is no existing checklist that fits exactly into the context of piano playing, at least not without some modification. This justifies the relevance for this study to propose a modified Rapid Upper Limb Assessment for pianists (RULA-p).

4 Modification of RULA-p

Although the evaluation checklist of RULA is widely available in various industries [74], the checklist does not fit into piano playing. In this regard, this study proposed to modify the existing RULA, which will be labelled as Rapid Upper Limb Assessment for pianists (RULA-p) as a rapid assessment for pianists’ posture. This study adapts Lueder’s [77] approach in modifying RULA, which includes modifications in terms of: (i) the muscle use score; and (ii) the force/load score.

4.1 Modified muscle use score

The muscle use score in the original RULA checklist is based on the duration of a static posture or the occurrence of a repeated action [65]. Static postures, defined as the maintenance of the same position throughout physical exertion, predominantly manifest in occupational tasks such as sitting, standing, prolonged bending or twisting of the trunk, neck, or wrists, as well as working with hands above shoulder level, kneeling, or squatting postures [78]. Therefore, according to the above definition, pianists adopt static postures rather than dynamic ones while playing the piano. The modified RULA in Lueder’s [77] study, titled ‘A Proposed RULA for Computer Users’, Lueder [77] modified the muscle use score based on the number of hours spent working at the computer without getting up. As the RULA evaluation of this study focuses on pianists, this study modifies the muscle use score based on the number of hours per piano practice session. The modified muscle use score is +1 if more than two hours per session are spent at the piano (without getting up).

4.2 Modified force/load score

The force/load score in the original RULA checklist is based on the contribution of forceful actions or holding loads [65]. However, the force required to depress the piano keys (i.e. the weight of the piano keys) can vary from piano to piano [79]. Additionally, a variety of potential forces can produce a musical tone with equivalent levels of volume and duration [80]. The modified RULA in Lueder’s [77] study modified the force/load based on the total hours spent working at the computer per day. As the RULA evaluation of this study focuses on pianists who spend long hours in practising [32, 33] and long hours of practice is one of the risk factors contributing to pianists’s PRMDs [17, 19, 38]. Therefore, this study modifies the force/load score based on the total number of hours spent practicing at the piano per day. The modified force/load scores are: (a) +1 if the total number of hours per day spent at the piano is between four and six hours; and (b) +2 if the total number of hours per day spent at the piano is greater than six hours.

4.3 The posture scores for body parts

4.3.1 Upper arm and upper arm adjust

For clarity, this study uses a positive angle to represent the forward raised position of the upper arm and a negative angle to represent the upper arm position in extension, where the arm is posited backwards from the neutral position. The upper arm score is: (a) +1 if the upper arm position is posited in the neutral position or within the range of –20° – +20°; (b) +2 if the upper arm position is in extension, where the arm is posited backwards from the neutral position; (c) +2 if the upper arm is in the forward raised position within the range of +20° – +45°; (d) +3 if the upper arm is in the forward raised position within the range of +45° – +90°; and (e) +4 if the upper arm is in the forward raised position within the range of > +90°.

The upper arm adjust score is: (a) +1 if the shoulder is raised; and (b) +1 if the upper arm is abducted.

4.3.2 Lower arm and lower arm adjust

The lower arm score is: (a) +1 if the lower arm position is raised within the range of 60° – 100°; (b) +2 if the lower arm position is raised within the range of 0° – 60°; and (c) +3 if the lower arm position is raised within the range of > 100°.

The lower arm adjust score is +1 if either arm is working across mid-line or out to the side of the body.

4.3.3 Wrist position, wrist position adjust and wrist twist

For clarity, this study uses a positive angle to represent the upward bend wrist position and a negative angle to represent the downward bend wrist position. The wrist score is: (a) +1 if the wrist position is in the neutral position; (b) +2 if the wrist position is in the neutral position within the range of –15° – +15°; (c) +3 if the wrist position is bent upwards within the range of > +15°; and (d) +3 if the wrist position is bent downwards within the range of < –15°.

The wrist position adjust score is +1 if the wrist is bent from mid-line.

The wrist twist score is: (a) +1 if the wrist twist is in the mid-range; and (b) +2 if the wrist twist is at or near the end of range.

4.3.4 Neck position and neck adjust

The neck position score is: (a) +1 if the neck position is bent forward within the range of 0° – 10°; (b) +2 if the neck position is bent forward within the range of 10° – 20°; (c) +3 if the neck position is bent forward in the range of >20°; and (d) +4 if the neck position is in extension, which is the neck bending backwards.

The neck adjust score is: (a) +1 if the neck is twisted to either side; and (b)+1 if the neck is side bent to either side.

4.3.5 Trunk position and trunk adjust

The trunk position score is: (a) +1 if the trunk position is in the neutral position (0°); (b) +2 if the trunk position is in the neutral position and within the range of 0° – 20°; (c) +3 if the trunk position is bent forward in the range of 20° – 60°; and (d) +4 if the trunk position is bent forward in the range of > 60°.

The trunk adjust score is: (a) +1 if the trunk is twisted to either side; and (b) +1 if the trunk is side bent to either side.

4.3.6 Leg position

The leg score is: (a) +1 if the legs and feet are supported; and (b) +2 if the legs and feet are not supported.

4.4 The steps for the recording the posture score

When using the RULA-p worksheet to observe a pianist’s posture, either the left or the right side is assessed at a time. However, if undecided, the assessment could be done for both sides [65]. The step-by-step guide for recording the posture scores when adopting the RULA-p worksheet for pianists is as follows:

1
Step 1: Identify the upper arm position score.
2
Step 1a: Identify the upper arm adjust score (if necessary). Then add the scores from Step 1 and Step 1a to obtain the total upper arm score.
3
Step 2: Identify the lower arm position score.
4
Step 2a: Identify the lower arm adjust score (if necessary). Then add the scores from Step 2 and Step 2a to obtain the total lower arm score.
5
Step 3: Identify the wrist position score.
6
Step 3a: Identify the wrist adjust score (if necessary). Then add the scores from Step 3 and Step 3a to obtain the total wrist score.
7
Step 4: Identify the wrist twist score.
8
Step 5: Based on Table A, locate the posture score A by using values from Step 1 to Step 4.
9
Step 6: Obtain the muscle use score based on the modified muscle use score from section 4.1.
10
Step 7: Obtain the force/load score based on the modified muscle force/load score from section 4.2.
11
Step 8: Find the sum of the values from Step 5 to Step 7 to obtain the wrist and arm score.
12
Step 9: Identify the neck position score.
13
Step 9a: Identify the neck adjust score (if necessary). Then add the scores from Step 9 and Step 9a to obtain the total neck score.
14
Step 10: Identify the trunk position score.
15
Step 10a: Identify the trunk adjust score (if necessary). Then add the scores from Step 10 and Step 10a to obtain the total trunk score.
16
Step 11: Obtain the leg position score based on the score given in section 4.3.6.
17
Step 12: Based on Table B, locate the posture score B by using the values from
18
Step 9 to Step 11.
19
Step 13: Obtain the muscle use score based on the modified muscle use score from section 4.1.
20
Step 14: Obtain the force/load score based on the modified muscle force/load score from section 4.2.
21
Step 15: Find the sum of the values from Step 12 to Step 14 to obtain the neck, trunk, leg score. To obtain the final RULA-p score, locate the row and column in Table C based on thescores from Step 8 and Step 15, respectively.

4.5 Final RULA-p score

The final RULA-p scores are divided into four action levels, such as:

•
A final RULA-p score of 1 or 2 indicates that the posture is acceptable.
•
A final RULA-p score of 3 or 4 indicates that further investigation is needed and changes may be required.
•
A final RULA-p score of 5 or 6 indicates that further investigation and changes are required soon.
•
A final RULA-p score of 7 indicates that investigation and changes are required immediately.

Appendix A is the modified RULA for pianists (RULA-p) in the worksheet format.
5 Conclusion

Although both professional and non-professional pianists are at risk of developing PRMDs, pianists are subject to a high occurrence of PRMDs. Over-practice, incorrect piano techniques, and physical limitations are some of the factors that lead to pianists’ PRMDs. However, since a ‘one-size-fits-all’ keyboard size has been the standard in the present-day piano making, performing, teaching, and learning process, pianists are highly susceptible to higher ergonomic risk compared to other musicians.

Although the RULA assessment checklist is widely used in various industries, there is no existing checklist that exactly fits into the context of piano playing, at least not without some modifications. Poor postures commonly identified among pianists that lead to PRMDs are often associated with the upper body, making the neck, shoulders, upper back, wrists and hands the anatomical areas most affected by PRMDs during piano playing [44, 52]. Hence, the novelty of this study is to propose a modified Rapid Upper Limb Assessment for pianists (RULA-p) as a rapid assessment for pianists’ posture. These changes were established to enhance the relevance of assessing pianists’ postures in piano playing. While RULA is suitable for analysing postural risks for sedentary tasks such as piano playing, and can assess the risks of overall posture and/or a specific body segment [72], including the lower body, the main focus of RULA is on the upper body [73]. Given that this study primarily targets pianists, the RULA-p proposed herein may not be ideally suited for assessing the posture of other musicians. Generally, RULA was designed to identify work postures or risk factors deserving further attention; however, a low RULA score does not guarantee the absence of ergonomic hazards, nor does a high score necessarily indicate the presence of a severe problem [77]. The same applies to the RULA-p score.

Ethical approval

Not applicable.

Informed consent

Not applicable.

Conflict of interest

The authors declare that they have no conflict of interest.

Footnotes

Acknowledgments

The authors have no acknowledgements.

Funding

The authors report no funding.

Appendix A. Modified RULA Worksheet for Pianists (RULA-p)

Notes

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