Tiina Lahtinen-Suopanki PT, BHSc

Orton Oy, Scientific and Physiotherapy Departments, Helsinki, Finland.


There is a high risk, up to 87%, for classical musicians to develop playing related musculoskeletal dysfunctions and pain (Dommerholt 2009) which can limit or prohibit the musician from continuing to work. The incidence of overuse syndrome among musicians is as high as 80% and even a minor clumsiness or numbness in a finger can end the career (Delbert et al 2012).

Playing an instrument means countless amounts of repetitions and a high load for the performing hands.  The repetitive movement overloading can result in various symptoms including deficits in motor control, loss of strength and endurance, numbness, tingling and pain. The studies that have been done to find out the peripheral tissues and mechanics mostly involved in the production of symptoms have focused on muscles, tendons, nerves and the minor injuries and inflammation processes produced by cumulation of repetitive stress (Barr & Barbe 2002). The studies have not included the fascial structures in the pain producing structures even though it is densely innervated tissue with intrafascial free nerve endings and mechanoreceptors (Stecco et al 2013) and it is in close relationship to the intra- and inter muscular force transmission (Huijing 1999, Yocesoy et al 2008) and has shown to be more sensitive to pain after exercise than muscle tissue (Lau et al 2015).  The fascia has also been proposed and shown to participate in proprioception and motor control (Stecco 2004, Stecco et al 2011).

Musicians are often exposed to stressfull situations f ex while performing. One of the most common reactions is the change in breathing pattern, usually higher respiratory frequence and lowered CO2mmHg- levels in exhaled air that can lead to decreased tissue oxygenation, increased exitability in the nervous and muscular system that can lead to formation of myofascial trigger points, lack of force and endurance, pins and needles kind of sensations and pain (Mc Laughlin 2008, Chaitow 2004).

Material and Methods

The study group consisted of eight musicians (seven violinists and one pianist) who had upper extremity pain and dysfunction and five asymptomatic violinists formed the control group. 

The musicians in the study group were 25.8 (±4.0) year old women, who had been playing the same instrument for 19.3 (±4.9) years and had had their upper extremity symptoms for 3.5 (±3.1) years. The disability in connection to playing the instrument caused by the upper extremity dysfunction was measured by VAS-scale 0-10 at the baseline and at the end of the study.

The control group musicians were women at the age of 23.4 (±1.8) who had been playing the violin for 17.0 (±1.8) years.

Jamar hydrolic dynamometer was used to assess the grip strength.  Three consecutive grips were measured and their average value was counted and compared between the symptomatic and asymptomatic upper extremity at the baseline and between the two extremities and study groups at the end of the study.

In assessing the breathing pattern frequency and end exhalation CO2-level (mmHg) an educational capnometer (Capno Trainer), a carbon dioxide monitoring instrument designed for evaluating breathing was used.

The patients were evaluated and treated by the Fascial Manipulation® (FM) method. The areas of the deep fascia, Centers of Coordination (CC) and Fusion (CF) to be treated by FM were chosen based on the information of the movement and palpation verification. The study group patients had three FM interventions within two months.

All the musicians who participated in the study were voluntary and gave their written approval for the use of the data.

6. Results

The results are expressed as means with a standard deviation (SD). Due to non-normal distribution of data nonparametric statistical test were used. The groups are compared using the Mann-Whitney U-test and differences between baseline and follow-up measures were calculated using Wilcoxon Signed Rank Test. The α-level was set at 0.05.

The baseline disability in connection to playing the instrument was 8.50 (±1.31) and at the end of the study 4.25 (±1.83) showing a good effect of FM- treatment on the disability (p = 0.011).

Comparing the grip strength at the baseline between the two groups the symptomatic side of the study group and corresponding upper extremity of the control group showed   statistically significant difference between the two groups (p = 0.019). There was no statistical significant difference in the grip strength between the asymptomatic side of the study group and the corresponding side of the control group (p= 0.045).

The capnometer measurements of the breathing pattern showed no difference between the two groups. The breathing frequency was 13.3 (± 2.5)/min in the study group and 12.2 (±1.6) /min in the control group.  The end exhalation CO2 mmHg-level of the study group was 32.6 (±2.0) mmHg and 32.8 (0.8) mmHg in the control group. The low levels of end exhalation CO2 mmHg -levels are due to low calibration of the capnometer and was noticed in the middle of the study during the control group measurements. The normal mimimum values for end exhalation CO2mmHg are 35-40. The calibration was the same for all and the real values are 2mmHg higher for all.

7. Discussion

Musicians´ upper extremities are prone to vast number of repetitions during their career which usually begins in a very early stage of life. The incidence of overuse syndromes is high and can stop the career already in the beginning of the profession.  In the study group there were three persons unable to play at all or  maximum 10 minutes without pain in the beginning and an interesting feature is that this did not show clearly  f ex in their the grip strength test or other movement tests. Mechanosensitivity and pain   during playing is a common complaint but clumsiness, lack of force, numbness and tingling are 

as common and so far the peripheral explanation for those complaints is not fully understood.  In the absence of nervous compression or other typical explanations for those symptomes the situation can be very frustrating and fearfull for the person.

Over one third of muscle contraction force is transmitted via the fascial structures and it is connected to every single note the musician plays. The fascia is in connection with intra- and extrafusal fibers of the muscle spindle and golgi tendon organs as well as mechanoreceptors so the signalling from the fascia to the central nervous system during playing is constant. Studies have shown changes that can take place in the fascial biomechanics due to overuse, traumas etc and their influence on motor control, feeling of stiffness and lack of force and increased mechanosensitivity during normal movements.

This study was carried out with a small group of symptomatic musicians. The results are encouraging, the experienced disability was significantly decreased and the grip strength   increased in the symptomatic hand.  One interesting feature during testing the grip strength was that at the baseline during repeated grips the score lowered after each repetition in the symptomatic hand and after FM treatment the scores remained the same or increased in the same manner as in the asymptomatic side or control group. This feature does not show in the grip force because the average force was taken into the calculations. The lack of force was perceived to happen more as a result of fast muscle fatique than pain. The explanation could be that the normalizing of fascial biomechanics changes the afferent signalling from the fascial mechanoreceptors and normalizes the co-operation between muscle spindle – golgi tendon-organ and results in coordinated smooth movements.    

The normal breathing pattern is between 12-15 breaths per minute. In this study there was no statistical difference in breathing frequence or end exhalation CO2mmHg-levels between the two groups.

8. Conclusions

The fascia seems to play an important role in the peripheral mechanical sensitisation and disability in connection to playing a musical instrument. A short intervention of three treatments with FM resulted in a significant decrease of experienced disability (p = 0.011) that had lasted for 3.5 (± 3.1) years. A notable improvement (p = 0.019) of grip strength of the symptomatic hand was a part of recovery.

This study indicates the importance of evaluation of fascial biomechanics as a part of repetitive strain injuries and also the need for FM-treatment in order normalize the function and relieve the symptoms.