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Rationale: Three-dimensional (3D) motion analysis has proved helpful in the diagnosis of different musculoskeletal syndromes and identifying injurious movement patterns in high string players. Furthermore, an optoelectronic 3D motion capture system allows an accurate and objective assessment of upper body posture and motion during violin and viola performance. However, no reference upper body model of high string players has been proposed as yet. Moreover, a more physiological shoulder model that separates the joints of the shoulder complex has not been reported. Especially in view of given the role of the scapula in the normal movement of the humerus, it cannot be disregarded when evaluating musculoskeletal strain in the shoulder.
The International Society of Biomechanics recommends definitions of joint coordinate systems for the report of upper body joint motion using anatomical landmarks as reference for the placement of surface markers. Using markers on the skin for some of the proposed locations is, however, inappropriate when an instrument is being played. There are skin movement artifacts, e. g. caused by the movement of the scapula underneath the skin, whereas some markers interfere with the instrument on the shoulder or might be occluded by the bowing arm in motion.
Purpose: The aim of this study was to develop a marker-based method for quantifying 3D upper body kinematics of high string players and to demonstrate its clinical feasibility in violin and viola performance. The method is intended to provide an objective evaluation of high string players’ motor strategies, especially in the shoulder complex, while minimizing skin movement artifacts, marker occlusions and limitations in instrument placement.
Methods: A custom marker set was developed consisting of thirty-one single markers to define the anatomical coordinate systems of sixteen upper body segments including the pelvis, thorax, spine and head, as well as both scapulae, upper arms, forearms and hands. Twenty-one of these markers as well as two pre-built and four custom-made rigid marker clusters were used for tracking the segment motions.
Twelve professional violinists without history of musculoskeletal or neurological problems were recruited for assessing the clinical feasibility of the method. They were asked to perform a single sequence of two consecutive musical notes on each of two adjacent strings (G- and D-string) in real time, played at 50 bpm with tempo audibly regulated by a metronome, and using a standardized violin and bow. The participants played up- and down-bow alternately using the whole length of the bow.
A custom biomechanical model was applied to the motion capture data and the rotation angles of fifteen joints were calculated. The location of each glenohumeral joint rotation center was computed by upper arm movements with respect to the scapula based on a functional method. For a description of the motion patterns, minimum, maximum and range of angular motion were averaged across participants for each string and rotation. Inter-subject variability was assessed by calculating the standard deviation (SD) at each sample of the angle-time series between participants for each rotation and for both strings. Then SD was averaged over sequences for each rotation and string. For comparing mean rotation angles between strings over time, random effect models were used.
Results: The highest range of motion was observed in the right elbow flexion and right wrist flexion/extension. Also, high ranges of motion (> 10°) were found in all right glenohumeral rotations and right wrist deviation and pronation/supination. In conclusion, lumbar and thoracic spine, thorax, neck, and left upper limb were quite static, while large motion occurred in the right upper limb during up and down bowing.
Most rotation angles showed a reasonable inter-subject variability except for left and right glenohumeral plane of elevation as well as left glenohumeral internal/external rotation, and left and right wrist pronation/supination (> 10°).
Significant differences in the rotation angles between G- and D-string bowing were detected especially in the left wrist and right shoulder joints.
Conclusions: This is the first study that used quantitative 3D analysis to explore the upper body kinematics of high string players during performance, providing a detailed view of the motor control in the shoulder as well as in the lumbar and thoracic spine. The biggest advantage over previously published methods is the more physiological shoulder and spine models while providing a simple application.
The method was found to give consistent motion patterns across participants and to be sensitive to differences between adjacent strings. Although the method appears to be valid, more rigorous validation is necessary. Since there is no gold standard with which we could compare results, we were only able to assess the clinical feasibility. We believe that our method represents a good compromise between accuracy and practicability for clinical application.
Due to the inclusion of multi-segmented shoulder and spine models, it will improve understanding of the motor strategies adopted by high string players and may contribute to injury prevention, diagnosis and treatment.
Hintergrund Die physiotherapeutische Dokumentation spielt im Therapieprozess eine wichtige Rolle, erfolgt jedoch auf unterschiedlichste Weise. Es existieren derzeit eine Vielzahl von Softwarelösungen für die physiotherapeutische Dokumentation, welche sich jedoch in ihren Funktionalitäten stark unterscheiden. Ziel Mithilfe einer Befragung soll ein Konsens von Expertenaus der Physiotherapie im Themengebiet der softwarebasierten Dokumentation ermittelt werden. Anhand der Ergebnisse wird ein Anforderungskatalog für die Entwicklung einer neuartigen und benutzerorientierten Dokumentationssoftware erstellt. Methode Online-Delphi-Befragung mit neun Experten über drei Befragungswellen.
Ergebnisse Hinsichtlich der Anforderungen an die Anamnese konnte ein Konsens erzielt werden. Bei der Gliederung des Befundes kam es zu keiner Übereinstimmung der Experten. Das Ergebnis lässt sich durch unterschiedliche manualtherapeutische Konzepte erklären, die für die Befunderhebung verwendet wurden. Schlussfolgerung Eine softwarebasierte Dokumentation sollte standardisierter als bisher erfolgen, um den ClinicalReasoning-Prozess zu unterstützten. Gleichzeitig ist dabei eine gewisse Flexibilität geboten. Die gesammelten Anforderungen können für die Entwicklung einer neuartigen und benutzerorientierten mobilen Anwendung zur Effizienzsteigerung in der physiotherapeutischen Dokumentation verwendet werden.
Rationale:
Instrumentalists often suffer from playing-related (neuro-)musculoskeletal disorders (PRMDs). Most common PRMDs in string players are related to upper-body regions. Motion analysis has proven to be helpful in the evaluation of functional disorders. It was already shown that it is a valid and clinically feasible tool for accurate, repeatable, and objective assessments of functional movement in string players. Thus, it may guide clinicians to improvements in injury prevention, diagnosis, and treatment. Nevertheless, its application in clinical consultation is still very uncommon. For this reason, there is a lack of well-established motion analysis protocols for the examination of PRMDs in string players using advanced biomechanical instruments in clinical settings.
Purpose:
To demonstrate the development and application of a motion analysis protocol for the evaluation of functional upper-body movements in violinists, violists, and cellists in a clinical setting for the investigation of PRMDs.
Approach:
The protocol was to be integrated into a clinical reasoning process for testing clinical hypotheses and evaluating treatment outcomes in physiotherapy. As a starting point, a primary clinical question was defined, and then, specific upper-body symptom regions as well as measurement parameters (relative rotation angles and muscle activities over time) were identified. Subsequently, involved segments, joints, and muscles were assorted. For quantification of upper-body kinematics a novel, marker-based method was used which provides multi-segmented shoulder and spine models while providing simple application. Based on that, a comprehensive mechanical model of the upper body as well as the associated coordinate systems and rotation sequences were specified. This further guided both, the definition of a custom-made marker set as well as the selection and placement of surface electrodes. Furthermore, required static and functional calibration trials as well as movement tasks for functional assessment were specified. Finally, advanced approaches, such as a comprehensive kinematic model and functional determination of joint centers and axes were established for extraction. Then, outcome parameters and their form of representation were determined for further analysis and interpretation.
The application of the method first includes the selection of segments, joints, and muscles to examine – originating from one or more clinical (working) hypotheses or symptom regions. This drives the configuration and placement of required surface markers and electrodes. Then, the required calibration and functional movement trials are executed. After measurement, the outcome parameters get extracted and analyzed. Based on the results the hypothesis is discarded or verified.
Content:
The method was applied to a violinist (female; 18 years old; 13 years of experience; practicing 2 to 3 hours per day, 7 days per week) with playing-related demands in the left cervical-shoulder-arm region.
Subjective findings indicated that the pain regularly occurred after 30 minutes of playing fast or difficult musical pieces. Physical examination showed that strength testing of left serratus anterior muscle caused pain, lower trapezius muscles seemed weak, forearm muscles were sensitive to pressure, movement of the cervical spine to the left was reduced, and upper limb neural tension test was noticeable.
This led to the following working hypothesis: Neck-related arm pain with neurodynamic component and motor control problem in the scapulothoracic region. Thus, left-sided cervical-shoulder-arm region was selected for functional examination.
Optoelectronic motion capture system and surface electromyography were used for data collection. Static and function calibration trials as well as functional assessment trials (chromatic scale with different tempi) were conducted. Afterwards, data was further processed, and outcome parameters were extracted.
Results showed that greater tempo and pain had an impact on the rotation angles and muscle activities. They led to less overall joint movement and range of motion, to less muscle activity in the forearm muscles, and to greater activity inputs in the scapulothoracic muscles. Overall, greater tempo and pain led to a different motor program which verified the working hypothesis.
The procedure was repeated after treatment (four appointments over one week) with manual therapy, training, and education. The pre-/post-interventional comparison showed changes in the motor program. There was noticeable higher mean activity in upper trapezius and deltoid muscles and simultaneously less in the remaining ones. In addition, only marginal differences in ranges of motion and muscle activity inputs were found between tempi. The playing style appeared to be more stable now. Overall, it appeared that nearly the same motor program was used for each tempo.
Clinical Implications:
Potential applications are intraindividual evaluations of simultaneously joint and muscular function in string players during clinical consultation. It is intended to contribute to the diagnosis of PRMDs in terms of an objective, comprehensive and yet clinically feasible diagnostic assessment as well as pre-post-intervention outcome evaluation.
Nonetheless, motion analysis must be used with care in clinical decision making. Motion data is subject to both, intraindividual variations, and measurement errors. In addition, the smallest clinically relevant changes are not clear yet. Therefore, results should only be interpreted together with other clinical findings.
Hintergrund: Instrumentalisten leiden häufig unter spielbedingten (neuro-) muskuloskelettalen Erkrankungen. Diese zeigen sich bei Streichern, wie Violinisten, Bratschisten und Cellisten, am häufigsten in Form von Beschwerden im Oberkörper – insbesondere im Schulter-Nacken-Bereich. Die apparative Bewegungsanalyse hat sich bereits als hilfreich bei der Beurteilung von muskuloskelettalen Erkrankungen und schädlichen Bewegungsmustern erwiesen und wird für die Diagnostik bei funktionellen Störungen empfohlen. Es wurde bereits gezeigt, dass die apparative biomechanische Bewegungsanalyse ein valides und klinisch praktikables Werkzeug für die genaue und objektive Untersuchung von Bewegungen bei Streichern ist, jedoch ist ihr Einsatz in der klinischen Konsultation immer noch sehr unüblich. Aus diesem Grund existiert ein Mangel an gut etablierten Bewegungsanalyse-Protokollen zur Untersuchung funktioneller Störungen bei Streichern unter Einsatz biomechanischer Instrumente in einem klinischen Umfeld wie der Physiotherapie.
Ziel ist es daher, die Entwicklung und Anwendung eines solchen Protokolls vorzustellen für die Beurteilung der funktionellen Spielbewegungen des Oberkörpers bei sowohl hohen als auch tiefen Streichern in einem physiotherapeutischen Umfeld.
Methode: Zunächst wurden auf Basis einer klinischen Fragestellung relevante Symptombereiche und Messparameter bestimmt. Anschließend wurden beteiligte Segmente, Gelenke und Muskeln selektiert. Darauf basierend wurde ein umfassendes (mechanisches) Modell des Oberkörpers sowie die dazugehörigen Koordinatensysteme und Rotationssequenzen definiert. Dies lenkte sowohl die Spezifikation eines speziell angefertigten Marker-Sets sowie fortgeschrittener Ansätze wie zur funktionellen Bestimmung von Gelenkzentren und -achsen, als auch die Auswahl und Platzierung von Oberflächenelektroden. Schließlich wurden Aktivitäten zur Kalibrierung und Untersuchung der Bewegungsfunktion sowie relevante Analyseparameter und deren Darstellungsformen festgelegt.
Die Protokolldurchführung beinhaltet zunächst die Auswahl der zu untersuchenden Segmente, Gelenke und Muskeln ausgehend von einer oder mehreren klinischen (Arbeits-)Hypothesen bzw. von den spezifischen Symptombereichen. Darauf basierend werden die benötigten Marker und Oberflächenelektroden konfiguriert und platziert. Anschließend werden die festgelegten Kalibrierungsmessungen und Bewegungsaufgaben durchgeführt. Schließlich werden die relevanten Ergebnisparameter zur Überprüfung der Hypothesen extrahiert.
Der klinische Einsatz der Methode wird exemplarisch anhand einer Violinistin mit spielbedingten Schmerzen erläutert.
Klinische Implikationen: Die potenzielle Anwendung des vorgestellten Vorgehens ist die intra-individuelle Evaluation von gleichzeitig der Gelenk- als auch der Muskelfunktion bei hohen und tiefen Streichern während der physiotherapeutischen Konsultation. Dies soll sowohl zur Diagnose funktioneller Erkrankungen des Bewegungsapparates in Form einer objektiven, umfassenden und dennoch klinisch praktikablen diagnostischen Untersuchung als auch zum prä-post-interventionellen Vergleich beitragen.
BACKGROUND: Recently, Wolf et al. proposed a novel, marker-based method to analyze the three-dimensional upper-body kinematics of high string players for clinical application. The method provides an objective evaluation of high string players’ motor strategies, especially in the shoulder complex, by distinguishing between the scapulothoracic (ST) and glenohumeral (GH) joints, while minimizing skin movement artifacts, marker occlusions, and limitations due to instrument placement. Nevertheless, reproducibility of kinematic measurements is crucial for clinical applications. The aim of this study was to assess the method’s reproducibility in terms of reliability and repeatability.
METHODS: One healthy professional violinist underwent a total of nine bowing trials in three different laboratory sessions. Each trial was conducted by one of two different examiners. A biomechanical model was applied to motion capture data of the pelvis, thorax, spine, and head, as well as both upper limbs (consisting of the scapula, upper arm, forearm and hand). Reproducibility was assessed by calculating inter- and intra-tester, inter-session, and intra-subject measurement errors for each rotational degree of freedom in the upper-body segments and joints.
FINDINGS: Small measurement errors were accepted to be good indicators for reproducibility. Intra- and inter-tester errors were found to be small (< 3° for the most part). Both inter-session and intra-subject repeatability were found to be larger (< 5° for the most part).
INTERPRETATION: This study generally showed the novel, marker-based method to have good reproducibility for a healthy violinist. This indicates that the proposed method is a reliable tool for quantifying upper-body movements during violin playing across subjects, examiners, laboratories, and motion capture systems.
Hintergrund: Die Dokumentation spielt in der Physiotherapie eine entscheidende Rolle. Ihre Qualität ist jedoch oft mangelhaft und entspricht teilweise nicht den gesetzlichen Anforderungen. Die Digitalisierung kann eine Chance sein, diesen Mangel zu beheben.
Ziel: Evaluierung des Einflusses der Dokumentationsart auf die Qualität und den Zeitaufwand der Dokumentation bei Patient*innen mit muskuloskelettalen Erkrankungen.
Methode: Explorative Beobachtungsstudie mit quantitativer Evaluation von Qualität und Zeitaufwand. Es wurde ein (validiertes) Instrument zur Qualitätsbeurteilung aus den Niederlanden verwendet, das für den deutschsprachigen Raum übersetzt und für die Schweiz validiert wurde. Der Zeitaufwand wurde mit einer Stoppuhr gemessen. Eine Gruppe von Physiotherapeut*innen aus einer ambulanten Physiotherapiepraxis in Deutschland verglich die beiden Dokumentationsarten. Abschließend wurden die Kriterien Qualität und Zeit zwischen den beiden Gruppen verglichen. Die statistische Auswertung der Daten erfolgte mittels Mann-Whitney-U- und unabhängigem T-Test.
Ergebnisse: Ausgewertet wurden 64 Dokumentationen, 42 handschriftliche und 22 digitale Dokumentationen von insgesamt 5 Physiotherapeut*innen. Bei der Betrachtung der Gesamtdokumentationsdauer konnte für die handschriftliche Dokumentation ein Mittelwert von 902,52 (± 292,28) Sekunden und für die digitale Dokumentation von 813,32 (± 271,703) Sekunden errechnet werden. Die statistische Auswertung für die Dokumentationszeit ergab einen kleinen Effekt mit d = –0,312 sowie einen nicht signifikanten Unterschied mit p = 0,24. Die Gesamtpunktzahl für die Qualitätsbewertung ergab für die handschriftliche Dokumentation einen Wert von 55,6 ± 4,97 Punkten und für die digitale Dokumentation einen Wert von 64,82 ± 3,43. Die Berechnung der Effektstärke ergab einen starken Effekt mit r = –0,718 sowie ein signifikantes Ergebnis mit p < 0,0001.
Schlussfolgerung: Die Umstellung auf digitale Dokumentation bringt deutliche Qualitätsvorteile, wie sie auch in anderen Disziplinen zu beobachten sind. Die Ergebnisse zeigen, dass die Qualität der Dokumentation durch die digitale Dokumentation steigt. Es ist daher wünschenswert, die Digitalisierung in der Physiotherapie auch im Bereich Dokumentation voranzutreiben.
Musculoskeletal disorders (MSDs) are prevalent among musicians, posing challenges for both musicians and physiotherapists. Clinical Movement Analysis (CMA) permits the accurate and objective assessment of posture and movement during musical performance, which can enhance MSD diagnosis. However, tools for CMA data analysis that are tailored to physiotherapy workflows are lacking. The aim of this study was to design an interactive tool that integrates CMA data to assist physiotherapists in diagnosing musician-specific MSDs, addressing limitations of traditional diagnostic methods. Following a user-centered design process and visualization design model, the tool was iteratively refined with expert feedback. It meets six key requirements by integrating biomechanical data (i.e., joint rotation angles and muscle activity) with clinical findings to support hypothesis-driven assessments. The prototype features an intuitive, mobile-friendly interface, interactive visualizations of time-oriented data, and reference values for detecting abnormalities. It enables efficient analysis of posture and movement patterns while linking findings to diagnostic hypotheses. Preliminary evaluations have highlighted its usability, alignment with physiotherapy workflows, and potential to bridge the gap between CMA data and clinical decision-making. By enhancing MSD diagnosis and treatment planning, the tool promises to improve patient outcomes. Future work involves clinical validation, broader application to diverse musician populations, and the incorporation of advanced analytics, including machine learning, to further enhance the tool’s capabilities.