1. Musculoskeletal Injuries in MusiciansEvaluation & Treatment Shannon Marie Scott, OTR/L

2. Injuries in Musicians Musicians are prone to musculoskeletal injuries (MSI) Musicians are notoriously hard to persuade to reduce or stop their playing Instructors or parents may tell a student to ignore the pain and accuse them of trying to avoid practice May assume condition is normal and find ways to mask a developing injury Belief that “the show must go on”

3. Types of Injuries Most common include: Carpal tunnel syndrome Tendonitis Bursitis Tenosynovitis DeQuervain’s Syndrome Tendinosis Thoracic Outlet Syndrome Myofascial Pain Syndrome Cubital Tunnel Syndrome Trigger Finger/Thumb Focal Dystonia Strains (Similar to that of computer overuse)

4. Why are Musicians Prone to MSI? Long hours of practice, rehearsals, performances Overuse Incorrect postures Non-ergonomic technique, faulty technique Excessive force Stress Insufficient rest periods Avoidance of breaks during practice Lack of education Many musicians develop these injuries because their bodies were not conditioned enough to put in the many hours of strenuous muscular activity

5. Symptoms Approximately half of professional musicians and music students experience symptoms Pain Weakness Numbness Tingling Stiffness (reduced ROM) Loss of muscular control

6. Other Warning Signs Difficulty grasping items Weakness of the hands Increased feeling of clumsiness Constantly sore forearm muscles Coldness in the fingers while playing Hands turn blue or flush erratically Restricted motion

7. Pain Pain is often first and most prominent symptom Result of inappropriate repertoire or performance habits Secondary to illness or trauma Myofascial pain commonly occurs in neck and shoulder girdle, as well as forearm flexors and extensors Musicians often have to make frequent, rapid ballistic movements or perform wide-hand techniques such as chords Intensity of practice often correlates with prevalence of symptoms Performers often attempt to play through the pain Playing through the pain results in incoordination due to antalgic inhibition of the find hand movements

8. Numbness Usually along ulnar border of the forearm and hand Symptomatic thoracic outlet syndrome is often accompanied by myofascial neck and shoulder girdle postural deficits

9. Incoordination Often directly associated with numbness and pain Some experience incoordination as a focal dystonia or occupational cramp

10. Level of Injury Level I Pain occurs after playing, but are able to perform normally Level II Pain occurs during playing, but are not restricted in performing Level III Pain occurs during playing and begins to affect some aspects of daily life, must alter technique or reduce the duration of activity Level IV Pain occurs as soon as you attempt to play and is too severe to continue, many aspects of daily life are affected Level V Pain is continuous during all ADLs and you are unable to participate in playing

11. Evaluation Observe the performance of the activity Look at posture Look at technique Assess the playing environment if possible Evaluate other activities May be caused by other things the musician is doing frequently Computer use Child care Hobbies Sports Determine if the size, weight, or shape of the instrument is appropriate for the individual

12. String Instruments String players are most prone to injuries in the back, shoulders, and neck Complain of muscle stiffness, pain, soreness, tension Complain of numbness of fingers, hand, wrist, neck, jaw, back, and shoulders

13. Case Study – Violinist with Shoulder Pain 22 y.o. violinist with hx of persistent, aching, bilateral shoulder pain that occurred during and after playing Noted increased tension in head and neck while playing Pain during resisted abduction and external rotation with painful arc during active abduction Pain at outer range of passive internal and external rotation Used increased scapular movement to facilitate internal rotation Diagnosed with rotator cuff tendonitis Treatment Decreased length of performance, increased rest time Did not require change in position or technique Prolonged passive stretching at 30-second intervals and use of ultrasound for deep-heating Conditioning program to improve shoulder girdle endurance with progressive resisted exercises

14. Case Study – Cellist with Fibromyalgia Middle-aged cellist with increased pain Pain in neck, back, and all four extremities Started as aching and later became sharp with increased movement, especially when playing cello Myofascial tenderness throughout infraspinatous and infrascapular areas, trapezius, acromial process, extensor and flexor surfaces of the forearms, low back Repetetive use of forearm flexors increased pain Treatment Recommended aerobic program, suggested warm-up exercises and shorter practice sessions Performance improved with better sleep and stretching program Modified playing technique, engaged in relaxation exercises and more active exercise program

15. Case Study – Guitarist with Forearm Pain Guitarist with bilateral forearm pain during and after playing Pain extended into each hand mainly along extensor surface but also on flexor surface Treatment Used videotapes to demonstrate to the player his poor ergonomic position of the guitar Adopted a more upright position of playing and although it felt “foreign” to him, he was able to play for 30 minutes without pain Treatment focused on improving range of motion and strength

16. Wind Instruments Wind players are prone to ear, nose, throat, mouth, lip injuries Also prone to neck, shoulder, and arm injuries

17. Case Study – Flautist with Shoulder Girdle Pain 20 y.o. flautist with shoulder girdle pain and sensory loss Parasthesia and aching in left hand Symptoms began after MVA which caused a flexion-extension injury of cervical spine Pain and numbness along medial aspect of left arm from mid-forearm radiated to 4th and 5th digits Decreased hand coordination and limited time she was able to hold the flute upright Decreased sensation to touch and pinprick over dorsal and volar surfaces of 4th and 5th digits and along ulnar border of forearm Treatment Conditioning program for cervical spine and shoulders to improve posture Modified practice time to play within tolerance of symptoms rather than through the pain Symptoms worsened when she neglected to perform exercises or performed any type of unaccustomed activity

18. Percussion Percussionists often complain of back, shoulder, neck, hand, wrist, fingers, and arm pain and tension Some of the most common injuries of percussionists are tendonitis and carpal tunnel syndrome Be aware of awkward postures and positions while percussionist is playing

19. Keyboard and Piano Hand injuries as a result of fast movements and wide-hand movements and inappropriate warm-up techniques Postural concerns with sitting position at the piano

20. Case Study – Organist with Numbness Organist with numbness and parasthesia in 4th and 5th digits of right hand Difficulty sensing keys with affected digits Decreased sensation to touch and pinprick on palmar surface of 5th and 4th digits Positive tinel’s sign over the right cubital tunnel Treatment Suggested the player avoid pressure on the cubital tunnel and use an elbow pad

21. Treatment Basics Appropriate warm-up and stretching of affected area Performance of easy pieces and later progression to more technically difficult pieces Frequent breaks to allow recovery during play Review playing technique and modify if necessary Review and modify the instrument if necessary

22. Conservative Treatment Permits player to continue playing, but modifications are made Practice segments are reduced with increased breaks Control of posture and body awareness improved Alexander Technique, Yoga Technique of the player is reviewed and repertoire causing pain is stopped

23. Radical Rest Treatment Total avoidance of pain-inducing activities Essential to keep joints moving through full range of motion to avoid secondary changes, but not against resistance or load Begin with a very small amount of hand use and increasing incrementally

24. Posture and Conditioning Musicians often fail to build strength and endurance through other forms of activity Exercise program should include aerobic activities, progressive resisted exercises, and postural training Stretching scalenes by lateral neck flexion Chin retraction and neck rotation movements sustained at end range Stretching pectoral muscles

25. Adjunct Treatment Ice, e-stim, acupuncture for chronic pain control Localized symptoms – ultrasound Basic goal – to return to the highest level of movement, strength, endurance, sensation, coordination

26. Instrument Modification Adjust chin rest of violin or viola Changing supporting pins of cello to more vertical position Fit flute with thumb support Etc.

27. Prevention Don’t skip warm-up exercises Attend to good posture Be aware of good technique while playing Listen to your body Take breaks while playing

28. Exercise Basics for Musicians Commit to 3 days a week Involve both weight training and aerobic training Musicians should concentrate on high repetition, low to medium weight exercises (15 repetitions) Drummers need arm and leg strength Cellists need overall upper body strength Routine should be tailored to the type of instrument Focus on developing muscles for posture and core control

29. Education Educating musicians is essential for preventing recurrence of symptoms Include understanding of the ergonomics of performance Play without causing symptoms and play regularly to maintain endurance, appropriate warm-up periods, proper instrument maintenance, maintaining general physical fitness Start by educating students when they are just beginning to develop good playing habits and techniques Educate music majors in colleges

30. “Top-Ten” 1. listen to your body 2. take more breaks (5-10 minutes every 45 minutes) 3. avoid sudden increase in playing time 4. be careful when changing instruments 5. be aware of playing environment 6. prepare body before playing (stretch, warm-up) 7. watch your posture (try videotaping self) 8. become “one” with the music (let your body move while you play, don’t stay rigid) 9. drink plenty of water 10. eat a healthy diet