This is an observational study that will allow to understand if and how posture at the instrument can affect musician health and ability to work.

The study will last 3 years during which the investigators will evaluate 250 orchestral players: all musical instruments will be included. Postural assessments will be performed in the various venues of the participating orchestras.

The study participant, would initially answer a questionnaire that will investigate lifestyle habits (physical activity), professional activity (e.g. instrument played, hours of study/work, study methods) and general health (e.g. presence of pain with functional limitation at the present time or in the past, diagnosis of scoliosis).

The subsequent postural assessment will consist of two phases: phase 1 without an instrument in a sitting position, phase 2 with the musical instrument .

Disposable ECG electrodes will be applied to the skin and will serve as landmarks and will be removed at the end of the assessment.

In both phases, the Physical Analyzer Portable system will be used, which allows the acquisition of calibrated photographs and the subsequent processing of the data obtained through special software, calculating with numerical values the postural asymmetries between the right and left sides and the degrees of inclination of the trunk.

The execution of the planned assessments will take place in the constant presence and under the guidance and control of suitable and qualified personnel who will provide instructions on the activity to be carried out and assistance in case of any need.

The data obtained in this way will be correlated with the information collected with the questionnaire.

Improving musician posture awareness with the musical instrument could prevent the onset of pain and limitations in work activity.

In fact, the identification of risk factors for musculoskeletal pathologies in professional musicians (PRMDs) would allow the development of specific prevention and treatment programs and the development of a network of territorial services dedicated to the musicians themselves.

For musicians, movement takes on a particular significance as it allows them to express their creativity through their instrument. The sensation they convey to the audience is one of a body in perfect harmony and symbiosis with their instrument, seemingly free of muscular tension and pain. However, numerous musculoskeletal and neurological disorders afflict musicians, limiting their performance and sometimes forcing them to cease their professional activity. Musicians often tend to underestimate their problems, ignoring pain and symptoms that require care or rest.

In 1713, Bernardino Ramazzini was the first to describe an overview of occupational diseases affecting musicians. Zaza, on the other hand, was the first to introduce the term Playing-Related Musculoskeletal Disorder (PRMD) to define musculoskeletal afflictions as "chronic, disabling personal health problems that affect the entire person physically, emotionally, and in terms of work and social aspects".

Recent systematic reviews report a prevalence of musculoskeletal disorders among musicians ranging from 57% to 68%, PRMDs from 9% to 68%, and one-time PRMDs from 62% to 93%. Fishbein highlighted that approximately 76% of members of the International Conference of Symphony and Opera Musicians (ICSOM) experienced at least one medical issue in their career that compromised their performance.

To find effective solutions for preventing the development of PRMDs or minimizing their impact, it is essential to first identify the main risk factors. The most frequently cited factors in the development of PRMDs include gender, age, professional status and years of experience, type of instrument, repertoire, individual technique, long hours of practice with insufficient breaks, poor physical condition, muscle fatigue, lack of preventive behaviours, and previous injuries. Additionally, several studies have revealed a correlation between the presence of musculoskeletal disorders and psychological stress factors (anxiety and stress, depression, and perfectionism). The weight of the instrument and the imposed posture may also influence the prevalence of musculoskeletal injuries among musicians.

Many researchers confirm that prolonged adoption of forced body positions required to play a specific instrument increases the likelihood of overloading the osteo-artro-neuromuscular system. However, few researchers have attempted to clarify the influence of playing classical musical instruments on posture. On average, a musician plays 1300 hours per year in an ergonomically unfavourable position. Instruments that require different positions and playing techniques are associated with varying prevalence of musculoskeletal disorders. A study conducted among conservatory students highlighted a high prevalence of postural alterations without the instrument (66.2%) and a non-optimal posture with the instrument in 73.4% of cases. Instruments that impose asymmetrical postures, such as the violin, viola, and flute, were found to be the main risk factors for incongruent postures.

Musicians who play with their arms above the scapulo-humeral plane are also more prone to suffer from PRMDs in the upper limb compared to those who play in a neutral position. Correcting these conditions, which represent one of the main risk factors for the development of musculoskeletal disorders in workers, depends on understanding the influencing factors and implementing an appropriate therapeutic and preventive approach.

Regarding the ergonomic risk assessment in orchestra musicians, recent reviews have highlighted that there are few publications on this subject. There is more information available on questionnaires used to assess symptoms reported by musicians due to inflammatory processes and musculoskeletal disorders, such as the "Standardized Nordic Questionnaire"; the DASH (Disabilities of the Arm, Shoulder, and Hand), and the MPIIQM (Musculoskeletal Pain Intensity and Interference Questionnaire for Musicians).

The objectives of the study on a sample of orchestra musicians are:

• To study the prevalence of abnormal posture with and without instruments and describe them quantitatively.
• To investigate whether and which abnormal posture are associated with pain and PRMDs.
• To identify any risk factors for the development of abnormal posture, pain, and PRMDs.
• To study the impact of abnormal posture and PRMDs on professional life. If the study hypothesis is confirmed, it would demonstrate the high prevalence of abnormal posture among professional musicians and the significant impact on their performance and professional activity. Another effect would be raising awareness among professional musicians about the physical stresses they are exposed to and the disorders they may develop, which are still often misunderstood and underestimated by the musicians themselves.

Confirming our hypothesis would concurrently lead to an enhancement of the ongoing activities.

Inclusion Criteria:

• Professional musicians from major Italian orchestras

Exclusion Criteria:

- Pain associated with acute trauma

orchestral musicians playing symmetrical and asymmetrical musical instruments