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Investigating the Prevalence of Playing-Related Musculoskeletal
Disorders in Relation to Piano Players’ Playing-Techniques and
Practising Strategies
LiLi Allsop
B Mus. with 2A Honours
B Mus. Majoring in Piano Performance
This thesis is presented for the degree of
Master of Science
of
The University of Western Australia
The School of Human Movement and Exercise Science
2007
i
Acknowledgements
This research work and thesis could not have been completed without the support and
encouragement, the inspiration and assistance given by my family, friends, colleagues and
particularly the academic staff of The School of Human Movement and Exercise Science of The
University of Western Australia. I would like to dedicate the research work to my late father
Professor Ying Ye, my mother Kathleen Quan, and my son Alexander C Y Allsop; they are the
source of strength of my life.
There are many people to whom I am greatly indebted and deserve special mention.
Firstly, exceptional thanks to Dr. Dawne Larkin & Professor Tim Ackland, who gave very
valuable and constructive guidance and feedbacks, especially Dr. Dawne Larkin whose patience
was ultra stretched. Careful nurturing from both supervisors with their exceptional knowledge in
research work has made possible the completion of this thesis.
Very special thanks must be given to the Music Librarian Miss Jennifer Wildy, for her
musical knowledge, many other areas of knowledge and professional assistance, particularly, her
patience and ever-ready support when I was in the crisis situations. Without her input this thesis
would not be finished in the present time-length and would be certainly less rich.
My sincere thanks to Dr. Peter Hamer & Dr. Xiao-Zhen Hu for their assistance in
initiating the research work, and my very sincere thanks to Dr. Peter E. Goodwin & Susan F.
Goodwin for their medical knowledge and help, materials and personal support whenever I was
in need. My sincere thanks go to Jessica Yeh, for her assistance with input of computer-skills.
Finally I would also like to give special thanks to Rev. Bryan Shattock, who strongly
encouraged me to follow my dreams when I felt that life was almost over, and to treasure
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whatever is left, to make a useful contribution. I could not have managed without you all, and
thanks again from the depths of my heart!
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Abstract
This study placed specific emphasis on the motor-skills and practice strategies employed
by piano players when practising and performing in relation to playing-related musculoskeletal
disorders (PRMDs). The survey questionnaire-instrument was designed by the researcher to
investigate the prevalence of PRMDs among both professional and non-professional piano
players. Five hundred and five respondents completed the self-administered survey
questionnaire. Out of the total 505 participants, 42% of the players reported PRMDs. The
professional players (72%) reported a significantly higher incidence (p < 0.05) of PRMDs in
comparison with the non-professional group. The professional players with piano as their major
instrument, using predominantly neutral wrist posture (i.e., open-kinetic chain playing
technique), reported a significantly higher incidence of PRMDs. Although the present study
showed a greater number of years of playing was associated with greater risk of PRMDs, the
result also showed that the years of playing had no significant effect on the incidence of PRMDs
(p > .05) when it was analyzed with the practice hours within seven days. Moreover, analyzing
the practice hours over seven days with the piano major/non-major instrument, the various grade
levels and PRMDs; the results showed that the practice hours had no significant effect on the
groups with and without PRMDs (p > .05). Although women reported a significantly higher
percentage of PRMDs (p < 0.05) than men, there was no significant association between the
groups with and without PRMDs when analyzing practice hours over seven days by grade levels
and gender. The PRMDs seem to arise when overuse is compounded by misuse and/or adverse
playing conditions. The best and safest practice would be to minimize consumption of
musculoskeletal force production and combine this with effective practice-breaks between
sessions to achieve the optimum goal of daily practice.
Keywords: hand injury, PRMDs, wrist pain, hand-span size, playing-technique, and piano player.
Table of Contents
Acknowledgement………………………………………………………………………………....i
Abstract…………………………………………………………………………………….…….iii
Table of Contents…………………………………………………………………………….…..iv
List of Figures……………………………………………………………………………….…..vii
List of Tables……………………………………………………………………………….…......x
Chapter
I Introduction……………………………………………………...…………………….....1
Problem Statement……………………………………….………………………..3
Purpose of the Study…………………………………….………………………...6
Significance………………………………………………..……………………....8
Limitation……………………………………………………………………….....8
Definition of Terms………………………………………………………………..8
II Literature Review.............................................................................................................10
Introduction………………………………………………….…………….……..10
Development of Playing-Techniques…...….……….……………………………10
Motor-Skills and Playing Postures ………..…..……………….……………..….20
Functional Differences………………..……………….…….…..……………….29
Playing Time and Practice Habits and Practice Methods..…..………...................33
PRMDs Associated with Specific Motor-Skills……...…….………..…………...40
Incidence and Syndromes of PRMDs…………………….………...………….…46
Education in PRMDs Prevention…..……………….………………………….…52
Summary………………………………………………………...…………….….60
III Method………………………………….………………………………...………….…..64 iv
v
Participants………………………….…………………..………………………..64
Instrument…………………………..………………….………………….……...65
Survey Procedure……………………………….………….…..………….……...66
Statistical Procedures..………………………………………..………………......68
IV Results...............................................................................................................................70
Introduction……………………………………………………................………70
Playing-techniques…………………….…………..………………….…………..70
Wrist Postures…...………………...………………………………….…..70
Finger Postures and Elbow Postures…………………………………..…71
Shoulder Postures.….....………………………………………….………72
Finger Movements…………………………..……………………………72
Exploring Different Playing-Techniques..………………….…………………….73
Playing-Occupations…….……………….…………………………………….…73
Professional and Non-Professional Players…………….………….……………..75
Different Types of Practice Strategy……..……………………………………....75
Number of Breaks within Daily Practice...…………..…..…………….....75
Break Length within Daily Practice Session………………………....…..76
Practice Hours over Seven Days……….……………………….………..77
Years of Playing……………...………………………………………….……….79
Different Levels of Playing……..…….……………...……….………….………81
Piano as the Major or Non-Major Instrument…..……………………….……….82
Differences in Age…………………..…………………….………….…………..83
Gender……………………………………………………….….…………....…..83
Hand-Span Sizes..………..…………………………………….….……………...84
vi
Onset of PRMDs by Playing Certain Piano Techniques…….…………….……..85
Locations of PRMDs…………………...………………………………….…......85
Types of PRMDs.…………………………………………………………....…...86
Seeking Help when PRMDs Occurred…….…………….…………………….…86
V Discussion……………………………………………………………..………………....87
Introduction……………………………………………..………..……................87
Playing-Techniques and Playing Postures…………………...……………...……89
Playing-Occupations…...………………………………….……….…………......93
Professional and Non-Professional Respondents…...….…………………….…..94
Practice Strategy…..…………………….......…………….……….…………......94
Years of Playing……………………………………………………………….....95
Different Levels of Playing………………………………………………………96
Age………………………………………………………………………………..96
Gender…...……………………………………………………….…………..…..97
Hand-Span Size……..……………………………………….…………………...97
Association between PRMDs and Piano Techniques.……………………….......98
Symptons and Seeking Help when Discomfort Occurred…………….………....99
Limitations of the Study.….……………………….………………....................100
VI Summary..……………………………………………………..…………………....….102
References...………………………………………………………………………….…...……107
Appendix A……………………………………………………………………………….…….116
Appendix B……………………………………………………………………….…………….127
Appendix C……………………………………………………………………………………..129
Appendix D……………………………………………………………………………….…….131
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List of Figures
Figure 2.1. Traditional playing postures (i.e., Naïve-playing).
Figure 2.2. Weight playing posture.
Figure 2.3. The passive tension in the extensor muscles is low when the wrist is in an extended
posture.
Figure 2.4. The passive tension in the extensor muscles is high when the hand is in a flexed
posture.
Figure 2.5. Position 1 using straight finger posture.
Figure 2.6. Position 2 using curved finger posture.
Figure 2.7. In the photos A and B, the fingers and hand move down to depress the key, and then
lift from depressing the keys by the elbow joint motion.
Figure 2.8. (A) Rolling the wrist joint upward without lifting the fingers away from the surface
of the keys, and (B) dropping the wrist joint downward when fingers depress the keys to reduce
the passive tension (using closed-kinetic chain playing-technique).
Figure 2.9. Theoretical framework.
Figure 4.1. The percentage of PRMDs reported by respondents who used the traditional (n =
108), weight (n = 41), neutral (n = 349) and the Levinskaya system (n = 5) wrist playing
postures.
Figure 4.2. The percentage of PRMDs reported by respondents who use a flat (n = 54) or a round
finger posture (n = 437), and percentage of PRMDs reported by respondents who use the straight
elbow posture (n = 103), or the bent elbow posture (n = 397).
Figure 4.3. The percentage of PRMDs reported by respondents who use an elevated shoulder
posture (n = 99), or a non-elevated shoulder posture (n = 394).
Figure 4.4. The percentage of PRMDs reported by respondents who use a vertical finger
movement (n = 319), or a horizontal finger movement (n = 182).
Figure 4.5. The percentage of PRMDs for the ‘explorer’ group (n = 187) and the ‘non-explorer’
group (n = 318).
Figure 4.6. Rates of PRMDs by performer group (n = 21), teacher group (n = 50) and player
group (n = 434).
Figure 4.7. The degree of PRMDs (M ± SD) reported by the performer group (n = 14), teacher
group (n = 34) and player group (n = 166). No PRMDs = 0, while maximum PRMDs = 4.
Figure 4.8. Rate of PRMDs among respondents with different rest frequencies within the daily
practice session – none (n = 292), once (n = 122), twice (n = 55) and more rests (n = 36).
Figure 4.9. The frequency of various practice break length, (n = 106) with 0 break, (n = 19) with
3 minutes break, (n = 27) with 5 minutes break, (n = 27) with 10 minutes break, (n = 16) with 15
minutes break, (n = 7) with 30 minutes break, and (n = 12) with 60+ minutes break.
viii
ix
Figure 4.10. The Mean and SD of Professional players without PRMDs (n = 18) and with
PRMDs (n = 46) and, Non-Professional players without PRMDs (n = 273) and with PRMDs (n =
168).
Figure 4.11. The percentage of PRMDs in groups that played 1 – 5 hr (n = 349), 6 – 10 hr (n =
105), 11 – 20 hr (n = 38) and 21 – 40 hr (n = 12) hours per week.
Figure 4.12. The practicing hours over seven days (M ± SD) tested with incidence of PRMDs,
Professional or Non-Professional with Piano Non-Major players (n = 184), Professional or Non-
Professional Piano Major players (n = 320).
Figure 4.13. The percentage incidence of PRMDs among years of playing piano: 2 – 5 years (n =
164), 6 – 15 years (n = 250), 16 – 40 years (n = 65), and 41 – 89 years (n = 26).
Figure 4.14. The hours of practice over seven days (M ± SD) with 2 – 5 years (n = 164), 6 – 15
years (n =250), 16 – 40 years (n = 65), and 41 – 60+ years (n = 26); and with PRMDs (n = 214)
and with no PRMDs (n = 291) reported by the respondents.
Figure 4.15. The percentage incidence of PRMDs among preliminary, grade 1, 2, 3 (n = 173),
grade 4, 5, 6 (n = 163), grade 7, 8, & associate, licentiate and tertiary (n = 164).
Figure 4.16. The percentage of PRMDs among players of differing age: 12 - 20 years of age (n =
372), 21-40 years of age (n = 57) and 41 - 89 years of age (n = 76).
Figure 4.17. The Mean and ± SD of hand-span sizes in relation to the incidence of PRMDs
between gender, and small hand (n = 218) and big hand (n = 269).
x
Figure 4.18. The frequency of PRMDs at various locations of the body: neck or shoulder (n =
109), back (n = 79), upper arm (n = 12) forearm or elbow (n = 56), wrist, hand or finger (n =
136).
Figure 6.1. Summary diagram of the theoretical framework.
Table
Table 1. Symptoms of PRMDs reported in the sample.
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1
Chapter I
Introduction
Many of the playing-related musculoskeletal disorders (PRMDs) that musicians have
encountered appear to be due to inefficient motor-skills, awkwardness in handling keyboard
instruments, and adverse working/playing conditions. Because of the nature of the occupation,
professional and non-professional piano players are at risk of PRMDs. Factors that may
contribute to the incidence of PRMDs, which appear to include:
1) biomechanical inefficiency of postures and motor-skills,
2) the extremely long hours of practice, and
3) insufficient regard for characteristics and structural differences in individual pianos.
Musculoskeletal complaints were commonly the result of tendonitis, overuse
syndrome, and carpal tunnel syndrome at the wrist, or radial nerve compression at the elbow
(Harding et al., 1989). Lippmann (1991) argued that „overuse‟ is a simplistic descriptive label
that ignores various other possible correctable causes of malfunction in the playing of a
musical instrument. Physicians are challenged to assess the physical, technical and behavioral
basis of malfunction, the combination of which defines the individual musician‟s problems
and leads to a diagnosis that can be a very specific guide for remedial treatment. Such
remedial action is preferable to mere rest; for the following reason expressed by Winspur:
“Since overuse implies a need for therapeutic rest, it may cause unwarranted disuse, which
remains second best to appropriate use in otherwise healthy musicians who have developed
malfunction from misuse” (Winspur, 2003; p. 328).
In piano playing and performance, the most important skills in order for a player to
complete the task of performance are the motor-skills. The Australian Music Examinations
Board‟s Manual of Syllabuses used for assessing piano technical work does not emphasize the
motor-skills (e.g., motion economy) involved in the performance, though the manual has
2
specified that speed of playing, evenness of sound, and quality of touch should be
demonstrated during the examination. Individual performance can only be evaluated on the
basis of the musical result of the action at a particular moment, but not the motor-skills that
were used when achieving the goal. This may reflect that we are not sure what kind of motor-
skill/movement technique is the most energy efficient; and whether the mechanical force
production in the upper extremities will respond differently when playing different pianos.
Furthermore, what is the healthy practice strategy that is optimum for the practice result,
without giving rise to PRMDs?
There are two main kinds of motor-skills in common use: (1) the traditional playing-
technique and (2) the weight playing-technique. The traditional playing-technique was
developed during the clavichord and harpsichord period, and was also used on the early
models of piano, having been applied continuously through to the present day acoustic piano
and various keyboard instruments. However, the arrival of the weight playing-technique
resulted when greater force and greater speed were needed to produce a much more powerful
sound than the 20th
century acoustic piano was able to offer. The different keyboard
instruments and the different characteristics of each individual piano require adaptation or
change in motor-skills and movement techniques to deal with these different mechanical
characteristics.
Breithaupt established the definition of the weight playing-technique as achieving the
goal of energy-efficiency, combined with use of natural gravitational force (Breithaupt, 1909).
Ortmann (1929) described the complex problem of physiological mechanics as applied to
piano playing, and the variations of force produced at the key-surface by the player.
Ortmann‟s study was concerned with the manner in which these force-variations are produced
(Ortmann, 1929). Neuhaus, in 1973, further explained that the generation of the force was
combined with activation of the musculoskeletal system. He explained how the weight of the
segments of the body was also a result of natural gravitational force (Neuhaus, 1973).
3
Several questions still remain, including what is the difference between the weight
playing-technique and the traditional playing-technique; and what is the relative frequency of
PRMDs for the various movement techniques? We have insufficient knowledge to be able to
specify a standard criterion for assessing the motor-skills of performance. Consequently, in
the third decade of researching PRMDs of instrumentalists, we still cannot offer effective
strategies for PRMDs prevention in piano playing (Manchester, 2006).
Problem Statement
In the 18th
Century Bartolomeo Christofori invented the first generation of pianos
(Crombie, 1995). These were used in a drawing room for an audience of a few aristocrats.
One hundred years of piano evolution between 1750 and 1850 represented a search for more
power, more volume, a greater dynamic range and a wider compass of pitches. The piano of
today is able to satisfy a large audience of three to four thousand people in a concert hall. The
touch-weight of each key varies from very light, which is similar to the computer keyboard, to
the touch-weight of 52g for present day acoustic pianos. Much of the music that had been
composed for various keyboard instruments in different periods of history is often performed
on the present day acoustic piano, which has a much heavier mechanical action of the
hammers. There is no publication cited on the instructions given to direct a player on how to
apply different physical movements or motion-economics to adapt to these changes.
Despite this long history of piano playing, the majority of players (including
professional players) are to some extent ignorant of the fact that playing musical instruments
can cause serious physical injuries. Research has shown that players have inadvertently
subjected themselves to cumulative trauma through highly repetitive movements, using
inappropriate body postures and potentially harmful playing-techniques, extremely long hours
of practice without rest or a break during the practice-session, the anxiety of performances
and competitions, resulting in many musicians suffering a number of musculoskeletal
4
disorders (Blackie et al., 1999). Some of the PRMDs were severe enough to threaten and even
end the players‟ careers before retirement age, and many developed physical handicaps that
impacted on all aspects of the musicians‟ lives (Scourfield, 1999).
Playing-related musculoskeletal disorders and other conditions caused by playing
musical instruments have been recorded since the early 19th
Century. Robert Alexander
Schumann (1810-1856) was in his 20s when he developed a disorder to his right hand from
some unidentifiable device for cultivating finger strength and independence (Howitt, 1995),
and ended his performing career during 1832 (Daverio, 2007). During the 1990s, a
concertmaster of a symphony orchestra took early retirement due to PRMDs which forced
him to end his performing career in his early fifties. In this case the focal dystonia was
causing an involuntary spasm of a muscle in the player‟s right arm. More than 20 medical or
peripheral treatments had been employed; from neurological to the Feldenkrais method, but
all failed (Scourfield, 1999). These are just two examples of many musicians whose careers
had been affected by PRMDs.
The nature and the potential consequences of PRMDs are unique to musicians as well
as to the individual instruments they play (Blackie et al., 1999). The piano has the capacity to
accommodate very difficult and complex music; the player often has to accomplish very
complex polyphonic music, sometimes with four to six parts of a fugue, frequently using all
10 fingers simultaneously. For example, the La Campanella Etude in B major by F. Liszt
(1811-1886) requires a constant interval over an octave and sometimes two octaves leaping
between the thumb and fifth finger of the right hand, with a speed of around 500 semiquaver-
notes per minute, or more than 8 semiquaver-notes per second, simultaneously with a very
difficult part for the left hand. Some pieces require extreme mental and physical endurance
and strength with a very lengthy performance. The Goldberg Variations by J. S. Bach (1685-
1750) for example, takes about 80 minutes to perform. One cannot possibly calculate the time
a pianist has to practise each day to reach the required standard of performance.
5
Moreover, on the 20th
Century acoustic concert-grand piano, the weight of every key
is regulated to the standard force around two ounces (62.0g) on its front edge (Crombie,
1995). For instance, in the Etude in G# minor Op.25 No.6 by F. Chopin (1810-1849), there is
a total of 928 chromatic parallel-third in semiquaver-notes on the right hand, and the player
has to complete playing the semiquaver-notes within 3.5 minutes on the right hand alone. The
player has to exert a collective force of near between 48.26 to 57.54 kilograms per minute, or
between 168.9 to 201.4 kilograms within 3.5 minutes. (This calculation did not include
dynamics of acoustic, velocity and gravitational factors). These seemingly impossible tasks
can lead to a physical breaking point and cause incredible stress to the musculoskeletal
systems of the body, especially in the hands and arms. Highly disciplined professional
pianists are likely to experience PRMDs to the hand and wrist due to the motions necessary to
play the instrument with strict regimen of practices (Blackie et al., 1999).
Specialized clinics for the medical problems of artists and musicians have opened in
New York, Boston, and San Francisco according to an article in the New York Times (The
New York Times, July 27, 1986). As a consequence of this field of interest, journals such as
the “Medical Problems of Performing Artists”, the “Performing Arts Health News”, and the
“International Journal of Arts Medicine” are now available, which discuss the risks and types
of PRMDs (Rogers, 1999). As medical intervention has become more accessible, the dialogue
between medicine and pedagogy specialists becomes increasingly active. Lister-Sink (1994)
in his „Rethinking Technique‟ stated that piano teaching was saturated with tradition; one of
the strongest practices was to carry on teaching the way as we had always been taught. The
one-to-one teaching method still dominates the studio-teaching environment at present day.
With the availability of education today, not only are more people interested in learning piano
performance for professional purposes as well as recreational needs, they often seek a
learning environment (with lower cost and leisure format) to suit their lifestyle. The 20th
Century development of electronic-keyboard classes and the possibility of multi-student
6
classrooms with one teacher can result in a lack of supervision for proper use of the hands
when playing piano, which may increase the risk of PRMDs. Brandfonbrener (1991) believed
that although PRMDs came from some studios of teaching more than others, it was rare that
PRMDs had a single origin. In order to find the root of the problem of PRMDs, one should
look at how students are taught when they begin to learn to play the piano.
The question still remains, as Lippmann (1991) pointed out earlier, that the factors
may be closely related to the misuse by both professional and non-professional players and
educators, in the manner of the habitual strategy of practices, motor-skills and movement-
techniques that were used. The complexity and multi-factorial etiologies of PRMDs are too
great for either the medical profession or the musicians to resolve alone (Spaulding, 1988). In
order to provide the players with preventative programs for PRMDs, the development of an
interdisciplinary approach is essential. Using effective treatment, promoting the
biomechanical energy efficiency of motor-skills, and encouraging pianists to develop healthy
practice habits, therefore, may ultimately reduce the incidence of PRMDs in the population.
Purpose of the Study
The purpose of this study was to gather and analyze information about professional
and non-professional piano players‟ daily habitual practices, playing postures, and movement
techniques used while playing. The study also investigated the degree of awareness of
PRMDs that existed within the population, and explored what interventions were used to
prevent and treat these problems. The questions addressed in this study were:
1) What was the incidence of PRMDs when using various playing-techniques (postures and
movements)?
a. wrist postures,
b. finger posture and movements,
c. elbow postures, and
7
d. shoulder postures.
2) Did players explore different movement techniques and playing-techniques throughout the
playing periods in relation to the incidence of PRMDs?
3) What was the frequency of PRMDs in different playing occupations (i.e., performers,
teachers and players)?
4) What was the incidence of PRMDs between professional and non-professional players?
5) What was the incidence of PRMDs when using the following practising strategies?
a. number of breaks within a daily practice session,
b. the length of break during a daily practice session,
c. the average practice-hours over seven days,
d. the number in years of playing, and
e. difference of practice hours over seven days in relation to the years of playing groups.
6) Were there any differences in practice hours over seven days between the groups with and
without PRMDs, when controlling for gender, piano as major instrument and different levels
of playing?
7) What was the difference in incidence of PRMDs in relation to players for whom the piano
was the major instrument compared to those for whom the piano was the non-major
instrument?
8) What was the frequency of PRMDs in different age-groups?
9) Was there a difference in the hand-span size of the groups with and without PRMDs when
controlling for gender?
10) Was there any difference with onset of PRMDs by playing certain piano techniques?
11) What was the frequency of PRMDs in different parts of the body?
12) What types of PRMDs did players experienced?
13) Where did players go to obtain treatment for their PRMDs?
14) Where did players obtain preventative information on PRMDs?
8
Significance
By investigating different motor-skills, movement techniques, playing postures, and
strategies of practice, the aim is to gain some insight into the occurrence of PRMDs; and to
determine whether motor-skills and habitual practices are associated with the incidence of
PRMDs. Data collected from the self-administered questionnaire during July to September
2006 (see appendix A: “An Investigation of Professional and Non-Professional Piano
Players‟ Playing Postures and Techniques”) may offer some clues for further investigations.
Furthermore, the results from the study may contribute toward the discovery of injury-free
piano playing and performance. The study will also promote the awareness of PRMDs. It
should, therefore, encourage educators to incorporate preventive programs for PRMDs into
the curriculum of piano pedagogical programs.
Limitation
Although the pilot study results indicated that the survey instrument is reliable (r =
.92), the data reflected the individual piano players‟ perception and application of playing
postures. Especially in defining postures, which had stimulated serious thoughts during
answering the questionnaire as to what kinds of posture actually had been applied when
practising. An investigation of various models of piano that were used in daily practice was
beyond the scope of the present study.
Definitions of Terms
Piano technique – refers to various types of scales, octaves, chords, arpeggios and
embellishment of piano music skills.
Playing-technique – refers to motor-skills, postures of upper limbs and movement techniques
of keyboard instruments.
9
Touch – refers to the way in which fingertip pulp, the soft tissue interface, modulates the
transmission of forces during contact of the finger with the piano keys to produce various
sounds.
Closed-kinetic chain – when both ends of an extremity are fixed, movement at one joint
within the chain produces predictable movement at all other joints (Prentice, 2001).
Open-kinetic chain – when only one end of an extremity is fixed, the distal segment of
extremity is mobile, and therefore, the movement occurring in other segments within the
chain is not necessarily predictable (Prentice, 2001).
Professional player – refers to the respondent who earns an income or part of an income from
performing and teaching.
Non-professional player – refers to the respondent who does not earn any income from the
playing.
Performer – refers to performing is the respondent‟s predominant activity.
Teacher – refers to teaching piano performance is the respondent‟s predominant activity.
Player – refers to the player who does not perform nor teach.
10
Chapter II
Literature Review
Introduction
The occurrence of playing-related musculoskeletal disorders (PRMDs) is almost
unavoidable when a given motion is highly repetitive, combined with the prolonged use of
body segments and without a proper understanding of the physiological limits of the human
body. The cause of PRMDs was not often due to a single origin (Brandfonbrener, 1991).
Interest in PRMDs has dramatically increased over the last three decades, with the journal
Medical Problems of Performing Artists evolving into a distinct medical specialty in response
to these concerns. All books, articles, and videotape series reviewed concerning PRMDs dealt
mainly with the treatment of these problems. Most articles discussed prevention of PRMDs
from the biomechanics and ergonomics point of view, but fewer discussed the correlation
between PRMDs and piano playing-techniques (Wristen, 1998). Even fewer articles
mentioned the piano instrument in relation to movement techniques and motor-skills. In order
to investigate further the causes of overuse and possible misuse in music PRMDs, it is
imperative to have some understanding of the evolution of the acoustic piano and the
development of playing-techniques and motor-kills. It is futile to analyze keyboard playing-
techniques and motor-skills that may cause the risk of PRMDs in players without knowledge
of the mechanical capability of different keyboard instruments and the consequent
development of certain playing-techniques.
Development of Playing-Techniques
Piano techniques were developed following the evolution of the piano instrument. The
pedagogical methods of motor-skills and movement techniques have consistently lagged
behind the innovative development of piano techniques in any given period. Part of this lag
11
has been due to the development of the piano itself (Norman, 1968). Players must use finger
force movements against the mechanical resistance of a piano keyboard. Compensational
application of a greater muscle effort to stabilize the finger joints would naturally occur when
the upper limbs exert more force against a heavier mechanical weight of the present-day
piano.
Published pedagogical methods of motor-skills and movement techniques have lacked
instructions on the proper use of the mechanical force generated by the upper limbs and body.
Without proper training in the use of an appropriate force, the upper limb muscles are unable
to respond adequately to the demands of piano techniques. Therefore, according to Tubiana
(2005a), imbalances in the strength of upper limbs and the rest of the musician‟s body is a
potential source of risk for PRMDs. Although there are various playing-techniques and
motor-skills in use at present, the two commonly applied playing-techniques can be
categorized as „traditional‟ and „weight‟ playing-techniques.
Development of Traditional Playing-Techniques
During the Baroque period of Bach and Handel, the mechanism of keyboard
instruments (clavichords, harpsichords and organs) required minimum physical strength for
their manipulation (Altenmuller, 2006). The movement and weight of the fingers alone were
sufficient to complete the task. Systematic writing of compositions for finger-exercises in
order to develop the necessary motor-skills for the acquisition of piano techniques was
evident in the Baroque period. The earlier clavier music (keyboard music), up to the time of J.
S. Bach, has the least of all demands for wrist work and arm force. While this method of
technical training was suited to the piano techniques and mechanical conditions of the
instruments of the time, it involuntarily caused much retardation in the development of
playing-techniques when the mechanics of the instruments changed. Greater physical exertion
was needed for instruments that had much greater manipulation of sound production and
12
speed. Despite the changes that had occurred, performers and teachers continued to base their
playing-techniques on previous methods (Fielden, 1961).
The piano began to assume a position of importance as a concert instrument during the
19th Century (Wier, 1940). This required an instrument that not only combined the fullness
and roundness of tone of the Viennese and the English piano, but also had facilities for speed
and repetition that would fill a large hall (Summer, 1966). Therefore, the double-escapement
action (i.e., repetition capability of the mechanism to increase the frequency of hammer
action) was introduced to the piano; it allowed greater scope with repeated notes (Norman,
1968). Meanwhile, composers were extending the piano techniques of their music outside the
scope of existing methodology, which contributed to the gap between demands of
performance and pedagogical knowledge (Norman, 1968). An example of such composition
would be Beethoven‟s Pianoforte Sonatas Opus 106, 109, and 111, where the players were
taught to use previous methods, which were generally written by theorists who were many
years behind the innovators‟ compositional achievement and instrumental techniques
(Spangler, 1950). Under such unreliable conditions, little accuracy of procedure was possible.
Such inconsistency between methods is apparent in a review of more than one hundred years
of piano teaching. François Couperin‟s L‟art de toucher le clavecin, published in 1716, was
one of the earliest methods of keyboard technique. This treatise offered finger exercises and
the common practice of embellishments for practical purposes. Muzio Clementi in 1801, in
his Introduction to the Art of Playing the Pianoforte, developed a style of playing which
exploited the characteristics of the piano, as opposed to those of the harpsichord (Crofron,
1986). However, the treatise did not offer instructions for the physical force production of
these finger-exercises. Many like them followed these early treatises during the eighteenth
and nineteenth centuries, mostly written by French and German pianists. The essential
drawbacks of the 17th
Century and 18th
Century methodology were that there was too much
13
emphasis on the finger movements and no consideration was given to biomechanical
constraints of the entire arm (Wristen, 1998).
Theodore Leschetizky (1830-1915) was a Polish-born teacher, pianist and composer.
“The Leschetizky Method: A Guide to Fine and Correct Piano Playing” (Brée, 1997)
promoted the idea that the forearm is held in position by the upper arm muscles, and is
withdrawn or held up rather than being allowed to drop or relax on the keyboard. Thus finger
flexion is opposed antagonistically to extension as well as to the gravitational force (Figure
2.1). The hand and fingers should keep a noticeable arched shape that would give a full
strength in the finger-touch. Leschetizky also stated that the fingers should be raised a
centimeter more above the surface of keys before depressing them (Brée, 1997). The raising
finger-touch technique would greatly increase energy consumption and promote the early
onset of fatigue.
Figure 2.1. Traditional playing postures (i.e., Naïve-playing).
With this technique, the wrist is fixed in a neutral or a flexed position. Some activities
of flexion that are possible against the resistance of the keyboard are replaced by activation of
the extensor muscles. Thus, the fingers are raised by means of extensor muscle activation,
where early fatigue and pain frequently occurs. The joints of shoulder, elbow, and wrist are
also fixed in a position that inhibits mobility (Hmelnitsky and Nettheim, 1987). The
traditional playing-techniques and motor-skills were geared to the mechanical action of
clavichords, harpsichords and organs rather than the present piano.
14
During development of the early generation of piano, Carl Czerny (1791-1857) was a
principal promoter of the technical playing approach using the fixed hand position with
emphasis on finger movement. Czerny was a student of Beethoven and had been schooled in
the Clementi method of teaching (Norman, 1968). Czerny composed hundreds of studies
based on different piano techniques. Each study was written so that it required a considerable
amount of drill on the emphasized technical difficulty. The purpose of this kind of repetitive
drill is to train the fingers to cope with the various difficulties of piano techniques, as well as
to develop muscular abilities of the finger actions to the point where they become automated.
The metronome apparatus for controlling the evenness of playing speed came into
existence in Czerny‟s lifetime to assist with achieving accuracy of musical tempo, and Czerny
was among the first to make use of it (Norman, 1968). Czerny‟s method of extensive technical
development resulted in virtuoso performances, and he is known today for his teaching of
piano techniques. In fact, his technical exercises (i.e., the composition of studies) are still used
today for training purposes. Czerny‟s pedagogical technique produced many virtuoso pianists
during his lifetime, including Franz Liszt (1811-1886), one of his most famous pupils
(Crofron, 1986).
Development of Weight Playing-Techniques
Musicians, however, wanted a louder piano with better tone and greater dynamic
response. During the early 20th
and continuing to the 21st Century, the touch weight of piano
keys is approximately 52g with a full size pitch range of 88 keys, and a frequency range from
27.5 Hz to 4.2 kHz (Cromdie, 1995). The piano could produce the largest range of frequencies
of any acoustic musical instrument, with the exception of the pipe organ (Williams, 2002).
The full size concert-grand piano alone, could entertain an audience of three to four thousand
in a concert hall, and this prompted the pedagogical theorists to rethink the playing-techniques
that had been employed in the past. Although Ludwig Deppe (1828-1890) did not belong to
15
the 20th
Century, his ideas laid the foundation for 20th
Century pedagogy. Deppe was the first
to describe coordinated arm action in piano technique (Wristen, 1998). He believed in
distributing the effort of piano playing over every anatomical part, from the shoulder down to
the fingertips. Deppe recommended sitting in a low position that allowed the elbow to be
placed below the keyboard level, and playing with the tip of the fingers. Forearm motion at
the elbow gave force to the action, while the wrist and hand were to be kept „light‟ (Wristen,
1998). He was opposed to the use of extreme extension of the metacarpophalangeal joint, but
recommended using laterally flexed wrist movements. The finger muscles were to cooperate
with the muscles of the entire upper limb, and the larger muscles of the upper body were to
provide strength, with the goal being to apply uninterrupted motions when playing (Wristen,
1998). Deppe‟s approach differed from the traditional-playing method in that the arm was
developed as well as the wrist and fingers. Emphasis on the flexibility of the entire playing
apparatus marked a contrast to the traditional rigid hand position (Norman, 1968).
The fourth finger might move when the third finger played and the fifth finger might
similarly move during the playing of the fourth finger owing to the sharing of the extensor
tendon of the fourth and fifth digits. Leschetizky (1830-1915) believed that suppression of the
above motion might lead to injury (Boardman, 1954). Where fast repeated action was required
of the fingers, Leschetizky advised moving the finger from the metacarpophalangeal joint
while maintaining a stabilization of the hand, and with a flexed and loose wrist (Boardman,
1954).
Josef Lhevinne (1874-1944) believed that in learning to produce a „singing‟ tone on
the piano, the player should poise the hands about two inches (~5cm) above the keys, then
allow the hands to fall a little with the peripheral interphalangeal joint leading the way. As the
hand descends, the fingers are curved naturally; and when the finger touches the key surface it
feels as though it is grasping the key with the largest possible surface of the fingertip, not
hitting or striking it. Lhevinne thought that hitting or striking strokes prevented a „singing‟
16
tone. Meanwhile, the wrist should remain very flexible so that the weight of the descending
hand and arm carried the key down to the key-bed without banging upon it, and the wrist
ought to be so loose that it normally sinks below the level of the keyboard as the key is
depressed (Lhevinne, 1924).
Franz Xaver Scharwenka (1850-1924), a German pianist and composer, deplored the
misuse of the relaxation principle, and regarded it as being as „disastrous‟ as the over-
stressing of rigidity (Norman, 1968). According to Scharwenka, the participating limbs should
be relaxed, except to the degree of fixation necessary to perform any given passage. His
approach to piano technique was a balance between tension and relaxation of the muscles
when playing (Norman, 1968). Scharwenka advised that the arm should hang through its
length from the shoulder. The use of falling, throwing and swinging motions in octave playing
was encouraged, and Scharwenka suggested implementing these motions in order to achieve
the freest motions in the elbow joint (Spangler, 1950).
The development of the piano instrument together with virtuosi literature of the 19th
Century had stimulated the advancement of piano playing-technique. Both Breithaupt and
Matthay reached a high level of finger-technique of the Stuttgart School. Rudolph Breithaupt
(1909), the German founder of the school of weight- and relaxation-playing skills, realized the
importance of using the arm. His two major works, The Natural Piano Technique, and School
of Weight-Touch, criticized the incorrect use of high fingers and a low, stiff wrist, favoring
instead a higher wrist with naturally curved fingers. The goal was free-falling arm weight and
complete relaxation, a contradiction of the earlier technique, with no concern for finger
articulation (Rogers, 1999).
In order to explain the weight playing-technique, Heinrich Neuhaus (1973) in an
attempt to help the pupil understand and experience the freedom of playing, compared the arm
from shoulder to fingertip with a hanging bridge, one end of which was fixed to the shoulder
joint and the othe attached via the fingers onto the keyboard. The bridge (i.e., the upper limb)
17
was flexible and resilient, whereas its support was strong and firm (Levinskaya, 1930; Gat,
1958). This technique is depicted in Figure 2.2.
Figure 2.2. Weight playing posture.
As Hmelnitsky and Nettheim (1987) explained, the finger that was presently playing
was strongly flexed. This action provides a gripping force tending to keep the fingers in
contact with the keyboard. The forearm is allowed to fall (Hmelnitsky and Nettheim, 1987) as
flexion of the distal interphalangeal joints actively grip against the keyboard allowing the arm
to hang passively from the shoulder, using a closed-kinetic chain playing-technique (Figure
2.2). This is contrary to the traditional playing-technique in which the forearm is withdrawn
from the support of keyboard (i.e., resulting in an isometric contraction by the muscles of
upper arm and shoulder, using an opened-kinetic chain playing-technique). Extension of the
wrist position allows the finger-flexion to be at its strongest (Li, 2002). The wrist extension
position is achieved by gravitational force acting upon the forearm, while the flexor muscles
maintain the integrity of the metacarpophalangeal joint. Upward wrist movement is achieved
by increased flexion against the resistance of the keyboard. This may contribute to strain on
the tendons, which may in turn lead to carpal tunnel problems (Hmelnitsky and Nettheim,
1987). The weight playing-technique may be applied to the majority of piano techniques with
an occasional exception when, for example, in playing a full chord, the player uses a fixated
wrist together with the triceps brachii muscle supplying additional downward force, as a
synergist to the gravitational force. The immediate release of tension in the musculoskeletal
18
system of the upper limb after the sound was produced is also a characteristic of weight
playing-techniques.
Otto Ortmann (1889-1979) was the first to apply the principles of physics together
with an understanding of human anatomy, to undertake a scientific study of piano techniques
and playing skills (Wristen, 1998). In Ortmann's (1929) publication, he described the
physiology of playing-techniques. Movement of a joint is constantly determined by expansion
and compression, extension and contraction of physiological tissues, which cannot occur with
equal ease, or against equal resistance, throughout the range of motion of the joint. The
movement was easiest and smoothest near the middle of the joint range, increasing in
difficulty and awkwardness as it approached either extremes of the range (Ortmann, 1929).
This was the basic position of reference, and was useful for the purposes of orientation,
although it was seldom applied intact for any length of time in actual piano playing, because
completing the given task involved movements beyond and through the mid-range position
(Ortmann, 1929).
The near neutral position of the wrist was developed further by Neuhaus during the
mid 20th
Century. With the wrist slightly extended to allow the arm to fall, the back of the
hand ascends toward the metacarpophalangeal joint, each finger-joint is flexed, and all joints
move through an approximate mid-range, thereby permitting maximum accuracy with
minimum fatigue (Gat, 1958; Neuhaus, 1973). Chung (1992) tried to identify the required
range of wrist movements of nine pianists using biaxial electrogoniometers during their
playing of standard piano techniques of trill, arpeggio, octave, and broken octave. The author
compared wrist motions of pianists trained under the weight playing and traditional playing-
techniques. Chung (1992) found the average weight playing pianists' wrist-motion, during the
exercises of classical music, to be less than that of traditional-playing pianists, although
weight playing pianists showed greater flexion-extension activity in arpeggios and trills.
Traditional-playing pianists tended to exhibit increased radio-ulnar activity.
19
The Levinskaya System
Maria Levinskaya (d. 1960) (Russian School) worked at perfecting a system to
incorporate the best features of the traditional finger methods and those of the weight school
exemplified by Breithaupt (Gerig, 1974). In 1930, Levinskaya published a work on the
complete circle that embodies the art and science of piano playing. This was presented as the
Levinskaya System (Levinskaya, 1930). Both advantages and possible disadvantages in
traditional playing-techniques and weight playing-techniques were analyzed in her system.
Levinskaya‟s concern for flexibility of the entire playing apparatus was contrasted with the
traditional rigid-hand position; and the disadvantages of exaggeration of arm movements and
lack of depth and intensity of tone when applying weight playing-techniques was also
analyzed (Gerig, 1974). She concluded that the order for training must proceed from finger
control and arm control (i.e., traditional) up to a point before the application of weight
playing-technique (G.G., 1930). It has been said, however, that although Maria Levinskaya‟s
approach is commendable, without any scientific experiment any benefits can only be viewed
as anecdotal experience (Seashore, 1967).
The reviewed literature indicates that piano playing-techniques developed over a
period of time, but not exactly in parallel with the development of the piano and the literature
of music at the time. The attitude toward the piano playing-technique during the 20th
Century
was drawn from many areas of physiology, motor-learning, biomechanics, ergonomics and
the empirical methods of the past; and by using the functional application of science in order
to understand fully how the physical act of playing can be achieved with greater ease.
Instrumental music performance requires a constant conscious control in manual
activities, and the intimate collaboration between the brain and the hands does not allow for
any distraction. The hands become the messenger of players‟ ideas of musical interpretation,
and they are threatened by many traumatic processes of misuse and overuse (Tubiana, 2005b).
Without the input of scientific knowledge, the occurrence of PRMDs was inevitable.
20
Motor-Skills and Playing Postures
During the 18th
and early 19th
Centuries, when piano playing-techniques were
developing, the early generations of the piano possessed a much lighter mechanical action,
with a relatively small body of resonant sound (Altenmüller, 2006). The players were taught
to use only finger playing-techniques. At this time composers wrote extensive music
compositions with piano techniques for players to develop impressive skills and dexterity for
the performance. Although this may have worked well with the smaller and lighter keyboard
instruments of that time, it is not well suited for the present acoustic piano.
By the late 19th
Century, greater finger force was needed to strike the key. The wrist
motion and arm weight of weight playing-technique that combined with finger force of the
traditional playing-technique were needed for tone-production and resiliency to embrace the
modern acoustic pianos, which are equipped with greater string tension, heavier mechanical
action, and bigger sounding bodies (Lee et al., 1990). Lee and colleagues (1990, p. 76)
advocated the “joint mobility and hand weight were the only two ergonomic aspects found to
be associated with temporal and polyphonic control [i.e. spatial] in the playing of the scale
exercise”. Pianists with greater wrist mobility played the passage with faster tempo than those
with rigid wrist joints. Lee and colleagues also stated that there was a high correlation
between wrist mobility and evenness of dynamics and articulation.
Since the early 20th Century, there have been publications by famous pedagogues who
approached piano technique via anatomical, physical, and physiological analyses. As a result,
various piano playing-techniques have been brought to the field of debate (Matthay, 1932;
Ortmann, 1929; Gat, 1958; Neuhaus, 1973).
In the early 20th
Century, a developing interest in biomechanical functions of the body
as critical factors in piano teaching technique began to emerge, with the motions of piano
playing-techniques and motor-skills being assessed in a scientific and objective manner.
Although some of the playing-techniques have been validated by scientific observation, many
21
of these playing-techniques were founded on an incomplete or even incorrect knowledge of
anatomical motions (Wristen, 2000). Most of the primary sources of technical motor-skills
were based on top performers‟ subjective experiences, and although some anecdotal
knowledge may prove helpful, many of them were without scientific basis (Wristen, 2000).
Tone Production
In the early 1900s in England, Tobias Mathay (1858-1945) summarized the relationship
between touch (i.e., the way a finger-tip generates force to depress a key) and tone (i.e., the
character of the sound achieved in performance on an instrument) (Randel, 1978). Mathay
classified playing touch techniques into three different anatomical locations: pattern (1) =
exertion of the finger at the metacarpophalangeal joint, pattern (2) = exertion of the hand at
the wrist joint, and pattern (3) = arm weight produced by relaxing the supporting muscles
(Sakai et al., 1996). The third method appeared to provide better control of touch for a modern
acoustic concert grand piano and appeared to be the most efficient playing-technique if
combined with the finger works of the traditional playing-technique.
Matthay claimed that the tone-producing action was not applied until after the arm, or the
hand, or the finger arrived at the key. The force was produced by the fingertip at the moment
of key depression; and the weaker intrinsic hand muscles should continue holding the note
after the key had been depressed (Matthay, 1932). Theoretically, this would allow the long
muscles of the forearm to rest, once the key was depressed, and the forearm and hand would
thus feel free of tension.
In Matthay‟s view, the intrinsic muscles of the hand served as the basis for moving the
finger, and the muscles of the forearm provided hand movement. No tone can be produced
without the exertion of the finger, but a tone can be supported by exertion of the hands or
exertion of hands and arms. Matthay identified two forms of finger movement: (1) a grasping
22
motion, and (2) a reaching motion. When the finger is raised in an extended position, the
finger curves naturally when descending to the key (Matthay, 1932). In order to achieve
energy efficiency, economy of motion is required to limit hand and arm movements only to
the area or areas that produce a given tone (Norman, 1968).
Matthay, in his second edition, identified six ways to use the arm, as follows: (1)
suspended-arm; (2) forearm rotation; (3) the forearm-weight alone released for light tone
effects; (4) the whole arm fully released during the act of tone production for „singing‟ and
chordal effects; (5) forearm downward exertion combined with upper-arm weight release for
loudest tone effects; (6) upper-arm forward motion with forearm downward exertion to be
only used for special effects (Matthay, 1964). The sixth way of using the arm, pushing the
upper arm forward along with a downward motion by the forearm is a major cause of bad
tone-production and should be avoided (Wristen, 1998). Matthay was against the use of „free-
fall‟ of the arm, and believed if the arm was „dropped‟ onto the key, the player could not
control how much force was applied to produce the desired tone.
Ortmann (1929) systematically explained the mechanical function of the whole arm
with a series of experiments. He stated that where one or two joints might be in full relaxation
between the fingertip and the shoulder girdle, to maintain the fingertip in a fixed position on a
key, all other joints should be fixed at least to the extent necessary to overcome the weight of
the intervening joints. Sakai and colleagues (1996) stated that tendon excursion and joint
movement are intimately related. The effect of tendon excursion is to influence and
coordinate the motion of joints along the kinetic chain of the upper limbs. To move the co-
contraction of the musculoskeletal joint system that is responsible for keeping the hands on
the keyboard toward the distal part of finger or hand, when playing the piano or the
pianissimo passages, maintains the balance of upper limbs. Lippmann (1991) believed that the
reciprocity in recruiting distal versus proximal muscles of the upper limb is maintained
throughout the whole dynamic range from pianissimo to fortissimo when playing piano and a
23
very soft touch requires maximum control. This theory agreed with the experiences of many
top pianists and although the anecdotal evidence was practical and commendable, it still needs
scientific experiments to prove that it is reliable.
Whiteside (1955) stated that the center of the body controlled the periphery; so the
upper arm and its connection to the torso should control the action of the fingers. Only when
the upper arm is actively involved in sharing the production of tones, may full speed and
power be achieved without the overburdening of small muscles. The author believed that
overburdening the small muscles can frequently produce a crippling strain as well as
inadequate facility. Conversely, over-recruiting the muscles by using inefficient playing-
techniques can also cause unnecessary strain on the musculoskeletal system of the upper
limbs.
Tubiana (2005a), in a series of three articles, stated that instrumental musicians adopt
positions and develop movement techniques to facilitate their playing without considering the
physiological balance of the muscles or joint biomechanics of the whole arm. Many positions
of the upper limbs used may put the musicians at risk for the development of PRMDs. The
upper arm together with the forearm are the vector of the hand, and the mechanical function
of the entire upper limb is geared to optimal use of the hand and fingers, which provide the
functional purpose for sensory information and execution (Tubiana, 2005a). This means that
one cannot complete the playing tasks without involving and considering the use of the entire
apparatus of the upper limbs. The important point being made here is to use the most efficient
force production of playing-techniques to integrate the entire apparatus of the upper limbs, so
as to achieve the desired results regardless of whether the muscles and joints are actively
involved or participating passively with certain parts of the upper limbs and body.
24
Movements of Hands and Arms
Ortmann (1929) pointed out that the multi-planar movements were compounds of
movement in single planes, and that curved movements were angular movements in an
infinite number of planes. The principle was the same as that which considered the circle as
being made up of an infinite number of triangles whose bases were straight lines. The
mechanical disadvantage of angular movements was that they required abrupt changes of
direction, whereby a sudden mechanical readjustment became necessary; this caused the
muscles to constantly accelerate and decelerate to accommodate the angular direction of the
movements, with sometimes an impossible tempo, thus consuming greater energy (Gerig,
1974). Therefore, in the field of movement mechanics, smooth and steady movements that
involve multi directions were movements in curves (Gerig, 1974). In his experiments,
Ortmann (1929) observed that pianists used the arm in addition to the fingers in fast repetitive
motions, and that the natural response of a coordinated mechanism was for a larger lever to
automatically take over in assisting the rapidly moving smaller muscles. He evidently
believed that this was a natural physiological response in order to avoid muscle fatigue
(Rogers, 1999).
Norman (1968), in his doctoral dissertation, suggested that the development of piano
pedagogy could be divided into three major categories:
1) The primary emphasis of finger action and the set position of the hand were the technical
approach carried over from the early (pre-piano) keyboard instrument to the early piano.
2) The fixed position of the hand was replaced by the flexible position, and technical
emphasis moved away from the fingers and hand to the shoulder and arms.
3) A scientific approach to technique replaced conjecture about the playing apparatus with a
physiological analysis of what was taking place.
Norman had also suggested that a fourth category existed, which selectively drew from all
three abovementioned areas when the need arose (Norman, 1968).
25
Varying Tensions with Different Positions of the Wrist Joint
Savage (1988) argued that the „minimal active tension‟ (i.e., the least active force to
produce movement) in the flexor muscles of the wrist position just exceeds the passive
tension in the extensors (see Figures 2.3 & 2.4). The author attempted to measure the passive
tension in the extensors, which is the same or almost the same as the „minimal active tension‟
in the flexors. The results showed that the passive tension in the wrist/finger extensor muscles
had a greater effect on the „flexion force‟ of the flexor muscles of the wrist/finger than the
passive tension in the intrinsic muscles (Savage, 1988).
Figure 2.3. The passive tension in the extensor muscles is low when the wrist is in an extended posture.
Figure 2.4. The passive tension in the extensor muscles is high when the hand is in a flexed posture.
Savage (1988) further stated that with the wrist extended and the metacarpophalangeal
joint flexed, as is shown in Figure 2.3, the passive tension in the extensors would be lower
because the extensor muscles are short. Therefore, the „minimal active tension‟ in the flexors
will be correspondingly lower. By the same token, the position in Figure 2.4 shows that when
the wrist and metacarpophalangeal joints are fully flexed the passive tension in the extensor
26
muscles will be high because the extensor muscles are elongated and as a result, the flexion
force of the interphalangeal joints may be reduced. The outcome of Marras' (1992) study
revealed a positive correlation between greater acceleration of flexion and extension
movements at the wrist, which could lead to a significant increase in the risk of developing
carpal tunnel syndrome and wrist disorders.
Finger Position
Improved piano playing skills should lead to efficiency in force-production and
motion-economy in the finger and the forearm movements (Altenmüller, 2006). Ortmann
(1929) believed that the fleshy part of the fingertip was best for striking the key, and the
easiest range of action for the three finger-joints may be determined to be near the middle of
the joint-range of all fingers. Harding and colleagues (1989) reported a 68% difference in
force production at the fingertip at various velocities between experienced players and less
experienced players. Harding and colleagues believed that joint forces could be minimized
through developing proficiency of playing-techniques. There were two arbitrarily selected
finger positions illustrated in Figures 2.5 and 2.6 in Harding and colleagues‟ (1989) study. A
reduction of finger tension was achieved by changing from the position shown in Figure 2.5
to that shown in Figure 2.6, as a result of increased flexion angles at the distal interphalangeal
and proximal interphalangeal joints and a decreased key contact angle (Harding et al., 1989).
Figure 2.5. Position 1 using a straight finger posture
27
Figure 2.6. Position 2 using a curved finger posture.
Hmelnitsky and Nettheim (1987) stated that the „interossous hood‟ (for anchoring
expansion to palmar ligament) migrates proximally during digital extension and distally
during digital flexion. When the finger that is currently playing is bearing the weight of the
forearm, the extensors in the forearm thus contribute only as weak accessories, so Hmelnitsky
and Nettheim believed that a prime cause of overuse syndrome was thus removed.
Tubiana (2005b) stated that each finger has independent motion, but must be
constantly re-equilibrating with the entire hand. This equilibrium was maintained and
stabilized through the extensor carpi ulnaris and abductor pollicis longus muscles, and
preserved by the longitudinal and transverse arches of the hand between the thumb and fifth
finger. There is a growing interest in finding ways to accomplish all activities of playing an
instrument that place a minimum amount of strain on the structures of the upper limbs.
Elbow Position
The elbow position may also affect the strength of the handgrip and the finger action.
Placing the elbow at 30º to 40º flexion angle gave the optimal position of the joint for playing
movements (Ortmann, 1929). Mathiowetz and colleagues (1985) tested 29 females and the
results revealed that grip force was significantly higher when the elbow was in a 90º flexed
28
position than when it was fully extended. There was a similar result for the key pinch strength
when the elbow was placed in 90º flexion. LaStayo and colleagues (1995) investigated
dynamic forearm rotation with isometric grip in real time, and showed that grip strength does
not significantly decrease when moving from a neutral wrist-forearm position throughout a
70º supination and a 70º pronation range of positions.
Shoulder Position
An elevated shoulder position commonly occurs when performing under a certain
degree of mental and physical stress (Tornqvist and Kilbom, 2001). Additionally, the patterns
of movement could also result in unnatural motion, with joint positions that are not usually
employed during everyday life (Heijink and Meulenbroek, 2002). In piano playing, the cause
of neck and shoulder pain could be the sustained use of an elevated shoulder posture and
awkward neck postures (Hagberg et al., 2005). Long-term playing with a raised shoulder
posture (i.e. holding an isometric contraction of levator scapulae and trapezius muscles) can
put pressure on the roots of the brachial plexus, which give rise to the ulnar, radial and median
nerves (Moore and Dalley, 1999). This may cause the early onset of fatigue, reduced
flexibility of the hands, lessened dexterity of the finger movements, and reduced control and
endurance of the muscles of the upper limbs.
Different Motions under Different Playing Conditions
A study examined whether there were differences in the motions employed by pianists
when sight-reading as opposed to performing repertoire (Wristen et al., 2006b). During the
tests, two completely different styles of music (Jazz and Romantic) were played by the same
person using the same playing-techniques. The results indicated that the subject‟s motion was
less efficient in sight-reading tasks (i.e., non-prepared tasks) than in the repertoire tasks (i.e.,
prepared tasks) (Wristen et al., 2006b). The differences in physical movements may have
29
resulted because of the different types of music rather than the experimental condition. It may
have been more beneficial to use the same piece of music applying different playing-
techniques to investigate the differences in motion-economy that were used to complete the
same task.
Although there are individual differences among instrumentalists, all humans are
basically constructed in a similar way. Therefore, it is possible to generate standard principles
of biomechanical techniques and outlines that may be applicable to all players, which may
potentially aid in building a foundation of appropriate motor-skills that lower the incidence of
PRMDs by avoiding potentially harmful motions (Wristen, 2000). However, although a
standard scientific model of motor-skills and movement-techniques are necessary tools to
complete the playing tasks, individual anatomical differences may still play a crucial part in
the ultimate success or the failure of a performance. It is necessary to understand these
differences in order to adequately adapt to the situation when it is needed.
Players should aim to develop an optimum playing-technique with the motor-skills
that integrate coordinated motions with biomechanical efficiency. In so doing, this will allow
the forces to be distributed throughout the body and limbs instead of being localized.
Reducing angular movements allows tendons and muscles to stretch gradually and smoothly,
avoiding impulse loading. The kinetic motions of the entire forearm in a playing task utilize
the momentum in circular motion including the use of gravitational force (Wristen, 2000).
Functional Differences
Considerable differences exist in structure and performance, both within and between
people (Meinke 1995). These differences can appear in performances, on different days and
even at different moments within a day. Variations in force production, for example, are due
partly to the variations in both static and dynamic anthropometrics (Niebel, 1988). Musical
performance is a skilled and demanding task; it involves serial execution of a sequence of
30
notes. The upper limb movements in instrumental performance are also subject to
biomechanical and neural constraints (Alternmüller, 2006). Several factors affect response-
time (i.e., procession and execution of required task), among them age and gender. Also, as
work demands higher precision or increases in difficulty, or the environment becomes more
adverse, the response-time will vary within and between people (Niebel, 1988). There is
variation in both the muscle strength and motor-skill of the force production among human
beings. In addition, the differences in psychological reaction to the various performing
situations will result in varying force production despite the differences due to individual
anatomical (Anson, 1950), environmental, and occupational factors. Therefore, the
comparison of task-forces should be based on the results of research obtained from
participants taken from a representative population of a particular task being studied.
Reports on musicians‟ pain and PRMDs have alerted medical doctors as well as
pedagogues to recognize the need to address proper use of the body and the mind of the
instrumentalists. Researchers have investigated the ergonomic factors of keyboard players
(Wagner, 1984; 1988; Lockwood, 1988; Middlestadt, 1989), and showed that piano players
visited doctors for PRMDs more frequently than other instrumentalists, and that females
developed problems more often than males, suggesting that the smaller hand size may be a
factor. These findings suggest that further examination of hand size and shape, together with
the biomechanics of movements in relation to music performance may be of importance to
healthy musical training and prevention of PRMDs (Lee et al., 1990).
Hand Size
On the basis that one standard key size of piano fitted all players from children of four
years of age to adults and all body shapes and limb lengths, the arrival at a hypothesis that
small hand size was a possible factor associated with PRMDs is not surprising. Yet, both
31
recent and past studies fail to support the corollary that the larger hand with long fingers had
fewer technical difficulties and fewer PRMDs than players with smaller hands.
Anatomical variation in hand size is very common; making each hand unique as far as
function is concerned (Sforza et al., 2003). Wagner (1988) obtained an overall view of the
variation of hand size and joint-range in professional pianists. His study showed negative
relationships between hand size and the mobility of joints, concluding that the mobility of
joints and the ability of finger spans had a positive correlation with success at piano
performance, but not the hand size or shape (Wagner, 1988).
Lee and colleagues‟ (1990) study examined the relationship between the functionally
defined, hand ergonomic variables and specific piano-touch variables of the performances of
two different types of piano technique. The study also found that the size of the hand had little
influence on touch control for the pianist. Instead, when playing scale exercises, wrist
mobility had a relatively high correlation with evenness of dynamics and evenness of
articulation, as did hand-weight (Lee et al., 1990).
In Ong‟s (1992) survey, which had 53.7% overall prevalence of PRMDs among the
student population, general hand flexibility did not correlate with the tendency to develop
PRMDs, and did not support the hypothesis that students without PRMDs have larger hand-
spans. Although Tubiana (2005a) surveyed only 14 participants, once again the results
showed that the participants with bigger hands reported a 100% injury rate, whereas an 83%
incidence of PRMDs occurred within the smaller-hand group.
It is also true that hand size will affect the motions when playing piano; in particular,
the motions of lateral adjustment at the wrist. In general, the small hand will need a greater
degree of radial and ulnar deviation when playing (Wristen, 2000). The amount of required
extension is greater for players with smaller hands, and it may simply be that pianists who
experience greater difficulty in reaching certain intervals of music need to practise more, thus
32
possibly leading the small handed players to a greater risk of PRMDs. Since a smaller hand
has to stretch more for the playing tasks, muscle fatigue might occur more readily.
On the contrary, the bigger hand in its naturally relaxed form, significantly reduces
the proportion of time that the muscles are activated and may, in turn, increase the endurance
of the muscles (Donison, 2000). However, the oversized hands with thick fingers often have
difficulty fitting in between the two black keys. When playing close interval chords, the
players with oversized hands also experience difficulty placing their fingers comfortably.
A particular piano model with a slightly smaller keyboard and narrower keys was
produced by Steinway & Son piano manufacturers, but it proved unpopular (Winspur, 2003).
The present full-size acoustic pianos are commonly presented with a keyboard of 88 notes
which spans 48 inches, and this feature remains the same throughout the world. It is
impractical for piano players to practise on instruments of different size because at present, no
performance venue is prepared to keep pianos with different key-width sizes just for the
smaller handed players. Moreover, the majority of players cannot afford to carry their own
individual instrument wherever they travel.
Wristen and colleagues (2006a) examined whether the use of a 7/8-keyboard
contributed to the physical ease of small handed pianists compared with the conventional
piano keyboard. Although the narrower key-width led to perceived ease and better
performance, whether the 7/8-keyboard would reduce the frequency of PRMDs in small
handed players is still unknown. If playing-technique is a key contributing factor, the narrow
7/8 size keys might only postpone the occurrence of PRMDs. The present study used ≥ 20.1
cm hand-span size instead of > 22 cm to define the „big‟ hand size, as classified by Wristen
and colleagues (2006b). The 20 cm hand-span (from the tip of the 5th
finger to the tip of the
thumb) can comfortably complete the task of octave interval playing on the piano. The octave
is a big interval and is most frequently used in piano compositions. Whether the hand size
does influence the rate of incidence of PRMDs still remains to be seen.
33
In the early 20th
Century, Ortmann had already pointed out that differences existed in
adult hands, and similarly in the hands of children of various ages and various stages of
growth. These differences should be carefully considered in the assignment of tasks, allowing
wide variations in the manner of playing or fingering a passage in order to adapt it to the
physiological nature of individual hand, wrist and arm (Ortmann, 1929). Also, such
adaptation is frequently influenced by the formation of an individual hand. Human
morphologies vary (Anson, 1950), and all bodies have idiosyncratic differences. However, at
the most basic anatomical level, our bodies are constructed in a similar form, and one study of
the basic tasks of finger ability had found there was no difference between male and female
pianists (Aoki et al., 2005). Each anatomical part has biological tolerances, and when these
tolerances are exceeded, PRMDs can occur. So far, hand sizes have not yet shown any direct
link to the incidence of PRMDs, whereas playing time, practice habits and practice methods
used when playing may offer some further clues.
Playing Time, Practice Habits and Practice Methods
Evidence of PRMDs suggests that musicians unintentionally subjected themselves to
the stresses of highly repetitive movements, difficult playing-techniques, excessively long
hours of practice with awkward positions, and the psychological anxiety to achieve an
excellent level of performance. As a result, instrumentalists suffer a number of physical
disorders, some severe enough to threaten careers (Scourfield, 1999) and many have been
scarred with psychological difficulties that filter into all aspects of the musician‟s life (Blackie
et al., 1999). Take the historical case of Robert Schumann for example, who permanently
injured his right hand after using an invented device that was intended to strengthen the
fingers of his right hand (Howitt, 1995). A sensationally talented pianist, Paderewski injured
his right hand and was unable to use the fourth finger during an extended concert tour of the
United States in 1881, yet completed 107 concert performances in 117 days. He finished his
34
tour by using different fingering to avoid using the injured fourth finger (Brandfonbrener,
1986).
Further risk of additional or exacerbated injuries may result from ignoring or adapting
to pain (Blackie et al., 1999). This situation often leads to activating different muscles to
execute the movement that continues to inflict the involved joints and limb, which were
already suffering pain. Playing time, practice habits and practice methods are all closely
related with player‟s physical and mental capabilities and with one purpose that is to complete
the designated tasks. Any methods that violate the tolerance of human physical and mental
capacities may result in tissue or system failure.
Playing Time
Music students seeking performance level qualifications usually practise from three to
six hours per day. During the exam period, students may practise for excessively long hours.
Much of the practice is extremely repetitive with difficult passages; the aim being to gain
absolute accuracy, security of motor memory, musculoskeletal endurance, and ease of
execution (Fry, 1987). Fry stated further that there was a correlation between the onset of
symptoms and an increase in the time and intensity of practice (Fry, 1987). Additional hours
of practice were usually due to studying a new piece of music or a set of unfamiliar and
difficult exercises, and also during examination periods, preparing for a recital or for a
competition. The onset of symptoms may also occur when changing to a different teacher who
applies different playing-techniques together with the associated psychological tension.
A population-based telephone survey (Morse et al., 2000) was conducted to obtain the
prevalence of hand, arm, and neck pain of musicians. The results showed the highest (48%)
incidence of pain was among those who played 5-9 hours per week, followed by 20 hours or
more (42%), 0-4 hours (24%), and 10-19 hours (18%). Overall, 29% of all musicians
indicated that they suffered from a significant pain (Morse et al., 2000).
35
In Chong and Chesky‟s survey of keyboard players, where the majority of participants
reported daily playing time of less than three hours, the incidence of PRMDs was 57%. While
36% of respondents reported between three and five hours practice time, the incidence rate
among the whole group was 63%. Less than 10% of respondents reported over five hours of
daily playing time, with a PRMDs incidence of 52%, which was significantly less than those
whose playing time was much shorter (Chong and Chesky, 2001).
Although the results of Chong and Chesky‟s (2001) study showed a higher incidence
of PRMDs than Morse and colleagues‟ (2000) study, both revealed that greater hours of
practice per week did not yield the higher incidence of PRMDs. This indicates that long hours
of practice alone may not be the only risk factor for the occurrence of PRMDs.
Practice Habits
According to Gilbreths‟ law of motion economy (Gilbreth, 1911) when moving hands
from one end of the piano to the opposite end, applying continuous curved motion is
preferable to straight-line motion; the latter involving sudden and sharp changes in direction.
Niebel (1988) stated that greater time is required when making an abrupt 90º directional
change. Niebel further pointed out that continuous curved motions do not require
deceleration, and consequently are performed faster per unit of distance. This knowledge may
help musicians to understand how to develop habits of energy efficiency by applying circular
motion into daily practice of playing-techniques.
The intrinsic muscles of the hand carry out all the manipulations needed to maintain
finger posture and to convey them from one keyboard location to another, whereas the
extrinsic arm muscles and shoulder movements are used to reach large intervals of keys.
Flexion of digits 2 – 5 uses the extrinsic muscles of flexor digitorum profundus and flexor
digitorum superficialis to manipulate the production of sound (the thumb has its own group of
36
muscles for these activities). Coordination of these muscles is well developed in top
professional pianists who engage in healthy habits of practice. This may explain why some of
the top professional pianists, who have greater hours of practice per week, do not suffer a high
incidence of PRMDs compared to those who practised for less time.
The lumbricals and interossei muscles also have vital roles in playing piano; they are
well furnished with special nerve endings which provide them with a positional sense
(Hmelnitsky and Nettheim, 1987). Finger motions are the fastest of the five motion classes
when the remainder of the arm is kept stationary. Finger motions are also the weakest of the
motion classes (Gilbreth, 1911). This type of finger motion would be highly suitable for
playing mezzo-piano to pianissimo passages of any music. The first-class motion requires the
least amount of effort and time, and the fifth-class motions are considered the least efficient
(Gilbreth, 1911). Provided that the necessity of the force has not exceeded the chosen
classification of motion class or classes, an instrumental player should always utilize the
lowest motion classification to perform the tasks properly. Muscle groups work within their
defined tolerances, and the stored energy of muscle is depleted as the music practice is carried
on. It is wise, therefore, for the players to have breaks during sessions of practice, to ensure
that quality is maintained, and mental tension reduced. In addition, applying breaks during the
practice session may reduce the risk of overloading the defined tolerances of muscle. If
healthy habits of practice and abolition of static muscle force loading are the major
preventative strategies of PRMDs, musicians and music educators must apply and promote
healthy daily practice strategies.
Recommendations for protective programs include the need for warming up muscles
to their optimal functional temperature and cooling them down after practice to prevent
muscle soreness and cramping were found in studies of Wristen (2000) and Norris (1990).
Wristen (2000) believed that the most important recommendation to prevent PRMDs was to
avoid a sudden increase in the amount and the intensity of practice. This was also suggested
37
by Brandfonbrener (1990) and Newmark & Hochberg (1987). Any changes in long-
established habits of practice may lead to unaccustomed biomechanical and psychological
tension. It is well recognized that stress can cause muscular tension, particularly in the
trapezius muscle and neck areas (Tubiana, 2003). In fact, unhealthy postures of fingers,
hands, arms and body, including hyperextension of the joints or fingers, excessive forceful
loading of playing-techniques, unfamiliar repertoire, and repetition of overuse and misuse
practices are all considered factors contributing to piano PRMDs (Riley et al., 2005). The
sudden increase in daily playing duration prior to a concert schedule or performance and
exam may also be a factor for PRMDs (Manchester, 2006).
Players should be aware of any awkward postures, and must become conscious of the
different mechanical effects of the instrument and the effect of gravitational force.
Instrumentalists must ensure that the upper body is placed squarely over the feet to achieve a
balanced posture, and then try to practise with complete independence of the functioning
limbs (Tubiana, 2003). One of the healthy playing-techniques was balancing between tension
and relaxation of the muscles when practising, therefore the function of muscles may be more
reliable with extended endurance (Riley et al., 2005). Work economy is interpreted as a
balanced ratio of the output of work and the consumption of oxygen. By using appropriate
practice strategies that improve the rate of force development, including metabolic
adaptations within the muscle, and the ability of the muscle to store and release elastic energy,
the work economy is also improved (Helgerud and Hoydal, 2007; Mohr and Krustrup, 2007).
Applying a therapeutic muscle strengthening program to balance both the intrinsic and the
extrinsic muscles of the forearms and hands, may also prevent possible risks of misuse
(Norris, 1990; Brandfonbrener, 1990).
38
Practice Methods
Traditionally, the majority of piano teachers taught beginners to learn and practise a
piece of music with separate hands for a period of time before practising with both hands
together. Possible reasons for using this method were: (1) to reduce the difficulty of reading
multiple clefs (i.e., treble clef and bass clef of a piano score), or (2) to work with one hand at
a time to reduce the physical complication. This method not only consumes triple the amount
of time to complete the learning process, but also develops a much retarded sight-reading
skill. This practice method disregards the contralateral influence on bimanual skills and
violates the laws of motion economy.
According to Gilbreths‟ laws of motion economy (Gilbreth, 1911), it is natural for the
hands to move in symmetrical patterns, and any deviations from symmetry in a two-handed
work situation result in slow, awkward movements of the operator. The difficulty of
performing non-symmetrical movements and actions is exemplified by the attempt to play
staccato-touch (i.e., short and detached notes) with the left hand, while the right hand plays a
legato-touch (i.e., smooth and connected notes) on the piano. The fundamental motions are
linked longitudinally so that the completion of one movement coincides with the other, and
sometimes may overlap with the beginning of the next (Meinke, 1995). Greater fatigue may
result when one hand is working and the other hand is idle, as the body exerts an effect to put
itself in balance (Niebel, 1988).
The linkage of laterality in the motions occurring in one hand is temporally and
physiologically dependent on those occurring in the other hand when the hands are playing at
the same time. Swinnen and colleagues (1996) reported that the dominant hand tended to lead
the non-dominant hand, and that the phase difference was greater in right-handers than in left-
handers. Left-handers showed less consistent hand lead pattern – the author believed that one
explanation for the lower rate by left-handers may be that they are less lateralized than right-
handers (Swinnen et al., 1996).
39
The results of Pellegrini and colleagues‟ study demonstrated a reduced movement time
and a lower frequency of errors when attention was orientated to the non-preferred hand
(Pellegrini et al., 2004). The left-handers tend to use the non-preferred hand more frequently
than right-handers as the interaction with the environment that requires the child to use the
right hand and, as a consequence, when performing a bimanual task the non-preferred hand of
the left-handers tended to be more accurate than the non-preferred hand of the right-handers
(Provins, 1997). In bimanual task activity, handedness may not be the only factor that
determines which hand will lead, but the direction of movements of the hands could also be a
factor (Franz et al., 2002). This may indicate that when practising separate hand exercises,
players should consider working with the non-preferred hand first; and when a player is
confronted with complicated music it is often the supporting part of the music (i.e., whatever
hand is playing the non-dominant part of music) that needs equal or more attention. The
success of one hand of piano playing certainly depends on balancing control of the other hand
in the bimanual activities.
Motor-skills of piano playing are very complex processes of bimanual tasks that
require the nervous system to coordinate a number of separate actions in an efficient manner.
Riek and colleagues (2003) stated that the temporal coordination is based on a pattern of hand
and eye movements that are organized with extreme precision. Therefore, piano players
should be encouraged to practice with both hands at the first lesson. The co-ordination of
hands is an essential skill of piano playing, and should not be delayed or separated from any
other learning component. This method of delay and separation of learning components may
cause learning deficiency and over strain the musculoskeletal system. Further study and
application of knowledge on the contralateral influence on bimanual task skill may assist the
piano player to improve the learning process of playing accuracy, reduce the error rate, and in
turn, reduce the daily practice duration. To some extent, this may help to reduce the incidence
of PRMDs.
40
PRMDs Associated with Specific Motor-Skills
The music score gives the description and specifications on how a piece of music
should sound and be interpreted. It gives no instruction, however, on the motor-skills and
movement techniques that show the players how to achieve the goal of performance. The
science of ergonomics is concerned with optimization of work-products with the availability
of resources, and aims to minimize the amount of labour-intense effects with the
consideration of workers‟ health and well-being. Failure to understand the principles of
ergonomics by music-educators and pianists may result in careers cut short by chronic muscle
strain, tendonitis, carpal tunnel syndrome, and dystonia (Meinke, 1995). Healthy motor-skills
and playing-techniques should aim to maximize work efficiency and endurance of the body
with the consideration of various mechanical types and sizes of pianos. This is particularly
important for pianists who cannot carry their own instrument when performing away from the
regular practice-room. Some of the top pianists in the world request the piano to be prepared
to their personal specification of mechanical tension before their concert performances, in
order to secure their quality of performance and reduce strain on the musculoskeletal system
(W. Haass, personal communication, April 13, 2007)¹. The majority of players have no
knowledge about the effect that variations in mechanical tension of the instrument have on the
force production of their musculoskeletal system. Even if players knew what was to be
prepared for their piano, ordinary performers would not be granted this level of service. Piano
technicians who lack knowledge of ergonomics frequently perceive the request as a
psychosomatic reaction to the performance. This is especially a problem before exams,
competitions or even concert performance, as players are not allowed to become familiar with
the piano. In these situations, the risk of PRMDs may be increased.
1. Mr. Walter Haass is an international level piano technician who prepares concert hall pianos for visiting
international artists.
41
PRMDs Associated with Traditional Playing-Technique
The traditional playing-technique of repeated octaves by the thumb and little finger of
one hand simultaneously playing keys requires a near-maximum span. The elbow joints are
responsible for raising and moving the hand and fingers from one octave to the other, while
the wrist joint is kept in a fixed position. With the traditional playing-technique, A and B in
Figure 2.7, the wrist is withdrawn during playing as opposed to being allowed to relax on the
keyboard (i.e., opened-kinetic chain versus closed-kinetic chain playing-techniques).
A
B
Figure 2.7. In the photos A and B, the fingers and hand move down to depress the key, and then lift from depressing the keys by the elbow
joint motion.
In the traditional playing-technique: (a) the forearm is moved by elbow joint motion
and (b) the wrist extension is used separately or in combination with the motion of elbow
joint. Hmelnitsky and Nettheim (1987) stated that the contraction of agonist and antagonist
muscles of the shoulder girdle, the upper arm, and the forearm to stabilize the wrist and
fingers when playing, may lead to PRMDs. Raising the fingers above the key surface more
42
than the key dip between 9.5 – 10 mm is redundant, though such methods are commonly
taught when using traditional playing-techniques (Hmelnitsky and Nettheim, 1987). Players
are often inadvertently moving their fingers, hands and arms with very little consideration of
efficiency of force production and motion economy.
PRMDs Associated with Weight Playing-Techniques
In contrast with the traditional playing-technique, Figure 2.8 shows the weight
playing-technique postures and the manner of wrist and swing-movement (where the arrows
show the directions of the wrist movements).
A
B
Figure 2.8. (A) Rolling the wrist joint upward without lifting the fingers away from the surface of the keys, and (B) dropping the wrist joint
downward when fingers depress the keys to reduce the passive tension (using closed-kinetic chain playing-technique).
The weight playing-technique promotes the swing motion (i.e., drop and roll) at the
wrist joint with minimum lifting of fingers and hands above the keys when playing. The
43
positions and motions of the technique offer less tension in the wrist joint and produce a
greater force and endurance when performing. Li (2002) found that the peak of individual
finger forces and the peak of total hand gripping force occurred at the wrist position of 20º
extension and 5º of ulnar deviation. The outcomes of Li‟s study may support optimal wrist
positions when producing hand motion and finger gripping force for depressing the keys. At
present, the biomechanical details of weight playing-techniques are not well understood. Li's
(2002) finding supports the weight playing-technique that promotes a slight extension of the
wrist position and uses the finger gripping motion from the distal interphalangeal joint. This
motion is activated by the flexor digitorum profundus from the deep layer of forearm flexor
muscles.
Conversely, using extreme wrist motions when playing may also contribute to the
development of PRMDs as has been suggested in several medical, biomechanical, and
ergonomic studies (Wristen, 2000). Virgilio (2007), for example, analyzed the movements for
„useful sound production‟ and „erratic extraneous‟ playing movements, and compared the
difference of unitary kinetic energy between concert players and tertiary piano students and
teachers. The results showed that, on average, the concert players used more total unitary
kinetic energy than the students and teachers, but the useful unitary kinetic energy was similar
(Virgilio, 2007). The accurate advantage and disadvantage of using the „erratic extraneous‟
movements of hand and fingers when playing are still unknown.
PRMDs Associated with Various Piano Techniques
Hand and forearm pain due solely to the playing of piano among four men and thirty-
six women pianists with an average 23.5 years of age, were investigated by Sakai (1992). Of
these pianists, 30 reported the development of physical problems by practising certain piano
techniques such as octaves (interval between 1st and 8
th notes of diatonic scale), chords (two
or more notes sounding together), fortissimo (very loud), arpeggios (broken chords), and wide
44
extended passages (large and difficult intervals sections). The octave, chords and fortissimo of
piano techniques accounted for a total of 77% of the cases, and the abduction of both the
thumb and the fourth or fifth finger were involved in playing (Sakai, 1992). The author
believed the above piano techniques may be responsible for the majority of the hand and
forearm pains, lateral epicondylitis, de Quervain‟s tenosynovitis, pain in the thenar muscle or
abductor digiti minimi, and first metacarpophalangeal or fifth proximal interphalangeal joint
pain (Sakai, 1992).
It is important to know which of these special piano techniques represent a risk for the
development of PRMDs among performers. Return to practise will cause a recurrence of the
same problem, even after treatment, if the causal factors are unknown or ignored (Sakai,
1992). It was noted that a tendency to use certain special piano techniques especially octaves
brought on hand or other pains. A player suffered fifth proximal interphalangeal (PIP) joint
pain that occurred during repeated practice of extended chords. The pain in the radial
collateral ligament of the fifth PIP joint, which occurred while striking the piano key with the
fifth finger abducted, may be due to a repeated valgus stress and joint laxity (Sakai, 1992).
The use of highly repeated wide-hand-span positions may increase the risk of
developing hand pain. Shields and Dockrell (2000) reported the results of a hand-delivered
questionnaire that was distributed to 182 students from seven participating music schools
Fifty-two percent of respondents reported pain when playing particular piano techniques,
especially while playing double-octaves (Shields & Dockrell, 2000). Finally, Sakai (2007)
showed that dorsal interosseous muscle pain was common in the pianists‟ hand when striking
the keys while playing scales techniques.
“Musicians are involved in an activity that is the most repetitive of all activities,
however – can play up to 5595 notes in just over four minutes and, in places, use 72 finger
shifts per second – and many accomplished professionals can complete a full playing career
having suffered no complaints at all” (Winspur, 2003; p. 325). At present we know little about
45
how these successful players managed their playing career with no physical problems. The
occurrence of PRMDs may be postponed if the time and habits of practice are changed, but
may not be avoided. The possible prevention of future occurrence of PRMD is to seek a set of
suitable playing-techniques that is user friendly. Digital manipulation when the fingers bear
the weight of the forearm, which has been found to be the most advantageous mode in piano
playing, should be given more attention in the medical and scientific literature of piano
playing motor-skills (Hmelnistky and Nettheim, 1987). It is possible that hand pains and
various other complaints due to misuse could be prevented by improved education in piano
motor-skills and movement techniques when performing difficult piano playing tasks.
Different Mechanical Actions of Keyboard Instruments
There has been a tendency to increasingly demand more technical performances from
the modern acoustic concert-grand piano because of the much greater capability of the
instrument. In early 19th
Century pianos, each key involved about 6mm travel to the base of
keyboard and the action tension of a key was about 23g, with a tension of the middle string
section of 12 to 15 kg; whereas the 20th
Century pianos involves about 10.5mm travel to reach
the base of keyboard, the action tension of a key is about 50 to 60g, and string tension is about
90kg (Grieco, 1989). Additionally, for large concert hall performance, the concert-grand
piano comes with a bigger hammer set. The individual piano has its unique characteristics of
tone; especially as the top concert-grand pianos are still hand made by individual piano
technicians throughout the entire process of production (W. Haass, personal communication,
April 2007). If we continue to use 18th
Century traditional piano playing-techniques, and
ignore the different mechanical actions among the acoustic upright piano, acoustic grand
piano and various types of key instruments (including 20th
Century electronic keyboard
instruments), the musculoskeletal apparatus of players‟ upper limbs may not be able to sustain
the various load demands of modern performance requirements.
46
Incidence and Syndromes of PRMDs
The most commonly reported disorders in pianists (Bejjani and Ferrara, 1989) were
playing-related musculoskeletal disorders (PRMDs). Lacking consideration of physiologic
balance of muscles and joint biomechanics, pianists use their hands and arms continuously
with one goal in mind, that is to complete the task as required (Tubiana, 2005b). Therefore,
the necessity to control highly repetitive musculoskeletal activity combined with rapid
changing of the playing speeds and the playing dynamics by high level players, means they
may be at risk for a variety of occupational PRMDs (Caldron et al., 1986). Although there has
been a recent increase in interest in the medical problems of performing artists, the PRMDs
existed in parallel with the evolution of the instrument. The majority of players were not
aware of the phenomenon, and problems were often only acknowledged by those players who
had suffered from PRMDs. Whether the prevalence of PRMDs is greater than in the past, or
just that it is now more noticeable is unknown, but the frequency and impact of the problems
on the present players must be recognized and correctly treated (Brandfonbrener, 1990).
Despite the long history of PRMDs, the concern for medical problems among
musicians, especially instrumentalists, is a relatively new phenomenon. This may reflect that
musicians, music educators and physicians to some extent ignored the fact that PRMDs
existed in the past, and disregarded it as a serious problem.
Difficulties exist in generating accurate assessments of these problems among
musicians. Many musicians are still unclear of the potential harm associated with overuse and
misuse of their upper limbs and body. The acceptance of „no pain, no gain‟ as a professional
motto causes many to practise and perform despite players were experiencing pain and
discomfort. Others may be reluctant to acknowledge PRMDs because of the concern for
professional consequences associated with a highly competitive occupation. A musician may
not seek care, even though a problem exists, believing that the average physician lacks the
knowledge and experience to treat the problems correctly.
47
Symptoms
The most common symptoms reported by piano players were pain and discomfort,
such as tightening, aching, and soreness of the body. The results of Blackie and colleagues'
(1999) study indicated 80% of those injured reported pain to be intermittent, while 20%
described it as continuous. In the Guptill and colleagues (2000) study, of those who sought
treatment, 95.7% had experienced pain symptoms as a result of playing their instruments. The
author speculated that pain was the major symptom that directs a player to seek medical
treatment (Guptill et al., 2000).
The upper limbs were the most common location of PRMDs, while the instrument that
was played influenced the lateralization and specific anatomic location of the injuries. Most
frequent problems included musculoskeletal pain syndrome and excessive muscle tension-
loading causing pain. Unbalanced physical strength and poor instrumental playing postures
and movements were also common conditions.
Sakai (1992) listed the following symptoms of hand and forearm pain due solely to
playing the piano:
Lateral epicondylitis
Medial epicondylitis
Olecranon pain
Muscular pain in the forearm
Distal pain in the flexor carpi radialis or ulnaris
Pain in the extensor retinaculum
De Quervain‟s tenosynovitis
Second-fifth flexor tenosynovitis
Pain in the thenar muscle
Pain in the abductor digiti minimi
First metacarpophalangeal joint pain
48
Proximal interphalangeal joint pain
The most common disorders were lateral or medial epicondylitis, or distal pain of the
flexor carpi radialis or the ulnaris, followed by de Quervain‟s disease or 2nd
-5th
flexor
tenosynovitis and pain at the olecranon was also an enthesopathy, involving the insertion of
triceps brachii (Sakai, 1992).
Keyboard players tended to have more right-sided and bilateral complaints in the
distal upper extremity (Burkholder and Brandfonbrener, 2004). This supported previous
findings (Knishkowy and Lederman, 1986; Newmark et al., 1987; Fry, 1988). Chong and
Chesky (2001) also found that the highest prevalence of PRMDs was seen in the right wrist.
The melodies and major parts of keyboard music are usually played by the right hand. This
may explain why pianists are more likely to experience symptoms of PRMDs in the right
hand rather than bilateral intrinsic muscle strains.
Musicians are often affected by the playing-related pain conditions that include
musculoskeletal overuse syndromes, myofascial pain syndromes, nerve entrapment
syndromes, osteoarthritis, and fibromyalgia (Brodsky and Hui, 2004). The condition of pain
and discomfort can interfere with musicians' ability to play the instrument at their level of
capability, and can have detrimental consequences on the professional, personal, social, and
financial aspects of their lives.
Musculoskeletal Disorders
There are three categories of PRMDs: “musculoskeletal disorders, compression
syndromes, and overuse syndromes. Musculoskeletal disorders, such as arthritis, tendonitis,
and ligament sprain, involve connecting tissues, joints, ligaments, tendons, and muscles and
they cause pain. Syndromes that compress the peripheral nerves include carpal tunnel
syndrome and cubital tunnel syndrome” (Rogers, 1999; p. 8-9). Synovial cyst of the wrist or
nerve entrapments may occur within the hand and wrist, and entrapment of the ulnar nerve in
49
Guyon‟s canal could occur but it was uncommon (Brandfonbrener, 1990). The pathology may
be proximal to the wrist, as in ulnar nerve entrapment, at the elbow, the radial nerve (posterior
interosseous branch) may be compromised, or there may be a postural related thoracic outlet
syndrome (Brandfonbrener, 1990). Grieco pointed out that the high prevalence of PRMDs
affected all segments of the spine and the trapezius muscles. More than 60% of spinal
disorders occurred after two hours of piano practice, and in 75%-80% of cases, the wrist and
arm pain was manifested in the initial phases of practice (Grieco, 1989).
Musicians‟ musculoskeletal problems are typically referred to as cumulative trauma
disorders, repetitive motion disease, repetition strain injuries, upper limb syndrome, and
shoulder-arm syndrome (Blair, 1987). The common presenting symptom of above disorders
was pain, which may be acute or chronic, localized or referred and have various
characteristics (Brandfonbrener, 1990). “Tendonitis and tenosynovitis are two of the most
common syndromes in instrumentalists. Other types of inflammatory nodules may occur
especially on the flexor tendons and may be a consequence of systemic processes. Many types
of joint pathology are commonly seen in the hands and wrists of musicians. Some of these are
the direct result of playing a particular instrument, some are the effects of the instrument
superimposed on an unrelated systemic inflammatory or degenerative process, still others are
the consequence of an individual‟s genetic tendency toward joint laxity” (Brandfonbrener,
1990; p. 367) and others are due to various individual non-musically induced trauma.
Musicians‟ cramp is a disorder that is often triggered by a specific task. Among keyboard
instrumentalists, male musicians have a higher prevalence of this disorder than females (Lim
and Altermüller, 2003).
Anatomic locations involved were the upper extremities disorder with 93% of the 292
music students aged 18 and younger in Burkholder and Burkholder (2004) work, and hands
and fingers in 42% of 132 patients. In the same study, the laxity was more common in
females. Other diagnoses that were more frequent among female musicians included a lack of
50
conditioning, intrinsic hand muscle weakness, and scoliosis. In males, carpal tunnel syndrome
and tendonitis were more common than among female players (Burkholder, 2004).
Incidence
Ong (1992) reported an overall 53.7% prevalence of overuse among the student
population; however, neither the age of the pianists nor the number of years of experience in
playing the piano seemed to influence the state of PRMDs. The survey of Nicholas and
Quarrier (1995) had a return rate of 54%. When questioned whether the teachers themselves
had ever experienced PRMD, 47% of them reported affirmatively. Another survey completed
by 16 of 25 piano students aged between 18 to 24 years, revealed 93% of the participants had
experienced PRMDs; the most injured areas being hand and wrists, followed by back injuries
(Blackie et al., 1999). The participants spent an average of 117 minutes practising per
weekday, and 21% reported that their injuries restricted participation in everyday activities
(Blackie et al., 1999).
Guptill and colleagues (2000) conducted a client-centered and occupation-based
survey that was administered to music majors at a large mid-western university in USA. The
survey response rate was 92.3% (108/117), and 88% of respondents indicated that they had
experienced PRMDs at some time (Guptill et al., 2000). The author also examined the
relationship between academic year and the incidence of PRMDs. Although no significant
association was found, the PRMDs frequency increased with academic level until the senior
year, at which point it decreased, but sophomore (92.6%) and juniors (94.1%) had the highest
incident rates of PRMDs (Guptill et al., 2000).
Although the keyboard is one of the most played instruments, medical problems
associated with the keyboard-instrument have been rarely addressed in the context of large-
scale studies. Chong and Chesky (2001) studied 455 keyboard players and reported on the
distribution of keyboard instrumentalists by age, gender, musician type, and daily time of
51
playing. Participants ranged in age from 14 to 69 years, with 45.8% males and 54.2% females.
Classical keyboard players were 40.6%, outnumbering the other musician types. PRMDs were
categorized by different locations, with the right wrist being the most frequently reported
problem site, followed by left wrist, right fingers, right hand, left hand, and left fingers. The
authors emphasized that the prevalence of wrist problems was the highest compared with the
finger and hand problems (Chong and Chesky, 2001). The authors further stated that female
keyboard instrumentalists reported a 66% incident rate, significantly higher than males (51%).
There was a 73% incidence of PRMDs between the 10 to 20 years age group, followed by
63% for participants aged 21 to 30 years, which was much higher than the 50% incidence
among the 51 to 60 years age group (Chong and Chesky, 2001). There was 59% prevalence of
musculoskeletal pain in keyboard instrumentalists, while jazz musicians reported the highest
prevalence of 81%, followed by classical musicians with 63% (Chong and Chesky, 2001).
Burkholder and Brandfonbrener (2004) also found that young age was not a protective factor
against PRMDs for occurrence in the distal upper extremities.
Risk Factors
The small intrinsic muscles of the hands and the longer extrinsic muscles of the
forearm perform the actual manipulation of keys. The extrinsic muscles act upon the various
joints in the hand, and the muscles having long tendons and bigger cross sections of the
muscle belly to produce greater force. The intrinsic muscles of the hand play an important
role for the fine manipulation of piano-techniques, and are responsible for the rapid changes
in finger position on the keyboard (Dawson, 2005).
The factors leading to PRMDs may be identified as follows: (1) the vulnerability of
certain genetic factors which cannot be altered; (2) the player‟s techniques which can be
improved; (3) the intensity of practice time and force-loading which is totally within the
student‟s control (Fry, 1987); and (4) job strain, high demands together with low decision
52
participation (Tornqvist and Kilbom, 2001). The term „overuse‟ has been used in the past, but
this term may conceal many possible causes of malfunction, especially those disorders that
can be corrected, for instance, by changing strategies of practice. In practice, „misuse‟ is
similar to overdoing any exercise when activity is continued beyond the point of soft tissue
tolerance. “Since „overuse‟ implies a need for therapeutic rest, it may cause unwarranted
disuse, which remains second best to appropriate use in otherwise healthy musicians who
have developed malfunction from misuse” (Lippmann, 1991; p. 60). An unskilled flexion of
any musculoskeletal system which yields at that instant is ready to cause flexor and extensor
strain and possible injury, and this has been miss-termed „overuse‟.
While numerous risk factors and medical conditions have been discussed at length in
recent journals (Gohl and Greathouse, 2006; Sakai, 2002; 2006; Wristen et al., 2006a;
Wristen et al., 2006b), difficulties exist in generating accurate assessments of the extent of
these problems among musicians. Most musicians are unaware of the potential harm that is
associated with playing keyboard-instruments (Sakai, 2006). The PRMDs mentioned above
were closely related to the players‟ strategies of practice used when completing the daily tasks
of practice. Musicians need to develop scientific protocols of practice to avoid PRMDs.
Education in PRMDs Prevention
The rising in piano music complexity over time was made possible by optimizing the
musical instrument, expert music performance and widely accessible music education and
training (Lehmann and Ericsson, 1998a). This accessibility of music training today made it
possible for students to commence as young as 4 – 5 years (Altenmüller, 2006). Music
teachers must find ways to accelerate the training process to accommodate the demand of
increased complexity of music performance at the highest levels (Altenmüller, 2006).
However, the high incidence of PRMDs sustained by instrumental musicians, coupled with
their self-reliance for resolving PRMDs, underscores the importance of education and
53
prevention. The general approach to the teaching and practising of instrumental music often
remained constant from one generation to the next (Brandfonbrener, 1990). This was
reinforced by the nature and characteristic of the individual teaching format. Music educators
and instrumental musicians should become actively involved in obtaining anatomical and
biomechanical knowledge, to understand the human body‟s capabilities and limitations. This
enables instrumental musicians and music educators, through playing and teaching, to
promote the use of healthy body postures with well balanced strength of muscles (Norris,
1990), gaining well coordinated, energy efficient, and seemingly effortless playing-
techniques.
Teaching Environment
There are two main teaching environments of piano performance: (1) the individual
studio for one-no-one teaching (Rogers, 1974; Kennell, 2002) and (2) group piano teaching
(Enoch, 1974). The development of an electronic keyboard instrument made it easier for
group classroom teaching with only one instructor (Shender, 1998). Both teaching formats
have only one teacher at any teaching session. If the teacher lacks knowledge of the proper
use of upper limbs and postures together with inefficiency of force production of
musculoskeletal system, this naivety may put the players at risk of PRMDs (Llobet and
Odam, 2007). In order to convince musicians and music educators of the importance for
inserting the preventive programs into their curriculum of music education, musicians and
music educators should address the attitudes toward PRMDs.
Studio Teaching
In the traditional one-on-one studio teaching format, experienced teachers may be
aware that proper playing posture is required to prevent injurious stresses and strains, but they
often lack knowledge of the efficient postural control for production of efficient motor skills
54
and motion economy (Rogers, 1999). Therefore, incomplete and inefficient playing-
techniques may be carried on from one generation of players to the next.
A regular interactive group learning environment (e.g., master class) is mainly in place
at the tertiary level of education. Whether motion economy and efficiency of force production
were included as issues to be addressed in the group learning class (Rogers, 1999) or
promoting healthy practice habits (e.g., warming-up and cooling-down) (Llobet and Odam,
2007) would depend on the teachers‟ knowledge of the matter of concern. It would also
depend on the beliefs of the individual educational body whether motion economy and
efficiency of force production were the important issues affecting instrumentalists‟ success or
failure of the subject and their well being.
Electronic Keyboard Classroom Teaching
The 20th
Century electronic keyboard and computer technology classroom teaching
format, which made it possible for any age group of students to learn with one teacher
(Shender, 1998), often left the players to adopt unchecked postures and playing-techniques. If
playing postures and playing-techniques were addressed during classroom teaching, the
individual needs may not be given immediate attention because of the high student: teacher
ratio.
Attitudes
Recognition and understanding of music PRMDs is not yet uniformly required in the
curriculum of music education in Australia. Unlike some other countries, a health promotion
educational course is not required in secondary school. Some tertiary institutions in the USA
have health promotion courses (Manchester, 2007). Furthermore, some musicians and music
teachers who have experienced PRMDs themselves with limited information and knowledge
of PRMDs may have developed predisposed ideas about principles of prevention and
55
management (Rogers, 1999). Without complete knowledge of PRMDs, players would often
believe that the occurrence of PRMDs was a personal problem rather than related to playing
piano (Llobet and Odam, 2007). Some musicians and music teachers may have recognized the
existence of PRMDs, but did not believe the problems were serious (Quarrier, 1995). If
musicians and music teachers have no experience of PRMDs during their entire playing
career, they may assume that the complaints are psychosomatic and may not believe in the
actual occurrence of music PRMDs (Nicholas and Quarrier, 1995).
Difficulties
One of the difficulties for musicians to recognize medical problems that could
compromise performance was to face temporary or permanent change in their playing-
techniques. In addition, in accepting being an injured performer may result in the enforcement
of a lengthy period of rest with possible significant economic losses. Facing large medical
expenses was of greater significance, which may even result in career changes together with
enduring physical pain and inconvenience in coping with daily life (Brandfonbrener, 1990).
Many mid-level piano players were resistant or reluctant to change their playing-
techniques and seemed to adhere to the guidelines which were set out by their previous
teachers (Blackie et al., 1999). Apart from the difficulty of changing already established
motor habits, often the presenting reasons for the need for change were not convincing and,
may perceive the change as a preference for just another playing style (Brandfonbrener et al.,
2004). This reinforces the need for education in awareness of PRMD to be started at a very
early stage of learning. As Brandfonbrener and colleagues (2004) pointed out, teaching
methods should be directed toward using physical protective techniques and suitability of
individual repertoires that do not stress the body beyond the tolerance of musculoskeletal
system and the abilities of individual player.
56
A survey conducted by Blackie and colleagues (1999) was completed by 16 of 25
piano students from 18 to 24 years of age. The results revealed that many participants did not
receive education on prevention of PRMDs, nor did they practise using a PRMDs preventive
method. Musicians have shown a broad reluctance to seek medical assistance for PRMDs.
Blackie and colleagues (1999) summarized three primary reasons: (1) the perception of
musicians that health care professionals were not well informed of the physical and emotional
demands related to their performance; (2) the threat to their employability when a disability
becomes known; and (3) the culture of acceptance of physical pain as a natural part of
professional music. Many musicians alter their playing manner to adapt to the physical pain in
an attempt to play through the problems with the hope that the pain may disappear.
Risk Areas
The areas of risk that can be addressed are: (1) unbalanced musculoskeletal tension
and conditioning of the body with unhealthy playing postures, (2) inefficient force production
of playing-techniques, (3) unsuitable methods of practice, (4) unhealthy habits of practices,
(5) ignoring the differences in mechanical tension of the instruments and, (6) unsuitable
repertoires for individual musicians.
Warm-up before Playing
Many of the PRMDs can be avoided or reduced in severity, especially those of the
hand and wrist. An important key to prevention lies in proper conditioning of the
musculoskeletal system, as emphasized by Norris (1990). The presence of healthy muscular
tone, flexibility and endurance depends on appropriate exercise, warming up before playing,
cooling down and stretching after playing the instrument, and attention to maintaining
mechanically sound playing postures. Thomas and colleagues stated that the warm-up has a
significant effect on temperature-dependent physiological processes. The elevation of core
57
temperature can increase the dissociation of oxygen from hemoglobin and myoglobin,
enhance metabolic reactions, facilitate muscle blood flow, reduce muscle viscosity, increase
the extensibility of connective tissue, and improve the conduction velocity of action potentials
(Thomas and Jack, 2001). The increase in core temperature will improve the biomechanical
performance of the motor-system, while stretching may reduce the possibility of muscle strain
and also maximize the power that a muscle can produce.
Break during Practice Session
The medical literature stresses the importance of resting the muscles to avoid overuse.
Adequate breaks during the practice session not only relieve physical tension, but also can
improve mental concentration. Pianists must recognize that a break from practising should not
involve any intense activity of upper limbs (Rogers, 1999), and should understand the effects
of physiological fatigue. The supply of oxygen to the working-muscles is insufficient to
prevent a build up of the by-products of metabolism in the body during the course of the
practice session. Performing depletes the reserve of oxygen in muscles with the symptoms of
pain and physiological fatigue or muscle weakness (Niebel, 1988). It is important to stop
periodically to relax the muscle and allow the blood supply to be replenished. The issue of
what is an appropriate length of break and its frequency during each piano practice session is
still uncertain.
Practice Strategies
The player may be more susceptible to PRMDs when learning a new piece of music
with unfamiliar physical motions or movements. Extreme care should be taken to avoid
PRMDs (Wristen, 2000) by using a relatively shorter practice duration and smaller quantity of
the new piece of music in each practice session. In general, when practising with a slower
tempo the more pronounced and visible the motion will be (Wristen, 2000). Especially at the
58
early learning stage when facing an unfamiliar piece of music and physically unfamiliar piano
techniques and/or unfamiliar motor-skills, a slow tempo of practice is necessary to reduce the
frequency of mistakes. The slow tempo of practice, together with application of the
knowledge of contralateral influence on bimanual skills, should promote greater learning
accuracy and help to avoid excessive frequency of practice and repetitive motions.
Modifying Playing-Techniques and Working Conditions
By modifying playing-techniques and refining movement techniques that are in a
circular movement rather than in an angular contortion are essential to understanding the
function of muscles and joints, and how they assist each other in producing efficiency of
motor-skills (Rogers, 1999).
In terms of ergonomic improvements, the piano seats currently used are without a
backrest and most are without shaping of the seating surface. Grieco (1989) suggested the
student should use seats with semi-rigid upholstery and a shaped seating surface plus a
backrest that will support the spine, at least during the practice-sessions. There have been
many ergonomic studies regarding the optimal computer typing environment, which have
showed an effective reduction in tension in the musculoskeletal system by correcting the
postures of operators and altering the work environment (Hedge et al., 1999; Serina et al.,
1999; Woods and Babski-Reeves, 2005; Delisle and Lariviere, 2006; Dennerlein and Johnson,
2006). Although the force production and motor-skills of upper limbs in the computer typing
tasks are much less complicated than piano playing, the principle of interaction between
players with various instruments is similar.
Healthy Life-style
Musicians use particular parts of the body excessively which characterized by the
individual musical instruments that they are playing. A video tape Therapeutic Exercise for
59
Musicians is a user friendly and practical source of PRMDs prevention exercises for musical
instrumentalists (Norris, 1990). Piano players may benefit from the program that greater
attention is being paid to musicians‟ life-style, with proper rest, conditioning the muscles, and
regular exercises. Without complete knowledge of musculoskeletal functioning of the body,
the possibility of over exercising the muscles, which are already in need of therapeutic rest,
can be harmful and need to be eliminated (Wu, 2007). Various non-medical techniques such
as the Alexander Method, Feldenkreis, Yoga, visualization, and biofeedback of body
relaxation and awareness are playing an increasingly important role in the lives of musicians
(Brandfonbrener, 1990).
Suitable Repertoires
When choosing suitable repertoires, there is not only a need to consider the
characteristic of the compositions that match the individual players‟ preferences, but also the
limitation of their anatomical and biomechanical capabilities. Many players are attracted to
the world famous compositions, which not only possess the unique compositional creation,
but also display impressive instrumental techniques. Performing instrumental music at a
professional level is one of the most complex of human accomplishments. For example, in the
No.6 Paganini Etude by Franz Liszt, the pianist has to bimanually coordinate the production
up to 1800 notes per minute (Münte et al., 2002). Furthermore, the complexity of music has
increased over time because the piano has been optimized, and this increased complexity has
required teachers to find various ways to accelerate the acquisition of existing and new
techniques (Altenmüller, 2006). Without applying a scientifically sound training program on
how to achieve the highly skilled and sophisticated performance task; the players can often
became physical and mental casualties.
60
Summary
The majority of piano players may not have a good knowledge of various structures or
mechanical tensions of individual pianos. Players may use the preferred playing-techniques
that they have been taught, and may practise daily with an available instrument in their
practice room, but be confronted with a different or unfamiliar instrument in the teaching
studio, examination room, or on the stage when performing. These situations inevitably cause
a sudden change in musculoskeletal activities to perform a series of complex tasks, and may
lead to physical and psychological tensions and stresses to the players‟ body and mind.
Knowledge of the literature on motor-skills and movement techniques is not usually
part of the standard requirements of the curriculum of teaching, and is often left to the
individual teacher‟s discretion. As a result, players may be given a limited understanding of
the relationship between the tasks of music, the motion economics and the capacities of
individual instruments. Such deficiencies may directly result in the misuse and overuse of the
instrumentalists‟ physical capacity.
Non-specific hand and arm pains were a common presenting complaint in the cases of
the instrumental musician. The various pains were attributed to simple fatigue and tiredness of
the muscles that may result from incorrect technical application of the instrument, excessive
practice with unhealthy practice habits, and unsuitable repertoires. While numerous risk
factors and medical conditions have been discussed at length in recent journals, most
musicians are unsure of the potential harm that is associated with playing a musical
instrument. Others may be reluctant to acknowledge the existence of PRMDs because of the
professional risk associated with a highly competitive occupation. Musicians may not seek
help despite their problems, believing the average physician lacked the knowledge and
experience to treat the problems.
Many accomplished professional players successfully complete a full playing career
having suffered no PRMDs and at present, we know very little about the stratagems these
61
players used to manage their practice and performance. Further examination of players‟
motor-skills, movement techniques, and habitual strategies of practice, may help to better
understand the risk factors associated with PRMDs.
The theoretical framework in Figure 2.9 shows that the risk factors of PRMDs may
come from three major sources: (1) misuse, (2) overuse, and (3) playing conditions. Among
the „misuse‟ risk factors, the literature has identified problems associated with playing-
techniques (i.e. whether the player uses predominantly a traditional, weight, neutral playing-
technique or the Levinskaya system) and playing postures (i.e., whether the player practises
with elevated shoulders, extended elbows or extended fingers). With respect to „overuse‟ risk
factors, there appear to be problems associated with exposure to more years of playing,
extremely long duration of each practice session without rest breaks and high frequency of
playing over seven days. Problems may also be related to using complex and high physical
intensity of repertoires that were beyond a player‟s capability in order to accelerate the
learning process. The literature also identified that players‟ age, gender (i.e. females more
susceptible to PRMDs) and hand size (i.e., small hand) may be linked with PRMDs. Finally,
two important risk factors were categorised as „playing conditions‟ and included using an
unfamiliar piano during performance or examination that increases players‟ tension both
physically and mentally and, sudden increases in practice hours and intensities to meet the
demand of performance or heavy work load that go beyond the physical capacities.
Although one individual source may not directly cause PRMDs, when compounded
with other risk factors, the occurrence of PRMDs becomes more likely. Practising in a high
risk level of task exposure does not necessarily mean that players will be injured, although
players would be more susceptible to PRMDs if they „misuse‟ their bodies and ignore the
playing conditions.
A successful prevention strategy requires an holistic approach that includes local
treatment and assessment with correction of contributing factors being the most important
62
component. Music educators need to apply scientific knowledge to the piano pedagogic
teaching techniques, and include a component of the player‟s physical and psychological
health as part of the ongoing curriculum program.
63
Figure 2. Theoretical framework.
PRMDs
Missuse
factors
Overuse
factors
Playing Conditions
factors
Playing-
techniques/
movements
Playing
postures
Use of
unfamiliar
instruments
Sudden
increase in
practice time
& intensity
Exposure Force
s
Individual
factors
Complexity
& intensity of
repertoires
-Age
-Gender
-Hand-span size
a. Duration
- chronic
- acute
b. Frequency
- days/week
- rest breaks
64
Chapter III
Method
Participants
Of the 580 copies of the self-administered survey questionnaire distributed, 505 piano
players from 12 to 89 years of age responded. Participants had played piano for two years or
more, and piano was the major instrument or second instrument. Of the 505 respondents, 46%
of the players (n = 231) were still playing and 54% (n = 274) had stopped playing at the time
of the survey. The sample comprised 31% male players [professional (n = 17) and non-
professional (n = 137)], and 69% female players [professional (n = 47) and non-professional
(n = 304)].
The majority of participants were living in the Perth metropolitan area and country
regions of Western Australia, while a small number lived in the other states of Australia.
Some participants were obtained from three private girls‟ schools, two private boys‟ schools,
and one government co-educational school. These schools had special music programs in the
curriculum, with a large number of students studying music in the school‟s programs as well
as outside the school system. Participants also included students and staff of a School of
Music of a university, and the students of another tertiary institution. Participants from the
community were obtained from a retirement village and the congregation of a church.
Completion of the self-administered survey questionnaire was considered evidence of
respondent‟s consent to participate in the study. Respondents were free to withdraw consent
to further participation without prejudice, and were not required to supply a reason or
justification for such a decision. A parental consent form was used for the participants who
were under 15 years of age when the survey was conducted on the premises of Australian
Music Examinations Board (AMEB), as this was requested by the AMEB (see appendix C).
65
Instrument
The self-administered survey questionnaire, „An Investigation of Professional and
Non-Professional Piano Players‟ Playing Postures and Techniques,‟ was created and
designed by the researcher (see appendix A). It was used to investigate the motor-skills,
movement techniques and practice-strategies used when practising and performing on the
piano, and the frequency of PRMDs. The reliability of the survey questionnaire means when
the process was applied repeatedly it produces a consistent result. A pilot study was
conducted prior to the actual survey to obtain the reliability of the instrument. There were 14
heterogeneous, professional and non-professional players aged from 10 to 87 who completed
the pilot study. The participants had been tested three times with the interval of two weeks in
between each test. The results showed that the instrument was reliable (r = .92).
The survey instrument contained a total of 33 questions. Questions 1 to 10 included
the participants‟ history of playing, habitual practices and playing-occupations. Questions 11,
12 and 14 used photographs to identify various playing-techniques and movement techniques.
(The names were used for the various wrist postures in this research only for the convenience
of labeling).
Question 13 requested the players to record the maximum stretch of their hand-span.
This questionnaire required the measurement of actual length of hand-span during the data
collection. The maximum hand-span was measured from the tip of digit 5 to the tip of the
thumb. Those with a measurement of ≤20cm were categorized as small hand size, and
≥20.1cm as having a large hand-span. This measuring method was determined on the basis of
the ease of playing octave and chords (that within the interval of an octave range). The actual
interval of the octave on a keyboard is from one note (e.g., C note) to the same note but
different pitch (C note) being twelve semitones (12 keys) above or below the original C note.
This method equates the morphology of hand with the actual piano techniques that would
66
result in better understanding of the subject matter (i.e., the measurement is directly related to
the playing action).
Questions 15 to 26 covered the history of PRMDs. Questions 27 to 33 relating to
personal information were placed at the end of the questionnaire to avoid early fatigue before
completing the questions. It took about 5 to 10 minutes to complete the questionnaire, which
depended on the individual‟s situation (i.e., the player with PRMDs needed greater time to
complete the questionnaire).
The Survey Procedure
The total data collection period took less than three months. All participants were
approached by the researcher directly or indirectly via the head of their institution prior to
actual completion in the survey questionnaire.
The West Australian Music Teachers‟ Association advertised this research program in
their September 2006 newsletter to actively encourage their members to participate. After the
teachers' and players' addresses and contact numbers were received, the respondents were sent
copies of the survey questionnaire.
Before being presented with the actual questionnaire, the respondents were given the
Information Sheet (see appendix B) to ensure they were made aware of their rights prior to
completion of the survey. Each questionnaire booklet was assigned an identification number,
thus participants remained anonymous at all times. The last page of the booklet was detached
upon returning the questionnaire before data entry, for those who chose to participate in
further research studies, and to ensure their names and contact addresses in relation to the data
would not be identified at any stage of the research.
67
Four Kinds of Data Collection Procedures
1) Upon agreement to undertake the survey, participants were requested to complete the
questionnaire then post it back to the researcher using the pre-paid envelope, which was
provided. A follow-up phone call was made after three weeks of initial posting to further
encourage participants to complete and return the questionnaire as soon as possible.
2) The head of keyboard instruments at a university School of Music and the head of
keyboard instruments of another tertiary institution were approached through a letter sent by
the investigator to seek agreement to participate in the survey. After permission had been
given to proceed with the survey, the questionnaire was presented to the students by the head
of keyboard in the regular piano master class and collected upon completion, and then the
questionnaires were posted back to the researcher.
3) The principals of six high schools in Western Australia were approached by the
investigator to seek their participation. The Director of Music of each participating school
then nominated a suitable day and chose whether to present the questionnaire after the
morning school choir and orchestra rehearsal before students return to class, or to use the
school‟s lunch break period. The Music Department of each school then allocated a room for
conducting the survey, and the students chose to complete the questionnaire entirely of their
own free will. The researcher was present in the room when the survey was conducted and
answered any questions raised, and then collected the completed questionnaires before the
students vacated the room.
4) The Australian Music Examinations Board of Western Australia (AMEB) was contacted to
seek their agreement to participate. Agreement was reached to support this research project by
granting a three-day access period to the players who were undertaking an AMEB piano
examination at their main premises. The researcher was present at all times during data
collection, and was required to follow the conditions set by the academic development officer
68
of AMEB during the access period. The parental or guardian consent form was used for those
who were 15 years or under at the AMEB premises.
Statistical Procedures
The descriptive statistics and Pearson Chi-square tests, Independent t tests, one-way
ANOVAs, and two-way ANOVAs (SPSS version 13) were used for data analysis. The
percentage of PRMDs was obtained for the three age groups (between 12 - 20 years, 21 - 40
years, and 41 - 89 years) within the sample. The relative frequency of PRMDs was obtained
for professional and non-professional players.
Pearson Chi-square tests were used to assess the significance of association of PRMDs
in relation to the levels of playing, different playing-techniques/playing postures and
movements, whether the piano was the major or non-major instrument, different playing
occupations, practice strategies, number of years of playing, different types of music, different
piano techniques and gender differences.
Independent t tests were used to identify: professional status in relation to severity of
PRMDs. One-way ANOVAs were used for identifying: (1) different levels of PRMDs
between performers, teachers and players; and (2) differences in severity of PRMDs between
piano as a major instrument or non-major instrument.
A two-way ANOVA was used to identify: (1) gender differences in incidence of
PRMDs in relation to various practice hours over seven days; (2) different practice hours over
seven days in relation to incidence of PRMDs and various years of playing groups and; (3)
gender and hand size differences in relation to incidence of PRMDs.
A multi-way ANOVA was used to identify differences among practice hours over
seven days in relation to incidence of PRMDs between piano as major or non-major
instrument, gender, and grade level groups. Where necessary, some variables were
69
transformed to ensure the assumption of normal distribution was not violated. Statistical
significance was accepted when p < 0.05.
List of Grouping Variables:
Playing Type Groups – performer, teacher and player.
Professional Status – professional and non-professional player.
Piano Major and Non-Major – piano as major instrument or non-major instrument.
Years Playing Groups – from 2-5, 6-15, 16-40, and 41-60+ years of playing.
PRMDs – player with and without PRMDs.
Grade Level Groups – preliminary, grade 1, 2, 3; grade 4, 5, 6; and grade 7, 8, associate,
licentiate and tertiary.
Age Groups – from12-20, 21-40, and 41-89 years of age.
Gender – male and female.
List of Dependent Variables:
Degree of Discomfort – discomfort increase from 0, 1, 2, 3, 4 degree of severity.
Practice-Break Length – in minutes.
Practice Hours over Seven Days – total hours per week.
Hand-Span Sizes – that are ≤ 20.0cm = small hand sizes and ≥ 20.1cm = big hand sizes.
70
Chapter IV
Results
Introduction
The survey results relating to playing-techniques, movement techniques, playing
postures, playing occupation, professional status, practice strategy, grade levels, years of
playing, age, gender, hand-span size, and whether players are seeking any help for
management of PRMDs are reported below. Out of the total 505 participants, 42% (n = 214)
reported playing-related musculoskeletal disorders (PRMDs). A list of missing data is placed
in Appendix D.
Playing-Techniques
In this section of the results, chi-square analyses were used to explore the relationship
between playing techniques and the presence or absence of PRMDs. Percentages are reported
graphically to show the incidence of PRMDs among the players using the various playing-
techniques.
1) Wrist Postures
The Pearson Chi-square test showed a significant relationship among traditional,
weight, neutral and Levinskaya System of wrist postures and presence of PRMDs [χ ² (3, N =
503) = 16.57, p < .001]. The percentages reported below (Figure 4.1) showed that players who
use a weight-playing wrist posture experienced the lowest rate of PRMDs, while players who
use a neutral wrist posture were associated with a higher incidence of PRMDs compared to
those who use traditional-playing wrist postures. Players using the Levinskaya system had the
highest incidence of PRMDs. It is important to note that there were only five players applying
the Levinskaya playing-technique and four of those reported PRMDs.
71
0
10
20
30
40
50
60
70
80
% PRMDs
Playing Techniques
traditional
weight
neutral
Levinskaya S
Figure 4.1. The percentage of PRMDs reported by respondents who used the traditional (n = 108), weight (n = 41), neutral (n = 349) and the
Levinskaya system (n = 5) wrist playing postures.
2) Finger Postures and Elbow Postures
The Pearson Chi-square test, χ ² (1, N = 491) = 2.34, p = .13, showed there was no
significant association between the occurrence of PRMDs and the flat or round finger postures
(Figure 4.2). The Pearson Chi-square test [χ ² (1, N = 500) = 3.47, p = .06] also indicated there
was no significant relationship between the occurrence of PRMDs and the straight and the
bent elbow posture (Figure 4.2), although there was a trend. There was higher percentage of
PRMDs among those who used the straight finger posture.
0
10
20
30
40
50
60
% PRMDs
Finger postures Elbow postures
flat
round
straight
bent
Figure 4.2. The percentage of PRMDs reported by respondents who use a flat (n = 54) or a round finger posture (n = 437), and percentage of
PRMDs reported by respondents who use the straight elbow posture (n = 103), or the bent elbow posture (n = 397).
72
3) Shoulder Postures
The Pearson Chi-square test [χ ² (1, N = 493) = 5.42, p = .02] indicated that players
using an „elevated‟ shoulder posture had a significantly higher incidence of PRMDs compared
with the „non-elevated‟ shoulder posture (Figure 4.3).
0
10
20
30
40
50
60
% PRMDs
Shoulder Postures
elevated
non-elevated
Figure 4.3. The percentage of PRMDs reported by respondents who use an elevated shoulder posture (n = 99), or a non-elevated shoulder
posture (n = 394).
4) Finger Movements
The Pearson Chi-square test [χ ² (1, N = 501) = 1.15, p = .22] showed there was no
significant difference in contribution to the incidence of PRMDs between players using the
vertical and the horizontal movement of fingers when playing piano (Figure 4.4).
0
10
20
30
40
50
% PRMDs
Finger Movements
vertical
horizontal
Figure 4.4. The percentage of PRMDs reported by respondents who use a vertical finger movement (n = 319), or a horizontal finger
movement (n = 182).
73
Exploring the Relationship between PRMDs and Playing-Techniques
Thirty-seven percent of the sample (n = 187) explored different playing-techniques
throughout their period of playing. Among the „explorer‟ group, 48% reported PRMDs,
whereas 39% reported PRMDs in the „non-explorer‟ group (n = 318). There was a significant
association between players who explore different playing-techniques and the incidence of
PRMDs [χ ² (1, N = 505) = 4.02, p = .05] (Figure 4.5).
0
10
20
30
40
50
% PRMDs
Exploring different Playing-Techniuqes
non-explorer
explorer
Figure 4.5. The percentage of PRMDs for the „explorer‟ group (n = 187) and the „non-explorer‟ group (n = 318).
Playing-Occupations
Survey respondents were stratified according to playing-occupations: performers,
teachers and players. The Chi-square test indicated a significant association [χ ² (2, N =
505) = 21.55, p < .001] between the incidence of PRMDs and playing-occupation (Figure
4.6).
74
0
10
20
30
40
50
60
70
% PRMDs
Playing-Occupation
performer
teacher
player
Figure 4.6. Rates of PRMDs by performer group (n = 21), teacher group (n = 50) and player group (n = 434).
Among those participants (n = 213) who reported PRMDs, a one-way ANOVA
revealed significant difference in the degree of discomfort [F (2, 211) = 4.64, p = .01]
between the groups (Figure 4.7). Post-hoc Tukey HSD showed: (1) a significantly higher
degree of discomfort between the teacher group in comparison to the player group [p = .03];
(2) no significant difference in degree of PRMDs between performer and teacher groups [p =
.99]; and (3) no significant difference in the degree of PRMDs between the performer in
comparison to the player group [p = .14].
The Degree of PRMDs Associated with Playing-Occupation
0
1
2
3
4
1 2 3
performer teacher player
Mea
n a
nd
SD
of
PR
MD
s
Deg
ree
Figure 4.7. The degree of PRMDs (M ± SD) reported by the performer group (n = 14), teacher group (n = 34) and player group (n = 166). No
PRMDs = 0, while maximum PRMDs = 4.
75
Professional and Non-Professional Players
Out of 64 professional respondents, 72% (n = 46) reported that they sustained
PRMDs, whereas among 441 non-professional respondents, 38% (n = 168) experienced
PRMDs. The analysis revealed a significantly higher incidence in the professional group [χ ²
(1, N = 505) = 26.12, p < .001]. Looking at the degree of discomfort among the professional
and non-professional players with PRMDs, the independent t test revealed that the
professional group (M = 2.52) experienced a significantly higher degree of discomfort [t (N =
214) = 2.80, p < .006] than the non-professional group (M = 2.08).
Different Types of Practice Strategy
The following sections focused on questions related to overuse. Chi-square analyses
and various ANOVA techniques were used to explore the association among practice
strategies, professional status, piano major or non-major instrument, years playing, age,
gender, hand span-sizes and the presence or absence of PRMDs.
1) Number of Breaks within Daily Practice
Pearson Chi-square test results [χ ² (3, N = 505) = 21.94, p < .001] confirmed that
there was a significant relationship between the number of practice breaks and presence of
PRMDs. The percentages reported in Figure 4.8 showed a higher incidence of PRMDs among
those who took two or more breaks.
76
0
10
20
30
40
50
60
70
% PRMDs
Frequency of Practice-Break
none
once
twice
more
Figure 4.8. Rate of PRMDs among respondents with different rest frequencies within the daily practice session – none (n = 292), once (n =
122), twice (n = 55) and more rests (n = 36).
2) Break Length within Daily Practice Session
The results demonstrated that among players with PRMDs (n = 214), 50% (n = 108)
had varying lengths of practice-break, while the remainder (n = 106) had no practice-break
during the daily practice session (Figure 4.9).
0
10
20
30
40
50
Frequency
Break Length
0 minute
3 min.
5 min.
10 min.
15 min.
30 min.
60+ min.
Figure 4.9. The frequency of various practice break length, (n = 108) with 0 break, (n = 19) with 3 minutes break, (n = 27) with 5 minutes
break, (n = 27) with 10 minutes break, (n = 16) with 15 minutes break, (n = 7) with 30 minutes break, and (n = 12) with 60+ minutes break.
77
The two-way ANOVA [PRMDs (2) x Professional Status (2)] of length of breaks
revealed a significant main effect [F (1, 501) = 29.95, p < .001] and a significant interaction
between professional status and PRMD groups [F (1, 501) = 7.18, p = .008]. Overall the
professional group took longer breaks; however, the interaction indicated that professional
players without PRMDs took longer breaks. In contrast the non-professional players with
PRMDs took longer breaks (Figure 4. 10).
Professional and Non-Professional Players'
Length of Practice-Break
0
5
10
15
20
25
30
35
40
45
50
1 2 3 4
(1) Prof. no-PRMDs (3) Prof. PRMDs
(2) Non-Prof. no-PRMDs (4) Non-Prof. PRMDs
Me
an
an
d S
D P
rac
tic
e-
Bre
ak
Le
ng
th
Figure 4.10. The Mean and SD of Professional players without PRMDs (n = 18) and with PRMDs (n = 46) and, Non-Professional players
without PRMDs (n = 273) and with PRMDs (n = 168).
3) Practice Hours over Seven Days
The Pearson Chi-square test showed χ ² (3, N = 504) = 18.28, p < .001) that a greater
number of practice hours over seven days was associated with a higher percentage incidence
of PRMDs (Figure 4.11).
78
0
10
20
30
40
50
60
70
% PRMDs
Practice hours groups per seven days
1-5 hours
6-10 hours
11-20 hours
21-40 hours
Figure 4.11. The percentage of PRMDs in groups that played 1 – 5 hr (n = 349), 6 – 10 hr (n = 105), 11 – 20 hr (n = 38) and 21 – 40 hr (n =
12) hours per week.
However, when practice hours over seven days was tested with respect to the PRMD
groups (2), professional status (2) and piano-major or non-major players (2), a three-way
ANOVA revealed no significant difference [F (1, 497) = .34, p = .56] in the practice hours of
the groups with and without PRMDs. There was a significant main effect for professional
status [F (1, 497) = .18.89, p < .001] and with piano as the major instrument [F (1, 497) =
32.90, p < .001]. The results showed no significant interaction [F (1, 497) = .48, p = .49]
between PRMDs and professional status with practice hours and no significant interaction
between PRMDs and major or non-major groups [F (1, 497) = .07, p = .79]. There was no
significant three way interaction [F (1, 497) = .24, p = .63] (Figure 4.12).
79
Reported PRMDs over Seven Days of Practice Hours Analysed with
Professional Status and Piano Major or Non-Major Groups
-2
3
8
13
18
23
28
1 2 3 4 5 6 7 8 9 10 11
[non-maj. prof. (1) no-PRMDs (2) PRMDs] [maj. prof. (7) no-PRMDs (8) PRMDs]
[non-maj. non-prof. (4) no-PRMDs (5) PRMDs] [maj. non-prof. (10) no-PRMDs (11) PRMDs]
Me
an
an
d S
D H
ou
rs
pra
cti
ce
ov
er 7
da
ys
Figure 4.12. The practicing hours over seven days (M ± SD) tested with incidence of PRMDs, Professional and Non-Professional with Piano
Non-Major players (n = 184), Professional and Non-Professional Piano Major players (n = 320).
Years of Playing
Participants were divided into four groups based on the number of years of playing – 2
to 5, 6 to 15, 16 to 40 and 41 to 60+ years. Pearson Chi-square test [χ ² (3, N = 505) = 35.74, p
< .001] revealed a significant relationship between the presence of PRMDs and years of
playing. The percentages reported in Figure 4.13 indicate that the incidence of PRMDs
increase with the years of playing.
80
0
10
20
30
40
50
60
70
% PRMDs
Years of Playing Groups
2-5 years
6-15 years
16-40 years
41-89 years
Figure 4.13. The percentage of PRMDs among years of playing piano: 2 – 5 years (n = 164), 6 – 15 years (n = 250), 16 – 40 years (n = 65),
and 41 – 89 years (n = 26).
When using practice hours over seven days as a dependent variable, a 2 (PRMDs) x 4
(years playing groups) ANOVA revealed no significant difference [F (1,497) = 2.07, p = .15]
between the groups with and without PRMDs. It also revealed [F (7, 497) = .61, p = .61] no
significant difference among years of playing groups in relation to practice hours, although
significantly greater hours were spent in practice over seven days between 16 – 40 years and
41 – 60+ years groups in comparison with 2 – 5 years and 6 – 15 years groups [F (7, 497) =
16.94, p < .001] (Figure 4.14).
81
Practice Hours over Seven Days by PRMDs and
Playing Years Groups
0
5
10
15
20
25
1 2 3 4 5 6 7 8 9 10 11
(1)+(2) 2-5 yrs (4)+(5) 6-15 yrs (7)+(8) 16-40 yrs (10)+(11) 41-60+ yrs
(1,4,7,10 = no PRMDs) (2,5,8,11 = with PRMDs)
Mean
an
d S
D P
racti
ce
Ho
urs o
ver 7
Days
Figure 4.14. The hours of practice over seven days (M ± SD) with 2 – 5 years (n = 164), 6 – 15 years (n =250), 16 – 40 years (n = 65), and 41
– 60+ years (n = 26); and with PRMDs (n = 214) and with no PRMDs (n = 291) reported by the respondents.
Different Levels of Playing
The Pearson Chi-square test [χ ² (2, N = 500) = 42.50, p < .001] revealed a significant
association between PRMDs and the various Grade Level groups. The percentages reported
below (Figure 4.15) suggested that participants who had achieved the level of piano grade 7
or higher of the Australian Music Examination Board to tertiary level had 62.8% the highest
incidence of PRMDs in comparison with the other two groups.
82
0
20
40
60
80
% PRMDs
Different Level of Playing
prelim, grade 1,2,3
grade 4,5,6
grade 7, 8, associate,licentiate, tertiary
Figure 4.15. The percentage incidence of PRMDs among preliminary, grade 1, 2, 3 (n = 173), grade 4, 5, 6 (n = 163), grade 7, 8, & associate,
licentiate and tertiary (n = 164).
When using the number of practice hours over seven days as the dependent variable, a
2 (PRMDs) x 2 (Gender) x 2 (Piano as Major) x 3 (Grade Level) ANOVA revealed no
significant difference [F (1, 476) = 1.62, p = .20] between the groups with and without
PRMDs. The result also revealed no significant main effect of Gender [F (1, 476) = .02, p =
.89]. As expected, there was a significant main effect for Piano as Major [F (1, 476) = 12.96,
p < .001] and for Grade Level groups [F (2, 476) = 23.10, p < .001]. There were no significant
interactions. Post hoc analysis showed that the grade 7, 8, associate, licentiate and tertiary
group had significantly higher practice hours (p < 001) in comparison with preliminary, grade
1, 2, 3, 4, 5, 6 grade levels.
Piano as the Major or Non-Major Instrument
Participants for whom the piano was the major instrument group (n = 321) had 49%
incidence of PRMDs, whereas those for whom the piano was the non-major instrument group
(n = 184) reported 31% incidence of PRMDs. The Pearson Chi-square test [χ ² (1, N = 505) =
83
15.40, p < .001] showed significantly higher percentage of PRMDs in the group with piano as
major instrument group.
Differences in Age
Participants ranged from 12 to 89 years of age and were divided into the following
three age groups: 12 to 20, 21 to 40 and 41 to 89 years. The Pearson Chi-square test [χ ² (2, N
= 505) = 22.50, p < .001] revealed a significant relationship between percentage of PRMDs
and age. The frequency increases with age (Figure 4.16).
0
10
20
30
40
50
60
70
% PRMDs
Different Age Group
12-20 yr
21-40 yr
41-89 yr
Figure 4.16. The percentage of PRMDs among players of differing age: 12 - 20 years of age (n = 372), 21-40 years of age (n = 57) and 41 -
89 years of age (n = 76).
Gender
There were 70% female and 30% male players within the sample. The female group (n
= 351) reported a 46% incidence of PRMDs, and the male group (n = 154) reported a 34%
incidence of PRMDs. Pearson Chi-square test revealed females reported a significantly higher
percentage of PRMDs than males [χ ² (1, N = 505) = 5.75, p = .02)]. When using the number
of practice hours over seven days as the dependent variable, a 2 (PRMDs) x 2 (Gender) x 2
84
(Piano as Major) x 3 (Grade Level) ANOVA, the result revealed no significant main effect of
Gender [F (1, 476) = .02, p = .89] (see page 82 for all result of analysis).
Hand-Span Sizes
Using a 2 (PRMDs) x 2 (Gender) ANOVA with hand-span size as the dependent
variable (Figure 4.17), the analysis revealed no significant difference between the PRMD
groups [F (1, 504) = 2.6, p = .11]. As expected males had significantly bigger hand-span sizes
than females [F (1, 501) = 14.10, p <. 001]. The result also revealed no significant interaction
[F (1, 504) = .33, p = .57] between PRMD and Gender.
Different Hand-Span Sizes were Analysed with
PRMDs and Gender
0
5
10
15
20
25
30
1 2 3 4 5
1,no-PRMDs males 2,no-PRMDs females 4,PRMDs males 5,PRMDs females
Mean
an
d S
D H
an
d-S
pan
Siz
es
Figure 4.17. The Mean and ± SD of hand-span sizes in relation to the incidence of PRMDs between gender, and small hand (n = 218) and big
hand (n = 269).
85
Onset of PRMDs by Playing Certain Piano Techniques
There were 96 players who reported the onset of PRMDs associated with various
piano techniques. Furthermore, 59 players reported the occurrence of PRMDs when playing
octaves, 27 when playing fast passages, 20 when playing chords, 20 when playing fortissimo,
13 when playing arpeggio, 11 when playing trills, 11 when playing scales, 2 when playing
polyphonic music, 1 when playing pianissimo and 7 respondents did not specify any piano
technique.
When reporting the onset of PRMDs in relation to playing certain piano techniques,
the statistical test [χ ² (36, N = 505) = 161.18, p = .001] showed a significant relationship
between the occurrence of PRMDs and the piano techniques. The onset of PRMDs was more
frequently reported when playing octaves in comparison with other piano techniques.
Locations of PRMDs
Among the 214 participants who reported PRMDs, the frequency of PRMDs was
located in various parts of the body (Figure 4.18). Clearly, the participants were able to
identify disorders at multiple sites on the body.
0
20
40
60
80
100
120
140
Frequency
neck or shoulder
back
upper arm
forearm or elbow
wrist, hand or finger
Figure 4.18. The frequency of PRMDs at various locations of the body: neck or shoulder (n = 109), back (n = 79), upper arm (n = 12)
forearm or elbow (n = 56), wrist, hand or finger (n = 136).
86
Types of Discomfort
This sample also suffered many types of physical complaints (Table 1). Pain was the
most frequently reported symptom, followed by ache, stiffness, fatigue, pins and needle
(paraesthesia), swelling, spasm, and numbness.
Table 1. Symptoms of Discomfort reported in the sample.
PRMDs n
Pain
Ache
Stiffness
Fatigue
Pins and needles
Swelling
Spasm
Numbness
140
124
83
67
18
14
13
9
Seeking Help when PRMDs Occurred
Among 214 cases of PRMDs in the sample, 44% of players (n = 94) sought help from
someone. However, among the other 56% (n = 120), 111 players did not seek any help, two
players were trying different playing postures and seven players stopped playing altogether.
Out of 94 players who sought help for their PRMDs, 57 players sought help from teachers, 22
players visited physiotherapists, 17 players had treatment by medical doctors, 13 players
visited chiropractors and nine players sought other options.
87
Chapter V
Discussion
Introduction
Playing related musculoskeletal disorders (PRMDs) are a range of conditions
characterized by persistent pain in the muscles, tendons and other soft tissues. A number of
risk factors may contribute toward the occurrence of PRMDs: lack of awareness of PRMDs,
lack of muscle fitness and tolerance for the assigned repertoires, duration and variation of
practice habits, inefficient playing postures and playing movements, lack of knowledge about
biomechanical requirements for different types of keyboard instrument, and previous trauma.
The important finding of this study was that a significantly higher percentage of
PRMDs were reported when players held a neutral wrist position and adopted an elevated
shoulder posture (Figure 4.1 and 4.3). However, there was no significant difference in the
incidence of PRMDs between small and big hand-span sizes. Among the playing-occupations,
the performers and the music teachers revealed a significantly higher percentage of PRMDs in
comparison with student players. Overall, the professional group took longer breaks;
however, the interaction indicated that professional players without PRMDs took longer
breaks than the professional players with PRMDs. In contrast, the non-professional players
with PRMDs took longer breaks than the non-professional without PRMDs. Participants who
practised more hours over seven days reported a significantly higher percentage of PRMDs
compared to those who practised less. However, when PRMDs, gender, piano as major or
non-major and different grade level playing groups were analyzed by practice hours over
seven days, no significant difference was found between the groups with and without
PRMDs. Females reported a significantly higher percentage of PRMDs than males. However,
88
gender comparison in relation to the incidence of PRMDs, when stratified by practice hours
over seven days, revealed no significant difference between male and female participants.
The possible causes of PRMDs are: (1) using inefficient playing postures and playing
movements during force production; (2) frequently applying angular movements that increase
the frequency and acceleration of concentric and eccentric muscle actions when playing; (3)
using practice-breaks during the daily training session only after the occurrence of PRMDs
rather than to minimize the fatigue of working muscles; (4) maintaining unhealthy body
postures when practising that increase the risk of neck, shoulder and back pain; (5) working
with unsuitable repertoires without consideration of physical capability; (6) acceleration of the
learning process without applying a standard muscle conditioning and strengthening program
with appropriate training repertoires; (7) working with sudden increases in practice-time when
under greater physical and psychological pressure; (8) ignoring the differences of various
mechanical structure and tension of the keyboard instruments when playing or performing;
and (9) maintaining an unhealthy lifestyle, which is also an important factor related to the
failure of piano-playing careers.
It has long been recognized in the ergonomics literature that occupational overuse
syndrome (OOS) is caused by one or more of the following factors: using highly repetitive
movements without applying break time; long term work with excessive forces loading and
straining the musculoskeletal system; holding isometric contractions on certain joints over a
lengthy period of time; working with poor or awkward postures and putting direct pressure on
nerves (Ackland, 2007). Tasks involving fast movements with rapid acceleration and
deceleration also promote a higher risk of OOS (Burgess-Limerick and Straker, 2004).
Common sites of disorders are carpel tunnel syndrome (Wu, 2007), medial and lateral
epicondylitis, shoulder and neck strain, and back pain. In piano playing, apart from the above
syndromes, PRMDs may include distal pain in the flexor carpi radialis or ulnaris muscles, de
89
Quervain‟s tenosynovitis (Sakai, 1992), synovial cyst, nerve entrapment, tendonitis, and
phalangeal joint and tendon pain.
According to Worksafe Australia (1994), the preventative strategies to control the risk
of OOS are: maintaining force efficiency posture; taking regular breaks during a working
session; introducing movements rather than holding static postures; maintaining healthy
working postures; avoiding prolonged use of bending and twisting; non-excessive working
duration and frequency; training and education programs to obtain skills and experience,
allowing employees to regulate their task, while meeting work demands.
Playing-Techniques and Playing Postures
The adoption of elevated shoulder postures and neutral and Levinskaya System wrist
postures reported significant higher percentage of PRMDs in the sample (Figure 4.1, and
Figure 4.3), whereas different finger postures, elbow postures and finger movements did not
yield a statistically significant contribution to the percentage of PRMDs (Figure 4.2 and
Figure 4.4).
Compared with the non-elevated shoulder posture, piano players holding a sustained
elevated shoulder posture reported a significantly higher percentage of PRMDs. The result
supports Hagberg and colleagues‟ (2005) findings that the highest musculoskeletal disorders
of instrumental practice were neck and shoulder pain. Using an elevated shoulder posture
when playing can greatly increase tension in the upper trapezius muscles. This portion of the
muscle attaches at the lower part of the neck where the roots of the ulnar nerve (C8, T1),
radial nerve (C6-C8) and median nerve (C6-C8) emerge from the vertebral column. Using the
elevated shoulder posture for extensive periods of practice-time may reduce the functional
capacity of the fingers, hands and forearms and may cause the early onset of fatigue. Players
were often unaware of their elevated shoulder posture at the time of practising or performing,
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especially when under an excessive workload (external pressures) compounded with stage
fright (internal pressure). Respondents who reported neck pain commonly expressed using the
elevated shoulder posture. Psychological and physical reactions frequently influence with
each other with a parallel trend (Fjellman-Wiklund, 1998; Bragge, 2006).
There was no significant relationship between the groups with and without the
PRMDs when using a near right-angle elbow position compared to an extended elbow
position. This result did not support Ortmann (1929) who argued that an elbow position of
between 30º to 40º gives the easiest position for playing. Marley and Wehrman (1992)
showed that the elbow extension tends to produce greater grip strength. It is probably
necessary to use dynamic measurements to further investigate the elbow position in relation to
the fingers‟ grip strength when playing piano.
Four kinds of wrist-postures were presented in the survey questionnaire (Appendix
A): the traditional-playing wrist-posture, the weight-playing wrist-posture, the neutral wrist-
posture and the Levinskaya System. There are differences in playing-movements, and a
different emphasis on predominantly using a closed-kinetic chain or an opened-kinetic chain
in relation to the above four playing-techniques. Although the Levinskaya System revealed
the highest percentage of PRMDs, the small number of players who reportedly used this
system warrants further investigation. Among the remaining three commonly used wrist-
postures, the weight-playing and traditional-playing wrist postures reported the lowest
percentage of PRMDs, while players adopting the neutral wrist posture reported a
significantly greater percentage of PRMDs. This result does not support Chung‟s (1992)
finding that the weight playing-technique demands less wrist motion than the traditional
playing-technique.
The risk assessment section of the “National Code of Practice for the Prevention of
Occupational Overuse Syndrome” by Worksafe Australia (1994) states that when muscles are
required to hold a position (i.e., in an isometric contraction) for any length of time they will
91
fatigue very rapidly. It also recommends that whenever possible, the orientation of the task
should allow different muscles to be used in rotation to allow tired muscles to recover,
thereby reducing the risk of PRMDs.
Unlike a neutral wrist posture and traditional playing wrist posture, the weight
playing wrist posture promotes working with gravitational force production, not against it.
The metacarpophalangeal joints are held flexed when using the weight playing wrist posture.
According to Savage (1988), this results in the minimization of passive tension in the extensor
tendons of the forearm, and reduced active tension in the flexor tendons because the extensor
muscles are shortened. Wristen (2000) recommended examining piano technique with the aim
of minimizing extreme wrist motions, including the use of gravitational force in combination
with kinetic motion of the entire upper limb. Unfortunately, the author then stated the
contradictory notion that “the vertical movement of the wrist is needed to allow the passing
under of the thumb to facilitate motion across the keyboard” when playing (Wristen, 2000 p.
62). It is not at all necessary to raise the wrist if the fingers are flexed to form a volar-arch
posture, which increases the force production of the fingers, thereby allowing the thumb to
travel beneath the fingers to minimize the vertical wrist movements.
Wrist posture and motion is, to some extent, influenced by the type of music played.
Tubiana and colleagues (2005, p.193) explained, “Playing of staccato passages is facilitated
by slight wrist flexion which is accompanied by finger extension.” The above wrist and finger
motion of staccato playing-technique may be defined as semi-staccato (i.e., playing 75%
length of the note-value) or non-legato (i.e., playing full length of note value with
disconnection between the notes) playing-techniques for different articulation of the music.
The movements of the wrist-staccato are used in extension rather than flexion in the wrist-
staccato playing-technique of the eighteenth century repertoire during the classical period.
The wrist-staccato (i.e., playing 50% of note value) playing-technique is one whereby the
92
wrist is extended to lift the fingers soon after the key is struck and also to produce the shortest
duration of sound (i.e., staccatissimo, playing 25% of note value).
The 88 keys of the piano are arranged side by side from left to right in a parallel
fashion according to the gradation of the pitch. Players‟ wrists do not only use flexion-
extension motion but also radio-ulnar deviation. Whole arms are constantly moving from one
side of the keyboard to the other side, which may result in frequent adjustments to the angular
direction of the wrist and arm movements. In the ergonomics literature, holding an isometric
posture in neutral is suggested to be much less risky than with the wrist in flexed, extended,
adducted or abducted positions when working. However, in piano playing, holding a neutral
wrist posture (i.e. neither in flexion nor extension) demands constant co-contraction of the
forearm musculature to stabilize the wrist joint, thus greatly reducing the speed of playing
when multi-directional movements are involved. Moreover, in order to accommodate the high
frequency of angular movements when using the neutral wrist-position, the forearm muscles
and tendons need to be activated in frequent acceleration and deceleration modes, thereby
increasing energy-expenditure and causing early fatigue. This may increase the risk of
PRMDs. Therefore, to maximize the movements of fingers and hands when playing piano,
using circular movements at the wrist is essential to reduce consumption of energy.
For the actual tone production during piano playing, finger flexion movements are
used at a constant as well as in an extreme frequency at the metacarpophalange, proximal
phalange and distal phalange. Li (2002) found that the wrist position had a significant effect
on individual finger force and total force production, such that peak finger forces were
produced at 20º of wrist extension and 5º of ulnar deviation. Flexion at the distal phalanges
produces gripping forces to maximize the control in production of tone quality, and at the
same time, allows the arm to rest against the keyboard (i.e., using a predominantly closed-
kinetic chain playing-technique). Using 20º of wrist extension and 5º of ulnar deviation in
piano playing would also reduce the passive tension in the extensor muscles, while at the
93
same time reducing the active tension of flexor muscles in the wrist and forearm to avoid risk
of early fatigue (Savage 1988) and, more importantly produce peak finger force. If the wrist is
in an advantageous position for actual force production, then the players do not have to
„work‟ as hard to achieve the designated performance outcome. This may help to further
explain why certain playing-techniques have a lower incidence of PRMDs in the sample.
Playing-Occupations
There were three main categories used in the analysis of playing-occupations: (1)
performer group, (2) teacher group, and (3) player group. A significantly greater number of
teachers (68%) suffered PRMDs than the player group (38%), but the performer group (67%)
was not significantly different from the teacher group (Figure 4.6 and 4.7). Both the performer
group and the teacher group also suffered a significantly higher degree of severity of PRMDs
compared to the player group. This phenomenon may support the claim that imbalance
between high work demands and lack of autonomy in the work environment may cause
negative stress that can increase the risk of ill health, especially amongst female secondary
school teachers and their perception of high demands at work (Fjellman-Wiklund, 1998).
Professional and Non-Professional Respondents
Seventy-two percent of the players in the professional group reported PRMDs. This
result supported the finding of a previous study in which 88% of the players who majored in
music at the university level indicated that they experienced PRMDs (Guptill et al., 2000).
The common predisposing factors for PRMDs among this cohort were the significantly
greater number of hours spent practising over seven days and the greater number of years they
had played piano. Furthermore, the players were at a significantly higher risk of PRMDs to
94
the upper extremity. With professional and non-professional players pooled for analysis, 42%
of the respondents reported PRMDs. This result was lower than the finding of Chong and
Chesky (2001), where 59% of those surveyed experienced PRMDs; however, the difference
may be due to a greater percentage of 12 – 20 year old participants who responded to the
present survey.
Although the incidence in the present survey of PRMDs reached 72%, it is difficult to
convince professional players whose major instrument is the piano to simply reduce practising
hours to control the risk of PRMDs, because they fear the high standard of performance
would not be reached. Analyzing piano as major or non-major instrument and PRMDs with
the practice hours over seven days, no significant difference between the groups with and
without PRMDs was revealed. This result showed that greater hours of practice over seven
days alone might not cause the occurrence of PRMDs. Clearly then, exposure to the task may
be an important contributor, as noted in the theoretical framework model (Figure 2.9), but it is
not the only factor leading to the onset of PRMDs.
Practice Strategy
The results showed that the group of players who practised 11 – 20 hours and 21 – 40
hours over seven days reported significantly higher percentage of PRMDs in comparison with
the 1 – 5 hours and 6 – 10 hours groups (Figure 4.11). Grieco found that more than 60% of
PRMDs cases appeared in the initial phases of the practice-session, or after two hours of daily
practice (Grieco, 1989). The above reports may also suggest that the length of practice hours
over seven days alone may not cause the incidence of PRMDs.
Within the Practice Break group (n = 215), 51% of the players who reported PRMDs
not only applied frequent breaks during their daily practice-sessions, but also had longer break
times (Figure 4.8, Figure 4.9 and Figure 4.10). Overall the professional group took longer
95
breaks; however, the professional players without PRMDs took longer breaks than the
professional players with PRMDs (Figure 4.10). In contrast, the non-professional players with
PRMDs took longer breaks than the non-professional players without PRMDs. This finding
may suggest that the non-professional players with PRMDs applied breaks during daily
practice-sessions only when they were experiencing some degree of PRMDs. This behaviour
may also indicate that applying practice breaks during the daily practice-session may not be
recognized as a preventive strategy of PRMDs among 57% of the sample (n = 290).
Years of Playing
Exposure to the task, and therefore increasing PRMDs risk, can also be expressed in
terms of the number of years of playing. The results revealed a significantly greater
percentage of PRMDs between respondents with 16 to 60+ playing years in comparison with
2 to 15 years of playing (Figure 4.13). However, when the practice hours over seven days was
analyzed with PRMDs and years of playing groups, no significant difference was found
between the groups with and without PRMDs in relation to the playing years groups (Figure
4.14).
Different Levels of Playing
Participants who had achieved grade 7 piano level of the Australian Music
Examination Board through to tertiary level reported a significantly greater percentage of
PRMDs (Figure 4.15). The grade 7, 8, associate, licentiate and tertiary group played a
significantly greater number of hours over seven days compared with the other groups (Figure
4.15).
96
In addition, the higher-level players must increase daily practice time because the
workload is generally double or triple in quantity compared to lower level players (e.g., scales
and arpeggios of all other technical works are played with four octaves in length rather than
two octaves, and pieces from three to five pages increase to thirty to fifty pages).
Furthermore, these pieces greatly increase in difficulty of piano techniques. Moreover, if
pieces are to be performed in the concert recital program, memorization of the works is
required for a solo performance. Therefore, the risk of piano players developing PRMDs
appears to be a function of exposure (number of hours of practice) as well as the task demands
(complexity and physical demands of playing). However, when practice hours over seven
days were analyzed with PRMDs and playing level groups, that revealed no significant
difference between the groups with and without PRMDs (p = .85). Therefore, those without
PRMDs may have better playing-techniques and, despite the fact that they have been exposed
to a similar level of activity, they may not „misuse‟ their musculoskeletal system by adopting
poor postures and/or playing-techniques.
Age
The present results showed the trend of consistent increase in the frequency of
PRMDs as the age increased [12 – 20 years (36.3%), 21 – 40 years (54.4%) and 41 – 89 years
(63.2%)] (Figure 4.16), whereas Chong and Cheskys‟ (2001) study revealed a trend of
decreasing incidence, from a 72% incident rate between 10 – 20 years down to 50% between
51 – 60 years of age. The result of the present study also differed from Fry‟s (1986) study in
which the 25 – 35 years age group had the highest incidence of PRMDs.
Gender
97
The findings related to the frequency of PRMDs between male and female piano
players, both in the existing publications (Caldron et al., 1986; Chong and Chesky, 2001;
Fjellman-Wiklund, 2003; Wu, 2007) and the present study, revealed that females reported a
significantly higher percentage of PRMDs in comparison with males. When using the number
of practice hours over seven days analyzed with PRMDs, gender, and piano as major
instrument, the result revealed no significant difference between males and females (see p.
82).
Hand-Span Size
The categorization of a hand-span size of ≤20cm as a small hand stretch and ≥20.1cm
as a big hand stretch was in accord with the frequent use of octaves and chords in playing
from Grade 5 level of the Australian Music Examination Board to tertiary level. The present
study yielded no significant difference in the incidence of PRMDs between the two hand-span
size groups (Figure 4.17). This was in agreement with Ong's (1992) study, which showed the
hypothesis that players without PRMDs have larger hand-spans was not supported. This result
also differed from the study of Tubiana (2005a) in which there was 100% incidence of
PRMDs in the “big hand size” group. However, Tubiana classified a big hand size as being
>22cm.
Although this method of categorizing hand size had not been used in any previous
studies, the author believes any physical measurement that does not take into account the
actual playing-related activity is worthless. Thus, any results derived from such measurement
cannot truly answer the matter in question. The reduction in key width to a 7/8-keyboard size
piano, which contributed to the physical ease of the small-handed pianists (Wristen et al.,
2006a) perhaps offered little help in controlling the risk of PRMDs. But unlike some other
musicians, piano players are unable to carry their instrument with them because of physical
98
and economical limitations. However, a very important point is that the force production of
the forearm between the conventional piano and the 7/8-keyboard size piano offered no
discernible difference for the player (Wristen et al., 2006b). In fact, the size of the hand itself
had little influence on the touch control of playing (Lee et al., 1990). The heavier weight of
touch-key control, longer strings and greater mechanical properties of present day acoustic
pianos need much greater force, physical strength and ability to complete the playing task.
Further investigations of the advantages of 7/8-width keyboard may prove beneficial.
Association between PRMDs and Piano Techniques
A significant difference in various piano techniques associated with PRMDs was
reported. Octave playing was reported as having the highest frequency for onset of PRMDs in
the sample. The results support earlier studies showing that the players‟ wrist pain, finger pain
and hand pain were experienced while playing double-octaves (Sakai, 1992; Shields and
Dockrell, 2000). Octave playing involves two or more fingers on each hand working at the
same time. Whether playing a loud or soft tone of octave or octave-chord, the gripping motion
of the fingers has to combine with finger-stretching positions. Abduction of two or more
fingers, together with the flexion of all phalangeal joints, combine to produce force that could
cause higher tension in the mechanical systems of hands and wrists. In addition, if the octave
or octave-chord position on the keyboard is very awkward and in a constant use, the muscles
of the upper limbs may experience extreme tension. Working with octave and octave-chord
playing with high or low force exertion, and with high repetition or high speed, without an
economical force production technique, compounded with an unhealthy practice protocol
could mean that the risk of PRMDs is inevitable.
99
Symptoms and Seeking Help when PRMDs Occurred
The most common presenting symptom was pain (65%) and ache (58%) among the
players who experiencing the PRMDs (Table 1). The PRMDs were also frequently occurred
at the wrist, hand and finger (Figure 4.18).
Among the 214 respondents who reported experiencing PRMDs, only 90 players
sought help for their PRMDs. Fifty-six players sought help from their teachers, 22 players
sought help from physiotherapists, 17 players visited medical doctors, 13 consulted
chiropractors, and 9 sought help from other sources. The above figures showed that the
majority of players turn to their teachers for help when experiencing PRMDs, yet these
teachers were the group reporting the higher percentage of PRMDs. This information supports
Brandfonbrener‟s findings (1990). Brandfonbrener was also concerned that the players lacked
confidence in medical practitioners; the injured players were reluctant to seek medical help in
the early stage of PRMDs, which caused difficulties in evaluating and eradicating the problem
(Brandfonbrener, 1990). Guptill‟s (2000) study had the same finding that pain and ache were
the most frequent presenting symptom among the instrumental players. These data reinforce
the problem that there is no appropriate musician clinic or organization in Western Australia
made known for players to seek advice when PRMDs occurred.
The experienced piano teacher may know that certain playing postures are required to
prevent stress and strains of playing-techniques, but may be lacking in the awareness of the
mechanically sound posture positioning for anatomic- and energy-efficiency. Some piano
teachers may have experienced PRMDs themselves and as a result, may have anecdotal ideas
about principles of prevention and management. These ideas may or may not be consistent
with current information published by the performing arts medical practitioners. If the
teachers had no experience themselves with PRMDs during their career, they may not
acknowledge the existence of PRMDs, and therefore assume that the complaints were merely
psychosomatic. As mentioned in previous chapters, recognition and understanding of music
100
PRMDs were still not required in the curriculum of the music education system. Therefore,
the ability of teachers to properly assist the injured players was very limited.
Medical practitioners and physiotherapists may help to reduce and even remove the
symptoms of injured players, but without any knowledge of piano playing-techniques and
skills, motion-economy and mechanical efficiency, they may not be able to offer any practical
advice for the prevention of further injuries.
Limitations of the Study
Using survey techniques that require recall of information and respondent‟s perception
of tasks has some limitations. One possible limitation of the study was that the information
extracted from the self-administered questionnaire might contain a degree of discrepancy
between the players‟ perception of playing-techniques and postures and those that they
actually applied when practising. Without standard criteria set before the players, there was no
way to know the correct way to play the piano. The majority of respondents expressed that
they did not pay much attention to the kind of techniques and postures they actually used
when playing, because they lacked the knowledge of different playing-techniques, and they
had never been given a choice. They had neither seriously thought about the subject matter,
nor they had any discussion with anyone before.
Although the questionnaire did not investigate the effect of playing conditions on
PRMDs, it seems likely that using unfamiliar instruments (i.e., acoustic grand piano, upper
right piano, and various touch control electronic keyboards), during performance on stage or
practical examination may directly or indirectly contribute to the high incidence of PRMDs.
Understanding the differences that exist in every piano may help players to take precautions
and to appreciate the necessity of physical adaptation when performing. It also seems likely
101
that when players engaged in sudden increases in practice time before performance or
practical examination there may be an increase in the risk of PRMDs.
Even though face-to-face interviews might have been preferable, the self-administered
survey questionnaire was economical and harvested 505 returned copies in a relatively short
period of time. On the basis of the players‟ self-reported information, important feedback on
the playing-techniques and postures in relation to PRMDs were gathered that could be used as
a directional tool to the next level of a research program.
The most important information obtained from the surveyed population was the
various piano playing-techniques and postures that were commonly used in relation to the
incidence of PRMDs that had not been previously researched at the time of the present study.
102
Chapter VI
Summary
This study used a self-administered survey questionnaire that was designed by the
researcher to investigate the incidence of PRMDs among piano players, together with details
of their playing techniques and postures, and practice strategy. The range of respondents (N =
505) included: professional and non-professional players, with piano as the major or non-
major instrument. The respondents included playing occupations (i.e., performers, teachers
and players), aged from 12 to 80+ years, and both males and females.
The unique aspect of this research was that, for the first time, a questionnaire targeted
the players‟ playing-techniques and playing postures (i.e., under the risk factors of misuse) in
relation to the incidence of PRMDs. These issues had not been previously investigated among
piano players with a large number of participants, although some earlier studies were
concerned with the general matter of misuse. A theoretical model (i.e., Figure 2.9) was
developed to help explain the factors that may give rise to PRMDs. The primary factors of
misuse, overuse and playing conditions were identified and specified in this theoretical model.
Total of 580 copies of the self-administered survey questionnaire were distributed.
The survey instrument contained a total of 33 questions for obtaining information of various
playing-techniques and movement techniques, participants‟ history of playing and habitual
practices, playing-occupations, hand-span sizes, the history of injuries and personal
information. All participants were approached by the researcher directly or indirectly via the
head of their institution prior to actual completion in the survey questionnaire. The majority
of participants were living in the Perth metropolitan area and country regions of Western
103
Australia, while a small number lived in the other states of Australia. The statistics of SPSS
version 13 was used for data analysis.
Focusing on the risk factors for misuse, the results of the study revealed that a
significantly higher percentage of PRMDs were associated with the neutral wrist playing-
technique in comparison with traditional and weight playing-techniques (p < .05). Rigid wrist
conditions are not only detrimental to the finger force-productions, but are possibly linked
with the significantly high risk of PRMDs. A significantly higher percentage of PRMDs (p <
.05) was revealed when using an elevated shoulder posture. Two types of finger playing
movements and two types of elbow postures were investigated in the study; however the
respondents reported no significant association with the PRMDs. The result indicated that
both injured and non-injured groups tried different playing-techniques during their playing
period (p = .05). There was no literature found to compare with the above findings.
When risk factors of overuse were analyzed, the performers and teachers reported a
significantly higher percentage of PRMDs compared to the players (p < .001). The results
revealed a significantly higher incidence of PRMDs with 16 and more years compared with
15 and less years of playing (p < .05). It was clear that extended hours of practice within
seven days, as reported by the respondents of the grade 7 and 8 level of the AMEB up to
tertiary and professional pianists, may be linked to a significantly higher incidence of
PRMDs. This result may also indicate that excessive workloads with complexity of
compositions and intensity of repertoire might be linked to the incidence of PRMDs. The
results revealed a significantly higher incidence of PRMDs (p < .05) when players engaged
with more than 5 – 40 hours of practice compared to those who practised less than five hours
within seven days. The above result supported an earlier study (Fry, 1987), that practising
longer hours was associated with a higher risk of PRMDs; however, it differed from some
studies (Morse et al., 2000; Chong and Chesky, 2001) in which that 5 – 9 hours or <3 hours
had the highest incidence of PRMDs. The professional players without PRMDs took frequent
104
practice breaks and a lengthy break time during daily practice sessions compared to those
with PRMDs (p < .05). However, non-professional players with PRMDs took longer practice
breaks compared to those without PRMDs. It appeared that the non-professional players in the
sample may have used practice breaks when they experienced PRMDs rather than for
preventative purposes, whereas, the professional players may have benefited from lengthy
break time when practising.
Seventy-two percent of the players in the professional group reported PRMDs. The
result supported the finding of a previous study in which 88% of the players who majored in
music at the university level indicated that they experienced PRMDs (Guptill, 2000). The
onset of PRMDs was frequently reported when playing octaves in comparison with other
piano techniques. This finding was in line with existing studies (Sakai, 1992; Shields and
Dockrell, 2000).
The 21 to 80+ years of age players reported a significant association between the
groups with and without PRMDs compared to those 12 to 20 years of age. This result differed
from previous studies, where the 25 to 35 years age group (Fry, 1986) and the 10 to 20 years
age group (Chong and Chesky, 2001) had reported the highest incidence of PRMDs. Females
reported a significantly higher incidence of PRMDs than males and this was in line with the
earlier studies (Caldron et al., 1986; Fry, 1988; Manchester and Flieder, 1991; Roach and
Martinez, 1994; Chong and Chesky, 2001). Conversely, when practice hours were analyzed
by gender, the result revealed no significant difference between the groups with and without
PRMDs (p > .05). There was no study found in the literature to compare the above findings.
The different hand-span sizes revealed no significant difference in the incidence of PRMDs in
the study (p > .05). This result supported the findings of earlier studies (Wagner, 1988; Lee et
al., 1990; Tubiana, 2005a) that showed the hand sizes had no significant influence on
PRMDs.
105
Pain was the most predominant symptom of PRMDs, while pain and ache were most
frequently reported in the locations of wrist, hand and fingers. Of the 214 cases of PRMDs
reported, only 44% (n = 94) of the players sought help from teachers (n = 56), medical
doctors (n = 17) and other health professionals (n = 35). The majority of players sought help
and obtained the preventative advice of PRMDs from their teachers.
The following summary statements address the possible relationship among the risk
factors of misuse, overuse and the playing conditions (see Figure 2.9 for the comprehensive
version of theoretical framework).
Figure 6.1. Summary diagram of the theoretical framework.
The professional players with piano as their major instrument, using predominantly neutral
wrist posture (i.e., open-kinetic chain playing technique), reported a significantly higher
incidence of PRMDs. Although the present study showed a greater number of years of
playing was associated with greater risk of PRMDs, the result also showed that the years of
playing had no significant effect on the incidence of PRMDs (p > .05) when it was analyzed
with the practice hours within seven days. Moreover, analyzing the practice hours over seven
days with the piano major/non-major instrument, the various grade levels and PRMDs; the
results showed that the practice hours had no significant effect on the groups with and without
PRMDs (p > .05). There was no study found in the literature to compare with the above
findings. These results suggest that players who engage in overuse practices may not
Misuse risk factors
Overuse risk factors
Playing conditions risk factors
PRMDs
106
necessarily trigger PRMDs. The PRMDs seem to arise when overuse is compounded by
misuse and/or adverse playing conditions. The best and safest practice would be to minimize
consumption of musculoskeletal force production and combine this with effective practice-
breaks between sessions to achieve the optimum goal of daily practice.
The significantly high prevalence of PRMDs in the professional group of pianists
warrants further investigation could focus on questions including:
1) What are the different finger force-productions in relation to different playing postures of
the wrist and elbow?
2) What are the differences in biomechanical force-production and energy-efficiencies when
playing acoustic grand piano as opposed to an acoustic upright piano?
3) Whether the knowledge of contralateral influences on bimanual motor-learning skill
improves the learning processes, and ultimately shortens the lengthy practising hours that are
needed to complete the given task, that in turn may reduce the incidence of PRMDs.
4) What are the types of practice-break-practice training programs that are energy-efficient
and risk free from the PRMDs for professional and non-professional piano players?
107
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1
Appendix A…………………………………………………………………………………116
“An Investigation of Professional and Non-Professional Piano Players‟ Playing Postures and
Techniques” (Self-Administered Questionnaire)
Appendix B……………………………………………………………………….………...127
Information Sheet
Appendix C………………………………………………………………………………....129
Consent Form
Appendix D……………………………………………………………………………..…..131
Missing Data
Appendix A
Appendix A
116
117
There is no right or wrong answer.
1) At what age did you start your first piano lesson?
3 8 13 18 31-40 4 9 14 19 41-50 5 10 15 20 51-60 6 11 16 21-25 61-70 7 12 17 26-30 71+
2) How long (in years) have you been playing?
1 3 5 7 9 20
2 4 6 8 10 more
3) Have you ever had a break since you began playing? (Apart from the usual
holidays)
Yes , did you go back to play again? Yes No
No
4) How many hours do/or did you practise within 7 days?
Less than 1hr <2 hr <5hr <10hr
<20hr <30hr <40hr more 5) Did you have any rests during above practice session?
Yes No (if no, go to question 8). 6) How many breaks did you have during the daily practice?
Once twice more none
7) For how long (in minutes) did this break last?
3 5 10 15 30 or more
8) On average how many days do you practise a week?
1 2 3 4 5 6 7
118
9) What is the grade level that you are in at present according to the
Australian Music Examination Board or equivalent?
Preliminary Grade 3 Grade 6 Associate
Grade 1 Grade 4 Grade 7 Licentiate
Grade 2 Grade 5 Grade 8 Tertiary
10) Do/or did you spend most of the time performing /or teaching?
performance teaching practicing
11) Place a tick one box to match your present playing posture. (Mark only the present boxes at the style) Wrist position only
A B present past present past
C present past
Fingers posture
A B present past present past
119
Elbow posture A L.H R.H
A B present past present past Shoulder posture
A B present past present past 12) Did you change your playing posture at any time in the past?
Yes What posture did you use in the past? (Please mark the posture pictures on the past box under question 11)
No (go to question 13) 13) What is your maximum stretch of hands from tip of the thumb
to the tip of little finger? (Please measure with the lines provided on the side of the page. Put your finger 5 at the top where line A is drawn and after stretching your hand mark the tip of your thumb with your own lines.)
120
14) What are your fingertip movements when pressing the key?
A Vertical movement (up and down) (tick A or B or both)
B Or horizontal motion (sweeping back and forth) (tick A or B or both)
15) During the playing period have you ever experienced any physical
discomfort/or pain? Yes No (go to question 27)
121
Mark your discomfort/or pain on the photos (Please use pen to mark as many places as you need) A Front B Back
122
123
16) Were you practising any special keyboard technique at the time of the onset of your problems?
Yes No go to question (18) 17) What kind of techniques when playing causes your discomfort? Octave
Chord
Scale
Arpeggio
Fortissimo
Fast passage
Pianissimo
Polyphonic music
Trill
Others (Please specify) ____________________________________
18) How would you describe your discomfort, and degree of
intensity? 0 (none) 1 (mild) 2 (moderate) 3 (severe) 4 (very severe). Tick your relevant symptoms on the scale
Pain
0 1 2 3 4
Spasm
0 1 2 3 4
Pins and needles
0 1 2 3 4
Stiffness
0 1 2 3 4
Numbness
0 1 2 3 4
Fatigue
0 1 2 3 4
Swelling
0 1 2 3 4
Ache
0 1 2 3 4
19) How long did the discomfort/or pain last?
minutes_________, hours_________, days__________,
weeks__________, months________, years_________.
20) Was the discomfort/or pain always present when playing piano?
Yes No sometimes present 21) At what age did the discomfort/or pain occur after you had
started to play the piano? ____________________________ 22) Have you sought (looked for) help in any way?
Changing playing posture Seek some one’s help
Did not seek any help (go to question 27) Stopped playing altogether (go to question 27)
23) Who helped you? (Tick as many boxes as you need)
Teacher Chiropractor
Medical Doctor Physiotherapist
Others please specify _________________________ 24) Have you had any medical treatment for the discomfort/or pain? Yes No (go to 26) 25) Has treatment been successful?
Completely gone Reduced Same as before It came back when practicing
124
26) Did the discomfort/or pain stop after changing the playing posture?
Completely gone Reduced Same as before Did not change posture 27) Are you a professional musician?
Yes No if no, what is your occupation? ___________ 28) Is piano your major instrument?
Yes No 29) Do you play any other musical instrument?
Yes what instrument? __________________ No
30) What type/types of music have you played? (1) all the time (2) most of the time (3) some of the time (4) least of the time (5) None
Classical ( ) Jazz ( ) Church ( ) Pop ( ) Rock ( )
31) You are Male Female
32) What is your present age? 3 – 5 31 – 40 6 – 10 41 – 50 11 – 15 51 – 60
16 – 20 61 – 70 21 – 25 71 – 80 26 – 30 81 – 90
125
126
33) Would you like us to contact you for further research work?
Yes No If yes, please give Your name:_________________________________________ Telephone No._______________________________________
Email: ________________________________ Thank you for your time. Researcher: Lili Allsop 2006
127
Appendix B
128
129
130
APPENDIX C
131
132
APPENDIX D
133
