Preventing musculoskeletal complaints in music students: a randomized controlled trial

Abstract

Background

Musculoskeletal complaints in music students are common. Little is known about effectiveness of interventions.

Aims

To assess whether a biopsychosocial prevention course is better at reducing disability due to musculoskeletal disorders compared with physical activity promotion.

Methods

This was a multicentre randomized controlled trial with intention-to-treat analysis. Participants were first- and second-year students from five conservatories, randomized to experimental or control groups. The experimental group participated in 11 classes on body posture playing the instrument according to postural exercise therapy, and performance-related psychosocial aspects. The control group participated in five classes promoting physical activity according to national guidelines. The primary outcome was disability using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, including the performing arts module. Secondary outcomes were pain, quality of life, playing-related musculoskeletal disorders and health behaviour. Outcomes were assessed at six points, from baseline until 2-year follow-up.

Results

One hundred and seventy participants were randomized to experimental (n = 84) or control (n = 86) groups. Loss to follow-up was 40% during the trial and 69% at 2-year follow-up. The dropout rate was equal in both groups. Overall, there were no significant differences between groups for any outcome adjusted for baseline characteristics: percentage disability, odds ratio was 1.31, 95% confidence interval (CI) 0.69–2.51; general DASH, β = −0.57, 95% CI −3.23 to 2.09; and performing arts module, β = −0.40, 95% CI 5.12–4.32.

Conclusions

A biopsychosocial prevention course tailored for musicians was not superior to physical activity promotion in reducing disability. Large numbers lost to follow-up warrant cautious interpretation.

Introduction

Playing a musical instrument at a professional level is physically and mentally challenging.

Many years of intense practice result in higher levels of sensorimotor control [1]. The high demands on the musculoskeletal system in combination with psychosocial factors such as performance stress make the musician vulnerable to developing musculoskeletal complaints [2]. Lifetime prevalence of injuries in musicians is reported to be up to 93% [3]. The neck and shoulders are most often affected [3]. The fundamentals for building a lifelong career as a musician are laid during music education. Music students already experience more musculoskeletal complaints [4] and worse mental health [5] compared with age-matched medical students. A longitudinal study showed that the incidence of playing-related health problems was already 29% at the start of year 1, increasing to 42% in year 2, after which complaints declined to 36% in year 3 [6]. The first study year is especially challenging, with increasing levels of fatigue, depression and stage fright during the year [7]. Complaints are related to a lower quality of life [8] and lead to considerable levels of playing-related disability for the individual music student [6,8] and are a serious threat to performance quality [8].

There is an increasing call for educational institutions to take responsibility for teaching music students to take care of their own health. Health responsibility among music students is low [9]. Creating awareness, providing general information on healthy lifestyle and specific guidance on prevention and treatment of performance-related problems during student life are believed to positively influence the musician’s entire career [9,10]. However, only limited studies evaluating prevention programmes are available [11] and most of these are observational in study design, limiting conclusions. Programmes offered varied from concise theoretic [12] or exercises classes [13] to extensive programmes over the course of a semester [14] or academic year [15,16] combining lectures and practical exercises. Topics frequently covered were functional anatomy and physiology, body posture while playing the instrument, practising routines and coping with performance. Effects varied, showing a positive effect on application of prevention strategies in daily life [12], perceived exertion [13] and mental well-being [15]. Only one study found decreased physical complaints [16].

The PRESTO study (PREvention STudy On preventing or reducing disability from musculoskeletal complaints in music school students) was designed to enhance knowledge on effective strategies to prevent or reduce musculoskeletal complaints in music students. A biopsychosocial prevention programme was compared with general physical activity promotion. The two research questions were as follows: (1) Is participation in a biopsychosocial prevention course tailored for musicians more effective in preventing or reducing disability due to musculoskeletal disorders in music students compared with general physical activity promotion? (2) Is a biopsychosocial course more effective in increasing quality of life, reducing playing-related complaints and inducing a positive change in health behaviour compared with physical activity promotion?

Methods

The PRESTO study is a multicentre parallel-group randomized controlled trial undertaken at five conservatories in the Netherlands [17]. The trial is registered in the Nederlands Trial Register NTR3561. The medical ethics committee of Maasstad Ziekenhuis Rotterdam approved the study (NL39564.101.12). An independent research assistant conducted the concealed randomization procedure by means of a computer-generated list. Randomization was stratified by conservatory with variable block sizes and a 1:1 allocation rate. Students were randomized into experimental (PRESTO-Play) or control groups (PRESTO-Fit). Outcome assessors were blinded. A pilot study was conducted to investigate prevalence of musculoskeletal complaints in third- and fourth-year students, confirming high numbers of complaints in this population [8]. The study protocol was published before study commencement [17]. A process evaluation was conducted with the aim to evaluate implementation (V. A. Baadjou, submitted for publication). Intervention took place in the academic years 2012–13 and 2013–14 and follow-up lasted to June 2016. Outcomes were measured at baseline (T0), 10 weeks (T1), 20 weeks (T2), post-treatment (T3), 16-month follow-up (T4) and 24-month follow-up (T5).

PRESTO-Play is a biopsychosocial course tailored to music students. The aim of PRESTO-Play was to create awareness about musician's health; educate on human anatomy and physiology in relation to playing the instrument; provide strategies for coping with anxiety, stress and overcommitment; how to handle pain and discuss general health issues such as physical activity and nutrition. The course consisted of 11 classes during one academic year. Following the I-Change Model, awareness, motivation and implementation skills were incorporated to induce health behaviour change [18]. The focus of the first six classes was on body posture while playing. Principles from the postural exercise therapy methods of Mensendieck or Cesar were incorporated. Central themes are body awareness, balanced posture and controlled movements; awareness of tension and relaxation; and functional respiration. Instrument-specific instructions were provided on playing in a biomechanically correct position according to the method of Samama [19]. The aim of this method was to assume a posture that provides stable balance and prevents overload on the muscles used to play the instrument [20]. From class seven onwards, discussion about psychosocial themes was added. The maximum group size was eight participants. The total time investment was 18 h.

The PRESTO-Fit course provided education about physical activity recommendations for the general population. Students received a pedometer, were instructed to monitor daily physical activity and walk 10000 steps a day, complying with the international physical activity recommendations for the general population. Intervention development and implementation were inspired by studies by Jackson and Howton [21], Tully and Cupples [22] and De Cocker et al. [23]. During in total five classes, students were encouraged to set physical activity goals, while discussing the importance of being physically fit as a musician (Table 1). No efforts were made to induce long-term behavioural changes. Although short-term positive health effects of physical activity promotion in young adults have been shown, it was not expected that this programme would affect long-term playing-related disability and, therefore, served as a control group [24]. The maximum group size was 16 participants. Total time investment was equal to the 18 h of PRESTO-Play, because students in PRESTO-Fit needed to practise in their leisure time to increase their daily activity up to the levels required.

Students were informed about the research during a lecture by the first author (V.B.). Participants provided written informed consent before randomization. Included were first-year bachelor students from the academic year 2012–13 and first- and second-year students from the academic year 2013–14. All students could participate, whether or not they had playing-related musculoskeletal complaints and regardless of pre-existing physical activity level. Excluded were students who were not able to understand Dutch or English and students with a specific comorbidity that could be associated with musculoskeletal complaints related to an underlying disease such as rheumatoid arthritis. Participants received several small incentives during the trial to stimulate trial commitment. Two conservatories provided study credits for participation. Participants could stop without disclosing a reason; the time of quitting was defined as the last completed questionnaire. All therapists were trained before the start and by the end of the first year to ensure compliance with the standardized course protocol. The five participating conservatories have different curriculums. None offered a structural obligatory health course at the start of the present study.

The primary outcome was disability, as measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, including the performing arts module containing four questions related to playing a musical instrument. The outcome was further divided into (1) performance-related disability defined as a positive answer on one of the questions of the performing arts module; (2) the total score on the performing arts module and (3) the total score on the DASH. Secondary outcome measures included Pain and Disability Index, Short-Form 36 (quality-of-life) and a self-developed health behaviour change questionnaire specific to the intervention. Psychometric properties have been described elsewhere [17]. Playing-related musculoskeletal disorders were defined as ‘pain, weakness, lack of control, numbness, tingling, or other symptoms that interfere with your ability to play your instrument at the level you are accustomed to’ [25]. An overview of primary and secondary outcome measures is presented in Table 2.

Recorded baseline values were socio-demographic, playing related, general health and personal variables. Eating habits were measured using a Numerical Rating Scale from 0 (very unhealthy) to 10 (very healthy). Hypermobility was measured with a simple and reproducible self-reporting questionnaire [26]. Depression, Anxiety and Stress Scale-21 measured psychological distress [27]. Multidimensional Perfectionism Scale measured perfectionism [28].

The power calculation is described in the study protocol [17]. A total of 65 people per group were needed. Taking into account a 15% dropout rate, the total group size was set at 75 people and thus a total sample size of 150 students was required. Baseline differences between groups and between responders and non-responders were examined using independent samples t-test, Mann–Whitney U-test or chi square test. An intention-to-treat analysis was performed. Overall group effects on primary and secondary outcome measures were analysed using logistic generalized estimating equations with exchangeable correlation matrix for dichotomous outcomes and linear multilevel analysis with two-level structure for continuous outcomes. All analyses were adjusted for the baseline value of the outcome. Besides crude analyses, analyses adjusted for conservatory, age, gender and distress were also performed. Between-group differences were presented as overall mean difference (95% confidence intervals [CI]) in the case of continuous outcomes or odds ratio (OR) (95% CI) for dichotomous outcome measures. Additional analyses were performed to evaluate the differences between the groups at time point T3 (end intervention) and T5 (end follow-up) by adding time and the interaction between time and group to the models.

Results

Figure 1 shows the flow chart of the study. In total, 170 students were interested in participation. All students were found to be eligible and were randomized. Thirty-four students were not able to start the course, mainly because they were not available at the time of the class, which means that 136 students (68 to each randomized group) started the allocated intervention. From the total of 170 randomized students, 52 (62%) and 50 (58%) of PRESTO-Play and PRESTO-Fit, respectively, were still enrolled by the end of the intervention. The number of participants in PRESTO-Play and PRESTO-Fit was 30 (36%) and 36 (42%) at 16-month follow-up, and 27 (32%) and 25 (29%) at 24-month follow-up. Ninety-seven (57%) participants were female. Most (91%) participants were studying in first year and were enrolled in the bachelor of classical music (65%), pop/jazz (15%), music in education (14%) and others (7%). Instruments played were strings (40%), wind (22%), keyboard (16%) and percussion (10%). Ten per cent studied voice and 2% conducting. Of the students who answered the baseline questionnaire, median age was 20 years (19–22.25 years), 58% were Dutch, 30% from another European country and 13% from another continent. Baseline characteristics are presented in Table 3. No differences in baseline characteristics between groups were found. Analyses of differences between responders and non-responders showed that males were more likely to drop out compared with females and that students from other European countries were the least likely to stop. Five conservatories participated in the project, 27% of participants were from Utrecht, 24% from Groningen, 20% from Maastricht, 19% from Rotterdam and 9% from Tilburg.

The recruitment period did not diverge from the intended duration. Three PRESTO-Play classes, and one PRESTO-Fit class, were cancelled. On average, 55% of the students were present in PRESTO-Play and 60% in PRESTO-Fit. Blinding of outcome assessor was successful. The majority of the students, 67% in PRESTO-Play and 63% in PRESTO-Fit, reported not to have heard about the contents of the course they were not allocated to. Numbers of students having other therapy or taking part in other health classes did not differ between groups by the end of the intervention period.

The percentage of students with performance-related disability changed from 67% at baseline to 44% at the end of follow-up in PRESTO-Play and from 79% to 40% in PRESTO-Fit. Performing arts module score changed from a median of 12.5 (0–31.25) to 0 (0–6.25) in PRESTO-Play and from 18.75 (6.25–32.81) to 0 (0–25) in PRESTO-Fit. General DASH changed from a median of 7.5 (3.33–15.83) to 2.5 (0–8.33) and from 8.33 (3.33–14.17) to 3.45 (0–12.08) in PRESTO-Play and PRESTO-Fit, respectively (Table 4). No significant differences were observed between the groups. Also, for the secondary outcomes as well as for the differences at T3 and T5 no significant differences were found (Table 5).

Discussion

Performance-related disability and the presence of playing-related musculoskeletal disorders seem to decrease substantially in both groups over time. However, this randomized controlled trial did not show any differences in disability or any other secondary outcomes between PRESTO-Play and PRESTO-Fit. The strength of the trial is the inclusion of a large number of students from multiple conservatories, with a long period of follow-up. The biopsychosocial course was designed in cooperation with leading therapists and conservatory staff intending to induce healthy behaviour, teach students to play in a biomechanically optimal posture and learn to cope with the mental challenges of being a musician. Although the protocol was based on current evidence and clinical expertise, this pragmatic trial did not result in the expected better results for the biopsychosocial PRESTO-Play course tailored for musicians as compared with the general PRESTO-Fit course. This could be due to four reasons: (1) results are hampered by the large number lost to follow-up, (2) the control group intervention was also effective, (3) crosstalk between the two interventions could have occurred and (4) the outcome measures used were not sensitive enough to detect change.

Firstly, numbers lost to follow-up were high, and selection bias cannot be ruled out because we have no outcome data of dropouts. For example, it is possible that the healthy students dropped out and the students with complaints were more likely to stay engaged. However, dropouts were equal between groups and the multilevel analysis used accounted for missing values. Unfortunately, the high numbers lost to follow-up are common in this population [6]. Although a large amount of effort was undertaken to keep students actively engaged in the study, it was concluded in the process evaluation that music students prioritize music-related activities over health classes and that engagement of the conservatory is paramount to success (V. A. Baadjou, submitted for publication). Further information on compliance, dose delivered, dose received, reach, recruitment and context in relationship to these results is also provided in this process evaluation (V. A. Baadjou, submitted for publication). Secondly, we could have underestimated the beneficial effect of physical activity promotion on musician’s health, implying that education on the importance of physical activity for a musician might also be a good intervention to decrease disability [29].

It is likely that participation in this study increased awareness of the importance of healthy music making for participants in both groups because the trial was the only structural health course at the participating conserva tories. Awareness is an important factor in health behaviour change and it might have been that all students were stimulated to take action to improve their health, just by raising awareness on the issue. Future studies should elaborate on the role of awareness in the prevention of musculoskeletal complaints in music students. The contrast between intervention and control groups may also be limited by the fact that 35% of participants indicated they had heard about the contents of the course they were not allocated to. Nonetheless, results revealed that disability declined in both groups throughout the intervention and during follow-up. However, the design of this study does not allow us to conclude whether this is an intervention effect or the natural course. Our pilot study among third- and fourth-year students in 2012 showed that the disability level was 52%, with a median performing arts module score of 6.25 (0–25) [8]. The disability levels of the primarily third-year students after participation in the current trial were 44% and 40%, with median performing arts module scores about a quartile lower compared to the pilot study, suggesting that both interventions could have reduced disability. This assumption is supported by the fact that the percentage change in disability level between the start of the study and the end of follow-up almost reached the a priori hypothesized reduction of 50%. Therefore, it is plausible that both PRESTO-Play and PRESTO-Fit were effective in reducing disability. Finally, one limitation is that (performance-related) disability values were in general quite low and it could be questioned whether the outcome measures used were sensitive enough to pick up relevant changes in disability in this population functioning at elite level. The fact that we used general functional measures instead of musician-specific measures such as ease of playing or playing quality might have obscured our results.

This study provides valuable insights into prevention of musculoskeletal complaints in music students. In conclusion, a biopsychosocial prevention course tailored for musicians was not superior to physical activity promotion in reducing disability. Interestingly, disability declined in both groups throughout the intervention and up to 2 years of follow-up. Better preventive effects might be achieved by provision of more personalized programmes, tailored to individual needs.

Funding

This work was supported by a grant from the University Fund Limburg/Ans Samama Fund. The person who funded the grant (Mrs Ans Samama) was chosen because of her specific knowledge in writing the protocol for the experimental intervention. She was not involved in collection, analysis and interpretation of data, and writing of the report, nor was she involved in the decision to submit the article for publication.

Acknowledgements

We thank the Academy of Music and Performing Arts Tilburg, Codarts University for the Arts Rotterdam, HKU University of the Arts Utrecht, Maastricht Academy of Music and Prince Claus Conservatoire Groningen for their willingness to participate in the study and support during recruitment and data collection. We thank the participating therapists for their commitment and support. We express gratitude to all participating students.

Competing interests

None declared.

References