These research questions address the core focus of the study, namely the practical implementation of a multimodal, research-intensive health promotion program in youth orchestra rehearsal camps.

These research questions aim to objectively characterize health-relevant exposure conditions in youth orchestras. They provide essential contextual information for interpreting both feasibility outcomes and exploratory health indicators but are not designed to establish causal intervention effects.

These research questions explore short-term, exploratory associations between participation in specific intervention modules and selected psychological, physical, and behavioral indicators. Given the non-controlled design, these questions are explicitly formulated as exploratory and do not permit confirmatory inference.

Taken together, the research questions follow a multilevel evaluation logic, with feasibility and uptake constituting the primary evaluative focus of the study. Acoustic, audiological, and physiological measures provide essential contextual information on exposure conditions, while psychological, physical, and behavioral indicators are examined exploratorily to inform future, more controlled intervention research.

A total of 136 musicians from two European youth orchestras participated: the Landesjugendorchester Hamburg (LJO; n = 67, 49%) and the Norwegian National Youth Orchestra (NUSO; n = 69, 51%). The cohort covered all major orchestral sections: upper strings (n = 55), lower strings (n = 32), brass (n = 21), woodwinds (n = 19), percussion (n = 6), and others such as keyboard and harp (n = 3). Ages ranged from 13 to 27 years (M = 18.3); 48% were adults, 50% minors, and 2% undeclared. Gender distribution was balanced across the sample. The age distribution across instrument groups is shown in Figure 1, indicating slightly higher mean ages among wind and upper string players. Participation was voluntary; written informed consent was obtained from all adult participants, and from legal guardians for participants under 18 years of age.

All musicians participated in the core program, which was composed of daily orchestra warm-ups, hearing protection lessons, and baseline health screenings. Additional intervention modules were optional and selected by the participants in advance through pre-camp consent forms, either filled out by the participants themselves or, in cases of underage participants, by their parents. Uptake was high across modules; for example, 61 participants (47.7%) marked “I would love to do this” for BodyFit, and 54 (42.2%) did so for Mental Training (assigned the label “excited” in Figure 2). Most of the remaining respondents selected “It is okay to be assigned to this group” (see Figure 2).

Due to the nature of the project, methodological considerations regarding sample size for the overall questionnaires were considered superfluous, since the number of attendees was determined by the program’s organizational capacity. The musicians therefore functioned as a convenience sample.

Regarding the intervention groups, we aimed to assign around 20 participants to each intervention group to be able to test for middle to large effect sizes (16–20 people for Pearson’s r as well as Cohen’s d > 0.5), taking a natural drop-out risk of 5–10% into account. As funding was limited to only 15 smartwatches, only large effects were able to be accounted.

Final groups were allocated based on participants’ preferences and included 57 musicians in BodyFit (27 adults, 30 minors), 54 in Mental Training (28 adults, 26 minors), and 13 in VRET. Overall, fewer than 8% of participants declined participation in any additional module.

The project consisted of two main phases. The first phase was a 10-day summer camp in Bodø from August 3–11, 2024, which culminated in a concert at the Stormen Concert Hall. The second phase was a 3-day autumn camp in Hamburg from October 2–4, 2024, culminating in a public concert under professional performance conditions at the Elbphilharmonie on October 5, 2024. This design enabled repeated measurements in intensive rehearsal and high-pressure performance contexts.

A brief feedback questionnaire was administered immediately after the Bodø phase, followed by a comprehensive questionnaire six weeks later to enable comparative analyses. All participants took part in daily collective interventions (tutti warm-up routines, the “Get in the Zone” instructional video, an educational lecture format, and audiometric screening) and were additionally assigned to one intervention track comprising three structured sessions of approximately 60 min per week.

The orchestral camp in Bodø, Norway, followed an intensive daily schedule of tutti and sectional rehearsals, health-related workshops, and intervention sessions. Short breaks and frequent transfers between accommodations, rehearsal venues, and dining facilities affected physical strain. Evening activities such as concerts and social events further reduced recovery opportunities. The Arctic summer light conditions may have influenced sleep and recovery patterns.

The joint concert program featured György Ligeti’s Lontano, excerpts from Sergei Prokofiev’s Romeo and Juliet Suites Nos. 1 and 2, and Ottorino Respighi’s Pini di Roma, conducted by Torodd Wigum and Johannes Witt. In Bodø, the program additionally included Ingebjørg Vilhelmsen’s Festivity (Fest Overture).

The study was embedded within the Erasmus+ pilot project The Future of Youth Orchestra – Addressing Physiological and Psychological Needs in Young Orchestral Musicians (TFOYO), coordinated by the Norwegian National Youth Orchestra (NUSO) in collaboration with the Landesjugendorchester Hamburg (LJO) and the Austrian Society for Performing Arts Health & Music Psychology (ÖGfMM), with the scientific conception, study design, and evaluation led by the ÖGfMM research group. A mixed-methods approach combined quantitative measures (e.g., audiometric thresholds, SPL exposure, biometric stress markers) with qualitative data (e.g., self-reported anxiety and reflections on training experiences) to support a comprehensive evaluation of the program. Rather than testing isolated components, quantitative and qualitative data were jointly interpreted to assess the feasibility and acceptance of the overall multimodal intervention framework. The overarching aim was to support health awareness, resilience, and performance readiness in young musicians by integrating evidence-based interventions into youth orchestra rehearsal culture.

To document the acoustic conditions within the orchestra, sixteen measuring microphones (Behringer ECM8000) recorded in a multitrack session in Adobe Audition (16 mono tracks, each 48.000 Hz, 32 Bit) were placed at representative musician positions during a rehearsal of Ingebjørg Vilhelmsen’s orchestral piece, “Festivity” (Vilhelmsen, 2023). This piece was chosen because, within three minutes, it runs through a variety of volumes between ppp and fff, which are the typical dynamic extremes in an orchestra. Calibrated to 114 dB_SPL at 1000 Hz using an ND9 acoustic calibrator, the microphones were placed at ear level for musicians from 15 instrument groups and the conductor. This allowed the musicians’ sound exposure during the performance to be recorded as sound pressure levels in dB_SPL. In addition, these sixteen synchronized orchestra tracks were used to create a soundscape visualization in which the listener can interactively observe the listening positions of individual orchestral musicians to explore the orchestra’s internal soundscape. Additional documentary recordings were made using an Insta360 Pro camera with 360° Ambisonic audio and 8 K video capabilities, providing immersive audiovisual documentation.

Audiometric testing was conducted by a certified occupational health physician using a Zeisberg CA350 clinical USB audiometer with AudioApp software and calibrated HDA280 headphones. Standard air-conduction thresholds (125–8,000 Hz) were assessed following pure-tone audiometry protocols. In total, 77 participants (41 female, 36 males; aged 14–27 years) completed audiometry during the Bodø rehearsal phase, covering all major instrumental groups (50 strings, 11 woodwinds, 16 brass, 1 percussion). A small number of staff musicians and instructors (up to 57 years old) were also included to provide reference data. As part of the hearing-health module, all musicians received an illustrated fact sheet on safe exposure limits and hearing-protection strategies by Bertsch et al. (2024), followed by an interactive Kahoot^® quiz attended by over 100 participants. This combined diagnostic-educational approach supported awareness and prevention. If no clinical audiometer is available in follow-up studies or for self-diagnosis by musicians, the BHI Quick Hearing Check (Kochkin and Bentler, 2010) can be recommended as an inexpensive and time-saving alternative for evaluating hearing thresholds.

Fifteen musicians (10 string players, 5 wind players) participated in continuous psychophysiological monitoring using Empatica EmbracePlus smartwatches. Participation was voluntary and restricted to musicians aged 18 years or older who had expressed strong interest in this module during pre-camp consent procedures. All participants were members of the Hamburg orchestra cohort, as devices were distributed and configured locally in Hamburg for logistical reasons.

The smartwatches recorded electrodermal activity (EDA; tonic skin conductance level in μS, 4 Hz), blood volume pulse (BVP; 64 Hz), wrist skin temperature (1 Hz), and tri-axial accelerometry (64 Hz). In the present study, analyses focused on tonic EDA, pulse rate derived from BVP, and wrist temperature. Other parameters provided by the device (e.g., HRV, sleep detection) were not included in the analyses reported here.

Physiological data were time-stamped and transmitted via dedicated smartphones to a GDPR-compliant secure cloud infrastructure, where all data were stored under anonymized numeric participant IDs. Only the participants themselves and the project lead could link IDs to individual identities, in accordance with the approved ethics protocol.

To enable event-related analyses, physiological data streams were temporally synchronized with private video recordings of rehearsals, concerts, and virtual reality sessions using shared timecodes. Musical events (e.g., entrances, solos, structurally demanding passages) were identified based on annotated scores and video footage, allowing alignment of physiological signals at the level of minutes and, where applicable, seconds.

Qualitative self-reports were collected through audio-recorded semi-structured interviews comprised of open questions conducted before and after concerts, which were subsequently transcribed. In addition, follow-up questions were sent by e-mail approximately one week after the project, asking participants to describe particularly memorable or emotionally salient moments during the concert. All qualitative data were linked to the corresponding physiological recordings via the anonymized participant IDs and used to support multimodal interpretation.

Analyses were exploratory and focused on assessing the feasibility and ecological suitability of wearable stress monitoring in live orchestral performance contexts, including the robustness of data acquisition, the presence of movement artefacts, and the interpretability of individual time courses.

The virtual reality exposure training (VRET) module was designed to simulate high-stakes performance situations in photorealistic concert venues, with the primary aim of examining the feasibility and ecological suitability of VR-based exposure settings within youth orchestra rehearsal camps. Visual recordings were captured using stereoscopic 8 K 360° images and videos from established concert venues, including the Elbphilharmonie in Hamburg and concert stages in Vienna. The performance scenarios additionally included a big band solo rehearsal setting. Although the Augmented Practice Room system (developed by IEM Graz and implemented at the Motion-Emotion Lab, mdw Vienna) allows real-time augmented room acoustics, it was not sufficiently portable for use during the Bodø camp. Accordingly, the VRET module employed pre-rendered visual scenes without real-time acoustic augmentation.

Participation in the VRET module was voluntary and restricted to brass players, as this instrument group can perform without direct visual reference to the instrument, ensuring methodological comparability across participants. Following the consent procedure, 15 wind players expressed strong interest in participating. Thirteen participants (aged 16–20 years) attended an initial introductory and briefing session and thus constituted the VRET sample (N = 13). Across the camp, six VRET sessions of approximately 60 min were offered; participants were invited to select up to three sessions depending on availability. Individual active playing time within each session was approximately 10–15 min, while other participants observed the session in a group setting.

During the Bodø camp, VRET sessions were conducted in a classroom environment using Meta Quest Pro head-mounted displays. To minimize the risk of cybersickness, all scenarios employed fixed panoramic viewpoints without artificial spatial movement. The visual scenarios were comprised of solo audition excerpts, selected orchestral passages, and improvisation prompts. Stress-inducing elements were introduced through simulated jury presence and camera recording, accompanied by task instructions (e.g., performing short, memorized excerpts), while no explicit time pressure was imposed. All sessions were video-recorded with second-level timecodes; selected performances were additionally live-streamed via a private YouTube channel to increase evaluative salience. Participants were informed about the recording procedures and were free to discontinue participation at any time in accordance with the approved ethics protocol. No cases of cybersickness were reported.

The VRET module was designed for multimodal research integration. Physiological monitoring via Empatica EmbracePlus smartwatches was conducted for a subset of participants who also took part in the stress-monitoring module (see Section 3.4). In addition, time-stamped VR event information (e.g., task onset, performance phases) and brief qualitative self-reports collected after sessions were used to enable exploratory, case-based, event-locked analyses linking task characteristics with psychophysiological responses. The focus of the VRET module was on feasibility, technical robustness, and the interpretability of synchronized multimodal data in live rehearsal and performance contexts rather than on evaluating therapeutic efficacy.

The practical intervention program consisted of daily warm-ups, instructional media, educational activities, and small-group workshops, all delivered by certified specialists and integrated into the rehearsal schedule.

To assess psychological, physical, and hearing-related health parameters, a standardized survey battery was administered at two measurement points: pre-camp (July 2024, before the Bodø phase) and post-camp (September/October 2024, before the Elbphilharmonie concert).

Each participant received a pseudonymized study ID to link pre- and post-camp data while preserving confidentiality. Data were stored in a secure, password-protected database in accordance with the ethics approval granted by the University of Music and Performing Arts Vienna (May 2024).

By summarizing the dynamic values at the ears of the individual musicians (see Tables 2, 3), it can be seen, particularly at the median and maximum levels, that the ears of the conductor (79.0 dB_{SPL median}, 91.8 dB_{SPL max,} 75.2 dB_{A median}, 83.8 dB_{A max}) and double bass players (79.8 dB_{SPL median}, 90.8 dB_{SPL max,} 73.5 dB_{A median}, 83.0 dB_{A max}) are at least at risk. In contrast, the ears of wind and percussion instrumentalists are particularly at risk: with median levels of up to 87.8 dB_{SPL median} (83.0 dB_A, French horn) and maximum values of up to 101.1 dB (95.5 dB_A. timpani) they mainly play in a range above 85 dB_SPL, where sound begins to have a harmful effect on hearing after extended exposure.

As shown in Figure 3, the spatial distribution of sound pressure levels within the orchestra is visualized online¹ as an interactive heatmap based on the recordings of the 16 calibrated microphone positions. Color gradients represent the sound pressure level measured at each musician’s ear, ranging from 37 to more than 100 dB_SPL, with the highest exposures observed among brass and percussion players. The visualization highlights the acoustic heterogeneity across orchestral sections and enables users to listen from each instrument’s perspective, comparing perceived timbre and intensity across positions. Furthermore, a virtual rehearsal tour created with 3DVista Virtual Tours integrates audio samples and navigable viewpoints, offering an additional educational resource on orchestral acoustics².

Audiometric screening (125–8,000 Hz) revealed that most tested musicians exhibited hearing thresholds within normal limits. However, early high-frequency threshold shifts (>20 dB_HL above 4 kHz) were observed in several brass players, particularly trumpets, horns, and trombones. In some cases, these shifts were asymmetric between ears, consistent with the directional exposure pattern of the brass instruments.

Group-level observations:

Overall, most young musicians in this cohort still showed healthy auditory profiles, yet the earliest signs of high-frequency hearing decline were already evident in high-exposure groups. These findings underscore the importance of early preventive education and action.

As shown in Figure 4, audiometric results of the youth orchestra musicians demonstrate that most hearing thresholds fall within the normal range (light green area). However, early high-frequency threshold shifts are visible in several brass players, particularly trumpets, horns, and trombones, indicating initial signs of exposure-related hearing loss. The interactive online audiogram tool³ allows users to explore hearing thresholds for each instrument group and compare left- and right-ear measurements across the orchestra.

To address these risks, all participants received a “Hearing Basics” fact sheet (Bertsch et al., 2024) and joined an educational session on acoustic safety, including a Kahoot^® quiz attended by nearly 100 musicians. Qualitative feedback indicated that the session increased awareness and motivation to use hearing protection more consistently.

The BodyFit and Mental Training workshops were conducted as afternoon group sessions, held after or alongside the intensive rehearsal schedule. Participant motivation was high, with full attendance during the initial sessions. Toward the end of the demanding rehearsal period, attendance declined somewhat, primarily due to time constraints and performance-related stress.

This study suggests that a multimodal health-promotion program can feasibly be implemented in the rehearsal culture of large youth orchestras. Three main findings stand out.

First, regarding hearing health: although most young musicians still exhibited normal audiograms, some brass players already showed early high-frequency threshold shifts. This finding is consistent with previous evidence indicating that the risk of noise-induced hearing loss may begin early in orchestral training and highlights the need for preventive strategies, such as consistent and context-appropriate hearing protection.

Second, concerning physiological stress monitoring: smartwatch-based recordings captured both group-level activation patterns (e.g., anticipatory arousal before rehearsals and concerts) and fine-grained individual stress trajectories linked to solos, performance errors, or unexpected cues. These findings support the ecological sensitivity of wearable monitoring in performance contexts and illustrate its feasibility for linking subjective experiences to objective psychophysiological markers.

Third, regarding practical interventions: structured warm-ups, BodyFit workshops, and mental training sessions were well accepted and widely perceived as beneficial. One pragmatic implementation technique was to carry out the warm-up at the beginning of each rehearsal rather than adding it beforehand, which was associated with improved participation and punctuality. Participants reported increased body awareness and a normalization of psychological skills training, while typical pre-concert increases in anxiety were noted as less pronounced. In line with this, group-level stress-monitoring patterns exhibited transient downshifts in arousal during short on-stage warm-ups or mental focusing exercises before high-stakes run-throughs.

Virtual Reality Exposure Training: VRET elicited physiological stress responses comparable to those observed during live performances, highlighting its potential as a controllable platform for training and exploratory research. Instead of avatar-based or gendered imagery, the training employed photorealistic, 360° scene-captured video of concert halls with ambisonic audio. Participants reported the content as highly realistic and acceptable. The platform was perceived to enhance face validity (i.e., the content looked and felt like the “real thing” to users) and to foster engagement. Adding real-time augmented acoustics may further improve ecological fidelity while preserving experimental control (Bertsch and Frank, 2022; Bertsch and Peschka, 2023).

In classroom deployments, stand-alone VR headsets were rarely plug-and-play in practice, as an initial configuration (guardian/boundary setup, controller pairing, stable Wi-Fi) was usually required. Although all sessions ran successfully, they depended on in-room expertise and small setup buffers. Based on these experiences, we recommend the following implementation measures for educational rollouts: (1) pre-session checks and local content caching, (2) a 10-min setup buffer, (3) a wired or standalone fallback option without casting in low-connectivity scenarios, and (4) basic operator training for staff.

Taken together, these results indicate that targeted health education, preventive interventions, and technology-supported monitoring can be feasibly integrated into youth orchestras and may support resilience and sustainable performance development. A key observation is the modules’ consistently high uptake: over 90% of participants expressed willingness to engage in warm-ups, audiometric testing, and surveys, suggesting that health promotion initiatives are not only feasible but also well received by young musicians.

The survey results further demonstrate that health issues and dysfunctional behaviors are widespread rather than exceptional. This corroborates the initial observations of Britsch (2005), who found that even adolescent orchestra members frequently experienced pain and performance anxiety yet rarely received guidance on prevention or coping strategies. Almost half of the participants reported health problems related to practice, and one-third reported practicing through pain despite knowing it was not advisable.

Musculoskeletal discomfort was almost universal, with over a third of musicians reporting pain “most of the time” or “always.” The pain was most frequently located in the areas of the body that bear the most load when playing an instrument, such as the neck, shoulders, lower back, and hands. Alarmingly, 12% of participants felt that their complaints of pain were not at all taken seriously, revealing a gap between the actual burden of health problems experienced by musicians and the recognition these problems receive in educational contexts. In line with previous studies of competition-level youth musicians (Gembris et al., 2020), most participants reported mild to moderate musculoskeletal discomfort, indicating that PRP may develop prior to tertiary education. These findings reflect the broader spectrum of health and illness in musicians’ medicine, where overuse, psychological stress, and acoustic load interact to cause diseases specific to musicians (Spahn, 2022).

Pain and anxiety stayed the same or increased between the two measurements, but this might be because the first measurement was taken during the summer holidays and the second one right before the concert weeks after the intervention, when school/university had already started for the participants. Also, the response rate was lower than expected, so these results should be treated with caution, as roughly half of the participants responded to both questionnaires in some groups.

The integration of acoustic, physiological, psychological, and behavioral data revealed important synergies across the different modules. Elevated sound exposure among brass players coincided with early high-frequency hearing threshold shifts and low reported use of earplugs, underscoring the urgent need for targeted hearing-protection education. Conversely, the percussionist(s) who consistently used custom-fit protection showed exceptionally good thresholds, providing a positive counterexample.

Physiological stress markers such as electrodermal activity, pulse, and temperature fluctuations were evident, not only during live concerts, but also in Virtual Reality simulations: validating VR as both an intervention and an experimental paradigm. Arousal peaks observed after concerts were linked to social and celebratory contexts, illustrating that wearable monitoring must be interpreted within the broader ecology of musicians’ lives rather than only in terms of performance demands.

Survey findings on pain, anxiety, and guilt complemented both the audiometric and physiological data. The high prevalence of practicing through pain (32%) aligns with dysfunctional practice patterns and anxiety about insufficient practice (73%), which, in turn, resonate with the stress responses captured before rehearsals and concerts. These converging data illuminate a systemic culture of overpractice and perfectionism that places young musicians at heightened risk.

The linkage between survey-based reports of pain in high-strain body regions, physiological stress responses during difficult passages, and feedback from BodyFit workshops further strengthens the case for integrated interventions. While BodyFit sessions improved awareness of posture and tension, the persistence of pain across the cohort indicates that more sustained or intensive programs may be needed. Moreover, the very low rate of medical treatment uptake highlights an unmet need for structured health education and accessible physiotherapeutic support within youth orchestra programs.

Taken together, the interdependence of the modules shows that the challenges identified (hearing risk, stress reactivity, pain, and maladaptive practice) are mutually reinforcing. This underscores the necessity of a holistic approach to health promotion in youth orchestras, where acoustic, psychological, and physiological dimensions are addressed simultaneously rather than in isolation.

The present findings are consistent with previous evidence indicating that adolescent musicians already experience musculoskeletal pain, stress, and early-stage hearing problems at rates approaching those reported for professional musicians (Gembris et al., 2018; Schink et al., 2014). Comparable prevalence rates of 60–90% have been reported among professional orchestral musicians worldwide (Blum and Ahlers, 1994; Zetterberg et al., 1998; Abréu-Ramos and Micheo, 2007; Ackermann et al., 2012; Steinmetz et al., 2015; Kenny and Ackermann, 2015; Gasenzer et al., 2017). The underuse of hearing protection observed in this cohort mirrors long-standing challenges documented by Pawlaczyk-Łuszczyńska et al. (2011a, 2011b), pointing to persistent barriers in translating risk awareness into consistent protective behavior.

The observed associations between mental training participation and reduced performance anxiety are in line with earlier reports by Kenny and Osborne (2006), who emphasized the need for age-appropriate psychological support, and by Campbell (2020), who demonstrated the value of implementing mental skills and body-based interventions in youth orchestra training. Early preventive approaches addressing performance anxiety appear particularly relevant, given that even pre-adolescent students exhibit substantial levels of music performance anxiety (Nusseck et al., 2015). Similarly, the VRET-related findings align with prior work (Williamon et al., 2014; Glowinski et al., 2015; Bissonnette et al., 2016), demonstrating the potential of immersive technologies in performance-anxiety research. The present study extends this line of work by illustrating comparable patterns of physiological activation during VR exposure and live performance within a complex, ecologically valid orchestral context.

Although physical health issues among musicians have been widely documented, holistic models of well-being, such as those proposed by the Ecology of Musical Performance (EMP) framework, remain underrepresented in empirical research (Fukumura et al., 2025). This gap is particularly evident for young musicians in pre-professional training contexts.

Finally, the wearable stress-monitoring data provide fine-grained insight into both group-level arousal patterns and individual trajectories, responding to established calls for ecologically valid, field-based psychophysiological measurement in performance research (Williamon et al., 2014) and aligning with recent developments toward more realistic, context-rich performance simulation and monitoring tools (Waddell et al., 2025). Together, these findings situate TFOYO within a growing body of research advocating integrated, multimodal approaches to musicians’ health.

Key strengths of this project include its real-world orchestral setting, the integration of multiple data modalities, and the ecological validity afforded by combining rehearsals, concerts, and residential camps. The combination of subjective self-reports with objective physiological and acoustic measures enabled a more nuanced interpretation than would have been possible using a single-method approach. Like recent participatory approaches in health protocol development for young musicians (Shoebridge and Osborne, 2025), the intervention framework was informed by direct input from students and orchestra staff, underscoring the relevance of tailored and co-designed preventive strategies.

Several limitations must be acknowledged. Subsamples within individual modules were relatively small (e.g., VRET participation was limited primarily to brass players), which restricts generalizability. Wearable devices, while offering rich physiological data, were susceptible to motion-related artefacts: EDA signals were affected by arm movements, and wrist skin temperature was sensitive to ambient conditions. Participation was voluntary, and self-selection into specific interventions may have introduced a bias toward participants with greater health awareness or interest. In addition, age, experience level, and professional aspirations appeared to shape outcomes, with musicians pursuing professional careers reporting higher dysfunctional practice scores and more pronounced pre-concert anxiety.

The documentation of consent preferences prior to the study provided valuable insight into participant motivation and supported intervention planning. At the same time, the notability high rates of reported willingness may partly reflect social desirability effects. Future research should therefore complement self-reported measures with longitudinal behavioral indicators to more accurately assess sustained engagement and longer-term impact.

In addition, the intensive rehearsal schedules and limited recovery opportunities inherent to residential orchestra camps posed additional practical constraints. Daily walking distances between venues, combined with extended working hours and prolonged daylight exposure during the Bodø phase, likely affected rest and sleep quality. These contextual factors highlight that, although the multimodal framework proved feasible under field conditions, its implementation must carefully account for musicians’ restricted time resources and cumulative environmental load.

The present findings inform several practical considerations for promoting health awareness and resilience in youth orchestras:

Looking ahead, health awareness could be conceived as a normalized and continuous element of music education, from schools and youth orchestras to conservatory curricula, rather than as an optional supplement.

Overall, the findings suggest that health promotion initiatives in youth orchestras may be particularly promising when coupled with digital innovation and active youth participation. Preventive strategies were perceived as more acceptable when embedded in broader educational and cultural frameworks, indicating that future European collaborations may benefit from pursuing such integrated approaches to support long-term adoption.

While the project demonstrated feasibility and promising outcomes, several limitations must be acknowledged:

Despite these limitations, the project provides a coherent multimodal feasibility framework and demonstrates that evidence-informed health promotion activities can be implemented and accepted within youth orchestra contexts. Rather than establishing effectiveness, the findings offer a structured basis for future controlled and longitudinal studies aimed at developing scalable and context-sensitive approaches to musician health.

This study shows that combining objective multimodal measurements—acoustic, physiological, and psychological—with a didactic intervention program is feasible and well-accepted in the youth orchestra context. By mapping orchestral soundscapes, screening hearing thresholds, and monitoring stress responses with wearables, as well as integrating structured warm-ups, body conditioning, and mental training, the project established an integrative framework for health promotion. The findings suggest that young musicians reported increased awareness of health-related risks and perceived value in practical strategies to support resilience, coping with pain, and reflection on performance anxiety. Further showing the effectiveness of the interventions at an institutional level, the participating orchestras initiated follow-up measures, including plans to provide filtered hearing protection as standard equipment, where previously only basic foam earplugs had been available.

This multimethod approach enables a differentiated understanding of individual and group needs and may inform targeted preventive strategies early in a musician’s educational trajectory. Beyond the immediate study context, the project generated sustainable educational outputs, including freely accessible instructional videos and informational materials that continue to be used and shared via social media and project channels and have already prompted inquiries from other youth orchestras.

A central strength of the project lies in its commitment to informational sustainability and open knowledge transfer. All developed materials—including daily warm-up routines, the Get in the Zone video, photorealistic VR scenarios, interactive online soundscape maps, audiometric tools, and health guidelines—are freely accessible as open resources. This ensures long-term availability for educators, musicians, and institutions beyond the project’s duration.

Informational sustainability was further supported by digital innovation and close collaboration between scientific experts and the leadership structures of youth orchestras. VR modules, training videos and handouts are permanently available online. Furthermore, youth committees and co-creation processes piloted in TFOYO offer a transferable model for integrating health, education and youth empowerment. Collaboration across European professional networks enhanced the project’s impact by enabling the development of context-specific solutions through international partnerships, cultural exchange and adaptation to diverse rehearsal settings. This kind of transnational collaboration makes it possible to share best practice between youth orchestras and professional training environments for young musicians. It provides a scalable framework for implementing evidence-based health promotion in orchestral training in Europe and beyond.