Identifying Vocational Deficiencies in Musicians: Comparison
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Please note this is a comparison between Version 2 by Vivi Li and Version 1 by Joseph Mizrahi.

A combination of factors exposes musicians to neuro-musculoskeletal disorders, which lead to pain and damage. These involve overuse due to long playing hours, containing repetitive movements under stressful conditions, usually performed in an unnatural posture. Although the evoked disorders are usually non-traumatic, they may often lead to prolonged or even permanent damage. For instance, in upper string players, these include bursitis and tendinopathies of the shoulder muscles, tendonitis of the rotator cuff, injury at the tendon sheaths, medial or lateral epicondylitis (also known as tennis elbow), myofascial pain, and wrist tendonitis (also known as carpal tunnel syndrome, or De Quervein’s syndrome). In cases of intensive performance, a traumatic injury may result, requiring drastic means of intervention such as surgery. It should be pointed out that the upper body and upper extremities are the most commonly affected sites of playing musicians.

  • vocation-related neuro-musculoskeletal disorders
  • evaluation of playing-related disorders in professional musicians
  • temporomandibular joint
  • diagnostics of muscular disorders
  • biomechanical aspects of neuro-muscular deficiencies

1. Introduction

Vocation-related deficiencies place a burden on the working individual, society and economy, requiring means to identify, evaluate and alleviate the factors responsible for evoking these deficiencies. Specifically, performing music players are exposed to the hazards of neuro-musculoskeletal injuries due to the high loads their body is subjected to, as well as discomfort and pain. It has been reported that among orchestra musicians, the incidences of pain and/or neuro-musculoskeletal disorders (percentages of tested players in a given group of instruments) are 75% for violin and viola players, 73% for cello, 60% for double-bass, 69% for woodwinds, 39% for brass and 32% for percussion players [1]. Players of the violin and viola are thus specifically recognized as the most susceptible to playing-related musculoskeletal disorders (PRMD) [2,3,4,5,6,7,8].

Vocation-related deficiencies place a burden on the working individual, society and economy, requiring means to identify, evaluate and alleviate the factors responsible for evoking these deficiencies. Specifically, performing music players are exposed to the hazards of neuro-musculoskeletal injuries due to the high loads their body is subjected to, as well as discomfort and pain. It has been reported that among orchestra musicians, the incidences of pain and/or neuro-musculoskeletal disorders (percentages of tested players in a given group of instruments) are 75% for violin and viola players, 73% for cello, 60% for double-bass, 69% for woodwinds, 39% for brass and 32% for percussion players [1]. Players of the violin and viola are thus specifically recognized as the most susceptible to playing-related musculoskeletal disorders (PRMD) [2][3][4][5][6][7][8].

In these players, the muscles and joints of the upper extremity are the most frequently affected, particularly on the left side, and the side on which the instrument is actually being held [7,9,10,11]. The unusual and non-symmetrical postures involved in generating the motion of the upper limb segments have been reported to enhance the formation of PRMD [12]. The neck, shoulder and temporomandibular joint (TMJ) are particularly prone to damage due to the continued flexion of the head and the shoulder required to grip the instrument in place. The limbs and trunk are subject to relatively high loading forces, repetitive movements, vibrations and fatigue, and the elbow and fingers are common sites of disorders [11,13,14,15]. In addition, upper string musicians perform nearly incessantly during the concert, which makes them even more susceptible to fatigue and injury.

In these players, the muscles and joints of the upper extremity are the most frequently affected, particularly on the left side, and the side on which the instrument is actually being held [7][9][10][11]. The unusual and non-symmetrical postures involved in generating the motion of the upper limb segments have been reported to enhance the formation of PRMD [12]. The neck, shoulder and temporomandibular joint (TMJ) are particularly prone to damage due to the continued flexion of the head and the shoulder required to grip the instrument in place. The limbs and trunk are subject to relatively high loading forces, repetitive movements, vibrations and fatigue, and the elbow and fingers are common sites of disorders [11][13][14][15]. In addition, upper string musicians perform nearly incessantly during the concert, which makes them even more susceptible to fatigue and injury.

Common neuro-musculoskeletal deficiencies will include temporomandibular deficiencies (TMD), disorders related to the active muscles involved during playing and disorders related to body posture, kinematics and dynamics. The issues discussed include motion detection and analysis, force and impact, multi-parameter detection and multidimensional analysis, as well as semi-quantitative methods using visual assessment, physical examination and questionnaires.

2. Temporomandibular Joint (TMJ) and Temporomandibular Disorders (TMD)

2.1. The Existence of TMD

Disorders of the TMJ pertain to the musculoskeletal system and are associated with complaints in the orofacial region where the muscles of mastication and/or the TMJ are involved [16,17]. The playing of musical instruments has frequently been linked to the presence of TMJ disorders (TMD).

Disorders of the TMJ pertain to the musculoskeletal system and are associated with complaints in the orofacial region where the muscles of mastication and/or the TMJ are involved [16][17]. The playing of musical instruments has frequently been linked to the presence of TMJ disorders (TMD).

2.1.1. Wind Instruments

Wind-playing musicians may overload the masticatory system due to straining of the masticatory muscles and facial muscles that control the shape of the stress and lips, leading to discomfort and pain [17,18,19,20].

Wind-playing musicians may overload the masticatory system due to straining of the masticatory muscles and facial muscles that control the shape of the stress and lips, leading to discomfort and pain [17][18][19][20].

2.1.2. Upper String Instruments

During playing of upper string instruments such as violin or viola, the instrument is supported between the left shoulder and angle of the jaw to fixate the instrument between the inferior border of the mandible and the shoulder (supraclavicular fossa). The myofascial trigger points of the muscles of mastication induce jaw pain [7,23,24,25,28].

During playing of upper string instruments such as violin or viola, the instrument is supported between the left shoulder and angle of the jaw to fixate the instrument between the inferior border of the mandible and the shoulder (supraclavicular fossa). The myofascial trigger points of the muscles of mastication induce jaw pain [7][21][22][23][24].

Mandibular lateral displacement, consisting of a lateral inclination of the occlusal plane and resulting in differences between the right and left masticatory muscles, gives rise to a marked uneven stress distribution in the mandible [31,32,33].

Mandibular lateral displacement, consisting of a lateral inclination of the occlusal plane and resulting in differences between the right and left masticatory muscles, gives rise to a marked uneven stress distribution in the mandible [25][26][27].

2.1.3. Lower String Instruments

Temporomandibular disorders, often with chronic low back pain, have also been reported in cello playing, due to the forward head posture, accompanied by a posterior thoracic curve and rounded shoulders [43]. 

Temporomandibular disorders, often with chronic low back pain, have also been reported in cello playing, due to the forward head posture, accompanied by a posterior thoracic curve and rounded shoulders [28]. 

2.2. Methodologies for TMD Identification and Evaluation

2.2.1. Imaging Methods

X-ray methods, including postero-anterior cephalogram, panoramic tomogram and lateral cephalogram have been used to compare between players, and gender- and age-matched controls. Significant morphological differences have been found between violin players and controls [31,32].

X-ray methods, including postero-anterior cephalogram, panoramic tomogram and lateral cephalogram have been used to compare between players, and gender- and age-matched controls. Significant morphological differences have been found between violin players and controls [25][26].

In the lateral cephalogram method, several cephalometric parameters are used for comparison [45]. Using these parameters, upper string players are found to have a measurable increase in the facial height compared to the matched controls, especially in the right side of the lower face, and an increase in the anterior inclination of the upper and lower incisors [31]. This can be considered to result from prolonged playing of the violin, involving increased face muscle activity. Thus, compared to controls, the categories of violin and viola players are shown to have a higher prevalence of brachyfacial type individuals, manifested by smaller facial heights and greater lengths of mandibular corpus [31]. This finding has been further confirmed not only for strings, but also for wind instrument players [32].

the lateral cephalogram method, several cephalometric parameters are used for comparison [29]. Using these parameters, upper string players are found to have a measurable increase in the facial height compared to the matched controls, especially in the right side of the lower face, and an increase in the anterior inclination of the upper and lower incisors [25]. This can be considered to result from prolonged playing of the violin, involving increased face muscle activity. Thus, compared to controls, the categories of violin and viola players are shown to have a higher prevalence of brachyfacial type individuals, manifested by smaller facial heights and greater lengths of mandibular corpus [25]. This finding has been further confirmed not only for strings, but also for wind instrument players [26].

2.2.2. Inserts and Devices

Occlusal Contact Insert
Intra-oral insert devices, fabricated by computerized three-dimensional methods, are used to correct occlusal contact disorders and restore the occlusal stability of upper string players [22]. 

Intra-oral insert devices, fabricated by computerized three-dimensional methods, are used to correct occlusal contact disorders and restore the occlusal stability of upper string players [30]. 

 
Chin Rest and Chin Force
A chin rest [47,48], consisting of a pressure-sensitive pad with shoulder pads as possible mediators [49], is often used in violin playing. Chin rests may also be used for measuring the compressive force on the left mandible by means of a custom-built force sensor fixed between the violin’s top plate and a chin cup [50].

A chin rest [31][32], consisting of a pressure-sensitive pad with shoulder pads as possible mediators [33], is often used in violin playing. Chin rests may also be used for measuring the compressive force on the left mandible by means of a custom-built force sensor fixed between the violin’s top plate and a chin cup [34].

Changing the chin rest and changing the shoulder pad, both reported to affect the pressure and force applied over the chin rest during violin performance, are common ways to modify the violin to accommodate the player for effectiveness and comfort. I

 
Displacement Measurements of the Mandible
Displacement of the mandible accompanied to the exertion of the chin force can be assessed using a digital camera attached to the head of the subject [50]. 

Displacement of the mandible accompanied to the exertion of the chin force can be assessed using a digital camera attached to the head of the subject [34]. 

2.2.3. Finite Element Analysis (FEA) in TMD

Using a three-dimensional finite element model (3D FEM) of the entire body has confirmed the earlier observations [51] that the occlusal plane in patients with mandibular lateral displacement rises in the direction of the mandibular displacement. 

Using a three-dimensional finite element model (3D FEM) of the entire body has confirmed the earlier observations [35] that the occlusal plane in patients with mandibular lateral displacement rises in the direction of the mandibular displacement. 

A lateral inclination of the occlusal plane has been found to induce cervical spine displacement and to cause the stress distribution in this area to be asymmetrical, thus affecting posture [52,53,54]. The simulation of the inclination of the occlusal plane, namely the effect of its lateral upwards inclination, has been carried out by studying the stress distribution in the mandible in conjunction with cervical spine morphology [33]. 

A lateral inclination of the occlusal plane has been found to induce cervical spine displacement and to cause the stress distribution in this area to be asymmetrical, thus affecting posture [36][37][38]. The simulation of the inclination of the occlusal plane, namely the effect of its lateral upwards inclination, has been carried out by studying the stress distribution in the mandible in conjunction with cervical spine morphology [27]. 

With the upward inclination of the occlusal plane towards the mandibular displaced side [51], as well as its lateral inclination [33,52], the FEA model has demonstrated high occlusal stresses on the left side of the mandible, with marked differences in the area corresponding to the left molar root apex. 

With the upward inclination of the occlusal plane towards the mandibular displaced side [35], as well as its lateral inclination [27][36], the FEA model has demonstrated high occlusal stresses on the left side of the mandible, with marked differences in the area corresponding to the left molar root apex. 

The above analysis suggests that in players suffering from mandibular lateral displacement, it is necessary to improve maxillo-mandibular antero-posterior imbalance, as well as to correct the right–left skeletal asymmetry [52].

The above analysis suggests that in players suffering from mandibular lateral displacement, it is necessary to improve maxillo-mandibular antero-posterior imbalance, as well as to correct the right–left skeletal asymmetry [36].

3. Muscle Activity and Disorders

3.1. Why Disorders May Result from Muscle Activity in Musicians

Playing musical instruments involves the activation of numerous muscles at considerable levels of intensities. Muscle activity is usually monitored by means of the electrical signals accompanying its activity, namely the electroyograpm (EMG).

The electromyographic activity of these muscles reveals their relative roles in actuating the shoulder and elbow joints [56,58]. Controlling the bowing motion is carried out by the forearm flexor and extensor muscles [1,4,35]. 

The electromyographic activity of these muscles reveals their relative roles in actuating the shoulder and elbow joints [39][40]. Controlling the bowing motion is carried out by the forearm flexor and extensor muscles [1][4][41]. 

3.2. Muscle Electrodiagnostic Methods

3.2.1. Measuring Muscle Activity

Most published works make use of surface EMG, while intramuscular electrodes are less common, and these studies mainly deal with the muscles of the upper limbs and trunk [64,65,66]. Quantitative EMG can also be used to study the force intensity in various muscles of playing violinists, including the trapezius, deltoids, biceps and triceps muscles [67,68].

Most published works make use of surface EMG, while intramuscular electrodes are less common, and these studies mainly deal with the muscles of the upper limbs and trunk [42][43][44]. Quantitative EMG can also be used to study the force intensity in various muscles of playing violinists, including the trapezius, deltoids, biceps and triceps muscles [45][46].

3.2.2. EMG Processing and Reproducibility

The EMG signals of string players are often processed in the time domain, e.g., using the average rectified EMG (AREMG) from different muscles, as detected by surface electrodes [67]. Another method consists of quantifying the EMG amplitude and duration distributions in defined time domains, using the exposure variation analysis (EVA) [57,69,70]. This processing method is based on the simultaneous assessment of amplitude variability, as well as the time period corresponding to the different amplitudes. 

The EMG signals of string players are often processed in the time domain, e.g., using the average rectified EMG (AREMG) from different muscles, as detected by surface electrodes [45]. Another method consists of quantifying the EMG amplitude and duration distributions in defined time domains, using the exposure variation analysis (EVA) [47][48][49]. This processing method is based on the simultaneous assessment of amplitude variability, as well as the time period corresponding to the different amplitudes. 

Rectified EMG signals are also used to study muscle synchronicity among the proximal/distal musculature of the limb by means of cross-correlation analysis [71,72], or among antagonistic muscles to reveal synchronicity and co-contraction in drum players [73].

Rectified EMG signals are also used to study muscle synchronicity among the proximal/distal musculature of the limb by means of cross-correlation analysis [50][51], or among antagonistic muscles to reveal synchronicity and co-contraction in drum players [52].

The processing of the EMG in the frequency domain is associated with the frequency content of the signal, and specific quantities, such as mean and median frequencies, and is used to express fatigue of the muscle [79,80].

The processing of the EMG in the frequency domain is associated with the frequency content of the signal, and specific quantities, such as mean and median frequencies, and is used to express fatigue of the muscle [53][54].

3.2.3. EMG using Wire Electrodes

Monitoring the electric activity of muscles may also be achieved with fine wire electrodes, which are inserted into the muscle of interest. This method is characterized by its high specificity and is therefore expected to produce more accurate activity results, compared to the conventional surface measurements. However, because it is invasive, it may cause discomfort and interfere with normal playing [81].

Monitoring the electric activity of muscles may also be achieved with fine wire electrodes, which are inserted into the muscle of interest. This method is characterized by its high specificity and is therefore expected to produce more accurate activity results, compared to the conventional surface measurements. However, because it is invasive, it may cause discomfort and interfere with normal playing [55].

3.2.4. Additional Electrodiagnostics Techniques

In addition to EMG, more specific electrodiagnostic techniques can be used in performers. These techniques include upper-limb H-reflex reciprocal inhibition [56], somatosensory evoked potential brain mapping techniques, and transcranial magnetic stimulation (TMS) [43][57], and these have been used particularly in studying focal dystonia and cortical excitability/plasticity. Repetitive TMS is being used for the treatment of complex regional pain syndrome (CRPS), a chronic progressive disease characterized by severe pain combined with sensory, autonomic, and motor disturbances [58].

3.2.5. EMG Applications in Performers

(a) Co-Activation of Muscles

Co-activation (or co-contraction) refers to the simultaneous activity of antagonist muscles. The consequence of co-activation is that the same joint torque can be produced in various different ways, depending on the activation level of each of the acting antagonist muscles [59].

3.2.4. Additional Electrodiagnostics Techniques

In addition to EMG, more specific electrodiagnostic techniques can be used in performers. These techniques include upper-limb H-reflex reciprocal inhibition [84], somatosensory evoked potential brain mapping techniques, and transcranial magnetic stimulation (TMS) [65,85], and these have been used particularly in studying focal dystonia and cortical excitability/plasticity. Repetitive TMS is being used for the treatment of complex regional pain syndrome (CRPS), a chronic progressive disease characterized by severe pain combined with sensory, autonomic, and motor disturbances [86].

3.2.5. EMG Applications in Performers

(a) Co-Activation of Muscles

Co-activation (or co-contraction) refers to the simultaneous activity of antagonist muscles. The consequence of co-activation is that the same joint torque can be produced in various different ways, depending on the activation level of each of the acting antagonist muscles [76].

In playing upper string instruments, co-activation takes place when the left forearm, the wrist and the finger flexor, as well as extensor muscles, are used to control the fingering movements in the hand. Similarly, in the right forearm both the flexors and extensors are used to control the bow of the instrument [1][4][41][60].

In playing upper string instruments, co-activation takes place when the left forearm, the wrist and the finger flexor, as well as extensor muscles, are used to control the fingering movements in the hand. Similarly, in the right forearm both the flexors and extensors are used to control the bow of the instrument [1,4, 35,56].

(b) Muscle Imbalance and Asymmetry

(b) Muscle Imbalance and Asymmetry

To reveal muscle imbalance, the quantitative EMG results of the bilateral trapezius, deltoid, biceps, and triceps muscles are compared between players with performance-related pain in the neck and shoulder region and players without pain [35,67].

To reveal muscle imbalance, the quantitative EMG results of the bilateral trapezius, deltoid, biceps, and triceps muscles are compared between players with performance-related pain in the neck and shoulder region and players without pain [41][45].

(c) Risk Assessment (e.g., Increased Deltoid Activity)

With raising the arm the deltoid also raises the humeral head. To counterweight the subsequent compression of the humeral head against the undersurface of the acromion and reduce the risk of injury of the supraspinatus tendon, simultaneous contractions of the infraspinatus, teres minor and subscapularis rotator cuff muscles occur [87]. An increased deltoid muscle activity will usually evoke a decrease in subacromial space and an increased compression of the humeral head, thus augmenting the hazard of injuring the supraspinatus tendon.

With raising the arm the deltoid also raises the humeral head. To counterweight the subsequent compression of the humeral head against the undersurface of the acromion and reduce the risk of injury of the supraspinatus tendon, simultaneous contractions of the infraspinatus, teres minor and subscapularis rotator cuff muscles occur [61]. An increased deltoid muscle activity will usually evoke a decrease in subacromial space and an increased compression of the humeral head, thus augmenting the hazard of injuring the supraspinatus tendon.

(d) Subacromial Impingement Syndrome (SAIS)

Subacromial impingement syndrome (SAIS), the commonest disorder of the shoulder, is a painful disorder due to loss of subacromial space [88].

Subacromial impingement syndrome (SAIS), the commonest disorder of the shoulder, is a painful disorder due to loss of subacromial space [62].

(e) Assessment of Shoulder Rest and Backrest Support

EMG of the upper arm muscles of the violin players can also be used to assess the efficacy of a shoulder rest attached to the violin. The EMG signals (rectified EMG) of the left trapezius and right sternocleidomastoid muscles reveal a significant reduction in muscle activity when the shoulder rest is used [62,91]. EMG reduction in these muscles (thus their forces) is associated with their increased lever-arm.

EMG of the upper arm muscles of the violin players can also be used to assess the efficacy of a shoulder rest attached to the violin. The EMG signals (rectified EMG) of the left trapezius and right sternocleidomastoid muscles reveal a significant reduction in muscle activity when the shoulder rest is used [63][64]. EMG reduction in these muscles (thus their forces) is associated with their increased lever-arm.

(f) Comparison Between Upper Strings and Cello Playing

Opposed asymmetry differences in the middle and lower trapezius MAI in the upper string and cello groups are also noted between bowing down (from tail to tip) and bowing up (from tip to tail). In upper strings, sliding the bow up requires higher muscle activity (about 50% higher than sliding it down) [56,59]. The reason is that there is a static loading of the left shoulder to support the instrument, and a dynamic, repetitive loading of the right shoulder to facilitate the bowing, the latter being eased by gravity during the bowing down movement [57,68].

Opposed asymmetry differences in the middle and lower trapezius MAI in the upper string and cello groups are also noted between bowing down (from tail to tip) and bowing up (from tip to tail). In upper strings, sliding the bow up requires higher muscle activity (about 50% higher than sliding it down) [39][65]. The reason is that there is a static loading of the left shoulder to support the instrument, and a dynamic, repetitive loading of the right shoulder to facilitate the bowing, the latter being eased by gravity during the bowing down movement [47][46].

(g) Piriformis Muscle Syndrome

A potential syndrome of great discomfort in cellists is piriformis syndrome, associated with the piriformis muscle, which can particularly become tight and cause pain through pinching of the sciatic nerve [43]. Although a monitoring of the surface EMG of the piriformis is possible [92], it might be preferable to make use of fine-wire electrodes, due to the deep location of the muscle [93].

A potential syndrome of great discomfort in cellists is piriformis syndrome, associated with the piriformis muscle, which can particularly become tight and cause pain through pinching of the sciatic nerve [28]. Although a monitoring of the surface EMG of the piriformis is possible [66], it might be preferable to make use of fine-wire electrodes, due to the deep location of the muscle [67].

(h) Muscle Fatigue

Through the processing of the EMG signal, information about muscle fatigue can be obtained both in the time domain (e.g., amplitude of the normalized the rectified signal) and/or in the frequency domain (e.g., median frequency) [79,80]. In musicians, EMG analysis has been found to be efficient for detecting muscle fatigue with PRMD players compared to those without PRMD [94].

Through the processing of the EMG signal, information about muscle fatigue can be obtained both in the time domain (e.g., amplitude of the normalized the rectified signal) and/or in the frequency domain (e.g., median frequency) [53][54]. In musicians, EMG analysis has been found to be efficient for detecting muscle fatigue with PRMD players compared to those without PRMD [68].

(i) Efficacy of “Taping” for Muscle Movement Restriction

As above-described, altering the resting position of the scapula due to muscle imbalance can stimulate pain [60]. This pain can be alleviated by taping the scapulae of violinists into a position that prevents excessive elevation and protraction whilst playing. EMG measurements can be used to evaluate the efficacy of taping treatment by recording the activity from the upper trapezii, the scapula retractors and the right sternocleidomastoid muscles.

As above-described, altering the resting position of the scapula due to muscle imbalance can stimulate pain [69]. This pain can be alleviated by taping the scapulae of violinists into a position that prevents excessive elevation and protraction whilst playing. EMG measurements can be used to evaluate the efficacy of taping treatment by recording the activity from the upper trapezii, the scapula retractors and the right sternocleidomastoid muscles.

(j) Biofeedback

The recording of surface EMG is also useful for biofeedback in the treatment of pain problems, and to train players to reduce excessive force, such as that produced in the left hand and wrist of violinists from gripping the neck of the violin too tightly [24].

The recording of surface EMG is also useful for biofeedback in the treatment of pain problems, and to train players to reduce excessive force, such as that produced in the left hand and wrist of violinists from gripping the neck of the violin too tightly [22].

(k) Assessment of Low Back Pain (LBP)

Using EMG measurements, it has been demonstrated that the presence of low back pain (LBP) can cause a modification of the activation between synergistic muscles of the lumbar back, suggesting that subjects with LBP experience higher fatigability of the erector spinae muscles at the thoracic part than at the lumbar part [96–99]. The increased fatigability of the thoracic part may be relevant in string players whose upper body is active during playing.

Using EMG measurements, it has been demonstrated that the presence of low back pain (LBP) can cause a modification of the activation between synergistic muscles of the lumbar back, suggesting that subjects with LBP experience higher fatigability of the erector spinae muscles at the thoracic part than at the lumbar part [70][71][72][73]. The increased fatigability of the thoracic part may be relevant in string players whose upper body is active during playing.

  1. Posture and Motion

4. Posture and Motion

4.1. Significance of Posture and Movement to Playing Disorders 

Information about posture and kinematics can be used for developing efficient and effective strategies to prevent overuse syndrome in violinists, keeping biological loads under physiological limits, focusing on physical economy for minimizing fatigue during training [103,104] and for the assessment of postural flaws [6,60,105,106].

Information about posture and kinematics can be used for developing efficient and effective strategies to prevent overuse syndrome in violinists, keeping biological loads under physiological limits, focusing on physical economy for minimizing fatigue during training [74][75] and for the assessment of postural flaws [6][69][76][77].

4.2. Measuring Kinematics and Dynamics in Playing

4.2.1 Three-dimensional Motion Analysis

Monitoring the kinematics of the body, violin and bow is accomplished by measuring the time-position of properly attached passive markers using an optoelectronic motion capture system [48]. 

Monitoring the kinematics of the body, violin and bow is accomplished by measuring the time-position of properly attached passive markers using an optoelectronic motion capture system [32]. 

Specific systems include the MacReflex 3D analysis system [15,107] and the Vicon multiple-camera motion capture system [15,58,108]. The three-dimensional time coordinate data are offline reconstructed using a Butterworth filter [56,109]. Angular information can also be obtained from these photogrammetric data [110]. Dynamic modeling using inverse dynamic analysis is used to estimate internal loads at the joints [108,111]. 

Specific systems include the MacReflex 3D analysis system [15][78] and the Vicon multiple-camera motion capture system [15][40][79]. The three-dimensional time coordinate data are offline reconstructed using a Butterworth filter [39][80]. Angular information can also be obtained from these photogrammetric data [81]. Dynamic modeling using inverse dynamic analysis is used to estimate internal loads at the joints [79][82]. 

4.2.2. Electrogoniometers (twin axis) and Potentiometers (single axis)

Bi-axial electrogoniometers are used to measure the range of wrist motion, to identify frequently assumed wrist positions, and to determine the differences between right and left wrist motions among professional violinists [113,114]. Single-axis potentiometers are used to measure finger movement in double bass players [15,115].

Bi-axial electrogoniometers are used to measure the range of wrist motion, to identify frequently assumed wrist positions, and to determine the differences between right and left wrist motions among professional violinists [83][84]. Single-axis potentiometers are used to measure finger movement in double bass players [15][85].

4.2.3. Impact Loading

Intensive, stressful activations of the upper limb during playing result in severe loading on the upper limb from each bowing beat, and are related to progressively increasing harm. The small intrinsic hand muscles, which are greatly involved in generating these recurrent abrupt movements, are thus exposed to risk of damage [116,117]. Similar to the muscles, tendons and nerves of the wrist, the forearm, elbow, shoulder, and neck are at great risk, and repetitive strain injury can take place [13].

Intensive, stressful activations of the upper limb during playing result in severe loading on the upper limb from each bowing beat, and are related to progressively increasing harm. The small intrinsic hand muscles, which are greatly involved in generating these recurrent abrupt movements, are thus exposed to risk of damage [86][87]. Similar to the muscles, tendons and nerves of the wrist, the forearm, elbow, shoulder, and neck are at great risk, and repetitive strain injury can take place [13].

4.2.4. Accelerometry

The application of accelerometers to measure movement, especially dynamic movement, can provide detailed information about abrupt dynamic loading, including intensity, timing and frequency content [80]. Although the application of accelerometers in assessing musicians’ movement has up to this point been limited, the potential of this method is promising [126,127,128].

The application of accelerometers to measure movement, especially dynamic movement, can provide detailed information about abrupt dynamic loading, including intensity, timing and frequency content [54]. Although the application of accelerometers in assessing musicians’ movement has up to this point been limited, the potential of this method is promising [88][89][90].

4.2.5. Other Force Measurements and Dynamometry

Forceplate measurements can be used to monitor the foot–ground reaction forces during playing. For instance, in flute playing, two forceplates, one for each foot, can serve to study the shifting effects from one foot to the other following changes in playing technique [102]. Forceplate measurements, together with kinematic and EMG measurements, may also be incorporated into a multi-segment biomechanical model for studying the biomechanics of violin playing [58].

Forceplate measurements can be used to monitor the foot–ground reaction forces during playing. For instance, in flute playing, two forceplates, one for each foot, can serve to study the shifting effects from one foot to the other following changes in playing technique [91]. Forceplate measurements, together with kinematic and EMG measurements, may also be incorporated into a multi-segment biomechanical model for studying the biomechanics of violin playing [40].

A custom-designed force transducer has been used to monitor the force exerted on the fingerboard of the instrument by the left finger in playing a musical note at diverse playing tempi or other playing conditions [129,130]. This finger force has been used as the input force in a 3D biomechanical dynamic model for the index finger, to simulate the internal tendon and joint forces of the hand [131,132]. 

A custom-designed force transducer has been used to monitor the force exerted on the fingerboard of the instrument by the left finger in playing a musical note at diverse playing tempi or other playing conditions [92][93]. This finger force has been used as the input force in a 3D biomechanical dynamic model for the index finger, to simulate the internal tendon and joint forces of the hand [94][95]. 

4.3. Combined Measurements

4.3.1. EMG and Kinematics/Dynamics

Combined measurements of kinematics of the bowing arm and of the EMG of the trapezius and serratus muscles are performed to look for differences between violinists with subacromial impingement syndrome (SIS) and uninjured violinists [70,81,111].

Combined measurements of kinematics of the bowing arm and of the EMG of the trapezius and serratus muscles are performed to look for differences between violinists with subacromial impingement syndrome (SIS) and uninjured violinists [49][55][82].

4.3.2. EMG and Acoustic Signals (Sound)

The simultaneous recording of muscle activity and its relationship to sound production as captured by its acoustic signals can be used to study a musical performance of violin playing with vibrato [133]. 

The simultaneous recording of muscle activity and its relationship to sound production as captured by its acoustic signals can be used to study a musical performance of violin playing with vibrato [96]. 

4.4. Multidimensional Signal Analysis (MSA)

Multidimensional signal analysis (MSA) involves the coordination and correlation between data collected through multiple experimental and analytic techniques [47,56,58,59,70,101,107]. 

Multidimensional signal analysis (MSA) involves the coordination and correlation between data collected through multiple experimental and analytic techniques [31][39][40][65][49][97][78]. 

4.5. Semi-Quantitative Methods Using Visual Assessment, Physical Examination and Questionnaire

Task-specific measures of PRMD, incorporated into qualitative posture assessment and physical examination, have been used in conjunction with questionnaires [2,7,60,106,134].

Task-specific measures of PRMD, incorporated into qualitative posture assessment and physical examination, have been used in conjunction with questionnaires [2][7][69][77][98].

5. Summary

This review provides a description of the playing-related motor disorders in performing musicians, and of the methodologies used to identify and evaluate these disorders. Methodologies to diagnose, characterize and evaluate PRMD are clearly of importance for the further improvement of devices and techniques aimed at reducing damage associated with the prolonged playing of music.

References

 

 
 

References

  1. Fry, H.J.H. Incidence of overuse syndrome in the symphony orchestra. Med. Prob. Perf. Art. 1986, 1, 51–55.
  2. Caldron, P.H.; Calabrese, L.H.; Clough, J.D.; Lederman, R.J.; Williams, G.; Leatherman, J. A survey of musculoskeletal problems encountered in high level musicians. Med. Prob. Perf. Art. 1986, 1, 136–139.
  3. Fishbein, M.; Middlestadt, S.E.; Ottati, V.; Straus, S.; Ellis, A. Medical problems among ICOSM musicians: Overview of a national survey. Med. Prob. Perf. Art. 1998, 3, 1–8.
  4. Lockwood, A.H. Medical problems in secondary school-aged musicians. Med. Probl. Perform. Artist. 1988, 3, 129–132.
  5. Manchester, R.A. The incidence of hand problems in music students. Med. Probl. Perform. Artist. 1988, 3, 15–18.
  6. Larsson, L.G.; Baum, J.; Mudholkar, G.S.; Kollia, G.D. Benefits and disadvantages of joint hypermobility among musicians. N. Engl. J. Med. 1993, 329, 1079–1082.
  7. Hohls, Q.R. An Investigation into Performance Related Musculoskeletal Disorders of Professional Orchestral String Musicians in South Africa. Master’s Thesis, Durban University of Technology, Durban, South Africa, January 2010.
  8. Lee, H.S.; Park, H.Y.; Yoon, J.O.; Kim, J.S.; Chun, J.M.; Aminata, I.W.; Cho, W.J.; Jeon, I.H. Musicians’ medicine: Musculoskeletal problems in string players. Clin. Orthop. Surg. 2013, 5, 155–160.
  9. Miller, G.; Peck, F.; Watson, J.S. Pain disorders and variations in upper limb morphology in music students. Med. Probl. Perform. Artist. 2002, 17, 169–172.
  10. Burkholder, K.R.; Brandfonbrener, A.G. Performance-related injuries among student musicians at a specialty clinic. Med. Prob. Perf. Art. 2004, 19, 116–122.
  11. Handal, C. Documenting Postural Changes and Repetition Among Violin Players and Their Influence in the Development of Musculoskeletal Disorders. Master’s Thesis, Louisiana State University and Agricultural and Mechanical College, Baton Rouge, LA, USA, 2013; p. 62.
  12. Brown, S. Shoulder pain and the instrumental musician. J. Back Musculoskelet. Rehabil. 1992, 2, 16–27.
  13. Newmark, J.; Hochberg, F.H. “Doctor, it hurts when I play”: Painful disorders among instrumental musicians. Med. Probl. Perform. Artist. 1987, 2, 93–97.
  14. Moraes, G.F.S.; Antunes, A.P. Musculoskeletal disorders in professional violinists and violists. Systematic review. Acta Ortop. Bras. 2012, 20, 43–47.
  15. Kelleher, L.K.; Campbell, K.R.; Dickey, J.P. Biomechanical Research on Bowed String Musicians. A Scoping Study. Med. Probl. Perform. Artist. 2013, 28, 212–218.
  16. De Leeuw, R.; Klasser, G.D. Diagnosis and management of TMDs. In Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management; de Leeuw, R., Ed.; Quintessence Publishing Co.: Chicago, IL, USA, 2013; pp. 127–186.
  17. Van Selms, M.K.A.; Ahlberg, J.; Lobbezoo, F.; Visscher, C.M. Evidence-based review on temporomandibular disorders among musicians. Occup. Med. 2017, 67, 336–343.
  18. Steinmetz, A.; Ridder, P.H.; Methfessel, G.; Muche, B. Professional musicians with craniomandibular dysfunctions treated with oral splints. Cranio 2009, 27, 221–230.
  19. Attallah, M.M.; Visscher, C.M.; van Selms, M.K.; Lobbezoo, F. Is there an association between temporomandibular disorders and playing a musical instrument? A review of literature. J. Oral Rehabil. 2014, 41, 532–541.
  20. Nishiyama, A.; Tsuchida, E. Relationship Between Wind Instrument Playing Habits and Symptoms of Temporomandibular Disorders in Non-Professional Musicians. Open Dent. J. 2016, 10, 411–416.
  21. Travell, J.G.; Simons, D.G.; Simons, L.S. Myofascial Pain and Dysfunction: The Trigger Point Manual, 2nd ed.; Lippincott, Williams and Wilkins: Philadelphia, PA, USA, 1999.
  22. Hoppman, R.A.; Patrone, N.A. A review of musculoskeletal problems in instrumental musicians. Semin. Arthritis Rheum. 1989, 19, 117–126.
  23. Liu, S.; Hayden, G.F. Maladies in musicians. South. Med. J. 2002, 95, 727–734.
  24. Taddey, J.J. Musicians and temporomandibular disorders: Prevalence and occupational etiologic considerations. J. Craniomandib. Pract. 1992, 10, 241–244.
  25. Kovero, O.; Kononen, M.; Pirinen, S. The effect of violin playing on the bony facial structures in adolescents. Eur. J. Orthod. 1997, 19, 369–375.
  26. Clemente, M.P.; Mendes, J.; Moreira, A.; Ferreira, A.P.; Amarante, J.M. Craniofacial morphology of wind and string instrument players: A cephalometric study. BMC Med. Imaging 2020, 20, 57.
  27. Shimazaki, T.; Motoyoshi, M.; Hosoi, K.; Namura, S. The effect of occlusal alteration and masticatory imbalance on the cervical spine. Eur. J. Orthod. 2003, 25, 457–463.
  28. Gallo, M.L. Pilates and String Musicians: An Exploration of the Issues Addressed by the Pilates Method, an Illustrated Guide to Adapted Exercises, and a Pilates Course for University String Players. Ph.D. Thesis, Arizona State University, Tempe, AZ, USA, May 2017.
  29. Ricketts, R.M. Perspectives in the clinical application of cephalometrics. The first fifty years. Angle Orthod. 1981, 51, 115–150.
  30. Dos Santos, B.F.; Branquinho, T.; Fragelli, O. Prevalence of temporomandibular joint disorders and neck pain in musicians: A sytematic review. Fisioter. Mov. 2017, 30, 839–848.
  31. Levy, C.E.; Lee, W.A.; Brandfonbrener, A.G.; Press, J.; Levy, A.E. Electromyographic analysis of muscular activity in the upper extremity generated by supporting a violin with and without a shoulder rest. Med. Probl. Perform. Artist. 1992, 7, 103–109.
  32. Rabuffetti, M.; Converti, R.; Boccardi, S.; Ferrarin, M. Tuning of the violin-performer interface: An experimental study about the effects of shoulder rest variations on playing kinematics. Med. Probl. Perform. Artist. 2005, 22, 58–66.
  33. Okner, M.; Kernozek, T.; Wade, M.G. Chin rest pressure in violin players: Musical repertoire, chin rest, and shoulder pads as possible mediators. Med. Probl. Perform. Artist. 1997, 12, 112–121.
  34. Obata, S.; Kinoshita, H. Chin force in violin playing. Eur. J. Appl. Physiol. 2012, 112, 2085–2095.
  35. Fushima, K.; Akimoto, S.; Takamoto, K.; Sato, S.; Suzuki, Y. Morphological feature and incidence of TMJ disorders in mandibular lateral displacement cases. J. Jpn. Orthod. Soc. 1989, 48, 322–328.
  36. Motoyoshi, M.; Shimazaki, T.; Maruyama, J.; Nakajima, A.; Namura, S. Biomechanical influences on the upper vertebrae during mastication, an examination using the finite element method. Orthod. Waves. 2000, 59, 183–190.
  37. Motoyoshi, M.; Shimazaki, T.; Sugai, T.; Namura, S. Biomechanical influences of head posture on occlusion: An experimental study using finite element analysis. Eur. J. Orthod. 2002, 24, 319–326.
  38. Motoyoshi, M.; Shimazaki, T.; Hosoi, K.; Wada, M.; Namura, S. Stresses on the cervical column associated with vertical occlusal alteration. Eur. J. Orthod. 2003, 25, 135–138.
  39. Wales, J. 3D Movement and Muscle Activity Patterns in a Violin Bowing Task. Master’s Thesis, Brock University, St. Catharines, ON, USA, 2007.
  40. Loram, A. A Scientific Investigation into Violin and Viola Playing. Master’s Thesis, University College London, Division of Surgery and Interventional Science, London, UK, 2013.
  41. Bejjani, F.J.; Kaye, G.M.; Benham, M. Musculoskeletal and neuromuscular conditions of instrumental musicians. Arch. Phys. Med. Rehabil. 1996, 77, 406–413.
  42. Kjelland, J.M. Application of electromyography and electromyographic biofeedback in music performance research: A review of the literature since 1985. Med. Prob. Perf. Art. 2000, 15, 115–118.
  43. Lederman, R.J. Neuromuscular and musculoskeletal problems in instrumental musicians. Muscle Nerve. 2003, 27, 549–561.
  44. Kok, L.M.; Groenewegen, K.A.; Huisstede, B.M.A.; Nelissen, R.G.H.H.; Rietveld, A.B.M.; Haitjema, S. The high prevalence of playing-related musculoskeletal disorders (PRMDs) and its associated factors in amateur musicians playing in student orchestras: A cross-sectional study. PLoS ONE 2018, 13, e0191772.
  45. Philipson, L.; Sorbye, R.; Larsson, P.; Kaladjev, S. Muscular load levels in performing musicians as monitored by quantitative electromyography. Med. Probl. Perform. Artist. 1990, 5, 79–82.
  46. Afsharipour, B.; Petracca, F.; Gasparini, M.; Merletti, R. Spatial distribution of surface EMG on trapezius and lumbar muscles of violin and cello players in single note playing. J. Electromyogr. Kinesiol. 2016, 31, 144–153.
  47. Fjellman-Wiklund, A.; Grip, H.; Karlsson, J.S.; Sundelin, G. EMG trapezius muscle activity pattern in string players: Part I—Is there variability in the playing technique? Int. J. Ind. Ergon. 2004, 33, 347–356.
  48. Mathiassen, S.-E.; Winkel, J. Physiological comparison of three interventions in light assembly work: Reduced work pace, increased break allowance and shortened working days. Int. Arch. Occup. Environ. Health 1996, 68, 94–108.
  49. Reynolds, J.F. Shoulder Joint and Muscle Exposure in Violin Musicians: A Three-Dimensional Kinematic and Electromyographic Exposure Variation Analysis. Master’s Thesis, University of Minnesota, Minneapolis, MN, USA, May 2009.
  50. Grasso, R.; Bianchi, L.; Lacquaniti, F. Motor patterns of human gait: Backward versus forward locomotion. J. Neurophysiol. 1998, 80, 1868–1885.
  51. Levin, O.; Forner-Cordero, A.; Li, Y.; Ouamer, M.; Swinnen, S. Evidence for adaptive shoulder-elbow control in cyclical movements with different amplitudes, frequencies and orientations. J. Mot. Behav. 2008, 40, 499–515.
  52. Beveridge, S.; Herff, S.A.; Buck, B.; Madden, G.B.; Jabusch, H.C. Expertise-Related Differences in Wrist Muscle Co-contraction in Drummers. Front. Psychol. 2020, 11, 1360.
  53. Suponitsky, Y.; Verbitsky, O.; Peled, E.; Mizrahi, J. Effect of Selective Fatiguing of the Shank Muscles on Single-Leg-Standing Sway. J. Electromyogr. Kinesiol. 2008, 18, 682–689.
  54. Mizrahi, J.; Verbitsky, O.; Isakov, E. Fatigue-related loading imbalance on the shank in running: A possible factor in stress fractures. Ann. Biomed. Eng. 2000, 28, 463–469.
  55. Visentin, P.; Shan, G. Applications of EMG Pertaining to Music Performance—A Review. Arts Biomech. 2011, 1, 15–32.
  56. Panizza, M.E.; Hallett, M.; Nilsson, J. Reciprocal inhibition in patients with hand cramps. Neurology 1989, 39, 85–89.
  57. Abbruzzese, G.; Marchese, R.; Buccolieri, A.; Gasparetto, B.; Trompetto, C. Abnormalities in sensorimotor integration in focal dystonia: A transcranial simulation study. Brain 2001, 124, 537–545.
  58. Nardone, R.; Brigo, F.; Höller, Y.; Sebastianelli, L.; Versace, V.; Saltuari, L.; Lochner, P.; Trinka, E. Transcranial magnetic stimulation studies in complex regional pain syndrome type I: A review. Acta Neurol. Scand. 2018, 137, 158–164.
  59. Katz, A.; Tirosh, E.; Marmur, R.; Mizrahi, J. Enhancement of muscle activity by electrical stimulation in cerebral palsy—A case control study. J. Child. Neurol. 2008, 23, 259–267.
  60. Michelotti, A.; Manzo, P.; Farella, M.; Martina, R. Occlusion and posture: Is there evidence of correlation? Minerva Stomatol. 1999, 48, 525–534, PMID: 10768011.
  61. Payne, L.Z.; Deng, X.H.; Craig, E.V.; Torzilli, P.A.; Warren, R.F. The combined dynamic and static contributions to subacromial impingement, a biomechanical analysis. Am. J. Sports Med. 1997, 25, 801–808.
  62. Michener, L.A.; McClure, P.W.; Karduna, A.R. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clin. Biomech. 2003, 18, 369–379.
  63. Jager, M.; Luttmann, A. The load on the lumbar spine during asymmetrical bi-manual materials handling. Ergonomics 1992, 35, 783–805.
  64. Chan, R.F.M.; Chow, C.-y.; Lee, G.P.S.; Xeni, L.-k.T.; Tsang, Y.S.; Yeung, S.S.; Yeung, E.W. Self-perceived exertion level and objective evaluation of neuromuscular fatigue in a training session of orchestral violin players. Appl. Ergon. 2000, 31, 335–341.
  65. Shan, G.; Visentin, P.; Schultz, A. Multidimensional signal analysis as a means of better understanding factors associated with repetitive use in violin performance. Med. Probl. Perform. Artists. 2004, 19, 129–139.
  66. Masala, S.; Crusco, S.; Meschini, A.; Taglieri, A.; Calabria, E.; Simonetti, G. Long-term follow-up in patients treated with percutaneous injection of anesthetic and corticosteroid under CT guidance. Cardiovasc. Interv. Radiol. 2012, 35, 375–382.
  67. Morimoto, Y.; Oshikawa, T.; Imai, A.; Okubo, Y.; Kaneoka, K. Piriformis electromyography activity during prone and side-lying hip joint movement. J. Phys. Sci. 2018, 30, 154–158.
  68. Möller, D.; Ballenberger, N.; Ackermann, B.; Zalpour, C. Potential Relevance of Altered Muscle Activity and Fatigue in the Development of Performance-Related Musculoskeletal Injuries in High String Musicians. Med. Probl. Perform. Artist. 2018, 33, 147–155.
  69. Steinmetz, A.; Seidel, W.; Muche, B. Impairment of postural stabilization systems in musicians with playing-related musculoskeletal disorders. J. Manip. Physiol. Ther. 2010, 33, 603–611.
  70. Oddsson, L.I.E.; De Luca, C.J. Activation imbalances in lumbar spine muscles in the presence of chronic low back pain. J. Appl. Physiol. 2003, 94, 1410–1420.
  71. Renkawitz, T.; Boluki, D.; Grifka, J. The association of low back pain, neuromuscular imbalance, and trunk extension strength in athletes. Spine J. 2006, 6, 673–683.
  72. Sung, P.S.; Andrew, R.; Lammers, A.R.; Danial, P. Different parts of erector spinae muscle fatigability in subjects with and without low back pain. Spine J. 2009, 9, 115–120.
  73. Hodges, P.W.; Richardson, C.A. Altered trunk muscle recruitment in people with low back pain with upper limb movement at different speeds. Arch. Phys. Med. Rehabil. 1999, 80, 1006–1012.
  74. Shan, G.; Visentin, P. A quantitative three-dimensional analysis of arm kinematics in violin performance. Med. Probl. Perform. Art. 2003, 18, 3–10.
  75. Hasselbach von, J.; Gruhn, W.; Gollhofer, A. Effects of training on mass balancing oscillations in the bowing of (pre) teen violin students: A quantitative micromotion study. Arts Biomech. 2011, 1, 1–14.
  76. De Araujo, N.; Cardia, M.G. Analysis of the frequency of postural flaws during violin performance. Med. Probl. Perform. Art. 2009, 24, 108–112.
  77. Barczyk-Pawelec, K.; Sipko, T.; Demczuk-Włodarczyk, E.; Boczar, A. Anteroposterior spinal curvatures and magnitude of asymmetry in the trunk in musicians playing the violin compared with nonmusicians. J. Manip. Physiol. Ther. 2012, 35, 319–326.
  78. Turner-Stokes, L.; Reid, K. Three-dimensional motion analysis of upper limb movement in the bowing arm of string-playing musicians. Clin. Biomech. 1999, 14, 426–433.
  79. Shan, G.; Visentin, P.; Wooldridge, L.; Wang, C.; Connolly, D. A frequency- based characterization of spiccato bowing in violin performance. Percept. Motor Skills. 2007, 105, 1027–1051.
  80. Konczak, J.; Vander Velden, H.; Jaeger, L. Learning to play the violin: Motor control by freezing, not freeing degrees of freedom. J. Mot. Behav. 2009, 41, 243–252.
  81. Yagisan, N.; Karabork, H.; Goktepe, A. Evaluation of three-dimensional motion analysis of the upper right limb movements in the bowing arm of violinists through a digital photogrammetric method. Med. Probl. Perform. Artists. 2009, 24, 181–184.
  82. Visentin, P.; Shan, G. The kinetic characteristics of the bow arm during violin performance: An examination of internal loads as a function of tempo. Med. Probl. Perform. Artists. 2003, 18, 91–97.
  83. Kihira, M.; Ryu, J.; Han, J.S.; Rowen, B. Wrist motion analysis in violinists. Med. Probl. Perform. Art 1995, 10, 79–85.
  84. Schuppert, M.; Wagner, C. Wrist symptoms in instrumental musicians: Due to biomechanical restrictions? Med. Probl Perform. Art. 1996, 11, 37–42.
  85. Guettler, K. Electromyography and muscle activities in double bass playing. Mus. Percept. 1992, 9, 303–310.
  86. Dawson, W.J. Intrinsic Muscle Strain in the Instrumentalist. Med. Prob. Perf. Art. 2005, 20, 66–69.
  87. Manchester, R.A.; Flieder, D. Further observations on the epidemiology of hand injuries in music students. Med. Probl. Perform. Artist. 1991, 6, 11–14.
  88. Staines, K.G.; Gorniak, S.; Brooks, F.; Collins, E. A pilot comparison of peak hand force in musicians using the Peg Retrained Intrinsic Muscle Evaluator (PRIME). J. Hand. Ther. 2016, 29, 383.
  89. Gorniak, S.L.; Collins, E.D.; Staines, K.G.; Brooks, F.A.; Young, R.V. The impact of musical training on hand biomechanics in string musicians. Hand 2018, 14, 155894471877238.
  90. Cobb, J.E. An Accelerometer Based Gestural Capture System for Performer Based Music Composition. Master’s Thesis, University of York, York, UK, December 2011.
  91. Lee, S.-H.; Carey, S.; Dubey, R.; Matz, R. Intervention program in college instrumental musicians, with kinematics analysis of cello and flute playing: A combined program of yogic breathing and muscle strengthening-flexibility exercises. Med. Probl. Perform. Art. 2012, 27, 85–94.
  92. Kinoshita, H.; Obata, S. Left hand finger force in violin playing: Tempo, loudness, and finger differences. J. Acoust. Soc. Am. 2009, 126, 388–395.
  93. Grosshauser, T.; Troster, G. Finger position and pressure sensing techniques for strings and keyboard instruments. In Proceedings of the 13th International Conference on New Interfaces for Musical Expression (NIME’13), KAIST, Daejeon, Korea, 27–30 May 2013.
  94. Brook, N.; Mizrahi, J.; Shoham, M.; Dayan, J. A biomechanical model of index finger dynamics. Med. Eng. Phys. 1995, 17, 54–63.
  95. Mizrahi, J. Neuro-mechanical aspects of playing-related mobility disorders in orchestra violinists and upper strings players: A review. Eur. J. Transl. Myol. 2020, 30, 1–15.
  96. Bejjani, F.J.; Ferrara, L.; Pavlidis, L. A comparative electromyographic and acoustic analysis of violin vibrato in healthy professional violinists. Med. Probl. Perform. Art. 1989, 4, 168–175.
  97. Tulchinsky, E.; Riolo, L. A biomechanical motion analysis of the violinist’s bow arm. Med. Probl. Perform. Artists. 1994, 9, 125–130.
  98. Vesamäki, E. Surviving Over-Practice Injury: The Quest to Find Freedom in Violin Technique. Master Thesis, Royal College of Music in Stockholm, Department of Classical Music, Stockholm, Sweden, 2015; p. 38.
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