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

Print

Abstract: The most frequently occurring performance-related health problems in musicians are musculoskeletal. Research on the performance-related health aspects of double bass playing, particularly musculoskeletal symptoms (MSS), is limited. Therefore, this literature synthesis aims to consolidate the existing research on the MSS experienced by double bassists. This article examines how the double bass has been represented in the musicians' health literature; explores the literature on double bass players' performance health; and investigates double bass pedagogical literature containing health-related information. Recent studies on double bassists' MSS provide a good foundation for further research. A promising amount of valuable health-related information can also be gleaned from non-academic sources such as double bass educational books. Double bassists experience MSS in the back, neck, and upper extremities, including shoulders, arms, wrists, hands, and fingers. However, the exact prevalence and risk factors of these MSS cannot yet be conclusively determined due to the small number of studies focussing on the double bass, the small numbers of double bass participants in research on string players' MSS, and the grouping of the double bass together with other instruments in these studies. Further research ascertaining the types, frequency, severity, and risk factors of double bassists' MSS, is necessary for the prevention and rehabilitation of double bassists' performance health problems, for enhancing performance, and for optimising pedagogy.

Keywords: Double bass; double bass pedagogy; musculoskeletal symptoms; musicians' health

• 1. Introduction
• 2. Background
• 3. Literature on musculoskeletal symptoms in string players
• 4. Literature on double bass players' performance health
• 5. Literature and resources on double bass pedagogy
• 6. Discussion
• 7. Conclusion
• Limitations
• References
• About the Authors

1. Introduction

The challenging physicality of double bass playing is summed up by Jeff Bradetich who describes how 'playing the double bass is an athletic event, perhaps the most gymnastic of all musical instruments' (Bradetich, 2009, p. 1). Although this sentiment is shared by many double bass players and authors, there are limited accessible resources on the musculoskeletal aspects of double bass playing. During a research study on effective practising techniques for double bassists, the first author found that the performance-related health of double bassists was an understudied topic (Levenderis, 2018). Subsequently, a literature review was conducted to map the research on MSS in lower strings (both cello and double bass). The findings revealed very few studies focusing on the MSS of double bassists specifically (Levenderis, 2020).

This article will summarise and synthesise the results of the literature reviews conducted for these two research projects. The literature which was reviewed comprised both double bass pedagogical material and peer-reviewed scholarly research. This paper will include content from double bass-specific research and method books that address double bassists' performance health; information on the representation of the double bass in musicians' health literature and the prevalence of double bassists' MSS; and discussion on the extent to which double bass players' specific musculoskeletal requirements have been addressed. The article aims to consolidate the available research data to enable the development of health promotion and injury prevention strategies for double bassists, and to stimulate further instrument-specific research on the double bass.

2. Background

Musicians' occupational health is a subfield of performing arts medicine and is multi-disciplinary in nature, combining the skills and knowledge of health professionals, and music educators and performers, for preventing and treating musicians' injuries, and optimising pedagogy and performance (Hinkamp et al., 2017; Salonen, 2018). Musicians' health conditions may be neurological, musculoskeletal, respiratory, auditory, dermatological, or psychological  (Stanhope, Tooher, Pisaniello, & Weinstein, 2019), with musculoskeletal problems being the most common (Ackermann, Driscoll, & Kenny, 2012; Fishbein, Middlestadt, Ottati, Straus, & Ellis, 1988; Stanhope et al., 2019; Wijsman & Ackermann, 2018). Among string players particularly, musculoskeletal symptoms are one of the most frequently reported health problems (Davies & Mangion, 2002; Fishbein, 1988). This literature synthesis will report only on the musculoskeletal aspects, with a focus on string players and double bassists.

The widely used term performance-related musculoskeletal disorder (PRMD)was coined by Zaza et al. (1998), and is defined as 'any pain, weakness, numbness, tingling, or other symptoms that interfere with your ability to play your instrument at the level you are accustomed to' (Zaza, Charles, & Muszynski, 1998, p. 1021). The broader term, musculoskeletal symptoms (MSS), which will be used in this paper, includes PRMD and encompasses injuries of all severities, including more mild symptoms, and both those related and unrelated to playing a musical instrument (Paarup, Baelum, Holm, Manniche, & Wedderkopp, 2011; Ranelli, Straker, & Smith, 2008; Stanhope et al., 2019).

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.

4. Literature on double bass players' performance health

A small number of studies focus solely on the double bass, offering valuable information on the musculoskeletal aspects of double bass playing. Most of these studies do not aim to report double bassists' MSS, but they do provide insight into the possible risk factors for injury.

In 1984, using electromyography, Allan Dennis explored the effect of three methods of supporting the double bass on muscle tension and performance quality, namely the Bass Standing Method, Student Standing Method, and Sitting Method. Anatomical locations studied included the upper and lower back, and left and right arms. The results demonstrated no particular advantage in utilising any one approach to double bass playing position, nor for bow hold (French or German). The author suggested that fluid balance and movement derived from weight shifts whilst playing was most advantageous. Another interesting finding was that although lower back pain was acknowledged as a common 'occupational hazard', the average lower back muscle tension was lower than the other muscle tension areas measured (Dennis, 1984, p. 100).

Knut Guettler's 1992 study, inspired by his many years as a double bass teacher, also analysed electromyographic readings of double bassists, focusing particularly on muscle use during vibrato. Electrodes were placed on the left shoulder and the upper left arm while the bassist played. Important results on muscular activation in the left arm during playing found that good technique was associated with reduced muscle tension which may therefore prevent injuries such as tendonitis (Guettler, 1992).

Linda Gilbert (2009) surveyed the musculoskeletal and psychological symptoms of over 520 bassists, obtaining data on the intensity, types, and locations of MSS in double bassists. Questions on demographics and bass setup were included in order to make comparisons between French or German bow, as well as sitting or standing. The symptoms studied included pain, fatigue, tension and weakness, and were graded as minimal, moderate, intense, and extreme. The areas of the body specified included hips; legs and feet; back; neck, chest and shoulders; arms, wrists, and hands; and eyes and jaw. Symptoms were cross-referenced with primary focus of work (professional orchestral, professional jazz, professional higher education, or professional other). The study results showed that all bassists experienced moderate to intense symptoms in the back, arms, wrists, and hands. French bow players generally had more symptoms on the right side of the body, while German players report more on the left side of the body. French bow players also experienced 'more symptoms in the neck and higher intensity levels of symptoms in the neck and shoulders' (Gilbert, 2009, p. 33). Ninety per cent of Jazz professionals stand, possibly associated with their reported fatigue in the feet and upper legs. Both jazz and orchestral professionals experienced high rates of MSS in the arms, wrists, and hands, although the side and exact location of the symptoms differed between the two genres. Most (70-90%) of college-, high school-, and middle school-level students experienced MSS in the back, neck, shoulders, arms, wrists, and hands (Gilbert, 2009).

Yun-Chieh Chou (2013) and Thierry Barbé (2017) focussed on the size of the double bass player and its association with playing. As a 'petite female bass player', Chou's research documented her experience of using the Alexander Technique (AT) to alleviate muscle tension (Chou, 2013, p. 11). Following intensive AT lessons for one year, she reported a significant reduction in lower back pain and increased stamina for long rehearsals and performances. Barbé's article provides helpful techniques for double bassists with small hands, as well as instrument setup changes that can be implemented, such as raising the tailpiece nut, finding a bass of a suitable size, and using a German bow for orchestral music where power can be difficult to achieve with the French bow (Barbé, 2017).

Woldendorp and colleagues (2018; 2016) surveyed posture and musculoskeletal complaints in a sample of over 100 professional and student bassists who played both double bass and bass guitar. The effects of playing double bass on MSS occurrence in the left shoulder (or neck side of the double bass); the effects of playing bass guitar on MSS occurrence in the right wrist area (or box side of the bass guitar); and the effects of using the German bow on MSS occurrence in the right wrist (or the wrist of the double bass bowing arm), were investigated. Self-reported questionnaires, designed for the study, assessed MSS in various locations of the upper body. Although the study results found no association between MSS and posture, findings demonstrated that 73.9% of bassists (bass guitar and double bass) reported experiencing MSS in the upper body. The most-reported complaints were MSS of the neck and back. The bow style (French or German) did not have an effect on MSS. The study shows that the identification of risk factors for MSS in a population is complex and requires the consideration of multiple factors rather than one aspect (such as posture) in isolation (Woldendorp et al., 2016). Subsequently, Woldendorp and colleagues (2018) published a further analysis of their original survey data on bassists' MSS, in two subpopulations: those who played more than one instrument, and those who played only the double bass or the bass guitar. Results demonstrated that multi-instrumentalism did not protect the participants against MSS, and in fact, resulted in an increased prevalence of MSS in the left shoulder (Woldendorp et al., 2018).

Although these examples provide double bass-specific scholarly literature in the field of musicians' health, it is evident that this literature is limited. Information more accessible for double bassists comes from pedagogical sources, most often penned by experienced double bassists in the community. What follows is an outline of these pedagogical sources which contain information on double bass performance health.

5. Literature and resources on double bass pedagogy

There is a wealth of knowledge about the double bass that is found outside the realm of academia. Pedagogical knowledge about the physiological aspects of playing the double bass is contained in books written by prominent and active double bass teachers and performers. More recently, online resources such as websites, YouTube channels, podcasts, and events organised by the International Society for Bassists have added to this bank of information. This section will review some of the literature that discusses the physiological aspects of double bass playing, providing insight into the MSS of double bass players, and the possible risk factors for these health problems.

In 'Double Bass: The Ultimate Challenge', Jeff Bradetich refers to double bass playing as an 'athletic event' (Bradetich, 2009). Numerous authors concur that musicians are like athletes in that optimal performance requires both physical and mental fitness (Dick et al., 2013; Green & Gallwey, 1986; Kenny & Ackermann, 2009; Rennie-Salonen & de Villiers, 2016; Stanhope, 2016; Tambroni, 2014). Bradetich highlights the uniqueness of the double bass in that it requires more stamina than others, meaning that double bassists cannot practice for as long as other instrumentalists. Furthermore, advanced techniques such as vibrato and thumb position require special consideration, due to the additional strength needed in the left hand to vibrate the string for vibrato Tambroni (2014) and the potential discomfort of thumb position (Bradetich, 2009).

Dr Randall Kertz's 2011 book, titled 'The Bassist's Guide to Injury Management, Prevention and Better Health', offers comprehensive information on the musculoskeletal symptoms experienced by both double bassists and bass guitarists. He describes the most common injuries and conditions that double bassists' experience including tendonitis, nerve impingement, muscle tightness, carpal and other tunnel syndromes, tennis elbow, thoracic outlet syndrome, and trigger finger amongst others (Kertz, 2011). The areas most prone to injury include the neck, back, shoulder, and arm, which is in line with Bradetich's suggestion that strength development in the shoulders, forearms, and fingers is important. However, whilst exercise and physical conditioning are beneficial, Bradetich (2009) cautions that injury from overuse is common, both from playing too much or exercising too much or improperly.

Bradetich (2009) mentions that physical characteristics such as smaller or weaker hands can be a disadvantage and that being slighter instead of heavier in build makes it more difficult to produce a fuller sound. Bass setup can be adapted depending on the height, size, and proportions of the player, such as the size of the bass, the string length (or fingerboard length), the width of the 'shoulders' of the bass, and a bent or straight endpin. Therefore, the size and proportions of the double bass that the player uses should be matched with the physical characteristics of the player (Bradetich, 2009).

Bradetich (2009) provides valuable and thorough recommendations for an optimal double bass playing position: the right arm should be kept closer to the body, as it is stronger in this position and therefore the instrument must be held more upright; sitting is often preferred, as standing without weight equally distributed can lead to balance problems and long-term injuries; both feet should be placed on the ground when sitting, which can prevent torsion of the spine and reduce lower back pain; utilising the larger muscles of the back instead of the smaller muscles of the right forearm and hand when drawing the bow; curving the fingers of the left hand in order to maximise efficiency of strength for 'hammering' the notes; using the 'fleshy' part of the thumb and not the knuckle when playing in thumb position, as this can cause injury to the ligaments in the knuckle.

Strength, flexibility, and coordination when playing the double bass are important. Developing these skills includes exercise both at and away from the bass for strength, stretches for flexibility, and technical exercises on the bass for coordination (Bradetich, 2009). Other methods for reducing the possibility of injury include: stretching before and/or after playing (Bruser, 1997; Kertz, 2011; Paull & Harrison, 1997); limiting practice time (Kertz, 2011); practicing awareness of movement quality (Green & Gallwey, 1986); and exercising frequently (Conable & Conable, 2000; Kertz, 2011). Conable and Conable (2000) mention that double bassists need to learn correct body and muscle use to sustain longer practice sessions.

It is clear that multiple factors are involved in double bassists' performance health. Double bass setup must be considered along with posture, technique, playing position and physical condition, as all of these aspects contribute collectively to the potential occurrence of MSS (Benfield & Dean, 1973; Bradetich, 2009; Conable & Conable, 2000; Kertz, 2011; Woldendorp et al., 2016).

6. Discussion

The double bass is unique in its large size, which contributes to the many distinctive features of the instrument, and to the athleticism needed to play it. Consequently, the literature suggests that double bassists may experience a particular set of musculoskeletal symptoms. However, there is a scarcity of empirical research studies that thoroughly examine this aspect of double bassists' performance health.

The limited scholarly literature on the topic primarily encompasses either the string instruments in general or the lower strings and does not provide sufficient double bass-specific findings. While string instruments can usefully be studied as a group, it is necessary to consider the vast number of differences in reported MSS between upper and lower strings. Similarly, due to the differences between the double bass and the cello, it is beneficial to study the lower strings independently from each other. Cello and double bass differ in many ways, including instrument size and proportion, playing position, and bow hold. Additionally, the available literature suggests that double bassists experience MSS in more and different locations to cellists. Although the research on musicians' health does provide considerable insight into MSS in string musicians collectively, there is minimal data addressing the specific needs of double bassists.

Articles appearing both in peer-reviewed academic journals and in professional magazines have been published by academics and experienced double bassists with an interest in double bass performance health. These papers provide helpful and valuable insight into the MSS of double bassists. Findings include, for example, that different playing positions do not have as much of an effect on MSS as initially believed; that excess muscle tension can be reduced by technical improvements and corrections; that setup adjustments can be made for players with a smaller physique or small hands; and that somatic methods such as the Alexander Technique may enhance stamina, reduce discomfort, and alleviate excess tension and physical limitations. The few studies that specifically explored the MSS of double bassists found that posture is not a prominent risk factor and that multi-instrumentalism is not a protective factor for MSS in double bass players. Furthermore, work type and primary genre played did have an effect on MSS occurrence, and student double bassists experienced a very high prevalence of MSS. Neither the French nor German bow hold was associated with elevated MSS occurrence (Woldendorp et al., 2016), and findings indicated a difference in the sidedness (Gilbert, 2009; Woldendorp et al., 2016) and severity (Gilbert, 2009) of MSS.

Limitations of the data generated from these studies include the small amount of research conducted and low double bass participant numbers. Additionally, it is critical to consider how the musculoskeletal aspects of performance health function interactively with the numerous psychological, behavioural, and environmental elements (Rennie-Salonen & de Villiers, 2020). In order to more fully explore the MSS of double bassists and collate, corroborate and compare the findings, more research needs to be done, for example, with different sub-populations, larger participant numbers, and the incorporation of psychosocial factors.

The global double bass community is connected via the International Society of Bassists, which creates, supports and provides fundamental double bass resources and networks. This proactive organisation facilitates contributions from many of the best double bass performers, orchestral players, and pedagogues, through publications, events and forums for knowledge exchange. Method books and literature from prominent double bassists provide important information pertaining to the physiological aspects of playing the double bass, postural recommendations and potential risk factors for MSS. In recent years, there has also been an increase in the availability and accessibility of resources due to technological advancements such as YouTube channels, podcasts, and online live events such as masterclasses, seminars and virtual lessons. Double bassists have been able to more easily document their vast experiential knowledge via digital platforms, creating an ever-growing information bank. These resources contribute a significant amount of pedagogical information to support double bassists' performance health.

7. Conclusion

Musicians' health research with a focus on the double bass is scarce. Double bassists experience MSS in the back, neck, and upper extremities, including shoulders, arms, wrists, hands, and fingers. Possible risk factors for MSS include biological sex, physical attributes, sitting or standing, chair ergonomics, French or German bow hold, angle of the instrument to the player, muscle tension, and muscle use. The exact prevalence and risk factors of double bassists MSS cannot yet be conclusively determined. There is, however, a promising amount of recent inquiry into the performance health of double bassists, including MSS, which provides a strong foundation for further research. Ascertaining the types, frequency and severity of double bassists' MSS, and the factors affecting their occurrence is crucial for the prevention and rehabilitation of double bassists' performance health problems, for enhancing performance, and for optimising pedagogy.

Limitations

The primary limitation of this literature synthesis is that it is derived only from literature in the English language.

References

Abréu-Ramos, A. M., & Micheo, W. F. (2007). Lifetime prevalence of upper-body    musculoskeletal problems in a professional-level symphony orchestra: age, gender, and instrument-specific results. Medical Problems of Performing Artists, 22(3), 97–104.

Ackermann, B., Driscoll, T., & Kenny, D. T. (2012). Musculoskeletal pain and injury in professional orchestral musicians in Australia. Medical Problems of Performing Artists, 27(4), 181–187.

Ajidahun, A. T., Mudzi, W., Myezwa, H., & Wood, W.-A. (2016). Upper extremity disability among string instrumentalists use of the quick DASH and the NDI. Cogent Medicine, 3(1), 1–11. https://doi.org/10.1080/2331205x.2016.1234535

Ajidahun, A. T., Mudzi, W., Myezwa, H., & Wood, W.-A. (2017). Musculoskeletal problems among string instrumentalists in South Africa. South African Journal of Physiotherapy, 73(1), 1–7.

Barbé, T. (2017). Playing the double bass with little hands. Strad, 128(1525), 72–75.

Bejjani, F. J., Kaye, G. M., & Benham, M. (1996). Musculoskeletal and neuromuscular conditions of instrumental musicians. Archives of Physical Medicine and Rehabilitation, 77(4), 406–413. https://doi.org/10.1016/S0003-9993(96)90093-3

Benfield, W., & Dean, J. S. J. (1973). The Art of Double Bass Playing. USA: Summy-Birchard Music.

Bradetich, J. (2009). Double Bass: The ultimate challenge (3rd ed.). Miami: Music For All To Hear.

Brown, A. N. (1997). Musculoskeletal misuse among youth symphony string players. Medical Problems of Performing Artists, 12(1), 15–18.

Bruser, M. (1997). The Art of Practicing. New York: Three Rivers Press.

Burkholder, K. R., & Brandfonbrener, A. G. (2004). Performance-related injuries among student musicians at a specialty clinic. Medical Problems of Performing Artists, 19(3), 116–122.

Chou, Y. (2013). When the Mouse Meets the Elephant: a Manual for String Bass Players With Application of the Philosophy and Principles of the F. M. Alexander Technique. Louisiana State University and Agricultural and Mechanical College.

Conable, B., & Conable, B. (2000). What Every Musician Needs to Know about the Body. Oregon: Andover Press.

Črnivec, R. (2004). Assessment of health risks in musicians of the Slovene Philharmonic Orchestra, Ljubljana, Slovenia. Medical Problems of Performing Artists, 19(3), 140–145.

Davies, J., & Mangion, S. (2002). Predictors of pain and other musculoskeletal symptoms among professional instrumental musicians - Elucidating specific effects. Medical Problems of Performing Artists, 17(4), 155–168.

Dennis, A. (1984). The Effect of Three Methods of Supporting the Double Bass on Muscle Tension. Journal of Research in Music Education, 32(2), 95–103.

Dick, R. W., Berning, J. R., Dawson, W., Ginsburg, R. D., Miller, C., & Shybut, G. T. (2013). Athletes and the arts - The role of sports medicine in the performing arts. Current Sports Medicine Reports, 12(6), 397–403. https://doi.org/10.1249/JSR.0000000000000009

Fishbein, M. (1988, March). Medical problems among ICSOM musicians: Overview of a national survey. Medical Problems of Performing Artists, Vol. 3, p. 1.

Fishbein, M., Middlestadt, S., Ottati, V., Straus, S., & Ellis, A. (1988). Medical problems among ICSOM musicians: Overview of a national survey. Medical Problems of Performing Artists, 3(1), 1–8.

Gilbert, L. (2009). Results from "A Survey of, for and about Bassists." Bass World, 29–33.

Gómez-Rodríguez, R., Díaz-Pulido, B., Gutiérrez-Ortega, C., Sánchez-Sánchez, B., & Torres-Lacomba, M. (2020). Prevalence, disability and associated factors of playing-related musculoskeletal pain among musicians: A population-based cross-sectional descriptive study. International Journal of Environmental Research and Public Health, 17(11), 1–13. https://doi.org/10.3390/ijerph17113991

Green, B., & Gallwey, W. T. (1986). The Inner Game of Music. In Inner Game. New York: Doubleday.

Guettler, K. (1992). Electromyography and Muscle Activities in Double Bass Playing. Music Perception, 9(3), 303–310.

Heredia, L., Hinkamp, D., Brodsky, M., & Llapur, C. (2014). Playing-related problems among musicians of the Orquesta Buena Vista Social Club and supporting bands [Other]. Medical Problems of Performing Artists, 29(2), 80–85.

Hinkamp, D., Morton, J., Krasnow, D. H., Wilmerding, M. V., Dawson, W. J., Stewart, M. G., … McCann, M. (2017). Occupational Health and the Performing Arts. Journal of Occupational and Environmental Medicine, 59(9), 843–858. https://doi.org/10.1097/JOM.0000000000001052

Hohls, Q. R. (2010). An investigation into performance related musculoskeletal disorders of professional orchestral string musicians in South Africa. Durban University of Technology.

Kenny, D. T., & Ackermann, B. (2009). Optimising physical and psychological health in performing musicians. In The Oxford Handbook of Music Psychology.

Kertz, R. (2011). The Bassist's Guide to Injury Management, Prevention and Better Health (2nd ed.). Illinois: Musician's Health Resources.

Kochem, F. B., & Silva, J. G. (2017). Prevalence and associated factors of playing-related musculoskeletal disorders in Brazilian violin players. Medical Problems of Performing Artists, 32(1). https://doi.org/10.21091/mppa.2017.1006

Kok, L. M., Huisstede, B. M. A., Voorn, V. M. A., Schoones, J. W., & Nelissen, R. G. H. H. (2016). The occurrence of musculoskeletal complaints among professional musicians: a systematic review. International Archives of Occupational and Environmental Health, 89(3), 373–396.

Lee, H.-S., Park, H. Y., Yoon, J. O., Kim, J. S., Chun, J. M., Aminata, I. W., … Jeon, I.-H. (2013, September). Musicians' medicine: musculoskeletal problems in string players. Clinics In Orthopedic Surgery, Vol. 5, pp. 154–160.

Levenderis, F. (2018). Effective Practicing Techniques: Suggested methods for advanced solo double bass players. University of Pretoria.

Levenderis, F. (2020). Musculoskeletal symptoms in double bass and cello players: a literature review. Stellenbosch University.

Middlestadt, S., & Fishbein, M. (1989). The Prevalence of Severe Musculoskeletal Problems Among Male and Female Symphony Orchestra String Players. Medical Problems of Performing Artists, 4(1), 41–48.

Paarup, H., Baelum, J., Holm, J., Manniche, C., & Wedderkopp, N. (2011). Prevalence and consequences of musculoskeletal symptoms in symphony orchestra musicians vary by gender: a cross-sectional study. BMC Musculoskeletal Disorders, 12(223).

Paull, B., & Harrison, C. (1997). The Athletic Musician. Lanham: Scarecrow Press, Inc.

Ranelli, S., Smith, A., & Straker, L. (2011). Playing-related musculoskeletal problems in child instrumentalists: The influence of gender, age and instrument exposure. International Journal of Music Education, 29(1), 28–44.

Ranelli, S., Straker, L., & Smith, A. (2008). Prevalence of Playing-related Musculoskeletal Symptoms and Disorders in Children Learning Instrumental Music. Medical Problems of Performing Artists, 23(4), 178–185.

Rennie-Salonen, B., & de Villiers, F. (2016). Towards a model for musicians' occupational health education at tertiary level in South Africa. Muziki, 13(2), 130–151. https://doi.org/10.1080/18125980.2016.1182823

Rennie-Salonen, B., & de Villiers, F. (2020). Musicians' occupational health in South Africa: Promoting awareness and understanding in music teaching. The South African Music Teacher, (154), 1–25.

Russell, J. A., & Benedetto, R. L. (2014). Perceived Musculoskeletal Discomfort Among Elementary, Middle, and High School String Players. Journal of Research in Music Education, 62(3), 259–276.

Salonen, B. L. (2018). Tertiary music students' experiences of an occupational health course incorporating the body mapping approach. University of the Free State.

Stanhope, J. (2016). Physical performance and musculoskeletal disorders: Are musicians and sportspeople on a level playing field? Performance Enhancement and Health, 4(1–2), 18–26. https://doi.org/10.1016/j.peh.2015.11.004

Stanhope, J., Tooher, R., Pisaniello, D., & Weinstein, P. (2019). Have musicians' musculoskeletal symptoms been thoroughly addressed? A systematic mapping review. International Journal of Occupational Medicine and Environmental Health, 32(3), 291–331. https://doi.org/10.13075/ijomeh.1896.01340

Stanhope, J., & Weinstein, P. (2020). Why do we need to investigate non-classical musicians to reduce the burden of musicians' musculoskeletal symptoms? Industrial Health, 58(3), 212–223. https://doi.org/10.2486/indhealth.2019-0094

Steinmetz, A., Scheffer, I., Esmer, E., Delank, K. S., & Peroz, I. (2014). Frequency, severity and predictors of playing-related musculoskeletal pain in professional orchestral musicians in Germany. Clinical Rheumatology, 34(5), 964–973. https://doi.org/10.1007/s10067-013-2470-5

Tambroni, P. (2014). An Introduction to Double Bass Playing (J. Goldsmith, J. Heath, & A. Albright, Eds.). Oak Park: Peter Tambroni.

Thaele, T. (2016). The prevalence of playing-related musculoskeletal disorders in selected Western classical music students at the South African College of Music, University of Cape Town. University of Cape Town.

Turner-stokes, L., & Reid, K. (1999). Three-dimensional motion analysis of upper limb movement in the bowing arm of string-playing musicians. Clinical Biomechanics, 14(6), 426–433.

Wahlstrom Edling, C., & Fjellman-Wiklund, A. (2009). Musculoskeletal disorders and asymmetric playing postures of the upper extremity and back in music teachers: A pilot study. Medical Problems of Performing Artists, 24(3), 113–118.

Waters, M. (2019). Perceptions of playing-related discomfort/pain among tertiary string students: A general overview of contributing factors. International Journal of Music Education, 37(2), 226–242. https://doi.org/10.1177/0255761419833078

Wijsman, S., & Ackermann, B. J. (2018). Educating Australian musicians: Are we playing it safe? Health Promotion International, 34(4), 869–876. https://doi.org/10.1093/heapro/day030

Woldendorp, K. H., Boonstra, A. M., Arendzen, J. H., & Reneman, M. F. (2018). Variation in occupational exposure associated with musculoskeletal complaints: a cross-sectional study among professional bassists. International Archives of Occupational and Environmental Health, 91(2). https://doi.org/10.1007/s00420-017-1264-5

Woldendorp, K. H., Boonstra, A. M., Tijsma, A., Arendzen, J. H., & Reneman, M. F. (2016). No association between posture and musculoskeletal complaints in a professional bassist sample. European Journal of Pain (London, England), 20(3).

Zaza, C. (1998). Playing-related musculoskeletal disorders in musicians: A systematic review of incidence and prevalence. Canadian Medical Association, 158(8), 1019–1025.

Zaza, C., Charles, C., & Muszynski, A. (1998). The meaning of playing-related musculoskeletal disorders to classical musicians. Social Science and Medicine, 47(12), 2013–2023. https://doi.org/10.1016/S0277-9536(98)00307-4

About the Authors

Frances Levenderis (Stellenbosch University, South Africa)
Dr Bridget Rennie-Salonen (Stellenbosch University, South Africa)

Frances Levenderis completed her bachelor's degree in music at the University of Pretoria in 2018 and a bachelor's degree in music at Stellenbosch University in 2020. She is currently pursuing a master's degree in music at the University of Stellenbosch. Frances has participated in masterclasses given by Uxia Martinez Botana, Jeff Bradetich, Nick Scales, and Gudrun Raschen. She travelled to Germany with the Johannesburg Youth Orchestra in 2018, and has performed with a number of orchestras in South Africa, including the Cape Philharmonic Orchestra, Kwazulu Natal Philharmonic Orchestra, Stellenbosch International Chamber Music Festival Symphony Orchestra (principal 2019), Johannesburg Youth Orchestra, University of Pretoria Symphony Orchestra, Rand Symphony Orchestra, South African National Youth Orchestra, and Cape Festival Orchestra.

Dr Bridget Rennie-Salonen, is a flautist, lecturer, and practitioner and researcher in musicians' health. She holds the positions of Postdoctoral Fellow at the Africa Open Institute for Music Research and Innovation, part-time Lecturer, and Head of Woodwinds, all at Stellenbosch University. She received her PhD in Music from the University of the Free State where she researched occupational health curriculum content, implementation, and assessment. She also holds certificates in the Essentials of Performing Arts Medicine and in Functional Movement Anatomy. For many years, Bridget served as the solo principal flute of the Cape Town Philharmonic, and she currently serves as the principal flute of the Cape Town Festival Orchestra and performs with Cape Town Baroque.

Corresponding author:
Frances Levenderis
frances@stargate.co.za