Lived experiences of musicians with pain: an interpretative phenomenological analysis of performance-related pain of professional violinists

ABSTRACT

The purpose of this interpretative phenomenological analysis (IPA) is to explore how five professional South African violinists make sense of their lived experiences of performance-related pain. The research problem this study investigates is multifaceted. It includes examining the career implications for violinists who play despite experiencing pain and are afraid to speak up because of the stigma associated with being injured. There is a lack of support and understanding from fellow musicians, doctors and other specialists when faced with diagnosing injuries and recommending treatment options. In South Africa, there is limited research on these aspects. In this IPA study, the data were collected through semi-structured interviews with five professional South African violinists with performance-related pain.

The six subordinate themes that emerged from the data analysis were: (i) Playing through the pain; (ii) Lack of identity; (iii) Depression when unable to play because of pain; (iv) Growth through faith and spirituality; (v) Support and lack of support from family, friends, management, doctors and other experts; and (vi) Lack of awareness and understanding of performance-related injuries. Heightened awareness of musicians’ lived experience of performance-related pain could bring about much-needed change and support advocacy for pain-prevention initiatives and assistance for violinists.

KEYWORDS:

• Performance-related pain and violinists
• pain experiences of violinists
• interpretative phenomenological analysis
• meaning-making
• faith and spirituality

This article is an interpretative phenomenological analysis (IPA) of the meaning-making journey of five professional violinists who experience performance-related pain. By recognizing how common performance-related injuries and pain are (Steinmetz et al., 2008), musicians might better understand how crucial their personal input can be in studies such as this one.

In writing about performance-related pain, we first need to describe our understanding of pain. The International Association for the Study of Pain’s revised definition of pain reads as follows: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (Raja et al., 2020, 1976). The sensation of pain is created by the brain when it recognizes the need to act against possible danger to body tissue (Moseley, 2003). Cohen et al. (2018) proposed a descriptive definition of pain, defining pain as “a mutually recognizable somatic experience that reflects a person’s apprehension of threat to their bodily or existential experience” (p. 1). In an IPA study by Kirkham et al. (2015), when participants were asked to paint their pain, they objectified pain as sinister and punitive. To summarize, pain is a complex, ineffable phenomenon that involves psycho-somatic interactions (Smith & Osborne, 2015).

Pain can overwhelm a person’s life, and the prevention and management of pain are imperative aspects of health care (Kumar et al., 2016). It has a negative influence on people’s identity and self-image (Smith & Osborne, 2007) and is thus an element of daily life that we need to learn to understand, manage and embrace to continue performing our daily activities.

Professional musicians may experience pain after countless hours of striving towards achieving perfectly executed repetitive movements, as they are expected to be at the top of their game day after day (Horvath, 2010). Performance-related pain, therefore, has career implications for violinists and musicians in general (B. Ackermann et al., 2012; Horvath, 2010; Zaza, 1998). Paarup et al. (2011) mention that pain has a considerable effect on orchestral musicians, as it can influence their functionality by compromising the way they play because of an injury.

Professional violinists are afraid to speak up about pain because of the stigma associated with being injured (Lubet, 2015). But keeping quiet about the pain and playing through the pain aggravates the situation (Horvath, 2010; Roger, 2017; Steele, 2007). Unfortunately, speaking up might not help since, apart from the stigma, there is a lack of support for those dealing with injury (Heming, 2004; Hiner et al., 1987; Horvath, 2010; Steele, 2007; Wilke et al., 2011). Furthermore, musicians might keep their condition secret since it could jeopardize future work and financial security (Roger, 2017).

Up to 86% of professional musicians are affected by injuries (Steinmetz et al., 2015). Wilke et al. (2011) state that years of playing an instrument can have a severe impact on a musician. They add that musicians must rehearse for many hours, which is physically and emotionally taxing. Therefore, it is not surprising that they develop musculoskeletal problems and suffer from stress-related disorders. There are numerous surveys that indicate that many orchestral musicians experience pain (Horvath, 2010). Steele (2007) confirms this by pointing out that most of the musicians in her orchestra are struggling with some form of pain. Wilkenson and Grimmer (2001) also add that musculoskeletal problems are highly prevalent in orchestral musicians and that more attention should be paid to helping musicians to be able to play with less or no pain.

Studies show that 70% of musicians report some form of over-use injury, and of those, about 65% to 88% are violinists (B. J. Ackermann & Adams, 2004). The list of typical ailments and injuries that violinists suffer from is long, ranging from neck and back pains or mild cases of tendonitis to severe pins and needles and numbness, as well as inflammation in the arms and hands (Johnson, 2009; Reel, 2005). The most common injuries were in the shoulder, neck, upper back and hand (Chan et al., 2013). Steinmetz et al. (2015) state that pain in the neck region was by far the most prevalent type of complaint among all orchestral groups. They add that violinists experienced the most problems and noted pain in more than five regions (Lahme et al., 2014). Musculoskeletal injuries of the shoulder, elbow, hand and fingers are the most frequent and significant painful conditions that violinists must endure.

Although there are many studies on musicians’ injuries from a medical perspective, research focusing on how individual musicians, especially violinists, make sense of their unique experiences of performance-related pain is exceptionally rare. In C. Guptill’s (2011) IPA study, she describes musicians as a vulnerable population needing care. In the Heideggerian phenomenological approach study by Bourne et al. (2019), the five professional and university-level string players were engaged in a range of musical activities but remarked that they found orchestral playing caused most of their pain. The findings from Bourne et al. (2019) study indicated that the pain turned their focus away from the music to their bodies. A sense of loss dominated their narratives, but they also said that pain facilitated personal growth. They were inhibited from disclosing their pain in professional orchestras. Although these IPA studies help to provide information on the lived experiences of musicians in general, there is no mention of how violinists specifically make sense of these lived experiences of performance-related pain.

Devroop (2014) notes that “there is a lack of research on the performance-related medical problems of professional musicians, especially in South Africa” (p. 47). Our research will be different from the studies mentioned above since it is an IPA study focused on five professional South African violinists’ lived experiences of performance-related pain. Andersen et al. (2013) write: “Professional musicians experience high rates of musculoskeletal pain, but only a few studies have investigated how this pain is accepted by musicians” (p. 124). This study intends to fill the gap in the literature between quantitative medical accounts and personal accounts of the subjective meaning of real-life experiences.

The research question that guided this inquiry was: In what ways do five professional South African violinists make sense of their lived experiences of performance-related pain? Therefore, the purpose of this IPA is to explore how five professional South African violinists make sense of their lived experiences of performance-related pain.

Procedures

Research design and approach

In this study, we adopted an IPA approach. According to Shinebourne (2011) and Smith et al. (2009), IPA is a qualitative strategy of inquiry dedicated to exploring how people make sense of their own real-life experiences. The building blocks upon which the IPA method was based are “phenomenology, hermeneutics and idiography” (Smith et al., 2009, p. 11). According to idiographic principles, we analysed each participant’s story separately and analysed each interview extensively before doing a cross-case analysis. This IPA study strives to provide the reader with a detailed analysis of each specific case and requires an in-depth detailed understanding of each particular violinist as well as their own understanding of their lived experiences of performance-related pain (Miles et al., 2014; Smith et al., 2009).

A characteristic of a sound IPA study is the ability to convey several insights into the participants’ lived experiences (Reid et al., 2005). Smith (2011) states that an outstanding example of IPA should consist of depth of interpretation, thoughtfulness of analysis and understanding of the significance of particular subjective statements. We remained true to these principles by sympathetically giving a voice to the participants and quoting key statements in their own words. This is in keeping with a qualitative research study that intends to offer rich illustrative interpretations of the phenomenon being examined (Merriam & Tisdell, 2016; Miles et al., 2014). Each of the five violinists is a specialist on their personal experience of performance-related pain, and their stories can provide the researcher with insight into the ways they deal with their specific pain experiences in significant detail (Reid et al., 2005). The cross-case analysis will provide insight into the emergent superordinate themes.

The role of the first author: I am a professional violinist

The first author is a professional violinist at a tertiary institution in South Africa and has about 20 years of professional playing experience as a chamber musician, teacher, and soloist. In her years as a violinist, she has faced both injuries and pain, and this affords her the experiential knowledge to make sense of the data collected from the selected professional violinists (Jormfeldt, 2019; Joseph, 2014). This personal real-life understanding equips her to interpret the experiences of the participants from an insider’s viewpoint (Shinebourne, 2011; Smith & Osborn, 2008).

Smith et al. (2009) and Smith and Osborn (2015) state that the role of the researcher includes the ability to understand and accurately illustrate the participants’ psychological and emotional conditions and experiences from the information that they reveal. The interviewer also has to give a voice to the participants so that they do not feel disconnected, misrepresented or disregarded during the interview and analysis process (Creswell, 2013; Pietkiewicz & Smith, 2012). It was the first author’s objective to write a truthful account of each story and to verify with the participants that her understanding of each case was correct throughout the whole process.

The participants

The group of five participants was consistent with the idiographic nature of the approach since the level of detail in an interpretative report related to each case can only be achieved with a small sample group (Smith & Osborn, 2015; Smith et al., 2009). The participants are all professional South African violinists who play, perform, teach, and earn their main income from these activities. We did purposeful sampling (Creswell, 2013) by asking five violinists, all with previous experiences of pain and injuries, if they were willing to participate in this study, and they all agreed. The participants, two males and three females chose their own pseudonyms to protect their anonymity; they are Fred, Batman, Violina, Teresa and Pirastro.

Data collection

The benefit of an IPA study is the ability to analyse the participants’ perceptions of their lived experiences in extensive detail (Smith & Osborn, 2015). According to Pietkiewicz and Smith (2012), Reid et al. (2005), Smith et al. (2009) and Smith and Osborn (2015), the method used to achieve this level of detail is conducting semi-structured interviews, where the researcher can deviate from the interview schedule to allow the participant to tell his/her unique story. Smith and Osborn (2015) point out that, at times, the original questions fail to evoke the detailed response needed, either because of the intricacy of the topic or the question being too broad for a suitable response. To obtain rich data (Smith & Osborn, 2015), the interviewer must be able to inspire and lead the participants to feel secure enough to give detailed, profound, powerful, and in-depth interpretations of their own experiences (Creswell, 2013; Smith et al., 2009).

Data were collected through in-depth semi-structured, face-to-face as well as Skype interviews. The primary interview questions included information about the participants’ pain experiences; their first experience of pain when playing or performing; what happened that they started to experience pain; what they felt when they first experienced pain; what they thought about their pain experiences and how they made sense of the pain; what they did regarding the pain; when did they not experience pain; what they thought their colleagues would think of their pain experience; how their experience of pain affected their everyday functionality and the quality of their lives; how the pain influenced their mental wellbeing; how they would experience music differently if they did not have pain; and finally, and how they would feel if they had to stop playing the violin. These questions were posed according to the approach set out by Smith and Osborn (2015), where follow-up questions could be asked to obtain greater detail and clarity when needed. In addition to the interview questions, we also requested that each participant provide a picture of an object of their choice (Table I) that depicts how they make sense of their lived experiences of performance-related pain. This enabled us to understand each participant on a deeper level and to truly capture their essence throughout the process.

Table I. Superordinate themes: salient quotes.

Superordinate Themes	Batman	Fred	Pirastro	Teresa	Violina
1. Playing through the pain	The show must go on “Music-making would be the same with or without pain.”		Determination “I will get there, I will play, and I will do it.”	More playing causes more pain “My body said: ‘Excuse me, I have had enough now.’”	Playing with pain “ … by hook or by crook, just keep it going.”
2. Who am I if I cannot play the violin?	Mixed feelings of possibly ending performance career “To stop playing might be a disaster or maybe I can finally stop practising.”	Fear “ … something is wrong, it’s quite scary.”	Playing makes the pain go away “ … gives me great joy.”		Journey “ … it was a journey to redefine who you are.”
3. Depression when not being able to play due to pain	Moods “I am a monster when I am not in shape.”	Depression “When you are in a lot of pain, then it’s not fun anymore, it’s a job.”	Emotional pain manifests as physical pain “You are fat and ugly.”	Depression “I had enough, this is it.”	Pain “Hi, stop what you are doing!”
4. Growth through faith and spirituality			Strongly opposed to certain treatments “I will not follow that route.”	Faith “I made a choice to reach out to Jesus Christ, not any other god.”	Spirituality “God’s plan for my life is one of prosperity, not adversity.”
5. Support from family, friends, doctors and other experts	Support “Everyone was 100% understanding.”	Treatment “When I don’t have pain, it’s great.”	Cause and treatment of pain “Pain can be physical or psychological.”	Coping with pain “You have this problem, which you believe is a medical problem, but nobody can really help you. You go for a scan, and they say: ‘Nothing is wrong.’”	Support “ … they were understanding, they carried the burden with me.”
6. Lack of awareness and understanding of performance-related injuries by musicians, management and health care professionals	Heightened awareness of injuries “I always thought they had bad technique, and here I have the same thing.”	Nobody cares “You don’t talk about it. It’s your business and you just keep it to yourself and nobody is interested.”	Lack of compassion for injuries “The doctor. said: Just don’t play.”	Lack of understanding of injuries “ … most people have no idea how big the issue really is.”	Lack of awareness of performance-related injuries “I didn’t even know that musicians could develop injuries until it happened to me.”

Data analysis

Smith’s six steps for IPA data analysis were followed (Smith et al., 2009). The first step was reading and re-reading the transcribed interviews numerous times to identify and organize what was fascinating, thought-provoking, relevant, and important (Smith & Osborn, 2015; Smith et al., 2009). The second step entailed making the initial notes and identifying any information that could be relevant and of interest to this study (Smith et al., 2009). In the third step, emergent themes from the data on each participant were developed separately (Reid et al., 2005; Smith et al., 2009; Van Manen, 2016). Step four was to search for relations or links across the emerging themes of a specific participant’s data (Smith et al., 2009). In step five, the same procedures were applied to the next case until all five participants’ stories had been analysed. The final step, step six, was to look for similarities throughout the cases to develop a cross-case analysis (Smith et al., 2009).

ATLAS.ti was used to organize and analyse the data from the interviews (Friese, 2019). Prefixes of the first letter of each participant’s pseudonym were used in the code list to keep participants’ codes separate and ensure a strictly idiographic approach. After the initial analysis on ATLAS.ti, the emergent themes of each participant were highlighted, and a table with the superordinate themes that emerged from the cross-case analysis was developed. In the second edition of Interpretative Phenomenological Analysis (Smith et al., 2021), individual emergent themes are now called Personal Experiential Themes (PETs) and superordinate themes are called Group Experiential Themes (GETs). We are still using the old terminology in this article, since the research was completed before the new editions were available to us.

Trustworthiness

Smith (2011) lists seven criteria for presenting a high-quality IPA study: “The paper should have a clear focus; the paper will have strong data; the paper should be rigorous; sufficient space should be given to the elaboration of each theme; the analyses should be interpretative not just descriptive; the analysis should be pointing to both convergence and divergence, and the paper needs to be carefully written” (p. 59). In the current study, these seven points were carefully followed to ensure that the themes were clear and the information derived was trustworthy and accurate. Each case was treated with the utmost respect, and no preconceived ideas or time limitations were imposed on any of the participants. This study intended to combine all the above criteria to create a truthful and detailed representation of each of the participants’ experiences and includes a well-defined comparison between similarities in their themes as well as differences in their stories.

In order to guarantee that our conclusions are trustworthy, we used Creswell’s (2013) member-checking strategy for validation. We, therefore, presented the transcripts of the interviews, as well as the analysis, to the participants in order for them to verify the data and to confirm whether they felt that they had been understood correctly. They were also asked if they would like to add any additional information or change or delete any part of their stories (Smith et al., 2009; Wiles, 2013). All of the participants responded positively and were satisfied that their stories represented them well and that the conclusions were accurate.

Ethics

According to Merriam and Tisdell (2016), all studies should collect and yield legitimate and trustworthy data in an ethical manner. This information is acquired through conducting interviews, and since this could have a potentially harmful effect on the individuals interviewed, permission needs to be obtained from each individual (Creswell, 2013). Therefore, each of the participants was invited to complete an informed consent form that authorized the researcher to use the information acquired in the interviews conducted for the stated research purpose (Creswell, 2013; Smith et al., 2009; Wiles, 2013). The consent form was sent to the participants before the commencement of the interviewing process. This ensures the protection of the participants and the researchers. Components of the consent form included the permission for participants to withdraw at any point during the investigation. With reference to Creswell (2013), Miles et al. (2014), and Smith et al. (2009), another component of the consent form was an explanation of the specific objective of the study as well as the methods that would be employed to acquire the information needed. The participants were notified that there were no risks involved that exceeded the risks of everyday life in participating in the study (Creswell, 2013) and that their participation would be kept strictly confidential (Miles et al., 2014). The researcher and the participants signed the consent form to make it official (Creswell, 2013). All the participants gave their consent to participate after ethical approval was granted by an ethics committee at a tertiary institution.

Apart from obtaining consent from each participant, the researcher needs to pay attention to certain vital realities. Van Manen (2016) warns the researcher of four points, namely that some participants may be profoundly influenced by the research (Pietkiewicz & Smith, 2012); there might be possible consequences of the investigative methods on the institutions involved; the research methods may have lasting influences on the participants, and an IPA study may profoundly affect the individual researcher personally. One needs to be careful and take great care in handling the voices and experiences of each participant so as not in any way to harm the integrity of the study or the participants. The first author took great care to keep the identity of each participant completely confidential and not to write anything that might make them feel uncomfortable or reveal their true identities.

Findings: individual cases

In this IPA, each participant’s interview was analysed separately, after which a cross-case analysis was undertaken (See Table I). Due to the scope of the article, we will only elaborate on the superordinate themes and not on the individual themes of each case. Six superordinate themes emerged across the cases and will be discussed in the following section, but first, here follows a brief introduction to each participant with a mention of their emergent themes.

Batman

Batman studied at one of the world’s foremost musical institutions and is a passionate solo performer, pedagogue, and chamber musician. Since he had never battled with performance-related injuries, he did not have any idea of how many musicians struggled with performance-related injuries or pain. After he developed problems with his shoulders, he soon discovered how prevalent these injuries were among violinists. Batman is someone who accepts and deals with situations as they occur; therefore, it was unexpected to read his comment on how deeply his injuries affected him. He selected a picture of handcuffs, describing what this represented for him: “It felt like being a prisoner of my own handicap, extreme vulnerability” (see Figure 1). Eight themes emerged from the analysis of Batman’s transcribed interview: cause of injury, heightened awareness of injuries, holistic approach, support, moods, missing out, mixed feelings of possibly ending performance career, and the show must go on.

Figure 1. Batman’s meaning-making picture.

Fred

Fred has been a passionate violin teacher and orchestral player for “too bloody long.” He has a strong sense of duty and believes that once a commitment is made to a performance, it should be kept, even if he experiences pain and discomfort. When asked for an image that represents Fred and his lived experiences of performance-related pain, he selected this painting from his bedroom wall. He says: “The gift in this painting represents the gift I receive every time I teach. I learn from every student. It is the gift of knowledge” (see Figure 2). Fred’s incredible sense of responsibility to his students often overrides his common sense to take some time off to give himself much-needed recovery time from previous injuries. Seven themes emerged from the interview with Fred: a sense of responsibility, factors that aggravate the pain, frustration, nobody cares, fear, depression and treatment.

Figure 2. Fred’s meaning-making picture.

Pirastro

Although Pirastro is a strong-willed and passionate orchestral musician, she has battled with physical and emotional pain for most of her life. Despite this, she is adamant that she will never stop playing the violin, no matter what. As a refuge from pain, Pirastro collects fine exotic fragrances, and over the years, she discovered the healing effects of aromas, perfumes and scented candles. She adds that she always has perfume close to her wherever she goes and boasts of having a large collection at home. The selected photo is of one of her prized possessions that she has accumulated from all over the world. She says: “I match my perfume with my mood. Pain and depression always play a major role in my choice. Certain aromas always help to take the mind to other places as well as recall good memories. Therefore, it alleviates the thought of pain” (see Figure 3). From Pirastro’s interview, six themes emerged: pain and treatment of pain, being strongly opposed to certain treatments, emotional pain manifests as physical pain, determination, playing takes the pain away, and lack of compassion for injuries.

Figure 3. Pirastro’s meaning-making picture.

Teresa

Teresa is a violinist who started playing at an early age, but performance injuries and pain have plagued her since her teenage years. Her pain was so consistent and overbearing that she had no choice but to make a career change and give up playing the violin professionally. Today, Teresa makes sense of this crossroads in her life by hanging onto her powerful belief in Jesus Christ, and this faith led to her acceptance of the battles with pain and injuries. In her faith, she found freedom. Teresa called the image that she chose to describe herself “Looking through and living beyond the fence” (see Figure 4). She explains: “Life has expanded to much more than a career in music. Music is still an important part of my life, and I enjoy it, but it does not define me.” Eight themes emerged in the analysis of Teresa’s interview: causes of pain, more playing more pain, coping with pain, identity, emotion, depression, faith, and lack of understanding of injuries.

Figure 4. Teresa’s meaning-making picture.

Violina

Violina is the director of a popular instrumental group in South Africa. She is a dynamic performer with an unquenchable love for music, and Violina’s performances are known for her passionate playing and infectious joy when sharing her music with the audience. Another important characteristic of Violina is her love of God. This love is palpable in all facets of her life as she sees her struggles with injuries and pain as a journey. The quote she provided to describe her picture is taken from first Corinthians 13:13: “But for now, three things last—trust, hope, love; and the greatest of these is love” (see Figure 5). Eight themes emerged from Violina’s interview: overuse injury, pain, playing with pain, journey, spirituality, treatment, support, and lack of awareness of performance-related injuries.

Figure 5. Violina’s meaning-making picture.

Findings: a cross-case analysis

Superordinate theme 1: playing through the pain

All of the participants noted that, at some stage, they had to play while experiencing pain. For some, like Violina, it was a matter of personal integrity not to cancel performances. Violina said: “Obviously, you take the responsibility of being a performer seriously, so no one knows that you are in pain. It is not a nice feeling, and many times I wondered: ‘Is it really worth it?’ It breaks your spirit.” Fred echoes Violina’s sense of integrity and explains that most musicians his age were raised to be responsible and always attend rehearsals and play concerts once they have committed themselves to do so. Fred explained it as follows: “if I don’t go to work, it is like there’s something more wrong with me than not being well … ”

Another example of this sense of responsibility is Batman, who never cancelled a concert before he had his shoulder operations, although he had to take ibuprofen before a performance in order to keep his shoulder pain controlled while he performed. He strongly felt “The show must go on” with or without pain.

Another important factor contributing to musicians exacerbating their injuries is the financial repercussions if they are unable to perform. Fred says: “I got a bond, I’ve got a dog, I’ve got electricity, and then it becomes quite overwhelming.” Fred and Pirastro both state that musicians know that if they are unable to play for a concert, there will always be someone else who can take their place.

Pirastro adds that, for her, playing with pain is a case of “mind over matter.” She explains that some of her emotional pain is alleviated when she plays in a three-hour orchestra rehearsal. However, for Violina “Playing with pain had a dampening effect on the performance.” Unlike Pirastro, Teresa’s performance-related pain was almost unbearable.

Teresa mentioned that she experienced pain every time she played. Teresa said: “I didn’t want to blow it. Then, my body crashed. It was like it was telling me: ‘Excuse me, I have had enough now’.” Pain while playing causes emotional distress and a feeling of insecurity about one’s ability to continue being a performer/violinist.

Superordinate theme 2: lack of identity: who am I if I cannot play the violin?

When a violinist is confronted with serious pain or injuries as a consequence of overuse of their physical capacities, they often experience an identity crisis. Teresa mentions that she felt completely helpless growing up and seeing all her friends and peers practise for hours on end and thinking that none of them had any pain issues. She often thought, “If I am not a violinist, who am I then? Who am I if this does not work?” Fred says: “It is your career, if it is gone, what the hell do you do?” Violina also expressed this sentiment but decided that her entire life could not be defined only in terms of being a violinist. Violina explained: “Very philosophically, I realized that I cannot define my life as a violinist. Your whole being does not add up to the fact that you are a violinist and a musician. We all want to live fruitful, meaningful lives, and we want to use our hands and be effective, so it was a crisis for me when I thought: ‘What can I do now?’”

While Fred and Pirastro mentioned that not playing the violin would destroy them, Batman did not necessarily see ending his career negatively. He said: “I felt like it would be a disaster if I had to give up the violin, but at the same time, I feel like my life will not fall apart if I cannot do it anymore. Life is far too interesting, and there are too many other things that could fill the void that stopping [to play] the violin would leave, I am sure of this.”

In contrast to the other participants, Teresa’s pain was so intense and relentless that she eventually decided to pursue an alternative profession. Although she is currently working in this new field, she reiterates that music is still an important part of her life. While some of the participants were positive about continuing to make music in some way if they were unable to perform, many violinists struggled to overcome the overwhelming feeling of defeat.

Superordinate theme 3: depression when unable to play because of pain

When confronted with a debilitating performance-related injury and pain, musicians often experience depression because of feelings of helplessness, loneliness and hopelessness. The same goes for all the participants in this study. Violina noted that her pain made her feel disheartened: “I won’t say that I had depression, but it was depressing. It was something that put you down, it was not something that encouraged you.” Similarly, Teresa felt disheartened because of chronic pain. Teresa revealed: “When you have pain over the long term, it breaks you. It makes you depressed and you feel inferior in a social context, because you look at other people and you think: ‘So you are all fine physically?’ […] you are more vulnerable, so it makes certain things more difficult to cope with.”

Batman is used to being able to practise four hours per day, and when he is unable to do this, he turns into a miserable person and starting to practise again is extremely difficult. Batman expressed: “It is the hardest thing in this life for me to start practising again, I hate it with my whole being.”

Fred had full-blown depression and was expected to put up a brave front. “I was aware that I was depressed, so when I was teaching it was a constant effort to be nice and be jolly and try and crack jokes, because I tend to be funnier when I am depressed. So, it didn’t affect my teaching, my students, they would never … they will never know.” He mentions that it is terrifying to know something is wrong, but you do not know what you should do about it. Fred loves playing the violin, but he says: “When you are in a lot of pain, then it’s not fun anymore; it’s a job.”

Sometimes depression does not only stem from the physical experience of pain but also from emotional pain. Pirastro suffered such emotional pain early in her life after she was insulted by her first violin teacher. Along with other traumas in her life, all of this led up to the depression she has to cope with today. Pirastro said: “I am still relatively young, and it makes me depressed, because normally, a musician can continue their career for much longer than most other people, even if you are old. It was very depressing for me. […] I became introverted, and I don’t talk to people about it. I close myself off to other people.”

Like Pirastro, Teresa also suffered from depression because of childhood trauma, but Teresa’s depression has its roots in an early period of her life when she felt that she had the burden of trying to mend her parents’ deteriorating relationship. This created a false sense of responsibility, as she felt responsible for things that were beyond her control.

Both Teresa and Pirastro mentioned that emotional pain manifests as physical pain at some stage. “I do not say the only thing that causes pain is negative thoughts and feelings, but you have to keep it in mind,” Teresa says. Pirastro adds: “I firmly believe that if you are sad about something, some of it manifests as physical pain.”

Superordinate theme 4: growth through faith and spirituality

The theme of faith and spirituality emerged from two interviews, those with Teresa and Violina. Both Violina and Teresa experienced intense spiritual growth through their injuries. Violina described her experience of pain and the search for treatments as “definitely not a positive one, but what an amazing journey.” “ … the most precious thing that you can cherish in your heart, is to continue to have hope. I mean, life, like I understand it, is not all rosy; after all, there are many thorns in a rose garden, and this was definitely a thorn moment for me. But all the while, it made sense, because I knew that something good would come from this, even if it only was to help other people deal with their own journey of suffering.” Violina mentioned that realizing God wants you to live in prosperity and not adversity is a game-changer.

Like Violina, Teresa went on a powerful journey in her attempt to come to terms with her pain experience. She became depressed after years of physical and emotional pain until she reached her lowest point. During this testing time, she spoke to a friend who advised her to try talking to God. The moment she did this, she says, it was like her depression vanished: “ … it was like my blindfold was lifted; it all vanished, literally in a moment.” She furthermore says that “The pain became a tool to live closer to God. Before that moment I saw pain as a ‘drag’ and something that held me back. I could not deal with it. But now, it is difficult, I don’t deny it, and it is not ideal, but it is not everything in my life, or that I am. Every time I experience pain, it reminds me that I am in a relationship with God, and that he loves me. I can take all my concerns to Him, share it with Him, and walk with Him.” Her pain was no longer an obsession; it no longer defined who she was. It was transformed into a positive experience because it became a means to learn more about God’s grace and support.

Superordinate theme 5: support and lack of support from family, friends, management, doctors and other experts

Three of the participants had strong opinions about healthcare professionals’ lack of awareness and understanding of performance-related injuries. Of the five violinists interviewed, only Batman and Violina felt that they could count on the support of their friends, colleagues and medical experts. Teresa, Pirastro and Fred chose not to talk about their pain with friends and co-workers and were discouraged by their doctors and specialists’ lack of compassion and understanding.

Batman said that his colleagues were “100% understanding” when he had to cancel concerts to have his operations. He also adds that he felt that his healthcare practitioners were well-informed and understood his needs. Violina also had a positive experience with support from her family and band members. Everyone accepted that she could not honour all of their playing commitments, and there were no ill feelings from her colleagues. She also speaks highly of one of her doctors, who took into account that she is a musician and determined that an alternative treatment would be better than an operation.

In contrast with Violina and Batman, Fred, Teresa, and Pirasto felt that being in constant pain and not functioning properly as a musician were not topics that they felt safe discussing with other people. As Pirastro explained: “I don’t talk to people about my pain and problems, who would want to listen to other people’s problems all day long?”

Because of not being able to discuss their pain with colleagues, their only option was to seek the help of medical experts and other healthcare providers, like biokineticists and physiotherapists. They both felt frustrated with most of the medical experts they encountered. Teresa said she thought she had a medical problem and that no one could help her diagnose it. She always felt that she was alone. After a while, Teresa was utterly discouraged because she went for scans, saw different specialists and changed teachers and technique, all without much success. She added that most of the healthcare practitioners she worked with only “applied conventional mainstream knowledge to her particular problem” and, therefore, could not diagnose her problem correctly. Teresa observes that healthcare practitioners working with musicians should realize that most musicians will not just quit playing. It is, therefore, in the majority of cases, pointless to suggest retiring from playing as a viable option. Teresa argued “that any person who works with a musician experiencing pain should be saying: ‘Let’s choose the life that you have and work with it, rather than to break it down.’ When you tell a musician that they have pain because they do this and that wrong, it will only add to the problem. The approach you take should be one of: ‘I will walk this path with you, let’s see what happens if we try this.’”

Pirastro made similar arguments to Teresa: “I am sure that there are doctors who tell their patients ‘Just give up’,” which was exactly the case with Fred. Fred mentioned that this specific doctor was disrespectful and unsupportive as he told Fred: “Just don’t play.” Fred thought: “Yeah right, just don’t play. Are you mad?”

Pirastro continues: “This is ridiculous and the wrong approach to dealing with the performance-related injuries of musicians.” Teresa and Pirastro agree that if the medical professionals can rather accept that the musician experiences pain and that it is a part of them, they can continue to work with the musician to find possible ways to manage to continue to play their instrument and deal with the pain. The fact is that musicians already feel inferior because of their injuries, so it is not productive to be put down by someone who should be helping them.

In contrast with the other participants, Batman’s experience with doctors was positive. He felt that the healthcare practitioners were very knowledgeable and sensitive to his problems, and he only regrets not seeking help sooner. Teresa later also had a positive encounter with a physiotherapist who had novel ideas about working on her injured, sore shoulders and weak muscles and worked out an exercise regimen tailored to her needs. Batman said that one should not “shoot down alternative resources, but have confidence in the mainstream medics and doctors; they know what they are doing.”

Lastly, another essential part of the support theme involves orchestra management. The three participants (Fred, Teresa and Pirastro) who were involved in many hours of orchestral playing complained about the chairs that the orchestras use. Fred stated: “If the profession was to take it more seriously, they would perhaps, and some orchestras do that, they have appropriate chairs for your size, where you can sit with your legs on the ground and your back on the chair, but it has never happened to me in this country. So, I think it is a very serious thing. It’s a simple thing, it is a chair, it’s just a chair, and to take more care, especially in pit orchestras.” Teresa said that after sitting in cramped spaces on chairs that were not designed for orchestral players, her body felt frozen in one specific position, which was not good for her neck and shoulders. Pirastro also complained about constantly experiencing pain when she had to use the chairs provided. Fred added: “I wish care were taken with simple things that can really affect a musician’s health.” He feels like he is just not being heard and adds that if management supplied the correct chairs, this would have an enormously beneficial impact on musicians’ health.

Superordinate theme 6: lack of awareness and understanding of performance-related injuries by musicians

Teresa is passionate about this topic and said that “most people have no idea how big the issue is.” Batman and Violina admitted to knowing almost nothing about performance-related injuries. Violina mentioned that she had no idea that musicians could develop injuries until it happened to her. Batman told of a similar experience: “Do you know what is weird? All these years, I have been playing for 50 years, occasionally, you read about the medical problems of performers, and about five years ago, when I started experiencing this discomfort in my shoulder, I started looking on the internet to see what injuries musicians can develop. I always thought, oh, they have bad technique, or they play with too much tension, and when I looked again, here I am with the same problems.” Batman now has a heightened awareness of performance-related injuries and understands the problems that musicians, even those with good technique, can develop

Violina’s thoughts are like Batman’s, and she emphasizes that musicians do not have enough awareness of performance-related injuries and pain. Teresa added that there is a lack of awareness and insufficient support for South African musicians struggling with pain and stated: “I always felt like I was alone. I lost faith, in medicine, especially with regards to my pain problems and playing without pain. I thought that these people have no idea what they are talking about, they apply broad-spectrum knowledge to a very specific problem.”

Violina said that the divide between classical solo musicians, orchestral musicians and lighter classical performers is unnecessary. Therefore, it is essential to have an open communication channel between musicians of all genres so that they feel comfortable enough to ask for advice and help.

Discussion

The following section will discuss the six themes derived from our findings in light of the relevant scholarly literature.

Playing through the pain

Most musicians who experience pain continue to play, even if they know they are exacerbating their injuries. The findings from this study (Fred and Pirastro) are in line with the scholarly literature: musicians keep their condition secret since it can jeopardize their future work and financial security. Most musicians are also left without options since they need income from their playing.

Not only do they need the income, but they are also passionate about making music. Being passionate about one’s profession is admirable but could, in some cases, be dangerous to musicians’ physical and mental health, according to Paull and Harrison (1997), who also note that it is almost futile to persuade an injured musician to play less when they are focused on a goal. They suggest that we should stop practising if we are not practising mindfully; otherwise, we might injure ourselves.

Lack of identity: who am I if I cannot play the violin?

When music major students were interviewed by Park et al. (2007), they said that the music is “just part of who you are; it’s what you do, and this is who I am, it defines me” (p. 91). The same was found to be true in this study. Four of the violinists interviewed expressed the view that their whole identity would be lost if they could no longer play the violin.

C. A. Guptill (2011) writes about a participant who stated that if she were unable to play the violin, it would be like “cutting off my whole way of communicating” (p. 88). The fact that many musicians base their identity solely on the ability to play the violin points to the potential danger of becoming depressed if they become incapable of playing as a result of injury or pain, which was the case with Fred in our study.

Depression when not being able to play as a result of pain

Teresa, Pirastro and Fred were severely affected by their emotional and physical pain, and all had to find ways to cope with their depression. Pain results in the individual feeling alone, making it difficult to discuss the pain experience with others (Howden, 2008). Therefore, pain is not only a physical response to tissue injury, but it also affects emotional and social reactions (Shipton, 2013). The high number of musicians affected by performance-related pain and depression (Kenny & Ackermann, 2015), and the related stigmatization, are sufficiently alarming to highlight the need to start taking more drastic supportive and preventative steps.

Growth through faith and spirituality

Feeling pain, experiencing a disability and feeling alone are all factors that could drive people to seek encouragement and strength from churches and religious establishments (Lysne & Wachholtz, 2011). Studies on the biology and neurobiology of pain have also shed light on the association between spirituality and pain. According to Dedeli and Kaptan (2013), “Patients with pain use a number of cognitive and behavioural strategies to cope with their pain, including religious/spiritual factors, such as prayers and seeking spiritual support to manage their pain” (p. 1).

Violina’s journey with pain was highly spiritual. Through prayer, she could cope with the obstacles she encountered with her injuries. Teresa had a physical experience when she accepted God as her Saviour and felt her depression lift immediately. Studies have established that prayer and faith in God can positively impact attempts to deal with pain and illness (Dedeli & Kaptan, 2013; Heo et al., 2009). Spirituality and faith could even be integrated into the treatment plan for performance-related injuries and pain (Dedeli & Kaptan, 2013).

Support and lack of support from family, friends, management, doctors and other experts

One of the apparently most insignificant factors in making music is one of the most talked-about dimensions of pain and injury among musicians. The three orchestral players (Fred, Teresa and Pirastro) noted that they had to sit through long rehearsals on chairs that were not designed for orchestral players (Horvath, 2010). Paull and Harrison (1997) emphasize that management should be conscious of the advantages of supplying ergonomically correct chairs to musicians.

Concerning medical practitioners, the participants were frustrated because they felt as if the doctors and specialists could not identify the root of their pain correctly. Kumar et al. (2016) write that it is imperative for medical practitioners to correctly diagnose the source of the pain and the associated illness to decide on the best and most effective treatment or pain-management regime.

Steele (2007) states that if professional musicians were able to consult the right specialist as soon as the pain starts, they would be able to prevent aggravation of existing injuries, reduce the amount of sick leave as well as emotional distress, and limit medical expenses for treatments. Batman mentioned this, as he felt that he was lucky to have been helped by the right specialists fairly quickly. Unfortunately, many musicians have given up on finding a cure (Paull & Harrison, 1997).

Orchestral violinists are more prone than other instrumentalists to develop injuries, as their rehearsal and performance schedules are often particularly demanding (B. Ackermann et al., 2012; Steinmetz et al., 2015). With support from specialists in musicians’ injuries, orchestral musicians could be helped to understand better how to use their bodies correctly when rehearsing for long hours sitting in one position. Teresa added that postural problems improved significantly when she also practised her solo repertoire. This is interesting and valuable information since we did not find anything in the current literature suggesting that more deliberate solo practising is helpful when combined with orchestral playing and repertoire.

Lastly, we would like to mention support from family and friends. Batman and Violina were very open in talking about their pain and injuries with colleagues, family and friends. It seems that they both had a smoother road to recovery than Fred, who chose not to speak about it at all, while Teresa and Pirastro both confided in only one person each. Having support from friends and family when experiencing chronic pain caused by a medical condition improves overall health and morale (Evers et al., 2003; Mawdsley et al., 2015).

Lack of awareness and understanding of performance-related injuries by musicians

Musicians should be mindful of their physical wellbeing to prevent performance-related injuries. Knowledge of possible causes of injuries should become second nature to musicians and educators (Speck, 2009). It is also essential to add that many painful injuries are also caused by failing to stretch and do proper warm-up exercises before a rehearsal or practice session (Speck, 2009), as well as by a lack of frequent breaks during rehearsals (Horvath, 2010). Teresa and Violina confirmed Speck’s (2009) and Horvath’s (2010) findings by highlighting the importance of a proper warm-up before any playing. Teresa and Pirastro both said that their injuries were aggravated while sitting in one position during orchestral rehearsals. Therefore, violinists should have the option of rotating to other seats in the section or even switching sections (Paull & Harrison, 1997).

The first and second authors state from their personal experience that yoga helps manage performance-related pain for violinists and musicians. Phillips and Fenton (2019) write about three analogous elements of yoga and string playing: breath, gravity and the wave. Firstly, by “allowing the breath to lead the movement,” we can systematically release tension in our bodies and experience total freedom of movement (Phillips & Fenton, 2019, p. 56). Secondly, using gravity effectively can take away some unnecessary tension when pressing into the string with the bow hand (Phillips & Fenton, 2019). The third element is “the wave.” Phillips and Fenton (2019) explain that “when the breath leads the movement of the spine, we experience postures not as fixed affectations but rather as shapes through which we continuously flow” (p. 57). Yoga is but one of many beneficial methods that musicians can use as a relaxation technique or as a warming-up or cooling-down tool (Johnson, 2020).

While it is easy to blame many external factors for aggravating our experience with pain, we as musicians need to take more responsibility and educate ourselves on the risks of performance-related pain and the preventative measures available to us. Although discussing performance-related pain is still something musicians tend to avoid, we need to realize that we are not alone. We can create greater awareness of preventative and support measures by talking about it.

Conclusion: implications and future research

The purpose of this IPA study was to explore how professional South African violinists make sense of their lived experiences of performance-related pain. The implication is that, through these narratives, one can create awareness of the plight of musicians who struggle with performance-related injuries and pain. Reading about the experiences of musicians living with pain might open the door to more frank discussions about this subject.

Our study has a number of important implications for various stakeholders. Firstly, violin teachers could incorporate aspects of musicians’ health from the first lesson while teaching and tertiary institutions could educate musicians on how to remain healthy. Secondly, parents should never encourage children to practise when they are in pain. Thirdly, orchestra managers could make simple changes, such as providing ergonomically more appropriate chairs. Lastly, performers should be courageous, speak about their pain, and ask for the help they need. Describing one’s experiences with performance-related pain might encourage other violinists to speak up.

Talking about injuries could set up a platform for future research and prevention programmes, specifically in South Africa, where the phenomena of musicians’ injuries and experience of pain are still not frequently discussed. Inter alia, more topics for future research could include, firstly, the influence that the support of friends and family could have on the wellbeing of a musician that experiences pain, secondly, the effect of prayer and religion on a musician suffering from pain, and, finally, what influence yoga could have on the wellbeing of violinists.

Becoming mindful of the high percentage of musicians who struggle with pain may well be a start towards removing the stigma associated with musicians who battle with injuries. Just because a musician has an injury does not make them a bad or damaged player, and they should not be labelled as such. Most musicians are able to rehabilitate their bodies after their injuries and continue with long and fruitful careers. Creating heightened awareness of musicians’ lived experiences with performance-related pain could bring about much-needed change and serve as advocacy for pain prevention and support for violinists and musicians.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Sharon de Kock

Sharon de Kock, started playing the violin in 1985 as a student of Louis van der Watt and later continued her studies with Jürgen Schwietering and Gina Beukes. Sharon left South Africa to study in the USA at the age of 17 and is a BMus (magna cum laude) and MMus graduate of the College-Conservatory of Music at the University of Cincinnati (CCM) and DMus graduate at North-West University. She studied under the well-known concert violinist Chee-Yun Kim, as well as with Kurt Sassmannshaus, Piotr Milewski and Dorothy DeLay and worked with members of the Amernet Quartet, La Salle Quartet and the Tokyo Quartet. After playing in orchestras and teaching in Mexico and Costa Rica, Sharon returned to South Africa in 2006. She has been a violinist in the Odeion String Quartet and violin lecturer at the University of the Free State since 2008.

Liesl van der Merwe

Liesl van der Merwe is a professor in the School of Music and MASARA at the North-West University, South Africa. Her research interests lie in the fields of music and well-being, positive psychology, music and spirituality, Dalcroze Eurhythmics, and lived musical experiences. Liesl supervises qualitative postgraduate music studies in the field of music education and also teaches research methodology, music education and bassoon. She has published articles in high-impact journals. Currently, Liesl is a National Research Foundation (NRF) rated researcher. She completed the research project: Social Cohesion Through Community Music Engagement in South African Higher Music Education. She was one of the volume editors of the Peter Lang book: Ritualised Belonging: Musicing and Spirituality in the South African Context. Liesl is on the steering and scientific committees of the Music, Spirituality and Wellbeing International Network (MSW) and vice-chair of the scientific committee of The International Conference of Dalcroze Studies (ICDS). She is a guest editor of a special edition on positive psychology and music education in the International Journal of Education and the Arts. She also performs as a bassoonist in chamber music ensembles and is the conductor of the North-West Youth Orchestra.

Catrien Wentink

Catrien Wentink completed her DMus degree in piano performance at the North-West University in 2017 under the guidance of Dr Truida van der Walt. Her focus was on ensemble music and piano accompaniment. In 2009, after postgraduate studies in Youngstown, USA, with Caroline Oltmanns, she received the ABRSM performance licentiate (solo piano) (LRSM) and the Unisa performance licentiate (two pianos) with distinction and was invited to participate in the Unisa bursary winner’s competition. She has been a member of Trio Joie de Vivre since 2018, and together they have performed at numerous festivals. She performs regularly as chamber musician and accompanist. She has worked at the NWU for the past ten years. First, as a lecturer in music education at the Faculty of Education, before joining the School of Music as senior lecturer in music theory in 2016. Her research focus is on Dalcroze Eurhythmics and music theory analysis. Her current research has been on the application of Dalcroze Eurhythmics in different settings (music ensembles, education on tertiary level, and the elderly). She is also actively involved in community work at a care facility for the elderly since 2018.