Musician’s Injuries

Jennine Speier MD Rehabilitation Medicine

SISTER KENNY REHABILITATION INSTITUTE PERFORMING ARTIST’S CLINIC

Chorus America Conference

Incidence

• 75% of orchestra musicians have problems during career • Keyboard & Strings most common

PSYCHOLOGICAL FACTORS

• Performance Anxiety • Expectations of perfection • Competition • Self identity and esteem as musician • Financial – it’s a

JOB

!!

• Travel stress, Sleep disturbance

ENVIRONMENTAL FACTORS

• Inadequate, cramped performance space • Poor chairs and seating • Location in relation to stand, conductor • Lighting • Temperature • Acoustics • Special effects

PHYSICAL FACTORS

• Awkward postures including that defined by instrument or piece • Too much force with movement -high tension playing with high tension • Muscle imbalance • Abrupt increase in playing time

PHYSICAL FACTORS

• Change of playing technique, teacher, instrument • Size of instrument related to body habitus of musician • Sheer repetition and speed • Lack of warm up time • Playing too long, too much

COMMON PROBLEMS

• OVERUSE AND MISUSE SYNDROMES – Tendonitis, epicondylitis, bursitis, arthritis • HYPERMOBILITY • FOCAL DYSTONIA • NERVE COMPRESSION SYNDROMES • TRAUMATIC INJURIES • DISEASE RELATED CONDITIONS

COMMON PROBLEMS

• HEARING LOSS-TEMPORARY OR PERMANENT • HYPERACUSIS AND TINNITUS • DERMATOLOGIC PROBLEMS • TMJ AND DENTAL PROBLEMS • BACK AND NECK PAIN

OVERUSE

• 6,400

LEFT HAND FINGER MOVEMENTS for STRING PLAYERS in LAST MOVEMENT of MAHLER SYMPHONY No. 5

• 740

BOWING STROKES for CELLO in 2 MINUTES of HANDEL’S MESSIAH

MUSCLE &TENDON INJURIES

• Where tendons attach muscle to bone – Lateral & medical epicondylitis • Where tendons attach to muscles – Extensor tenosynovitis • Where tendons pass through narrow tunnels – Rotator cuff, Flexors DeQuervain’s tenosynovitis • Where tendons insert into the bone

OVERUSE & MISUSE

• Result from stress that exceeds the anatomic or physiologic limits of a tissue • Tendonitis, bursitis, epicondylitis, myositis • Ganglion cysts • Tendon nodules

HYPERMOBILITY

• Can cause overuse from attempt to stabilize joint • Can strain joint if unable to stabilize joint in a neutral position • May be a localized problem or part of a syndrome

FOCAL DYSTONIA

• Painless incoordination of fingers or embouchure from repetition • Can also result from highly repetitive writing or computer keyboarding • Previous repetitive stress injury or nerve compression may have occurred • Abnormal “map” of hand in sensory & motor cortex of brain related to near simultaneous stimulation of the fingertips. (seen on special type of MRI used for research)

NERVE ENTRAPMENT

• Aggravated by awkward prolonged static postures-holding a score or instrument • Repetitive motion in awkward posture such as keyboarding on computer • May be secondary to localized swelling or inflammation of tendons and should resolve with treatment

MEDIAN NERVE ENTRAPMENT

• CARPAL TUNNEL – Numbness & tingling in thumb & index – Aching hand – Weak grip- drop things

CUBITAL TUNNEL SYNDROME

• Compressed & stretched Ulnar N around elbow • Numbness & Tingling in ring, small fingers • Ache in ulnar forearm • Weak small hand muscles

THORACIC OUTLET SYNDROME

• Compression of nerves as they pass thru front of neck & shoulder • Numbness & tingling some/all fingers • Tight rounded shoulders

THORACIC OUTLET SYNDROME

• Elevated first rib common in hypermobile patients • Simple self mobilization stretching exercises are very effective • Surgery very rarely needed

INSTRUMENT SPECIFIC ISSUES

PIANO

• Flexor tendonitis from excessive force • DeQuervain’s tenosynovitis from compensation for tight thumb muscles with excessive thumb abduction (octaves and chords) • Ulnar tendonitis due to wrist deviation, 5 th finger strain, octaves, computer mouse • Extensor pain from lifting fingers off keys, hypermobility with poor stabilization

GUITAR

• Neck or back pain from flexed posture • Shoulder pain on L related to combination of trunk & shoulder girdle posture • Focal dystonia, classical > rock guitar • Small hand muscle overuse • Stretch of ulnar nerve as elbow flexed

VIOLIN and VIOLA

• Neck, shoulder pain from clamping down on chin rest plus sustained arm elevation • Poor breathing habits • Chin rest too short, shoulder rest too high • Instrument too BIG

ACUTE INJURY MANAGEMENT

• Rest---Stop playing • ICE • Compression/stabilization and support • Elevation • See MD and Therapist if not better in 4-5 days

HELPFUL HISTORY

• Location, intensity, character, duration of pain • Onset and association with total playing time; changes in TOTAL playing time, teacher, instrument, or repertoire • How many instruments are played • Practice habits- do you take breaks?

• Previous treatments & response including time away from playing • General fitness level and program • Other activities involving hand & arm use - computer, texting, biking, sports, hobbies, etc

ANALYSIS at the INSTRUMENT

• Observation of posture • Observation of technique, looking for signs of excessive force or tension, excessive movement, collapse of joints, awkward posture. • Biofeedback to assess and modify tension • Videotaping • Observation of instrument, size and how instrument fits body

REHABILITATION

• Treatment to reduce pain or inflammation • Soft tissue and/or joint mobilization • Strengthening in pain free range • Stabilization exercises esp. shoulder girdle • Flexibility exercises when appropriate • Splinting-hard & soft for resting, protection, stabilizing

REHABILITATION

Hand (PT or OT) as well as Speech Therapy will work on • Endurance exercise • Flexibility • Postural correction • Breathing • Body awareness-Alexander, Feldenkreis • Biofeedback • Instrument modification • Assistive devices for activities of daily living • Computer set up modification

BIOFEEDBACK

• Monitor electrical activity of muscles with patch electrodes • Monitor multiple muscles • You can see voltage level indicating how much force you are generating (no shocks!)

INSTRUMENT MODIFICATIONS

• Can get a 7/8 keyboard into existing piano • Adjust stiffness of action of piano • Slight decrease in bridge height can decrease string tension • Decrease grip force by wrapping or padding handle of bow • Custom height and shaped carved chin rests • 30 or 45 degree angled head for flute

CUSTOM SPLINTS

POSTURE CORRECTION

• Wedge shaped firm foam cushion to optimize pelvic tilt • Ergonomic chairs • Foot rests for guitarist • Straps for bassoon and other large instruments • Core work with Pilates

AVOID

• Free weights • Push-ups • Downward dog position in Yoga • Basketball, sports that stress wrists • Awkward wrist postures- strive for neutral • Overuse of small muscles, use large instead

AVOID

• Excessive force with gripping and pinching activities-often means also modifying writing, driving habits • Exposure to vibration • Sustained rigid postures • Poor ergonomics of computer use

RETURN TO PLAYING GUIDE (Dr Richard Norris)

PREVENTION

• DON’T play through pain • Build up gradually to full playing schedule after a break for any reason • Take breaks of 10-15 minutes every 45 minutes. • Separate practice sessions if able • Greater than 5-6 hours daily is asking for TROUBLE

PREVENTION

• Don’t forget to use diaphragmatic breathing instead of overusing traps • Erect, balanced relaxed posture • Don’t use more force than needed • Avoid static loading---MOVE !

• Pay attention to ALL work involving arms and hands in a whole day-driving, computer, crafts, sports

PREVENTION

• Keep instrument in good repair • Do stress reducing activity /exercise-Tai Chi or Qi Gong • Take a day off per week

GOOD PRACTICE HABITS

• Vary repertoire • Set up a plan if lots of music to learn • Memorize away from the instrument • Tape yourself to listen for problem areas • Play longer phrases • Avoid repetition > 3 times of short phrases • Be prepared-no cramming !

WARM UP

• In cold weather, run arms and hands under warm water • Warm up away from the instrument • Then warm up on the instrument, starting with slow easy moves, gradually building intensity • Cool down after playing with gentle stretches

Music is lifelong

• I always tell patients:

“

Remember, YOU are the instrument….”

REFERENCES

• The Musician’s Hand-A Clinical Guide – Ian Winspur, Christopher Wynn Parry • Journal of Performing Arts Medical Association: “Medical Problems of Performing Artists” • Journal of Hand Therapy • Playing (less) Hurt by Janet Horvath