ProQuest Dissertations

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RECOGNITION, EVALUATION, AND TREATMENT OPTIONS OF
PERFORMANCE-RELATED INJURIES IN WOODWIND MUSICIANS
A Dissertation
Presented for the
Doctor of Musical Arts
Degree
The University of Memphis
Sandra Elaine Cox
August 2009
UMI Number: 3400154
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Copyright © Sandra Elaine Cox
All rights reserved
To the Graduate Council:
I am submitting herewith a dissertation written by Sandra Cox entitled
"Recognition, Evaluation, and Treatment Options of Performance-Related Injuries
in Woodwind Musicians". I have examined the final copy of this dissertation for
form and content and recommend that it be accepted in partial fulfillment of the
requirements for the degree of Doctor of Musical Arts with a major in Music.
Angelin#Case-Stott, M.M.
Major Professor
We have read this dissertation and
recommend its acceptance:
W r k T . Jobe/TfcD
•Mel Phillips, M.M
Michelle Vigneau, D.M.Al
Accepted for the Council:
K a r e i m Weddle West, Ph.D.
Vice Provost for the Graduate Programs
ACKNOWLEDGEMENTS
I would like to thank my family for the support they have provided
throughout my academic endeavors. In particular, I would like to thank my
parents, Jere and Rachel Cox, who have given support and encouragement in
every imaginable way. I could not have done this without them. My aunt and
uncle, Will and Karen Stafford, have been to every recital and spent numerous
hours reading this document. My niece, Elizabeth Cox helped with the drawings,
for which I am most grateful.
I have many friends who have been instrumental in getting to this point.
Nathan Wilensky has assisted with computer issues and formatting. Beverly
Chumbley, M.S., L.M.T., has shared knowledge for many years regarding
complementary medicine, come to recitals and been a great support throughout
the long process of getting a doctorate. Carol Lowry has helped me research
every obscure topic of interest over the years, never complaining about the
difficulty in helping me locate information. Charles Lewis, Kelly Kramer, and
Kennith Freeman have been supportive, providing a voice of reason and an
endless shoulder on which to lean.
I am indebted to my major professor, Angeline Case-Stott, who has spent
numerous hours assisting me with this dissertation and providing support during
the completion of a long and arduous process. Without her help, this document
might never have been completed. I would like to thank my committee
iii
members, Michelle Vigneau and Pu-Qi Jiang, for all their contributions toward
completion of this document, and, especially, to Dan Phillips for helping out at
the last minute. I am especially grateful to Dr. Mark Jobe, and his assistant Diane
Campbell, for taking time out of their schedules to assist me. I am forever
indebted to Bruce Erskine, who has been a friend and mentor while teaching me
how to be the best flute player and musician possible.
Lastly, I have had many friends, colleagues and students over the years
that have discussed their performance injuries with me. Without them, I would
not have realized the need for a document of this type. I am appreciative of their
confidences and all they taught me over the years.
iv
ABSTRACT
Cox, Sandra Elaine. DMA. The University of Memphis. May 2009.
Recognition, Evaluation, and Treatment Options of Performance-Related Injuries
in Woodwind Musicians. Major Professor: Angeline Case-Stott, M. M.
This document is a detailed study of the performance-related injuries
experienced by woodwind musicians. Care is given to explain injuries in a
language that is understandable to the non-medically trained musician. The
document introduces the subject with a brief history of performing arts medicine,
discussing the development and need for this highly specific specialty. This is
followed by a discussion of the literature available to the musician who wants to
understand performance-related injuries and how to prevent them.
Chapter three is devoted to the injuries and the treatment options
available to the musician. Disorders are grouped according to cause, such as
overuse disorders or entrapment neuropathies, and specific anatomic locations in
which the injuries are seen, such as left index finger disorders, or skin and
shoulder injuries. Advice is given for discerning which injury the musician is
experiencing, followed by a discussion of the typical management found in
traditional medicine. Some of the causes of injuries, such as poor posture and
lack of conditioning, are included.
Chapter four discusses treatment of the injuries. It includes traditional
medical treatment and several examples of complementary treatments that can
augment or substitute for traditional medical care, depending on the musician's
preferences. The complementary treatments are defined and discussed according
v
to how they can benefit the musician. Included in this section are treatments
such as massage, acupuncture, Alexander Technique, Physical Therapy, Reiki,
and Reflexology.
The conclusion stresses the need of all musicians for education in
performance related injuries, as well as the teacher's role in recognizing and
preventing these injuries. A glossary is included to explain some of the unfamiliar
medical terms used to define the conditions.
vi
Table of Contents
List of Illustrations
x
Chapter
1
Musicians and Medicine
1
2
The Literature of Performance Disorders
11
3
Performance Disorders
29
Carpal Tunnel Syndrome
34
Cubital Tunnel Syndrome
44
Thoracic Outlet Syndrome
52
Reflex Sympathetic Dystrophy
57
Ganglion Cysts
60
Focal Dystonia
61
Tendonitis
64
DeQuervain's Tendonitis
Epicondylitis
65
71
Lateral Epicondylitis
72
Medial Epicondylitis
73
Disorders of the Fingers
74
Thumb Disorders
74
Left Index Finger Disorders
86
Trigger Finger
91
vii
4
Disorders of the Neck
93
Disorders of the Shoulders
99
Subacromial Bursitis
100
Impingement Syndrome
103
Bicep Tendonitis
104
Disorders of the Skin
104
Temporomandibular Joint
109
Disorders of the Teeth
113
Hypermobility
115
Posture
117
The Treatment of Performance Disorders
Traditional Treatment
119
121
Non-Steroidal Anti-Inflammatory
Medications .
123
Steroids
125
Physical Therapy
126
Splints
128
Complementary Therapies
129
Bodywork
130
Therapeutic Massage
130
Feldenkrais Method
132
Alexander Technique
133
viii
Reiki
134
Reflexology
136
Chiropractic
139
Aromatherapy
139
Color Therapy
141
Eastern Medicine Techniques
144
Acupuncture
144
Jin Shin Do
145
Shiatsu
146
Yoga
146
Herbal Therapy, Vitamins
5
and Nutrition
147
Stretching
150
Exercise
166
Psychotherapeutic Treatment
166
Conclusions
:
168
Glossary
176
Bibliography
179
IX
Illustrations
Figure
Page
1. Median Nerve Innervation
35
2. Median Nerve Innervation
35
3. Wrist Anatomy
36
4. Wrist Anatomy
37
5. Tinel's Test
39
6. Phalen's Test
40
7. Wrist Splint for Carpal Tunnel Syndrome
42
8. Wrist Splint for Carpal Tunnel Syndrome
42
9. Ulnar Nerve Innervation
45
10. Elbow Anatomy
47
11. Elbow Splint for Cubital Tunnel
49
12. Elbow Splint for Cubital Tunnel
49
13. Brannen-Cooper Finger Extension
50
14. Elevate Arm Stress Test
54
15. Elevate Arm Stress Test
54
16. Poor Posture
55
17. Improved posture with Ergonomic Chair
56
18. DeQuervain's Tendonitis Anatomy
66
19. Thickened Tendon Sheaths in DeQuervain's Tendonitis. . . .
66
20. Finkelstein's Test 1
68
x
68
69
69
24. Thumb Spica Splint
70
25. Elbow Joint Anatomy
71
26. Clarinet with Moveable Thumb Rest
77
27. Clarinet with Improvised Thumb Cushion
78
28. Clarinet with Manufactured Thumb Cushion
79
29. Thumbports
81
30. Thumbports on Flutes
81
31. Incorrect Right Thumb Position
83
32. Incorrect Right Thumb Position
83
33. Correct Left Thumb Position
84
34. Saxophone Thumb Rests
85
35. Saxophone Thumb Rests
85
36. Bassoon with Improvised Strap
87
37. Thumb Position with Improvised Strap on Bassoon . . . .
88
38. Placement of Improvised Strap from Bassoon to Chair. .
89
39. Bo-Pep on Flute
90
40. Improvised Finger Rest on Flute
91
41. Saxophone with Incorrect Posture in Neck
94
42. Saxophone with Improved Neck Posture and Neckstrap
94
xi
43. Ergonomic Chair
95
44. Improvised Foot Rest
97
45. Shoulder Anatomy
101
46. Area of Impingement in Shoulder
102
47. Flute Headjoint with Contact Paper
106
48. Dental Aid for TMJ
112
49. Wax Lip Shield for Clarinets and Saxophones
114
50. Repaired Teeth After Years of Saxophone Playing
115
51. Bishop's Putty for Strengthening the Hand Muscles . . . .
127
52. Example of Physical Therapy Program from Campbell
Clinic, Memphis, Tn
128
53. Reflexology Foot
137
54. Reflexology Hand
138
55. Stretching Exercises for Upper Body 1
152
152
153
153
59. Stretching Exercises for Upper Body in Sitting Position 1.
154
155
156
62. Stretching Exercises for Arms 1
157
63. Stretching Exercises for Arms 2
xii
157
64. Arm Stretch Using a Chair
158
65. Shoulder Stretch 1
159
66. Shoulder Stretch 2
159
67. Upper Back Stretch 1
160
68. Upper Back Stretch 2
161
69. Neck Stretch 1
162
70. Neck Stretch 2
162
71. Neck Stretch 3
163
72. Neck Stretch 4
163
73. Face Stretch 1
164
74. Face Stretch 2
165
75. Injury Comparison Table
172
XIII
Chapter One
Musicians and Medicine
As a specialized group with specialized problems, musicians have long
been ignored by the medical community. While individuals have access to their
health care providers for various aches and pains associated with performing,
there have been, in the past, very few medical personnel trained to deal with
specific health issues related to playing one's instrument. Over time this has
begun to change. The medical and musical communities have begun to
recognize the need for specialized training, so that the medical problems of
performers can be addressed. The need for specialized health care, both
traditional and complementary, has become increasingly more apparent. We
now find performance health centers scattered throughout the nation, although
most are found in major metropolitan areas that have significant orchestras and
musical communities.
Another aspect of the ever-increasing problems of performing artists is
the need for specialized education for the performers and their teachers. When
looking at specific problems arising in performers, one cannot help but wonder
what might have been prevented. How different it could have been if young
musicians had been offered solutions to awkward positions when sitting or
standing, or had been given advice regarding which instrument suited their
1
physique. One thing that is glaringly obvious is that most musicians, both
teachers and performers, have a substantial void in their education with respect
to performance health. Sadly, most of us don't really become knowledgeable
about a performance related problem until we experience it or see it in a
student. The unfortunate reality of this situation is that we ignore the problem
until it is too late. This inevitably leads to an inappropriate approach to the
resolution. The best thing would be to avoid the problem altogether. If this is
not possible, both the musician and teacher need a resource that can provide
instruction and a possible solution when a problem arises.
Musicians, during their educational years, typically do not have a course
that addresses aspects of performance health. There are some programs that
offer the Alexander Technique or Yoga, but a true course in performance health
is not available to those who need it most. If the person who starts most of us
on our instruments has inadequate information, then how can we avoid the
problems that will surface ten to fifteen years later? Since classes in
performance health do not exist in most schools of music, it stands to reason
that there are no textbooks. While there are two medical textbooks, Textbooks
of Performing Arts Medicine by Robert Thayer Sataloff, M.D., Alice G.
Brandfonbrener, M.D., and Richard J. Lederman, M.D., and Medical Problems of
the Instrumentalist Musician by Raoul Tubiana, M.D., and Peter C. Amadio,
M.D., that address problems performers experience, these problems are only
vaguely mentioned in orthopaedic or rheumatic medical texts. These texts are
2
very specialized and are not part of a traditional medical curriculum, so the
average health care provider is not exposed to problems frequently
encountered by musicians. It is true that anyone can read these texts, but
medical knowledge is usually required to interpret and relate the information to
the musician. Musicians want information, but they need it in a format that is
accessible to a non-medical person. This is the basis for my document, a guide
for woodwind players in the recognition, management, treatment options and
prevention of performance-related problems.
My document is not meant to be a substitute for actual medical care. It
is intended to be used as a guide to give direction when deciphering a problem
and making a decision about the best approach to dealing with it. It will cover
the most common problems experienced by woodwind players and will include
a variety of treatment options, since some prefer complementary medicine to
traditional techniques. The main purpose of my document will be to provide a
bridge between the medical community and the musician, allowing the
musician to recognize problems, as well as avoid them. As a Master's prepared
Nurse Practitioner, I have cared for many patients, both musicians and nonmusicians, with the disorders discussed in this document. Having advanced
degrees in both fields gives me a unique perspective on the problems
encountered by musicians. Hopefully this guide will provide the information
needed to make the best possible decision for each individual situation.
3
It is understood that, when problems develop and the musician of any
age or level of performance seeks to find help in this document, there may not
be time to read it all in one sitting. For this reason, I have purposely included
specific information related to management and treatment in several different
sections. This will allow the reader to quickly find help in understanding
approaches that may be useful before early danger signals become chronic
injuries.
When evaluating problems seen in musicians and reading available
literature, one quickly ascertains that the problems of some performers and
their instruments have been addressed better than others. The vocalists have
received much attention, as have pianists. In addition, string players have had
considerable material written about them. This is not true of woodwind players.
Typically, the most attention woodwind players get is a phrase "can occur in
clarinet and oboe players" at the end of a lengthy medical explanation of a
problem. The optimal solution would be the institution of performance health
courses in all schools of music. Hopefully that will become a reality, but, until it
does, musicians need medical information that they can readily understand.
This document will bring us one step closer to filling that void.
When thinking about the plethora of problems one encounters in
musicians, two categories emerge: the overuse syndromes and nerve
entrapment syndromes. Overuse syndromes are also called Repetitive Strain
4
Disorders or Cumulative Trauma Disorders. Overuse syndromes, as defined by
Kelly et al. in the Textbook of Rheumatology, are "injuries caused by the
cumulative effects on tissues of repetitive physical stresses that exceed
physiologic injuries."1 Simply stated, Overuse Syndrome occurs when a joint,
tendon, ligament, or muscle is subjected to the same movement repeatedly.
When this occurs, the joints, tendons, ligaments, and/or muscles become
irritated, inflamed, and swollen, and continued repetitive motion aggravates the
problem. The main symptom, at least in the beginning, is pain. Initially, the
pain will improve when the movement stops. After time passes, the pain will
persist even after the movement stops. Overuse Syndromes can occur in many
areas. The hands and wrists suffer from movements involving extension and
flexion. Rotation injuries may occur in the neck as a result of turning the neck
to the side. These injuries are also found in the cervical spine and left shoulder.
Another area that may suffer from overuse is the embouchure. The
overuse is seen in the lips, soft palate, and muscles of the pharynx, resulting in
damage to the muscle fibers. The continued repetitive use of these small
muscle groups leads to hypertrophy, or increase in size, of the actual tissues.
1
William Kelly, M.D., et al., Textbook of Rheumatology (Philadelphia: W.
B. Saunders Company, 1993): 1712.
5
This compresses the nerves at various sites and is one reason for entrapment
disorders.2
Nerve Entrapment Disorders are defined as compression on a nerve
within a closed space. This happens when the nerve passes through an opening
or tunnel. It can occur when there is scar tissue, a narrowed opening in the
canal or passageway, swelling of the soft tissue deformity, tumors, masses, or
hypertrophied muscles. Damage can occur when high pressure is exerted for
short periods or low to medium pressure is exerted for long periods. The most
common cause is direct mechanical injury, caused by chronic low pressure
being exerted at the site or friction.3 The close relationship between the two
types of injuries makes it even more imperative that the musician seeks
medical help before it is too late. A good rule of thumb to help distinguish
between the two is that entrapment neuropathies will produce weakness and
changes in sensation in addition to the discomfort, pain, and loss of ability to
play produced by overuse syndromes.4 Another prevalent problem that arises is
that many of the nerve entrapment disorders are actually caused or
exacerbated by overuse of the joint or muscle. This leads to further confusion
for the musician about the exact cause, making prompt evaluation by a
physician trained in these disorders even more critical.
2
Ibid.
3
Kelly, Rheumatology, 1712.
4
Ibid.
6
Many people liken musicians to athletes and assume the treatment of
their injuries should be similar. While musicians are similar to athletes in one
respect, in that both practice many hours repeating the same motions in an
effort to improve and polish performance, the problems occurring in musicians
are different from those encountered in athletes. Musicians tend to use small
muscles requiring fine movements as compared with the athlete's use of large
muscle groups. Therefore, types of injuries are markedly different. When an
athlete tears ligaments in his knee, he cannot walk. When a musician injures a
finger or wrist, it is much harder for the outside world to detect, since we still
continue to perform most daily activities. Therefore, we must understand that
musicians' health is a specific branch of medicine, which should have health
care providers that understand medical disorders specific to our profession.
Musicians must be prepared to take the initiative in getting the appropriate
treatment by understanding what is occurring when they practice or perform. It
is important to understand that posture, the design of the instrument played,
the physical mechanics of performance on the instrument, and how much they
practice can directly impact their careers and health.
In researching performance health, one quickly sees that the history of
this specialty is somewhat sparse. While there are documents relating to some
of the more common injuries experienced by performers, for example,
Schumann and his hand injury, very little had been devoted to performing arts
medicine as a specialty until the 1960's and 1970's. Bernardino Ramazzini, an
7
Italian physician, wrote the first known study of musicians' performance health
in 1713. His treatise, Diseases of Tradesmen included a summary of
occupational diseases of musicians.5 In the late 1800's, many physicians were
interested in writer's cramp and researched the condition. During this period,
both musicians and physicians were discovering the links between human
anatomy, physiology, and the playing of musical instruments. Many of the
instrumentalists played the piano or keyboard, ergo this is where much of the
research was focused. This pattern of hand injuries, with Robert Schumann
being the most notable, led many important teachers of the day to write texts
on piano pedagogy, although many were based on the author's own misguided
beliefs. This misinformation was related to the musicians' inability to
understand the medical and scientific data. Eventually some musicians did
understand and published books on piano technique that were detailed,
scientific, and geared to the musician. One example is Otto Ortmann, a
professor at Peabody Conservatory in Baltimore, who wrote The Physiological
Mechanisms of Piano Technique in 1929. Ortmann used the most modern
technology available at the time to evaluate every aspect of piano performance.
5
Robert Thayer Sataloff, M.D., Alice G. Brandfonbrener, M.D., and
Richard J. Lederman, M.D., Textbook of Performing Arts Medicine (New York:
Raven Press, 1991): 1-4.
8
His treatise included information on individual differences in the hand and arm
and how this impacted technique.6
In 1932, Kurt Singer, a German neurologist who was also trained as a
musician, became interested in the problems encountered by working
musicians. His musical background was quite extensive as a music critic,
conductor, and performer, giving him an unusual capacity to write about the
subject. He worked as both a neurologist and music critic before writing his
book. He lectured on diseases of the professional musician and the psychology
of music for ten years before he published his book Diseases of the Musical
Profession: A Systematic Presentation of Their Causes, Symptoms, and Methods
of Treatment. The book addresses many aspects of caring for the musician,
including nervousness, occupational cramps, and problems with the
embouchure, vision, laryngitis, and dental disorders. Singer also devotes an
appendix to what he called The Healing Effect of Music-The Hygiene of Playing'
in which he elaborated on how sleep, water, air, exercise, and sunshine are
essential to the musician. While many of his ideas are outdated, some are still
pertinent, such as his statement that "any exertion, according to its intensity,
must be followed by adequate recovery."7
6
Ibid., 3.
7
Kurt Singer, M.D., Diseases of the Musical Profession, trans. Wladimir
Lakond (New York: Greenburg Publisher, Inc., 1932): 167.
9
The next book was written in 1948 and entitled Music and Medicine,
edited by Dorothy M. Schullian and Max Schoen. This text has many examples
from both musical and medical literature of musicians and occupational
diseases that relate to performance. Most of the examples refer to vocal and
dental problems.8 The 1960's saw an increase in musicians complaining of
hearing loss related to performance, which coincided with the advent of rock
music. During this time, there was increasing interest in the field of music
medicine by physicians. In 1972, at the Danube Symposium in Vienna, the
focus was neurology in music. As a result of the meeting, two participants, R.A.
Henson and MacDonald Critchley, collaborated to write Music and the Brain:
Studies in the Neurology of Music. Published in 1977, this treatise is credited
with starting the field of music medicine. This book was separated into
sections: the first focusing on how the nervous system functions during musical
activity and the second on how specific neurological disorders affect musical
function. Many occupational diseases and their relationship to musicians are
discussed.9
Sataloff, Brandfonbrener, and Lederman, Performing Arts Medicine, 4.
9
Sataloff, Brandfonbrener, and Lederman, Performing Arts Medicine,
7-9.
10
Chapter 2
The Literature of Performance Disorders
Throughout the 1960's and 1970's, the physical problems of musicians
were addressed in many different journals and books. The real turning point in
accepting that such problems needed attention occurred in 1981 when two
famous musicians, Leon Fleisher and Gary Graffman, admitted they had a
problem with their hands.1 The avenue they took to seek a solution magnified
the lack of an understanding medical community. When these two men stepped
forward and admitted they had hand problems, it opened the door for all
musicians suffering with performance-related injuries to identify their problems.
It was now readily apparent that specialists were needed to treat these
problems. Although many different types of problems were getting exposure,
most musicians were still reluctant to verbalize their concerns, for fear of being
labeled as less competent or losing their jobs. Articles appeared in medical as
well as music journals. In 1982, the National Flute Association's (NFA) annual
convention had several presentations related to performance health. The
Dysfunction Committee was formed in 1985 and continues to exist, working to
1
Robert Thayer Sataloff, M.D., Alice G. Brandfonbrener, M.D., and Richard
J. Lederman, M.D., Textbook ofPerforming Arts Medicine (New York: Raven
Press, 1991), 9.
11
educate flutists about injury prevention.2 The NFA committee, now called the
Performance Health Committee, meets and does presentations at each annual
convention. In 1983, the first conference on "Medical Problems of Musicians" was
organized and is now an annual event that occurs in conjunction with the
Colorado Music Festival in Aspen, Colorado.3 Since that time, many countries and
other organizations have had conferences relating to various concerns in the
field. The NFA continues to address the subject in its publication The Flutist's
Quarterly. In 1986, a magazine devoted to the topic was first published. Medical
Problems of Performing Artists addresses issues related to singers,
instrumentalists, and dancers. By 1989, the Aspen Conference had evolved to
form the Performing Arts Medicine Association (PAMA).4 Musicians in the 1990's
had several clinics, usually found in larger cities with major orchestras, where
they could go for help. The field continues to grow and evolve to this day as
musicians continually seek to improve and deal with the results of striving to be
better on their instruments.5
The Textbook of Performing Arts Medicine, edited by Robert Sataloff,
M.D., Alice Branfonbrener, M.D., and Richard J. Lederman, M.D., was first
2
Mary Louise Poor, "Dysfunction Committee Column," The Flutist
Quarterly, (Winter 1985): 22.
3
4
Ibid.
5
Ibid., 10-17.
12
published in 1991. It is the first modern textbook to deal with issues related to
performance health. This book is a medical text covering all aspects of
dysfunction observed in musicians. The history of the field is discussed as well as
how the problems develop, and problems are discussed according to system, in
other words, musculoskeletal, neurological, ophthalmologic, and psychiatric. The
text also includes extensive detail regarding care of the voice and about hearing
loss, diagnosis, and surgical treatment of the hand, reproductive disorders in
dancers, and medical-legal aspects of caring for performing artists. Appropriate
medical experts in the field have written each chapter. This is a superb book for
the health care provider, but it would be difficult for the average, nonscientifically oriented musician to comprehend. For the medical professional, it
provides information regarding the majority of problems seen in musicians and
their required treatment. While not as detailed or as extensive as some other
medical texts, it is a good introduction to the field.
There are numerous medical textbooks that describe cumulative trauma
disorders. One text that is helpful is the 2-volume Textbook of Rheumatology by
William Kelley, M.D., Edward D. Harris Jr., M.D., Shaun Ruddy, M.D., and
Clement B. Sledge, M.D.6This publication provides explicit detail about the
anatomy of the joints and muscles. There are in-depth explanations regarding
6
William Edward D. Kelley, M.D., et al., eds., Textbook of Rheumatology
(Philadelphia: W.B. Saunders Company, 1993).
13
examination of the affected areas, pain in each individual area of the body, and
subsequent treatments. There is also a separate chapter on the disorders related
to nerve entrapment.
Another helpful book is Common Musculoskeletal Problems by Arun J.
Mehta.7 This book includes concise explanations of conditions and provides
simplified drawings to enhance understanding, with suggestions for diagnosis
and treatments. The general medical text Principles of Ambulatory Medicine,
edited by L. Randol Barker, Nicholas H. Fiebach, David E. Kern, Patricia A
Thomas, and Roy C. Ziegelstein,8 includes detailed explanations of different
entrapment syndromes that are encountered by primary care doctors on a daily
basis.
You Are Your Instrument by 3u\\e Lyonn Lieberman9 is a uniquely relevant
guide that clarifies the effect of our bodies on our performance. There are many
suggestions on how to stay healthy and how to avoid many of the referenced
problems. This book has simplified anatomical drawings that enhance the writing
and includes suggestions on how to avoid development of the conditions I will be
7
Arun J. Mehta, M.D., Common Musculoskeletal Problems (Philadelphia:
Hanley & Belfus, Inc., 1997).
8
L. Randol Barker, M.D., et al., Principles of Ambulatory Medicine
(Philadelphia: Lippincott, Williams and Wilkins, 2007).
9
Julie Lyonn Lieberman, You Are Your Instrument: The Definitive
Musicians Guide To Practice and Performance (New York: Huilksi Music, 1991).
14
addressing. Lieberman discusses the connections between the body and the
mind and the roles they play in performance. She addresses many of the daily
problems a musician encounters and suggests brief and practical remedies, with
an overview of many different treatment modalities for various problems. This
book does not discuss the various specific medical disorders experienced by
musicians.
In Musical Excellence-Strategies and Techniques to Enhance Performance
by Aaron Williamon,10 a chapter is devoted to obtaining optimal performance on
a musician's instrument. This chapter addresses key areas that require special
attention and provides a concise breakdown by instrument of commonly
encountered problems. Several alternative treatments are discussed in the later
portion of this book.
In Bailliere's Clinical Rheumatology, volume 8, number l, 11 an entire
chapter is devoted to the musculoskeletal problems found in performing artists.
Important concerns are discussed, such as problems of performing artists and
the doctor's responsibility. Emphasis is placed on the importance of the doctors'
awareness of the possibility that physical complaints of musicians may be related
10
Aaron Williamon, Musical Excellence: Strategies and Techniques to
Enhance Performance (Oxford: Oxford University Press, 2004).
11
J.M. Greer, M.D., and R.S. Panush, M.D., "Musculoskeletal Problems of
Performing Artists," in Baillere's Clinical Rheumatology, ed. R.S. Panush, M.D.,
and N.E. Lane, M.D., (London: Bailliere Tindall, 1994): 103-36.
15
to the playing of their instruments. The chapter also advises that many of these
gifted performers are in the lower income bracket, and health care may not be
easily accessible to them. It includes brief descriptions of typical problems
peculiar to musicians and addresses possible causes such as hypermobility. Brief
references are made to the treatment, management, and prevention of such
impairments. The authors stress that problems are hampered by a lack of
knowledge and recognition of the symptoms, noting that most of the literature
on the subject is recent. The chapter concludes with a brief history and a case
study.
Another useful resource is Warren D. Blackburn's Approach to the Patient
With a Musculoskeletal Disorder.12 This small book has very brief and concise
explanations of some of the more common disorders such as Carpal Tunnel
Syndrome. It includes simple diagrams to aid in understanding, references to
situations in which the problems occur, and various treatment options.
The magazine Performing Art Medicinefocuses on medical issues of all
varieties common to performing artists. This magazine grew out of the
recognition by a small group of doctors that there exists a need for information
among those providing treatment for artists in all areas. The article "Prevalence
of Playing-Related Musculoskeletal Symptoms and Disorders in Children Learning
12
Warren D. Blackburn, Jr., M.D., Approach to the Patient With a
Musculoskeletal Disorder (Birmingham: Professional Communications, Inc.,
1999).
16
Instrumental Music" (2008)
examines playing-related musculoskeletal
problems seen in younger children. Components such as age and sex were
factored into the study. Risk factors were considered; a questionnaire was
developed; and data was presented. The article concludes with data supporting
the premise that increasingly, younger musicians are developing health issues
related to performance, and the observation that the need for awareness in
teachers is becoming increasingly evident.
There are several articles related to specific problems in Medical Problems
of Performing Artists. All four issues in 1993 concentrate on disorders found in
woodwind players. "Conservative Management of Thoracic Outlet Syndrome in
the Musician"14 by Christine Novak, a Physical Therapist, offers a concise
definition of Thoracic Outlet Syndrome and includes sections on the evaluation,
assessment, and management of this problem. Several articles on upper
extremity nerve entrapment syndromes seen in musicians appear in the June
issue. A very informative article by Carol Brooks, an Occupational Therapist,
entitled "A Therapist's Perspective on the Treatment of Upper Extremity Nerve
13
Sonia Ranelli, M.Sc, Leon Straker, Ph.D., and Anne Smith, Ph.D.,
"Prevalence of Playing-related Musculoskeletal Symptoms and Disorders in
Children Learning Instrumental Music," Medical Problems of Performing Artists
23, no. 4 (December 2008): 178-85.
14
Christine B. Novak, P.T., M. Sc, "Conservative Management of Thoracic
Outlet Syndrome in the Musician," Medical Problems of Performing Artists 8, no.
1 (March 1993): 16-22.
17
Entrapment Syndromes in Musicians"15 details the evaluation of these problems
and has separate sections related to problems associated with the median and
ulnar nerves. Many helpful illustrations assist the reader in understanding what is
occurring from a physiologic standpoint. William B. Nolan and Richard G. Eaton
focus solely on Cubital Tunnel in "Evaluation and Treatment of Cubital Tunnel
Syndrome in Musicians",16 which details the signs and symptoms while relating
them to all possible diagnoses. Treatments, both conservative and surgical, are
discussed. The article "Entrapment Neuropathies in Instrumental Musicians" by
Richard J. Lederman focuses on Carpal Tunnel and Ulnar Neuropathies, the
treatment options, and the problems that one encounters with various
modalities. Lederman provides charts related to his findings and according to
instrument group. The thumb rest on the clarinet, oboe, saxophone, and English
horn presents problems often resulting in pain in right thumb. W. Paul Smutz,
Ph. D., Allen Bishop, M. D., Howard Noblock, M. M., Maria Drexler, and Kai-Na's,
Ph. D., article "Load on the Right Thumb of the Oboist"17 in the September 1995
5
Carol E. Brooks, O.T.R./L., "A Therapist's Perspective on the Treatment
of Upper Extremity Nerve Entrapment Syndromes in Musicians," Medical
Problems of Performing Artists 8, no. 2 (June 1993): 61-69.
16
William B. Nolan, M.D., and Richard G. Eaton, M.D., "Evaluation and
Treatment of Cubital Tunnel Syndrome in Musicians," Medical Problems of
Performing Artists 8, no. 2 (June 1993): 47-51.
17
W. Paul Smutz, Ph.D., et al., "Load on the Right Thumb of the Oboist,"
Medical Problems of Performing Artists 10, no. 3 (September 1995): 94-99.
18
edition of Medical Problems of Performing Artists addresses this problem in a
detailed article on problem solutions, followed by a study of different
apparatuses that may alleviate this problem.
A set of articles by Raoul Tubiana entitled "Functional Anatomy of the
Hand"18 in the December 2005 edition of Medical Problems of Performing Artists
is a concise and detailed explanation of how the upper extremities work. It is
divided into three sections: the first dealing with the upper limbs; the second
concentrating on the fingers and their contribution to performance; and the third
relating how the upper extremities function with the rest of the body to facilitate
a fluid performance. Dr. Tubiana is a specialist in orthopaedic surgery and an
authority on the hand, having researched the hand and its functions as related to
musicians. This set of articles offers excellent points relative to anatomy and
physiology and their relationships to instrumental performance. The articles are
very detailed and utilize medical terminology, making it somewhat unfriendly
reading unless one has a knowledge of anatomy and physiology.
Medical Problems of Performing Artists has many articles with numerous
studies pertaining to many of the conditions addressed in its articles. Many of
these studies concentrate on some aspect of performance, a related syndrome,
and options for treatment, diagnosis, or research that is being investigated.
18
Raoul Tubiana, M.D., and Philippe Chamagne, P.T., "Functional
Anatomy of the Hand," Medical Problems of Performing Artists 20, no. 4
(December 2005): 183-94.
19
There are also articles detailing the need for training in this field for all
musicians, whether they are educators, performers or both. A set of three
articles entitled "Health Promotion Courses for Music Students"19, lists programs
in the United States and Europe that offer a course in health promotion for
musicians.
There are many articles devoted to the topic of performance health and
education in the Music Educators Journal. In the article "Performing Arts
Medicine and Music Education: What Do We Really Need To Know?"20 Valerie
Trollinger recognized the need for musicians to know and understand
performance health. She focuses on the deficit in musical education of this area
and points out that an uneducated teacher may inadvertently do more harm than
good. Trollinger also points out that one problem in delivering this type of
education is the scarcity of instructors with education in both the medical and
music fields who can explain and understand what is happening with such
disorders. William Dawson's article "Playing Without Pain: Strategies for the
Developing Instrumentalist"21 suggests possible solutions for prevention,
9
Ralph Manchester, M.D., "Health Promotion Courses for Music Students:
Part I," Medical Problems of Performing Artists 2, no. 1 (March 2007): 26-29.
Valerie Trollinger,"Performing Arts Medicine and Music Education: What
Do We Really Need to Know?" Music Educators Journal 92, no. 2 (November
2005): 42-48.
21
William J. Dawson, "Playing without Pain: Strategies for the Developing
Instrumentalist," Music Educators Journal^, no. 2 (November 1, 2006): 36-71.
20
recognition, and recurrence of problems. In "Fit to Play: Musicians' Health
Tips,"22 Karen B. Frederickson gives an overview of what behaviors might result
in some of the long range problems experienced by musicians. She gives brief
suggestions for warm-ups, stretching, and strength training, specific for certain
muscle and joints.
In his 1991 book Making the Connection: Music and Medicine?3 Franz L.
Roehmann examines how the body, long deemed the property of the medical
community, is connected to that part of us that creates music. He also examines
what he terms the "music and medicine movement", making clear how one
relates to the other. He explores specific disorders often seen in musicians and
stresses the need for specialists in the area of performance medicine. Roehmann
further explores the multiple things in life that can be stressful for a musician,
leading to a loss of skill for a variety of reasons. He compares traveling musicians
with athletes in his analysis of the traveling orchestra and the pitfalls associated
with travel. Roehmann states that, as a result, many of the large orchestras
travel with performance physicians, much like traveling sports teams. He
recommends the need for education of the music student with respect to the
medical factors that impact performance.
Karen B. Frederickson, "Fit To Play: Musicians' Health Tips," Music
Educators Journal88, no. 6 (May 2002): 38-44.
23
Franz L. Roehmann, "Making the Connection: Music and Medicine,"
Music Educators Journal77, no. 5 (January 1991): 21-25.
21
Two books written to assist in instructing music education majors'
woodwind method classes are also helpful in showing ways to hold and play
woodwind instruments. In A Guide to Teaching Woodwinds24 by Frederick W.
Westphal, the chapters are arranged by instrument and have checklists for a
myriad of subjects, ranging from assembly to hand position. This book has many
photographs to assist in understanding the basic physical concept of playing. The
companion book by Westphal, Beginning Woodwind Class Method,25 also
provides pictures with correct hand and body position, as well as exercises
formulated to assist in learning the correct fingerings and position.
The Hand26 by Frank R. Wilson provides an entirely new and different way
of thinking about the hand. Wilson addresses the role it plays in the art of
making music.
Richard Norris, a physician and amateur flutist with an interest in
performance health, wrote a short guide for musicians entitled The Musicians
Survival Manual: A Guide to Preventing and Treating Injuries in
Frederick W. Westphal, Guide to Teaching Woodwinds (Boston: McGraw
Hill, 1990).
25
Frederick W. Westphal, Beginning Woodwind Class Method (Boston:
McGraw Hill, 1983).
26
Frank R. Wilson, The Hand (New York: Pantheon Books, 1998).
22
Instrumentalists
. This book provides concise explanations of some of the most
common problems encountered in the musical sector and describes non-surgical
treatments and therapeutic exercise. Of special interest is a chapter devoted to
flutists, including pictures and diagrams. In order to alleviate medical problems,
Norris has made various therapeutic devices, which he promotes in the book.
Many of the drawings in his book are anatomical drawings extracted from
medical books and are probably too detailed for the non-medical person.
There are many books replete with information on both traditional and
complementary therapies. One is The Alexander Technique28 by Wilfred Barlow.
Barlow, a rheumatologist, was one of the first teachers instructed by Alexander.
Barlow's book provides a detailed explanation of the Alexander method, including
pictures with correlations to conditions that contribute to overuse syndromes. In
Fundamentals of Yoga,29 Rammurti Mishra provides a comprehensive explanation
of the different principles of yoga and applies these principles to different
physiologic systems in the human body. There are selected drawings of different
Richard Norris, M.D., The Musicians Survival Guide: a Guide to
Preventing and Treating Injuries in the Instrumentalist (San Antonio:
International Conference of Symphony and Opera Musicians, MMB Music, 1993).
28
Wilfred Barlow, The Alexander Technique (New York: Warner Books,
1973).
29
Rammurti S. Mishra, Fundamentals of Yoga (Garden City, New York:
Anchor Books, 1974).
23
poses to aid in understanding. Universal Life Energy, by Bodo J. Baginski and
Shalila Sharamon, provides detailed information about Reiki's complementary
therapy. It begins with a history of how Reiki operates and the application of
Reiki to the human body. It concludes with a chapter referencing the
interpretation of different symptoms in the various systems of the human body.
Another useful book on a commonly used complementary therapy is Yochanan
Rywerant's The Feldenkrais Method.31 This book includes an introduction by Dr.
Feldenkrais, who mentored the author for over thirteen years, and provides an
explanation of the Feldenkrais Method and its basic techniques. It concludes with
a chapter of case histories that explains how Feldenkrais provides physical relief.
The first study, a story of a flute player, details the role Feldenkrais played in
recovery.
Frances M. Tappan writes about the history of massage and the general
principles of massage, reviewing different methodologies of massage in his
textbook entitled Healing Massage Techniques.32 One section is on the use of
massage for various healing purposes; another section discusses various
massage techniques which accommodate various diseases. Bob Anderson, in his
30
Bodo J. Baginski and Shalila Sharamon, Reiki: Universal Life Energy
(Mendocino, California: Life Rhythm Publication: 1988).
31
Yochanan Rywerant, The Feldenkrais Method (New Canaan,
Connecticut: Keats Publishing, Inc., 1983).
32
Frances M. Tappan, Healing Massage Techniques: Holistic, Classic, and
Emerging Methods (Norwalk, Connecticut: Appleton & Lange, 1988).
24
book Stretching, recommends stretching exercises to aid in everyday fitness. His
book includes drawings to assist the reader in comprehending which muscles are
affected by specific movements. This is a useful reference for musicians who
want to ascertain that their muscles are warmed up before they play or practice.
Another advocate of Tappan and Anderson's methodologies is Thomas
Hendrickson, author of Massage for Orthopedic Conditions.23 Hendrickson, a
chiropractor, emphasizes the connection between the nervous system and the
spine. He emphasizes massage as a healing technique in the management of
musculoskeletal pain and dysfunction. The New Holistic Health Handbook,34
edited by Sheperd Bliss, is an excellent resource tool that provides concise
information regarding many complementary therapies. If one chooses to explore
the multiple and varied therapies, Bliss' book offers a good foundation.
Informed Touch: A Clinicians Guide to the Education and Treatment of
Myofascial Disorders35 by Donna Finando, L.Ac., L.M.T, and Steven Finando,
Ph.D., L.Ac., is a practical manual written by a licensed massage therapist and
acupuncturist for health professionals who deal with syndromes and conditions
Thomas Hendrickson, Massage for Orthopedic Conditions (Baltimore,
Maryland: Lippincott, Williams, &Wilkins, 2003).
34
Sheperd Bliss, ed., The New Holistic Health Handbook (Lexington,
Massachusetts: The Stephen Greene Press, 1985).
35
Donna Finando, L.Ac., L.M.T., and Steven Finando, Ph.D., L.Ac.,
Informed Touch: A Clinicians Guide to the Evaluation and Treatment of
Myofascial Disorders (Rochester, Vermont: Healing Arts Press, 1999).
25
that occur in the musculoskeletal system. This book is a simplified, easy-tounderstand guide to different muscles and the pain experienced in these areas.
The helpful drawings of the affected areas are highlighted in red, allowing one to
identify the muscles causing the pain. Concise explanations of trigger points and
muscles, and of Oriental manipulation therapy and their relationship to our
health are provided. The book relates how touch is used to treat and diagnose
pain. Descriptions of movements related to affected muscles are included along
with stretching exercises for the affected muscle. Included are muscular
diagrams, which are very helpful to musicians who want to warm up specific
muscle groups prior to playing their instrument.
Another useful book is Ben E. Benjamin's Listen to Your Pain: The Active
Person's Guide to Understanding, Identifying, and Treating Pain and Injury.36
Benjamin is a Ph.D. in Sports Medicine and Education and uses therapeutic
massage to treat muscular injuries. He explains injuries and provides guidelines
to therapists on assessing and treating the most common injuries. Included are
illustrations, which make it much easier for the non-medical reader to
understand. This book includes exercises that facilitate healing and provides
suggestions for self-treatment, as well as medical treatment. With a section on
precaution, the book introduces the concept of rehabilitation and recovery and
gives examples of injuries and probable causes. Causes of the injuries are
36
Ben E. Benjamin, Ph.D., Listen to Your Pain (New York, New York:
Penguin Books, 2007).
26
somewhat vague but tend to be sports related. Evaluation and treatments are
explored in a separate section. While the health-care professional may find this
book's contents more relevant than the musician, it does serve as a useful
reference in performance medicine literatures.
Yvonne D'Arcy's article "Difficult-to-treat chronic pain syndromes"37, found
in The Clinical Advisor, offers a simplified explanation of pain and its treatment.
She divides the article into sections that include recommending the appropriate
medication for specific pain types, such as neuropathic pain. She also includes
recommendations on the avoidance of addiction to certain medications.
Raoul Tubiana and Peter Amadio's book Medical Problems of the
Instrumentalist Musician2* is a detailed text providing medical personnel a
therapeutic framework for treatment of the musician. The book begins with the
functional anatomy of the hands, upper arm, and spine and contains information
on how the body affects performance. The disorders are discussed in separate
chapters related to location, cause, and management. The psychological aspects
of performance are detailed in chapters on performance anxiety and the
psychology of specific disorders. Surgical resolution and rehabilitation are also
included in the text. Chapters on prevention, ergonomics, and piano and violin
Yvonne D'Arcy, "Difficult-to-treat chronic pain syndromes," The Clinical
Advisor (December 2008): 27-33.
38
Raoul Tubiana, M.D., and Peter C. Amadio, M.D., Medical Problems of
the Instrumentalist Musician (London: Martin Dunitz, 2000).
27
technique conclude the text. This is a comprehensive medical text written for the
physician specializing in treatment of musicians.
28
CHAPTER 3
Performance Disorders
Some basic tenets are needed to understand the mechanics of
performance disorders. Many people compare musicians with athletes. Athletes
are known for the way they take care of their bodies, such as exercising, refining
movements through strength training and agility, eating properly, and getting
adequate sleep. They are taught that the entire body must be healthy if one
wants all parts to function correctly. Musicians are like athletes in that certain
muscle groups are highly developed. The comparison ends there. Many
musicians, especially in the younger age groups, do not understand the need for
proper maintenance of the entire body in order to provide a state of wellbeing
that enables instrumental performance at an optimum level. Our bodies were
designed to work best when the complete body is balanced. Each part of the
human body is affected by one or more of the other parts. The hand cannot work
in a highly skilled manner if the shoulder and elbow, and any of the upper limb
supporting structures are functioning less than normal. The elbow and shoulders
exist to position the hand in space and to assist the hand in functioning at its
very best. Even though hands and fingers are used to play an instrument, they
must have a foundation and an upper limb that is functionally sound in order for
successful playing to occur. There are many reasons why the upper extremity
fails as a system.
29
The muscles, along with the joints, provide movement, which allows us
the ability to play an instrument. Muscles work in conjunction with other muscles.
The medical term for this action is called synergy. Synergistic muscles work in
concert with each other, such as finger flexion (bending) and wrist extension
(moving a limb into a straight position). Non-synergistic muscles, such as finger
flexors and wrist flexors work in conflict. The brain signals the limb to perform a
specific movement, and a cascade effect will occur. Muscles are not controlled
individually, and this is one reason musicians tend to be troubled by performance
injuries. They are unaware or forget that everything is connected. When we have
numbness in our thumb, we think we have a thumb problem. In reality, the
numbness begins much farther away than where the problem is actually located.
Problems with the hand seem to typify the complaints of musicians. The hand is
a moveable organ and is manipulated by numerous muscles. The principal
muscles are referred to as the intrinsic and extrinsic muscles. The intrinsic
muscles are located in the hand and assist in performance of fine, coordinated
movement. The extrinsic muscles are in the forearm, but the insertion points of
the tendons are found in the hand. This allows the hand to be graceful and light,
which is necessary for the types of movement made by musicians.
The wrist is an important joint of the upper extremity. Every movement of
the wrist affects the hand, thumb, and fingers. The muscles that mobilize the
wrist either insert on the pisiform or the metacarpals, which is why hand and
wrist position are so important. When the wrist is moved, the functional length of
30
the fingers changes. The capacity of the fingers to exert force is also dependent
on the position of the wrist. The ability of the fingers to play an instrument lightly
and with quick agility is influenced and governed by wrist position.
Posture is something that is often compromised, especially among
younger players just beginning to play. At this junction, instruction on how to
stand and sit correctly is crucial, as bad habits are hard to break. One must never
forget that the body is always in a state of counteracting gravity. Both the large
and fine muscle groups throughout our bodies are used to accomplish this. The
skeleton, ligaments, tendons, and muscles all work together to allow us to stand,
sit, and ambulate. The same is true when an instrument is being played. It is a
group effort. The posture of the back, as well as the position of the arms and
wrist, has a profound impact on performance. When posture is compromised,
playing will be compromised. Whenever the equilibrium is interrupted, both the
performer and the performance will suffer. This is why it is so critical to learn
correct posture.
When a player is standing, the feet should be planted apart, approximately
shoulder width apart. The player's shoes should allow the feet to be planted
firmly on the floor, providing a steady base for the body/Standing in a correct
anatomic position, with the head held up, will free the rib cage and allow for
maximum use of air. This position is vital to players of woodwind instruments.
Playing an instrument requires that the arms should be held in front of the body,
31
allowing the arm and instrument to be supported proximally. When the correct
anatomical positions are not used, the fine motor control needed to play an
instrument is compromised.1 There is a domino effect when one of these is less
than optimal.
Earlier, I gave brief definitions of some of the more commonly seen
performance-related disorders in musicians. One of the most common is Overuse
Syndrome, which is observed when the muscles are stressed beyond their
anatomical or physical capacity, usually due to repetitive motions, such as
extended practice sessions during which the body is held in fixed positions. The
musician does not always recognize the insidious beginning of a problem. When
a problem occurs, a cascade of events follows. The repetitive motions cause
microscopic tears in the tissue to occur, followed by swelling into the tissues. The
body then sends inflammatory cells to the area, which further complicates the
problem. If this continues, permanent damage can ensue and can lead to scar
tissue and adhesion development. This restricts the musician and will eventually
prohibit playing at the levels previously achieved. When the muscles stay in the
same position for long periods of time, the blood supply is compromised, which
will cause damage as well. When one tissue is damaged, it affects the use of the
surrounding tissues. As it places new tension in these areas, a domino effect is
created. By the time the musician realizes there is something wrong, the damage
1
Raoul Tubiana, M.D., and Phillipe Chamagne, P.T., "Functional Anatomy
of the Hand," Medical Problems of Performing Artists 2Q, no. 4 (December 2005):
192-93.
32
has been occurring for some time, since it starts out so subtly. The presenting
complaints are pain, weakness, and sometimes loss of fine motor control. While
these are the most common complaints, there can be a combination of any of
these or just one complaint when the musician goes to the health care provider.
Unfortunately, if the musician continues to play when the symptoms are evident,
it can result in permanent damage.2
One of the difficulties when seeking medical care is reproducing the
symptoms so that the health care provider can determine the nature of the
musician's problems. It is important to have your instrument available, so the
problem can be properly diagnosed. Many problems are not evident to the
observer, since the symptoms are often subjective. Accompanying swelling is
often minimal due to the location and size of the joints. This subjectivity makes
these problems really difficult to classify. Another obstacle to classification is the
overlapping of symptoms between the syndromes. Because of this, it is crucial to
seek evaluation by a health care provider. Often more extensive testing is
needed to distinguish between conditions. When trying to discern if one should
seek medical care, always compare the affected side to the unaffected side. If
the two sides have different symptoms and react to playing the instrument
differently, then one should seek help. This is a very important consideration.
2
Performing Artists," in Baillere's Clinical Rheumatology, ed. R.S. Panush, M. D.,
and N.E. Lane, M.D., 8, no. 1 (February 1994) London: Bailliere Tindall, 1994,
103-7.
33
When we are healthy, both sides of our bodies should react and feel similarly.
When we have an injury, this is not going to be true.
Carpal Tunnel Syndrome
One of the most frequently encountered disorders is Carpal Tunnel
Syndrome. Carpal Tunnel Syndrome (CTS) can be observed to some degree in
virtually all instrumentalists but is not exclusive to musicians. It occurs in various
occupations, especially ones that require repetitive movements in the wrist and
fingers or the use of vibratory tools. The musician must be keenly alert and avoid
tasks that can exacerbate this condition, especially extended periods on the
computer or video game playing.
Nerve entrapment occurs when a nerve is caught between two anatomic
areas. Carpal Tunnel Syndrome is the most common of the nerve entrapment
syndromes and occurs when the median nerve is constricted in the carpal tunnel.
The median nerve provides sensation to the thumb, index finger, third finger and
the radial or thumb side of the ring finger (figs. 1 and 2).
34
Figure 1. Median Nerve Innervation. Drawing by Elizabeth Cox, based on
several models.
Figure 2. Median Nerve Innervation. Drawing by Elizabeth Cox,
based on several models.
This tunnel is found in the wrist and is partially formed by the carpal
bones that form the "floor" of the tunnel. In addition to the carpal bones, the
tunnel has ligaments (transverse carpal), which form the "roof" of the tunnel
(figs. 3 and 4).
Figure 3. Wrist Anatomy. Drawing by Elizabeth Cox, based on several models.
36
Figure 4. Wrist Anatomy. Drawing by Elizabeth Cox, based on several models.
The carpal tunnel contains nine flexor tendons and the median nerve. CTS
develops when pressure increases in the carpal tunnel and exerts pressure on the
median nerve. This is usually the result of increased edema or water content of
the flexor tendon. The extent of damage to the median nerve will depend on the
cause, severity, and duration of the pressure that is occurring in the carpal tunnel
area. There are many things that can cause CTS. The most significant problem
one sees with CTS is a sensory impairment.3
3
Raoul Tubiana, M.D., and Peter C. Amadio, M.D., Medical Problems of
the Instrumentalist Musician (London: Martin Dunitz, 2000), 286-88.
37
With CTS, many people do not realize that damage is occurring in the
early stages. This is why it is so important to seek help when something unusual
happens and before there is permanent damage. The most common symptoms
are tingling and numbness of the hands and fingers. Some people experience
pain in the wrist, sometimes radiating to the forearm or shoulder, since the pain
may not be limited to the areas innervated by the median nerve. Some of the
most frequent complaints are: numbness in the hands or arms while sleeping or
driving and dropping objects while distracted. As long as the symptoms are
intermittent, it is unusual to have permanent median nerve damage.
There are some simple tests that the musician can perform to check for
CTS. These are not meant to replace a visit to a health care provider, but rather
to aid the musician in management of the condition. One of the tests is Tinel's
sign. This involves gentle tapping on the wrist, in the center just proximal
(closest to the body) to the wrist flexion crease, to see if one can elicit the
tingling along the median nerve distribution (fig. 5).4
4
Arun J. Mehta, M. D., Common Musculoskeletal Problems (Philadelphia:
Hanley & Belfus, Inc., 1997), 233.
38
Figure 5. Tinel's test.
Another is Phalen's test. In this test, the person is asked to hold his or her
wrists in maximum flexion for 30-60 seconds. To perform this test, the person
must hold both arms up, bent at the wrists. The back of the hands should be
touching. This will result in numbness and tingling on the affected side (fig. 6).5
5
Ibid.
39
Figure 6. Phalen's Test.
Carpal Tunnel Syndrome will affect the muscle strength on the affected
side. The median nerve innervates the muscles of the thenar eminence located at
the base of the thumb, which allows one to oppose the thumb to the tips of the
other digits (fingers). There are several ways to evaluate muscle strength. An
easy one is to have the person place the tip of the thumb and the tip of the fifth
finger together while another person tries to separate them. The side that is
affected by CTS will be weaker. In advanced cases, there may be flattening or
atrophy of the thenar emminence.
There are other tests that can be performed to evaluate for the presence
of CTS, primarily electrical or nerve conduction studies. There are some
conditions that are associated with CTS, including diabetes, thyroid disorders,
pregnancy, and arthritis. It is seen more commonly in women who are
40
premenstrual or pregnant. Any condition that causes swelling of the wrist can
elicit the symptoms of Carpal Tunnel Syndrome.5
There are options for treatment, especially in the early stages of the
disease. Most of these options can be used for all the disorders that will be
discussed. The first nonsurgical treatment is to avoid activities that precipitate
the problem. If the musician also plays video games frequently, for example,
avoiding the games might alleviate the symptoms and allow the musician to
resume normal musical activities. The next step is to wear a splint. Simple wrist
splints that maintain the wrist in a neutral position can be obtained at any drug
store and may be used day or night (figs. 7 and 8).7 CTS can be aggravated by
sleeping with your arms and hands curled.
6
Ibid., 231-34.
7
Ibid., 244.
41
MM
tttSSBBET
Figure 7. Wrist Splint for Carpal Tunnel Syndrome.
Figure 8. Wrist Splint for Carpal Tunnel Syndrome.
42
An additional treatment is to use one of the over-the-counter Nonsteroidal Anti-Inflammatory medicines (NSAID). These are readily available at
local drugstores. Any of them, such as Tylenol, Advil, or Aleve might be effective
if taken on a regular schedule. Ice to the wrist for at least 20-30 minutes two to
three times a day will also be beneficial and often relieve symptoms. These are
all possible ways to help relieve the symptoms and may be done while waiting to
see a health care provider.
The next step in treatment is to consider steroids, either by mouth or as
an injection. This will require a visit to a health care provider. Many people have
a baseless fear of steroid injections. A local injection involves placing a very small
amount of medicine directly into the area that is sore and swollen. Systemic side
effects are normally not experienced. The injection may be mildly painful initially
and for a few hours afterward, but the rapid return to normality is worth the
inconvenience. In order to protect the joints, most health care providers will have
a limit of 3-4 injections given over an individualized time span. If pain persists
and conservative and non-invasive measures are not effective, injection is a
viable alternative and easier than a surgical procedure. While this is not the
solution for everyone, it works well for many people who suffer from CTS.
Another possible treatment is a diuretic or water pill, which will require a
prescription from a health care provider. These medicines might assist in
43
relieving the swelling that occurs in the flexor tendon. If there is some
apprehension about the diuretic, vitamin B6 (Pyridoxine) is a possibility, which
does not require a prescription. The dosage is 50 milligrams once a day. It is a
natural diuretic and functions to protect the nerves. It is inexpensive, easy to
obtain and worth the effort if improvement is noted.
While many individuals will benefit from some of the above treatments,
others will require surgery. Surgery is considered a last resort and something
most musicians do not undergo lightly. It is understandable that musicians would
be frightened and concerned about surgery involving their hand(s) and the
possible threat to their livelihood. However, one must be cognizant of the
surgical option if a patient is non-responsive to conservative medical treatments.
If having surgery preserves function in the hands and fingers, then the benefits
outweigh the risks. Surgery for CTS is a very simple procedure, and in the hands
of a competent surgeon, a return of function is often realized.9
Cubital Tunnel Syndrome
Cubital Tunnel Syndrome (QTS) is a nerve entrapment disorder in the area
of the elbow. This is the second most common upper limb entrapment syndrome.
It is frequently seen in flute players, especially in the left arm, although it can be
8
Kelly, Rheumatology, 1713-15.
9
Tubiana, Medical Problems of Performing Artists, 288-89.
44
seen in other instrumentalists as well. Unlike CTS, which typically involves a
sensory deficit, Cubital Tunnel typically results in some loss of motor function.
The ulnar nerve, which innervates the little or fifth finger and half of the ring or
fourth finger that lies next to the little finger (fig. 9), is compromised in this
syndrome.10
Figure 9. Ulnar Nerve Innervation. Drawing by Elizabeth Cox, based on several
models.
Mehta, Common Musculoskeletal Problems, 215-24.
45
The ulnar nerve is located in the ulnar groove, which is behind the medial
epicondyle. The elbow is made up of three bony prominences, the lateral and
medial epicondyle and the olecranon process. The medial epicondyle is on the
inner side and the olecranon is posterior. The ulnar nerve passes through a
tunnel formed between the olecranon and medial epicondyle.
The arm and forearm bones are held together at the elbow by several
ligaments, which form the floor of the cubital tunnel through which the ulnar
nerve passes (fig. 10). n
Ibid., 215-44.
46
I
tctra! a^n-rf^:
Figure 10. Elbow Anatomy. Drawing by Elizabeth Cox, based on several
models.
The main symptoms of Cubital Tunnel are pain along the medial border of
the forearm and numbness or tingling primarily in the small finger. When left
untreated, QTS will result in the loss of function in the small muscles of the hand.
This problem arises when there is repeated flexion and extension of the elbow or
prolonged flexion of the elbow.
47
The tests used to aid diagnosis of CTS can also be used in Cubital Tunnel.
Tapping the area over the nerve in the affected elbow will demonstrate tingling if
the percussion test is positive. Elbow flexion, or the provocative test, can be used
like Phalen's test. Expect the result to be a tingling in the little finger and the
adjoining side of the ring finger if the ulnar nerve is affected. In Cubital Tunnel, it
is possible to palpate the nerve in the elbow ("funny bone") and elicit pain or
tenderness, resulting in tingling in the affected fingers.
Treatment of Cubital Tunnel Syndrome will depend on the causes and
severity of the nerve compression. The duration of the problem will determine
the need for medical intervention. Nonsurgical treatments discussed in CTS are
also applicable to Cubital Tunnel, that is, NSAID's, ice, and splinting. NSAID's
have not been found to be as beneficial in QTS as they are in CTS. Splints for the
elbow are not as easy to find but are available (figs. 11 and 12). A suitable splint
is anything that can be used to keep the elbow straight, especially while
sleeping.12
48
Figure 11. Elbow Splint for Cubital Tunnel.
Figure 12. Elbow Splint for Cubital Tunnel.
49
The flute player, or any musician with QTS, should limit playing sessions
and take frequent breaks while practicing. A flute with an offset G will help
prevent and alleviate this condition. Smaller hands have to accommodate a flute
with an inline G by stretching the arm more, and this puts more strain on the
ulnar nerve.
Any open hole flute allows an open hole to be plugged with a special key
extender. Normally these must be purchased from the flute manufacturer.
Brannen-Cooper manufactures these to fit all of the different keyholes of their
flutes (fig. 13).
Figure 13. Brannen-Cooper Finger Extension.
50
Simply purchase the one or ones needed to plug whatever holes are hard
to reach. The goaJ is to minimize elbow flexion. By using the extenders for the
left hand, one is significantly minimizing the left elbow flexion and the stretch of
the left hand pinky finger and pressure on the ulnar nerve.
Cubital Tunnel may require surgical intervention if conservative or
complementary measures fail. The surgery should only be performed after
appropriate testing and evaluation by an orthopaedic surgeon specialized in
upper extremity disorders. There are multiple procedures that can be used to
alleviate the symptoms of Cubital Tunnel. One surgical treatment is transposition
of the ulnar nerve. In this procedure, the surgeon will move the nerve out of the
ulnar groove and place it anteriorly, alleviating the stress caused by extensive
flexion of the elbow. Another treatment is removal of the medial epicondyle
(often called the funny bone). A third option is the cutting of the fibrous arch that
forms part of the tunnel. None of these procedures will remedy a problem that
has been allowed to linger and persist for long periods of time without treatment.
The only way to avoid permanent damage is to seek early evaluation and
treatment, when the symptoms are first noticed.13
The best treatment is to avoid the problem. This may mean correcting bad
posture and hand positions that have been used for years. If one is unable to
make an accurate evaluation, consult with a teacher or peer to help discern if
posture or particular motions are responsible for the problem. Changing to a flute
Kelly, Rheumatology, 1716.
51
with an offset G will help, as will relaxing the shoulders and upper body
musculature.
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome (TOS) often manifests itself with the same or
similar symptoms to other conditions. TOS occurs when the brachial plexus and
vascular bundle (group of blood vessels) are compressed while exiting the
thoracic cage or bony structure. It can involve some or all of the various
components of blood vessels and nerves. The area through which this
neurovascular bundle passes is made of muscles on each side of the neck (the
scalenus anterior and the scalenus medius), and the first rib. Stated simply, the
nerves and blood vessels are entrapped between fibrous ligaments, muscles and
bony structures that are located in the upper rib and shoulder areas. In
musicians experiencing this problem, the main complaint will simply be pain.
Most will know which positions cause TOS symptoms and modify playing
positions to prevent the pain.14
Symptoms will depend on whether the blood vessels or nerves are being
compressed. Typical symptoms are numbness and tingling in the little finger and
medial parts of the hands and forearms. This numbness and tingling will
14
Christine B. Novak, P.T., M. Sc, "Conservative Management of Thoracic
Outlet Syndrome in the Musician, "Medical Problems ofPerforming Artists 8,
no. 1 (March 1993): 16.
52
frequently awaken a person during the night. Carrying something or holding the
arms in the same position for prolonged periods of time can provoke the
symptoms. Poor posture, which allows the shoulders to droop, may stretch the
brachial plexus and cause the symptoms. Symptoms are usually worse at night.
If blood vessels are affected, the hands may be cold and there may be
discoloration of the fingertips. This discoloration is sometimes referred to as
Raynaud's phenomena.15
There are tests that detect this disorder. In the Elevate Arm Stress Test
(EAST), arms are elevated over the head, while flexing and extending (opening
and closing your fists) the fingers quickly. A person with TOS will not be able to
do this for one minute or longer (figs. 14 and 15).16
15
16
David B. Roos, M.D., F.A.C.S., "Thoracic Outlet Syndromes: Symptoms,
Diagnosis, Anatomy, and Surgical Treatment," Medical Problems of Performing
Artists 1, no. 3 (September 1996): 92.
53
Figure 14. Elevate Arm Stress Test.
Figure 15. Elevate Arm Stress Test.
54
Most people with TOS will realize improvement with conservative
treatment. This syndrome can be found in any instrumentalist, since all hold
instruments for extended periods of time. When treating this problem, posture is
one of the first issues that should be addressed (fig. 16).
£.-*'•'.•>>
/- >
* r - , ' -.11
Figure 16. Poor Posture.
55
Correcting a slumping posture or drooping shoulders will often resolve the
symptoms. An important consideration for the musician is posture whether sitting
or standing. Avoidance of chairs with sloping seats is imperative to alleviation or
prevention of symptoms peculiar to this disorder (fig. 17).
Figure 17. Improved Posture with Ergonomic Chair.
56
Another important consideration for the flute player is the position of the
right arm, which must not be allowed to hang over the back of the chair. This
position is seen frequently when the player does not have adequate space and is
trying to accommodate the flute with inadequate room to maneuver. This habit
tends to develop in the young player. Turning the chair at an angle and bringing
the flute forward with the arms will provide a more natural posture and prevent
many problems in subsequent years.
Avoiding the cause of the problem is usually the only requirement for
correcting it. Surgical treatments are available but are not considered until
conservative measures fail.
Reflex Sympathetic Dystrophy
Reflex Sympathetic Dystrophy (RSD) is a disorder characterized by a
severe, burning pain in the affected extremity, accompanied by sensitivity to
touch, swelling, and vasomotor changes. This disorder can be seen in any type
of musician, since the causative factors are not limited to specific movements or
postures. There are several supposed triggers for this condition, such as injury to
the soft tissues, fractures, operations and nerve injuries.
The main complaint in the initial stages is a burning pain in the affected
extremity out of proportion to the injury.17 This is aggravated by movements,
touch, and sometimes, loud noises. The painful area can include the shoulder,
17
57
although the pain is not as intense as that occurring in the hand. The obvious
visual symptom is swelling, which results from increased blood flow, and
increased sweating, called hyperhydrosis. Many times the hand will also be warm
to the touch. Movement of the hand causes pain, so the hand is not moved. The
lack of movement makes the swelling and pain worse. The swelling becomes
chronic and leads to deposits of fibrous tissue, which will cause the hand to
contract. The increased blood flow also precipitates a thinning of the bones in the
hand. When this condition begins, the swelling is noticeable, as is the
discoloration of the skin, which can be bright red to dusky red, eventually
becoming pale. When this occurs, the hand tends to be atrophic or shriveled in
appearance.18 The fingers will become contracted and the shoulder on the
affected side can have some loss in range of motion. Whatever the precipitating
event, this disorder has the potential to cause severe disfigurement and a
contracted extremity.
Reflex Sympathetic Dystrophy is usually seen in stages. The first stage
occurs when one experiences intense, burning pain. The second stage shows a
progression of the problem. The pain often lessens but the muscle and skin
wasting begin, with the skin in this stage cooler and dusky in appearance. This
disorder will eventually progress and evolve into a wasting of the skin and
muscles, accompanied by contractures in the fingers. The problem with RSD is
18
58
how each stage blends into the next. Many people do not experience all the
symptoms, thereby making diagnosis much more difficult.19
Although treatment of this disorder is difficult, the primary goals are to
decrease pain and prevent contractures. Pain medication and physical or
occupational therapy are begun immediately. Some people respond to oral
steroids, while some get some relief with injections of medicines. These
injections are called "stellate ganglion blocks" and are usually beneficial in the
early stages. The number of injections in individualized, but the musician may
need a series of injections. Besides pain medications, therapy with desensitization
and range-of-motion (ROM) exercises is the mainstay of treatment. This can last
for many months, for up to 8 hours a day. Another form of treatment is paraffin,
or hot wax, baths. These hot wax baths, alternated with warm air from a blow
dryer, will help alleviate the pain temporarily. This can be combined with active
range of motion exercises, elevation of the affected extremity, and compression
of the extremity to help decrease swelling. Some people use a splint to protect
the extremity, especially at night. Surgery is rarely used in this disorder and
would only be indicated after all conservative measures have failed.20
19
20
Ibid., 248-51.
59
Ganglion Cysts
Ganglion cysts, benign cysts seen in the hand, can occur in or near any
joint; however, they are most frequently seen in the dorsal and volar wrist and
the base of the finger. They may be present for many years and never change in
size. The cyst is full of a thick fluid (synovial fluid) inside a cavity within a fibrous
capsule. The cyst may be connected to the joint by a capsular stalk. These are
usually seen on the dorsal or topside of the hand, as opposed to the palmar
surface. They can cause a feeling of weakness or heaviness in the wrist and pain
after performing specific movements. They are more common in women and
frequently cause no symptoms at all. They are the result of degeneration of the
capsular tissue in the wrist or hand. There is no precipitating movement or
posture that causes a ganglion cyst. Most ganglia will resolve on their own,
requiring no treatment, but a large cyst can put pressure on a nerve, which will
result in pain.
Treatment is not needed unless there is pain or the cyst is unusually large
and unsightly. Those that do not resolve on their own can be treated with steroid
injections, aspiration with multiple perforations, or surgical removal. The most
common complication following surgery is a tender scar, wrist stiffness, and
recurrence (5%). This type of problem can be seen in any musician, regardless
60
of the instrument played. Many times the main issue regarding a ganglion cyst is
cosmetic.21
Focal Dystonia
Focal Dystonia (FD) also called occupational cramp, writer's cramp, and
musician's cramp, is characterized by a loss of voluntary motor control in the
affected areas. This is one of the few disorders seen more in males than females.
Focal Dystonia occurs in musicians when we overuse certain specific muscles
associated with playing our instruments. Our muscles were designed so that
when the muscle on one side of a joint contracts, the muscle on the other side
relaxes, allowing free motion of a joint. If a person has FD, the muscles contract
at the same time making movement of the joint difficult if not impossible. It can
occur when someone performs highly skilled and complex movements for hours
at a time, allowing no time for rest. Our bodies were not designed to perform
these movements at such a high level for so long. It is no wonder that the
nervous system can 'short-circuit'.
Sometimes, FD is precipitated by a traumatic event, but typically there is
no identifiable precipitating event. The initial presentation is seen only in the
61
muscle used in the repetition of the highly skilled movement. If not addressed,
the Dystonia will eventually progress to activities not associated with playing.22
One of the biggest obstacles in diagnosing FD is identification of the exact
muscle that is creating the problem.23 Focal Dystonia can occur in any area of the
body, such as the fingers, shoulders and the embouchure muscles. When
confronted with this problem, many musicians delay medical treatment due to
the psychological aspects associated with having a chronic debilitating,
sometimes career ending, diagnosis.
Treatment of FD is as elusive as finding the cause and identification of the
affected muscle. Treatment goals include rehabilitation of the neuromuscular
system. The treatment is for the whole body, not just the affected part. Resting
the affected area has not proven advantageous. Some people have used
Botulism injections into the affected muscle with limited success. One of the
problems with botulism injections is that many musicians are reluctant to have
continued injections to treat the FD. The botulism injections do treat the spasms
Richard Norris, M.D., The Musician's Survival Guide: a Guide to
Preventing and Treating Injuries in the Instrumentalist (San Antonio,
International Conference of Symphony and Opera Musicians, MMB Music, 1993),
91-93.
23
Maurizio Ferrarin, DrEng, Ph.D., et al., "Does Instrumented Movement
Analysis Alter, Objectively Confirm, or Not Affect Clinical Decision-making in
Musicians with Focal Dystonia?" Medical Problems of Performing Artists 23, no. 3
(September 2008): 99.
62
that occur but do not affect the motor coordination elements of the disease.24
One of the most successful treatments to date has been "retraining" of the
affected area. This necessitates finding the expertise of a master teacher familiar
with the disorder and how to retrain the affected muscles. Traditionally, the
medical community has advocated a change in technique to alleviate this
problem, but many aspects of the disorder remain a mystery. Studies are
currently being conducted on evaluation and identification of possible causes and
treatment success for those afflicted with this problem.25,26 One study that
needs further investigation suggests that Pseudoephedrine, at a dose of 60mg, is
helpful in alleviating symptoms associated with FD. Pseudoephedrine is a
common over-the-counter medication that is used as a decongestant. The study
was done after a flutist with FD noticed improvements in her playing after taking
a dose of Pseudoephedrine. While not a cure, this does suggest that these type
of medications may be of help in the disorder.27 At this time, treatment consists
of a combination of modalities, such as medication, botulism injections, splinting,
sensori-motor rehabilitation, and psychological support. Many players find that
24
Tubiana, "Functional Anatomy of the Hand," 4.
25
Norris, Musician's Survival Guide, 93-95.
26
27
Richard A. Hoppmann, M. D., et al., "Pseudoephedrine for Focal
Dystonia," Medical Problems of Performing Artists 6, no. 2 (June 1991): 250.
63
changing to a new instrument, a new teacher, and alteration in playing technique
will relieve at least some of the symptoms.
Many of the performers who develop FD are perfectionists and have great
artistic ambition; they tend to be totally invested in their profession. All of these
factors place great emotional and psychological stress on musicians when they
develop a condition that prohibits playing and performance. Many become
frustrated and depressed, so a counselor is helpful when dealing with the
frustrations associated with inability to play the instrument and the resultant loss
of work.
Focal Dystonia is a frightening diagnosis for the musician. While it will
involve a major change, many musicians will eventually recover with
rehabilitation and strenuous attention to therapy.28
Tendonitis
Tendonitis (tenosynovitis) occurs when the outside covering of the tendon
becomes inflamed. It is a general term that can apply to an inflammatory process
anywhere in the body, and its occurrence in some areas is given a specific name,
such as DeQuervain's Tendonitis. When the tendon is moved or stretched, pain is
28
Raoul Tubiana, M.D., F.R.C.S., "Prolonged Neuromuscular Rehabilitation
for Musician's Focal Dystonia," Medical Problems of Performing Artists 18, no. 4
(December 2003): 167.
64
experienced. This can be chronic or acute. Tendonitis can result from several
conditions such as repetitive motion, infection, or inflammatory diseases.
Management of tendonitis will depend on its cause. Infection should be treated
with an appropriate antibiotic, with the more severe cases requiring incision and
drainage of the infection. When tendonitis results from a disease such as
arthritis, treatment involves rest of the joint and a local steroid injection. Most
musicians will benefit from a NSAID, ice, and an appropriate splint.
DeQuervain's Tendonitis
DeQuervain's Tendonitis is an inflammation of the outside covering of the
tendon found on the radial or thumb side of the hand. This tendon controls
extension and abduction of the thumb. This condition can be caused by any
repetitive type action performed in daily life and may be seen in any type
musician. Initially there exists inflammation and a thickening of the sheath. As
time progresses, especially without treatment, the tendon sheath may become
fibrosed, or thickened and scarred. The outside covering is the problem, not the
tendon itself (figs. 18 and 19).
Tubiana, Medical Problems of Performing Artists, 25.
65
Anatomical snuffbox
Extensor poll ids
longus
Synovial sheath
Figure 18. Thickened Tendon Sheaths in DeQuervain's Tendonitis. Drawing by
Elizabeth Cox, based on several models.
Insertion of the abductor
pollicis longus tendoj
Insertion of extensor
pollicis brevis tendon
Figure 19. DeQuervain's Tendonitis Anatomy. Drawing by
Elizabeth Cox, based on several models.
66
Musicians having DeQuervain's Tendonitis tend to complain of pain in the
thumb or on the lateral side of the wrist. Occasionally pain will radiate down into
the thumb or up into the forearm area. Any movement may elicit pain. A
frequent complaint is that the person is unable to hold objects, such as a coffee
cup and will complain of weakness and pain in the wrist. It is also possible to
experience swelling over the wrist accompanied by tenderness. Musicians must
be cautious to avoid activities that could cause problems to flare during
performance. Finkelstein's test is used to aid in the diagnosis of this problem. In
this test, the person brings the thumb into the palm (figs. 20 and 21), closing the
other fingers over the thumb (fig. 22) and moving the wrist outwards (ulnar side)
or toward the pinky finger (fig. 23). This movement will result in pain along the
inflamed tendon sheath.30
30
Ibid., 444-45.
67
ms
$m
Figure 20. Finkelstein's test 1.
68
69
The initial treatment for DeQuervain's is rest of the joint. NSAID's can be
taken but are rarely successful in alleviating the problem. Usually, DeQuervain's
is cured with a localized injection of steroids into the tendon sheath (85%). To
aid in resting the joint, a splint may be prescribed, although injections are just as
successful without splinting. A thumb spica splint is preferred since it protects the
thumb (fig. 24).31
Figure 24. Thumb Spica Splint.
31
70
After the pain subsides, Physical Therapy, in conjunction with exercise,
may improve the range of motion in the joint. Surgery should be considered the
last choice and involves incising the overlying tendon sheath.32
Epicondylitis
Epicondylitis is an inflammation of the tendon at the origin from the lateral
or medial epicondyle. This occurs as a result of chronic repetitive movements or
overuse and may occur on the lateral (outside) or medial (inside) aspect of the
elbow (fig. 25).
%
Figure 25. Elbow Joint Anatomy. Drawing by Elizabeth Cox,
71
Lateral Epicondylitis
The elbow is the junction between the upper arm bone, the humerus, and
the lower arm bones, the radius and the ulna. The tissues and tendons
surrounding the joint can become inflamed, leading to pain and resulting in loss
of function and mobility. This tends to occur in people who have excessive wrist
flexion.
Areas of inflammation will be tender to the touch, often extending out
several centimeters on every side. To evaluate this condition, you need two
people. The musician should position the hand on the affected side as if one is
shaking hands. The other person should try to pull the musician's hand
downward while the musician tries to resist. This action should elicit pain in the
elbow.33 Wrist splints may ease the pain caused by Lateral Epicondylitis by taking
tension off the extensor tendon origin. Forearm circumferential straps (CPB
Band) placed just distal to the lateral epicondyle may also provide symptomatic
relief or improvement during activities.
Lateral Epicondylitis typically responds to rest, ice, and NSAIDS. More
severe cases will benefit from steroid injections, but surgery is not usually
needed. Physical Therapy is frequently useful in the alleviation of symptoms. For
Ibid., 215.
72
the musician, it may be necessary to alter hand or arm position to avoid
recurrences.34
Medial Epicondylitis
Medial Epicondylitis is similar to Lateral Epicondylitis in its physical
ramifications and management. This condition occurs on the inner side of the
elbow, where the funny bone is located. Medial Epicondylitis is referred to as
Golfer's Elbow, because it often occurs following a golf stroke in which the club
hits the ground. The principal symptoms are pain and tenderness over the medial
epicondyle.35
To diagnose Medial Epicondylitis, the wrist should be flexed against
resistance.36 After the wrist is flexed, pain is then usually elicited.37 Medial
Epicondylitis is managed like Lateral Epicondylitis. When someone is diagnosed
with this disorder, as with comparable disorders, activities that may aggravate
the condition should be avoided. Frequently, musicians are focused on musical
activities that may be problematic, while ignoring related activities that are nonmusical, which may be just as troublesome, often to the detriment of the
34
35
Warren D. Blackburn, Jr., M. D., Approach to the Patient With a
Musculoskeletal Disorder (Birmingham: Professional Communications, Inc.,
1999), 221.
36
Mehta, Common Musculoskeletal Problems, 221.
Blackburn, Approach to Patient with Musculoskeletal, 221.
73
musician. Many times the nonmusical activities are continued, which delays or
impedes recovery. Abstaining from these activities is essential. One of the more
seemingly innocent activities that can cause or aggravate this condition is
gardening; another big offender is use of the computer and computer games.
When one is diagnosed with performance-related disorders such as Lateral or
Medial Epicondylitis, a close lifestyle examination may be indicated.
Disorders of the Fingers
Thumb Disorders
All instrumentalists use their thumbs to play instruments. When this digit
or joint is not functioning properly, playing is limited or suspended. The thumb is
subjected to repeated trauma and excessive force, often from simply holding the
instrument.
The right thumb is the only central support when playing the oboe and
clarinet, and one can develop a condition referred to as Oboe or Clarinet Thumb.
In playing the oboe or clarinet, undue disabling stress is exerted on the thumb
joint, but this is not as crucial in the English horn, saxophone, and bassoon,
because these instruments utilize neck straps, which aid in distributing the
weight.38
38
Medical Problems of Performing Artists 10, no. 3 (September 1995): 94-99.
74
Tendons, ligaments, and muscles support the thumb, much like other
joints in our body. As oboists and clarinetists play an instrument, pressure is
exerted on the thumb, which functions as the stabilizer for the instrument. When
this is done over an extended period, the thumb can become stressed, since the
supporting ligaments are strained. This may result in a laxity, or relaxation of the
ligament at the base of the thumb, a painful condition leading to excessive wear
and tear of the joint. Whenever the body is stressed in one area, it compensates
by calling another area into use. When the thumb joint ligament becomes lax,
the adjacent thumb muscles are used to stabilize the joint. If this continues,
eventually the muscles will tire, and the musician will notice cramping and
eventually pain.39
Instruments are equipped with thumb rests to help reduce the transferred
weight, by distributing the weight in a more ergonomic manner. Most of these
thumb rests are placed in a standard position that is suitable for most hand sizes.
Unfortunately, this is often not in an appropriate position for the player,
considering there are different sized hands and fingers. Some instruments have
adaptable or moveable rests, but if they do not, the instrument must be adapted
to accommodate the player. Some players have the attached thumb rests
permanently relocated on the instrument.
Mehta, Common Musculoskeletal Problems, 221.
75
Various types of commercial thumb rests are available for purchase, such
as the Dutch or Loree for the oboe.40 The Loree must be attached permanently
to the instrument.
The FHRED is a device on which the oboe can rest, preventing the transfer
r
of excessive weight to the thumb. It has an adjustable peg that attaches to the
thumb rest and rests on the chair. It can be modified with a belt adaptor, which
allows the player to stand while playing.
Sataloff, Brandfonbrener, and Lederer, Performing Arts Medicine, 57-58.
76
The clarinet can also have a moveable thumb rest (fig. 26).
Figure 26. Clarinet with Moveable Thumb Cushion.
77
Some players improvise and devise a thumb rest cover out of common
household items (fig. 27).
Figure 27. Clarinet with Improvised Thumb Cushion.
78
As long as it does not damage the wood or keywork, anything providing
support and a cushion to the thumb will help alleviate the problem. There are
examples of cushions made specifically for oboes and clarinets (fig. 28).
** *
*. >JWk
Figure 28. Clarinet with Manufactured Thumb Cushion.
Many types of tubing that will fit over the thumb rest can also be used.
Examples are the spongy covers available in many different colors that can be
placed over pencils to make them more comfortable. Clear plastic tubing, such as
that found in aquariums, is another option.
79
Another cause of thumb problems is the incorrect placement of the thumb
on the thumb rest. If the thumb is placed under the rest on the joint, there is
much less stability than if it is placed on either side of the joint. The optimum
placement would be just proximal to the joint of the thumb, which provides more
stability and tolerates the weight for longer periods than will placing the rest
directly on the joint.41
While the oboists and clarinetists have thumb issues most frequently, the
issues are also experienced with other instruments. The right thumb of a flute
player can also be stressed by excessive pressure while holding the instrument in
an incorrect hand position. The flute player has available several options that will
assist in maintaining the proper position and alleviate pressure on the right
thumb. One such device is the Thumbport, a metal device covered with soft
plastic that is placed around the body of the instrument. This device is also
available for the piccolo and alto flute (figs. 29 and 30).
Smutz, "Load on Right Thumb of Oboist", 94-95.
80
Figure 29. Thumbports.
Figure 30. Thumbports on Flutes.
81
The flute player may also experience problems with the left thumb, which
manipulates the B and B-flat thumb keys. If held in a position that is excessively
flexed, the thumb is strained, leading to many of the problems already discussed.
Playing with the thumb flexed will affect dexterity and hinders one's ability to
move with speed. When the hand position is incorrectly placed between the
thumb and the base of the left index finger, the hand is placed in a position
resembling a claw (figs. 31 and 32).
82
Figure 31. Incorrect Right Thumb Position.
Figure 32. Incorrect Right Thumb Position.
83
This may affect the entire left hand and may lead to the development of
problems resulting from the strain of holding the flute too rigidly. A thumb in a
neutral position will allow the most flexibility and agility, preventing future
problems (fig. 33).
Figure 33. Correct Left Thumb Position.
The saxophone includes a thumb rest that is attached to the instrument,
but most players use a neck strap to assist with holding their instrument (figs. 34
and 35).
84
Figure 34. Saxophone Thumb Rests.
Figure 35. Saxophone Thumb Rests.
85
As a result, the thumb is not usually as stressed, as might be the situation
with the oboe and clarinet. One has to be careful with hand size and placement
of the rest, since it is also situated generically. Available for the saxophone are
detachable thumbrests, which can be used to help mitigate the weight of the
instrument.
Left Index Finger Disorders
The thumb is not the only digit to experience stress associated with
repetitive movements and gripping an instrument too tightly. Each instrument
has its own peculiarities that may cause the player to experience both
inflammatory and nerve entrapment problems.
The bassoon player may develop problems with the left hand index finger
if the instrument is held incorrectly. Normally, the instrument is held in place by
the left index finger and a strap placed under the buttocks of the player. By
sitting on the strap the player helps support the weight of the instrument. The
other point of support is the left index finger. When the bassoon is gripped too
tightly, the index finger may be stressed. This may cause tendonitis or nerve
entrapment disorders in the index finger or other fingers on the left hand. A
quick and easy way to diminish stress on the index finger is to attach a bungee
cord by one end to the left side of the chair in which the musician is sitting and
86
the other end to the bassoon at the neck strap ring near the top of the boot
joint, (fig. 36).
fm
•.%m
l HP-
m
«sf
t # ^
ft
:M
K9-
Figure 36. Bassoon with Improvised Strap.
87
This will secure the bassoon to the body, assuaging the pressure and
stress on the left hand index finger (figs. 37 and 38).
Figure 37. Thumb Position with Improvised Strap on Bassoon.
88
Figure 38. Placement of Improvised Strap from Bassoon to Chair.
The flute player may be stricken with pain in the left hand index finger in
the region of the first joint. Flutist's Digital Nerve Compression is an injury
affecting the palmar digital nerve on the radial side of the left index finger.
Symptoms of this affliction include pain at the base of the left index finger,
numbness along the radial (side toward the thumb) side of the finger, and
constant aching in the radial side of the hand.42
The left index finger is one of the three areas upon which the flute rests
and is an anchor for keeping the instrument steady. This area may also develop
problems related to how tightly the instrument is held. A tight grip, if continued
42
Sataloff, Brandfonbrener, and Lederer, Performing Arts Medicine, 191-
92.
89
for an extended period of time, may lead to stress on the joint. Another cause of
stress is a change of instruments, either to a heavier flute or a larger instrument,
such as an alto flute. Devices are available that can be attached to the flute that
will lessen this problem and minimize the pressure. One such device is the BoPep (fig. 39).
Figure 39. Bo-Pep on Flute.
One problem with the Bo-Pep is that it is available in only one size and
may not be adjusted for different hand sizes. Another problem is that the area
where the Bo-Pep is placed on the flute is directly adjacent to the B and B-flat
keys, which does not allow movement toward the center of the barrel of the
flute. If one has small hands, one tends to hold the flute closer to the center of
the middle joint, so the Bo-Pep cannot be placed on the barrel of the flute where
it is needed to alleviate the pressure. If the musician's hands are small, the BoPep may not fit correctly and may actually create more problems. Many people
have devised solutions to the mal-fitting Bo-Pep problem. On metal flutes, one
90
can use adhesive to attach something to the instrument without causing damage.
Any material providing padding and thickness to the problem area will minimize
the problem. Some people have used moleskin, Dr. Scholl's corn pads (without
the medication), felt pads, and cut-to-size spongy adhesive pads used in crafts.
When replacements are needed, alcohol can be used to remove any remaining
adhesive, and there should be no damage to the body of the flute (fig. 40).
Figure 40. Improvised Finger Rest on Flute.
Many flutists have devised inexpensive ways to allay problems with the left
index finger. As with the thumb rest on oboes and clarinets, there are multiple
solutions. Spongy pencil covers and clear tubing are equally adaptable to the
flute.
Trigger Finger
The disorder known as trigger finger tends to affect the middle finger and
is characterized by difficulty in moving the finger, specifically with flexion and
91
extension. When one attempts to move the finger, it tends to lock in place,
causing pain. One of the known causes of Trigger Finger is repeated trauma,
which can happen with repetitive movements and overuse. The sheath that
surrounds the tendon is a major component in the movement of the finger, and
this condition causes a narrowing of the sheath around the tendon and a
subsequent nodule. This impedes movement and leads to thickening of the
sheath, making it difficult for the tendon to move within the sheath. The fibers
start to cluster, and the nodule is unable to pass easily through the sheath due to
the clustering of fibers. When the finger catches on the nodule, it cannot bend
and straighten as it should. It tends to snap into place after much effort and
occasionally may require moving it back into place with the other hand.43 If
corrective action is not taken, the finger may become totally immobile. To
evaluate and diagnose this ailment, palpate over the palmar flexion crease in line
with the involved digit. One can often feel the nodule, which will be located near
the flexor tendon in the palm. The nodule should move when the finger is
moved. Initial treatment may be a local steroid injection. If this does not resolve
the problem, the next option will be surgery, which involves cutting a portion of
the flexor tendon sheath where the tendon first enters the sheath in the palm.44
43
44
93.
92
Disorders of the Neck
Disorders of the neck region are common among woodwind players who
utilize a neck strap to offset the weight of the instrument from the hands. Many
neck disorders are related to posture. When the bassoon player reaches toward
the bocal with his neck outstretched, the neck is postured in an unnatural
position that will eventually cause problems if not corrected. A simple solution is
to bring the instrument toward the musician, rather than moving toward the
instrument. It is important to remember that the instrument cannot feel pain, but
the musician can. The instrument must accommodate the musician.
Saxophone and clarinet players wearing neck straps will often pull on the
straps. Neck straps are worn to alleviate pressure on the thumb, so musicians
must be careful that they do not grip the instrument so tightly that they are
actually pulling the instrument forward by the strap (fig. 41).
93
Figure 41. Saxophone with Incorrect posture in Neck.
Figure 42. Saxophone with Improved Neck Posture and Neckstrap.
94
Many complementary therapies can help prevent or resolve these
problems. Some of these therapies concentrate on posture and relaxing the
body, enabling the musician to play in a more comfortable and healthy position.
For younger players, especially, one must make sure the music stand is
positioned correctly, so that it is not necessary for the player to lean forward to
see the music. Many students need glasses, and one of the first clues is leaning
toward the music. If the player is sitting, it is important to make sure the chair is
not contributing to poor posture. A proper chair has a flat-bottomed and slanted
seat (fig. 43).
Figure 43. Ergonomic Chair.
95
A rounded chair bottom and back may cause the back to slump
backwards. This will cause the spine to fold in, thereby preventing the player
from holding the instrument correctly. To compensate, a player may pull on a
neck strap and elevate the instrument in order to allow herself more room. Poor
posture will also stress the thumb joint. If ergonomic chairs are not available, ask
the musicians to move forward toward the edge of their chairs and sit erectly.
Many young students will be short and unable to reach the floor with their
feet, leading to neck strain. If the feet are not firmly on the floor, the foundation
or base is not there for the body to maintain good posture. To compensate,
many young players will hold the instrument up too high, leading to neck,
shoulder, and arm problems. This will also compromise the air column. An
abnormal position can place undue stress on the thumb and thumb joint, thereby
causing stress. Some adults are also too short to touch the floor when the chair
has a rounded bottom and back. A simple footrest can be made of telephone
books taped together. Footrests that are more expensive and look better are
available, but phonebooks work very well. The books can be covered in cloth or
colored paper when used in performance. Other footrests may be improvised
(fig. 44).
96
Figure 44. Improvised Foot Rest.
Although the flute player does not require a neck strap, the very nature of
how the flute is played and held predisposes the player to problems in the neck
area. The head of the flute player tends to be tilted and rotated to the right. This
97
places strain on the neck, which can lead to nerve impingement. This could result
in numbness and tingling of the hand or radiculopathy.45
There is no good way to arrange the flute in order to keep the body in
alignment. When one area is adjusted, another area is stressed. To offset these
problems, many flute players make minor adjustments in more than one area.
The right elbow is dropped toward the body, which will relax the shoulder and
help right hand dexterity. The head then has to tilt or be angled to the right.
There is no easy way to hold the flute economically, but it is important to
remember to bring the instrument toward one's face, rather than reaching out
toward the instrument. This principle applies whether sitting or standing and will
prevent the flutist from stretching the neck toward the instrument. Many young
players, cramped by lack of space, will try to remedy this situation by sitting
straight forward in a chair while hanging their arm over the back of the chair.
This will stress not only the arm but also the shoulder and neck as well. This
should be monitored by band directors and corrected immediately. If this is
ignored, the stage is set for potential problems in later years. The solution is
simple. Turn the chair at an angle and bring the flute toward the front. This will
resolve most of the problems in the arm, neck, and shoulder.
The music industry and flute makers have experimented with altered flute
headjoints in an effort to rectify these problems. Emerson Musical Instruments
devised an angled headjoint in 1989, in collaboration with a medical doctor,
45
98
Stephan Mitchell, who is an amateur flutist. Other individual flute and headjoint
makers have experimented and made headjoints allowing the flute to be played
vertically. Neither of these modifications has become widely used. By changing
the angle of the headjoint, other problems occur with stability, tone and
intonation of the instrument.
Disorders of the Shoulders
Shoulder problems are found in all instrumentalists, not just woodwind
players. The shoulder is the most mobile joint in the body and is in continuous
use. For the hand and fingers to move and play an instrument properly, the
shoulder must function properly. Many times the shoulder is held in stationary,
fixed positions for extended periods of time while performing or practicing. This
is very stressful and strains the shoulder joint, a very complex joint made of
many different bones, ligaments, tendons, muscles and bursa. Numerous
problems may occur, but the most common are Impingement Syndrome,
Subacromial Bursitis, and Tendonitis of the Bicep. Management of all three tends
to be conservative, but will require some physical therapy to aid in healing. Two
simple exercises are swinging the arm in an arc like a pendulum and walking the
Tubiana, Medical Problems of Performing Artists, 600.
99
fingers up a wall. To ignore restorative exercises will most likely result in a
lengthy disability.47
Subacromial Bursitis
Bursae are found throughout the body and function as padding in the
joints, providing a cushion between the two bones that comprise a joint. The
bursa in the shoulder is found between the top of the humerus and the
acromium; in conjunction with the rotator cuff, the bursa acts as a pad between
the bones (fig. 45).
47
100
Acromion
Figure 45. Shoulder Anatomy. Drawing by Elizabeth Cox,
Subacromial bursitis is often a result of overuse or repetitive motion.
Musicians must be careful to avoid non-musical activities such as painting and
racket sports that may precipitate or aggravate this problem.48 The main
symptom noticed by the musician will be pain, which is worse at night. Even
though treatment is often symptomatic, it is essential that musicians get medical
48
Ibid.
101
evaluation. Many other musculoskeletal problems, such as rotator cuff pathology,
have similar presentations (fig. 46).49
Glenoid
Figure 46. Area of Impingement in Shoulder. Drawing by Elizabeth Cox,
Subacromial bursitis is noticed when the arm is abducted or raised approximately
45° to 60°. The individual feels pain, although there are no visible symptoms.
Treatment is conservative at the outset, calling for rest, NSAID's, and
physical therapy. If these do not resolve the problem, a steroid injection would
likely be the next step.50
49
Ibid.
102
Impingement Syndrome
Impingement Syndrome occurs when the supraspinatus tendon is caught
between the end of the acromium and the top of the arm bone. This may occur
with any musician whose shoulder is in a fixed position for long periods of time.
The flutist tends to experience this in the right shoulder, which remains
stationery while playing. Impingement Syndrome can develop if the shoulder is
not relaxed and kept low. If diagnosed and treated early, then conservative
measures tend to relieve the symptoms and resolve the problem. When allowed
to progress untreated, Impingement Syndrome can advance to more severe
diagnoses that may become chronic. The complications of untreated
impingement syndrome can be very difficult to treat. Most will require complete
rest, steroid injections and physical therapy. In the more advanced stages of
Impingement Syndrome, musicians ignoring physical therapy and restorative
exercises may develop a frozen shoulder. For this to heal, the static load on the
affected shoulder must be lessened.51 Depending on the instrument of choice,
one can get different types of straps, posts and devices that will reduce the
stress placed on the shoulder. The FHRED stand for oboe is an example of a rest
that would reduce the load on the shoulder.
50
Ibid.
51
Ibid., 81-82.
103
Bicep Tendonitis
The last type of shoulder disorder experienced by musicians is not as
common in woodwind players as in other types of instrumentalists, such as string
players or percussionists. Bicep Tendonitis is an inflammation of one of the upper
arm muscles and is caused by sustained movement of both the shoulder and the
forearm. It is caused by flexion and abduction of the shoulder, with flexion and
supination of the forearm, movements that are vital to playing an instrument. An
instrumentalist with bicep tendonitis will experience pain when the biceps muscle
is palpated and when playing. If conservative treatment fails, the next
consideration is a steroid injection, in addition to the other conservative
measures.52
Disorders of the Skin
Skin disorders in musicians vary according to the instrument played. The
biggest problem is called contact dermatitis, which can be caused by an allergic
reaction or exposure to an irritant. Physical factors of performing such as
Blackburn, Approach to Patient with Musculoskeletal, 225-26.
104
pressure, friction, perspiration, and occlusion can contribute.
Another common
skin disorder experienced by musicians is blister or callus formation as a result of
playing their instruments. Most of the time, this causes no problems and does
not prevent playing. In fact callus formation is often necessary to allow musicians
to play comfortably, especially string players. The location of the callus is
dependent on the type of instrument.
Skin disorders are frequently experienced by flutists as a result of contact
with the metal alloy nickel that is used in metal flutes. This is a common allergen
for many people. If the flutist is allergic to nickel, the skin under the lip plate will
become red and swollen and may itch or be painful. Inflammation can be treated
with over the counter cortisone cream when nickel allergy becomes a problem.
The lip plate will have to be modified so that the flutist does not have contact
with the alloy containing nickel. This allergy can also create problems for the
hands of the flutist. There is not always an easy solution to this problem, since
most silver flutes have some of the metal alloy mixed with the metal.
Many people also have high levels of acid in their skin and will react to the
metal in the flute. The chin where the flute comes in contact with the skin will
turn black. This problem has been addressed in the past by putting a postage
stamp on the mouthpiece. Unfortunately, the stamp is not big enough to cover
the entire lip plate, and the stamp comes off rather easily, sometimes ending up
53
Jeff Harvell, M.D., and Howard I. Maibach, M.D., "Skin Disease Among
Musicians," Medical Problems of Performing Artists 7, no. 4 (December 1992):
114.
105
on the chin instead of the flute. Contact paper is a better solution. It is possible
to get the type that appears to be etched glass, which can alleviate slipping of
the headjoint, in addition to providing a barrier between the metal and skin. The
player makes a template of her mouthpiece with the contact paper and applies it.
The contact paper is hardly noticeable, tends to stay on better than a stamp, and
is less expensive (fig. 47). The adhesive does not harm the metal and is easily
removed with alcohol.
Figure 47. Flute Headjoint with Contact paper.
106
Another problem experienced by flute players is called Flutist's Chin, which
occurs where the flute contacts the skin on the chin. Flutist's Chin can be
aggravated by the perspiration and saliva that keep the skin wet underneath the
lip plate. The skin tends to break out with acne-like lesions or red and thickened
skin, much like the lesions seen among violin and viola players.54 When this
becomes severe, it may require treatment with an antibiotic.55
The clarinet player can develop Clarinetist's Cheilitis, which is an exotic
word for inflammation of the lips. The inflammation, found at the border of the
lower lip, results from the drooling of saliva or formation of perspiration beads
under the lower lip, and has an eczematous component. Keeping the area as dry
as possible will help correct the problem. An outbreak of Clarinetist's Cheilitis can
be minimized if the clarinetist avoids licking the lips and wears some sort of lip
balm that provides a protective layer. Since saxophone players have similar
mouthpieces to clarinets, they can also suffer from this'condition.56 Application of
a hydrocortisone cream to the affected area can resolve most symptoms.
Instruments made of wood, such as the piccolo, can trigger allergic
reactions. Many people do not realize that they have an allergy to the woods
most commonly used in piccolos. The most common allergy is to cocus wood.
The only solution to this is using a headjoint that is made of metal or another
54
Sataloff, Brandfonbrener, and Lederer, Performing Arts Medicine, 149.
55
Harvell, "Skin Disease," 116.
56
107
wood. Another wood reaction can occur with the reeds that are made from
bamboo.
A common problem experienced by all musicians, regardless of the
instrument, is the fever blister. The medical name for this is Herpes Simplex Type
1 (HSV-1) or Herpes Labialis. This disorder is not caused by overuse or repetitive
practice, but is a contagious lesion that causes significant pain and dysfunction of
the embouchure, including swelling and numbness. The musician cannot
necessarily do anything to prevent HSV-1 but needs to be aware of transmission
and treatment. Care should be taken to avoid contact with a fever blister or
canker sore. Transmission is possible even when there is no evidence of a fever
blister, which makes it very difficult to know when a person is contagious. Ergo,
the best advice is to not share instruments or allow others to test your
instrument, reeds, or mouthpieces. Alcohol should be readily available for
cleaning mouthpieces if trying out instruments.
Many people are exposed to HSV-1 before they become musicians. If one
has a history of fever blisters, there are precautions one can take to prevent
recurrences. The anti-viral medications Acyclovir, Zovirax, Valtrex and Famvir can
be taken on a daily basis to decrease the frequency and length of outbreaks.
Kenalog in Orabase is a topical ointment that may be used to alleviate outbreaks.
This requires a prescription but is very effective in treating fever blisters. It can
also be used to treat common ulcers or areas in the mouth that have been
108
traumatized, such as severe bites of the tongue or cheeks. The best practice is to
be careful and alert and not allow others to use a player's personal instrument.
Another overlooked allergen is cleaning compounds used in instrument
maintenance. This is a problem, especially with younger players, who wish to
keep their instruments shiny and clean for high school marching band
competitions. While cleanliness is encouraged, there is a danger in exposing the
band members to potential chemical allergens.57 When an allergy exists, a simple
solution is to use a special cleaning cloth to wipe metal instruments. Other
measures include keeping hands clean and lotion-free to avoid excessive
fingerprints; also the instrument case should not be used to store food and
candy.
Temporomandibular Joint
Temporomandibular Joint (TMJ) pain or dysfunction is a common malady
that is experienced by most people at least once in a lifetime. Usually the result
of an acute event, TMJ will limit movements secondary to pain and is related to a
malfunction of the internal components in the jaw. Biting on a hard food item or
performing other routine activities can trigger it. Regardless, it can become a
chronic problem that can be very painful. This pain can be localized in the actual
Temporomandibular joint or can be referred to the head and neck. This can be
57
Harvell, M.D., and Maibach, M.D., "Skin Disease Among Musicians," 114.
109
especially problematic for players of woodwind instruments, since all use the
mouth and jaw muscles and joint. The use of this joint is a daily event as we talk,
eat, and perform. The exact cause of TMJ is difficult to identify.58
There are several possible causes of TMJ pain. The joint itself can be sore
and tender, which causes painful jaw movements. The joint can have actual
degenerative joint disease, where the joint is starting to deteriorate. Laxity of the
tendons and ligaments of the joint will create pain and embouchure problems.
Regardless of the cause, normal range of motion of the jaw is compromised
when TMJ becomes painful.59
There are several guidelines for treating TMJ. The first is to rest the joint
and muscles. This is not limited to rest from playing but includes eating foods
that are soft and do not require chewing. NSAID's can help ameliorate the pain
and inflammation. Frequently the dentist may recommend a splint to relieve
some of the stress from TMJ. After the inflammation starts to subside, the jaw
will benefit from range of motion and stretching exercises.60
The most common cause of TMJ pain is identified as Myofascial Pain
Dysfunction Syndrome. This pain may radiate into the ear and neck. The exact
cause of this problem is unknown, but stress is known to play a major role in its
development. When a person is stressed, the jaw is clenched, and muscles
58
59
Ibid.
60
Ibid., 131-38.
110
spasm. Often the stress will lead to grinding of the teeth, compounding the
problem. Teeth not properly aligned can aggravate the condition. If one is not
careful, the pain will lead to a reduction in mobility and may cause the jaw to
become fixed or contracted. Many with this condition will experience other
symptoms resulting from TMJ pain, such as fullness or pain in the ear and
hearing loss or tinnitus (ringing in the ear). Musicians find these particularly
stressful, which can exacerbate the condition, creating a snowball effect. Another
source of TMJ pain is a lack of mobility in the jaw resulting in the creation of a
click or pop. This can be very painful and is frequently the result of acute trauma,
although chronic stress to the joint can also be a cause. The jaw can Nock' in the
open or closed position and may require physical manipulation to realign it back.
Temporomandibular Joint pain, caused by inflammatory diseases, tends to
progress over time, with the main symptoms being pain and stiffness.61
The diagnosis of TMJ will require inspection of the teeth to check for
missing or crooked teeth that could be compromising the jaw joint, so many
times a visit to the dentist will be necessary. The joint, found directly in front of
the ear, can be palpated for warmth and tenderness. Many people suffering with
this problem are helped by a dental aid that keeps the teeth from grinding at
night (fig. 48).62
61
Sataloff, Brandfonbrener, and Lederer, Performing Arts Medicine, 120-
62
Ibid.
28.
Ill
Figure 48. Dental Aid for TMJ.
Physical therapy may be helpful, especially with range of motion,
stretching, and flexibility exercises. Eating foods that do not stress the joint will
assist in resting the area. Medications such as NSAID's are frequently prescribed
to alleviate pain and inflammation. If the condition is caused by stress, an antidepressant may provide relief. The joint is sometimes injected with local
anesthetics. If all conservative treatments fail, a last resort would be a surgical
procedure to replace the defective disc in the joint.63
112
Disorders of the Teeth
Teeth are necessary to maintain pressure while playing a wind
instrument. Woodwind instruments require the use of the mouth or chin as an
anchor while playing. Undue pressure on the lips may result when teeth are
misaligned. This pressure may strain the musculature of the lips and lead to
muscle fatigue and numbness. With excessive pressure on the lip, sharp and
uneven teeth can cut into the lower lip. Maximum relaxation of pressure against
the teeth and the use of a lip shield may alleviate some of these problems. Lip
shields made of wax are available at most music stores and will provide a cushion
for uneven or sharp teeth (fig. 49). They can also be used to cover orthodontic
braces that cut into the lips.64
113
f^JP
f&tf
Figure 49. Wax Lip Shield for Clarinets and Saxophone.
The importance of maintaining good dental hygiene cannot be stressed
enough to the player of a woodwind instrument. Teeth are necessary for the
formation of the embouchure, and care must be taken to avoid backpressure on
the teeth from excessive pressure of the instrument against the mouth. Excessive
pressure may cause loosening of the teeth or shifting of the teeth in the mouth
(fig. 50). Both would require extensive retraining of the embouchure and dental
work.
114
Figure 50. Repaired Teeth After Years of Saxophone Playing.
Hypermobility
Hypermobility, or joint laxity, is a phenomenon that is found in musicians
and considered by many medical professionals and musicians to be a factor in
the development of musculoskeletal injuries in performance-related injuries. The
extreme flexibility of Niccolo Paganini is well documented. Over the years, many
have speculated that Paganini's superior playing was due to Marfan Syndrome. In
reality, it was most likely due to benign hypermobility.65 Most hypermobility in
musicians is considered a benign occurrence and unrelated to a causative
disease. There is no gold standard for measuring the laxity of a joint. Only in the
65
Alice G. Brandfonbrener, M.D., "Joint Laxity in Instrumental Musicians,"
Medical Problems ofPerforming Artists 5, no. 3 (September 1990): 117-19.
115
past thirty years has the medical profession begun to look at the association of
hypermobility with other problems experienced by performing artists.66 Studies
have found that women tend to experience hypermobility more frequently than
men. While hypermobility does not mean that a musician will be stricken with a
performance-related injury, it does seem to predispose musicians to
musculoskeletal injuries and their complications, such as tendonitis. There is no
known treatment for hypermobility. The criteria for hypermobility is: "1) passive
hyperextension of the fingers greater than 90°, especially the little finger, back
toward the arm; 2) passive apposition of the thumb to the flexor aspect of the
arm; 3) greater than or equal to 10% hyperextension of the elbow or knees; and
4) forward flexion of the trunk with knees extended so palms rest on the floor."67
To test for joint laxity, check for any joint that exhibits passive range-of-motion
10° or more beyond normal, as applied to the hands, wrists, and fingers.68 To be
diagnosed with hypermobility, some think it is only necessary to have one of the
criteria.
66
Performing Artists," in Bailleres Clinical Rheumatology, 8, no. 1 (February 1994):
116-17.
67
Sataloff, Brandfonbrener, and Lederman, Performing Arts Medicine, 87-
89.
68
Alice G. Brandfonbrener, M.D., "Joint Laxity and Arm Pain in
Instrumental Musicians," Medical Problems of Performing Artists 15, no. 2 (June
2000): 73.
116
Teachers should be aware of the possibility of joint laxity and the potential
for development of problems associated with this condition. Instruction about
hand position and posture should be emphasized to aid in avoidance of playing
problems in future years.
Posture
Poor posture has been linked to many of the disorders discussed.
Regardless of the instrument played, posture will affect the performance. Posture
deviating from the proper anatomic position may lead to problems, whether the
person is sitting or standing. When selecting a chair or bench with which to
practice or perform, it is important to use one that is the correct height and
modified to maintain the best posture for performance. If tension or rigidity of
the body is required to keep the body stable, then the chair or bench is not the
correct choice. When we strain or hold ourselves rigid, this is relayed to every
muscle in the body, including the musculature utilized in playing an instrument.
The chair must be the correct height or the back will be tense.
The ability to breathe and support the breath is dependent upon posture.
If the player is slumped in any direction, breath support will be altered.
Additionally, the legs must rest comfortably on the floor to avoid numbness,
tingling in the feet, and stress of the entire body. A chair not having the correct
height may also be a factor causing neck disorders. This may result in neck,
shoulder, and upper back tension. Holding the neck forward in a fixed position
117
may exacerbate these problems. The music stand should be elevated to a height
that will allow the body to be in a natural position. Musicians should have regular
eye exams. Many musicians not wearing prescribed glasses have to contort their
bodies to accommodate their vision. By the end of the playing session, they may
experience a strained shoulder, neck and upper back. This can lead to swelling
and muscular pain, which left untreated, may evolve into one of many problems
already discussed.
Videotaping is excellent for correcting poor posture because a student can
easily see poor posture on a tape of herself. If videotaping is not possible, get
someone to take pictures. Videotapes or photographs can be invaluable as a
corrective measure.
118
Chapter Four
The Treatment of Performance Disorders
The diagnosis of a performance-related injury is frightening for any
musician. It is imperative that a medical professional diagnose the musician to
ensure that more damage is not incurred. Choices for treatment are varied and
include both traditional and complementary medicine. Health care professionals
today are receptive to a combination of treatments, allowing the musician to
choose the best treatment to suit their individual lifestyle and circumstances. The
most important objective is to identify and choose treatments that are acceptable
and affordable to the individual. If the musician with a diagnosed performancerelated injury does not adhere to the advice and chosen treatment, it is
immaterial whether the treatment is complementary, medical, or a combination
of both. Treatment should be individualized to the musician, since some prefer
traditional medicine, while others lean toward complementary methods, and
some prefer a combination of both. The musician who is unfamiliar with
complementary medicine will not recognize some of the therapies and techniques
commonly utilized by practitioners of complementary health care. Many people
may find the complementary approach to be suspect. The author is not
attempting to influence anyone but is simply introducing the different modalities
to let the individual decide.
119
For the musician or anyone else, the best treatment is avoidance of the
problem. This necessitates knowledge of the potential injury and avoidance of
causative factors. Musicians must assume responsibility for their own health.
Teachers must assume responsibility for helping the student establish correct
posture or hand positions, identifying instruments in poor working condition, and
adjusting incorrectly placed thumbrests.
Many of the bad habits leading to overuse syndromes are established in
middle and high school. Serious students must understand that, even though
they play with their hands, the entire body is used when playing an instrument.
Young students should be nurtured and alerted to these issues, so that they do
not suffer in later years. Many students are simply instructed to practice but are
not taught how to practice. They are advised to practice longer but are not
instructed to take rest periods and stop if symptoms such as pain, numbness, or
tingling are experienced. Many start playing an instrument rented from a local
music company and may have no guidance or instruction regarding purchasing
an instrument that works well and fits the hands comfortably. Even the young
student should have an instrument that works well and fits the hands. Placement
of music on the stand, the height of the stand, and/or the position of the chair is
usually not addressed until a problem develops. At this stage, the musician may
already be in trouble and experiencing an injury or the beginning of one.
120
Music teachers can not stress enough the importance of getting enough
sleep, eating correctly, posture, hand position, and avoiding harmful behaviors
such as smoking. The instructor should teach the student how to stand and sit
during performances. Proper positioning of the chair, music stand, and player are
important while sitting. The height of the music stand should be individualized
and adjusted to the height of the musician. Musicians wearing shoes with heels
to a recital will have decreased ability to breathe and support the sound, since
balance will be altered, especially if they are not used to standing for long
periods in this type of shoes. A cold room or hall affects technique, therefore
arms should be covered to aid in keeping the muscles warm. Many students are
unaware of these and other ways to improve their performance. While seemingly
obvious, these precautions are frequently neglected during the educational
process.
The following overview describes various treatments and therapies, both
traditional and complementary. Becoming familiar with these various modalities
requires a deeper exploration on the part of the musician to consider specific
treatment options.
Traditional Treatment
Many of the previously mentioned disorders benefit from traditional
treatments, which are similar to each other, often incorporating many of the
121
same modalities. Basic conservative medical treatment consists of rest, ice,
splinting, and some form of NSAID. Depending on the problem, oral steroids are
often recommended. These basic measures will often lead to resolution, if the
musician will actually rest the affected limb sufficiently. When the musician
begins recovering, it may be a mistake to resume the same practice techniques
as before. The best advice is to resume systematic practice in small increments,
gradually building up to the length and intensity of the regular practice session.
If basic measures do not resolve the problem, it is prudent to consult with a
professional for diagnosis of the problem. After these options have been tried
and if the symptoms have not resolved, an injection of steroids would likely be
the next step in treatment. This is curative in many cases and should not be a
cause for fear on the part of the musician. Another component of traditional
medicine is physical and occupational therapy. Both of these are geared to
rehabilitation of the musician, so they can start playing again.
When conservative treatments are unsuccessful, traditional medicine may
suggest a surgical option. This is an individual decision and should be discussed
with the health care provider. There are multiple surgical options available for
disorders common to the musician. The surgeon and the musician should
examine the symptoms and the musician's response to conservative treatments
and then decide on the best approach.
122
Non-steroidal Anti-Inflammatory Medications
Non-steroidal anti-inflammatory medicines are some of the most
commonly utilized medicines for the treatment of musculoskeletal disorders.
These drugs were developed to treat inflammatory conditions, and their main
purpose is to relieve pain, lower fevers, prevent the blood from clotting, and
reduce tissue inflammation. Higher dosages are necessary to provide the antiinflammatory effect. NSAID's are non-narcotic, do not cause sleepiness, and can
be taken before a performance. They reduce pain and inflammation by blocking
the effect of prostaglandins. Unfortunately, the dosages necessary to reduce
pain and inflammation may cause gastric upset, gastric ulcers, and renal failure
in some people. It is important to consult a health care provider before taking
large dosages, so proper monitoring can be performed, thereby avoiding possible
complications. This precaution is especially important if one is diabetic, since
diabetics are susceptible to kidney damage. Aspirin should be avoided while
taking NSAID's, since aspirin may trigger many of the same side effects.
Another complication can be allergic reactions, which may cause a
significant rash over the body. If a rash develops while taking these drugs, the
medicine should be stopped immediately. If NSAID's are taken in excess, they
may cause central nervous systems (CNS) effects, the most notable being
rebound headaches. Other CNS effects are vertigo (dizziness), tinnitus (ringing in
the ears) and reversible hearing loss. These are dose-dependent and occur most
typically with aspirin, although it can occur with any of the NSAID's. Asthmatics
123
should be cautious when using these drugs in order to avoid a possible spasm of
the bronchial tubes. When NSAID's cannot be tolerated, a safe alternative is
Tylenol, which has fewer side effects. To avoid gastric complications, these
medicines should not be taken on an empty stomach. If one is taking other
medications, consultation with a health care provider is necessary. Some of the
more common NSAID's are Motrin (Advil, Ibuprofen), Naprosyn (Anaprox, Aleve),
Lodine (Etodolac), Oruvail (Orudis, Ketoprofen), Relafen (Nabumetone), and
Indocin (Indomethacin).1 Recently there have been NSAID formulations in a
topical gel or cream. Voltaren is an older NSAID used in the treatment of
musculoskeletal disorders and is now formulated in both a patch and gel.
Voltaren Gel is available by prescription and is indicated for application on the
hands and knees. It is not absorbed systemically like the pill forms, and will not
cause as much gastric upset.
When taking any medicine for pain, caution must be exercised not to
overextend oneself while playing. When pain lessens, there is often an inclination
to overcompensate for lost practice. This should be avoided in order to prevent
further damage to joints or tissues. Practice should be increased gradually,
allowing the body an opportunity to heal.
1
Richard A. Hoppmann, M.D., "Non-steroidal Anti-Inflammatory Drugs in
Performing Arts Medicine," Medical Problems ofPerforming Artists 8, no. 4
(December 1993): 122-24.
124
Steroids
Steroid medications used in the treatment of inflammatory conditions
modify the body's immune response to negative stimuli. Steroids are potent antiinflammatory drugs and work well in acute musculoskeletal conditions. Steroid
medications should not be used long-term, since deleterious side effects may
result. Steroids taken for extended periods may mask infection, or cause mood
swings, insomnia, euphoria, depression, and personality changes. Steroids may
also cause gastric upset, much like the NSAID's, and should always be taken with
food. Steroids are typically used when a joint is injected, but they can be
administered orally. Systemic side effects tend to be less when steroids are
injected into a specific area. The injections are usually mixed with a numbing
medicine, such as lidocaine, to help with pain. Musicians should not be
apprehensive of steroid injections, if conservative measures have failed. A local
injection of medicine into a specific area will frequently resolve the problem. The
joint should not be moved much after the injection is given, as too much
movement will cause the medication to disperse too quickly, lessening its effect.
While the medicine is being absorbed, the first 24-48 hours may be painful.
Following this procedure, the affected joint should be less painful and there
should be a resolution of symptoms.
125
Physical Therapy
Many injuries that do not heal with conservative treatment will benefit
from Physical Therapy (PT). The objective of PT is to restore function, mobility,
and flexibility to an area that has been injured. Physical Therapy will allow the
affected area an opportunity to heal with slow introduction of range-of-motion
exercises, stretching, ultrasound, electrical stimulation, and hot or cold therapy.
A therapist can provide deep tissue or muscle massage and frequently may
prescribe splints or other devices to help achieve maximum function of the area.
One of the primary goals of Physical Therapy is strengthening of the muscles. A
useful adjunct to therapy is Bishop's Putty. This firm putty is held in the hand,
getting softer as the hand squeezes the putty, which builds muscle strength in
the fingers, hands, and arm (fig. 51).
126
Figure 51. Bishop's Putty for Strengthening the Hand Muscles.
At the conclusion of the weeks or months of therapy, the client has
exercises he or she can continue that will help the body stay healthy and
hopefully, prevent further injury later in life (fig. 52).
127
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Figure 52. Physical Therapy, Sample Rehabilitation Program from Campbell Clinic,
Memphis, Tennessee.
Splints
Many times conservative corrective medical measures will include the use
of a splint. The splint will allow the joint to rest and prevent use of the
problematic area in activities that could worsen the problem. Many different
types of splints are used to treat symptoms of conditions experienced by
musicians. It is important to wear the splints as prescribed, in order to avoid
further damage in the affected area. Splints can be made for the individual to
help support the instrument or to make playing more comfortable.
128
Complementary Therapies
Complementary, sometimes called Alternative, therapies are becoming
more commonplace. A study performed by the Harvard Medical School found
that at least one of every three people has utilized some form of complementary
therapy.2 This study also found that people with more education and higher
income levels were more likely to seek complementary therapy.3 Another study
showed that 42.1% of Americans are using some form of complementary
therapy.4 While various complementary treatments are available, some are
common and others are more difficult to locate. The number of therapies
available can be overwhelming to the musician unfamiliar with this approach. A
simplified list of the more common treatments includes reflexology, color
therapy, acupuncture, crystal therapy, rolfing, herbals, vitamins, aromatherapy,
iridology, macrobiotics, sound therapy, and nutritional therapy.5 One of the most
common complementary treatments is Therapeutic Massage. Another established
2
Scott L. Montgomery, "Illness and Image in Holistic Discourse: How
Alternative is "Alternative?" Cultural Critique no. 25 (Autumn 1993): 69.
3
Susan E. Lederer, "Alternative Approaches to Healing," Science 299, no.
5604 (January 10, 2003): 205.
4
Peter A. Clark, "The Ethics of Alternative Medicine Therapies," Journal of
Public Health Policy 21, no. 4 (2000): 447.
5
Montgomery, Illness and Image, 69.
129
complementary treatment is Chiropractic. Many musicians are familiar with and
have used the Alexander Technique and Yoga.
Complementary therapies operate on the premise that the body is a whole
entity that must use energy to survive. When an imbalance or blockage in the
body's energy occurs, disease can ensue. The goal of the complementary
treatments is to restore the energy, allowing the body to heal.6
Bodywork
Therapeutic Massage. Massage has been used for many years to relieve sore
muscles and musculoskeletal complaints. It is one of the most widely accepted
and practiced forms of complementary therapy,7 having been used for many
years to treat both well and injured persons. Massage therapy can be the
primary treatment or an invaluable companion to traditional medical treatment in
many performance-related disorders. Frequently, the musician is tense and
stressed. When there is tightening of the musculature, pain and swelling will
ensue. This can put pressure on nerves, causing pain and leading to many of the
overuse disorders. Whenever a person experiences a situation causing stress or
strain on the soft tissues, massage can be utilized. The recipient of massage will
experience relaxation, pain relief, and reduction in swelling, with an increased
6
Ibid., 71-74.
7
Renee Gecsedi and Georgia Decker, "Incorporating Alternative Therapies
into Pain Management," The American Journal of Nursing 101, no. 4 (April
2001): 38.
130
range-of-motion of the body. The purpose of massage is to prepare the body for
some type of strenuous activity and assist with recovery after such an activity.
Musicians undergo strenuous activity each time they practice and perform. While
not using the big muscle groups one would use in running a marathon, the small
muscle groups that are being utilized undergo a workout similar to the large
muscles of the marathon runner. Massage is an invaluable resource for the
musician.
The massage therapist is trained in the identification of muscles and
muscle groups and often can identify the muscle from which the pain came. Pain
is always a symptom of the problem. It is essential to locate the muscle that is
causing the problem, so pain relief can be obtained.8 Stress is a factor in
everyone's life, regardless of profession. The musician is constantly being
challenged to do their best, which will result in increased stress, especially in one
with a perfectionist personality. A major component of every treatment for
performance-related injuries should be one that addresses stress. Massage
therapy does just that, by physically kneading the body and helping the
musculature relax. Massage should not be considered as an unaffordable luxury
for the musician but rather as an important component in achieving rehabilitation
and recovery, with a return to optimal playing in a timely manner. The musician
should think of it as an important element of the practice routine. Frequently,
8
Frances M. Tappan, Healing Massage Techniques: Holistic, Classic, and
Emerging Methods (Norwalk, Connecticut: Appleton & Lange, 1988), 43-48.
131
massage therapy should be continued after the injury is healed, in order to
prevent the tightening and thickening of the muscles that occur with the
constant movement that accompanies playing and performing. There are
numerous types of massage, and each is used to address different complaints.
The massage therapist will frequently use a combination of these and will
individualize the treatment for each client. Many massage therapists incorporate
acupressure into a therapeutic massage, a technique using finger pressure on
specific areas of the body to relieve symptoms.
Feldenkrais Method. Feldenkrais is a form of bodywork that involves
movement re-education, and is identified as "Awareness Through Movement" or
ATM, with individual training sessions identified as "Functional Integration". This
method was developed by Moshe Feldenkrais, a medical doctor, as a way to
retrain the brain to perform efficient movements that may heal the body.9
Functional Integration involves a sequence of minimal manipulations or
movements designed to improve breathing and alignment. This is supposed to
teach the body to move intelligently. Awareness Through Movement teaches a
series of relaxed movements aimed at educating the client regarding the use of
the body. This type of bodywork is specifically geared toward instructing a
9
Sheperd Bliss, ed., The New Holistic Health Handbook (Lexington,
Massachusetts: The Stephen Greene Press, 1985), 333.
132
person to become aware of the body and the effects of movement upon it. The
Feldenkrais Method is useful for the injured musician as it teaches awareness of
movement. Many injuries experienced by musicians are related to a negative
form of movement. Feldenkrais can assist in retraining the musician to use less
stressful movements and positions that place strain on the body. Many times the
musician is not aware of the origin of the problem. This method teaches the
musician with an injury to be aware of the source of the problem, not just the
location of the symptoms. Feldenkrais teaches awareness of not only how to use
the body, but how misuse of the body can evolve into a performance-related
injury.10
Alexander Technique. The Alexander Technique is a method of bodywork
familiar to many musicians. F. Matthias Alexander, the founder of the Alexander
Technique, described it as "a way of improving the use of self."11 This form of
bodywork focuses on proper posture of the body and its effect on performance.
It is similar in some ways to Feldenkrais, in that it has a goal of instructing one
with respect to bodily activities and how to make the body lighter, with increased
freedom of movement. Much like the Feldenkrais method, the Alexander
10
Mary Spire, M. M., "The Feldenkrais Method: An Interview with Anat
Baniel," Medical Problems ofPerforming Artists 4, no. 4 (December 1989): 15962.
11
Wilfred Barlow, The Alexander Technique (New York, New York: Warner
Books, 1973), 1-14.
133
Technique seeks to retrain the body. It works on the premise that there are ways
to move your body that are both positive and negative. If a musician ignores this
tenet, the body will likely react in a negative fashion and begin to suffer. The
Alexander Technique aspires to teach the difference between positive and
negative, by observing self and others. There are two basic principles inherent
with this technique. The first is awareness of the use of the body and each
movement. The second is the functioning of the body and its effect on the
musician's health. By applying this technique, one should improve posture,
balance, and body positioning while playing the instrument. When learning the
Alexander Technique, it is helpful to have your instrument with you. The benefits
become readily apparent if it is applied before and after practicing or
performing.12
Reiki. Reiki is defined as universal life energy. Reiki therapy is an ancient
Tibetan therapy that focuses on transference of energy from the practitioner to
the client.13 It is a natural healing method and a method of transferring healing
energy to others. Reiki is a "hands-on healing art that is a powerful adjunct to
Eleanor Rosenthal, J.D., "The Alexander Technique—What It Is and
How It Works," Medical Problems of Performing Artists 2, no. 2 (June 1987): 53.
13
Gecsedi and Decker, Alternative Therapies, 37.
134
conventional therapeutic modalities.
Reiki induces a relaxation response that
promotes healing in the body. The relaxing of the body intensifies the body's
natural defense to disease, resulting in stimulation of endorphins, the body's
natural opiates, which results in a heightened state of well-being.15 The Reiki
practitioner is a conduit for this energy, as it moves from one to the other. As
the Reiki practitioner brings balance, she promotes healing, relieving stress and
anxiety.16 Traditional medicine focuses on disease and seeks a cure. Reiki does
the opposite, seeking to magnify wholeness and wellness of the person.17
Reiki manifests itself differently in each person. The Reiki practitioner
places the hands with fingers together, very gently on the body and transfers
energy to the client. Reiki is based on the belief that we are all in a state of
balance, and when this is upset, we will exhibit signs of illness. Reiki functions to
cleanse the body, allowing it to be whole again. It should elicit a state of
relaxation and will prompt many to explore other methods to assist in
maintaining a state of balance and health. Reiki may promote healing with the
body, renew energy and achieve a state of well-being. Reiki may be practiced on
clients, even if they are not physically present. The Reiki Master may transmit
14
Libby Barnett, Maggie Chambers, and Susan Davidson, Reiki: Energy
Medicine (Vermont: Healing Arts Press, 1996), 2.
15
Ibid., 4-5.
16
Gecsedi and Decker, Alternative Therapies, 37.
17
Barnett, Reiki, 7.
135
healing energy to the recipients who may learn to treat themselves, but this
technique does require acceptance on the part of the client. The musician cannot
be passive when using Reiki and must be involved in the procedure, if it is to
work.18 Reiki can be learned and self-practiced on a daily basis or as needed.
Reflexology. Reflexology is an old healing art that was founded in massage. It
involves the use of pressure to manipulate the feet, resulting in relieved tension,
enhanced circulation, stimulation of nerves, and promotion of well being in the
body's organs. Reflexology enhances the body's innate ability to heal.19 Our feet
are divided into zones, or sections, that correlate to the major organs and
systems in the body.20 Manipulation of the foot, in the area of a specific organ,
aids in healing and restoring the balance of the body. The foot has trigger points
that correlate to the body, just like the trigger points found in other modalities.
Each foot is related to its side of the body (fig. 53).21
Bodo J. Baginski and Shalila Sharamon, Reiki: Universal Life Energy
(Mendocino, California: Life Rhythm Publication, 1988), 15-37.
19
James F. Balch, M.D., and Mark Stengler, N.D., Prescription for Natural
Causes (New Jersey: John Wiley & Sons, 2004), 686.
20
Frankie Avalon Wolfe, Ph.D., The Complete Idiot's Guide to Reflexology
(New York: Alpha Books, 2006), 10-11.
21
Arnold Fox, M.D., and Barry Fox, Ph.D., Alternative Healing (New
Jersey: Career Press, 1996), 27-28.
136
Figure 53. Reflexology Foot. Drawing by Elizabeth Cox, based on several
drawings.
137
Reflexology works on the premise that the environment is filled with
toxins that affect our bodies. These toxins occur when our bodies do not
metabolize food correctly and produce toxic by-products. These by-products,
made of uric acid and calcium collect and form crystals surrounding the nerve
endings. If nerve endings become blocked, then the body may be thrown out of
balance. Reflexology works to break up these toxins, so the body can become
healthy again. This can also be applied to the hand (fig. 54). 22
; Siw^ses
'
!#
/J\
Figure 54. Reflexology Hand. Drawing by Elizabeth Cox, based on several
drawings.
22
Bliss, Holistic Health Handbook, 198-200.
138
Chiropractic. Chiropractic is one of the better known of the complementary
therapies. The basic premise is that the body has intrinsic healing powers in the
central nervous system (CNS). Daniel Palmer, the founder of Chiropractic,
believed that disease occurs when the spinal vertebrae exert pressure on or
interfere with the nerves. When this happens, the organ supplied by the nerve
will become damaged or diseased. The resulting spinal misalignment may lead to
physiological, neurological, or musculoskeletal problems throughout the body.
Palmer felt that the solution was to relieve the pressure by manipulation of the
spine. Chiropractors continue to function on these basic principles, although
many have branched out and include other forms of the healing arts, including
physical therapy. Ultrasound, heat therapy, cold therapy, therapeutic exercise,
stress reduction, and nutrition are some of the forms of therapy practiced by
chiropractors.23
Aromatherapy
Aromatherapy has been used for thousands of years in the treatment of a
variety of maladies. It involves using essential oils to promote healing by
inhalation, internal use, or direct application. Specific essential oils have clearly
defined properties that can alleviate particular symptoms. The essential oils used
23
Fox and Fox, Alternative Healing, 15-16.
139
in aromatherapy are extracted from plants. They provide their healing powers to
the body through smell and by their ability to permeate the bloodstream.24 Oils
are used in virtually every type of consumer goods: foods, toiletries, medicines,
natural flavorings, perfumes, and toothpaste.25
There is a link between the olfactory (sense of smell) system, the lymph
nodes (body's drainage system), and the limbic system (emotional center) in the
brain. Applying essential oils topically triggers this link and can produce mindaltering effects.26 In order to utilize aromatherapy correctly, it is imperative to
have a proper physical diagnosis. Each disease may be treated with different oils,
and many conditions can be treated by more than one type of oil. Depending on
the diagnosis, the musician must choose the most effective oil. Tendonitis is best
treated by birch or rosemary oil.27 Many different oils, with lavender oil and
rosemary oil being the best choices, can be used to treat rheumatism.
Some people choose to mix two or more of the choices for a specific
problem. Muscle aches, pains, muscle tension, and stiffness may all be treated
with a vast array of oils. Care must be taken when applying oils to the skin, as
24
Balch and Mark Stengler, Prescription for Natural Causes, 651.
25
Robert B. Tisserand, The Art of Aromatherapy (Rochester, Vermont:
Healing Arts Press, 1977), 13.
26
Enid Gort, "Review," American Anthropologist95, no. 4 (December
1993): 1070-71.
27
Jeanne Rose, The Aromatherapy Book (Berkley, California: North
Atlantic Books, 1992), 23-29.
140
some can be irritating when undiluted. The eyes and surrounding areas must be
avoided. There are many different formulas or recipes available to treat most
common illnesses. If one uses any of the available treatments, it would be
prudent to purchase a book explaining how to mix different formulas and how to
choose specific oils.
Color Therapy
Color surrounds us and is a major part of how we perceive and react to
the world. The use of specific colors for an activity or to represent some emotion,
place, or thing has been practiced for many years, with the combination of color
and sound being linked by both healers and musicians. This makes logical sense
because all colors have a certain frequency that is specific to a key or pitch. The
corresponding color will have the same frequency as the pitch or key. Each color
evokes a different feeling or represents different levels of healing, depending on
the frequency it emits.28 Many musicians correlate specific colors to specific
musical keys.29 Additionally, certain musical keys can be identified with an
Barbara Ann Brennan, Hands of Light: A Guide to Healing Through the
Human Energy Field (Toronto: Bantam Books, 1987), 237-42.
29
Robert A. Cutietta and Kelly J. Haggerty, "A Comparative Study of Color
Association with Music at Various Age Levels," Journal of Research I Music
Education 35, no. 2 (Summer 1987): 88.
141
emotion. The different parts of the body respond to the frequency emitted by
both color and sound in an individualized manner.30
Health practitioners have been aware of the role of color in healing for
quite some time. Color is recognized as a healing power in both complementary
and folk medicine.31 Certain colors trigger certain reactions and feelings.
Different cultures view colors various ways. Fast food restaurants are aware of
this fact, which is why they decorate with the 'triggering' colors of red and
yellow, hoping to increase the consumption of food. For many years, hospitals
were painted in shades of green, because it is known to promote healing. The
color yellow is known to stimulate mental acuity and is a good choice for clothing
if one is taking a test. Conversely, yellow also stimulates psychiatric patients
negatively and is avoided by mental hospitals for this reason. Blue is calming,
orange is a sexual stimulant, and pink is the color of love. Red stimulates
courage, which is one reason you often see that color associated with
courageous acts. White is a lack of color, while black is all colors mixed together.
In some cultures, white represents purity or death and black is often chosen to
portray evil. Other factors are involved in choosing colors, and the use of color in
healing incorporates many of these beliefs. Color is also applied when describing
how you feel. We are green with envy, feel blue, and are tickled pink. Since color
30
31
Brennan, Hands of Light, 237-42.
Donna Marie Wing, "A Comparison of Traditional Folk Healing Concepts
with Contemporary Healing Concepts," Journal of Community Health Nursing 15,
no. 3 (1998): 149.
142
affects every aspect of our lives, it can be used as a form of treatment for
unhealthy states.
Each color has a different energy and level on which it vibrates. All colors
correspond with a different part of the body and can exhibit positive and
negative effects on the body. Just as each color has its on vibration, every
disease has a different energy level on which it vibrates. In the past, people
wore specific colors to promote healing or were enclosed in a special box or
space that bathed the individual in colored light. Today, there is the capacity to
measure vibrations of color and apply these colors directly to an unhealthy area.
Color may also be introduced by eating foods in a specific color, painting rooms
in a chosen color, or using gems and crystals as adjuncts in healing. Color
therapy has as its purpose restoration of balance and equilibrium to the body,
components required for a healthy state. One must be careful to not overload on
a specific color or use the incorrect color. Misapplied color therapy may inflict
harm. Color absorbed through the skin will affect all the glands and substances
in the body. Trigger points, such as the ones in Acupressure, can also be treated
with color therapy.32 Because it surrounds us, color may be used in many ways
to treat illness. Many medical practitioners are aware of the value of color and
light therapy for skin conditions. The psychological impact of color on our
feelings should not be ignored. A musician under stress will not heal as quickly
32
Morton Walker, M.D., The Power of Color. (New York, Avery Publishing
Group, 1975), 77-107.
143
as the musician who is relaxed and open to treatment and rehabilitation. Color
has a distinct role and should not be overlooked in evaluating our wellbeing. It is
inexpensive and at every musician's disposal. Color is accessible to everyone, just
by learning about its uses and mindfully charting one's own responses to color.
Eastern Medicine Techniques
In recent years, the field of Chinese Medicine, an ancient art, has become
more popular. As with any type of complementary medicine, it is important to
make sure that the provider is a licensed practitioner of the treatment. One of
the most commonly known complementary therapies of Chinese Medicine is
acupuncture.
Acupuncture. Acupuncture, one of the most commonly used forms of
complementary therapy,33 is based on the premise that all body organs are
connected to a specific point on the external body. Manipulation of this area will
have an effect on the associated organ. Specific areas are related to meridians,
which are pathways or channels within the body, which provide a continuous
cycle of energy throughout the body. The purpose of Acupuncture is to balance
out the energy levels of the internal organs by stimulating or depressing their
33
Gecsedi and Decker, Alternative Therapies and Pain Management, 37.
144
actions. Meridians are named according to the organ controlled by the energy
flow. In Chinese Medicine, any disruption in a meridian will cause the associated
organ to exhibit physical symptoms. Sites of needle insertion will correspond to
the different meridians. The electrical excitability of the nerves can be reduced
by the insertion of the acupuncture needles. Sites of acupuncture energy points
will correspond to trigger points over the entire body. The amount of pressure
used to insert the needles will be individual, depending on symptoms.34
Jin Shin Do. Jin Shin Do is a method of using finger pressure to relieve tension
and reduce both muscular and emotional stress. It utilizes points along the
meridians known as acupoints. These points are believed to be located where the
life force energy is closest to the body surface. The premise of Jin Shin Do is that
pressure on the acupoints will release the stress, allowing the body to heal. The
body should have a free flowing of the energy to function optimally. When there
is blockage, energy is impaired, and dysfunction will become evident in the
physical body. Jin Shin Do is a useful adjunct in chiropractic. When Jin Shin Do is
performed before a chiropractic adjustment, the client will have an easier
adjustment and it will last longer.35
Tappan, Massage Techniques, 133-66.
Ibid., 167-181.
145
Shiatsu. Shiatsu has been practiced for thousands of years, evolving from
acupuncture and Japanese massage. Shiatsu, like other forms of eastern
medicine, focuses on the meridians, rather than body systems that are the basis
for Western medicine. The purpose of Shiatsu is to assist the body in maintaining
equilibrium of the energy as it moves throughout the meridians. Shiatsu
practitioners focus on the complete individual. The goal of therapy is a wellbalanced body that is healthy: physically, mentally, and emotionally. The
practitioners of this type of massage use several techniques such as acupressure
and massage.36
Yoga
Yoga is a form of bodywork that focuses on the entire body. It is a
constant quest for balance in all aspects of one's life. Yoga attempts to reach the
mind by educating one about choices that affect the body, such as foods and
exercise. Learning about why we make choices and how to change our choices
affects our bodies on multiple levels. The physical body is used by the mind to
achieve increased flexibility, relaxation, and to promote fitness. Combining
physical and mental aspects leads to balance in all areas of life.
Many people use Yoga as a form of meditation. It does not function to
heal, but rather to create an internal atmosphere that promotes good health.
Ibid., 183-195.
146
Yoga is thought of as an oriental based concept, but in reality it is universal and
not associated with any particular religion or region of the world. The basic
premise of Yoga is healing of the whole person in order to achieve optimum
health.37 Classes in Yoga can impart to the musician an awareness of the body
and how movement affects the balance of the body. Utilizing stretching and
flexibility, yoga exercises promote improved posture and relaxation while one is
playing the instrument. The techniques learned in yoga practice can help
improve focus needed for practice and performance.
Herbal Therapy, Vitamins, and Nutrition
There are many nutritional elements and herbs that may be useful in the
treatment of disease. The World Health Organization estimates that 80% of the
people in the world use herbs as a primary source of medicine.38 Vitamins are
organic substances that are vital for life. Most cannot be processed by the body
and must be obtained with supplements or with food.39 Minerals are inorganic
substances that are an important component in the tissues and fluids. They are
necessary to maintain optimal functioning of most of the body's metabolic
Bliss, Holistic Health Handbook, 33-40.
Clark, Alternative Medicine Therapies, 449.
Balch and Stengler, Prescription for Natural Causes, 550.
147
activities. These compounds are available in most department and grocery
stores and do not require a prescription from a health care provider. Many
people find that these preparations often relieve their problems. However, one
should use caution when using these or any other medications. Unlike medicines,
the herbs are not regulated and there is no way to ascertain their purity. This
makes it difficult to determine the exact dosage being ingested and this can vary
from bottle to bottle. It is important to inform your health care provider when
you are taking these preparations, since there could be an interaction with
prescribed medicines.
A common vitamin used for the injuries suffered by the musician is
Vitamin B6. Vitamin B6 is a natural diuretic, which will help alleviate swelling,
although not to the extent seen with prescription medications.41 There have been
studies that link low Vitamin B-6 (Pyridoxine) and Vitamin B-2 (Riboflavin) levels
with the development of Carpal Tunnel Syndrome.42 Additional studies have
4U
Ibid., 553.
41
Larry Trivieri, Jr., and John W. Anderson, Alternative Medicine: The
Definitive Guide (Berkeley: Celestial Arts, 2002), 397.
42
Karl Folkers, Anna Wolaniuk, and Surasi Vadhanavikit, "Enzymology of
the Response of the Carpal Tunnel Syndrome to Riboflavin and to Combined
Riboflavin and Pyridoxine," Proceedings of the National Academy of Sciences of
the United States of America 81, no. 22 (November 15, 1984): 7076.
148
shown that only Vitamin B-6 deficiencies exist in persons with CTS. The dosage
of both Vitamin B-6 and B-2 is 50 milligrams a day. Other studies have shown
that B-6 given twice a day resulted in improvement of CTS to two-thirds of those
using 40-80 mgs a day. If the musician decides to try B-6, it should be done
under the care of medical personnel.44
Magnesium is a common mineral and a natural muscle relaxer, which will
not make you sleepy like so many prescription medicines. Magnesium is an
important mineral for the health of bones, joints, and connective tissues.45 It is
necessary for food metabolism, energy release by the body, and optimal nerve
function.46 Deficiencies in magnesium result in muscle spasms, tremors, and poor
coordination. The dosage for Magnesium is 400 milligrams a day.47 Magnesium
should not be taken, if kidney disease or heart disease is present, unless the
musician discusses its use with medical personnel. Too much magnesium can
cause diarrhea, so the recommended dosage should not be exceeded.
43
John M. Ellis, et al., "Response of Vitamin B-6 Deficiency and the Carpal
Tunnel Syndrome to Pyridoxine," Proceedings of the National Academy of
Sciences of the United States of America 79, no. 23 (December 1, 1982): 749498.
44
James Duke, Ph.D., The Green Pharmacy (Emmaus, Pennsylvania:
Rodale Press, 1997) 126.
45
Duke, The Green Pharmacy, 109.
46
Trivieri, Alternative Medicine, 398.
47
Balch and Stengler, Prescription for Natural Causes, 557.
149
Vitamin E is essential for nerve health and is used for joint health.
Deficiencies in this vitamin will result in complications that include muscle and
neurological disorders. The optimal dosage is 400 mg a day.48 There are many
herbs, minerals, and other substances that can be used to promote a healthy
state and assist in the treating of a multitude of diseases. When any herbal or
vitamin preparations are begun, the musician should notify the health care
provider in order to avoid interactions with medically prescribed therapies.
Stretching
Some treatments are used in both traditional and complementary
management. Stretching is one such treatment. Regular stretching, when done
correctly, reduces muscular tension, improves coordination, and increases
flexibility, while possibly preventing muscle strains. Stretching a muscle will aid in
warming it up, which is helpful for playing an instrument. Musicians who stretch
are not as injury prone. Stretching sends a message to the muscles and lets
them know they are about to be used. Blood flow to the area is stimulated,
which is needed for proper function of the muscle. When we stretch, we also
gain an awareness of the muscles in of our bodies. Extended periods of
stretching will facilitate easier body movement.
It is important to stretch before any physical activity, and stretching at
any time should be therapeutic, reducing tension and stress. A musician needs to
48
Balch and Stengler, Prescript/on for Natural Causes, 554.
150
stretch those areas utilized during performing or practicing. Of course these
areas will vary, depending on the instrument. Each limb and area of the body
has specific stretches that will benefit the musician. Musicians could benefit from
a book that demonstrates stretches for various muscles groups and areas. One
such book that recommends stretches based on muscle groups is Informed
Touch by Donna Finando and Steven Finando. This book has illustrations of the
stretched muscle groups in red, so that the bothersome areas can be easily
identified.
A good stretch for the upper body can be done utilizing a towel. Take the
towel, one end in each hand. The hands should be far enough apart to allow the
towel to go over your head. Begin by holding the towel in front of the body while
slowly bringing the towel over your head and down the back. When the towel is
being held behind the hips, the hands should be placed a little closer together.
Hold the stretch for 10-20 seconds. The ends of the towel may be held farther
apart, if it is more comfortable and provides more flexibility (figs. 55-58).49
Bob Anderson, Stretching (California: Shelter Publications, 1980), 8586.
151
Figure 55. Stretching Exercises for Upper Body 1.
152
153
It is also possible to do stretches while you are sitting down, and this is a
good way to take a break from a practice session. Extend your hands out in front
of you with fingers interlaced. Straighten the arms out in front of the body until
the stretch can be felt. Hold this stretch for at least twenty seconds and repeat
twice (fig. 59).
Figure 59. Stretching Exercises for Upper Body in Sitting Position 1.
Next, raise the arms above your head, with palms facing toward the
ceiling. Hold this position for ten seconds and repeat three times (fig. 60).50
Ibid., 87.
154
Maintain this arm position for the next stretch. First, hold the outside of
the left hand with the right hand as the left arm is pulled to the side. Keep the
arms straight, holding for fifteen seconds. Repeat the procedure for the right
side (fig. 61).51
Ibid., 87.
155
4**J^-
a a ^HkLriMP .*/
For the next stretch, the right arm should be raised and bent back
towards the elbow. Hold the right elbow with the left hand, pulling the elbow
behind the head until the stretch is felt. Hold this position for thirty seconds and
repeat on the other side (figs. 62 and 63).52
52
Ibid., 87.
156
Figure 62. Stretching Exercises for Arms 1.
Figure 63. Stretching Exercises for Arms 2.
157
It is possible to stretch the forearms by placing the palms flat on a chair,
with the fingers pointing backwards. Slowly lean the arms back to stretch the
forearm (fig. 64).53
Figure 64. Arm Stretch Using a Chair.
Ibid., 88.
158
To continue stretching the upper body, hold your right arm just above the
elbow with the left hand (fig. 65).
Figure 65. Shoulder Stretch 1.
Grasp and pull your elbow toward your left shoulder. Hold this for ten
seconds and repeat on the right side (fig. 66).54
Figure 66. Shoulder Stretch 1.
Ibid., 89.
159
The upper back needs to be stretched also. Lace the fingers and put them
behind the head. Keep the elbows straight out to the sides, pulling the shoulder
blades together. Hold this position for ten seconds and repeat several times daily
(figs. 67 and 68).55
Figure 67. Upper Back Stretch 1.
Ibid., 88.
160
Figure 68. Upper Back Stretch 2.
The neck is a common area that often becomes stressed and tense. To
stretch this area, the head should be rolled in a full circle. If there is an urge to
hold a stretch at any time, then do it. This stretch will assist one in adopting a
better posture (figs. 69- 72).56
Ibid., 89.
161
Figure 69. Neck Stretch 1.
162
163
Stretching the face is really important for the woodwind player and for the
health of the face. This neglected area often becomes tense and strained,
although many of us do not think about it. To stretch the face, raise the
eyebrows and open your eyes as wide as possible (fig. 73).
Figure 73. Face Stretch 1.
While doing this, open the mouth, with the tongue protruding. Hold this
stretch for ten to fifteen seconds and repeat as needed. This will relax the face
164
from the frown that frequently occurs when we are concentrating, producing
smiles when you relax (fig. 74).57
Figure 74. Face Stretch 2.
These are just a few of the stretches that should benefit the upper body,
upper extremities, neck, and face. There are many good, instructional books
available for guidance in stretching.
Ibid., 85-89.
165
Exercise
Many musicians are not only lax in stretching but in exercise. By the time
we practice or play our instruments for several hours a day, we often do not
have the energy to go exercise. This is a mistake, since exercise and stretching
will allow us to become better players. To be the best possible musician, we
must care for our bodies, just like athletes. Exercise and stretching will help keep
us healthy and can be used to break up practice sessions, allowing the body a
much-needed respite. All musicians will benefit from exercise, whether done
early in the morning or between practices. Whether walking, getting on a
treadmill, or taking a swim, exercise should not be neglected. Wii is an excellent
way to exercise at home and will provide a body fitness evaluation, as well as
weight and body mass index. Exercise is a worthwhile activity and should be
included in a planned regimen.
Psychotherapeutic Treatment
Many musicians are perfectionists who are driven to perform at their
optimal level. This motivation, whether self-induced, peer-promoted, or from a
fear of joblessness or losing one's employment, can become crippling if help is
not forthcoming. Whenever a musician experiences stress, a negative
environment is established, possibly resulting in injuries. The role of stress in
disease has been known for many years. Performing in a competitive profession,
where there is always intensive competition, can be stressful for anyone. Many
166
problems experienced by musicians are amenable to some form of
psychotherapy.
The person who becomes a musician is often self-centered and
independent. Because of the personality traits found in musicians, therapy often
must be tailored to these traits. Many musicians do not fare well with group
therapy, do not want to hear about other musician's problems, and prefer to talk
about themselves. Therapists should understand that a musician may require
special treatment. These same personality traits that set the musicians apart will
predispose them to the development of injuries. Frequently, fearful of the
termination of their careers, musicians attempt to overcompensate with
excessive practice. The musician should not be apprehensive about consulting
someone with respect to their injuries and concerns. Seeking advice and
assistance is a much better alternative than experiencing a possible career
ending injury. Often, the therapist is nothing more than a sounding board. In
today's stress filled world, any of us may need to converse with someone
regarding personal matters.58
Peter F. Ostwald, M.D., " Psychotherapeutic Strategies in the Treatment
of Performing Artists," Medical Problems of Performing Artists 2, no. 4
(December 1987): 131-32.
167
Chapter 5
Conclusion
While there are multiple courses in theory, history, pedagogy, and
performance, rarely is there instruction involving the prevention and treatment
of injuries. The music teacher has the responsibility of teaching the student
about posture, body alignment, and hand positions. If music teachers are
unaware of ergonomics and cannot convey the principles to their students, the
students may find incorrect solutions for their problems. The students'
uninformed responses to early symptoms may cause or compound an injury
later in life and jeopardize their careers. Surveys of music teachers have shown
that performance health is not being taught in music programs. Many teachers
admit they do not know how to manage injuries or are hesitant to educate
themselves.1 While an in-depth course of study may not be offered, the most
common causes of injuries should be addressed in lessons with the instructor at
all stages of development.
When confronted with an injury, many musicians want to ignore the
situation. They are fearful of losing their chair position or job termination if their
dysfunction is detected, so they simply ignore the situation. When this occurs,
the feared result may become inevitable. The injury becomes disabling and may
1
Nicholas F. Quarrier, M.H.S., P.T., O.C.S., "Survey of Music Teachers:
Perceptions about Music-related Injuries," Medical Problems of Performing Artists
10, no. 3 (September 1995): 110.
168
threaten the musician's career. Musicians' worst fears are those involving the
unknown, especially the possible termination of a career or, less bothersome, a
loss of practice time. One reason musicians tend to react in this manner is a lack
of adequate health insurance or proper health habits and their maintenance.
The musician who develops an injury should seek assistance as early as
possible. The health care provider should be a licensed practitioner, whose
practice is governed by a board of their peers. This will help ensure quality in
managing the problems musicians encounter. Many permanent injuries could be
avoided if early intervention occurred. Though medical treatment does not
always advocate complete rest of the affected area, often, short playing sessions
with frequent breaks are best. If the instrument is not suited to the hands, a
change in the instrument may be needed, or the instrument may require
modification to make it more ergonomically suited to the player. The importance
of stretching and exercise cannot be emphasized too highly. Every part of our
body is involved in playing an instrument. All musicians need to think of the
entire body as playing the instrument and not limit thinking to the hands. If we
ignore exercise, don't get enough sleep, and don't warm up before playing, we
are inviting an injury. The musician who has hypermobility should be cognizant
of the potential complications that can ensue if a disorder develops. If a
169
musician ignores musculoskeletal symptoms, there is a good possibility that this
will impact their career.2
The importance of prevention cannot be emphasized too strongly, and
the teacher plays an influential role in this. The musician can develop positive
practice habits aimed at decreasing the possibility of an injury, and there are
many options for development of a practice schedule. Treatment of the injured
musician must be individualized, with particular attention paid to correcting
technical problems and reduction of both static and dynamic loads.3 A good
general rule for practice is to play 25-30 minutes, then take a short break. The
amount of time playing can be extended as endurance increases. Shorter
practice sessions are "essential when rehabilitating a muscle or other organ.
When practicing while treating an acute injury, the length of practice times may
need to be shortened to 15 minutes with 5-10 minute breaks between sessions.
This can be modified to fit the individual, depending on the types of pieces being
studied. The length of sessions can be based on the injury or time constraints.
Musicians must be careful to practice with goals in mind and not play
mindlessly. If one is unable to focus for extended periods, then shorter periods
should be utilized to achieve the best possible results. It is important to initiate a
2
Lars-Goran Larsson, M.D., et al., "Nature and Impact of Musculoskeletal
Problems in a Population of Musicians," Medical Problems of Performing Artists 8,
no. 3 (September 1993): 76.
3
170
routine and to be consistent with stretching and exercise.4 Our bodies were
never meant to work constantly without breaks. The breaks give muscles a
much-needed rest from repetitive motion. The room should not be cold, so the
muscles do not have to work harder to retain warmth. We should maintain our
instruments in good working order to lessen the strain on muscles and joints. A
mirror and a video recorder are outstanding teaching aids, since so often we do
not realize the extent of our actions until there is a visual reminder.
Many musicians find the different injuries confusing. The following table is
a guide to assist the musician in determining the type of injury and deciding the
next course of action (table 1).
4
Carol E. Brooks, O.T.R.L., "A Therapist's Perspective on the Treatment of
Upper Extremity Nerve Entrapment Syndromes in Musicians," Medical Problems
of Performing Artists 8, no. 2 (June 1993): 64.
171
Table 1. Injury Comparison Table
OVERUSE
ENTRAPMENT
DYSTONIAS
NEUROPATHY
REPETITIVE
CAUSE
OCCASIONAL REPETITIVE
CHRONIC
USE, POOR
REPETITIVE
REPb111IVE MOTION,
POSTURE,
INCORRECT
MOVEMENT
USE,
UNUSUAL
INSTRUMENT
INCREASED
POSITIONING PLAYING
SIZE,
INAPPROPRIATE
TIME,
INCREASED
STAND/CHAIR
INTENSE
HEIGHT,
PLAYING
POSITIONING
Tingling
Localized
Burning
Pain
Occasional,
Numbness
over affected Numbness
Not a typical
symptom
tendons
Aching
Tendon
Swelling
Over affected
Occasional
Not usually
muscle-tendon Sheaths
junction
Inflammation Not usually
Yes
Sometimes
Not usually
Secondary to Yes, Clumsiness, Yes, Smooth
Yes,
Weakness
pain
Muscular
Generalized
muscle
atrophy (Late)
coordination is
diminished
Range-ofWill eventually Pain
Decreased, seen Decreased in
be decreased
limitations
in later stages
Motion
later stages
due to
decreased
muscle control
Tenderness
Subtle, Diffuse Point
no
Anywhere
Wrist, Hand, Wrist, Hand
Hands,
Most
Arm
Common
Fingers,
Embouchure
Locations
TENDONITIS
The health care providers' responsibility to the musician suffering from an
injury does not end when the injury has become manifest. Teachers and
employers should be understanding of the injury and not expect musicians to
172
return to playing prematurely. Allowing time for rest is important for the healing
process. An inability to see the injury does not eliminate the results of damage.
When comparing a few weeks of rest to a lifetime and a possible career change,
the weeks should not be a major inconvenience. Encouraging students to play a
challenging piece without warming up and stretching should be avoided.
The musician has a responsibility to have and maintain the best possible
instrument. Instruments should receive regular cleanings and adjustments to
keep them in optimal working order, so that a player will not be struggling with a
leaking, unresponsive instrument. The person who repairs instruments should be
reputable and aware of the specifications for specific instrument brands. The
keys should be set to the correct height over the tone holes and not overly stiff.
When an instrument has keys that are too high or are difficult to press, problems
in the upper extremities may occur. Frequently it will be incumbent upon the
teacher to detect problems and recommend a qualified repair person in your
vicinity.
Equipment should be ergonomic to prevent the establishment of bad
habits, especially in younger players. Stands should be at the correct height, and
the chairs should have flat seats or be economically designed for musicians.
Good lighting and appropriate eyewear is essential in order to prevent straining
of the neck and leaning forward to view the music. Smaller musicians need
footrests to provide support and a firm base for their bodies. Temperatures of
173
rehearsal halls and practice rooms vary, so one should always have a sweater or
light jacket in order to protect the muscles in a cold area.
When an injury occurs, it is imperative that musicians seek help as soon as
possible. Students should be able to rely on their teachers to advise them
regarding injuries. Conservative measures can be instituted before making an
appointment with a health care provider, and many of the complementary
measures can be begun at any time. The best way to avoid injury is to keep fit,
exercise, and eat correctly in combination with an intelligently organized practice
regimen. Many musicians include some form of bodywork in their practice
routine. A massage or attending a yoga class on a weekly basis may be helpful in
injury prevention. It is always better to prevent an injury than repair it.
Musicians experiencing an injury have many options available to them now
because the medical profession is becoming more aware of the need for
specialized, individualized care for this very select group of professionals. With
the Internet, it is simpler than ever to search for and find a professional who can
address whatever problem one is experiencing. Today it is easier to locate health
care providers that specialize in medical problems of musicians. The primary
health care provider should provide guidance in locating a specialist that is
knowledgeable in treating musicians. Students should be able to seek advice
from the teacher, who also should be aware of treatment options. When faced
with an injury, the outcome is dependent on a team effort from everyone
involved.
174
Knowledge of musical injuries is of paramount importance to the health of
a musician and to their profession. When we understand the mechanics of these
injuries, both management and prevention, we can prolong and enhance musical
careers.
175
Glossary
Abduction- movement away from the median plane of the body
Adduction- movement towards the median plane of the body
Adhesion- two bodies or substances that stick together
Brachial Plexus- the bundle of nerves that supply the arm, forearm, and hand
Bursa- a pad or sac in the connective tissue, found around the joints, that helps
with movement of the joints
Carpal- pertaining to the wrist
Cervical- the area in the neck region
Contracture- permanent shortening of muscles, tendons and ligaments leading to
rigid joints
Cubital- pertaining to the elbow or ulna
Digit- finger or toe
DIP- distal interphalangeal joint, the joint in the fingers or toes that is farthest
from the body
Distal- farthest away from the body
Dynamic load- stress on the joint or supporting structure
Dystonia- impaired muscle tone
Eczematous- resembling eczema (red, inflamed, scaly, crusty, allergic lesions)
Epicondyle- the prominent part of a bone where it moves
Extension- moving a limb toward or into a straight position
Fibrous- composed of fibers or containing fibers
Flexion- the act of bending
176
Focal- pertaining to a specific area
Humerus- the upper arm bone, between the shoulder and elbow
Hyperextension- to stretch out beyond normal extension
Hyperhydrosis- excessive sweating
Hypertrophy- increase in size or bulk of the tissue
Inflammation- how the tissue reacts to an injury
Innervate- provide sensation to
Intrinsic Muscles- muscles whose origins and insertions are found entirely within
a structure
Lateral- to or toward the side
Laxic joint- a joint that is more loose or relaxed than normal
Laxity- a state of relaxation
Marfan Syndrome- inherited connective tissue disorder, causing looseness in the
joints
Medial- to or toward the middle
Metacarpals- bones of the hand
Meridian- invisible body pathways that must be open for the body to stay healthy
Nerve Entrapment- occurs when nerves are caught between two anatomic areas
Neuropathy- a disease of the nerves which causes numbness and tingling
Nodule- a collection of cells or a mass of cells
Objective- information that is observed
Palmar- referring to the palm of the hand
177
Paresthesia- unusual sensations such as numbness or tingling, without an
obvious cause
PIP- proximal interphalangeal joint, the joint in the fingers or toes closest to the
body
Pisiform- the smallest carpal bone
Prostaglandin- biologic substances that effect the smooth muscles
Proximal- closest to the body
Radiate- to spread from a common area
Radiculopathy- an irritation of the spinal cord and nerves as they exit the neck
that results in numbness and tingling in affected limbs
Radius- the outer, shorter bone of the lower arm
Static load- continuous muscle contraction and stress on a point and its
supporting structures
Subjective- information that is felt
Supination- turning the palm upward
Synergy- action of two or more organs working together, a coordinated action
Tenosynovitis- inflammation of a tendon or the tendon sheath,
also called tendosynovitis
Tendonitis- inflammation of a tendon
Thenar eminence- a bony prominence at the base of the thumb
Tunnel- a narrow passageway
Ulna- the inner, longer bone of the lower arm
Vasomotor- nerves exerting control over the blood vessels
Volar- referring to the palm of the hand
178
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