international journal of music education-2015-rickert

International Journal ofMusic Education

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DOI: 10.1177/0255761415582343ijm.sagepub.com

Are music students fit to play? A case study of health awareness and injury attitudes amongst tertiary student cellists

Dale L. L. RickertUniversity of Queensland, Australia

Margaret S. BarrettUniversity of Queensland, Australia

Bronwen J. AckermannUniversity of Sydney, Australia

AbstractInjury risks associated with musical performance continue to be a serious problem for professional and student musicians. Much research has focused on the incidence and severity of these problems yet less information is available on the potential influence of health awareness and attitudes to injuries in these populations. This study aimed to investigate health awareness and attitudes to injury amongst Australian music students. Using a qualitative case study methodology, in-depth semi-structured interviews were undertaken with 11 student cellists. Further interviews were undertaken with 10 orchestral cellists and five orchestral management staff as a means of triangulating student data. All data were analysed using a “themes-based” analysis of narrative approach. Findings indicated that in comparison to professional cellists students demonstrated poor health awareness and behaviours such as playing through pain and inaction in response to injury. Analysis of the combined interview data (student, professional and management) suggest that there is poor health awareness and knowledge of injury prevention strategies at all levels of education and training. All three participant groups felt that changes needed to be made to current music education practices and that health education should be integrated into core curriculum.

Keywordshealth awareness, injury prevention, music education, playing-related injury, student health behaviours

Corresponding author:Dale L. L. Rickert, School of Music, University of Queensland, St. Lucia, QLD 4072, Australia. Email: [email protected]

582343 IJM0010.1177/0255761415582343International Journal of Music EducationRickert et al.research-article2015

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2 International Journal of Music Education

Introduction

The inclusion of a Special Interest Group (SIG) for musicians’ health and wellbeing at the 2012 International Society of Music Education (ISME) conference in Thessaloniki, Greece, was a posi-tive development for music education. Coinciding with the 30th anniversary of the Medical Problems of Performing Artists symposium, the longest running event of its kind in the world, the establishment of this SIG presents an opportunity for music educators to work towards creating healthier music education practices. With playing-related injury rates for professional and student musicians remaining unchanged over the last 30 years despite increased knowledge in the medical community (Ackermann, Driscoll, & Kenny, 2012; Fishbein & Middlestadt, 1986; Kreutz, Ginsborg, & Williamon, 2008; Leaver, Harris, & Palmer, 2011; Zaza, 1992), there is clear evidence that new practices need to be adopted. Leading commentators in the field of performing arts medi-cine have noted that most music-medicine research focuses on the physical and biomechanical aspects of disease and suggest that future efforts should be given to developing and implementing prevention strategies (Guptill, 2011; Manchester, 2006).

The music education sector is well placed to be at the forefront of such injury prevention efforts because it is in music schools that students adopt the attitudes, values and behaviours that will define their professional careers (Chesky, Dawson, & Manchester, 2006; Palac & Grimshaw, 2006). An understanding of current health awareness and attitudes to injury in music schools is needed before changes to education practices can be undertaken. Research into these issues is timely, coinciding with international efforts to address health concerns in music schools (Ackermann & Wijsman, 2011; Dick, 2011). The current study aims to investigate attitudes to health and injury awareness amongst student cellists in Australia.

Background

Musculoskeletal problems in tertiary music students and professional orchestral musicians have been identified as significant issues in music-health literature (Kreutz et al., 2008; Leaver et al., 2011). Injury rates amongst musicians vary depending on the definition of injury and study design, however between 39–87% of tertiary music students (Brandfonbrener, 2009; Park, Guptill, & Sumsion, 2007; Zander, Voltmer, & Spahn, 2010) and up to 89% of profession-als report playing-based pain (Ackermann et al., 2012). The causes of injury in these popula-tions are multifactorial. Factors include individual physical and instrument-specific components as well as lifestyle, playing habits (Wu, 2007; Zaza, 1993), and psychosocial and environmental factors (Raymond, Romeo, & Kumke, 2012). Researchers usually identify these risks factors in terms of how easily they can be modified in order to minimise injury risk (Manchester, 2006; Zaza, 1993). For example, while individual physiology, instrument choice, and environmental factors are not easily modified, lifestyle factors (diet, exercise and health behaviours) and play-ing habits (length, intensity, content and breaks) are relatively amenable to change (Manchester, 2006; Zaza, 1993).

Many music students are reported to live unhealthy lifestyles. Issues identified include: poor stress management, inadequate nutrition and lack of exercise (Kreutz, Ginsborg, & Williamon, 2009); and, playing through significant levels of pain without seeking medical advice to resolve playing-related injuries (Brandfonbrener, 2003). As students move into the profession lack of health awareness may become a significant issue. Injury rates amongst musicians increase from the ages of 20–30 (Fry, 1986) and professionals indicate that they often only become aware of the risks in their 30s (Raymond et al., 2012). Where short-term music-health education programs have been implemented decreased physical symptoms (Spahn, Hildebrandt, & Seidenglanz, 2001), increased



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health awareness (Barton & Feinberg, 2008; Stegink, Dittrick, Narvaez, Boyette, & Staines, 2006) and positively changed health-behaviours (Zander et al., 2010) have been evidenced. Despite these changes, projects rarely make the transition from research trial into long-term courses or core cur-riculum (Zander et al., 2010). This may be attributed in part to programs being conducted by exter-nal researchers rather than co-run with music educators who have the environment-specific knowledge, influence and connections to make long-term change (Palac & Grimshaw, 2006). Palac and Grimshaw (2006) see this as part of a larger problem with music researchers failing to meet the challenges provided by the field of music-health:

Despite the interest evident in practice journals and a call for multi-disciplinary study by performing arts health specialists, the body of research on musicians’ health by musicians remains limited. The field of music education, which employs both quantitative and qualitative research methodology, would seem to be the natural locus for this type of inquiry. (p. 879)

Certainly the implementation of a SIG on “musician’s health and wellbeing” suggests that music education may be ready to address these issues.

The Australian context

Injury rates have not changed substantially amongst Australian professional musicians since initial research into this phenomenon in the 1980s (Ackermann et al., 2012; Fry, 1986). To address this problem, “Sound Practice”,1 a comprehensive research program and concurrent program of injury prevention measures has been implemented throughout the eight major state orchestras in the country (Ackermann et al., 2012). Through the implementation of this project it has become evi-dent that an emerging population of concern is student musicians. In response a national curricu-lum for musicians’ health “Sound Performers”2 has been developed (Ackermann & Wijsman, 2011). The current study arose from these larger projects and is part of a PhD dissertation3 on causes and prevention strategies for right shoulder injuries in cellists.

Initial investigations have found that student cellists demonstrate decreased scapulae support and increased muscular imbalances at the shoulder (Rickert, Barrett, Halaki, Driscoll, & Ackermann, 2012). These problems are known risk factors for ongoing shoulder injury (Cohen & Williams, 1998; Pyne, 2004; Wang & Cochrane, 2001; Warner, Micheli, Arslanian, Kennedy, & Kennedy, 1990) and suggest that students may not be physically ready for sustaining a professional perform-ing career. Questionnaire data arising from this study found that professional cellists did have higher injury occurrence over an 18-month period compared with students (89% compared with 56%) (Rickert et al., 2012). However, 40% of injured professionals resolved their injury over an 18-month period compared with only 8% of students. This finding indicates that students are less effective at dealing with injury issues when they do arise (Rickert et al., 2012). Greater levels of injury amongst professionals may be attributed to professionals spending almost twice as much time playing their instruments, demonstrating increased risk of injury with heavier playing sched-ules (Brandfonbrener, 2010; Ranelli, Straker, & Smith, 2011). When comparing current injury levels, both students (48%) and professionals (59%) had similar injury prevalence (Rickert et al., 2012). Finally, professionals spent most of their playing hours in structured rehearsals while stu-dents spent most time playing in private practice. This could indicate that changes in playing habits and health behaviours are easier to implement in the student population who have control over the nature of their playing tasks (Rickert et al., 2012). The current study will build on these findings by providing useful insights into student health awareness and attitudes that may have contributed to the poor health status shown above.




Aims of the current study

In order to explore health awareness and attitudes to injury amongst student cellists the study was guided by the following aims. Initially it sought to identify current health awareness and attitudes to injury amongst student cellists. With this as a foundation the study then aimed to investigate musicians’ (student and professional) and orchestral managers’ perceptions of tertiary music edu-cational programs and how effective these are in equipping music students to face the demands of music making.

Methods

This research project utilises a qualitative case study methodology (Stake, 1995, 2011). The case is student cellists in two tertiary institutions in Australia. The phenomenon under investigation is student health awareness and attitudes to injury (Blatter, 2008). To triangulate student accounts, professional cellists and orchestral management staff provided perspectives from the orchestral workplace (Gerring, 2006; Stake, 1995, 2011). Semi-structured, in-depth interviews (Bryman, 2008) were undertaken with 11 student cellists (from two music schools), 10 orchestral cellists and five orchestral management staff. The cellists’ interviews were conducted on a single day concur-rently with injury self-report surveys and physical examinations (Rickert et al., 2012). These inter-views were aimed at comparing levels of injury awareness as well as attitudes to injury between the two groups (student and professionals). Interviews with five orchestral management staff were undertaken in a separate phase of data collection after the research involving the cellists had been completed. These interviews were informed by preliminary analysis of data arising from the cel-lists’ (student and professional) interviews.

Ethics

The Human Research Ethics Committee of The University of Queensland approved all interviews and questionnaires for this project. The identity of the participants was protected throughout the research process and all names used within this paper are pseudonyms. For a list of participants’ names see Table 1.

Data generation and analysis

In-depth interviews were undertaken in person by the first-named author and were recorded and transcribed verbatim (Brinkmann, 2008). Trustworthiness was addressed through member-check-ing where participants were given the opportunity to review their transcripts for meaning and accuracy, add any additional information they felt was necessary, and remove information they did not want published (Stake, 1995, 2011). For this study one student participant chose to add addi-tional information by clarifying a previous verbal statement and one student and two professionals chose to edit their transcripts for grammar, making statements clearer and easier to understand. The final transcripts were then analysed using a themes-based “analysis-of narrative” approach (Polkinghorne, 1995). This involved the three investigators separately reading and rereading the transcriptions looking for similarities and differences across responses. Over time, many responses fell under broad theme categories. Where strong themes developed they were deductively used to inform the analysis of the rest of the interview schedule (Hatch, 2002). Once this process had been undertaken and with a sound understanding of the emerging themes, the interview transcripts were broken down into individual question responses from each participant. This process helped to



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understand differences in perspectives, agreements of perspective and account for biases in the participants. Each of the sets of interview data (professional, student and management) were then compared searching for source triangulations across each of the participant groups. After each researcher had completed the analysis processes outlined above, the researchers compared notes and discussed different possible interpretations in a process of investigator triangulation (Jensen, 2008b). Where differences of opinion arose discussions took place in order to arrive at a final set of themes that all investigators agreed upon.

Credibility issues were addressed through triangulation of source (students, professionals and orchestral managers) as well as investigator triangulation with three researchers undertaking the analysis to compare findings (Jensen, 2008b; Rothbauer, 2008).

Findings

During the ongoing themes analysis for this project it became evident that the emergent themes could be grouped under five categories: health awareness during playing; health awareness away from the instrument; injury attitudes and behaviours; health education and training; and percep-tions of health in music education. Each category below includes quotations directly from the interview transcripts to strengthen the confirmability of the themes-analysis (Jensen, 2008a). Throughout the Findings section of this article bold font indicates interviewer speech and italic indicates responses from interview participants.

Health awareness during playing

Students showed low-levels of health awareness during playing when compared with profession-als. Included below are a number of student responses to a question about maintaining right shoul-der health during playing:

Greg: I don’t really think about it at all.Emily: I don’t do anything … I just practice.Steve: I don’t really think about having a healthy right arm.

Professional musicians, on the other hand, had quite a good understanding of how to maintain health during playing:

Table 1. List of participant pseudonyms.

Student cellists Professional cellists Orchestral managers

Greg Shelly JohnEmily Nicole AndrewSteve Heather BridgetMatthew Liisa Claire Mary Terry Paul Susanna George Edwina David

Note. While not all participants were quoted in the Findings section, all participants’ data was used during data analysis.




Shelly: Posture would be the most significant thing. Balancing up how much you play. Don’t overdo it and take breaks. If you’ve got a busy season at work then have a few days off and use the weight of the bow when you play.

Health awareness away from the instrument

Similarly, professionals showed a good understanding of how fitness and health away from the instrument could influence playing health:

Dale: What do you believe are the most significant physical factors in maintaining healthy shoulders away from the instrument?

Nicole: Strength, stability, core stability, posture … General physical fitness and rest. I do Pilates and like general body posture, from the bottom up you should be like a pyramid.

Dale: Do you think that sitting posture affects the function of your left and right shoulders?

Nicole: Absolutely! I believe sitting posture has an important effect on the function of the left & right shoulders. If you don’t support the shoulder by securely planting feet on the floor and sitting correctly, also remembering to transfer weight from one side to the other and back again as you bow, then an increased load is placed on the shoulder which increases the risk of discomfort, pain and injury.

In comparison, students showed low-levels of knowledge or care about factors that may influence injuries:

Dale: What do you believe are the most significant physical factors in maintaining healthy shoulders away from the instrument?

Emily: I don’t do anything.Dale: Do you think sitting posture affects the function of the left and right

shoulders?Emily: Yes I guess it could do.Dale: Do you think general body fitness plays a role in avoiding injuries?Emily: Of course it does, but I don’t do anything about it.Dale: Do you do anything to maintain your fitness?Emily: No. Not really, I walk from the conservatorium to the city [A distance of approxi-

mately 300m].Dale: Do you think shoulder strength is important?Emily: Yes.Dale: What do you do to maintain shoulder strength?Emily: I don’t do anything to maintain my strength, but I do struggle with shoulder pain.

This excerpt taken from a student cellist interview is a worrying example of just how low levels of awareness can be amongst the student population. Perhaps the most alarming issue in this extract is the evidence that this musician is experiencing problems with shoulder pain but seems to take no interest in achieving injury resolution. Many student cellists demonstrated a similar lack of under-standing or concern about injury issues.



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Injury attitudes and behaviours

Inaction in response to injury risk or even existing pain has been noted in both professionals and students by other authors (Brandfonbrener, 2003; Kreutz et al., 2009), and was a noticeable issue for students in this study. This excerpt from Matthew’s interview demonstrates how deeply ingrained the “no pain, no gain” mentality is, even in the younger generation of musicians (Brandfonbrener, 2003).

Matthew: I have issues when I play piano, especially with shoulders, because I’m always tense. The up-and-down movement I find hurts my shoulder.

Dale: Where does it hurt?Matthew: In the traps [trapezius muscle]. So when I play cello I tend to avoid up-and-down

movements as much as I can … I can tell when my traps are hurting because it feels like it’s burning. It’s especially fun when you’re trying to go to sleep because it feels like they’re on fire.

Dale: Would heavy staccato cause trouble for you on the cello?Matthew: Not really, because I’m used to doing hours and hours of piano so any pain I get I’m

very used to it so I just tend to ignore it. It’s not so bad as to stop me from playing…Dale: Has it ever got to the point where it stops you from playing?Matthew: No, I have still been able to do up to 12 hours of rehearsals a day and get through

all that stuff, well, at least up to this point.

Apart from inaction in response to injury, other students indicated that their peers would be unlikely to take preventative action:

Dale: Overall what level of awareness do you think Australian student musicians have about injury prevention?

Claire: I don’t know, I don’t know people care a lot.Dale: Do you think it’s because people don’t think they will play the cello in the long-

term or is it because they don’t think it will affect them?Claire: They’ll worry about it if it happens.

For the professional players, those who had experienced injuries were better informed about injury prevention and treatment and also had greater empathy for other players with injuries.

Dale: Overall, what level of awareness do you think Australian orchestral musicians have about injury prevention?

Nicole: I wouldn’t say it was extremely high. I think there are pockets that are very well-informed, but they’re usually the ones who have been injured, who are interested in it for some other reason. I don’t think it’s very high and it comes far too late.

Heather: I think people are aware but I think the understanding is not always there … I think for a lot of things, the more you’ve experienced yourself, if you’ve had trouble yourself, you’d have more sympathy and understanding for someone who is having problems.

Health education and training

A finding common to both groups of musicians was a belief that increased focus needs to be given to correcting technique, posture and sitting style during university education. In many cases the




students felt that they were not given enough guidance from instrumental teachers and that posture and movement analysis may be needed.

Terry: I think that teachers should pay more attention to the way our posture is to make sure it’s relaxed. But then I guess the teachers aren’t always aware of the problems.

Another student felt that her teacher was not able to offer enough advice about how to deal with physical problems:

Susanna: I think that people need help with technique more … like a better way to play the cello. I asked my cello teacher how to stop my problem but he didn’t help much. It would be great if we could have someone come in and tell us how to play, how to sit and what to do when we play.

This view is also evidenced in the following two students’ comments:

Edwina: At the very least, there should be seminars held to provide information for students about how they can use their bodies most effectively when playing. If possible, there should also be an advertised specialist physiotherapist on campus.

Greg: They should have physiotherapists come in and assess the way we play. Technically, the teacher should be doing this but then at some level they should have a profes-sional working with them as well.

These views in the student population were corroborated by this professional musician:

Liisa: … another cellist I knew, she had such bad back problems and I always thought, “Your teachers should be looking at this, there is something wrong, if you have back problems at this age, you are too young!”… I’ve always thought that if students come along that have pains, that they are too young for it to be anything age-related so they have to look at what they’re doing.

These views indicate that teachers may not be equipped with knowledge about physiologically optimised movements and postures. This reinforces the importance of using translational research4 to engage instrumental teachers in applying health knowledge to music teaching. It is likely that efforts to establish strong inter-disciplinary collaborations between musicians and health special-ists will be a key factor in achieving healthy change in the music education sector (Brandfonbrener, 1991; Palac & Grimshaw, 2006; Zaza, 1993).

Perceptions of health in music education

At the end of the interview sessions with the musicians, and during the additional interviews with the orchestral managers, participants were asked to give recommendations about how improve-ments could be made to current practices in music education. Responses to these questions provide an overview of where problems lie, and potential future directions for music education.

The following response from an injured Masters student shows just how important it is that health becomes a central part of music education, not only in terms of the wellbeing of the students, but also because of the real risk of litigation:



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David: Throughout my undergraduate music degree there wasn’t even a single mention of injury prevention. I was not provided with any information about injury prevention until I undertook several Australian Youth Orchestra programs where they had resi-dent physiotherapists and scheduled several classes focusing on Alexander Technique. It is bordering on negligence that a professional music institution could neglect to inform students about these important issues.

The following view from a professional cellist suggests that education institutions are the ideal places for changes to take place:

Dale: In regards to injury issues for musicians, do you think that changes need to be made in the teaching institutions?

Nicole: Absolutely! I can’t say that strongly enough. It’s of the utmost importance. If you don’t start there, you’re a step behind addressing them at a professional level, where the injuries have already established themselves, or the progression towards the injury.

A number of professional musicians suggested changes to education could not be undertaken using a piecemeal approach, and should be structured or even compulsory course work:

Mary: There should be compulsory programs about physical health, and stretching. Our profession is very much like a specialist athlete and it’s very stressful for the body, the repetitiveness of the movements, and the long held postures means that there needs to be an awareness of how to strengthen the body and how to stretch to avoid injuries in the future.

Paul: I guess they probably should be just getting the students to learn more general health and it does in a way have to be organised, you kind of have to do it actively. If you program these things into your habits and into your life … it’s going to help a lot.

George: I think it’s human nature not to do anything unless you’re told to. I think at the con-servatorium as well, it shouldn’t be just a subject but something that you have to do as part of your course.

Interviews with the orchestral managers included similar calls for changes to music education but also brought up the concept that poor student health may arise from inadequate injury awareness amongst teachers:

John: I think the teachers at the conservatoriums need to be trained in injury prevention and I know that they aren’t … what the orchestras are doing with this prolonged study is cutting edge [reference to the “Sound Practice” study] … and all of those teachers need to be exposed to this type of thinking and then they’d be able to pass this onto their students and then this would be incorporated into the courses so that injury prevention techniques and management strategies become central to the learning environment.

This view suggests that benefits may arise from greater teacher training on the health risks of per-forming as a musician. If standard instrumental pedagogy were to include a health component this could have a profound influence on student health behaviours across the board. In the next extract John continues, hinting that the current piecemeal approach in music education may not be effec-tive at dealing with existing health risks:




John: It’s just not good enough to send somebody along to a physiotherapist session every now and then or to have a talk every six months, the education systems need to realise that musicians need to understand how to look after themselves in the same way an athlete would.

The following excerpt strengthens this argument and suggests that health education should be an integral part of tertiary and even pre-tertiary music training:

Andrew: I think there must be something in making sure we bring in good housekeeping … physically, technically, psychologically and that should be something being brought in at the tertiary and even the pre-tertiary level. I think this is definitely where it needs to happen, we need to educate the teachers right from the beginning and have more classes throughout the education system about the health needs of musicians.

Bridget (another orchestral manager) indicates that approaching health awareness amongst stu-dents may require deep changes to the way music education is delivered:

Bridget: I think that every institution in the performing arts needs to make sure that pastoral care is made to be a priority. Looking after people’s physical and psychological needs is enormously important and it needs to be integrated from the first year. Even though those things may not sink in immediately … if part of preparation is: “How am I looking after me, mentally and physically, and will I be able to continue a career in this over the long term?” then it will come back to you later and it will be part of your view of how you approach things. I think it needs to start with the teachers at the primary level but that would require big changes to the way we approach things.

Bridget goes on to explain how such education measures also need to address other music educa-tion institutions such as the state and national youth orchestras:

Bridget: I think the older they become the more aware they become, through experience. I do think it’s improving, I think it needs to start at the Youth Orchestra level. I think it should be integrated into the state and national youth orchestras…

In the following excerpt Bridget furthers her “call to arms” arguing that pastoral care in teaching institutions and training orchestras needs to be addressed and that care of the “whole person” needs to become a number one priority:

Bridget: The leading youth training orchestras and institutions of this country need to make sure that pastoral care is their number one priority. There needs to be focus on eat-ing well, sleeping well and positive responses to music rather than reinforced nega-tivity and competitive behaviour.

In the previous quote Bridget brings up the issue of re-enforced negativity and competitive behav-iours. This an issue which has been identified by other researchers (Chesky et al., 2006; Palac & Grimshaw, 2006) and may indicate that changes to music education cultures are needed in order to address the underlying causes of health problems.



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Discussion

This study demonstrates deficiencies in student health awareness, poor health behaviours (playing through pain and inaction in response to injury) and negative attitudes to injury. Further question-ing brought up the issue of health education in the training of teachers. Responses indicated that music teachers may lack key knowledge about injury prevention. Students also felt that teachers were ill equipped to deal with injury issues when they did arise. During interviews with manage-ment staff and in the final section of the interviews with musicians, participants indicated that changes needed to be made to the delivery of music education so that health awareness and injury prevention are incorporated into instrumental learning.

In relating these findings to the previously published study (Rickert et al., 2012), it should be noted that playing-related injuries were a common problem in these student cellists with 48% exhibiting an injury at the time of data collection (Rickert et al., 2012). Despite this, the students’ responses indicate that they have low levels of health awareness and seem unconcerned by the impact injuries could have on their future careers. Such lack of health awareness and inaction in response to injury may have contributed to strength deficiencies and low rates of injury resolution (8% over 18 months) seen within the student population (Rickert et al., 2012). This concept is sup-ported by the work of Kreutz et al. (2009) and Brandfonbrener (2003) who note that students undertake poor health behaviours such as inadequate exercise, playing through pain and reluctance to seek medical attention. These findings may indicate that future quantitative research in music student health would benefit from a longitudinal component that tracks rates of injury resolution and factors that influence injury outcomes.

Data presented in the Findings section suggest that techniques may be needed to address ingrained attitudes to pain in musical performance. Statements like “any pain I get I’m very used to it so I just tend to ignore” and “I have still been able to do up to 12 hours of rehearsals a day and get through all that stuff” are concerning. They indicate that some students view any pain they experience as normal, or perhaps more worryingly, see it as part of what it takes to become a musi-cian. Research suggests that early medical treatment, level of healthcare utilisation (Chong, 1997) and self-efficacy (Busch, Göransson, & Melin, 2007; Schwarzer, 1992) are important factors in determining injury outcomes. Based on this, any attempt to educate student musicians regarding injury issues should also address these underlying attitudes. Education efforts should focus on dispelling myths about pain in musical performance (Brandfonbrener, 1991) and replacing them with up-to-date information about the importance of early intervention and treatment (Chong, 1997; Culf, 1998).

Both groups of musicians felt that injury issues often arise from “poor technique” or “bad pos-ture” and that more emphasis should be placed on giving evidence-based advice about healthy body-use during playing. These interpretations corroborate clinical findings in music medicine that suggest that player technique and posture have a key role to play in the etiology of musicians’ injuries (Brandfonbrener, 2010). As mentioned, translational research may be of benefit here in translating the latest findings from music medicine and biomechanics into implementable health resources aimed at musicians.

Professionals had a better understanding of injury prevention strategies and the physical demands of performance. However, several cellists suggested that awareness of injury prevention or managing risks tends to arise from past injury experience. This would be consistent with other research showing that injury rates for orchestral musicians increase markedly when musicians are in their 20s (Fry, 1986) but awareness of risk factors often only comes at the end of this period (Raymond et al., 2012). This indicates that maximum benefits may be achieved by addressing health awareness and attitudes to injury at the tertiary or even pre-tertiary level, a concept noted




within the participant data from this study. Also, behavioural change may be easier to achieve in the younger generation of musicians who may not have such ingrained habits (Zaza, 1993) and have control over the nature and intensity of their playing environments (Rickert et al., 2012).

Recommendations

Awareness of the need for better health education and injury prevention was apparent from the inter-views with music students, professional musicians and orchestral management staff. The need to address health awareness and attitudes to injury in music students is an emerging concern for tertiary music education institutions. However, awareness and management of health issues and injury pre-vention is a life-span endeavour for all musicians and other professional music performance domains also need to make an ongoing commitment to the health of musical performers. Arguably, the data suggests the need for preparatory health awareness and injury prevention measures in youth orches-tra training programs and in the pre-tertiary experience of music performance students.

Tertiary institutions are a common gateway to professions in music, and attitudes reinforced at this level will go on to shape future practice, be that pedagogically or on stage (Chesky et al., 2006). In this regard, the issue of poor health awareness in students could be addressed with the provision of a well-developed music-health education program (Zaza, 1993). Such a program should also respond to resounding requests made by both students and professionals for postural and movement analysis as part of the teaching process. One area that may not react as quickly to interventions is ingrained attitudes and behaviours (Zaza, 1993) noted in some students who seem unconcerned by the possible consequences of injury. While these behaviours will be influenced by education, they may also be symptomatic of broader problems that arise from the intensely com-petitive musicians’ culture (Brinkmann, 2008; Palac & Grimshaw, 2006). Researchers from all sectors of performing arts medicine are increasingly seeing the “competition culture” as an under-lying factor in high illness rates and poor health behaviours seen across the board (Arcier, 2001; Chesky et al., 2006; Paarup, Baelum, Holm, Manniche, & Wedderkopp, 2011; Palac & Grimshaw, 2006; Robson, 2004). Achieving long-term and lasting change may require a paradigm shift in the way that we set goals and appraise success within music education.

In Australia and internationally, the implementation of a well-developed health education cur-riculum would be a positive development; however, efforts need to go beyond official measures and health behaviours need to be espoused by faculty staff and instrumental teachers (Bandura, 1986; Chesky et al., 2006). The influence of music school ethos and policies should not be dis-counted here, because as Chesky et al. (2006) affirm: “schools of music do influence student behaviours through factors such as collective values, beliefs, and actions” (p. 142). If school level changes succeed at influencing “values, beliefs and actions”, then over time, a cultural shift may take place that could have broad effects on behaviours and practices in the wider music community.

Throughout this process instrumental teachers need to be engaged as key partners in facilitating change so that future directions are based on personal ownership and self-advocacy (Lowe, 2004; Zaza, 1993). Balancing teacher self-efficacy with evidence-based clinical practice will be chal-lenging, however the key will be in establishing equal partnerships between medical professionals and musicians. Kris Chesky, a trumpet professor at the University of Northern Texas and organiser of the Health Promotion in Schools of Music conference, summarised this well:

Educating college music students about health issues is a daunting task that requires involvement from several disciplines and perspectives. Success will depend on our ability to create and sustain working collaborations that help challenge, redefine, and expand what is currently known and accepted. (2004, p. 1)



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The challenge he speaks of applies to both sides of music-medicine, as medical researchers need to understand the realities of instrument and art, just as instrumental teachers need to relinquish their long-held monopoly over how bodies and instruments combine in the creation of music.

Conclusion

The aims of this study were 1) to identify differences in current health awareness, and attitudes to injury in student and professional cellists and 2) to investigate musicians’ (student and profes-sional) and orchestral managers’ perceptions of tertiary music educational programs and how effective these are in equipping music students to face the demands of music making. Through interviews with student and professional cellists and orchestral management staff it is clear that student musicians have deficiencies in health awareness and poor attitudes to injury when com-pared with professionals. All groups of participants indicated that teachers may not be equipped with the knowledge needed to deal with injury issues in their students. Finally, participants felt places of music education (youth orchestras, pre-tertiary and tertiary) should place a higher priority on the health and wellbeing of their students through structured music-health education. Both stu-dent and professional cellists and orchestral managers felt that tertiary music institutions do not adequately address healthcare issues or prepare young musicians for the rigours of musical perfor-mance. These findings have implications for individual music students, for music schools in terms of litigation, but perhaps most importantly in terms of the future viability and sustainability of the music sector. This article constitutes an important introductory investigation of the emerging issue of how to incorporate healthy practices into music education. Further multidisciplinary research should be our guide as we reappraise what it means to strive for excellence in music education.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Funding

This research was supported by an Australian Research Council Linkage Grant: (LP 0989486).

Notes

1. “Sound Practice” is a joint initiative between the Australia Council for the Arts, the Australian Research Council (ARC), the University of Sydney and the eight premier state orchestras of Australia, and amounts to AUD$2m of research funding over 5 years. It is a comprehensive investigation into high-lev-els of physical and psychological illness in Australia’s professional orchestras. This Australian Research Council Linkage Grant: (LP 0989486) is administered by Dr Bronwen Ackermann, Assoc. Prof. Tim Driscoll and Professor Dianna Kenny.

2. The “Sound Performers” tertiary musicians’ health national curriculum project is a collaboration between the University of Sydney, the University of Western Australia and the Australian Council for Teaching and Learning. The project is the first of its kind in the world and offers a flexible, interactive, online music-health education curriculum aimed at increasing awareness of health risks and prevention strategies amongst music students. Applications for interest in the course should be sent to Bronwen Ackermann via [email protected].

3. This paper is number 2 in a set of 6 articles arising from an interdisciplinary cross-institutional PhD research project administrated by the University of Queensland School of Music and the University of Sydney School of Medicine. The PhD candidate is Dale Rickert and the supervisors include Prof. Margaret Barrett (UQ) and Dr Bronwen Ackermann (USyd). The project follows a mixed-method


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research methodology and includes significant qualitative and quantitative components. Associated researchers include Dr Mark Halaki (statistics, programming, and EMG analysis), Assoc. Prof. Tim Driscoll (epidemiology and occupational disease), Prof. Karen Ginn (EMG research manager), and Assoc. Prof. Suzanne Wijsman (cello advisor).

4. Translational research is research that translates the latest findings in a given field into measures that influence practices in a field of practical endeavour. In this context it means translating the research into the physiology of music making into implementable teaching methods and curricula for music teaching institutions.

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