Musculoskeletal problems are common health problems of musicians, irrespective of the instrument played. Playing-related musculoskeletal disorder (PRMD) is an umbrella term that denotes musculoskeletal problems associated only with playing the musical instruments (Bragge, Bialocerkowski & Mcmeeken 2006). The most commonly reported symptoms of PRMDs are pain, tingling, loss of flexibility and weakness in the upper extremity and trunk (Brusky 2010; Paarup et al. 2011). The aetiology of PRMDs (a derivative of work-related musculoskeletal disorders) is multifactorial.

The occurrence of PRMDs is associated with several intrinsic factors such as joint hypermobility, age (Ranelli, Straker & Smith 2011; Yeung et al. 1999) and gender and extrinsic factors such as warm-ups, playing hours, playing position, posture and playing techniques (Kaufman-Cohen & Ratzon 2011). Psychosocial factors such as stage fright and anxiety also contribute to the development of musculoskeletal problems among musicians. This may be because of increased stress and resultant muscle tension (Williamon & Thompson 2006). The awkward posture normally assumed by string instrumentalists when playing is also considered as a contributing factor to the occurrence and location of PRMDs (Moraes & Antunes 2012).

Playing a string instrument increases the instrumentalists’ risk of musculoskeletal problems, mainly in the upper extremities but also in the trunk and sub-mandibular regions (Abréu-Ramos & Micheo 2007; Moraes & Antunes 2012). String instrumentalists have a higher risk of developing musculoskeletal problems when compared to other instrument groups (Hagberg, Thiringer & Brandström 2005). The occurrence of PRMDs is similar regardless of professional level; music students, amateurs and professionals all report similar prevalence of PRMDs (Bragge et al. 2006; Kok et al. 2013).

Lederman (2003) reported 69% prevalence of PRMDs among string instrumentalists. The distribution of musculoskeletal problems is specific to and closely related to the instrument. Neck, upper trapezius, right and left shoulders are the most common body areas of musculoskeletal problems among cellists (Rickert et al. 2012), whereas the neck, shoulders and the temporo-mandibular joint are the most commonly affected areas among violinists and violists (Moraes & Antunes 2012).

Female string instrumentalists have a higher prevalence of PRMDs when compared to their male counterparts (Davies & Mangion 2002). Also, older instrumentalists report musculoskeletal problems affecting performance more often than younger ones (Ranelli et al. 2011). Over the last three decades, studies have emanated from North America, Europe and Australia evaluating musculoskeletal problems of musicians. There is, however, still a dearth of literature on musculoskeletal injuries of musicians in Africa. In the last 5 years, only three small-sampled studies were found reporting the epidemiology of injury among musicians at various study sites within South Africa (Ajidahun & Phillips 2013; Barnes et al. 2011; Hohls 2010).

The studies were conducted in specific groups. Barnes et al. (2011) reported the injury profile of musicians in one professional orchestra. The injury profile of musicians was reported in two professional orchestras (Hohls 2010) and a school of music (Ajidahun & Phillips 2013). This study is a national survey of the prevalence of musculoskeletal injuries among string instrumentalists in South Africa.

The aim of this study was:

The results of this study showed that 77% of string instrumentalists reported problems in one or more anatomic regions with 35% currently experiencing problems that interfere with their performances. The prevalence of musculoskeletal problems in this study is similar to studies that reported a high prevalence of musculoskeletal problems among string instrumentalists (Abréu-Ramos & Micheo 2007; Leaver, Harris & Palmer 2011; Lederman 2003). The prevalence of problems reported is significantly higher among females when compared with males, especially in the trunk and the left shoulder. The increased prevalence of musculoskeletal injury among female string instrumentalists is similar to previous studies (Davies & Mangion 2002; Heming 2004). Risk factors such as joint laxity (Brandfonbrener 2002), hormonal differences (Anderson et al. 2001) and smaller body frame (Ekman et al. 2000) have been identified in literature as contributing factors to the increased prevalence of musculoskeletal problems reported in females than males. It has also been reported that females are more predisposed to reporting illnesses when compared to males (Barsky, Peekna & Borus 2001). These differences between males and females should be considered in developing and implementing an injury prevention programme.

The lower string players in this study reported a higher prevalence of problems when compared to the upper string players as also reported in earlier studies with a professional symphony orchestra (Abréu-Ramos & Micheo 2007) and young music students (Ranelli et al. 2011). Problems are reported in the neck, low back and left shoulder. This distribution is similar to studies performed on professional orchestra instrumentalists (Leaver et al. 2011; Paarup et al. 2012). Postural and bowing demands of playing the specific string instrument are consistent with the body regions affected, and this explains the variability in the distribution of musculoskeletal problems with regard to each string instrument (Paarup et al. 2012). The increased prevalence of musculoskeletal problems in the low back among violists when compared to violinists in this study is an interesting finding. This is especially because the violin and viola are similar in the postural position required for performance with the only difference being that the viola is a heavier instrument (Turner-Stokes & Reid 1999). The influence of the weight of instrument on the distribution of musculoskeletal problems might be important in proffering injury preventative programmes.

The severity of musculoskeletal problems in this study was reported as mild to moderate. A study conducted by Steinmetz et al. (2015) among professional orchestra musicians reported similar results using the numeric pain rating scale. The numeric pain rating score was between 3.9 and 4.7 in the affected body regions (Steinmetz et al. 2015). Although the complaints of pain in our study on string players were reported as mild to moderate in severity, it is worth noting that more players had severe pain in the upper back, neck and both shoulders compared to other affected regions as shown in Figure 4. Regardless of the mild–moderate severity of the complaints in this study, there is an increased severity of problems in the upper back, neck, right and left shoulder in comparison with the low back.

Prolonged neck flexion and the abnormal static posture of the left shoulder could be responsible for the increased severity in the upper trunk and left shoulder (Moraes & Antunes 2012), whereas repetitive bowing action could be responsible for the increased severity in the right shoulder. In playing the string instrument, the right shoulder involvement in repetitive bowing activity could result in musculoskeletal injury within the shoulder (Turner-Stokes & Reid 1999). Similar results indicate that postural imbalance is common among string instrumentalists, and postural structures are the most injured body regions in the string instrumentalist (Barczyk-Pawelec et al. 2012; Moraes & Antunes 2012). This implies that in-depth ergonomic assessment and nuanced corrective action could potentially reduce and prevent musculoskeletal problems among string players. Interventions up to now have involved a general rehabilitation approach and may not be addressing the specific areas needed in the intervention.

Self-administered questionnaire studies rely on the subjective opinion of the respondent and it can be biased (Bowling 2005; Cook 2010). The questionnaire was administered and completed by the orchestras at different music seasons of the year. Some completed the questionnaire at the peak of their season, whereas some completed the questionnaire off-season. The data collected might not represent the overall prevalence of musculoskeletal problems among string instrumentalists in South Africa. Because of the difficulty with responses, different modes (online and paper-based) of data collection were used and could have influenced the quality of the data (Bowling 2005). Musicians with a history of musculoskeletal problems are more likely to be motivated to respond to the survey when compared to those without history of musculoskeletal problems. This may therefore skew the reported prevalence.

In conclusion, this study suggests that musculoskeletal problems of string instrumentalists are high in South Africa. The trunk, right and left shoulders are the most common areas of injury. An understanding of the most commonly affected body regions and the severity of injury coupled with the gender differences studied should be used in developing an injury prevention strategy to reduce the prevalence of musculoskeletal injury among string instrumentalists. In addition, an educational programme about causative factors and injury prevention strategies with the orchestra may be useful in developing a comprehensive injury prevention programme. Successful implementation of an effective programme is possible if health promotion is effected and collaboration is fostered between health practitioners and performers.