Muscular effort and musculo-skeletal disorders in piano students - epm

ERGONOMICS, 1989, VOL. 32, No. 7, 697-716Muscular effort and musculo-skeletal disorders in piano students:electromyographic, clinical and preventive aspectsA. GRIECO, E. OCCHIPINTi, D. COLOMBINI, O. MENONI,M. BULGHERONI, C. FRIGO and S. BOCCARDI`Ergonomics of Posture and Movement'—EPM—Research Unit,c/o Clinica del Lavoro 'Luigi Devoto', Via San Barnaba 8,20122 Milano, ItalyKeywords: Musculo-skeletal disorders; Piano players; Electromyography; Physicaleducation; Training.An investigation was made on the relationship between music practice andmusculo-skeletal disorders among piano students, with the main aim of developinghealth education programmes that would improve the performance and health ofthe students.The investigation covered three areas:(a) Analysis of study organization and main musculo-skeletal complaintsachieved by a questionnaire distributed to ali piano students at the MilanConservatory.(b) Vocational electromyographic analysis of the effort exerted by the variousmuscle groups of the trunk, of the shoulder and shoulder biade girdle, and ofthe arra during performance of a standard set of piano exercises, an unseenpassage and a passage of maximum difficulty. This analysis was made on asample of six subjects.(c) A series of preventive measures was developed on the basis of a criticaiassessment of the results (38% of the students practised for excessively longperiods without breaks; 62% had from 1 to 5 complaints, the most affectedsites being the spine and the trapezius muscles). These consisted largely of ahealth education programma aimed at helping the students to suitablyorganze practice and resi periods and in instructing them in appropriateexercises for relaxation and stretching of overused muscle groups andstrengthening the supporting muscle groups. Changes in lifestyle avere alsosuggested.L IntroductionRecent literature is poorly lacking in data on osteo-muscular disorders among pianista.The alterations most frequently attributed to piano practice are tendinitis of the handand forearm muscles and nerve compression which often manifests as a carpal tunnelsyndrome (Clark 1986).Paradoxically, the most detailed literature on the subject goes back to the lastcentury, with a description of `pianist's cramp' that was identical to the perhaps batterknown writer's and telegrapher's cramp. At that time, the condition was the subject ofampie discussion as to its etiopathogenesis and clinical definition which can in eachcase be identified as originating from overuse of the musculo-tendineous structures ofthe forearm and hand, which manifests, usually in an acute or recurrent forra, with pain,weakness and loss of co-ordination and control (up to a transitory paretic-likecondition), accompanied in some casca by excessive locai sweating.0014-0139/89 $3 . 00 (0 1989 Taylor & Francia Ltd.

71 698 A. Grieco et al.PIOn the basis of these bibliographic references of 100 years ago, Australian authorsrecognized the close similarities between pianist's cramp and the `overuse syndrome'defined as `those changes brought about in the muscles and joint ligaments fromexcessive use, causing pain, loss of function, and almost always demonstrabletenderness in the affected structures'. (Fry 1986, 1987).In a study made in seven of Australia's 11 music schools, covering 409 pianostudents, it was found that 9% of the students were affected by the overuse syndrome to amore or less marked degree. The syndrome was much more frequent in females (7%) thanin males (2%). The saure author reported that the overuse syndrome affects morethan 50% of the musicians in modern Symphony orchestrar in Australia.There has been a tendency to demand increasing technical performance frommodern concert pianos. The Grober concert piano of the early 19th century involvedabout 6 mm travel of the key and required a force of about 23 g to depress the key, with atension of the middle string section of 12 to 15 kg, whereas the modern Steinwayinvolver about 10 . 5 mm travel, a depression pressure of about 50 to 60 g and 90 kgtension (Fry 1986).On the basis of these observations, we undertook an investigation which had thefollowing aims:1. Estimate the frequency of disorders of the locomotor apparatus in pianostudents of the Milan Conservatory.2. Assess the effort of various muscle groups during piano practice by means ofvocational electromiography techniques, and also o utline a mode) fororganization of practice during the week.3. Identify prevention measures, with particular emphasis on ways to changestudents' individua) attitudes and train them in suitable mobilization, relaxationand stretching exercises.2. Methods2.1. Analysis of study day organization and analysis of musculo-skeletal disordersA specially developed questionnaire was used, divided finto three parts, i.e.:(a) generai information and features of organization of study and free time;(b) occurrence, site, and characteristics of any musculo-skeletal disorders;(c) occurrence of psychic, respiratory or digestive complaints.A total of 117 completed questionnaires were collected (54 males and 63 females),equivalent to a response rate of about 75% of the students contacted. The compositionof the respondents, by age class, is shown in table I.2.2. Electromyographic study2.2.1. subjects: The electromyographic study covered six piano students (three malesand three females) enrolled for the fina) years of the course. The subjects participated inthe experiment voluntarily. Generai anthropometric parameters (weight, height) weremeasured for all subjects, plus a number of specific parameters of the hand such asbreadth, length of the third finger, length of the hand at the third finger, angles betweenfingers at maximum aperture. The relative percentile was calculated for all parameters.2.2.2. Selected piano exercises: In order to standardize the exercises performed by thesix subjects, a set of standard exercises of varying difficulty was selected, each involving

Muscular effort and musculo-skeletal disorders in piano students 699Table I. Distribution of piano students examined via questionnaire, by age class and years ofstudy.Age classyearsNumberYears of studySC8-10 9 211-13 26 3.914-16 29 6.117-19 21 9.2620-22 20 11.223-25 8 10.8>25 4 16.5Total number of subject examined N=117.a different use of the hand/forearm system. The exercises were taken from Hanon (aclassic volume of preparatory exercises widely used in piano teaching) and wereclassified in groups according to the different aspects of muscular effort (figure 1). Eachexercise was performed at two speeds: (a) the minimum speed for the score; (b) thestudent's maximum possible speed. Also, each subject performed an unseen passage(Scott Joplin's 'Elite Syncopation') which was played again after 15 min practice.Each student then performed one or two passages from his/her repertoire whichhe/she considered to be the most difficult. Here, it was obviously not possible tostandardize the exercises so no comparison could be made, except for the Tirstvariation on a theme of Paganini-Brahms', which all three male students performed.2.2.3. Vocational electromyography: The processing method used was derived fromJonsson (1982), and is based on the definition of the probability distribution function ofmyoelectric signal amplitude. According to Jonsson, the static, maximum peak andmedian load levels can be identified on the amplitude distribution cumulative curves.Studies by Bjórksten and Jonsson (1977) on resistance to fatigue in exercises repeatedfor varying lengths of time, led to the definition of maximum limits for static, medianand peak load values that may be summarized as follows: static load should not exceed2-5% of the maximum voluntary contraction, median load 10-14% and peak load50-70%.In the present study we examined eight groups of muscles, i.e., right upper trapezius,right deltoideus, right biceps, right forearm muscles (epicondyle), right forearm muscles(epitrochlea), right lumbar erector, first interosseus dorsalis of the right hand, left uppertrapezius.Myoelectric signals were obtained using superficial electrodes connected to atelemetric electromyograph. The signal was then rectified and analogically integratetiand transmitted to an IBM/AT personal computer. The software specially developedto obtain and process the signals in rea) time also included simultaneous on-linevisualization of the eight electromyoelectrographic signals. Fina) graphicrepresentation and subsequent statistica) analysis were performed at the enti of theexperimental session on the memorized data.For each subject, myoelectric activity of each muscle was preliminarily recordedduring maximum voluntary contraction (MVC) against resistance. Figure 2 illustratesthe operation required to record the MVC of the epicondyle muscle group.

7N1A) Exercisesof scales& arpeggios,,,„,rA"8) Exercisesof octaves5139r,41Exercisesof notes repeated3x3 and trill44pagm fgr FAMMI! ELICTICErel CUCIMICI(W4-C) Exercisesof alternateoctave scale & tremolo&6- -3 ---- A5660m»s=mmM~ í48go - M –M=nng a r z a = g = c wD) exercisesof terzinastaccataOunwa g anagi,ffildir= A= mwiFigure I.Examples of Hanon exercises and theirgrouping.Figure 2. Operation required to record MVC of epicondyle muscle group.

Muscular effort and musculo-skeletal disorders in piano students 701Activity of the eight muscle groups under study was recorded continuously duringpiano practice; by means of sample recordings at a frequency of 300 per second, weobserved the number of times the sample recordings reached saturation in rangescorresponding to set percentages (at intervals of five) compared to the MVC. Figure 3Aillustrates the result of this procedure: over the total samples, which represented thewhole exercise, it is possible to establish the percentage of time a given muscle hasworked in the different classes of effort compared to the MVC. The percentage level ofeffort compared to MVC is shown on the x-axis and the percentage of time compared tototal practice time is given on the y-axis. In figure 313 the frequencies of the variouslevels of effort compared to total time are represented by the cumulative curve ofamplitude distribution, which also shows the key levels for interpretation of musculareffort. Further elaboration of the results will include the plotting of curves which will beidentica) for the individua) muscles, in single or group tests for groups of subjects, withdefinition of the relative statistica) parameters (mean, standard deviation).3. Results3.1. Organization of practice daysTable 2 summarizes the main data obtained via the questionnaire, in particular themean practice time weekly and on each day of the week for the students divided fintothree age classes (which more or less correspond to the course levels). Hours of practiceper week ranged from 14 in the youngest students to nearly 30 in the older age class. Onthe whole, distribution of hours of practice was homogeneous: only 15 students (about13%) distributed piano practice over the week in an extremely non-homogeneousmanner, and they avere all between 15 and 19 years of age. This could be due to thepressure of secondary school study.0.80AAm p litude d i s t r i b u t i o n c u m u l a t i v e curveTimeTime0.80Peaklevel0.670.530400.67~0.53 -..Staticleve l0.270.40 -0.13oUleve l0000.13edi20 30 40 50an10 20 30 4 W % MCV i0.00%MCsam Vp l e s o v e r 7 5 % o f M V C : ì % 0 . 1 P r o b a b i l i t y : 7 % M V C ( r e c o m m e n d e d v a l u e 5 % ) CAprobability:18% MVC (recommended value 14%) 0.9Probability:33% MVC (recommended value 70%)Figure 3. Amplitude distribution (A) and cumulative amplitude distribution (B) of samples ofEMG signals during a vocational EMG recording test. In (B) the broken lines representthe static, median and peck levels against which the obtained results can be evaluated.

702 A. Grieco et al.Table 2. Distribution of hours of piano practice (A) over the week and distribution of breaks(B).(A) Mean distribution of hours of practice per week.Ageclassyears Mon Tues Wed Thurs Fri Sat Sun Total8-13 1h41' 2h54' 2 h 6 ' 1h39' 2 h 7 ' 2 h43 ' 2 h10 ' 15h20'14-19 3h 14' 2h 53' 3h 18' 3h 36' 2h 18' 3h 20' 3h 52' 22 h 31'>19 4h 33' 3h 56' 4h 23' 4h 29' 3h 44' 4h 21' 3h 54' 29h20'Total 3 h 10' 3h 11' 3 h 16' 3 h 17' 2h 38' 3h 27' 3 h 23' 22 h 20'(B) Distribution of breaks.Number of subjectstaking breaks 96 82% (out of 117)*Mean durationof breaksInterval betweenbreaks11 min70 min* 21 do not take breaks, 17 take breaks bue every 2 or more hours.Ninety-six subjects (82%) took breaks during piano practice lasting on average11 min and taken at an average interval of 70 min. However, some students took breaksevery 2 h or more (N = 17); combining these subjects with those who did not take breaks(N = 21), gave a total of 38 subjects (32%) who practised for excessively long periodswithout breaks. This percentage, along with the number of hours of study, indicates theexistence of relatively high loads, especially considering the age of the subjects.3.2. Musculo-skeletal disordersTable 3 reports the number and prevalente of subjects without complaints (38%) andthose with one to five complaints (62%). The percentage is surprisingly high and thepercentage of subjects (about 14%) who had disorders affecting three or more sites isalso significane.Table 3. Prevalente of subjects with one or more disorders of the locomotor apparatus.DistributionNumberPercentageof interviewees(N=117)Subjects without disorders 45 38.4Subjects with 1 disorder 30 25.6Subjects with 2 disorders 23 19.6Subjects with 3 disorders 9 7.6Subjects with 4 disorders 6 5.1Subjects with 5 disorders 2 1.7Subjects with at least 1 disorder 72 61.5

Table 4. Site, forra of onset and characteristics of the most commonly reported disorders of the locomotor apparatus.Disorder Lumbar Dorsal CervicalUppe rTrapezius Shoulders Forearms WristsNumber of subjects 22 19 21 15 9 16 10with disorder* (109; 123) (119; 83) (99; 123) (11q; 4 ó ) (59; 4J) (9Y; 73) (59; 53)Percentage of 117 19 16 18 13 8 14 8When 01 at 4% 5% 5% 6% 11% 25% 40%No. % beginning (of 20)0218% 16% 15% 27% 44% 50% 40%after 1 h0464% 64% 68% 60% 44% 19% 10%after 2 h08when notplaying23% 10% 25% 13% 11% 6% 40%For how 1 year 47% 47% 25% 46% 25% 33% 40%long (of 19) (of 17) (of 20) (of 13) (of 8) (of 15)2 year 26%. 17% 20% 15% 25% 27% 10%3 year 21% 35% 45% 15% 25% 7% 30%4 year 5% 5% 15% 13% 10%

704 A. Grieco et al.Table 4 analyses in more detail the site, forra and time of onset, and thecharacteristics of the most frequently reported complaints of the locomotor apparatus.There was a high prevalence of disorders affecting ali segments of the spine and thetrapezius muscles. Onset was also typical: spinai disorders appeared in the majority ofcases (more than 60%) after 2 h of piano practice. Painful wrists and forearms, whichalso showed a significane prevalence (8% and 14%), tended to appear in the majority ofcases (75-80%) in the initial phases of practice. In many cases there was a history ofseveral years (from 2 to 4 years) and the subjects generally complained of a sense ofdiscomfort, or a sense of heaviness or stiffness of the site involved.A more detailed analysis of the disorders is made in Table 5, which reports thepercentages of subjects in whom the complaint was judged to be serious accordipg tothe following criteria:(a)Disorders of the spine, trapezius muscles, and shoulders when:appearing at the beginning of practice appearingindependently of hours of practice distinct pain isfelttherapeutic treatment is necessary(b) Disorders of the forearm and wrists when:appearing independently of hours of practicedistinct pain is felttherapeutic treatment is necessary.The percentage of subjects with serious disorders is certainly not negligible and in somecases (lumbar and cervical spine, wrists) represents a considerable portion (41-70%) ofthe subjects who had any complaints in these sites.Table 6 summarizes the range of therapeutic treatment for osteo -muscularcomplaints: massage was the most frequently used treatment, with or without otherforms of physical therapy.3.3. Muscular effort3.3.1. Warm-upexercises:Forthesakeofbrevity,onlytheresultsofgroupsofexercisesgrouped according to their similarity in muscular effort of the upper limbs are reported anddiscusseti. Referente is made in particular to exercises performed at maximumTable 5. Site and prevalence of serious disorders.NumberPercentageof 117Percentageof subjectswith disordersLumbar 9 8 41Dorsal 6 5 32cervical 10 9 48Trapezius 5 4 33shoulders 2 2 22Forearms 4 3 25Wrists 7 6 70

Muscular effort and musculo-skeletal disorders in piano students 705Table 6.Use of therapeutic treatment among piano students.PercentagePercentageType of of interviewees of subjectstreatment Number (N= 117) with disordersDrugs 3 2.6 4.2Massage 11 9.4 15.3Ultrasound 4 3.4 5.5ThermotherapyAcupuncture 3 2.6 4.2speed. Data on the first web-space muscle are not always reported since in some casesdifficulties in recording the signal arose during the tests.Table 7 summarizes the types of movements or attitudes that were prevalentlyencountered in the various exercises or groups of exercises under study. Table 8summarizes, for all subjects and by sex, the cases and the groups of muscles where anexcessive static and median loading occurred. Figure 4 reports, for the total number ofsubjects and for subjects divided by sex, the results of vocational electromyographyobtained by pooling all the exercises performed at maximum speed, which thussatisfactorily represent the warm-up phase preceding the study of a score.Taken as a whole, the results reveal:(1) the deltoid and bicipital muscles show a rather low level of effort,(2) effort of lumbar erector and trapezius muscles and of the muscles of theepitrochlea group was more conspicuous even though on the whole withinacceptable levels,(3) effort of trapezius muscles was on the whole asymmetric (with a tendency togreater effort of the left trapezius), but this is mainly due to the contribution ofthe ferrale sex; in the males both trapezius muscles were involved in an identicalmanner with respect to static and median loading, while for peck loading therewas by far greater involvement on the right,Table 7. Effort of anatomic structures for various exercises considered.ExercisesNotesAlternaterepeatedoctaveScales and 3 x 3 and scale and TerzinaMain movement involved arpeggios trill Octaves tremolo staccataFlexion/extension of fingersAdduction/abduction of fingersAdduction of thumbMovement of arms on lateral pianeLateral movement of trunkMaximum aperture of fingersFlexion/extension of wristsFlexion/extension of elbowInternal/externaì rotation

706 A. Grieco et al.Table 8. Synthesis, by groups of Hanon exercises, of excessive static and median loading of musclesexamined via vocational EMG, EMG and percentage.Excessive static loadingExcessive median loadingExercises M F Total M F TotalScales and EPIC. 9 EPIC. 8 EPIC. 8 EPIC. 20 EPIC. 24 EPIC. 22arpeggios TRAP. L. 7 TRAP. 6 TRAP. L. 16ERETT. 15Notes repeated EPIC. 9 EPIC. 6 EPIC. 7 EPIC. 20 EPIC. 18 EPIC. 193 x 3 and trill Web. sp. 7 Web. sp. 19Octaves EPIC. 6 EPIC. 9 EPIC. 7 EPIC. 22 EPIC. 23 EPIC. 23TRAP. L. 6 TRAP. L. 19 TRAP. L. 15ERETT. 15Alternate octavescale and tremoloEPIC. 9 EPIC. 8 EPIC. 9 EPIC. 19 EPIC. 25 EPIC. 22TRAP. L. 8 TRAP. L. 6 TRAP. L. 19 TRAP. L. 15ERETT. LO. 16Terzina staccataSynthesis ofall exercisesEPIC. 9 EPIC. 6 EPIC. 7 EPIC. 24 EPIC. 18 EPIC. 21EPITR. 6 TRAP. L. 6 EPITR. 16 TRAP. L. 15Web. sp. 9 Web. sp. 21EPIC. 7 EPIC. 7 EPIC. 7 EPIC. 20 EPIC. 20 EPIC. 20Web. sp. 8 TRAP. L. 15Web. sp. 22Epitr. = Epitrochlea; Epic. = Epicondyle; Trap. = Trapezius; Erect. = Erector; Web. sp. = Web-space.(4) the epitrochlea muscles avere used to a greater extent in the males bue thereverse was observed in the case of the lumbar erector and left trapeziusmuscles,(5) data on the first web-space muscle revealed excessive static and median loadingin the females indicating a marked effort of the intrinsic muscle structure of thehand, at least for the ferrale sex,(6) effort of the epicondyle muscles was clearly homogeneous and an excessivestatic and median loading of these muscles was constantly observed.An importane finding was that the smaller build and the lower muscle power of thefemales demanded greater effort of the large muscles of the shoulder and trunk tosustain the finger movement.3.3.2. Unseen passages: Figure 5 illustrates the results of vocational electromyography formales and females. The passages performed, although difficult at first sight, did notinvolve a significane effort of the forearm and arm muscles; nevertheless, comparison ofthe results for the two sexes confirmed also in this instance a greater effort of the largemuscle groups of the shoulder and trunk (trapezius and lumbar erector muscles) in thefemales. The results relative to the execution of the saure passage after 15 min practiceon the whole showed no substantial differences compared to the unseen execution.3.3.3. Extremely difficult musical passages: Only the results of the 'First Variation on atheme of Paganini–Brahms' are reported here as all the male students performed this

Muscular effort and musculo-skeletal disorders in piano students 707R I T W I T R I : CONFLO01 NUM ER O FRODE: 6 ALL IMusc: Trapezious Muse: Delt ide Illu c BI ep Musc: EpicondyleA) Muse: Lumbar E. Musc: 1 Inteross. Musc; Trapezious L.A T I I I I I T A I : C O N F L 0 0 1 N U M E R O F R O D E : ? FENALE ___________ 1usc: Deltoideus r7~sc: Biceps Musc:EpicondyleiB)Mese: Epitrochlea 1 Musc: Lumbar E. Mese: 1 Inteross. Muse; Trapezious LLd ____________xi RTT II JII AI : C ON FI 001 NUM ER O F RO DE: 3 MALEMuse: Trapezious R. Musc: Bicep Mise: EpicondyleC) ..e: Epitrochlea Mese: 1 Inteross.Figure 4. Results of vocational EMG for eight muscles in all subjects (A), in females (B) and inmales (C), recorded during performance of Hanon exercises at maximum speed.

708 A. Grieco et al.I O 1 1 1 9 1 1 0 1 : F R I M AU15 N UM ER O FRODE: 3 1 FEAALEM-, Trapezious R. u - : D.lt.ideus Us : B ps Pic..dy1.A) Muso: Epitrochlea Musc: LU.bar E. Musc: 1 Intero .A T I N I T A I : PRINAVIS NUMERO PRODE: 3 MALE„U-: B cepsso: Epicondy1e6)Muso: Epitro.hlea uso: Lumbar E.Musc: i Inteross.Musc: Trapezious L.Figure 5. Results of vocational EMG for eight muscles in females (A) and males (B), recordedduring performance of an unseen passag g i (Scott Joplin 'Elite Syncopation').piece, so that it is suitable for statistica) and comparative analysis. Figure 6 reports theresults of the EMG analysis for all the males. Here, too, there was excessive static andmedian loading of the epicondyle muscle group. Analysis of the results obtained in theindividua) subjects was significantly interesting: one subject (MF) showed markedeffort of the trapezius and first web-space muscles (in addition to the epicondyle groupof muscles). In another subject (BG) there was marked effort of the epitrochlea, whichwas nos observed in other subjects. Parallel analysis of physical constitutioncharacteristics and anthropometric parameters of these subjects (table 9), revealed apoor muscular structure and hand parameter measurements below the 50 percentile formales (where comparable) in the first subject (MF). Of the other two subjects, one (RS)had a well developed muscular structure and anthropometric parameters of the handbetween 40 and 70 percentile, and the other (BG) had a poorly developed muscular

Muscular effort and musculo-skeletal disorders in piano students 709I RTIMITRI: UELIA01 N U M E R O P R O V E : 3MUSO: Bic— c: Deltoideuspsusc: Epicondy1eiIusc: Lunbar E.Mu— 1 Inteross.Figure 6. Results of vocational EMG for eight muscles in the three males examined, recordedduring performance of Tirst variation on a theme of Paganini-Brahms'.Table 9. Constitution characteristics and anthropometric parameters of three male students.Name MF RS BGHeight (cm) 1.74 1.69 1.90(85 percentile) (50 percentile) (99 percentile)Weight (kg) 62 71 76Generai muscle Very poor Well developed PoorstruttureMaximum 1-11 74finger 11-111 46angles R + L* III-IV 31IV-V 41* R = right, L = lett.81.5 9541 5135 4643.5 49R 20 R 21 . 2 R 22.4Maximum finger (cm) L 20 . 3 L 21 L 22.8aperture R 20 . 15 R 21 . 1 R 22.6(40-50 percentile) (60-70 percentile) (90 percentile)x18 . 7 R18.6 x19.2Length of hand atthird finger (cm) R 8-2 R 8 R 8.5Length of third L 8 . 3 L 8 L 8.6finger (cm) R 8 . 3 R 8 R 8.55(50 percentile) (40-50 percentile) 70 percentile)

710 A. Grieco et al.structure but hand parameter measurements between 70 and 90 percentile. It cantherefore be concluded, without over-generalizing, that muscular structure andanthropometric features are undoubtedly factors that influence the degree of musculareffort a pianist is required to exert, at least in playing more difficult passages.4. DiscussionAnalysis of muscle involvement in piano exercises revealed an excessive loading ofcertain muscular structures, especially of the forearm. Moreover, musculo -skeletaldisorders avere extremely frequent for subjects of such a young age. It is highly likelythat relationships between risk conditions and injuries of the locomotor apparatus,although requiring further verification, do indeed exist and can be attributed to anumber of factors, such as:(a) intrinsic characteristics of the muscular work required in piano practice,(b) adequacy or otherwise of anthropometric characteristics and muscularstructure of the subjects for the type of functional effort required,(c) characteristics of the study posture and the placement of the piano and stool.From a prevention viewpoint, the first of these factors would be difficult to address,since the quality of music would Buffer. For the other factors a series of improvements canbe outlined which would ensure greater comfort and greater efficiency of thelocomotor apparatus of the pianist without affecting performance.S. Prevention via ergonomic improvements5.1. Posture at the pianoDuring practice, the pianist is seated without support of the trunk; the buttocks usuallyresi on the front part of the seating surface; the upper limbs are unsupported and areraised with the elbows at an angle between 90 and 130 degrees. The head is bent forwardat an angle varying between 20 and 45 degrees. The position of the trunk, depending onthe individuai, varies from erect and relaxed to bent and kyphotic (figure 7). On thebasis of evaluation criteria derived from posture analysis in other workingenvironments (Colombina et al. 1985, Occhipinti et al. 1985), postures of this kind areconsidered to constitute a risk because of the lack of support for the trunk and upperlimbs and because the posture tends to be maintained for prolonged periods of time(several hours) without breaks, and are such as to cause alterations in the correctnutrition mechanism both of the invertebral disks and other periarticular structuresand of the muscles (Kroemer et al. 1985).The seats currently used are without backrest or shaping of the seating surface. Wesuggest the students use, if not for concerts at least for practice, seats with semi-rigidupholstery and shaped seating surface plus a back-rest that will support the spine atleast from time to time.5.2. Health and movement educationThe possibility of preventing risk and injury of the osteomuscular apparatus in pianostudents (and allo in teachers and performers) is largely dependent on well plannedhealth education programmes to assist them in organizing their study and lifestyle in amanner that will help them to keep in good physical shape. This strategy is fundamentalnot only because in this context, ali the more so than in other situations, there is littlepossibility of improvement as regards functional performance and structural features(changes in study piace, in instruments, etc.), but because in other situations it has

Muscular effort and musculo-skeletal disorders in piano students 711ÍilbAOcàIc~Oori

712 A. Grieco et al.already proved to be efficacious for prevention, success being directly proportional tothe cultural levai of the subjects concemed (Postacchini et al. 1984).In planning a health education programma, at least three basic questiona arise:(a) message content,(b) message mediatore,(c) means of conveying the message.Here we will only deal with the aspects of message content, which should include thefollowing main topica:(a) reference to the anatomy and physiology of the spine, shoulders and upperlimbs,(b) description and assessment of effort of the locomotor apparatus structures inpiano practice,(c) description of the main disorders of the locomotor apparatus resulting frompiano practice,(d) suggestions regarding relaxation and stretching exercises for the muscle groupsmost involved during practice and exercises to strengthen the supportingmuscle groups. It is importane not only to explain how the exercises should beperformed bue also how to organize them during the day,(e) generai suggestions on life-style.On the basis of the above message content we have developed a draft booklet for pianostudente and teachers; appendix 1 is an excerpt from the booklet, with details of therelaxation and stretching exercises that we recommend to do during a practice day.

STRETCHING PROGRA.AMEStrecching che muscular and ligament structures is useful because:1) It tende to relax che tension accurnulated during hours of practice inrlxed positions (e.g., che spine)2) I t p r e p a r e s c h e m u s c l e s r o r i n t e n s e a c t i v i t y ( e . g . , f o r e a r mmuscles)3) I t he l ps co re l ax mu scular te nsion du e to FA TI G U E by i mp ro vingblood ci rcul ation In che mu scles involved (e .g ., neck and ro rearmmuscles, at che and of che day).With these concepts In mind, a typical programma could be organized asfollows:PHASE 1: in che MORNING as soon as you get up (5 -10 min)PHASE 2; BEFORE STARTING to play (10 min)PHASE 3: exercises DURING PRACTICE (severa! minutes)PHASE 4; ac che END of Praccice DAY (15-20 min)The e x e rcise s sbo u i d be do no si o -IV and p ro g re ssive ty and che tI nalposition shouid be mancained for at least 20-30 seconds.Movements should not be made In rapi d succession (e.g.. bouncing). Toachie ve g oo d re sults i t l e e sse ntial to do che e xe rcise s E V E RY DA Y.e v e n ! t o n l y f o r a f e w m i n u t e . A b o v e a l i , d o n o t d o e x e r c i s e srequiring consideratile effort or for prolonged periods in che micia!stages.Push your shoulders back, count co con,then relax. Push your shouldersforward, count to con enti then relax.Repeat 5 times..MOVEMENTS OF THE SHOULDERSRaise your shoulders, count to conand then relax; push yourshoulders forward, count io con adrelax. Repeat 5 times.PHASE 1 — IN THE MORNING AS SGOLA AS YOU GET UPRELAXATION OF THE BACKL i e o n y o u r b a c k wi t h l e g s , b e n ta n d b r e a t h e d e e p l y , l n s p i r i ' n gt h r o u g h c h e n o s e e n t i e x p i r i n gslowly through che mouth. Do 20f u l l r e s p i r a z i o n e . T r y t o t o o l tiboth your chest enyour abdomenrise and fall during respiratton.n- 2RELAXATION EXERCISELi * o n che fl o o r with l e g s be nta n d b r e a t h e de e p l y , i n s p i r i n gt h ro u g h che nose e n ti e x pl r i ngt h ro u g h che mo u t h . Tr y to fe e ìnot o nl y che chest bu t al so cheabdo me n rise and fal l wi th y ou rbreaching.TO STRETCH BACK MUSCLESFrom che relaxacion position hugyour knees and bring chem slowlytowards you r fo rehe ad as far aspossible. Keep this position for20 seconds and then relax for 30seconds.TO STRENGTHEN ABDOMINAL MUSCLESF r o m a r e l a x e c l p o s i t i o n o n c h et l o o r , b r i n g y o u r k n e e s t o y o u ra b d o me n an d r ai se yo u r he a d an dshoulders while explring, thenblow out che air vigorously.Repeat 5 "es.

TO STRETCH NECK MUSCLES .assumeche posicion shown, clasp y o u rf i n g e r s o n y o u r h e a d a n d pullyour head slowly downwards. Keep thisposition for 20seconds.TO STRETCH SHOULDER MUSCLESS t a n d i n g o r s e a t e d , p u t y o u rh a n d s y o u r s h o u l d e r b l a d e skeeping you r elbows well u p. Toi ncre ase che stre tching e f fe cty o u can p ro g re ssive l y i ncre ase.te nsion o f che he ad . H o l d cheposition for 20 seconds.TO STRETCH FOREAR11 MUSCLESO n a l i t o u r s , p a l m a d o w n a n dfi nge rs tu rne d backwards, mo vey o u r p e l v i s t o w a r d s y o u r f e e tu n t i l y o u f e c i a s t r a i n o n c h ef o r e a r m m u s c l e s . T h e s a m eexercise can also be dona seateda s i n B . Ke e p c he p o si ti o n f o r20-30 seconds.TO STRETCH CHEST MUSCLESWith arms stretched behind yourback and elbows straight, grasp ah a n d e r K i e f w i t h b o t h h a n d ss y m m e t r i c a l l y . T h e m o r e y o uraise your arms behind, che morey o u v i l i f e c i c he pu i l o n y o u rc h e s t a n d s h o u l d e r s . T h i sexercise can also be dona as inB . c h e p o s i t i o n f o r 4 0s e co n d s a n d t h e n r e l a x f o r 2 0seconds.PHASE 2 — BEFORE STARTING TO PLAYRepear exercises 1-4 and continue as tollows:TO S TR ETCH TRA P EZI US M USCL ESe ate d with head beni fo rward,a r m a c r o s s e d w i t h h a n d s o ns h o u l d e r s , b r i n g y o u r h e a dtowards your elbows, at che samet i m e p u l l i n g y o u r s h o u l d e r sf o r w a r d ( y o u s h o u l d f e c i as l i g h t s t r a i n b e h i n d y o u rneck enti between your shoul derb i a d e% ) . K e e p c h e p o s i t i o n f o r 20se conds and re l ax fo r anothe r 20seconds.n° 5FASE 3 — EXERCISES DURING BREAKSTO STRETCH BACK MUSCLESSI to n a chai r, back strai g ht, feetrestíng on che floo r, lega s l i g h t l ya p a r t . L e t y o u r a r m s dro pl oo sely be tween yo u r lega and l e ty o u rse l f tal i to rward , startingfro m y o u r head, u ntIl you cantouch che tloor with che b ac k s o fy o u r h an ds . H o l d che p o s i c i o nf o r 2 0 s e c o n d a t h e n pullyourself up slowly starting wi thche lover back, then back,shoulders and lastly head.Repeac exercises 4-7.TO STRETCH NECK MUSCLESIn seated or standing position, y o uc a n s c r e t c h a l i c h e n e c km u s c l e s : e x t e n s o r , l a c e r a if l e x o r . r o t a t o r a n d f l e x o r b yrotati ng your head very slowly .T h e n e c k m u s c l e s s h o u l d b ec o mp l e te l y re l ax e d : I n at tu ai f a c it b c h e a d s h o u l d m o v e b y .force ofgravity.n° 5PHASE 4 — AT THE END OF A DAY OF PIANO PRACTICERepeat exercises 1-6 and 8 and and wich:O n y o u r k n e e s , s i c o n y o u rh e e l s , s c r e t c h y o u r a r m sfo rward. H o l d che po sitio n fo r 20seconds.

Muscular effort and musculo-skeletal disorders in piano studente 715ReferencesBJóRKSTEN, M., and JoNmN, B. 1977, Endurance limit of force in long-terra íntermittent staticcontractions. Stand. J. Environ Health, 3, 23-27.CLARK, M., and GOSNELL, M. 1986, Hurt at Center Stage. Medicine Newsweek, August 18,42-43.COLOMBINI, D., Oem p iNTi, E., MOLTENI, G., GRIECO, A., DEDOTTI, A., BOCCARDI, S., FRIGO,C. and MENONI, O., 1985, Posture analysis. Ergonomics, 28, 275-284.FRY, J. H. 1986, Overuse syndrome in musícians-100 years ago. The Medicai Journal ofAustralia, 145, 620-624.FRY, J. H., 1987, Prevalente of overuse (injury) syndrome in Australian music schools. BritishJournal of Industrial Medicine, 44, 35-40.JoNssoN, B., 1982, Measurement and evaluatíon of locai muscular strain in the shoulder duringconstrained work. Journal of Human Ergology, 11, 73-88.KROEMER, J., 1985, Dynamic charactenstics of the vertebral column, ettects of prolonged loading.Ergonomics, 28, 95-97.OCCHIPINTi, E., CoLomBiNi, D., FRIGO, C., DEDOTTI, A. and GRIECO, A. 1985, Sittíng posture:analysis of lumbar stresses with upper límbs supported. Ergonomics, 28, 1333-1346.POSTACCHINI, F., PizzETn, M. and MASSOBRIO, M. 1984, Educazione sanitaria nei pazientilombalgici. Giornale Italiano di Ortopedia e Traumatologia (ruppi. X), 2, 244-251.On rend compie d'une recherche sur la relation entra la pratique d'un instrument de musíque etles affections musculo-squelettiques chez les élèves de piano. Ceci ayant pour bui de promouvoirun programme éducatif d'hygiène de vie qui favoriseraìt le travaìl et la sante des élèves. L'étudepresente troie aspects:(a) Une enquéte par questionnaíre auprès des élèves de la classe de piano du Conservatoire deMilan. Elle devait permettre de cerner les principaux troubles musculo-squelettiques.(b) Une analyse électromyographique de ]'effort exercé par les differente groupes musculairee dutronc, de l'épaule, de la ceinture scapulaire et du bras, au cours de l'exercice au piano d'unpassage standard, d'un passage nouveau et d'un passage de difficulté maximum. Cetteanalyse a porte sur six sujets.(c) A partir de ]'analyse critique des résultats (38% des élèves s'exercaient pendant despériodes excessivement longues, sans pauses; 62% faisaient état de 1 à 5 troubles, laplupart concemant la colonne vertebrale et les muscles trapèzes) on a établi un ensemblede mesures preventivar. Elles étaient incluscs essentiellement dans un programmeéducatif sanitaire visant à aider les élèves à organiser les périodes d'exercices au piano etles moments des pauses. Il proposait également des exercices de relaxation et dedécontraction des groupes musculaires sur-sollìcités, ainsì qua des exercices deraffermissement des groupes musculaires de soutien. On suggère aussi des changementsdans le style de vie.Mit dem Hauptziel einer Entwicklung von Gesundheitserziehungs -Programmen zurVerbesserung der Leistung und Gesundheit von Klavierstudenten wurden Zusamrnenhángezwischen dem Oben der Musik und muskulo -skelettalen Stórungen untersucht. DieUntersuchung deckte drei Bereiche ab:(a) Eine Analyse der Gliederung des Studiums und der wichtigsten muskulo-skelettalenBeschwerden anhand eines Fragebogens, der allen Klavierstudenten des MailánderKonservatoriums ausgeteilt wurde.(b) Eine elektromyographìsche Analyse der Anstrengung, die bei den verschìedenenMuskelgruppen des Rumpfes, der Schulter und des Schulterblattgiirtels sowie des Armswáhrend der Ausfiihrung einer Standard-Zusammenstellung von Klavieriibungen, einerunbeobachteten Abschnitts und eines Abschnitts maximaler Schwierigkeit aufgewandtwurde. Diese Analyse wurde bei einer Stíchprobe von sechs Versuchspersonendurchgefúhrt.(c) Auf der Basir einer kritischen Beurteilung der Ergebnisse wurde cine Serie vonáventiven Messungen entwickelt (38% der Studenten hatten úbermáßig langef bungsperioden ohne Pausen; 62% áußerten zwischen 1 und 5 Beschwerden, die ara

716 Muscular effort and musculo-skeletal disorders in piano studentsháufigsten in Mitleidenschaft gezogenen Stellen waren die Wirbelsáule und dieTrapeziusmuskeln). Diese bestand hauptsáchlich aus einem Gesundheitserziehungs-Programm mit dem Ziel, den Studenten bei einer angemessenen Organisation vonObungs– und Pausenzeiten behilflich zu sein sowie Anweisungen fiir geeigneteEntspannungs– und Dehniibungen iiberbeanspruchter Muskelgruppen und ffir dieKraftigung von Hilfsmuskelgruppen zu geben. Anderungen von Lebensgewohnheitenwurden ebenfalls vorgeschlagen.9± o t &50 M me W At m t- N «t-S z: à - C às ~ tz.0i tI T E 0) 3 53 Tft- #ì W é-- L fz.(a) - 99 i C ~k o) $ e 7 i ;z: W- ff L tc W P.I $k -C- íR tc 1 ts. r i It th 9* W 0) rf A- è- 1 71 3 -t(b) I 1 k 1K) C -7 Y #CRt1 1 :6J, CI tn Q 0) Mi ~ A t> C-575,L k, FIO ) W N ep o)(* m 0) m ' y t .0 0 M 91,à ±R M 4~ «:t CF NO) "t 0 CIAMM M 5}1Fr. *5}W y 1t 6 ZO)?W!R W -C 990- L tz.(e) .1 rt UN -T- 0) 1 A t i I 1V1 , T . (9 1:: M --5 t , -C —A 0) -T M M ; t- fV IZ L ft . ( 10) 3896 13 (* MO, fà I- -E ì@ It0)& 09rW1W9 L , 62 0 6 U I h , h 5 0')&R;tffi JS 0 , A t) L- W t--R 1 - ìtt 1- U (0 CM - C. 4 5 , k . )M M tì _t;z fv PR e IT At LWI k, ht 0 , (9 m ft li At @d Uìt a 9 19 * i- tz .I