By:
Jonathan Dropkin, ScD, PT, CPE
Associate Professor, Faculty Ergonomist

Yelena Globina, MD, MPH
Medical Director, Selikoff Centers for Occupational Health – Staten Island Clinic

Magnitude of problem

Musicians’ medicine dates back to at least Bernardino Ramazzini’s book, “A Treatise on the Diseases of Tradesmen” (circa 1713), although physicians did not, in earnest, examine and treat musicians’ musculoskeletal conditions, such as musicians’ cramp, until the end of the nineteenth century.^1,2

In a systematic review, Bragge and coworkers found professional musicians had a prevalence of playing-related musculoskeletal disorders between 26% and 93%,³ while in another systematic review, Kok et al. found a prevalence between 41% and 93%.⁴ In addition to neck, upper back and upper extremity conditions, these disorders include dental and jaw diseases, myofascial pain syndromes, craniomandibular dysfunctions, and percussion hemoglobinuria (hand trauma-induced mechanical hemolysis).¹

Health impact associated with playing-related musculoskeletal disorders

Musculoskeletal conditions with functional compromise, as well as sleep disturbances, are commonly reported by musicians.^4-8 These disorders affect musicians’ physical, psychosocial and financial well-being, and likely adversely affect over half of all professional musicians.^4-8 Indeed, the majority of professional musicians will experience playing-related musculoskeletal symptoms that interfere with their playing over their working life, and some may stop playing their instrument(s) secondary to these complaints.^4,6,9,10

Mechanical, temporal, and psychosocial exposures associated with these disabling conditions include instrument-specific workload, string player, employment duration, weekly work hours, work content, high job demands, low control, and lack of social support.¹¹

Characterization of exposure to inform primary prevention

A recent paper by Turner et al. analyzed pianists’ joint kinematics (movement and posture without considering force or load) with respect to “expressive intentions” – deliberate decisions for conveying artistic content¹² – for virtuosic musical passages (more difficult passages requiring higher technical skills) and less-virtuosic, more lyrical passages.¹³

Study highlights include:

• Overall, the study sought to examine how expressive intentions affect pianists’ movement strategies relative to performance and mechanical exposure.
• Specific objectives were to analyze (a) the influence of pianists’ expressive intentions on upper extremity movement and posture (non-neutral, static joint postures) and (b) distal upper extremity angular jerk (rate of change of acceleration, as a measure of human movement) on virtuosic and non-virtuosic excerpts.
• Results suggested that non-neutral upper extremity posture increased in pianists when using expressive intentions compared with when they did not use expressive intentions.
• Expressive intentions led to more static, non-neutral wrist postures, indicating higher exposure, while in the thoracic spine, more dynamic, neutral postures were seen.
• Expressive intentions produced jerkier wrist movements in lyrical, non-virtuosic musical excerpts, while in virtuosic excerpts, less exposure (wrist jerk) was observed.

Controls

Ergonomists are work scientists; they redesign the work environment to reduce occupational exposures linked with work-related musculoskeletal disorders. Ergonomists recommend solutions called controls, and have two types in their toolbox: work practice (work processes and methods) and engineering (equipment redesign). The most effective and efficient method to address playing-related musculoskeletal disorders is to employ both controls, coupled with physical rehabilitation.

Ideally, musicians should work with ergonomists and music teachers to help identify specific needs and tailor ergonomic solutions to them. Some examples of how work practice controls can help musicians:

Ergonomists can instruct musicians on:

• Paying attention to musculoskeletal symptoms;
• Resting, if they experience symptoms;
• Stopping and adjust their posture and technique through motor patterning (with an ergonomist) if they experience symptoms;
• Using a mirror to check and refine playing posture and technique;
• Warming-up (gently stretch before playing, focusing on their entire upper extremity and neck; stretching should be coupled with diaphragmatic breathing);
• Taking recovery periods (rest breaks) for three minutes after every twenty minutes of practice; recovery includes walking or stretching with breathing.¹⁴
• Relaxing their upper extremity, upper back, and neck while playing; avoid tightly gripping an instrument, as this can inhibit mobility and increase muscle activity (tension).

Two brief examples of ergonomic controls for specific instruments:

1. Violin: Use an adjustable, padded, “violin shoulder rest,” although a better name would be a violin neck / shoulder support. First, ensure the shoulder rest is compatible with the musician’s violin size. The shoulder rest should be adjustable for the musician’s anthropometry and preferred playing angle. This device bridges the gap between the musician’s shoulder and instrument. One of its goals is to securely and comfortably hold the violin between the lateral / anterior aspect of the neck / shoulder. Coupled with training, a shoulder rest can reduce muscle loading and “clamping down” between the chin and instrument, and instrument and shoulder. The musician should also consider violins with non-slip surfaces and lightweight construction.

      Other benefits of using a shoulder rest include:¹⁵

1. Reduces mechanical compression between the violin’s back and the player’s shoulder;
2. Provides stability, which contributes to better technique; stability is particularly beneficial when performing complex passages requiring rapid positional changes or extended left hand reaches;
3. Similarly, by stabilizing the violin, the shoulder rest improves the freedom to move the upper extremity more fluidly, and this relaxation is important for maintaining agility in the distal upper extremity for quicker, more precise finger work and bowing techniques;
4. Helps maintain the violin in the correct position, ensuring the musician can execute techniques accurately, without the instrument slipping or unexpectedly moving;
5. Reduces the violin from dampening due to contact with the body, thereby preserving the violin’s resonant qualities;
6. Aids in achieving an optimal bow angle and pressure, as the musician can focus more on bow control without worrying about supporting the violin’s weight, which can then lead to a more nuanced sound production.

2. Piano: Unlike the violin, piano ergonomics focuses more on work practices, including motor patterning of healthy postures and techniques to minimize mechanical exposure and work-related musculoskeletal symptoms, and to optimize sound production. Proper posture involves maintaining a neutral lower and upper back and C-spine (~ 0^°), no scapula elevation, and a neutral wrist (~ 0^°), with feet positioned shoulder width apart and flat on the floor, and elbow angles between 95^° and 100^° (toward elbow extension); the elbows should be slightly higher than the keys. (Most piano ergonomic guidelines position the elbow at 90^°, with the bench positioned so the elbows are level with the keys. However, in this position, the ulnar nerve in the cubital tunnel begins to compress; moreover, muscles work most effectively when lengthened just beyond resting length; at 90^° of elbow flexion, elbow musculature is shortened, not lengthened.)

      Some other points:

• Bench: Center the bench width wise to the keyboard and sit towards the front half of the bench; use a padded, yet firm, bench! Keep the bench out from underneath the piano.  
• Feet: The pelvic angle in a seated posture should be ~ 95^°, moving into lumbar extension. (Most piano ergonomic guidelines position the pelvic angle at 90^°; however, lumbar compression forces begin to increase in this position.) The heel of the pedal foot should rest on the floor.
• Weight distribution: The musician’s weight should be centered on her buttocks while maintaining a neutral lordotic curvature; do not lean backward or forwards (avoid trunk extension, trunk flexion, thoracic kyphosis, and hyper-lordosis).
• Trunk position: The musician should move over the keyboard using brushstroke techniques. Specifically, instead of lifting the fingers completely off the keys before playing the next note, this technique emphasizes a continuous flow of weight from one finger to the next by transferring weight from finger to finger; this then creates smooth, connected lines of sound. It involves relaxed, curved, finger positions, and subtle, rather than rigid, upper extremity movements. 
• Breathing: Ensure the musician is breathing deeply and regularly.

About the Selikoff Centers

The Mount Sinai Selikoff Centers for Occupational Health are dedicated to providing cutting-edge clinical services with a focus on prevention to keep workers healthy and their workplaces safe. Our multidisciplinary health care team includes physicians, nurse practitioners, industrial hygienists, ergonomists, social workers, workers’ compensation and benefits specialists who provide comprehensive patient-centered services.

We diagnose and treat occupational diseases, evaluate work conditions of our patients to determine whether other co-workers may be at risk, and suggest measures to improve work environments. Identification of workplace hazards are used to prevent work-related disorders, injuries and illnesses through training and education of unions, and workers and their employers, along with establishing effective workplace interventions.

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Author Bios

Jonathan Dropkin, ScD, PT, CPE, is an ergonomist at the Selikoff Centers. He works with musicians to reduce the impact of their playing-related musculoskeletal disorders using a combined approach of redesigning their musical instruments, incorporating motor patterning into the musician’s work practices, and physical rehabilitation, such as gentle stretching, diaphragmatic / relaxation breathing, and gentle cardiovascular exercise. He works closely with our occupational medicine physicians to ensure these individuals receive the most comprehensive medical and rehabilitation care available. 

Yelena Globina, MD, MPH, is a board certified Occupational & Environmental Medicine and Preventive Medicine – Public Health physician. She has 14 years of experience diagnosing and treating work -related illnesses and injuries, treating 9/11 responders and creating and implementing worker health and safety programs. Dr. Globina is an Associate Professor at Icahn School of Medicine at Mount Sinai, and is the Medical Director for the Staten Island Selikoff Centers for Occupational Health Clinic.

 

REFERENCES

1. Rotter et al. Musculoskeletal disorders and complaints in professional musicians: a systematic review of prevalence, risk factors, and clinical treatment effects. International Archives of Occupational and Environmental Health. 2020;93(2):149-187.
2. Singer K. Diseases of the musical profession: a systematic presentation of their causes, symptoms and methods of treatment. Greenberg Publisher, New York; 1932.
3. Bragge et al. A systematic review of prevalence and risk factors associated with playing-related musculoskeletal disorders in pianists. Occupational Medicine. 2006;56(1):28-38.
4. Kok et al. The occurrence of musculoskeletal complaints among professional musicians: a systematic review. International Archives of Occupational and Environmental Health. 2016;89(3):373-396.
5. Paarup et al. Prevalence and consequences of musculoskeletal symptoms in symphony orchestra musicians vary by gender: a cross-sectional study. BMC Musculoskeletal Disorders. 2011;12(1):223.
6. Kaneko et al. Pain as an incapacitating factor in symphony orchestra musicians in Sao Paulo, Brazil. Medical Problems of Performing Artists. 2005;20(4):168-174.
7. Spahn et al. Health locus of control and preventive behaviour among students of music. Psychology of Music. 2005;33(3):256-268.
8. Guptill and Golem. Case study: musicians' playing-related injuries. Work. 2008;30(3):307-310.
9. Kaufman-Cohen and Ratzon. Correlation between risk factors and musculoskeletal disorders among classical musicians. Occupational Medicine. 2011;61(2):90-95.
10. Parry CW. Prevention of musicians' hand problems. Hand Clinics. 2003;19(2):317-324.
11. Baadjou et al. Systematic review: risk factors for musculoskeletal disorders in musicians. Occupational Medicine. 2016;66(8):614-622.
12. Leman and Maes. The role of embodiment in the perception of music. Empirical Musicology Review. 2014;9(3-4):236-246.
13. Turner et al. Impact of expressive intentions on upper-body kinematics in two expert pianists. Frontiers in Psychology. 2025;15:1504456.
14. Nakphet et al. Effect of different types of rest-break interventions on neck and shoulder muscle activity, perceived discomfort and productivity in symptomatic VDU operators: a randomized controlled trial. International Journal of Occupational Safety and Ergonomics. 2014;20(2),339-353.
15. Sachs R. Essential guide to using a violin shoulder rest. https://ronaldsachs.com/blog/the-essential-guide-to-using-a-violin-shoulder-rest/. Accessed July 2025.