Volume 14, January 2022
Musculoskeletal symptoms of double bassists: a literature synthesis

by Frances Levenderis and Bridget Rennie-Salonen

3. Literature on musculoskeletal symptoms in string players

Much musicians' health research investigates the musculoskeletal symptoms (MSS) experienced by various orchestral instrumental categories, especially string players (Ajidahun, Mudzi, Myezwa, & Wood, 2016, 2017; Brown, 1997; Gómez-Rodríguez, Díaz-Pulido, Gutiérrez-Ortega, Sánchez-Sánchez, & Torres-Lacomba, 2020; Hohls, 2010; Middlestadt & Fishbein, 1989; Waters, 2019). Most studies focus on orchestral string musicians, with other genres including jazz and popular music being less represented in the literature (Heredia, Hinkamp, Brodsky, & Llapur, 2014; Stanhope & Weinstein, 2020).

Between 64 and 90 per cent of string players report MSS which interfere with their ability to play their instrument and the most common areas for injury in string players are the left upper limb and vertebral column (Kochem & Silva, 2017). Data on lower strings (double bass and cello) could possibly provide insight into the MSS experienced by double bassists, although there are usually considerably more cellist participants than double bass participants. Lower strings experience more MSS than upper strings in the lower back, right shoulder, right elbow, right hand, and the left elbow (Kochem & Silva, 2017).

Unfortunately, many of the studies on string players have very few double bass respondents in comparison to the other instruments (Ackermann et al., 2012; Brown, 1997; Russell & Benedetto, 2014; Wahlstrom Edling & Fjellman-Wiklund, 2009; Waters, 2019) and some exclude the double bass completely (Thaele, 2016; Turner-stokes & Reid, 1999). Furthermore, in most cases, the authors do not separate the instruments for the data analysis and discussion, meaning that the double bass results are hidden within 'strings', 'lower strings', or sometimes even grouped with other, unrelated instruments such as the harp (Črnivec, 2004).

The cello is one of the instruments that the double bass is most often grouped together with, and the field of musicians' health is no exception. Many studies report on the MSS of cellists and double bassists together as the lower strings (Abréu-Ramos & Micheo, 2007; Ackermann et al., 2012; Brown, 1997; Paarup et al., 2011; Steinmetz, Scheffer, Esmer, Delank, & Peroz, 2014). While the cello and double bass may seem similar, there are some important differences. The strings of the double bass are much thicker than those of the cello, therefore requiring more strength in the left hand to depress the string, and in the right hand to vibrate the string to create a full tone (Bradetich, 2009; Kok, Huisstede, Voorn, Schoones, & Nelissen, 2016). In addition, for German bow players, the bow grip differs from the cello (Lee et al., 2013). The double bass is very large, which accounts for many of the physiological difficulties in playing the instrument (Benfield & Dean, 1973; Tambroni, 2014). In addition, the increased size of the fingerboard of the double bass translates into more shifts for the player (Hohls, 2010). Double bass playing requires standing or perching on a tall stool, necessitating the player to lean forward and stabilise the instrument with their trunk (Lee et al., 2013). In the lower playing positions, the left arm is elevated while the right arm reaches down to play on the string, causing an asymmetric posture with some spinal rotation. In the higher playing and thumb positions, it is necessary to reach around the instrument with both arms, and also to reach even lower with the right arm to play closer to the bridge. There is currently insufficient research to establish whether any of these particular behaviours are associated with or may cause MSS in double bassists. However, they are notable characteristics which differentiate the double bass from other string instruments.

Some conclusions can be drawn from the research on string playing which includes double bass participants, as there are studies on string instruments in general which do present double bass-specific findings (Ajidahun et al., 2017; Burkholder & Brandfonbrener, 2004; Hohls, 2010; Middlestadt & Fishbein, 1989; Ranelli, Smith, & Straker, 2011). Double bassists experience a high prevalence of MSS in the back and neck (Bejjani, Kaye, & Benham, 1996; Lee et al., 2013; Middlestadt & Fishbein, 1989). It was reported by Ranelli et al. (2011) that double bassists experience a higher prevalence of MSS than cellists particularly in the regions of the elbow, shoulder, and left hand (Ajidahun et al., 2017; Hohls, 2010; Middlestadt & Fishbein, 1989). When compared to the cellist participants of the studies, double bassists experienced MSS in many more regions (including head, eyes, ears, nose, throat, both wrists, and left fingers) than the cellists (Burkholder & Brandfonbrener, 2004; Hohls, 2010).

While it is difficult to determine the causes of MSS experienced by double bassists, possible risk factors can be drawn from the findings of research on both lower strings and double bass. These risk factors included physical characteristics such as strength and endurance (Davies & Mangion, 2002), and having smaller hands (Lamb-Cook and Lamb (2001) in Hohls, 2010; Middlestadt & Fishbein, 1989) which could both contribute to the common finding that female lower string players are more likely to experience MSS. Biological sex is documented as a risk factor (Abréu-Ramos & Micheo, 2007), in that female lower string players are more prone to neuropathic symptoms in the back. A further risk factor is chair ergonomic variances, such as sitting on a stool with or without lumbar support (Abréu-Ramos & Micheo, 2007; Lee et al., 2013). For most studies which examined MSS in lower string players, the determination of risk factors was not the primary focus of the study and was not possible due to the type of data collected (Levenderis, 2020).

In order to most accurately represent the MSS experienced by musicians, it is necessary to study each string instrument individually (Kok et al., 2016). These studies are common for the violin and viola, but there are very few which specifically examine the prevalence, types and details of MSS of double bassists (Levenderis, 2020). The literature focussing on double bass players' performance health, specifically musculoskeletal aspects, will be discussed in the next section.