International Journal of Ergonomics
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Vol. 49, No. 3, 22 February 2006, 316-322 Taylor and Francis Group
Hand and arm problems in flautists
and a design for prevention
S. KOPPEJAN, C. J. SNIJDERS*, T. KOOIMAN and
B. VAN BEMMEL
Erasmus MC, University Medical Center Rotterdam, Dept. of Biomedical Physics and
Technology, PO Box 1738, 3000 DR Rotterdam, The Netherlands
Hand and arm problems are frequent in flautists. Severity is greatest in professional
players, which can result in being unable to work. Based on a
biomechanical analysis a support for the right hand was designed, which can
be easily clipped on to the flute. Tests by professional flautists demonstrated
that the right hand thumb support prevented rotation of the flute about its
longitudinal axis. The latter reduces tension in forearm, wrist and fingers. This
is the most important result of the study, which led to the introduction of the
right hand thumb rest on the market.
Keywords: Flute; Flautist; Biomechanics; Injuries; Ergonomics; Pain
The flute is an important instrument used as a solo instrument and in orchestras. The
form is classic and dates from the Middle Ages (Sadie 1988, Pinksterboer 2000). The flute
is carried on the right side of the body. Both hands of the musician are used to operate the
keys and also for support and positioning of the flute against the mouth. This, however,
requires an asymmetrical position with extreme excursion of the wrist and fingers.
Combined with other burdening factors, this results in complaints reported in literature
(Blum 1995, Larsson 1993, Winspur and Wynn Parry 1998); for example, compression of
the radial and ulnar nerve, carpal tunnel syndrome, focal dystonia and arthritis.
Contributory factors to complaints are stress, wrong posture, environmental factors, etc.
Several propositions have been made to solve the postural problems by changing the
design of the flute (bend head joint, lengthened keys, mechanism for the right-hand keys
placed on the opposite side of the flute; Samama 1981, Chamagne 1998). These, however,
were not accepted by the musicians, presumably because change of the classic form is not
Vol. 49, No. 3, 22 February 2006, 316-322
ISSN 0014-0139 print/ISSN 1366-5847 online ª 2006 Taylor & Francis
The aim of the present study was to prevent muscular skeletal injuries in flute-players
by easing the hand upper extremities. Retaining the classic design of the flute is hereby a
2. Biomechanical analysis
The mass centre of gravity is positioned asymmetrically with regard to the central axis of the
flute. Therefore, the flute tends to turn over and the fingers must prevent this (figure 1).
The main support points of the flute are the metacarpo-phalangeal joint of the left
index finger and the end phalanx of the right thumb. The embouchure is used only for
blowing the flute. It cannot be used as a support, because minimal forces on the lips will
influence the sound.
During playing there is one situation in which only the metacarpo-phalangeal joint of
the left index finger and the right thumb are supporting the flute. (Most of the time more
fingers grip the flute.) When a change of octaves occurs, all fingers, except the right
thumb, change position. This is the moment the flute tends to turn over. The joint of the
left index finger and the right thumb cannot counterbalance the gravitational forces,
because the surface of the flute is too smooth. As a result, the left-hand index finger and
right-hand thumb show compensating behaviour (figures 3 and 4).
The metacarpo-phalangeal joint of the left-hand index finger is pushed further
underneath the flute. The moment the force of the index finger produces is reversed. It no
longer adds to the moment of gravity, but counterbalances it (figure 2c).
The right-hand thumb is pulled further upwards along the side of the flute to increase
the moment directed against the gravitation (figure 2c).
The neutral position is the position of the arms, hands and fingers at rest. All muscles
are relaxed and no harm can be done to the structures (Greenberg 1977, Stanton 1998).
Consequently, this position should always be approximated when playing the flute.
However, this is not realistic, because the left hand cannot support the flute at the site of
the metacarpo-phalangeal joint. Therefore the photos in figure 2a are only used as an
ideal image to compare with.
The effects on the left-hand index finger (figure 3) and on the right-hand thumb (figure 4)
are similar. First, when the hand shows compensating behaviour, the distance a (lever)
increases. This means that the moment caused by the force of the flute on the wrist (left
hand: F6a¼Ffl6b, right hand: F6a¼Fex6b), respectively the metacarpo-phalangeal
joint (left hand: F6a¼Ffl6c, right hand: F6a¼Fex6c) increases. The left-hand flexor
and the right-hand extensor must deliver more counter force for equilibrium. Therefore,
the muscles are excessively static (Snijders 2001).
Second, the wrists are extended in the extreme compensating position. The tendons
move tightly along the carpal bones of the wrist and are more vulnerable to injuries. This
Figure 1. Flute turning over by gravitation. Statical force analysis showing the eccentric
position of the gravity force (Fz) acting at the mass centre of gravity of the flute.
Hand and arm problems in flautists 317
explains another effect found in the left-hand index finger. The tendons in this finger are
tense in the normal position. They become more tense in the compensating position,
because the finger is more extended. The flexibility of the finger decreases and operating
the keys becomes more difficult.
During playing, the change of octaves occurs often. Therefore, the normal and the
compensating position alternate and blend. This means that the increased strain on the
muscles and tendons caused by the compensating position is more stationary.
Another effect is the increased risk for injuries of the right little finger. Most of the time
the little finger is pushing a lever and therefore supporting the flute. Due to the constant
change of stability and instability, the force on the little finger is continuously increasing
and decreasing, as well as the strain on the tendons.
The muscles in the right hand are cramped due to the thumb showing compensating
behaviour and the little finger trying to balance the flute.
Figure 2. Compensating behaviour of the left-hand index finger and right-hand thumb,
(a) compared to normal (b) and theoretically neutral (c) hand position. Statical force
analysis showing the gravitational force (Fz), the force of the right-hand thumb (Fr) and
the force of the left index finger (Fl) acting on the flute.
318 S. Koppejan et al.
3. Main design specifications
The most important design specification for the flute support is to keep the flute from
turning over while playing, thus having a moment equilibrium. The thumb is the only
continuous support on the flute that is exercising force. Therefore, enlarging the moment,
which the force causes, to get the equilibrium is the most logical solution.
Other important design specifications relating to the geometry and appearance of the
. The device must accommodate the 5th percentile children (6 years old) to the 95th
percentile male adults;
. The device must be personally adjustable;
Figure 4. Strain on tendons in the right wrist and right thumb in the normal (a) and the
compensating (b) position. F¼force on right thumb; Fex¼extensor force; a¼lever of
external force; b¼lever of intrinsic force; c¼lever of intrinsic force.
Figure 3. Strain on the tendons in the left wrist and left index finger in the normal (a) and
the compensating (b) position. F¼ force on index finger; Ffl¼flexor force; a¼lever of
external force; b¼lever of intrinsic force; c¼lever of intrinsic force.
Hand and arm problems in flautists 319
. The flute must keep its original form;
. The device must not be associated with an aid;
. The contact between the flautist and the flute must feel unchanged.
4. Design of support
The support for the right hand is placed between the flute and the thumb, where the
thumb rests in a pre-shaped shell. The support can be easily attached to and removed
from the flute by two flexible silicon strips. These strips keep the device firmly in place due
to the rough surface properties of the material (figure 5).
The main function of the right hand support, the thumb rest, is to prevent the flute
from turning around the longitudinal axis. Due to the pre-shaped shell, the thumb has a
larger contact surface with the flute, which it uses as a lever to produce a larger moment.
The moment equilibrium is realized, the flute is in balance. As a consequence, the tension
in the fingers and wrist of the left and the right hand disappears; the compensating
positions are no longer necessary.
The part in which the thumb rests, the pre-shaped shell, is adjustable with regard to
the part that is attached to the flute. The shell can be rotated with regard to the upper part
to meet with personal differences in hand position. When used by smaller thumbs (less
strong) the shell reaches above the proximal (middle) joint, which reduces effort (figure 6).
The biomechanical analysis served as the basis for the design of a new support for the
right hand thumb. The analysis explains how extreme hand and finger positions arise in
which complaints can be expected in the structures of the hand and lower arm. These
positions are the starting point for a solution.
Figure 5. The right hand thumb rest. The upper part can be easily attached to the flute.
The lower part, a shell shaped like the thumb, rests on the medio-dorsal side of the
thumb. The lower part can rotate with regard to the upper part to accommodate the
difference in hand dimension and hand position. This prototype has been optimized and
has been put on the market.
320 S. Koppejan et al.
The existing commercially available solutions do not meet the requirements formulated
in the present study. The main deficiency failure is that the turning of the flute around its
longitudinal axis is not prevented. Other deficiencies are inefficient accommodation of
different individual hand dimensions, the appearance of an aid for the handicapped, the
weight and the ease of a removable adjustment to the flute. This explains why the
previous solutions were not successful. Even with achieved desired function it is of
paramount importance that the flautists accept the device as normal and not as
At present, the right-hand thumb rest has been put on the market because of the
positive reaction of the majority of the flautists in this enquiry.
The author would like to thank Mr. C.C. Delprat, Ms. M. Mosk and Mr. G.J.
Kleinrensink for their valuable advice, and the flautists Mr. R. Iterson, Ms. C. Beijdorff,
Mr. H. Starreveld,Ms. J.Machalett,Ms. J. Groesz,Ms.M. Franssen,Ms. D. Bieltyvkova,
Ms. J. Buter and Ms. M. van Haaren for participating in the research.
Figure 6. Person playing the flute with the final prototype of the right hand thumb rest.
Hand and arm problems in flautists 321
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