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** The information below is presented since it has relevance classical guitarists and their health. It was re-formatted by the WebMaster, and may contain errors and or omissions. The work was sent to me as a '.doc' file. I have attempted to maintain most of the formatting from the original, but I have removed/modified some things (i.e. the document is now single spaced.) Information between brackets '[ ]' was added by the WebMaster. Please send your comments on the document to it's author and comments on the web page to the WebMaster@Ga-USA.Com. The document is here because because 1) it is good information, 2) after the author offered to share what he had learned with the Classical Guitar Mailing List, I offered to post it here and 3) the author agreed (12/98).
Upper Extremity Injuries
And Instrumentalists:
Definitions, Causes and Prevention's
A Research Proposal
By
Clyde Thorpe
Austin Peay State University
Dec. 8, 1998
TABLE OF CONTENTS
- Introduction
- Purpose Statement
- Need for the Study
- Definition of Terms
- Limitations
- Delimitations
- Methodology
- Related Literature
- Bibliography
- Appendix
Almost any repetitive action can lead to a strain injury. Many people
suffer from repetitive strain injuries to their upper extremities. Such actions that can
lead to these injuries vary: keyboarding, knitting, assembly line production, etc. The
most common of these injuries are well known: tendonitis, carpal tunnel syndrome, tennis
elbow, trigger finger, etc.
Musicians often spend many hours a day holding a musical instrument and/or performing
repetitive motions. The body’s anatomical structures are simply not designed for the
repetitive actions required by musicians in practice and performance. This makes the
musician an ideal victim for a repetitious strain injury by the very nature of the
vocation. The causes of these injuries vary such as: lack of adequate and careful
warm-ups, excess tension in the upper extremities while practicing, improper musical
techniques, and faulty ergonomics (i.e., the wrong size instrument for a particular
musician).
Medical treatments for these injuries are physical rehabilitation, steroid therapies,
anti-inflammatory medications, hot and cold compresses, as well as newer surgical
procedures. Many of the more popular psychological treatments are meditation, biofeedback,
and yoga. The type of injury, and the action leading to the injury will not only vary from
instrument to instrument, but can also vary from individual to individual. Accordingly,
this may alter the preventative measures utilized to accommodate the instrument, the
technique required to perform on the instrument, the individual’s specific
practice/performance habits,
as well as their anatomical makeup (size of hands, shape of fingers, etc.).
The purpose of this research is to identify the most common injuries which
musicians suffer, as well as to describe preventative measures which may later help them
to avoid such injuries. This study is meant to serve as a compilation of preventative
measures which musicians could employ.
In order to accomplish this, the following issues will be addressed:
- To delineate the kind of upper extremity injuries which occur within the general population.
- A description of possible causes of repetitive strain injuries.
- A description of the kinds of injuries suffered specifically by musicians.
- A discussion of possible procedures utilized for these kinds of injuries (medical, surgical, psychological, and non-traditional).
- An explanation of preventative measures which musicians could employ to avoid injuries.
Need for the Study
According to Wallace, an astounding "50 to 60% of orchestra players at sometime
suffered from some type of injury in their arms and/or hands at some point in their
careers" (p. 396). Historically, some very famous musicians have suffered injuries.
"The case of Schumann’s hand injury is well known…Fewer people know about
Scriabin. Yet it was a serious hand injury which forced him to stop playing and to devote
his life to composing….He injured his hand by over-practicing while he was still a
student at the Moscow conservatory…" (Sen, p. 3-4). As prevalent as this is,
there is no one particular source that
addresses this extremely costly and important issue. It is costly in terms of both
treatment and loss of financial resources simply because the musician (especially if
professional) is unable to meet performance commitments. A study that addresses this topic
should be invaluable to all instrumentalists. Information about repetitive strain injuries
should be made available to all musicians in their formal training. This study is intended
as a reference for student instrumentalists to avoid problems, and for teachers to use to
help students who are already plagued by injuries.
Definition of Terms
- Carpal Tunnel Syndrome- A condition that occurs when the median nerve becomes compressed in the small, narrow bone channel in the wrist through which the tendons and median nerve pass on their way into the hand (Malka).
- Repetitive Strain Injuries (Also known as Repetitive Stress Injuries, Repetitive Motion Disorder, Upper Extremity Overuse Injuries, and Cumulative Trauma Disorder)- Injuries caused by overuse and/or repetitive motions that include Tennis Elbow, Tendonitis, Bursitis, and Tenosynovitis or DeQuervain’s syndrome (trigger finger). These injuries are diagnosed as the inflammation of the tendons and the associated bursa.
- Bursa- The sheath like structure through which the tendons travel.
- Synovium- The inner lining of the bursa.
- Range of Motion- The natural range of movement to each extreme of any given joint of the human body within normal operating parameters.
- Principles of Muscular Alignment- A set of principles developed by Aaron Shearer that states the alignment of human limbs in the middle of their range of motion is desirable in repetitive motion situations (Shearer).
- The time limitation for this study is one semester, Fall, 1998.
- The material compiled for this study is limited to those materials available at the Woodward library, through interlibrary loan, and information available on the internet.
Only instrumentalists will be examined, and the focus will be primarily, but not exclusively string musicians.
To carry out this study I will utilize books, articles, dissertations and theses as well as information from the Internet and television. The literature will be organized beginning with the general population and leading to a focus specifically directed toward guitar players.
Related Literature
Injuries such as carpal tunnel have been on the rise for the past two decades. The sudden
proliferation of computer technology has more people than ever before keyboarding, and
using a mouse to control a cursor on a computer screen at work and/or at home. While most
people would not think of such actions as being physically demanding, they do extract a
physical toll. A resulting consequence to the new technology is something that some
professions have dealt with for centuries, repetitive strain injuries. These types of
injuries have occurred regularly for quite some time, as any repetitive movement can be
the cause (i.e., knitting, using a screwdriver or wrench, playing a musical instrument).
[Listing of Injury Definitions]
The list of repetitive strain injuries include: carpal tunnel syndrome, tendonitis,
bursitis, tennis elbow (lateral epicondylitis), and trigger finger (also known as
DeQuervain’s syndrome and tenosynovitis). Even the title repetitive strain injuries
are known under many different names (repetitive stress injuries, repetitive motion
disorder, upper extremity overuse injuries, and cumulative trauma disorder).
Carpal tunnel is a condition caused by the pinching of the median nerve as it passes
through the tunnel in the wrist on the way to the hand.
The carpal tunnel is normally quite snug and there is just barely enough room in it for the tendons and one nerve that have to pass through it. If anything takes up extra room in the canal, things become too tight and the nerve in the canal becomes constricted or "pinched". This pinching of the nerve causes numbness and tingling in the area of the hand that the nerve goes to. The symptoms caused by the median nerve being pinched in the carpal tunnel are called the "carpal tunnel syndrome" (Malka 1). (See Appendix Plate A1 and A2)
There are many possible contributing circumstances to consider in the contraction of
carpal tunnel syndrome (CTS), the most central of which is tendonitis. The tendons which
travel through the tunnel can easily become inflamed with either microscopic or
macroscopic lesions (Chvapil), which cause pressure on the median nerve. From the tunnel
the tendons travel through synovial sheaths called bursa which keep them lubricated.
Tendon inflammation leads to the swelling of the bursa (due to the overproduction of the
lubricant synovium), and this in turn causes the synovium itself to become sticky instead
of acting as a
lubricant. The swelling of the tendons and synovial sheaths exerts pressure on the median
nerve in the carpal tunnel. Every time the hand is used, the inflamed tendons travel
through the bursa (with the now resistant synovium) which causes even more inflammation in
both the tendons and the synovial complex.
Other less prominent contributing factors to CTS are the misalignment of the radius and
ulna forearm bones leading to the wrist, a pre-existing trigger finger condition,
continued use of objects which vibrate (i.e., a jackhammer, chainsaw, hand-held grinder),
having an occupation in a cold environment (decreases blood flow to the affected tissues),
wrist fractures, and misalignments of the lower cervical spine (Jameson A).
The swelling of the synovial sheaths, as stated before, is also known as bursitis. While
this condition can accompany CTS and is always present with tendonitis, in these cases it
is considered more of a symptom and/or side effect than a cause. Usually the only instance
of bursitis contracted in the upper extremities, which is labeled as such is in the
shoulder area.
Another RSI that is quite common is trigger finger (tenosynovitis).
Trigger finger occurs when the tendons and associated ligaments used to operate the index
finger and thumb become inflamed or develop scar tissue (nodules). The cause of this
condition is the repetition of the tendon traveling across the ligaments. If this occurs
near or in the wrist area, it can cause carpal tunnel syndrome. Other possible
contributing factors include rheumatoid arthritis, partial tendon lacerations, and
repeated long hours of gripping things (Medical Multimedia Group). Symptoms of this
condition are a noticeable clicking sound and feeling
when closing the thumb and forefinger. If this condition progresses long enough untreated,
the forefinger may lock in place while closing and must be manually moved to a different
position.
Tennis elbow (lateral epicondylitis) occurs when either microtears
develop in the forearm (extensor/supinator) muscles at the insertion point (into the bone)
at the elbow (Siegel), or when tendonitis develops at the elbow (Glazebrook). In the
former, overextension and/or rotation of the forearm is usually the cause with few, if
any, mitigating circumstances causing contraction (Medisport). In the latter case, direct
blows to the elbow and excessive tensile forces can be a contributing factor (Curwin).
The susceptibility of the general population suffering one of these injuries include
fractures of the wrist and/or hand, and (to some extent) gender. Of those who suffer from
repetitive strain injuries (RSI), the majority (70%) are women. There are mitigating
factors contributing to this majority, as carpal tunnel is frequent during pregnancy
(Chiu). Smaller skeletal structure and water retention while not directly stated in the
literature would also seem to suggest themselves as reasons for the gender difference.
[Typical Injury Treatment Programs]
Treatment of RSIs usually occurs in two phases, a rest phase and a recuperative phase. The
rest period also includes immobilization for tissue repair to begin. This rest period may
be combined with anti-inflammatory medications, steroid therapies, ultrasound treatments,
frequent ice and/or heat baths, and massage. Another common non-surgical medical treatment
is cortisone injections (frequently used in the treatment of de Quervain’s syndrome,
bursitis of the shoulder, and trigger finger). Injections are used by and large to relieve
the localized discomfort associated with the condition. While injections do relieve
discomfort, they should be avoided in the hand, wrist, and elbow areas (Norris).
Once the rest period is over, the recuperative stage continues with much the same
treatment as the rest program (i.e., ice/heat baths, massage). Elements such as physical
therapy, stretching, and a very gradual return to the activity which caused the RSI and a
full recuperative program can be added. The gradual return to activity, also known as work
hardening, is done in very small increments. The beginning increment may vary from 15
minutes per day to 5 minutes every few months depending on the severity of the injury
(Taylor). The work hardening schedule gradually increases to 50 minutes followed by a 10
to 15 minute break. This routine is usually recommended for the patient from then on
(Norris).
While there are some people who are severely injured and require multiple hand surgeries,
there are some who have to give up their occupation or hobby altogether. However, these
cases are relatively small in number. In almost all of these cases warning signs such as
pain, tingling of the fingers, numbness in the extremities, etc. were ignored. The more
drastic measures taken these days are injections and surgical procedures. The relatively
new carpal tunnel release surgery has worked well for many suffering from RSIs. In this
procedure, performed only on those patients who do not respond to traditional treatments,
the carpal ligament in the bottom of the wrist (see Appendix Plate B) is cut through two
small incisions in the wrist (Appendix Plate C).
[Musically Exclusive Treatment
Programs]
Of the various RSI’s described, no one condition is more prevalent in
instrumentalists than another. Certain instrumentalists do have a higher occurrence of
some types of RSI’s than others, however. Common sense would dictate that the
flautist, violinist, and trumpet player would obviously be more at risk for developing
bursitis in the shoulder than say a cellist or guitarist.
The causes of RSIs in musicians are much narrower in scope than that of the general
population. Playing/performing with inadequate technique, faulty ergonomics, excess
tension, and/or not utilizing warm-ups are absolutely avoidable situations, and promote
the contraction of RSI (Jameson B).
Aaron Shearer has dealt with the issue of faulty ergonomics in guitarists
most effectively. His approach to positioning the guitar is based on "four
principles of efficient muscle movement". These four principles are based on
performing on an instrument in the power-zone of the human body. While specific joints
have a certain range of motion (ROM), the more directly aligned the various muscle-groups
performing the task are, the better the body is ergonomically. This is the most general
correction of faulty ergonomics, while more specific ones are the relation of the
instrument to the body, and hand size vs. instrument size.
For as long as instrumentalists have been dealing with RSIs, they have been dealing with
the psychological side of musical performance even longer. Bearing this in mind, it is
then no surprise that many systems exist that can help instrumentalists deal with
RSIs.
Two of the most well known systems are the Alexander Technique and the Feldenkrais
Method.
Fredrick Matthias Alexander (a vocalist) created the Alexander technique in the 1890s
(Nausbaum). A short, operational definition of the Alexander Technique is
"a way of learning how you can get rid of harmful tension in your body"
(Flechas, P. 1). The technique is based on ridding the body of excess tension such as the
startle response. The startle response is an instinctive lowering and protracting of the
head and neck which causes tension. Once the startling stimulus is removed, the body is
supposed to return to the relaxed state, but through learned tension it does not. In
totality the method not only
addresses reducing excess tension, but also improving individual coordination in all
things (not just music). By simplifying movements, correctly interpreting the movements we
make, and focusing on the breath, the musician may get rid of the tension, thereby making
their instrument easier to play.
The Feldenkrais Method "is about working with people around the
issues of the acquisition of skill, efficiency, simplicity and other improvements in
movement and ability" (Rubin). Developd by Moishe Feldenkrais in the 1940s, the
method is a combination of martial arts, what Feldenkrais knew of the Alexander Technique,
psychology and biomechanics (Nausbaum). The Feldenkrais method is a way of reprogramming a
person’s neuromuscular system to more accurately distinguish finer movements, and
letting the major muscle-groups do most of the work (thereby freeing up the hands)
(Nausbaum).
While both the Alexander Technique and the Feldenkrais Methods’ goals are in unison,
the ways in which they proceed are very different (Nausbaum). To best exemplify this one
must examine a typical student’s first few sessions in both practices. In the
Alexander Technique the first few sessions would involve identifying the pupil’s
patterns of tension in everyday movements, and eventually learning how not to respond to
stressful situations with muscular tension (Nausbaum). In the Feldenkrais Method, the
student would begin reorienting their neuro-muscular system by first being gently
physically manipulated by the
instructor (Functional Integration), and then by performing movements on verbal command
from the instructor (Awareness Through Movement) (Rubin).
[Prevention]
There are many other psychological forms used to deal with RSIs such as yoga, tai chi, and
meditation. They all seem to have the same end goal for the instrumentalist, that of
relieving excess tension and being adequately attentive during performing so as to avoid
lapses.
The process of adequately warming-up before practicing can not be emphasized enough, and
many exercises exist for this purpose (Jameson B). One of the most basic flaws in warming
up the hands is that of stretching. While it is always a good idea to stretch the hands
before practicing, it is not advisable to stretch cold muscles. A thorough way of warming
the muscles prior to stretching is by simply washing them well in warm water (Butturi).
The warmth of the water helps to increase blood circulation, as does the friction of the
hands rubbing together in washing.
It is startling how prone to RSIs instrumentalists are. While there is no way of saying
with certainty whether an instrumentalist will ever contract an RSI, the simple acts of
adequate warm-ups and stretching are a small price to pay as compared to the possible
consequences that accompany the contraction of a RSI.
BIBLIOGRAPHY
- Butturi, Renato "On Warming Up Before Practice" rb6@uev.edu
- Chiu "Endoscopic Carpal Tunnel Release Surgery: Carpal Tunnel Procedure" http://www.west.net/~chiu/endoscopic.htm
- Chvapil, M. Physiology of Connective Tissue. London: Butterworth, 1967.
- Curwin, S, Stanish WD: Tendinitis: Its Etiology and Treatment. Lexington, MA, Collamore Press, 1984.
- Flechas, Alfred "What Is The Alexander Technique?" http://alexandertechnique.com/at.htm
- Glazebrook, Mark et al "Medial epicondylitis: an electromyographic analysis and an investigation of intervention strategies". The American Journal of Sports Medicine, Sept-Oct, 1994 v22 n5, p.674.
- Jameson, Timothy "Carpal Tunnel Syndrome: Eight Causative Factors" http://www.musicianshealth.com/newpage2.htm (A)
- Jameson, Timothy "RSI Prevention Guidelines" http://www.musicianshealth.com/rsi.htm (B)
- Malka, Jeffery malkajef@orthohelp.com "Carpal tunnel syndrome: its diagnosis and treatment." http://www.os2bbs.com/malka/carpal.htm
- Medical Multimedia Group "A Patient’s Guide to Cumulative Trauma Disorder: Trigger Finger" http://www.sechrest.com/mmg/ctg/trigger/trigger.html
- Medisport "Medisport: Getting Better Guide pain in elbow" http://medisport.co.uk/elbow.htm
- Nausbaum, Nora "An Introduction to the Alexander Technique" http://www.musicstaff.com/article14.html
- Nausbaum, Nora "What is the Difference Between The Alexander Technique and Feldenkrais Method?" Strings, Sept/October 1997 issue, volume 64.
- Norris, Richard "Nonsurgical Treatment Options for Upper Extremity Overuse Injuries" RSI Network newsletter, Issues #21-23.
- Rubin, Paul "Interview with Paul Rubin" The American Suzuki Journal, Winter, 1995.
- Sen, Jonas "Playing the Piano, Playing…with fire?" A Study of the Occupational Hazards of Piano Playing. MA dissertation at City University of London, England, 1995.
- Shearer, Aaron "Learning the Classic Guitar Part 1" Mel Bay Publications Pacific, Missouri. 1990. Page 9
- Siegel, Mark "What is Tennis Elbow?" http://www.deaconess-healthcare.com/library/orthopaedics/tenniselbow.html
- Taylor, Billy "An Interview with Jimmy Amade" CBS Sunday Morning broadcast of November 22,1998.
- Wallace, H. "Performance-Related Injuries- a Dark Continent?" The Strad, Vol. 102, 1991, P. 396-404.
The research proposal above is Copyright © 1998 by Clyde Thorpe, All Rights Reserved
** Disclaimer - the information presented here is not authoritative medical advice. Please consult your physician should you have need.
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