Muresanu has a good point. When do esthetics cause harm? Certainly bending to an awkward position would cause musculoskeletal pain, but performance anxiety is surely a factor here. It is also worth noting that musicians and composers are at a higher risk for depression and other mood disorders (Onger et al, 2000). Ludwig (nd) from the University of Kentucky did a 10 year study on artists and non-artists and found that in the artistic group, 59-77% suffered from depression or another mood disorder, compared to the 18-29% in the non-artistic group. I highlight this point because depression had physical dimensions as well as psychological ones.

Your comment brings an important issue to bear--how much is too much? Are we as parents putting to much pressure on our children to perform? I too love music and have since I can remember. Neighbors of ours had a piano and I remember being very moved when I heard it. So, to your point: does the pressure we put on children to perform lead to depression? I think that it contributes to it. Music and depression have been linked for quite some time, but which comes first--the depression or the musical ability?

search about FOCAL DYSTONIA; an anomaly that inflict musicians as well other ones whose main activity involve fine and specific movements (i.e. athletes, surgeons, dancers, etc.). Although mostly painless, FD also seems to be related to "performance anxiety or other psychological or personality variables", as you mentioned.

I'm less convinced. My thoughts are: multiple awkward wrist positions, especially for violin and viola players, along with intense periods of practice (hours and days and weeks and months!), especially in people with weight gain can lead to carpal tunnel symptoms. Similarly if a person *is* anxious, the shoulder/neck/lower back muscles do tense - this isn't "injury" but can certainly be uncomfortable.

At the same time, focal dystonia is thought to have something to do with "cortical smudging" where, because of the intense repetitive practice, the usually separate cortical areas dedicated to sensory and motor processing for the fingers become smudged/less distinct. One of the treatments for this is very slow, very mindful single finger movements to help return the cortical and motor areas to their usual state, along with careful two-point discrimination work to help the same process.

I don't know whether this is associated with anxiety/stress, but it certainly does result in stress!

References - probably Norman Doidge's "The Brain that Changes Itself" is a good one to start with, then for more scientific material, Herta Flor's work, or Lorimer Moseley's work would be good starting points.

I think that performance anxiety, personality and injuries among musicians are certainly related. Chamagne (2000) believes that determination and perfectionism are common attitudes among musicians and considers those attitudes as risk factors for musculoskeletal injuries. In addition, the work of F. M. Alexander (Alexander Technique) has put forward the influence of goal-oriented attitude in the misuse of the self. Indeed a musician distracted by anxiety or a self-critical internal conversation while performing or totally absorbed (if not obsessed!) in solving a technical problem while practicing may lose touch with his internal sensations or kinaesthetic awareness, and this can lead to exceeding his own physiological limits… The issue of the relationship between personality traits and injuries among musicians has also been addressed by Levy, Lounsbury, and Kent (2009).

Chamagne, P. (2000). Prévention des troubles fonctionnels chez les musiciens. Montauban: Montauban : Alexitère.

Levy, J. J., Lounsbury, J. W.& Kent, K. N. (2009). Big Five Personality Traits and Marching Music Injuries. Medical Problems of Performing Artists.

Good question. There are certainly reasons why anxiety could lead to musculoskeletal pain in musicians. One of the characteristics of anxiety (i.e. the physiological and psychological consequences of perception of a stimulus or situation as threatening) is increased corticospinal excitability. This is a feature of the 'fight or flight' response to the stimulus, in that it readies the body for action. However, this increased corticospinal excitability during music performance could lead to excessive muscular activation, which could easily lead to damage of muscular and tendon fibres. That is, the anxiety-driven heightened excitability of neuro-muscular responses to motor commands could produce forces that exceed those that would normally be needed to make fine-grained musical movements. Of course, in terms of causal direction, pain and injury caused by such processes may lead to greater anxiety about practicing and performance so there is arguably a bidirectional effect.

My (admittedly limited) understanding of focal dystonia among musicians is that it is less associated with anxiety, but rather with neural cross-activity of different motor regions (muscle controllers) that is induced by over-repetition of particular movements. This, to my knowledge, is prevalent in musicians who are particularly perfectionist and tend to over-rehearse certain passages.

In terms of personality factors, trait anxiety is associated with neuroticism and extroversion. Of course, there may be many other factors influencing what particular musician is likely to suffer from anxiety and if that is likely to cause them musculoskeletal pain.

Of interest is maybe this study:

"A detailed questionnaire was completed by 240 permanently employed and freelance musicians working in Sydney's classical and non-classical music industry. Statistical regression analysis was used to determine the significant predictors. Two factors highly significant for the three outcomes were high levels of playing-related muscle tension and high levels of preventive behaviors. Playing-related stress was significant for pain/symptoms during the previous year and the playing lifetime, and high stress interacted in its effect with lack of warm-up and rest-break facilities in the workplace for those musicians with severe pain/symptoms."

Janet Davies, Sandra Mangion. Predictors of pain and other musculoskeletal symptoms among professional instrumental musicians: elucidating specific effects. Medical Problems of Performing Artists Journal, Vol. 17 Nr.4.

Bidirectional and highly individual.

As I have seen with many music Students and Professionals the relationship is strong and definitely existing in many different ways. 'Which would come first' is just a quantitative question, since pain leads to anxiety, and anxiety leads to stress, which can lead to various qualities of musculoskeletal pain.

I would expect no general explanation, because of individual acceptance and perception of pain. It is a question of character, if musician accept pain as part of playing or if they declare pain as problem and modify the way of playing, leading to unhealthy playing styles (-> pain) or leading to a loose of control and anxiety, followed by higher muscle tension and higher risk of tension and musculoskeletal pain.

25 % of our music students have strong pain, 25 % often or sometimes some pain, as I found in a survey at our University of Music in Vienna. Anxiety is also a common fact and 30 % use medicine or drugs to cope with the problem. Many cope with sport. Individually. Also the coping techniques (sport or drugs) can lead to pain.

Aleksandra, very interesting list of papers! Thank you very much! 

In some cases yes !; but in the majority it is due to the interaction of an epicritic and fine muscular exercise, together with the resistance of the instrument that, in addition, tends to vibrate (the paradigm would be strings and percussion), together with a bad posture and, of course, the physical and mental stress that generates tension and the state of arousal due to a good performance; thus, it would be something similar to "tennis elbow"