Movement is essential for musicians, enabling them to express creativity and connect with their audience. The integration of body and instrument creates an impression of effortless harmony, free from tension and pain. However, this idealized image often obscures the reality of musculoskeletal and neurological disorders that can affect musicians, limit performance, and, in some cases, end careers prematurely. Musicians often ignore pain and symptoms that need attention and rest [1].

Bernardino Ramazzini first described occupational diseases in musicians in 1713. Zaza et al [2] introduced the term playing-related musculoskeletal disorders (PRMDs) to describe musculoskeletal symptoms, such as pain, weakness, numbness, or loss of coordination, that are caused or exacerbated by playing a musical instrument and are severe enough to impair a musician’s ability to perform at their usual technical level. In this definition, a condition qualifies as a PRMD only when it interferes with musical performance, distinguishing it from symptoms that may occur in everyday life but do not affect playing. Zaza et al [2] further emphasized that PRMDs can become chronic and disabling, affecting musicians not only physically but also emotionally and socially [3]. Reviews report high prevalence rates of musculoskeletal disorders among musicians, with rates ranging from 57% to 68% for general issues, 9% to 68% for PRMDs, and 62% to 93% for one-time PRMDs [1,4,5]. Studies, such as those by Fishbein et al [6], show that many musicians, including 76% of International Conference of Symphony and Opera Musicians members, experience medical issues that compromise their performance.

Identifying risk factors for PRMDs is crucial for prevention [7]. Common factors include gender, age, professional status, years of experience, type of instrument, repertoire, technique, long practice hours, poor physical condition, muscle fatigue, lack of preventive behaviors, and previous injuries. Psychological stress factors, such as anxiety, depression, and perfectionism, also correlate with musculoskeletal disorders [1,4,8]. The weight of the instrument and playing posture can influence injury prevalence.

Research confirms that prolonged forced body positions increase the likelihood of musculoskeletal overload. Few studies focus on the impact of playing classical instruments on posture [9]. Musicians spend about 1300 hours per year in ergonomically unfavorable positions. Instruments requiring different playing positions and techniques have varying prevalence rates of musculoskeletal disorders [10]. A study among conservatory students found high rates of postural alterations without the instrument (66.2%) and nonoptimal posture with the instrument (73.4%). Asymmetrical postures, such as those required by the violin, viola, and flute, are significant associated factors [11].

Musicians playing with arms above the scapulohumeral plane are more prone to PRMDs in the upper limbs [12]. Addressing these conditions requires understanding the factors and implementing appropriate measures. Reviews on ergonomic assessment in orchestra musicians indicate a lack of publications on this topic [13]. More information is available on questionnaires assessing symptoms, such as the “standardized Nordic Musculoskeletal Questionnaire” [14] and the Disabilities of the Arm, Shoulder, and Hand [15].

Compensatory behaviors can be a significant associated factor linked to musculoskeletal disorders among musicians. Understanding and addressing these behaviors is essential for effective prevention and management.

The study aims are to investigate the frequency and types of postural changes, both while musicians are playing their instruments and when they are not, and evaluate whether these postural changes are associated with pain and pain leading to performance limitation. The study will also explore additional associated factors with postural changes and pain based on the demographic, clinical, and musical activity information obtained through the questionnaire.

Finally, it will explore how these postural issues affect the professional lives of musicians.

The study design chosen for this project is cross-sectional.

All collected data (demographic, clinical, postural, and questionnaire data) will be managed to ensure participant confidentiality. Data collection will use Research Electronic Data Capture (REDCap; Vanderbilt University), hosted on a secure server at Fondazione Don Carlo Gnocchi. Each participant will be assigned a unique study ID. The key linking the ID to personal identity will be stored in a password-protected file, separate from the research database, accessible only to the principal investigator. All data will be pseudonymized for analysis.

Photographs taken for postural assessment are considered sensitive personal data. Raw images containing faces will be accessible only to designated medical personnel and the enrolling therapist directly involved in the study. In accordance with the approved ethical protocol, all raw photographs will be permanently deleted upon completion of data analysis. The pseudonymized postural measurement dataset and questionnaire responses will be retained for 10 years after study conclusion for archival purposes, as required by Italian regulation and the funding body, on the secure institutional servers.

Statistical analysis will be performed using SPSS Statistics software (version 27.0; IBM Corp). The primary analysis will focus on within-subject comparisons of postural parameters measured in the 2 experimental conditions (without instrument vs with instrument). Continuous variables will be described using the mean and SD or the median and IQR based on their distribution. The Kolmogorov-Smirnov test will be used to assess the normality of the distributions. Categorical variables will be reported in terms of relative frequencies.

To address the primary objective of quantifying postural deviations induced by instrument playing, postural measurements obtained in the 2 conditions will be compared using paired statistical tests. Specifically, for continuous postural parameters such as shoulder height difference, cervical arrow, and scapula-rachis distance that are normally distributed, the 2-tailed paired t test will be used. For parameters deviating from normality, the Wilcoxon signed-rank test will be applied. These analyses will be conducted on the entire sample and subsequently stratified by instrument category (symmetric vs asymmetric) to elucidate instrument-specific effects. For each parameter, the magnitude of postural change will be calculated as the delta value, defined as the measurement obtained with the instrument minus that obtained without the instrument. These delta values constitute the primary measures of playing posture and will serve as key independent variables in subsequent regression models.

Given the multiplicity of postural parameters assessed, there exists an inherent risk of type I error inflation due to multiple comparisons. To mitigate this, several strategies will be implemented. Although all postural measures are considered exploratory, the analysis will prioritize a core set of clinically relevant parameters identified a priori based on the extant literature, including head-neck inclination, shoulder asymmetry, and lumbar arrow. As an alternative to multiple univariate comparisons, multivariate analysis of variance for repeated measures may be used to compare the overall postural profile between conditions, provided the underlying assumptions are satisfied. For exploratory analyses involving multiple univariate paired comparisons, conservative corrections such as the Bonferroni adjustment or false discovery rate control using the Benjamini-Hochberg procedure will be applied. Findings will be interpreted judiciously, and effect sizes, including Cohen d for paired samples, will be reported alongside P values to emphasize the magnitude of observed effects rather than relying solely on statistical significance.

Minimal missing data are anticipated owing to the standardized data collection protocol. Nevertheless, any missing values in postural measurements, for instance, due to obscured anatomical landmarks in photographic acquisitions, will be systematically reviewed. Should data be determined to be missing completely at random, complete case analysis will be performed. If the proportion of missing data exceeds 5% for a key variable, multiple imputation techniques will be considered, provided the missing at random assumption is tenable. Missing data in questionnaire responses will be addressed in accordance with the scoring manuals of each respective instrument, including the QuickDASH and Neck Disability Index.

To examine factors associated with the outcomes of pain and performance-limiting pain, logistic regression models will be used. The dependent variables will be the presence of pain during the preceding week and the presence of performance-limiting pain during the preceding week, both operationalized as binary outcomes. Independent variables will include demographic characteristics (eg, age and gender), occupational factors (eg, instrument type [classified as symmetric or asymmetric], years of professional experience, and practice hours), and postural delta values, which represent instrument-induced postural changes as described above.

To investigate factors associated with the severity of disability, as measured by the QuickDASH, Oswestry Disability Index, and Neck Disability Index scores, linear regression models (or quantile regression models, if model assumptions are violated) will be used, incorporating the same set of independent variables.

Variables achieving a P value of <.10 in univariate analyses will be entered into multivariable models to identify independent predictors. Results will be reported as odds ratios or regression coefficients with their corresponding 95% CIs. A P value of <.05 will be considered indicative of statistical significance in all final models.

The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [20] checklist was used in the development of the study protocol and will also be followed for the reporting of the final results in the main study paper.

This study protocol received ethics approval from the ethics committee of the IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy (09_16/12/2022). The study was registered on ClinicalTrials.gov (NCT06758349). The study will be conducted in full accordance with the ethical principles of the Declaration of Helsinki and Italian national regulations. Participation is entirely voluntary. Written informed consent will be obtained from all participants prior to any study procedure. The consent form explicitly details the study aims, procedures, potential risks, benefits, data management practices (including pseudonymization and secure storage), and the right to withdraw at any time without consequence. Participants will be informed that by signing the consent form, they agree to the use of their pseudonymized data for analysis and publication of aggregated results. Participants consented to the publication of aggregated, anonymized data derived from their assessments and questionnaires. In accordance with agreements among all study investigators, the study results and any resulting scientific publications will be disseminated in compliance with applicable regulations and publication standards. It should be noted that, as agreed between all participants in the scientific study, the results and the drafting of the scientific article will be published in compliance with the rules in force.

All information, both personal and clinical, collected during this study is confidential and will be treated in accordance with the relevant regulations. During the research, the following data will be collected: common personal data (first name, surname, and age), lifestyle data (physical activity), professional activity data (eg, instrument played, hours of study or work, and study mode), and health-related data (presence of pain with functional limitation at present or in the past and diagnosis of scoliosis). With the participants’ consent, the data will be entered in pseudonymized form into a computerized REDCap database. Within the digitized database, each patient will be associated with a numeric code (ID) for identification. The key linking participant identities to their corresponding IDs will be stored by the principal investigator on a protected file outside the digitized database for the duration of the study and deleted at the end of the study. Processing operations will be related to research purposes for the conduct of the study. Data will be processed in such a way as to ensure compliance with the principles and requirements established by the EU Regulation 679/2016 and current legislation. Security measures will be implemented to prevent data loss, unauthorized access, unauthorized processing, or any processing that is not consistent with the research purposes described above. Access to and processing of the data will be permitted to the Fondazione Don Carlo Gnocchi’s managers and appointees or authorized persons as well as other personnel involved in the study. Alphanumeric codes will be used to identify the person participating in the study, and only authorized personnel will be able to trace these codes to the participant’s identity. The data collected will be processed and stored by the Foundation for the time necessary to achieve the purposes of the study, after which they will be kept for 10 years from the conclusion of the study itself in the REDCap system, under the responsibility of RMC.

This study is designed to provide a comprehensive quantitative analysis of postural deviations in professional orchestral musicians and to explore their association with pain and PPL. By systematically comparing posture during instrumental performance and in a neutral, instrument-free condition, the study aims to identify posture-related associated factors, compensatory strategies, and their potential impact on musicians’ health and professional functioning.

Beyond estimating the prevalence of postural alterations, pain, and PPL, this investigation seeks to clarify how instrument-specific demands and asymmetrical playing positions influence musculoskeletal load. The comparison between neutral sitting posture and instrument-related posture is expected to highlight the extent to which musical performance exacerbates or induces postural deviations, thereby contributing to biomechanical strain. This distinction may help differentiate between baseline postural characteristics and those primarily driven by instrumental practice.

The anticipated findings may reinforce existing evidence that prolonged exposure to forced and asymmetrical postures represents a major contributor to musculoskeletal disorders in musicians. Instruments requiring sustained elevation of the upper limbs, trunk rotation, or unilateral loading—such as bowed string and certain wind instruments—are likely to be associated with greater degrees of postural imbalance, particularly at the cervical, shoulder, and scapular levels. These deviations may correlate with higher rates of upper limb and spinal pain, supporting the hypothesis that compensatory postural behaviors act as a key intermediate mechanism linking instrumental demands to PRMDs.

A central aspect of this study is the investigation of compensatory strategies adopted by musicians to meet technical and artistic performance requirements. While these adaptations may allow musicians to maintain performance quality in the short term, they may also increase cumulative musculoskeletal load over time, predisposing individuals to PRMDs. The identification of such compensatory patterns through objective postural measurements may therefore provide clinically meaningful insights that complement self-reported symptoms and disability assessments.

The use of standardized photographic acquisition and quantitative postural parameters represents a strength of the study, offering an objective framework for posture evaluation in a population that is often assessed primarily through questionnaires. Although the posture analysis device used is not formally validated, its use is consistent with established principles of clinical postural assessment and allows for reproducible measurements across participants. The integration of postural data with validated outcome measures of pain and disability enhances the ecological and clinical relevance of the findings.

Several limitations must be acknowledged. The cross-sectional design does not allow causal relationships between postural alterations, pain, and PPL to be established, and reverse causality cannot be excluded, as pain itself may influence posture. The use of a nonvalidated questionnaire for demographic and musical activity data may introduce reporting bias. Furthermore, although assessments were conducted in real-world orchestra settings to enhance ecological validity, variability in environmental conditions may have influenced postural measurements. Nevertheless, these limitations are offset by the relatively large sample size and the inclusion of professional musicians actively engaged in orchestral performance.

The results of this study are expected to have relevant implications for clinical practice, occupational health, and preventive strategies in the performing arts. By identifying posture-related factors and compensatory mechanisms associated with pain and PPL, the findings may inform the development of targeted ergonomic interventions, including instrument-specific adaptations, posture education, and individualized physiotherapeutic or occupational therapy programs aimed at reducing injury risk and supporting long-term professional sustainability.

The dissemination of the study results will be pursued through multiple complementary channels to maximize scientific, clinical, and professional impact. The primary findings will be submitted for publication in peer-reviewed international journals focusing on occupational health, performing arts medicine, musculoskeletal rehabilitation, and ergonomics. Where appropriate, secondary analyses (eg, instrument-specific or posture-specific findings) may be reported in additional manuscripts.

The results will also be presented at national and international conferences in the fields of occupational medicine, physical and rehabilitation medicine, physiotherapy, ergonomics, and performing arts medicine, fostering interdisciplinary dialogue and knowledge exchange.

To promote knowledge translation, tailored reports and educational materials will be shared with participating orchestras and musicians, highlighting practical implications and preventive recommendations in accessible language. When feasible, workshops or seminars may be organized in collaboration with orchestras to support the implementation of evidence-based ergonomic and preventive strategies.

In addition, the findings may be incorporated into educational initiatives for health care professionals involved in musicians’ health, including physiotherapists, occupational therapists, and physicians. Aggregated and anonymized data may also support future collaborative research projects and inform institutional or occupational health policies related to the performing arts.

This study aims to advance the understanding of the relationship between posture, instrumental performance, pain, and PPL in professional orchestral musicians. By quantitatively comparing posture with and without the instrument, it seeks to identify postural deviations and compensatory mechanisms associated with pain and PPL.

The expected findings may contribute to the development of evidence-based preventive and ergonomic interventions tailored to the specific demands of different musical instruments. In the long term, this approach has the potential to improve musicians’ health, reduce the burden of PRMDs, and promote professional longevity, supporting a preventive and sustainable model of occupational health in the performing arts.