Abstract
Playing-related musculoskeletal disorders (PRMDs) are highly prevalent among concert pianists due to the unique sociological and historical predispositions of the instrument. Although current literature explores PRMD risk factors in isolation, few studies have explored the complex interdependencies that exist between the procedural and postural practices of pianists. This study aims to reframe this discussion by holistically exploring how common educational principles in phalangeal curvature, wrist flexion range of motion, and technical exercises interact to precipitate in PRMDs. The practices of the Lhevinne and Taubman schools were comparatively evaluated through kinematic studies to discern potential biomechanical stresses, and the findings were compared with current empirical evidence to ascertain links to PRMDs. The findings from this review indicate pedagogical susceptibility patterns may be more nuanced than the claims of stakeholders. However, studies suggest that practitioners of the Lhevinne school should incorporate phalangeal postures with active flexion to reduce susceptibility to tendinitis, osteoarthritis, and carpal tunnel syndrome. Practitioners of the Taubman school should further apply low-intensity technical exercises for warm-ups to increase muscle flexibility and facilitate temperature-related benefits to performance. However, high-intensity exercises at the Lhevinne school such as consecutive intervals and flexibility studies are contrary to current biomechanical observations.
Keywords
Introduction
Pianists and musculoskeletal disorders
Many regard the modern concert pianist as a connoisseur of creative artistry and a priestly gatekeeper of classical masterpieces. Few will regard the profession as hazardous, yet performance at a conservatory standard is an endeavor comparable to a highly athletic discipline (Quarrier, 1993). Historical and sociological predispositions of concert pianists have cemented their vulnerability to many playing-related musculoskeletal disorders (PRMDs), with studies from Allsop and Ackland (2010) demonstrating a 71.5% PRMD prevalence for professional pianists.
PRMDs are injuries of the muscles, nerves, tendons, joints, and cartilage related to piano practice. Although clinical presentations are widely varied, the PRMDs that most acutely affect performance are localized to the wrist, forearms, and fingers. For most pianists, PRMDs rarely arise from a single episode. Instead, injuries materialize through chronic overuse, where microtrauma accumulated over an extended period overwhelms endogenous tissue repair processes (Verdon, 1996). PRMDs are difficult to predict as microtraumas are commonly caused by mechanical loads well within the physiologic range of the musculotendinous structures (Dennett & Fry, 1988). This leaves few presymptomatic markers until the onset of the disease. Pianists suffer from a variety of PRMDs including carpal tunnel syndrome (CTS), lateral epicondylalgia, trigger finger, and De Quervain’s tenosynovitis (Ciurana Moñino et al., 2017).
The pervasive nature of PRMDs can be contextualized by exploring the historical lineage of the piano. Cristofori first proposed a hammer-action grand piano in the early 18th century, introducing an instrument with a greater dynamic character for the private quarters of the aristocracy (Pollens, 2017). Throughout the ensuing century, the creative interests of innovative composers, the advent of virtuoso pianists, and the commercialization of piano performance in large concert venues necessitated an instrument with a superior projection. Consequently, the technical characteristics of Cristofori’s instrument were heavily modified, with key weight substantially increasing by 53% over the next century (Allsop & Ackland, 2010). Although this innovation secured the piano a place as a staple of the Western musical canon, the increased mechanical loads of the modern concert piano may prove difficult to negotiate using traditional pedagogy (Allsop & Ackland, 2010). Hence, the challenging kinematic constraints of the instrument may explain the high PRMD prevalence in the profession.
Although extensive research on PRMDs has been conducted, studies have largely remained retrospective and descriptive. Due to the inherent difficulties of conducting analytical occupational research on pianist PRMDs, studies by Allsop and Ackland (2010), Kaufman-Cohen et al. (2018), and Subsomboon (2017) have remained cross-sectional, relying primarily on recall to self-report risk factors. According to a systematic review by Bragge et al. (2006), weaknesses in these empirical study designs have resulted in female sex being the only significant reported PRMD risk factor. Other studies by Harding et al. (1993) and Oikawa et al. (2011) have explored PRMD risk by analyzing the isolated mechanical loads of fingers and wrists for common piano postures, but the interaction between ergonomic principles is seldom explored. This is problematic, as pianists cannot “hot-swap” biomechanics due to intricate interdependencies, an example being wrist posture that is dependent on arm and finger support. Thus, there is inherent merit in collating the evidence from kinematic studies to holistically explore PRMD risk factors from the perspective of the concert pianist, whereby the complementary postural and procedural methodologies of influential pedagogues will be comparatively deconstructed in the context of PRMD susceptibility.
Common postural practices in piano pedagogy
Traditional piano methods are largely divorced from scientific methods, instead relying on the idiosyncratic practices of famous concert artists and teachers. Hence, the isolated spheres of influential pedagogues have created a wide degree of variation in standard technique. To illustrate the effect of pedagogy on differential PRMD risk, this review will explore two influential piano schools with contradistinctive pedagogical approaches: the Lhevinne and Taubman schools.
The Lhevinne school was developed by Rosina Lhevinne, a Russian-born pianist who taught at the Juilliard school. The Lhevinne school emphasizes the use of arm weight and relaxation to produce a full, rich tone at the piano: the weight of the arm should be used to produce a deep, resonant sound, and tension in the hands and fingers should be avoided (Neuhaus, 1993; Whiteside, 1969).
The Taubman school was developed by Dorothy Taubman, an American pedagogue who taught at the Taubman Institute of Piano. She emphasizes the use of efficient movement and alignment to produce a clear, even sound at the piano. According to Taubman, the natural movements of the body should be used to produce a smooth, flowing sound, and anatomical principles are integrated to optimize physiological loads to minimize injury (Larimer, 2000; Mark et al., 2003).
Although the pedagogies differ significantly in many postural and procedural methods, this review will explore pedagogical differences in phalangeal curvature, wrist flexion, and warm-up exercises. These variables were selected through a preliminary review of current evidence, where the musculotendinous structures affiliated with the biomechanics were affected by highly prevalent PRMDs (Kaufman-Cohen et al., 2018; Subsomboon, 2017; Wristen, 1998). These variables are also representative of the pertinent differences between the two keyboard schools and are areas of significant variation and contention in the contemporary piano landscape.
Phalangeal curvature
Lhevinne. As cited by Lhevinne’s student John Browning, Lhevinne advocated for keystrokes to occur in the mid-shaft of the distal phalanx (DP) to allow the softest part of the finger to contact the keys. To accommodate this posture, some practitioners apply a conservative phalangeal arch (Lhevinne, 1972; Uszler, 2008). Others may elect to maintain some phalangeal flexion by incorporating wrist extension (dorsiflexion), as discussed below. In this review, a combination of both adaptations is considered for comparative analysis.
Taubman. A central tenet of the Taubman approach encompasses the joints acting as near to their mid-range of action as possible to minimize joint loads and fatigue (Taubman, as cited by Milanovic, 2011). Consequently, an extensive phalangeal arch is employed, where all interphalangeal and metacarpal phalangeal joints are flexed. The distal aspect of the DP contacts the keys, and the carpals and DP are perpendicular (Ortmann, 1929).
Wrist extension (dorsiflexion)
Lhevinne. Lhevinne advocated for weight-playing, to both reduce injury and produce a rich tone. Weight-playing required the forearm to be supported by the phalanges and the wrist hanging loose off the keyboard, resulting in dorsiflexion (Lhevinne, 1972). Lhevinne’s method may be best described as a “closed-chain” technique; the wrist and the forearm function as a “suspension bridge,” supported at the termini by the shoulder and the keyboard (Kibler & Livingston, 2001; Kochevitsky, 1995).
Taubman. Taubman argued that active muscular control of the playing apparatus facilitated greater tonal control (Ortmann, 1929; Whiteside, 1961). A key Taubman principle was the maximization of mechanical advantage, where the wrists must linearly function with the forearm as a fulcrum to transmit downward forces (Ortmann, 1929). This is more analogous to an open-chain kinematic, where the radiocarpal joint is actively stabilized (Kibler & Livingston, 2001). To maximize the leverage of the fulcrum, the carpals are linear with the ulnar (Taubman et al., 1995).
A graphical representation of the upper arm postures discussed in this review is represented in Figure 1. It should be noted that the postural variables have been accentuated to clearly differentiate between the two schools. The postures of concert pianists are dynamic and may deviate significantly from the figure according to the demands of the repertoire.
Photograph Depicting Postures of the Taubman (a) and Lhevinne Pedagogies (b).
Technical exercises
Exercises are purely mechanical note patterns divorced from musical content, which are specific to one technical skill (Wristen, 1998).
Lhevinne. Lhevinne promoted a diverse range of technical exercises to complement repertoire. Technical exercises were central to warm-up, including the implementation of scales and arpeggios at a moderate tempo in the initial stages of practice (Adderley, 2006). Lhevinne also introduced advanced exercises such as consecutive interval exercises for greater proficiency in finger independence and flexibility (Uszler, 2008).
Taubman. Taubman strongly disagreed with Lhevinne, stating exercises were a “waste of time,” because they were a poor substitute for technically interdependent repertoire. Independence exercises were posited to increase tension and susceptibility to injury and even passive exercises such as stretching were discouraged (Taubman et al., 1995).
It is important to note the inherent variability within both schools according to the practices of the individual teacher. Furthermore, posture is dynamic according to the requirements of the repertoire and the practitioner’s physiology. However, the foundational differences in sound production between the two schools will precipitate markable differences in postural and procedural practice, potentially leading to differential PRMD risk.
To the authors’ knowledge, no studies have thoroughly investigated the relationship between different pedagogical techniques and injury. Hence, the purpose of this study is to evaluate the doctrines regarding phalangeal curvature, wrist position, and technical exercises of the Lhevinne and Taubman pedagogies in terms of PRMD susceptibility. The musculoskeletal burden, resultant of the pedagogical ergonomics, will be explored, and potential links to common PRMDs will be established where possible. The findings from this analysis will allow music educators to proactively identify and resolve PRMD risk factors associated with their teaching methods, and allow performers to holistically appraise the vulnerabilities in their technique.
Methodology
To review the relevant literature, search engines such as Google Scholar and PubMed Central were used. Search terms such as “posture,” ‘musculoskeletal, “injury,” and “technique” were used to gather preliminary evidence and the “. . . AND pianists” Boolean restricted PRMD literature to studies investigating pianists. As there were limited studies directly establishing a causative relationship between pedagogy and pathology, transitive logic was applied. This involved first investigating the biomechanical variability of pedagogy through kinematic studies and exploring the effect on tendon and joint loads. Then, the scope of the literature review was broadened to include other empirical studies that investigated the relationship between biomechanical variables and injury. To further develop the breadth of the review, notable citations of systematic analyses and prior reviews were explored. Secondary search terms such as “dorsiflexion epicondylalgia” and “finger osteoarthritis risk” were used to investigate similar biomechanics in other occupational settings including sewing, typing, and sports. The methodology of the occupational literature was analyzed to evaluate the external validity in relation to pianists, which primarily involved force vector analysis and corroboration, as well as postural concordance with that of concert pianists.
Results
Table 1 outlines a synopsis of the literature and their respective findings. This review included biomechanical studies that produced mathematical models of phalangeal ergonomics. To establish injury risks, various empirical studies among pianists and in other occupational settings were explored. All sources contributing quantitative evidence have been categorized alphabetically, and the context and key findings of each study are briefly outlined.
An Overview of the Reviewed Sources.
PRMD: playing-related musculoskeletal disorder; OR: odds ratio.
Discussion
Part 1: Phalangeal curvature
Phalangeal biomechanical loads can be subdivided into two parts: the dynamic isotonic contraction of the fingers when initiating key depression, and the static isometric contraction to support the upper arm after key depression.
Dynamic loads
Harding et al. (1993) developed a kinematic model to investigate the dynamic loads required in key depression. The study modeled the phalangeal joint and tendon loads that were generated by a trilling motion of the index finger at 2.5 key strikes per second. Mathematical modeling techniques were used to predict the mechanical forces exerted on the distal interphalangeal (DIP), proximal interphalangeal (PIP), and metacarpophalangeal (MP) joints as well as the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and intrinsic (INT) muscles. Twenty common piano postures with differing finger flexion angles were trialed, where phalangeal postures ranged from an extended Lhevinne posture (Figure 1[b]) to a flexed Taubman posture (Figure 1[a]).
Figure 2 demonstrates the changes in tendon tension and joint forces as the phalanges are flexed. A prevailing trend for tendon tension was difficult to observe, but an aggregate decrease was observed as the phalanges were flexed. From extension to moderate flexion, FDP tension remained relatively constant, FDS tension declined, and sporadic increases in INT loads were observed. For full flexion, a precipitous decrease in FDP loads was observed, and the FDS and INT loads exhibited a compensatory increase. This was particularly interesting, as the results suggest periodic posture changes between moderate and full flexion could reduce chronic flexor tendon overuse in long practice sessions by activating different muscle groups.
Phalangeal Joint and Tendon Forces as a Function of a Normalized External Force During Isotonic Contraction.
A consistent trend with joint forces and stresses were observed. The MP joint consistently demonstrated the highest joint forces as it is most proximal to the articulation point. A parabolic trend was observed for the MP and DIP, where moderate flexion exhibited the greatest mechanical loads. By contrast, the PIP exhibited a consistent decrease in load as flexion angle increased. All joint loads were lower with the Taubman school relative to the Lhevinne school, supposedly due to the greater phalangeal pivot distance of the latter requiring greater torque. When the combined loads from tendons and joints were considered, Taubman produced 28% lower joint loads and 20% lower tendon tensions than Lhevinne for a similar force exerted by the finger. This exemplifies the importance of flexed phalangeal posture.
The primary limitation of the study was that only index finger loads were measured: differing anatomical characteristics and moment arms of other fingers limits the extrapolative ability of the kinematic model, compromising the external validity of the study. Another major limitation was the two-dimensional kinematic modeling, where only sagittal forces were considered. Piano playing involves extensive adduction-abduction movements, which engage intrinsic flexors and extensors (Brook et al., 1995). However, the strength of the association, as well as the congruence of physical attributes regarding rotational motion, suggests the Taubman school induces a lower dynamic load than the Lhevinne school.
Static loads
In addition to dynamic biomechanics, static loads were also considered. The consideration of static loads is particularly important for Lhevinne, as the closed-chain weight-playing technique necessitates the phalanges supporting the forearm. By contrast, the open-chain Taubman posture does not demonstrate the same dependency, as forearm stabilizers mechanically support the phalanges. No study to date has modeled static loads for piano performance. However, Weightman and Amis (1982) investigated static pinching loads for finger prosthetics. The study measured the muscle activity and joint forces of oppositional pinching postures which resembled the phalangeal flexion angles in pianists. The postures varied in phalangeal flexion angles in a similar manner to Harding et al. (1993).
Figure 3 demonstrates how isometric joint forces and muscle loads are strongly inversely correlated with phalangeal flexion. The perpendicular DP characteristic of Lhevinne’s pedagogy produced joint loads on the DIP, PIP, and MP that were greater than any other posture. This was likely due to the greater moment of inertia required to counteract forces when the radius from the MP pivot was increased. Similar to Harding et al. (1993), a prevailing trend regarding muscle loads was difficult to observe but all muscle loads except for the INT observed a net decrease as flexion angle increased. This suggested the Lhevinne school imparted greater static muscle activity than the Taubman method.
Phalangeal Joint and Tendon Forces as a Function of a Normalized External Force During Isometric Contraction.
A major limitation was that the study did not consider phalangeal postures of pianists: the Taubman method was not adequately represented by any of the five postures explored. For similar reasons, realistic musculoskeletal loads were not considered as the model did not consider the added effects of the closed-chain posture of Lhevinne. However, it could be conjectured the added joint and muscle loads associated with the higher total loads of the Lhevinne school may be substantial.
Despite the biomechanical differences between isometric and isotonic contractions, the overall findings from both studies are agreeable. The strength of the evidence is further corroborated by previous biomechanical studies by Chao and An (1978) and Smith et al. (1964), where agreeable findings were published despite differences in mathematical modeling techniques. The consistency of the literature strongly supports the notion that there is a significant causal association between phalangeal extension and higher joint and tendon loads.
Implications for injury
A cross-sectional study by Armstrong et al. (1987) determined that increasing phalangeal loads in high-repetition workloads increased tendinitis risk by 310% (p = .15). However, the study investigated an occupational environment with higher loads and cycle times relative to pianists, thereby limiting its external validity. A “healthy worker” selection bias may also be evident, as tendinitis patients may be unable to continue working in manual labor fields, causing an underestimation of the OR (odds ratio). Thus, the study suggests the higher tendon load typical in the Lhevinne school is associated with tendinitis, but the significance cannot be examined with any quantitative certainty.
Tendinitis is problematic, as all finger flexor tendons pass through the carpal tunnel (CT). The CT is located on the anterior wrist, where three sides are bound by carpal bones, and the palmer side is sealed by the transverse carpal ligament (Katz & Simmons, 2002). As the soft tissue volume is only slightly less than the tunnel, tendinitis can result in elevated pressure in the CT (Verdon, 1996). The increased pressures result in ischemia of the median nerve, which also passes through the CT. As the median nerve is 94% sensory, dysfunction causes sensory changes such as paraesthesia and pain (Verdon, 1996). This is debilitating for pianists, as the sensory abnormalities are commonly referred to as the digits.
Increased phalangeal joint loads have also been implicated as risk factors for finger osteoarthritis (OA). A cross-sectional study by Hadler et al. (1978) investigated finger OA susceptibility of textile workers with highly repetitive cycles, concluding the odds of OA significantly increased with phalangeal overuse. A limitation of the study was the small sample size (n = 29) and that previous co-morbidities were not assessed, leading to weak internal validity and an inability to establish causality. However, prospective random control trials have affirmed the correlation between joint loads and knee OA, reinforcing the biological plausibility of the phenomena (Messier et al., 2009). Thus, the Lhevinne school may be more susceptible to finger OA due to higher phalangeal joint loads, but empirical evidence for pianists has not yet been explored.
Part 2: Wrist flexion
During key depression, the wrist flexors act as fast agonists that provide downward force, whereas the extensors act as persistent wrist and hand stabilizers (Oikawa et al., 2011).
Wrist extensors experience greater mechanical stresses due to the muscular force of wrist flexors being stronger (Goubault et al., 2021; Singh & Karpovich, 1966), and the need to exert an upward force against gravity to stabilize the wrist (Goubault et al., 2021). Hence, this review will investigate wrist extensor activity in evaluating PRMD risk. Extensor activity was hypothesized to differ according to two pedagogical principles: weight-playing and dorsiflexion.
Weight-playing
Lhevinne’s weight-playing technique actively aims to reduce wrist tension by discouraging forceful playing, where pianists are instructed to “sink” into the keys through arm weight (Chang, 1994). van Elk et al. (2004) explored the effects of weight-playing on wrist extensors, where the effects of an external wrist extension force simulated the upward key force on the hand. The subjects were secured to ensure upper arm muscles did not actively support the arm. The study demonstrated that wrist extensor activity decreased when external extension forces were increased at 15° (p = .001), implying that the keys imparting a wrist extension force in weight-playing would decrease muscle strain over time. A major limitation of the study was that the subjects were examined while 90° supinated, compared to the pronated posture of pianists. This may have impacted electromyography load observations, limiting the external validity with regard to pianists.
Dorsiflexion
Another distinctive feature of Lhevinne’s pedagogy is wrist dorsiflexion, as opposed to the neutral wrist of the Taubman technique. Oikawa et al. (2011) investigated the impact of wrist dorsiflexion on wrist extensor activity. The study analyzed the electromyography readings of neutral wrist postures followed by extensive dorsiflexion. The study suggested oblique wrist postures induced higher stabilization loads onto the extensor muscles in louder dynamics. ANOVA of electromyography readings determined that extensors experienced significantly lower %MVC (maximum voluntary contraction) in neutral postures compared to the dorsiflexed alternatives at mezzo-forte and fortissimo, but not at pianissimo. A limitation of the study was that it investigated muscle loads using octave passages. This may have overestimated wrist extensor activity as octaves require significant wrist articulation compared to most monophonic passages.
These studies provide a complex understanding of extensor loads produced by differences in wrist postures. Closed-chain weight-playing is commonly touted to reduce wrist burden as the support from the fingers is speculated to reduce wrist stabilizer loads (Chang, 1994). This was largely reflected in literature, where external wrist extension forces reduced wrist extensor loads. However, the wrist dorsiflexion, resultant of the same technique, resulted in higher extensor stabilization loads. It was interesting that a side-effect (dorsiflexion) of a piano technique specifically designed to reduce muscle loads imparted antithetical effects. The findings from this review echo the previous observations of Kryzhanovsky—a musician and medical professional who specialized in pianist PRMDs. As cited by Tchernik (2017), Kryzhanovsky stated it would be “mistak[en] to conclude. . . the hands should be relaxed like rags. On the contrary, at certain moments, there is more muscle contraction and fixation of the joints than in playing by other methods”. As no current studies have explored both components simultaneously, there is limited understanding regarding the relative magnitudes of these antagonistic effects. Hence, the theoretical literature is currently inconclusive regarding the wrist loads of the pedagogies.
Recent empirical studies by Latz et al. (2019) have also suggested that wrist angle modulates phalangeal mobility from the MP joint. Although a universal trend was not observed for every phalanx, flexion/extension movements were better facilitated with a neutral wrist posture, and ulnar/radial deviation movements were better facilitated with 80° wrist flexion. Although increased lateral mobility may be beneficial in piano practice, the extreme flexion angles required for significant improvements are unrealistic for implementation. Overall, it is evident that neutral wrist postures provided the most extensive three-dimensional wrist mobility, indicating Taubman practitioners may experience a lower incidence of upper limb strain over time.
Implications for injury
Cross-sectional studies have investigated the wrist postures typical of Lhevinne’s pedagogy compared with the Taubman techniques, but the current understanding of PRMD susceptibility is inconclusive. Subsomboon (2017) (n = 219) explored the PRMD risk of weight-playing as opposed to neutral wrist positioning. PRMD prevalence among pianists with a neutral wrist (76.4%) was significantly lower (p = .021) than among pianists who used weight-playing (83.3%). However, another study by Allsop and Ackland (2010) (n = 349) refuted this claim, where practitioners of the weight-playing technique reported significantly lower PRMD prevalence (26.8%) relative to those who practiced neutral postures (30.6%) (p < .01). The study attributed the association to lower extensor loads due to the mechanical support of the phalanges.
The contradictory nature of this evidence may be due to inherent weaknesses in study designs. Both studies were conducted as self-questionnaires with poor case definitions, where no biomechanical classifiers were used to specify the definition of weight-playing. This may have induced uncontrolled variability as practitioners may synonymously classify different biomechanics due to the idiosyncratic nature of pedagogies (Wristen, 1998). The selection criteria for both studies were poor, considering only practicing pianists. This may have induced selection bias, where pianists who no longer participated due to PRMDs were excluded, causing an underestimation of PRMD prevalence. Thus, given the weak epidemiological strength of the cross-sectional studies and the contradictive findings, it is not possible to provide a conclusive determination of differential PRMD risk.
However, Kaufman-Cohen et al. (2018) did corroborate the theoretical modeling of Oikawa et al. (2011), where a significant association was determined (
Overuse of wrist extensors is particularly important in examining lateral epicondylalgia, which is the most prevalent PRMD among pianists (Sakai, 2002). Wrist extensors have a common origin in the lateral epicondyle of the humerus, and excessive stresses cause maladaptation in the tendon attachment point. Repetitive overuse and higher transient loads of wrist extensors have been observed to increase lateral epicondylalgia risk by 190% and 160%, respectively (van Rijn et al., 2009). Hence, the higher electromyography readings of dorsiflexion suggest that it is a likely risk factor for lateral epicondylalgia.
Wrist deviation from a neutral position has also been associated with CTS. Passive wrist flexion and extension resultant from closed-chain relaxation increased CT pressure by up to ten-fold (Gelberman et al., 1981), with dorsiflexion as acute as 15° being associated with increased CT pressure (Rempel, 1995). Elevated tissue pressures cause intraneural ischemia to the median nerve, precipitating CTS (D’Arcy & McGee, 2000). However, this effect is yet to be empirically demonstrated in a cohort of pianists.
Part 3: Technical exercises
Technical exercises are analogous to drill exercises in sports, where a specific skill is targeted for improvement. The aversion of the Taubman method toward technical exercises is both physiological and psychological, where repetitive mechanical exercises were conjectured to distract from productive practice and result in unneeded musculoskeletal strain (Newman, 1974; Taubman et al., 1995). While the de-emphasis of technical exercises may have been intended to stimulate musicality, there may be potential implications for injury. The primary benefits cited by proponents of technical exercises regarding PRMDs are those of controlled warm-up, greater flexibility, and finger independence (Chang, 1994; Lhevinne, 1972). Although the pathophysiological implications of these claims are seldom explored in music, the subject is well-established in sports literature.
Warm-ups
Warm-ups in sports physiology are diverse practices, with athletes incorporating varied sets of exercises to elevate performance. Technical exercises in the form of Czerny and Hanon etudes are most analogous to “specific warm-ups” in sports, where the musculotendinous structures localized to the subsequent performance undergo controlled exertions at a lower intensity (Sá et al., 2016). The application of these exercises is well known to enhance local temperature-dependent biomechanics. Controlled warm-ups optimize aerobic metabolism in tissue, where temperature elevations increase the enzymatic reaction rate in the mitochondria (Fangue et al., 2009). Combined with the lowered viscosity of the muscle protoplasm (Shellock & Prentice, 1985), warm-ups increase the mechanical efficiency of muscle contractions, resulting in less “sluggish” sensations during performance. Furthermore, elevated temperatures induce local vasodilation, allowing for greater oxygen delivery and removal of metabolic by-products (Taylor et al., 1984). The increase in oxygen delivery is compounded by the molecular properties of hemoglobin, where increased temperatures induce more rapid and complete oxygen dissociation (Weber & Campbell, 2011).
Flexibility
Technical exercises were touted by Lhevinne to offer physiological benefits beyond warming up, where repeated phalangeal abduction was conjectured to improve flexibility. These bespoke “stretching exercises” were heavily prescribed to assist in technique development, where arpeggiated exercises were developed to emulate the technical demands of repertoire (Lhevinne, 1972). The passages facilitated brief phalangeal abduction, intending to increase hand dexterity and range of motion. However, the touted benefits are contradicted by current evidence.
When a muscle is stretched, stretch receptors termed muscle spindles cause reflexive, resistive contraction of the muscle. This causes a momentary increase in muscle tension (Edin & Vallbo, 1990). If the muscle is continuously stretched for over 6 seconds, proprioceptive Golgi organs in the tendons override the muscle spindles, causing reflexive relaxation. The relaxation lengthens the muscle and allows for effective stretching with minimal injury risk (Prentice, 1983). However, the transient forces of the arpeggio do not provide continuous lateral forces on the phalanges, disallowing the Golgi relaxation reflex to occur. Furthermore, the jerking stresses cause repetitive activation of the muscle spindles, leading to continuous contractions of the muscle and increased tendon strains. It could also be argued that the discontinuous, repetitive strains imparted by the keystrokes resemble ballistic stretching. This technique is widely considered unfavorable as the jerking motions may exceed the extensibility limits of tissue, causing higher risks of injury (Shellock & Prentice, 1985). As established previously, the high transient stresses in the phalanges may be implicated in tendinitis.
Finger strength and independence
A core principle of the Lhevinne school is the centrality of technical exercises in developing the finger strength and independence necessary to undertake complex repertoire. Exercises such as consecutive thirds and sixths are contentious in pedagogy due to both antagonistic motion of adjacent phalanges and deviation of the radiocarpal joint. Taubman claimed the antagonistic motion of extensors and flexors caused excessive tension and pain. Her claims were supported by Leijnse et al. (1993), who conducted a kinematic study of the anatomical restrictions of two adjacent phalanges. As the muscles controlling flexion and extension are shared among the digits, the study demonstrated inherent anatomical shortcomings in executing antagonistic motion. A determination was made that finger independence was invariant of exercise, making the prospect of finger independence exercises largely irrelevant.
It is therefore evident that both schools articulate valid perspectives regarding technical exercises. While the application of controlled warm-ups may increase the physiological performance of local tissue, the production of high stretching forces or antagonistic motion was largely found to be ineffective and potentially injurious.
Implications for injury
Technical warm-up may serve as a protective factor against numerous PRMDs. Muscle elasticity is dependent on blood saturation and temperature, where cold muscles with poor blood saturation are more susceptible to damage than muscles that have performed warm-ups (Asmussen et al., 1976; Shellock & Prentice, 1985). Furthermore, warm-ups increase the range of motion of the phalanges, as temperature elevations increase the elasticity of tendons and ligaments. This reduces the risk of connective tissue damage resultant of tissue overexertion (Petrofsky et al., 2013). These factors are particularly important for pianists given the acute, vigorous blows imparted by the keyboard and the requirement of significant phalangeal articulation.
Similar to empirical studies investigating wrist loads, literature investigating technical exercises has employed poor case definitions and suffers from numerous methodological limitations (small sample sizes, no randomization, voluntary selection, no control group) (Fleet, 2021). For example, Yoshimura et al. (2008) determined a positive association between warm-ups and PRMDs among music teachers. However, the sample size was small (n = 47) and voluntarily self-selected, and the study factor was ascertained retrospectively through a questionnaire. Furthermore, the study did not adequately define “warm-ups,” and 95% of respondents self-defined their warm-up as a stretching routine. The association may also be attributable to reverse causation, given that injury-prone participants could have incorporated stretching to prevent repeat incidences.
While protective factors have been observed in sports, the applicability to pianists is inherently dependent on the external validity of warm-up exercises. Current empirical data for pianists has been inconclusive due to limitations in methodological design. However, there is theoretical evidence supporting the controlled application of low-intensity warm-up technical exercises in reducing PRMDs.
Limitations
The primary limitation of the present review was the binary classification of pedagogies. Although the Taubman and Lhevinne schools significantly differ in their approaches to posture and technical exercises, they do not represent the entire heterogeneity of contemporary piano pedagogy. Even within the domains of each pedagogy, techniques evolve according to the idiosyncratic teachings of practitioners, making monolithic comparisons difficult to undertake. Pianists also constantly adapt their postures according to repertoire, and many concert pianists elect to dynamically alter phalangeal and wrist postures to better negotiate passages. Furthermore, recent globalization and the mass democratization of visual media resulted in pianists employing combinations of pedagogies (Rutkowska, 2018). Although the pedagogical principles outlined remain influential in today’s music landscape, these limitations reinforce the need for practitioners to individually self-evaluate their technique.
Furthermore, the consequences of weight-playing may extend beyond the wrist and impart stresses on shoulder stabilizers. The pedagogical differences also extend to tuition methods, as well as practice strategies, psychological practices, and the duration and intensity of practice regimens—all of which have plausible links to overuse pathologies (Chang, 1994; Kenny & Ackermann, 2015; Rutkowska, 2018; Wristen, 1998). However, the scope of this review was restricted to three biomechanical variables due to limited empirical and theoretical research on other variables.
This review is also predicated on the external validity of various occupational studies, where findings were extrapolated from workplaces with similar biomechanical motions. Given this limitation, the predictive capacity of this review is limited without further research on piano-specific biomechanics.
Conclusion
The PRMD susceptibility of the Lhevinne and Taubman schools was comparatively evaluated in terms of phalangeal curvature, wrist flexion, and technical exercises. The extended phalanges of the Lhevinne school resulted in significant increases in tendon and joint stresses relative to the Taubman school. These biomechanical loads may place Lhevinne school practitioners at increased risk of tendinitis, carpal tunnel syndrome, and osteoarthritis. The closed-chain weight-playing method of the Lhevinne school significantly decreased wrist extensor loads, but the dorsiflexion common resultant of the method increased the stabilizer action of the wrist extensors. While empirical evidence linking weight-playing to injury has been inconclusive due to poor study design and confounding variables, dorsiflexion in isolation may exasperate PRMDs such as joint pain, lateral epicondylalgia, and carpal tunnel syndrome. Theoretical literature suggested both schools articulated valid perspectives regarding technical exercises: technical exercises were protective against injury when used as warm-ups, but stretching and independence exercises were largely ineffective and potentially injurious. This supports the importance of low-intensity technical exercises such as Hanon etudes before strenuous practice.
This report suggests that the PRMD susceptibilities of the Lhevinne and Taubman pedagogies are more nuanced and multifaceted than the claims of some practitioners. However, an inherent antagonism between health and virtuosity was discernible in both schools, where the quest for musicality in the form of tonal production or warm-up procedures may have impinged the long-term well-being of the artist. This may be considered a symptom of a wider dilemma in contemporary music education, where generations of idiosyncratic teachings may have instilled a culture of tuition that is largely divorced from evidence-based practice. To protect the future health outcomes of musicians, educators must proactively engage in academic literature and promote evidence-based practice in their teaching.
Future directions for research
The current state of empirical evidence of PRMDs indicates a need for further exploration into epidemiological study design principles, to help strengthen methodological approaches and minimize selection and information biases. Furthermore, future empirical studies should stratify participants by pedagogical principles to establish direct associations between pedagogy and PRMD risk. This would further strengthen the findings of this review beyond a transitive relation.
Although this review characterized common pedagogical practices, an inquiry into common postural errors in formative practice may be valuable given the recent mass-democratization of music teaching media. Associations between common postural misconceptions and the eventual precipitation of PRMDs may be informative for teachers who engage with a student population with contradistinctive postural assumptions compared to traditional students.
Furthermore, pedagogical PRMDs could also be explored in terms of repertoire. The historical advancement of the piano has facilitated repertoire with highly varied techniques and ergonomic adaptations. As pianists must master period-diverse repertoire, it may be beneficial to determine the optimal pedagogical techniques for each period.
Footnotes
Acknowledgements
The authors thank Professor Mark Forwood, Dr Diana Tolmie, and Mr Nigel Bardsley for providing guidance in the initial draft of this review.
Correction (September 2024):
Article updated to correct the article type from “Perspective Article” to “Research Article”.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Author biographies
References
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