Abstract

Background Professional musicians have high rates of musculoskeletal pain, but few studies have analysed risks by work activities or the psychosocial work environment.

Aims To assess the prevalence and impact of musculoskeletal pain, and its relation to playing conditions, mental health and performance anxiety, in musicians from leading British symphony orchestras.

Methods Musicians from six professional orchestras completed a questionnaire concerning their orchestral duties and physical activities at work, mental health (somatizing tendency, mood, demand, support and control at work, performance anxiety) and regional pain in the past 4 weeks and past 12 months. Prevalence rates were estimated by anatomical site and associations with risk factors assessed by logistic regression.

Results Responses were received from 243 musicians (51% of those approached), among whom 210 (86%) reported regional pain in the past 12 months, mainly affecting the neck, low back and shoulders. Risks tended to be higher in women, in those with low mood, and especially in those with high somatizing scores. Only weak associations were found with psychosocial work stressors and performance anxiety. However, risks differed markedly by instrument category. Relative to string players, the odds of wrist/hand pain were raised 2.9-fold in wind players, but 60% lower in brass players, while the odds of elbow pain were 50% lower among wind and brass players.

Conclusions Musculoskeletal pain is common in elite professional musicians. A major personal risk factor is somatizing tendency, but performance anxiety has less impact. Risks differ substantially by instrument played, offering pointers towards prevention.

Introduction

The work of professional musicians exposes them to a range of physical and psychological risk factors, which, in other occupations, have been linked with occurrence of musculoskeletal disorders (MSDs). These include static loading of muscles, repetition, precision grip and psychosocial work pressures. Understanding, however, about the burden, pattern and determinants of musculoskeletal pain in members of professional orchestras is incomplete.

A systematic review by Zaza [1] covering seven databases over a 16-year period, and including hand-searching of textbooks on the topic and performing medicine journals, identified 24 relevant studies, mostly cross-sectional and with information on prevalence. Of these, however, only two focused solely on professional musicians [2,3] and three others on an admixture of professionals and students [4–6]. In addition to the paucity of data relevant to professional orchestral musicians, Zaza drew attention to several other limitations in this field, such as small sample size, poor response rates, errors of sampling and analysis and widely differing case definitions. Moreover, none of the reports explored risk factors for symptom reporting, although the relation of regional pain to instrument type, workload, mental health and performance anxiety are relevant to preventive planning. In the decade or so following Zaza's review, there have been several further epidemiological surveys in professional [7–13] or mixed professional and amateur orchestras [14–16] and in players of particular instruments [15,17–19], together with a further systematic review [20]; but many of the limitations of earlier reports remain. In particular, despite this invested effort, relatively little is known about risks by work activities or the psychosocial work environment.

To supplement this literature, we assessed the frequency and impact of musculoskeletal pain and the relation of symptoms to playing conditions, including instrument category, mental health and performance anxiety, in a sample of musicians from leading British symphony orchestras.

Methods

The target population comprised orchestral musicians employed full time by professional symphony orchestras in Britain. Recent figures suggested that a total of 1200 musicians were employed in 14 major symphony orchestras. All the orchestras were approached and six (listed in acknowledgements) participated in our study.

Enumeration lists were prepared for each participating orchestra after excluding part-time workers and the study was publicized via discussions with orchestral managers, playing committee representatives and a series of presentations at orchestral rehearsals.

Subjects were approached during rehearsal sessions that were chosen to involve the full complement of musical parts. Subjects attending such rehearsals were invited to self-complete a questionnaire—either during the rehearsal or later with return by post. Members of the enumeration list who were absent from the relevant rehearsals were mailed the questionnaire, and reminders by telephone and email were sent to orchestral managers 1 week and 1 month after the rehearsals to encourage a full response. Data collection occurred in November 2008 to January 2009 in major UK concert halls and BBC rehearsal studies in London, Manchester and Birmingham.

Data were collected by orchestra, on age, sex, instrument category, working hours, somatizing tendency (using the validated Brief Symptom Inventory) [21], mood [using the mental health section of the Short-form-36 (SF-36)], demand, support and control at work (according to the Karasek model), performance anxiety, physical activities in a typical working day (elbow bending, working with the hands elevated, lifting weights, repetitive wrist/finger movements), job security, regional pain and knowing someone else affected by regional pain. The questions on musculoskeletal symptoms were based on the standardized Nordic questionnaire [22] and concerned pain in the low back, neck, shoulders, elbows, and wrists and hands over the past 4 weeks and past 12 months, including disabling pain in the past 12 months.

Following inspection of frequency distributions, age was categorized into three bands, somatizing tendency into rough thirds of the total distribution of scores for all respondents, SF-36 assessed mood into two bands (worst third of scores versus the rest) and instrument type into a single variable with four levels—strings, wind, brass, other. ‘Disabling pain’ was defined as pain in the past 12 months present for at least a month and which prevented attendance at work for at least 1 day (modified from the Nordic questionnaire [22], with a more specific definition of work limitation framed in terms of sickness absence). Univariate associations between the regional pain outcomes and risk factors were assessed using logistic regression and expressed as odds ratios (ORs) with associated 95% confidence intervals. Multivariable models were then constructed to assess risk of each pain outcome by instrument type, with adjustment for age, sex and risk factors showing reasonably strong associations (OR ≥ 1.5 or ≤ 0.67) with the outcome in univariate analysis.

Results

In all, 478 orchestral musicians were approached and this resulted in 243 usable responses (51% response rate overall and 35–67% by orchestra). The relative frequency of instrument categories among the study sample was close to the standard complement of UK symphony orchestras as a whole (Table 1). The mean age of participants was 44 years (range 23–64 years) with an inter-quartile range of 37–53 years. In comparison with the sex distribution of those in the six orchestras approached, women were over-represented among respondents (37% in orchestral enumeration lists versus 44% among respondents). On average, respondents played for 30 h/week and 58% had worked as professional musicians for over 20 years.

Table 1.

Response rates by orchestra and instrument type

Orchestra N (studied/approached) % response Instrument N (participants) % of all respondentsa 
58/86 67 Strings 151 62 
42/94 45 Wind 36 15 
38/82 46 Brass 39 16 
29/83 35 Other 17 
36/52 65    
40/81 49    
ALL 243/478 51  243 100 
Orchestra N (studied/approached) % response Instrument N (participants) % of all respondentsa 
58/86 67 Strings 151 62 
42/94 45 Wind 36 15 
38/82 46 Brass 39 16 
29/83 35 Other 17 
36/52 65    
40/81 49    
ALL 243/478 51  243 100 
a

A full symphony orchestra comprises a complement of 91 musicians, among whom 66% are string players, 13% are wind players, 14% are brass players and 7% play other instrument types.

Altogether 210 (86%) subjects reported musculoskeletal pain in the past 12 months, including 100 (41%) with ‘disabling’ pain. Table 2 shows the prevalence of symptoms by anatomical region. The commonest sites for pain in the past 12 months were the neck, low back and shoulder (51–56% in the past year), with 1 in 10 to 1 in 5 of respondents reporting ‘disabling’ pain at one of these sites.

Table 2.

Prevalence (%)a of regional pain among participants

Anatomical site Pain during the past
 
Disabling pain in the past 12 months 
12 months, N (%) 4 weeks, N (%) N (%) 
Low back 125 (51) 80 (33) 42 (17) 
Neck 135 (56) 88 (36) 54 (22) 
Shoulder 124 (51) 91 (37) 23 (10) 
Elbow 50 (21) 30 (12) 7 (3) 
Wrist/hand 79 (33) 59 (24) 14 (6) 
Any of these 210 (86) 172 (71) 100 (41) 
Anatomical site Pain during the past
 
Disabling pain in the past 12 months 
12 months, N (%) 4 weeks, N (%) N (%) 
Low back 125 (51) 80 (33) 42 (17) 
Neck 135 (56) 88 (36) 54 (22) 
Shoulder 124 (51) 91 (37) 23 (10) 
Elbow 50 (21) 30 (12) 7 (3) 
Wrist/hand 79 (33) 59 (24) 14 (6) 
Any of these 210 (86) 172 (71) 100 (41) 
a

% of all respondents (n = 243).

Table 3 sets out the univariate associations between regional pain in the past 12 months and the non-occupational risk factors investigated. Patterns of associations were similar for pain in the past month (data not presented). The strongest and most consistent associations were found with somatizing score (with ORs increased ∼2.5- to 5.5-fold in highest versus lowest band comparisons, and findings all significant at the 5% level). Risks tended also to be higher in women and in those with low mood; but elbow pain proved an exception, being associated with male sex and older age, and not with low mood. Smoking history showed little relation to pain.

Table 3.

Non-occupational risk factors for regional pain in the past 12 months

 N Low back pain (n = 125)a
 
Neck pain (n = 135)a
 
Shoulder pain (n = 124)a
 
Elbow pain (n = 50)a
 
Wrist/hand pain (n = 79)a
 
 N (%) OR 95% CI N (%) OR 95% CI N (%) OR 95% CI N (%) OR 95% CI N (%) OR 95% CI 
Sex 
    Male 135 64 (47) – 65 (48) – 57 (42) – 32 (24) – 39 (29) – 
    Female 108 61 (56) 1.4 0.9–2.4 70 (65) 2.0 1.2–3.3 67 (62) 2.2 1.3–3.8 18 (17) 0.6 0.3–1.2 40 (37) 1.4 0.8–2.5 
Age (years) 
    <40 86 43 (50) – 51 (59) – 50 (58) – 8 (9) – 30 (35) – 
    40–50 80 46 (58) 1.4 0.7–2.5 47 (59) 1.0 0.5–1.8 45 (56) 0.9 0.5–1.7 20 (25) 3.3 1.3–7.9 27 (34) 1.0 0.5–1.8 
    >50 75 35 (47) 0.9 0.5–1.6 35 (47) 0.6 0.3–1.1 28 (37) 0.4 0.2–0.8 22 (29) 4.1 1.6–9.8 21 (28) 0.7 0.4–1.4 
Smoking 
    Never 169 87 (52) – 92 (54) – 86 (51) – 34 (20) – 55 (33) – 
    Ever 74 38 (51) 1.0 0.6–1.7 43 (58) 1.2 0.7–2.0 38 (51) 1.0 0.6–1.8 16 (22) 1.1 0.6–2.1 24 (32) 1.0 0.6–1.8 
Somatizing scoreb 
    Low 83 31 (37) – 37 (45) – 29 (35) – 9 (11) – 19 (23) – 
    Medium 89 45 (51) 1.7 0.9–3.2 47 (53) 1.4 0.8–2.5 42 (47) 1.7 0.9–3.1 22 (25) 2.7 1.2–6.3 30 (34) 1.7 0.9–3.4 
    High 71 49 (69) 3.7 1.9–7.3 51 (72) 3.2 1.6-6.2 53 (75) 5.5 2.7–11.0 19 (27) 3.0 1.3–7.2 30 (42) 2.5 1.2–4.9 
Moodc 
    Normal 154 77 (50) – 72 (47) – 69 (45) – 32 (21) – 45 (29) – 
    Low 86 47 (55) 1.2 0.7–2.0 61 (71) 2.8 1.6–4.9 54 (63) 2.1 1.2–3.6 18 (21) 1.0 0.5–1.9 34 (40) 1.6 0.9–2.8 
 N Low back pain (n = 125)a
 
Neck pain (n = 135)a
 
Shoulder pain (n = 124)a
 
Elbow pain (n = 50)a
 
Wrist/hand pain (n = 79)a
 
 N (%) OR 95% CI N (%) OR 95% CI N (%) OR 95% CI N (%) OR 95% CI N (%) OR 95% CI 
Sex 
    Male 135 64 (47) – 65 (48) – 57 (42) – 32 (24) – 39 (29) – 
    Female 108 61 (56) 1.4 0.9–2.4 70 (65) 2.0 1.2–3.3 67 (62) 2.2 1.3–3.8 18 (17) 0.6 0.3–1.2 40 (37) 1.4 0.8–2.5 
Age (years) 
    <40 86 43 (50) – 51 (59) – 50 (58) – 8 (9) – 30 (35) – 
    40–50 80 46 (58) 1.4 0.7–2.5 47 (59) 1.0 0.5–1.8 45 (56) 0.9 0.5–1.7 20 (25) 3.3 1.3–7.9 27 (34) 1.0 0.5–1.8 
    >50 75 35 (47) 0.9 0.5–1.6 35 (47) 0.6 0.3–1.1 28 (37) 0.4 0.2–0.8 22 (29) 4.1 1.6–9.8 21 (28) 0.7 0.4–1.4 
Smoking 
    Never 169 87 (52) – 92 (54) – 86 (51) – 34 (20) – 55 (33) – 
    Ever 74 38 (51) 1.0 0.6–1.7 43 (58) 1.2 0.7–2.0 38 (51) 1.0 0.6–1.8 16 (22) 1.1 0.6–2.1 24 (32) 1.0 0.6–1.8 
Somatizing scoreb 
    Low 83 31 (37) – 37 (45) – 29 (35) – 9 (11) – 19 (23) – 
    Medium 89 45 (51) 1.7 0.9–3.2 47 (53) 1.4 0.8–2.5 42 (47) 1.7 0.9–3.1 22 (25) 2.7 1.2–6.3 30 (34) 1.7 0.9–3.4 
    High 71 49 (69) 3.7 1.9–7.3 51 (72) 3.2 1.6-6.2 53 (75) 5.5 2.7–11.0 19 (27) 3.0 1.3–7.2 30 (42) 2.5 1.2–4.9 
Moodc 
    Normal 154 77 (50) – 72 (47) – 69 (45) – 32 (21) – 45 (29) – 
    Low 86 47 (55) 1.2 0.7–2.0 61 (71) 2.8 1.6–4.9 54 (63) 2.1 1.2–3.6 18 (21) 1.0 0.5–1.9 34 (40) 1.6 0.9–2.8 
a

Some respondents did not answer all the questions.

b

Cut-points represent approximate thirds of the total distribution of somatization scores.

c

Low = worst approximate third of the total distribution of SF36 mental health scale.

As might be expected, physical activities involving use of the upper limb were frequently reported, with 209 (86%) musicians undertaking repeated movements of the wrist or fingers for >4 h in total per day in an average working day, 182 (75%) repeatedly bending and straightening their elbow for >1 h per day, 101 (47%) (violin, viola, double bass, harp) musicians working for >1 h per day with their hands above shoulder height and 37 musicians (16%, mainly from the brass family) holding weights of ≥5 kg for ≥3 h in total.

Regarding the psychosocial work environment, 44% of respondents felt that they could sometimes or often exercise choice over how much they worked, 77% reported feeling supported sometimes or often by other colleagues at work and 22% felt that their jobs would be unsafe or very unsafe if a significant illness kept them from attending work for ≥3 months. Very common factors that showed little overall variation (and were not considered in subsequent analyses) included: being under pressure to complete tasks by a fixed time (90% of musicians), seldom or never having a choice in the ingredients of work (86%) and job satisfaction (93% were satisfied or very satisfied). Frequent performance anxiety was far less prevalent (14%).

Table 4 (available as Supplementary data at Occupational Medicine Online) summarizes the univariate associations of regional pain with occupational physical activities, psychosocial aspects of the work environment, performance anxiety and the instrument played. Repeated bending and straightening of the elbow was significantly associated with low back and shoulder pain and repeated wrist/finger movements non-significantly with wrist/hand pain (all ORs being increased 2.4- to 2.7-fold). Occupational psychosocial factors were associated somewhat inconsistently with regional pain, but ORs of ≥1.5 were found in relation to low choice (for low back and wrist/hand pain) and low support (for low back, neck and shoulder pain) and an OR of 0.6 in relation to job insecurity and wrist/hand pain.

There were marked differences in prevalence of regional pain by the category of instrument played. For example, relative to a baseline of string players, players of wind instruments reported more wrist/hand pain (OR 1.9) and more neck pain (OR 1.6); but brass players had less low back pain, elbow pain and wrist/hand pain (OR >50% lower).

To assess the relation of pain to instrument type after allowing for the other occupational and non-occupational risk factors in Tables 3 and 4, separate multivariable models were constructed for each regional site of pain (Table 5). Age, sex, and somatizing score, as strong predictors of pain (Table 3), were included in every model. Adjustment was also made for factors from Tables 3 and 4 that were at least moderately associated with pain at the same site (OR ≥ 1.5 or OR ≤ 0.67). (However, no adjustment was made for physical activity on the assumption that differences in activity could lie on the causal pathway between instrument type and regional pain.) The footnotes to Table 5 record the final models used; the corresponding multivariate associations with somatizing tendency (the leading non-occupational risk factor) are given for comparison.

Table 5.

Association between instrument played and regional pain in the past 12 months—multivariate analyses

 OR (95% CI)
 
 Low back paina Neck painb Shoulder painb Elbow pain Wrist/hand painc 
Instrument played 
    Strings 1.0 1.0 1.0 1.0 1.0 
    Wind 0.78 (0.35–1.72) 2.53 (1.06–6.03) 1.10 (0.48–2.52) 0.58 (0.19–1.74) 2.90 (1.26–6.68) 
    Brass 0.45 (0.20–1.03) 0.95 (0.43–2.14) 0.73 (0.32–1.67) 0.39 (0.13–1.20) 0.41 (0.15–1.15) 
    Other 1.09 (0.38–3.17) 1.38 (0.46–4.15) 0.49 (0.15–1.61) 0.96 (0.29–3.17) 2.55 (0.84–7.70) 
Somatizing score 
    Low 1.0 1.0 1.0 1.0 1.0 
    Medium 1.60 (0.85 3.03) 1.52 (0.79-2.90) 1.61 (0.84–3.09) 2.91 (1.21–7.03) 2.04 (0.97–4.27) 
    High 3.61 (1.79–7.31) 2.46 (1.18–5.12) 4.01 (1.91-8.41) 4.35 (1.70–11.14) 3.07 (1.37–6.84) 
 OR (95% CI)
 
 Low back paina Neck painb Shoulder painb Elbow pain Wrist/hand painc 
Instrument played 
    Strings 1.0 1.0 1.0 1.0 1.0 
    Wind 0.78 (0.35–1.72) 2.53 (1.06–6.03) 1.10 (0.48–2.52) 0.58 (0.19–1.74) 2.90 (1.26–6.68) 
    Brass 0.45 (0.20–1.03) 0.95 (0.43–2.14) 0.73 (0.32–1.67) 0.39 (0.13–1.20) 0.41 (0.15–1.15) 
    Other 1.09 (0.38–3.17) 1.38 (0.46–4.15) 0.49 (0.15–1.61) 0.96 (0.29–3.17) 2.55 (0.84–7.70) 
Somatizing score 
    Low 1.0 1.0 1.0 1.0 1.0 
    Medium 1.60 (0.85 3.03) 1.52 (0.79-2.90) 1.61 (0.84–3.09) 2.91 (1.21–7.03) 2.04 (0.97–4.27) 
    High 3.61 (1.79–7.31) 2.46 (1.18–5.12) 4.01 (1.91-8.41) 4.35 (1.70–11.14) 3.07 (1.37–6.84) 

Separate models were constructed in relation to each site of pain. All models were adjusted for age, sex and somatizing tendency.

a

Also adjusted for low support, lack of choice.

b

Also adjusted for low mood, low support.

c

Also adjusted for low mood, low security and lack of choice.

Differences by instrument persisted after adjusting for other risk factors. Thus, the odds of wrist/hand pain were raised 2.9-fold in wind players, but almost 60% lower in brass players (a 7.1-fold difference for the brass-wind comparison); and against the same baseline the odds of elbow pain were ∼50% lower among wind and brass players; odds of low back pain were also over 50% lower in brass than in string players. Independently, somatizing tendency remained a strong, significant and consistent risk factor for regional pain, with ORs in the highest versus lowest band raised some 2.5- to 4.4-fold.

Discussion

As judged by these findings, regional musculoskeletal pain is common in professional musicians, the main sites of complaint being the low back, neck and shoulders. In some cases, pain was disabling. Expected associations were found with sex, mental health and especially somatizing tendency, but no independent effect of performance anxiety was seen. After allowing for other factors, the prevalence of regional pain varied markedly by instrument category.

This study had several limitations, notably cross-sectional design, incomplete response and moderate sample size. The first of these meant that those who dropped out of work because of musculoskeletal pain would not have been sampled. We tried to contact musicians who were not at rehearsal, but those giving up a career because of musculoskeletal pain would have been omitted from the enumeration list. Healthy worker selection bias may explain why neck and shoulder pain become less common with age in this group of orchestral musicians, but tend to become more common in the general population. If present, the bias would tend to lead to an underestimation of the extent of severe MSDs in professional musicians. However, the effect of non-response might operate in the opposite direction, if responders who were in pain were more motivated to participate. These limitations perhaps affect estimates of prevalence. However, prevalence rates were not dissimilar to those previously reported [1–20], and associations of pain with risk factors (e.g. with instrument type after controlling for important confounders) are unlikely to be biased unless these associations differed between responders and non-responders, while the choice for risk factor assessment of an internal comparison group may have served to limit the impact of the healthy worker effect on estimates of relative risk. The study lacked sufficient power to permit elaborate subanalyses by instrument type and some estimates of relative risk were bounded by fairly wide confidence intervals.

Accuracy of the information given may have been affected by errors of recall. Reassuringly, however, patterns of association between risk factors and regional pain were very similar over the past 12 months as over the past 1 month. Aspects of the occupational history, such as instrument played, are likely to be reported without important error.

Set against these limitations were some strengths. The study was large comparatively in its field—the largest so far in Britain—and the job experiences of study participants are likely to have been representative of professional orchestras as a whole (e.g. similar mix of instruments). Moreover, the analysis extends the boundaries of inquiry: while several earlier studies have focussed on MSDs in professional elite musicians or populations including professionals as well as amateurs [2–16], few allowed in analysis for important non-occupational risk factors [8] and seldom have risks been explored by physical activity [11]. Only occasionally have risks been compared systematically by instrument type [8–11]; even here, we found only one other study with data both by instrument and by anatomical site [10], as opposed to aggregated data on MSDs at all sites combined [8,9,11].

This study confirms previous findings [1–20] that musicians appear to suffer high rates of musculoskeletal pain. Additionally, it indicates marked differences in regional pain by instrument category. Such differences are largely explicable in terms of physical workload. For example, in string players, among whom higher overall rates of musculoskeletal pain have been reported previously [6,8,9,13], affected joints were those subjected to repeated movement or technical positioning as required by the instrument; and higher rates of shoulder, elbow, wrist and hand pain were found in string players as compared with brass players, in agreement with a survey of the Puerto Rico Symphony Orchestra [10].

The greater risk of neck and wrist/hand pain in woodwind players when compared with string players probably arises from static loading, with suspension of instruments that weigh up to 4 kg. To reduce static loading, some woodwind players have adopted slings that attach around the neck, and there may be a case for further development of ergonomic supports for these players. More generally, knowledge that regional pain is more frequent in particular instrument groups should raise awareness in physicians and in those who hope to design ergonomic solutions that satisfy the performance needs of elite professional musicians.

In keeping with another key report [6], and in contrast to some others [9,13], performance anxiety and psychosocial factors in the work environment did not show much independent association with musculoskeletal symptoms. Levels of overall job satisfaction were very high. To an extent, this limits scope for psychological interventions. However, somatizing tendency, which seems not to have been studied previously in musicians, proved to be a strong consistent non-occupational risk factor for MSDs, as it is in the general population [23]. This is a fluctuating and potentially modifiable trait that might be targeted therapeutically [24].

Hitherto, there have been few evaluations of interventions to prevent MSDs in musicians [25,26] and even fewer approximating to the design requirements of a randomized controlled trial [27]. One initiative, involving education, strengthening and flexibility exercises, suffered high attrition rates and drew no conclusions [25]; another, based on education and behavioural self-help goals, found gains in psychological but not in physical health [26]; and a third reported improvement in perceived exertion of playing after strength or endurance training, but no improvement in musculoskeletal pain [27]. In a small before–after comparison of students from the Zurich Conservatory, education, relaxation, postural exercises and playing analysis resulted in better coping, with fewer playing-related symptoms, but findings were not specific to the musculoskeletal system [28].

Considering the need for further research, a longitudinal study of musicians with a suitably large sample would provide information about the incidence of symptoms and premature medical retirements arising from musculoskeletal problems. A survey of retired musicians could provide further insight into the circumstances of such medical retirements. Ergonomic and observational studies could assess the impact of prevailing generic advice [29,30] (e.g. about posture, seating, warm-up sessions, adjustable music stands, chin rests, harnesses and other devices to reduce static loading) according to instrument played, informing the design of suitable intervention trials. Finally, investigation is merited to assess the impact on pain of psychological interventions to combat somatic distress and poor mental health.

Key points

  • Although musculoskeletal pain appears common in professional musicians, few studies have explored underlying risk factors.

  • In this survey, somatizing tendency was a major personal risk factor, more so than performance anxiety.

  • Risks also differed substantially by instrument played, providing a focus for prevention.

Funding

Colt Foundation (to E.C.H.).

Conflicts of interest

None declared.

We wish to thank the orchestral managers, playing committee representatives and musicians of the BBC Concert Orchestra, BBC Philharmonic Orchestra, City of Birmingham Symphony Orchestra, Hallé Orchestra, London Symphony Orchestra and Philharmonia Orchestra for supporting this study. Hazel Inskip kindly provided statistical advice. Sue Curtis helped prepare this article.

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