Article
Resistance Training for Professional String Musicians
A Prospective Intervention Study
Bertil Lundborg, MSc, RPT,1,2 and Wilhelmus Johannes Andreas Grooten, RPT 1,3
BACKGROUND: Many professional musicians report per-
formance-related musculoskeletal disorders (PRMDs).
Evidence shows that resistance training programs are
preventive for musculoskeletal disorders, but only a few
studies have been performed among musicians.
OBJECTIVE: The aim of this study was to evaluate
whether a functional resistance training program can
increase isometric back endurance and isometric
strength in the neck, shoulder, and wrist for professional
string musicians and affect their perceived performance
during instrumental play, as well as their muscle and joint
mobility and the occurrence and intensity of pain.
METHODS: 24 professional string musicians from three
Swedish symphony orchestras participated in the study,
performing individually designed exercise sessions twice a
week over an 11-week period. Isometric strength and iso-
metric back endurance were measured pre- and post-
intervention with a hand-held dynamometer and the
Biering-Sorensen test, respectively. A web-based ques-
tionnaire was used for assessing perceived performance
during instrumental play, as well as mobility and occur-
rence and intensity of pain.
RESULTS: After the training period, the group showed an
11% to 19% increase in isometric strength for neck and
upper extremities and 25% improved isometric endurance
in back extensors (p<0.05). Moreover, 29% to 59% of the
group showed improvements in mobility, performance
during instrumental play, and PRMDs, although these
improvements did not reach statistical significance.
CONCLUSIONS: This functional resistance training pro-
gram seems to be a non-harmful and advantageous exer-
cise method for professional string musicians, but ran-
domized and controlled studies are needed to confirm
the results.
Med Probl Perform Art 2018; 33(2):102–110.
From the 1Department of Neurobiology, Division of Physi-
cal Therapy, Care Sciences, and Society, Karolinska Insti-
tutet, Stockholm; 2Musikerkliniken, Stockholm; and 3Func-
tional Area Occupational Therapy and Physiotherapy,
Allied Health Professionals Function, Karolinska University
Hospital, Stockholm, Sweden.
The authors declare no funding or conflicts of interest
related to this study.
Address for correspondence: W.J.A. Grooten, Dep. of Neu-
robiology, Div. of Physical Therapy, Care Sciences, and
Society, Karolinska Institutet, 23100 Alfred Nobels Allé 23,
S-141 83 Huddinge, Sweden. Tel +46 8 524 888 61, fax +46
8 524 888 13. Wim.Grooten@ki.se.
https://doi.org/10.21091/mppa.2018.2017
© 2018 Science & Medicine. www.sciandmed.com/mppa
102 Medical Problems of Performing Artists
R ecent studies report that the 3- to 12-month prevalence
of playing/performance-related musculoskeletal disor-
ders (PRMDs) ranges between 63% and 97%, indicating that
nearly every professional musician is affected during his or
her career.1–3 In these studies, PRMDs are defined as “any
pain, weakness, numbness, tingling, or any other symp-
toms that interfere with your ability to play your instru-
ment at the level you are accustomed to.”4(p37)
PRMDs are likely due to combinations of biomechani-
cal and psychosocial risk factors that string musicians expe-
rience during their career, such as highly repetitive move-
ments, static work, precision work, awkward positions,4
and combinations of these, together with high mental
demands and low decision latitude.5 The exact pathophys-
iological pathways for the occurrence of musculoskeletal
pain are still unknown, but it is proposed that tissue
damage could be a result of the repetition of altered align-
ments and movements6 and could provide the basis for
nociceptive pain of mechanical origin.7 McCrary et al.8
showed that during arm movements, muscle activity pat-
terns differ between affected and unaffected violinists, and
load is redistributed from the scapula to the humerus. Stud-
ies have also shown a relation between static gripping and
increased shoulder muscle activity, which could lead to
increased load on the shoulder stabilizers, in particular in
elevated arm positions.9 It has been shown that performing
a concurrent cognitive task like the Stroop test while grip-
ping with an elevated arm also leads to less maximal grip-
ping strength, decreased activation of the deltoid muscles,
and increased activation of the trapezius pars descendens
muscles.10 In addition, the muscle activity of m. trapezius
pars descendens in string musicians showed little gap time
during playing.11,12 Altogether, these could be some of the
explanations for the high prevalence of back, neck, and
shoulder pain among professional string musicians.
Professional string musicians should be seen as an elite
occupational group with specific physical demands in their
work, and the daily exercise and complex neuromuscular
skills required of musicians who work at the professional
level can be compared to the training and performance
demands of top athletes or soldiers.2,13 It has been esti-
mated that the exposure for professional musicians is
about 1,300 hrs/yr of practice/performance,2 and the
duration of continued exposure can be >3 hrs/day of
active playing time during rehearsals and performances.14
Also, a violin with chin rest has an average weight of 428
g, and a viola between 511 and 731 g.15 Hence, musicians
need good strength, endurance, mobility, and motor con-
trol to perform at their maximal level on a daily basis, but
the load management and pain management strategies
used among musicians, in many cases, are currently left up
to the individual.
The high prevalence of PRMDs among string musicians
suggests that work demands are greater than the individual
capacity and several strategies are needed to restore this
balance. On one hand, it is important to increase the indi-
vidual capacity, e.g., through physical training as in sports
and in different occupations such as slaughterhouse work-
ers, since an increased maximal capacity leads to an
increased stress tolerance of the musculoskeletal system,
resulting in an increased reserve capacity and a relative
load reduction.16 Recent research in sports medicine sug-
gests that the aim to increase individual capacity, optimize
performance, and avoid illness/injury is best achieved
when all (internal and external) load is monitored and
managed with the aim to balance the acute/chronic load
ratio so that the individual is not exposed to excessive and
rapid increases in load relative to what the individual is
prepared for.17,18 This could perhaps be managed through
re-organization of work and education of both the individ-
ual and orchestra management (e.g., load management,
behavioral, lifestyle, and medical strategies) as well as pos-
ture correction and ergonomic information, which are
common applied strategies in occupational health.19 The
importance of a sound workplace culture for musicians
has been highlighted previously,1,20 indicating a role for
orchestra management in PRMD occurrence. Lowering
the work load can be obtained by better planning, cancel-
ing concerts, not taking extra jobs, and reducing practice
hours, etc.2 When pain gets more long-lasting or recurrent,
previous research data have shown that some symphony
orchestra musicians (44% of women, 26% of men) take
pain-killers such as paracetamol once or more times per
month and/or consult a physiotherapist (52% of women,
39% of men).2
The strategy of interest in this paper is to increase the
musician’s physical capacity, as suggested by previous stud-
ies.1,4 Steinmetz et al.3 hypothesized that PRMDs could be
related to dysfunction in postural stabilization systems
and called for interventions consisting of motor control
exercises. Wilke et al.,21 on the other hand, suggested that
training programs for string musicians should comprise
resistance training, combined with mobility and
endurance-increasing exercises. This strategy has been
found to be effective in lowering pain levels and time to
fatigue for different occupational groups with muscu-
loskeletal upper extremity disorders due to repetitive work
and static positions.17,22,23 Although the pathophysiologi-
cal explanations are yet not fully understood, it seems pos-
sible to increase fatigue resistance levels of musicians by
means of resistance training in order to elevate their work
capacity.16,22,23
To our knowledge, there are no studies that have
explored the effects of functional resistance training for
professional musicians. The aim of this study was to eval-
uate whether functional resistance training could influ-
ence strength in neck, shoulder, and wrist muscles and
back endurance in professional string musicians. More-
over, we studied if musicians had changes in perceived per-
formance during instrumental play, joint mobility, and the
occurrence and intensity of PRMDs after the intervention.
The hypothesis was that individual resistance training
could increase the strength in neck, shoulder, and wrist
and the isometric endurance of the back extensors, as well
as increase perceived performance during instrumental
play and improvement of PRMDs.
METHODS
A prospective intervention study including 11 weeks of
functional resistance training was conducted to test our
hypothesis. It was not practically possible to include a con-
trol group or to perform the evaluations blinded. Assess-
ments were performed pre- and post-intervention using
physical tests and online surveys for monitoring compli-
ance and PRMDs occurrence and intensity.
Participants
The study population consisted of string musicians with a
contract for permanent employment in Stockholm’s pro-
fessional symphony orchestras. All the orchestras were
approached (Royal Stockholm Philharmonic Orchestra,
Swedish Radio Symphony Orchestra, and Royal Court
Orchestra) and participated in our study. These orchestras
consist of around 30 to 60 string musicians with a sex dis-
tribution of about 40% women and 60% men.24 All musi-
cians were invited to participate in the study, through
information pamphlets from the orchestra board, and 28
agreed. Based on a pilot study prior to the project, this
number of participants was calculated to be sufficient to
obtain significant results on the main outcome measures:
isometric strength (n=21, based on an expected increase
from 12 to 14 kilogram–force [kgF, SD 2.3], with p<0.05 and
power 0.80) and back endurance (n=20, based on an
expected increase from 180 to 225 sec [SD 50], with p<0.05
and power 0.80), including a dropout rate of 25%. Of these,
24 (86%) participated in both the pre- and post-tests and
the training intervention. All participants provided writ-
ten informed consent prior to their enrolment in the study.
This study was approved by the Regional Board of Ethics
in Stockholm (Dnr. 2015/1336-31/1).
Intervention
The intervention was conducted from September 2015 to
January 2016, and the musicians were instructed to per-
form individually designed exercise sessions twice a week.
Each training session consisted of 5–10 min of warm-up
June 2018    103
 TABLE 1. Exercise Intervention and 30–40 min of resistance training. The warm-up ses-
Category/Exercises Comments sions consisted of a few typical, low-load motor control
exercises and mobility exercises. These exercises were per-
Warm-up exercises formed in standing, sitting, and/or four-point kneeling
Deadlifts without weights 5–10 min and consisted of items such as squats, deadlift without a
Wall angels The aim of the warm-up weight, bird/dog exercise, forward/backward/sideways
Scapula control (standing) exercises was to practice
lunges, and back flexion/extension/rotation exercises,
Lunges motor control and prepare
Forward the neuromuscular system which were aimed at boosting the participants’ ability to
Backward for load, while at the same control the joints in neutral positions as well as in close to
Sideways time increasing joint and end-range positions. For the shoulder, complex range of
Columna exercises muscle flexibility as well as motion exercises and shoulder/scapula exercises in supine
Flexion body temperature/pulse
and standing were used with the aim to find and maintain
Extension
Rotation good control and position of the scapulae and caput
humeri, as well as to find and maintain interplay between
Upper extremity exercises the scapulae and humerus.
Dumbbell wrist flexion 1–4 sets of 8–12 repetitions The individual training programs were based on find-
exercises ings during clinical examination, pain drawings using a
Scaption
One arm shoulder press mannequin, main instrument, fitness status, earlier train-
with dumbbell ing experience, time available, and individual preferences
Different rowing exercises of each participant. The participants were instructed to
Kettlebell or dumbbell perform exercises that were aimed to strengthen and con-
Seated with machine trol the scapulae and shoulder muscles together with
Active hang
Band-assisted hang muscles in the arm and trunk. The training program
Pull-ups included, on average, five functional resistance training
Band-assisted pull-ups exercises. The exercises scaption (scapular plane eleva-
Different push-ups tion), prone cobra (with and without dumbbells), and dif-
From floor ferent rowing exercises were commonly used in the indi-
Scaled push-ups
vidual training programs. Moreover, a large range of
Lower extremity exercises exercises were integrated in the training programs such as
Different squat exercises 1–4 sets of 8–12 repetitions dumbbell wrist flexion exercises, one-arm shoulder press
Air squat with dumbbell, active hang, pull-ups, band-assisted pull-
Goblet squat ups, push-ups, deadlift, Bulgarian deadlift, the diver, clam
Single leg box squat
exercise, different squat exercises, lunges, and glute
Pistol squat
Lunges bridges. Participants were instructed to perform one to
Forward four sets of 8 to 12 repetitions (approximately 65–80% one
Backward repetition maximum, 1RM) in the resistance training
Sideways exercises, following the principle of progressive overload.
Glute bridges
The training programs were designed so that they could
Band-resisted
Clam exercises be performed in an indoor/outdoor gym and/or in the
Band-resisted participants’ home or hotel room, depending on each
participant’s preference.
Whole body exercises
The exercises used in the different individual training
Prone cobra 1–4 sets of 8–12 repetitions programs are listed in Table 1. Videos showing the exercises
With dumbbells
Without dumbbells are available on the website of the Karolinska Institutet:
Lunges with weight https://play.ki.se/channel/Exercises_for_string_musicians
overhead
Deadlift exercises Procedure
Burpees
Bird dog exercise
Pre-intervention background data were gathered via a
Plank exercises
web-based questionnaire. Moreover, the participants were
After the warm-up session, participants performed their training program clinically examined (containing an anamnesis, standard-
consisting of a maximum of 5 exercises. Of these 5 exercises, 2 or 3 were ized physical therapist examination, and pain drawings) by
from the category “Upper Extremity” and the other 2 or 3 were from other
categories. The training program was performed twice a week, and partici- a registered physiotherapist (BL). After the clinical exami-
pants were instructed to perform 1–4 sets/exercise with 8–12 repetitions, nation, pre-intervention tests of muscle strength and
approximately 65–80% of one repetition maximum (1RM). endurance were performed. Thereafter, during a separate
Videos demonstrating the exercises are available at: session, the participants received a 60-minute introductory
https://play.ki.se/channel/Exercises_for_string_musicians session to their individual training program, which was

104 Medical Problems of Performing Artists

 TABLE 2. Demographic Data on Study Subjects ing the subjects to stop when pain occurred. Finally, iso-
Sex metric back endurance or endurance of the back extensors
Female 17/24 (71%) was measured by the Biering-Sorensen test, which registers
Male 7/24 (29%) the time in which the subject can maintain a supine posi-
Age, median (yrs) 51 (36–63) tion while only the lower body is supported.26
Instrument For the secondary outcomes, we used post-intervention
Violin 14/24 (58%) web-based questionnaires containing Likert questions with
Viola 6/24 (25%) three to five response categories. These questions were pre-
Cello 3/24 (13%)
Contrabas 1/24 (4%) viously tested in a pilot study and adjusted for usefulness.
Years in profession, median (min/max) 23 (10–39)
• For analysis of perceived performance during play after the
Average performance hours per week, median
training period, two questions were asked: “Do you feel that by
(min-max)* 10 (4–15)
training you have developed a change in your perceived performance
Frequency of physical activity per month/week
during instrumental play?” (Responses: “yes, for the better,”
None 4/14 (29%)
1–2x mon 2/14 (14%) “no, no change,” “no, for the worse,” “unsure”) and “How do
1x wk 4/14 (29%) you perceive your work ability/stamina during instrumental play?”
2-3x wk 3/14 (21%) (“very good,” “good,” “less good,” “bad,” “very bad”).
>3x wk 1/14 (7%) • For analysis of perceived mobility in muscles and joints, the
Previous experience from resistance training? questions were: “How do you perceive that your mobility has
Yes 5/14 (36%) changed during and after the training period?” (“for the better,”
No 9/14 (64%) “unchanged,” “for the worse,” “unsure”) and “How do you
* Performance for an audience. perceive your mobility in muscles and joints?” (“excellent,”
“good,” “less good,” “bad”).
• For analysis of perceived change in occurrence of PRMDs,
based on the clinical examination and pre-intervention pre- and post-intervention web-based questionnaires were
used that asked the following two questions: “Have you,
results. One-hour individual training follow-ups were
during the last week, experienced any complaints (aches, pain,
scheduled for intervention weeks 2, 4, and 8 to ensure
discomfort, regardless of the origin of the complaint) in the follow-
good technique and adherence to the principle of progres- ing body regions: face, neck, shoulder, elbow, hand/fingers,
sive overload. The participants were instructed to fill in upper back, lower back, hip/thigh, knee, lower leg/foot?” and
training diaries during the training period, since this can “Right now, are you experiencing any complaints in the above
stimulate compliance and enable compliance monitoring. mentioned body regions?” The occurrence of PRMDs was cal-
The participants also received training videos for most culated by using three variables: the number of answers,
exercises, either by filming with the participants’ smart- number of participants who reported perceived PRMDs,
phone and/or through collaboration with the websites and total number of participants.
Styrkeprogrammet (www.styrkeprogrammet.se) and • For analysis of perceived change of intensity of PRMDs, the
Fredrik Aronsson Optimal Prestation (www.fredrikarons- question “How would you rate your pain/your complaints?”
was asked pre- and post-intervention. This item was scored
son.se). Post-intervention tests were performed by the
on a numerical rating scale (NRS), where 0 = no pain/no
same examiner (BL).
disorders and 10 = the worst imaginable pain/disorders.
• For analyses of changes in perceived PRMDs after the
Outcomes training period, we asked the question at post-interven-
tion: “If you feel that you have, or have had, any work-related
Primary outcomes in this study were objective measures of disorders, have you perceived any change in your work-related
strength in the neck, shoulder, and wrist and back disorders during and/or after the training period?” (“yes, for the
endurance, while the secondary outcomes were subjective better,” “no, unchanged,” “yes, for the worse,” “unsure”).
measures of perceived performance during play, mobility
in muscles and joints, and occurrence and intensity of Finally, participants were asked to report any negative
pain. Due to the difficulty of measuring dynamic strength side effects of the intervention at the time of occurrence.
in a population with or without on-going pain, isometric
pain-free strength of wrist (dorsal extension, palmar flex- Data Treatment and Analysis
ion) and shoulder (abduction, and internal and external
rotation) of both the left and right side,25 as well as lateral For all isometric tests of pain-free strength in neck, shoulder,
neck flexion and neck extension were measured and and wrist at both pre- and post-intervention, the median of
expressed in kgF using a hand-held dynamometer the three test values was calculated as suggested by Grooten
(Nicholas Manual Muscle Tester [NMMT]; Lafayette and Äng.25 The occurrence of PRMDs was calculated by
Manual Muscle Tester, model 01163; Lafayette Instrument dividing the number of participants with PRMDs by the
Co., Lafayette, IN, USA). Tests of isometric strength were total number of participants. The survey data for measure-
conducted on the right and left alternately three times for ments of perceived intensity of pain (rated on a NRS rang-
respective movements, using the “brake test” and instruct- ing from 0 to 10) “during the last week” and “right now”

June 2018    105

 TABLE 3. Isometric Pain-Free Strength in Wrist, Shoulder, and Neck Muscles (kgF) and Isometric Endurance of the Back Extensors (sec)
Pre-Intervention
________________________________ Post-Intervention
________________________________
Median Min Max Median Min Max p-Value*
Wrist
Dorsal extension, right 14.7 8.3 32.5 16.3 11.3 28.9 0.022
Dorsal extension, left 14.7 5.0 36.4 14.8 10.0 28.5 0.040
Palmar flexion, right 14.5 6.3 33.4 15.0 7.8 23.6 0.909
Palmar flexion, left 14.6 7.5 31.4 15.5 9.0 25.2 0.679
Shoulder
Abduction, right 10.8 3.6 26.5 12.9 6.9 26.1 0.034
Abduction, left 10.3 4.1 27.0 12.1 4.6 23.9 0.026
Internal rotation, right 11.6 6.0 29.0 12.1 7.1 24.2 0.864
Internal rotation, left 10.9 5.6 26.3 10.9 6.7 23.3 0.721
External rotation, right 9.1 5.8 22.9 9.7 7.3 18.9 0.225
External rotation, left 9.4 5.2 24.5 9.4 7.0 22.0 0.149
Neck
Lateral flexion, right 7.6 3.5 27.3 8.5 5.3 22.6 0.033
Lateral flexion, left 7.6 3.5 32.0 8.8 4.8 21.8 0.035
Extension 16.3 9.3 48.2 16.3 9.6 29.7 0.475
Back extensors
Biering-Sorensen test 185 10 362 231 96 480 <0.001
Isometric pain-free strength in wrist, shoulder, and neck muscles is measured in kilogram–force (kgF), and isometric endurance of the back extensors, in seconds
(sec). For each outcome, the median and range (min/max) are presented (n=24), together with the level of significance.
*Wilcoxon rank sum test. Significant (p<0.05) differences shown in bold.

were used to calculate mean values on group level pre- and
post-intervention, using an “intention to treat” approach.
The Wilcoxon rank sum test was used to study the effect of
resistance training on isometric strength and isometric
endurance over time, while chi-square tests were used for
the research questions that concerned perceived changes
during the intervention period based on proportional data.
A Wilcoxon rank sum test was also used to study potential
changes in pain intensity. The significance level was set to
p<0.05. Data analysis was performed in Excel Professional
Plus 2010, ver. 14 for Windows, and Excel 2011, ver. 14.5.8
for IOS (Microsoft Corp., Seattle, WA, USA); SPSS, ver. 22
for Windows (SPSS Inc., Chicago, IL, USA); and EpiCalc
2000, version 1.02 for Windows (Microsoft Corp.).
and 1 double bass (Table 2). Out of the 24 participants, 17
answered the web-based questionnaire both at pre- and
post-intervention, and 15 returned their training diaries.
One participant reported no occurrence of PRMDs prior to
the training period. More than half of the group, prior to
this study, did not perform regular exercise and could be
considered physically inactive (median of 0 training ses-
sions of at least 20 min during the last month). Nine partic-
ipants stated that they had not performed any form of
resistance training ever prior to the intervention. The com-
pliance was high and participants had a median participa-
tion rate of 93% (min 55%, max 100%).
Primary Outcomes

RESULTS
Participants
Out of the 28 string musicians who agreed to participate in
the study, 4 dropped out. 3 did not start the training (due
to family reasons, an ongoing rehabilitation of the lower
extremity, and concerns that the resistance training might
lead to worsening musculoskeletal problems in the fore-
arm) and 1 participant chose to cancel early during the
intervention without giving reasons. These non-partici-
pants did not differ from the participants concerning fit-
ness status and prior training experience.
Therefore, a total of 24 participants (17 women, 7 men)
completed the training intervention. The median age of
participants was 51 yrs (range 36–63). The majority of par-
ticipants (n=19) worked at the Royal Court Orchestra. Of
the 24 participants, 14 played the violin, 6 viola, 3 cello,
After the training period, the group showed an 11% to 19%
increase in isometric strength for both the right and left
side of wrist extensors, shoulder abduction/elevation, and
neck flexors (p<0.05). For wrist flexors, internal and exter-
nal shoulder rotation, and neck flexors, there were no sig-
nificant changes in isometric strength (Table 3).
After the intervention, participants had a 25% increase
in endurance of the back extensors (p=0.05). The results of
the Biering-Sorensen test increased significantly (p<0.05)
with a median increase of 46 sec, from 185 sec at baseline
to 231 sec at the end of measurement (Fig. 1).
Secondary Outcomes
Based on post-intervention questionnaires, 7 of 17 partic-
ipants (41%) perceived that their performance when play-
ing their instrument had improved through resistance
training. Ten participants (59%) perceived that their

106 Medical Problems of Performing Artists


FIGURE 1. Biering-Sorensen test for muscular endurance
in the lower back muscles (sec). The graph shows median
values (black horizontal line), 25th to 75th percentiles
(boxes), and minimum and maximum values (whiskers)
(n=24). The results increased by a median of 46 sec, from
185 sec at baseline to 231 sec post-intervention (p<0.05).
mobility increased during and after the intervention.
Nine participants (53%) perceived a positive change
regarding PRMDs during and after the intervention,
whereas 5 (29%) did not perceive a change in PRMDs.
Finally, none of the participants perceived increased pain
during or after the training intervention period (Fig. 2).
The changes between pre- and post-intervention did not
reach statistical significance for these secondary outcomes
(p>0.05). None of the participants reported any negative
side effect of the intervention.
The participants reported complaints, on average, in
2.8 body regions during the last week, both prior to and
after the intervention (Table 4). For complaints “right
now,” the average was 0.9 and 0.8 body regions prior to
and after the intervention, respectively. On a group level,
the participants reported neither more nor less pain, nor
did they report any decrease/increase in the number of
locations with complaints after completing the training
period compared to before the intervention. There were
FIGURE 2. Proportion of participants answering yes, no, maybe, or unsure to questions on perceived positive changes in
performance, mobility, and PRMDs (n=17). The changes between pre- and post-intervention did not reach statistical sig-
nificance (p>0.05).
no differences in pain intensity “right now” after the
intervention period in any of the body regions (Tables 4
and 5).
DISCUSSION
In concordance with our hypothesis, the functional resist-
ance training was effective regarding isometric strength for
the neck and upper extremity and isometric endurance of
the back extensors, but in contrast to our hypothesis, no
statistically significant changes in the intensity and preva-
lence of PRMDs or perceived performance during instru-
mental play were reported. To our knowledge, our study is
the first intervention showing that functional resistance
training may be a non-harmful and advantageous exercise
method for professional string musicians.
Primary Outcomes
The significant increase in median strength in the upper
extremities and endurance of the back extensors in this
study implies that gains in strength can be obtained from
specific exercises, such as deadlifts, isometric prone cobra,
and rowing. Interestingly, it was noticed that despite all
median and minimum values being increased at post inter-
vention assessment, all maximal values were lowered. This
indicates that those with low strength at pre-intervention
increased their strength at post-intervention, while those
who had high strength at pre-intervention decreased their
maximal strength at post-intervention. One reason for this
observation could be an effect of the individualization of
our strength exercises, in which the exercises were target-
ing the weak muscle groups and not those muscles that
already were strong. In contrast to the increase in strength
seen in our study, a previous study in university music stu-
dents performing resistance training exercises such as
reverse fly, rowing, and back extension with Swiss balls
and weight bands did not show any transfers to increased
isometric strength and endurance.4 Consequently, further
studies in this field are warranted.
The present study is, to our knowledge, the first to
include exercises also aimed at strengthening the forearms
and hands, i.e., muscle groups used extensively by musi-
June 2018    107
 TABLE 4. Subjects with Complaints in Different Body Regions and it is possible that the participants in our study trained
(n=17) with too low loads and/or for too short a time with higher
Pain/Complaints, Pain/Complaints, loads to gain a clinically significant decrease in pain inten-
Last Week Right Now
_______________________ _______________________ sity and prevalence levels. On the other hand, the lack of
Pre- Post- Pre- Post- clinically significant intervention effects, regarding the
Intervention Intervention Intervention Intervention prevalence of PRMDs seen is this study, and the lack of
Face 1 0 0 0 intervention effects on pain intensity, were in concor-
Neck 7 6 2 1 dance with several previous studies on students at music
Shoulder 8 10 1 1 universities and/or professional musicians.1,4,27,28
Upper back 5 4 0 0 Chan et al.1 conducted a relatively large randomized
Elbow 3 6 3 3 controlled trial and reported clinically significant improve-
Lower back 7 5 2 2
Hand/fingers 6 4 1 1 ments in pain related to training. An additional method-
Hip/thigh 3 4 0 0 ological explanation for the lack of significant improve-
Knee 4 6 3 3 ments concerning pain in our study could be that the
Lower leg/foot 3 3 3 3 samples in the cited research and the present study were
TOTAL 47 48 15 14 too small and too heterogeneous with respect to these out-
comes (type II error), indicating a need for larger, random-
ized, and controlled studies. Moreover, in our study and the
cians and previously excluded in interventions for musi- abovementioned studies, the intervention was not directed
cians.1,4,27,28 Notably, none of the participants experienced to individual pain profiles using classification systems as
any negative side effects of participating in the training suggested by Fersum et al.30 In Fersum et al.’s review, it was
intervention. Increased and/or maintained high artistic found that intervention effects were significantly larger if
performance is mostly warranted for musicians, and this interventions were adapted to individual pain profiles, and
outcome should preferably be used in future studies using future studies should therefore try to combine individually
a quantitative or qualitative design. adapted resistance training with individual pain manage-
ment programs.30
Secondary Outcomes Finally, the intervention was directed to an individual
adaptation to the workload, and not to an adaptation of the
All participants were in their midst of their concert season workload to the individual. In sports medicine, the Interna-
(Aug 2015–June 2016) and were continuously rehearsing tional Olympic Committee recently made a consensus state-
and performing (up to 100) concerts as well as practicing ment on load and load management for reduction and pre-
individually on a regular basis during the intervention— vention of sports injuries, in which the importance of
this means that all participants were exposed to rehearsals, continuous scientific monitoring of loads and load manage-
performances, individual practice, and stress during the ment is highlighted as a key factor.17,18 Recommendations
whole intervention period. Chan et al.1 reported that the are also given for scientific monitoring of loads, monitoring
prevalence of PRMDs among professional orchestra musi- of injuries, and load management which could be applied to
cians nearly doubled during a concert season, and since we the field of performing arts medicine as well. Note that load
found no concert season-related increase in occurrence of due to occupational exposure should not be confused with
PRMDs, perhaps the intervention in our study could have load during intervention. The latter is carefully dosed
prevented the occurrence of PRMDs. Previous interven- regarding intensity and frequency, aiming to start the
tion studies on moderate to severe neck and shoulder pain process of muscle repair and building up muscles, while
in other occupational groups found a dose-response rela- ergonomic load does not build up strength or endurance.
tionship between increased strength and improvements in
pain and showed clinically significant effects of specific Methodological Considerations
exercises for painful muscles of the shoulder and
neck.22,23,29 These studies also found that a moderate dose A major limitation of our study was the lack of a control
of specific resistance training over a longer period, such as group, and the within-group effects found in the study
16 to 20 wks, had a significantly better clinical effect on could have been explained by the statistical phenomenon
neck/shoulder pain intensity compared to other interven- of “regression to the mean.” However, since the effects in
tions, such as low-dose physical activity, endurance train- strength and endurance following a period of resistance
ing, and ergonomic interventions.22,23 training have been monitored in controlled studies also,
The progressive approach with functional resistance we believe that regression to the mean did not occur in this
training and free weights used in our study required an ini- study. Moreover, the absence of within-group effects in
tial period of (low-dose) technique training before partici- PRMDs could be a sign of an effective preventive interven-
pants could perform high-load resistance training. The tion, since it has previously been shown that an increase
deadlift exercise could, for example, be considered as a in PRMDs occurs during the concert season in musician
low-load motor control exercise29 in the start-up phase, populations.1 This highlights the need for a control group

108 Medical Problems of Performing Artists

 TABLE 5. Pain Intensity for Complaints “Right Now” (n=17)
Pre-Intervention
_____________________________________ Post-Intervention
_____________________________________
N Median Min Max N Median Min Max p-Value*
Face 8 0.0 0 2 17 0.0 0 2 1.000
Neck 10 2.5 0 6 14 2.0 0 8 0.167
Shoulder 10 3.0 0 5 15 2.0 0 8 0.343
Upper back 6 1.5 0 3 14 0.0 0 7 1.000
Elbow 8 0.0 0 4 15 0.0 0 7 0.655
Lower back 12 1.5 0 8 14 1.0 0 8 0.799
Hand/fingers 7 2.0 0 6 14 0.0 0 8 0.109
Hip/thigh 7 0.0 0 4 14 0.0 0 5 0.655
Knee 8 0.0 0 4 15 0.0 0 8 0.180
Lower leg/foot 7 0.0 0 4 13 0.0 0 6 0.317
Pain intensity scored on a numerical rating scale (NRS), where 0 = no pain to and 10 = the worst imaginable pain.
*Wilcoxon rank sum test. All values are non-significant (p>0.05).

in future studies. However, conducting randomized con-
trolled trials for prevention of PRMDs in which musicians
are randomized into intervention and control groups
could be difficult, due to contamination effects or ethical
issues, such as stopping musicians from performing exer-
cises when randomized into the control group.
An additional limitation of the study could be the large
variation of exercises used in the intervention. However,
all exercises were addressing the aim to strengthen the
neck, shoulder, wrist, and trunk muscles, and we believe
that is possible to combine the subjects into one interven-
tion group. Moreover, there is a lack of information of the
non-participants’ activity level, training experience, or rea-
sons for non-participation in the study, which hindered
the analyses of the occurrence of a potential selection bias.
Among the strengths of the study was the high compli-
ance, as well as the highly reliable and objective instru-
ments used for the primary outcome measure, i.e., the
NMMT and Biering-Sorensen test.25,26 The secondary out-
come instruments used were commonly used subjective
questionnaire-based measures, and specially adapted to
the population in this study; however, the questions were
only tested in a small pilot study. In contrast to the source
population (string musicians in Swedish orchestras) in
which most musicians are men, the present study included
a larger proportion of women (71%). However, the propor-
tion of females was similar to that in previous intervention
studies on musicians,1,28 and this could be explained by a
higher willingness to participate in intervention studies
due to higher rates of PRMDs among female musicians.2
All types of string musicians were included in the study:
first and second violinists and viola, cello, and double bass
players. Violin and viola players have higher exposure
(playing more notes and playing with elevated arms) com-
pared to cello and contrabass players.14 There could also
be differences in exposure for those playing first and
second violin, since in classical music, the second violin
part can require playing more notes on the lower G and D
strings, which may mean longer duration of elevation of
the right arm. In the exposure assessment, it should also be
noted that the viola is a heavier instrument than the
violin.15 The low power in the study did, however, not
allow for stratified analyses.
Professional orchestral string musicians are a rela-
tively small (elite) occupational group, which means that
there may have been a selection bias, a “healthy worker
effect.”2 An orchestral musician must first manage to
acquire and maintain a sufficiently high level of crafts-
manship and musicianship to gain his or her job, and
this group could therefore differ in several respects from
a larger less-select group (e.g., music students), which
could make it difficult to compare our study with previ-
ous studies in music students.1,4
Conclusions
Both strength and back endurance in professional string
musicians were increased after an 11-week functional
resistance training program, but there were no statistically
significant changes between pre- and post-interventions in
self-rated pain, perceived performance in play, or mobility.
This study shows that functional resistance training could
be a non-harmful and advantageous exercise method for
professional string musicians. Further studies are needed
to confirm these results.
Acknowledgments: The authors thank all study participants and
the orchestra management of the Royal Court Orchestra, Royal
Stockholm Philharmonic Orchestra, and Swedish Radio Sym-
phony Orchestra.
Authors’ Contributions: BL was involved in designing the study,
was the contact person with the orchestras, performed the inter-
vention and all tests, analyzed the data, and wrote the ethics
application and manuscript. WG was involved in designing the
study, analyzing data, and writing the ethics application and
manuscript.
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Received 20-Mar-2017, accepted 2-Feb-2018
Published online 1-June-2018
https://doi.org/10.21091/mppa.2018.2017
Updated 12-June-2018: On page 104, the url has been updated to:
https://play.ki.se/channel/Exercises_for_string_musicians