Nikolaus Ballenberger, PHD, Msc, PT Dirk, Möller, Dipl. Sportwiss., PT

1. Occurrence of (Musculoskeletal) Health Complaints and associated Risk Factors in Music Students and Non-music Students – Interim Results from an ongoing Cohort Study Nikolaus Ballenberger, PHD, Msc, PT Dirk, Möller, Dipl. Sportwiss., PT Christine Guptill, PhD, OT, BSc, BMus, MS(OT) Julius Bruder, BSs, PT Christoff Zalpour, MD

2. Who is a musician?

3. Who is a musician? • Who haspain/complaintswhenplaying at themoment?

4. Who is a musician? • Who haspain/complaintswhenplaying at themoment? • Last year?

5. Who is a musician? • Who haspain/complaintswhenplaying at themoment? • Last year? • Ever?

6. Background • Systematic review of occurrence of musculoskeletal complaints in professional musicians (Kok, 2016) • point prevalences : 9 to 68 % • 12-month prevalences : 41 to 93 % • lifetime prevalences : 62 to 93 % • At beginning of studies: 79% of music students reported playing-related pain (Brandfonbrener, 2009) • Classification of Playing-related health complaints among musicians: • Physical : musculoskeletal health complaints (MHC) (Kok, 2013) • Psychological : stress, performance anxiety (Lockwood, 1988; Barthel and Thomson, 1994)

7. Problem • Sport physiotherapy/medicineisestablished • In Germany threetimesmore professionell musiciansthanathletes • Master degrees in Sport PT BUTnoacademiccoursein musicphysiotherapy • muchmoreinstitutes in sportsmedicinethanmusicmedicine

8. Background Overall goal: specificintervention/prevention Requirements for specific Therapy/Prevention: • Identification of etiological mechanisms (risk factors) for playing-related complaints and understanding of interaction necessary

9. Background Requirements for specific Therapy/Prevention: • Identification of etiological mechanisms (risk factors) for playing-related complaints and understanding of interaction necessary BUT : not sufficiently investigated due to inappropriate study designs  mainly cross sectional (Baadjou, 2016) • no incidences prospectively recorded, only prevalences • no causality due to lack of temporal relationship • hence, no (proper) Risk Factors identified (Longitudinal) Cohort Study at University ofappliedscienceofOsnabrueck

10. Cross sectionalvs longitudinal • E.g: oneaimstoevaluatewhetherdepressioncausespain

11. Cross sectionalvs longitudinal Cross-sectional No Depression Depression Hen egg problem!! NoPain Pain Time t0

12. Cross sectionalvs longitudinal longitudinal No Depression NoPain Depression causespain!! Depression Pain Time t0 t1

13. Goal Cohort Study: • Ocurrences(IncidenceandPrevalance) ofmusculoskeletal health complaints (MHC)among music students (University of Osnabrück and other study sites e.g. Alberta Canada) • Assessthedifference in physicalandpsychologicalhealthbetweenmusicstudentsandstudentsofotherdisciplines at baselineandcourseover time • Identification of risk factors  health complaintsbased on health related variables at baseline • Prediction modelhealth complaints

14. Difference in health between music students and students of other disciplines at baseline (cross-sectional) Recruitment

15. Occurrences (Incidence and Prevalence) of MHC over time

16. Identification of risk factors based on health related variables at baseline and prediction of MHC

17. Assessments • Questionnaireabouthistoryofpain, localisationofpain, habits, practicing , sports…. • Corestability planks and Biering-Sørensen-test (Biering-Sorensen 1984; McGill et al. 1999)   • Hypermobility Beighton-Score (Beighton et al. 1973) • CROM (Cervical Range of Motion) • Mechanosensitivity(Grossi et al. 2011; Persson et al. 2004) • Health related QuoL SF12 (Ware, JR und Sherbourne 1992) • Stress- und Coping Inventar(Satow, 2012) • Performance anxiety K-MPAI (Kenny, 2004)

18. Comparison of music students to control students at baseline (cross-sectional, adjusted) N=219

19. Differencesbetweenmusicstudentsandcontrolstudents (cross-sectional)

21. Distribution of MHC within 1 year (longitudinal) Control student Music student 4.6% 4.9% Head/face Neck/schoulder 22.4% 14.6% 11.2% Th.sp/chest 4.6% Up.ex. 10.3% 0.4% 0.5% 4.6% Lower back Low. ex. 4.9% 3.8%

22. Predictorsofmonthlyepisodeof MHC (longitudinal)

23. Things (riskfactors) youshould NOT have/bewhenstartingyourmusiccareerifyouwanttobepainfree….

24. Discussion/Summary • Cross-sectional (at baseline): • Bodily pain, N° stress symptoms, Physical health, Mental health, Physical activity, Planks, General mechanosensitivity, CROM • results are comparable to other research (Kok, 2013; Roach, 2013; Steinmetz, 2012; Voltmer,2012) • Risk factors based on longitudinal data (complete sample): • Music student, Bodily pain, Complaints (seven days), N° stress symptoms, Physical health, Mental health, Complaints (ever), Complaints (12 months), Smoking (years) • results are comparable to other research (Brandfonbrener,2009; Rosset-Llobet, 2000; Steinmetz, 2012; Baadjou, 2016;Kaufman-Cohen,2012)

25. Discussion/Summary • Of interest: mainly pain related variables and generic assessment are more relevant • Even though different between musicians and control not necessarily predictors for MHC  planks, general mechanosensitivity • Need for standardized definition of MHC and its assessment • use MPIIQM (Berque, 2014) in order to make data about MHC comparable across cultures • MPIIQM validated into German (Möller, 2018)

26. Discussion/Limitations Strengths: • Consistency of results  validity • Prospective design  causal relationship (risk factors) , incidences, reduced recall bias (see discrepancy to retrospective) • Detailed information about health Limitations: • compliance • monthly records do not allow to distinguish between recurrence (new episode) and lasting episode • heterogeneity of sample (age, gender)

27. Future • Expandourstudysites • Occurrences, risk factors and prediction model specific for body region and instrumentlow back, neck , upper extremity etc. • Developspecificintervention/prevention

28. Thank you! Questions?

29. References Kenny D, Ackermann B. Performance-related musculoskeletal pain, depression and music performance anxiety in professional orchestral musicians: A population study. Psychology of Music. 2015;43(1):43–60. doi:10.1177/0305735613493953 Rickert DL, Barrett MS, Ackermann BJ. Injury and the orchestral environment: Part I. The role of work organisation and psychosocial factors in injury risk. Med Probl Perform Art. 2013;28(4):219–29. Kok LM, Huisstede BMA, Voorn VMA, Schoones JW, Nelissen, Rob G. H. H. The occurrence of musculoskeletal complaints among professional musicians: a systematic review. International Archives of Occupational and Environmental Health. 2016;89(3):373–96. doi:10.1007/s00420-015-1090-6 Fishbein M, Middlestadt SE. Medical problems among ICSOM musicians: Overview of a national survey. Med Probl Perform Art. 1988;31–8. Wesner RB, Noyes R JR, Davis TL. The occurrence of performance anxiety among musicians. J Affect Disord. 1990;18(3):177–85. Barbar AEM, de Souza Crippa, Jose Alexandre, Lima Osorio F de. Performance anxiety in Brazilian musicians: prevalence and association with psychopathology indicators. J Affect Disord. 2014;152-154381–6. doi:10.1016/j.jad.2013.09.041 Kenny DT, Davis P, Oates J. Music performance anxiety and occupational stress amongst opera chorus artists and their relationship with state and trait anxiety and perfectionism. J Anxiety Disord. 2004;18(6):757–77. doi:10.1016/j.janxdis.2003.09.004 Brandfonbrener AG. History of playing-related pain in 330 university freshman music students. Med Probl Perform Art. 2009;24(1):30. Roset-Llobet J, Rosinés-Cubells D, Saló-Orfila JM. Identification of risk factors for musicians in Catalonia (Spain). Steinmetz A, Moller H, Seidel W, Rigotti T. Playing-related musculoskeletal disorders in music students-associated musculoskeletal signs. Eur J Phys Rehabil Med. 2012;48(4):625–33. Baadjou VAE, Roussel NA, Verbunt, J A M C F, Smeets, R J E M, Bie RA de. Systematic review: risk factors for musculoskeletal disorders in musicians. Occup Med (Lond). 2016. doi:10.1093/occmed/kqw052 Davies J, Mangion S. Predictors of pain and other musculoskeletal symptoms among professional instrumental musicians: elucidating specific effects. Med Probl Perform Art. 2002;17(4):155–69. Berque P, Gray H, McFadyen A. Playing-Related Musculoskeletal Problems Among Professional Orchestra Musicians in Scotland: A Prevalence Study Using a Validated Instrument, the Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians (MPIIQM). Med Probl Perform Art. 2016;31(2):78–86. doi:10.21091/mppa.2016.2015 Zaza C, Charles C, Muszynski A. The meaning of playing-related musculoskeletal disorders to classical musicians. Social Science & Medicine. 1998;47(12):2013–23. doi:10.1016/S0277-9536(98)00307-4 Biering-Sorensen F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine (Phila Pa 1976). 1984;9(2):106–19. McGill SM, Childs A, Liebenson C. Endurance times for low back stabilization exercises: Clinical targets for testing and training from a normal database. Archives of Physical Medicine and Rehabilitation. 1999;80(8):941–4. doi:10.1016/S0003-9993(99)90087-4 Coorevits P, Danneels L, Cambier D, Ramon H, Vanderstraeten G. Assessment of the validity of the Biering-Sorensen test for measuring back muscle fatigue based on EMG median frequency characteristics of back and hip muscles. J ElectromyogrKinesiol. 2008;18(6):997–1005. doi:10.1016/j.jelekin.2007.10.012 Demoulin C, Vanderthommen M, Duysens C, Crielaard J-M. Spinal muscle evaluation using the Sorensen test: a critical appraisal of the literature. Joint Bone Spine. 2006;73(1):43–50. doi:10.1016/j.jbspin.2004.08.002 Simmonds MJ, Olson SL, Jones S, Hussein T, Lee CE, Novy D, Radwan H. Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain. Spine (Phila Pa 1976). 1998;23(22):2412–21. Durall CJ, Greene PF, Kernozek TW. A comparison of two isometric tests of trunk flexor endurance. J Strength Cond Res. 2012;26(7):1939–44. doi:10.1519/JSC.0b013e318237ea1c Strand SL, Hjelm J, Shoepe TC, Fajardo MA. Norms for an isometric muscle endurance test. J Hum Kinet. 2014;4093–102. doi:10.2478/hukin-2014-0011 Beighton P, Solomon L, Soskolne CL. Articular mobility in an African population. Ann Rheum Dis. 1973;32(5):413–8.

30. References 2Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Archives of Physical Medicine and Rehabilitation. 2003;84(12):1858–64. Junge T, Jespersen E, Wedderkopp N, Juul-Kristensen B. Inter-tester reproducibility and inter-method agreement of two variations of the Beighton test for determining Generalised Joint Hypermobility in primary school children. BMC Pediatr. 2013;13214. doi:10.1186/1471-2431-13-214 Boyle KL, Witt P, Riegger-Krugh C. Intrarater and Interrater Reliability of the Beighton and Horan Joint Mobility Index. Journal of Athletic Training. 2003;38(4):281–5. Aartun E, Degerfalk A, Kentsdotter L, Hestbaek L. Screening of the spine in adolescents: inter- and intra-rater reliability and measurement error of commonly used clinical tests. BMC MusculoskeletDisord. 2014;1537. doi:10.1186/1471-2474-15-37 Gauvin MG, Riddle DL, Rothstein JM. Reliability of clinical measurements of forward bending using the modified fingertip-to-floor method. Phys Ther. 1990;70(7):443–7. Chaves TC, Goncalves MC, Moreira VC, Canonica AC, Florencio LL, Bordini CA, Speciali JG, Bigal ME. Pressure pain threshold in the craniocervical muscles of women with episodic and chronic migraine: a controlled study. ArqNeuropsiquiatr. 2011;69(4):607–12. eng. Persson AL, Brogardh C, Sjolund BH. Tender or not tender: test-retest repeatability of pressure pain thresholds in the trapezius and deltoid muscles of healthy women. J Rehabil Med. 2004;36(1):17–27. eng. Ware JE JR, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473–83. McHorney CA, Ware JE JR, Lu JF, Sherbourne CD. The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care. 1994;32(1):40–66. Satow L. Stress- und Coping-Inventar (SCI): Vollständige Test- und Skalendokumentation [Internet]. Available from: http://www.drsatow.de/tests/stress-und-coping-inventar/ Morton SMB, Bandara DK, Robinson EM, Carr PEA. In the 21st Century, what is an acceptable response rate? Aust N Z J Public Health. 2012;36(2):106–8. doi:10.1111/j.1753-6405.2012.00854.x Berque P, Gray H, McFadyen A. Development and psychometric evaluation of the Musculoskeletal Pain Intensity and Interference Questionnaire for professional orchestra Musicians. Man Ther. 2014;19(6):575–88. doi:10.1016/j.math.2014.05.015 Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143(1):29–36. doi:10.1148/radiology.143.1.7063747 Kok LM, Vlieland, Theodora P M Vliet, Fiocco M, Nelissen, Rob G H H. A comparative study on the prevalence of musculoskeletal complaints among musicians and non-musicians. BMC MusculoskeletDisord. 2013;149. doi:10.1186/1471-2474-14-9 Roach KE, Martinez MA, Anderson N. Musculoskeletal pain in student instrumentalists: a comparison with the general student population. Med Probl Perform Art. 1994;9125. Leaver R, Harris EC, Palmer KT. Musculoskeletal pain in elite professional musicians from British symphony orchestras. Occup Med (Lond). 2011;61(8):549–55. doi:10.1093/occmed/kqr129 Zamorano AM, Riquelme I, Kleber B, Altenmuller E, Hatem SM, Montoya P. Pain sensitivity and tactile spatial acuity are altered in healthy musicians as in chronic pain patients. Front Hum Neurosci. 2014;81016. doi:10.3389/fnhum.2014.01016