Musician’s Injuries

Jennine Speier MDRehabilitation 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, 5th 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