Written By:
Marial Williams, OTD, OTR/L
Virtual Hand to Shoulder Fellow ’23/’24
My name is Marial Williams, and I am currently an occupational therapist in an outpatient hand clinic. I have been playing violin since I was six years old, and an injury in college as a music student led me to occupational therapy. When I was in college there were not as many accessible resources and specialists in musician health as there are today, and my aim as an occupational therapist is to increase awareness and knowledge around musician health. The following is a brief review of the demands of playing the violin or viola, and the prevention techniques clinicians can teach these instrumentalists to decrease the likelihood of injury.
Introducing: The High Strings
In general, musician injuries are quite prevalent with a recent systematic review citing point prevalence of injury in musicians up to 63% and lifetime prevalence of injuries up to 90% (Rodríguez-Gude et al., 2022). While there are not many recent studies on specific instruments, from my clinical and musical experience, some common injuries in violinists and violists are wrist tendinopathies, lateral epicondylosis, cubital tunnel syndrome, temporomandibular joint disorders, thoracic outlet syndrome, and cervical radiculopathy.
Violin and viola are the “high strings” and are played up at the shoulder level. Playing these instruments requires the musician to hold the instrument asymmetrically on their left side between the clavicle/shoulder and the chin, requiring some degree of cervical flexion and lateral flexion and/or rotation, in combination with shoulder external rotation and flexion. The left hand is used for fingering the notes, with the left elbow flexed and the forearm in full supination (Rensing et al., 2018). The right arm is used for bowing, with a combination of movement coming from the digits, wrist, elbow, and shoulder with joint kinematics being most dependent on the type of bow stroke and the string being played (Michaud et al., 2022). Not only is there an asymmetry to this positioning, but there are contrasting demands from the left to the right side. One study found the highest demand techniques used by violinists for their LUE was the use of vibrato and increased playing speed, while the highest demand technique used in the RUE was playing forte (i.e. playing louder) (Mann et al., 2023). Although the study was on violinists, this is likely true in violists as well.
Between the two instruments, viola is a larger instrument. While the viola may be heavier leading to greater chances of injuries in the left upper extremity, clinicians should additionally consider the different playing demands of the two instruments (Rensing et al., 2018). Violinists often have higher notes and melodies, which can require them to shift into more awkward positions with their left hand such as maximal supination combined with wrist flexion and maximal thumb abduction. For violists, there may be more rhythmic musical demands requiring greater endurance in the RUE for bowing and heavier pressure required to make sound. Therefore, clinicians should always assess instrumentalists individually and consider the specific types of music that musicians are playing which may contribute to their injuries.
Preventing Injury in High String Players
Occupational therapists have the potential to educate high string players on preventive techniques including environmental and instrumental modifications; activity modification and biomechanics both on and off the instrument; routine management including warm-up/cool down; and general health recommendations for diet, exercise, and sleep.
Instrumentalists play in varying settings including practice settings (practice rooms, non-performance rehearsal spaces, bedrooms, living rooms, etc.) and performance settings (large concert halls, religious spaces, outdoors, pit orchestras, etc.). Most of the time, instrumentalists will not have only one place that they practice or only one place that they perform. It is therefore important to consider the different demands of each of these spaces and educate instrumentalists on generalized techniques that they can then apply to their varying playing settings.
Many of the same principles that we already teach other patients, such as workstation setup will apply to musicians as well. We can provide education on music stand height to avoid neck strain and poor postures. We can also discuss chair heights and seated or standing postures. While instrumentalists may not always have full control of their environments, they may be able to bring a seat cushion or foot stool depending on their needs. Stand lights may also be a way to control lighting to help avoid eye and neck strain for those in pit orchestras or other dim lit settings.
For instrumental modifications, working with a music teacher and luthier, or instrument maker, is essential. For violinists and violists, a simple modification may be made in finding well-fitting chin and shoulder rests (Rensing et al., 2018). There are many options for chin rests and shoulder rests which can promote improved proximal stabilization for distal disorders. The chin rest is attached to the instrument and is only removed when being switched for a new one by a luthier. It can vary in shape, height, and placement on the instrument (i.e. it may be placed to the left or in the center). There are also fully personalized chin rests available through fittings. The shoulder rest is an easily removable piece and is put on and taken off by the musician before and after playing. These are also highly customizable and have varying shapes/contours, heights, and materials (e.g. sponges, padding, malleable metals). There is contradicting evidence in the literature on what is “best” biomechanically (Kok et al., 2019), so efforts may be best directed in finding the musician’s most comfortable fit and/or adjusting to their particular malady.
Other modifications that can be made to violins and violas include adjustments to the bridge or fingerboard to decrease the amount of pressure needed to depress the strings, changing strings (different brands are easier to play than others), replacing the tuning pegs (some types require less pressure and have less resistance than others), or adding a grip onto the bow to decrease stress in the right hand. Individual musicians have created other adaptive equipment that they market online (e.g. the Violin/Viola Valet), so a quick Google search may help you find a unique fix that may be beneficial to specific needs.
Keep in mind that all modifications will have some effect on sound and appearance, which may not be desirable in the highest-level instrumentalists. As clinicians, we may not always know the exact musical demands or preferences of the musician, but we can help instrumentalists find modifications that decrease stress to their bodies and positioning that is more neutral for their joints. Additionally, recommendations may be given in clinic, and then modified and implemented outside of sessions with another musical expert (for example, their music teacher or a luthier).
When it comes to biomechanics, we should discuss proper lifting techniques as musicians are often carrying an instrument in addition to a bag with music or other supplies. Techniques that offload the distal musculature can be beneficial for musicians who are already placing high demands on their intrinsic and extrinsic hand muscles. We can give education related to other I/ADLs as well such as computer/deskwork setup, biomechanics while using a cellphone, driving, and sleep positioning. Additional biomechanical strategies that are specific to time on the instrument (e.g. proximal stabilization, neutral wrist, “c” positioning of the right thumb, avoidance of hyperextension in IP joints) should also be reviewed. These modifications to playing may be best implemented by collaborating with a musician’s teacher/professor or the musician themselves if they are a professional. Musicians are adaptable and have experience in changing their techniques, so any biomechanical recommendations made on the instrument should be collaborative rather than authoritative by the clinician.
We can also offer education on routine management for practicing. Musicians should have a warm-up and cool-down routine for both on and off the instrument. Body warmups should include a cardiovascular warmup, and muscles specific to playing; while cool-downs should focus on lengthening of muscles that have been in tight/static postures as well as those which were used at a higher intensity. To warmup on the instrument, musicians should start with scales or lower demand techniques, and gradually progress to more difficult techniques and repertoire. While these are techniques that musicians maybe hear from their teachers or peers, it is important as medical professionals that we reinforce the same ideas with evidence-based rationale. Analogy to athletes and sports is often helpful.
Lastly, as occupational therapists we are trained to treat the whole person and consider their full occupational participation. Therefore, recommendations on essential health behaviors including diet, exercise, and sleep can be an important part of our treatment plans, especially considering the role these activities may have on injuries and pain (Bourne et al., 2019). Current evidence suggests that there may be a benefit to creating exercise programs for strengthening of muscles that violinists and violists most frequently use (Rensing et al., 2018 & Rodríguez-Gude et al., 2022). Musicians often have unpredictable schedules or travel frequently leading to decreased health behaviors. Consequently, routine management, evidence-based resources on recommendations for health behaviors, or referring to other specialists in these areas may also be beneficial.
Key Take Aways
Instrumentalists may be at high risk for injuries due to the high demands of musicmaking, and high string players may have increased risks due to their asymmetrical playing position. Occupational therapists can aid in prevention of injuries through education in environmental and instrumental modifications; activity modification and biomechanics both on and off the instrument; routine management including warm-up/cool down; and general health recommendations for diet, exercise, and sleep. When musicians come to hand clinics for playing-related injuries or injuries of any type, we have the opportunity to provide this education. This may be of benefit not only to the patient in front of us, but they may further take that education to their music students, their professors, or their colleagues, thus preventing injuries in musicians on a larger scale.
References
Bourne, D., Hallaran, A., & Mackie, J. (2019). The lived experience of orchestral string musicians with playing-related pain. Medical Problems of Performing Artists, 34(4): 198-204. https://doi.org/10.21091/mppa.2019.4031
Kok, L. M., Schrijvers, J., Fiocco, M., van Royen, B., & Harlaar, J. (2019). Use of a shoulder rest for playing the violin revisited. Medical Problems of Performing Artists, 34(1): 39-46. https://doi.org/10.21091/mppa.2019.1009
Mann, S., Paarup, H. M., & Søgaard, K. (2023) Effects of different violin playing techniques on workload in forearm and shoulder muscles. Applied Ergonomics, 110. https://doi.org/10.1016/j.apergo.2023.103999
Michaud, B., Begon, M., & Duprey, S. (2022). Bow-side kinematics studies in violinists. Medical Problems of Performing Artists, 37(3): 135-142. https://doi.org/10.21091/mppa.2022.3020
Rensing, N., Schemman, H., & Zalpour, C. (2018). Musculoskeletal demands in violin and viola playing. Medical Problems of Performing Artists, 33(4): 265-274. https://doi.org/10.21091/mppa.2018.4040
Rodríguez-Gude, C., Taboada-Iglesias, Y., & Pino-Juste, M. (2022). Musculoskeletal pain in musicians: prevalence and risk factors – a systematic review. International Journal of Occupational Safety and Ergonomics, 29(2), 883–901.https://doi.org/10.1080/10803548.2022.2086742