Musicians and Musculoskeletal injuries

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Musicians and Musculoskeletal injuries
Cynthia C. Carsley B. Sc. Physiotherapy M.
Sc.(A) Occupational Health
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Musicians and MSI

• Overview of health issues
• Musculoskeletal injuries
• Anatomy
• Specific disorders
• Risk factors
• Prevention
• Treatment

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Overview of health issues

• Musicians websites
• Part 1 Introduction and Background.  Preventing
  Musculoskeletal Injury (MSI) For Musicians And
  Dancers
• A Resource Guide
•         http//www.shape.bc.ca/resources/pdf/part1
  .pdf
• Part 2 Musicians.  Preventing Musculoskeletal
  Injury (MSI) For Musicians And Dancers A
  Resource Guide         http//www.shape.bc.ca/res
  ources/pdf/part2.pdf
• Musicians and injuries. Engineering Electronics
  Shop         http//eeshop.unl.edu/music.html
• Daum, M.C. Musculoskeletal problems in musicians.
  
• Center for Safety in the Arts        
  http//www.sierranevada.edu/life/safety/musicsaf.h
  tm

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Musicians and MSI

• Overview of health issues
• Ear, nose throat
• Hearing loss
• Skin disorders
• Dental problems
• Psychological aspects

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Overview of health issues

• Ear, nose and throat
• Quick diagnosis
• Quick intervention

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Overview of health issues

• Hearing loss
• 30 rock (pop) musicians
• 50 classical musicians
• Solutions
• Environmental techniques
• Earplugs, monitors etc.
• Tinnitus
• Pitch perception problems
• Chasin, M. Musicians the Prevention of
  Hearing Loss. Hearing Review 1999. See www.
  musiciansclinics.com

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Overview of health issues

• Skin problems
• Vary widely
• Point of contact
• Bruises, calluses, cuts, abrasions, ulcers,
  eczema (bow resin)
• 62 violinists violists under chin (left)
• 32 string players
• 27 wind brass
• Ostwald, P.F. et al, Performing arts medicine.
  West J Med 1994.

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Overview of health issues

• Dental problems
• Periodontal disease
• Malocclusion
• Loose teeth
• Brasses woodwinds
• Ostwald, P.F. et al, Performing arts medicine.
• West J Med 1994.

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Overview of health issues

• Psychological
• Social pressure
• Fatigue
• Increased adrenaline
• Anxiety
• Financial instability
• Ostwald, P.F. et al, Performing arts medicine.
  West J Med 1994.

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Musicians and MSI

• "Some fingers, no doubt because of too much
  writing and playing in early years, have become
  quite weak, so I can hardly use them."

Schumann (1839)
Robert Schumann (1810 -1856)
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Musicians and MSI

• Musculoskeletal injuries
• Muscle, bone, tendon, joints, ligaments, nerves,
  blood vessels and related soft tissues
• Catch-all terms (RSI, CTDs, WRMSDs)
• 50 of all musicians
• Can limit, interrupt or end a career
• Part 2 Musicians.  Preventing Musculoskeletal
  Injury (MSI) For Musicians And Dancers A
  Resource Guide

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Musicians and MSI

• Overview of health issues
• Musculoskeletal injuries
• Anatomy
• Specific disorders
• Risk factors
• Prevention
• Treatment

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Anatomy

• Muscle
• Connected to bones by tendons (at either end)
• Elastic
• Provides movement and stability
• Fascia
• Sheets of fibrous tissue between layers of
  muscles
• Source of pain and tightness

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Anatomy

• Tendon
• Rope-like structure made of strong smooth fibers
• Non-elastic
• Tears if overstretched
• During movement, slides in lubricated
  tendon sheath

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Anatomy

• Joint
• Area of union between 2 or more bones
• Lined with synovial membrane
• Membrane produces lubricant called synovial fluid
• Synovial fluid allows smooth movement

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Anatomy

• Bursae
• Sac-like cavities filled with synovial fluid
• Found around joints
• Friction may develop

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Anatomy

• Cartilage
• Covers ends of bones for smooth joint movement

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Anatomy

• Nerves
• Cordlike structures transmit electrical impulses
  to and from body parts they control

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Anatomy

• Peripheral nerves
• Travel from cranial nerves in brain or spinal
  cord to outer regions of body
• Motor nerves
• Send signals to muscles
• Sensory nerves
• Transmit pain, temperature, position, and
  pressure in skin, muscles joints to the brain

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Anatomy

• Intervertebral disc and menisci
• Fibrous cartilage
• Provide extra cushioning

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Musicians and MSI

• Overview of health issues
• Musculoskeletal injuries
• Anatomy
• Specific disorders
• Risk factors
• Prevention
• Treatment

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Musculoskeletal disorders

• Signs and symptoms
• Swelling
• Redness
• Difficulty moving joint
• Loss of motor control
• Numbness
• Tingling
• Pain

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Musculoskeletal disorders

• Pain
• Unique for each individual
• High threshold in performers
• Performers normalize pain
• No pain, no performance
• Fear label musician with injury
• Lack of resources to subsidize and prevent early
  treatment

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Musculoskeletal disorders

• Pain
• Defensive mechanism intended to protect
• May not appear during activity responsible
• May occur during sleep
• May appear suddenly or gradually over months
• Pay attention to when? how long?
• influence on ability to perform ADLs?

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Progression of MSI signs symptoms in
performers(SHAPE-Preventing MSI for Musicians
and Dancers-A Resource Guide, 2002)
Level I
Pain occurs after class, practice, rehearsal or
performance, but the musician performs normally
Level II
Pain occurs during class, practice, rehearsal or
performance, but the musician is not restricted
in performing
Level III
Pain occurs during class, practice, rehearsal or
performance, and begins to affect some aspects
of daily life. Musician alters technique, ?
duration.
Level IV
Pain occurs as soon as the musician participates
in class, practice, rehearsal, or performance ,
and is too severe to continue. Many aspects of
daily life are affected.
Level V
Pain is continuous during all activities of daily
life, and the musician is unable to participate
in class, practice, rehearsal, or performance.
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MSI specific disorders

• Tendon muscle disorders
• Tendinitis inflammation due to irritation of
  the tendon and or sheath from excess tension and
  friction from repeated movements.
• Due to awkward postures that stretch and bend
  tendons around joints
• Excessive tension impact ? tears ? scar tissue
  ? thickened, bumpy irregular tendon sheath

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MSI specific disorders

• Focal dystonia
• Malfunction of muscle at a specific location
  resulting in
• Cramping
• Involuntary flexing or straightening of the joint
• Sense of fatigue
• Loss of coordination
• May or may not be painful
• Referred pain with cramping spasm
• Interferes with ability to play

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MSI specific disorders

• Focal dystonia typically affects
• Hands fingers of string and keyboard players
• Drummers feet
• Vocalists vocal cords
• Embouchure of brass players
• (Sternbach 1994)

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MSI specific disordersHand, wrist forarm

• Keyboard guitar players
• Straining small hand muscles
• Lateral finger movement finger spread
• Stress on finger flexors at large MCPs (knuckles)
• Loud repeated octaves or chords
• (Chong et al 1989)

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MSI specific disordersHand, wrist forarm

• String players
• Left wrist flexors (pressure on strings)
• Extensors of right wrist while bowing
• Small rapid bow movements
• Sustained rapid tremelo causes ? demands on
  flexors extensors

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MSI specific disordersHand, wrist forarm

• Certain wind instruments
• oboe
• french horn
• flute
• require sustained extension to hold
  instrument while allowing fingers to curl into
  position for fingering.

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MSI specific disordersHand, wrist forarm

• De Quervains tenosynovitis
• Pain in tendons at base of thumb thumb side of
  of forarm
• Painful to move thumb away from hand
• Painful firm grip or twisting motion

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De Quervains tendinitis

• Oboe players
• Clarinet, flute players use thumb extensors to
  support instrument
• Drummers extreme flexion lateral motion of
  wrist with rapid deceleration at impact
• Keyboard thumb under ascension
• (Chong et al 1989 Zaza 1998)

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MSI specific disordersElbow

• Lateral epicondylitis (tennis elbow)
• Epicondyle at elbow is anchor point for several
  muscles
• Pain at elbow, forarm or wrist

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MSI specific disordersElbow

• Medial epicondylitis
• (golfers elbow)
• Musicians complex postures
• forarm rotation
• bending wrist with independant finger movement
• keyboard, percussion, clarinet, harp, oboe,
  trombone

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MSI specific disordersShoulder

• Rotator cuff tendinitis
• Tendons of several muscles that stabilize arm at
  the shoulder
• Due to raised shoulder outward or forward
• Violin, viola,cello
• String bass
• Bassoon
• (Chong et al 1989, Zaza 1998)
• Pain
• usually at top or front of shoulder
• at outer part of arm
• at night

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MSI specific disordersBack neck

• Low back pain (LBP)
• Prolonged sitting restricted posture (Fry 1986
  Chong 1989)
• Flattens curve in spine
• ? intravertebral disc (IVD) pressure ? bulging ?
  herniation
• ? tension on posterior ligaments small muscles
  ?
• local swelling
• muscle spasm
• nerve compression

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MSI specific disordersUpper back neck

• Often due to
• Postures required to support instrument
• Strength required to support or play larger
  instruments (double bass, bassoon)
• Static head position ? face neck pain
  (viola violin)
• Turning head to one side (flute harp)
• Tilting head downward (sax keyboard)
• Methods of transporting carrying

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MSI specific disordersHead face

• Orbicularis oris
• Straining of muscles that control mouth lips
  (vocalists horn players)
• Temporomandibular joint (TMJ)
• wind instruments instruments that require
  careful and sustained jaw positioning
• (viola, violin, sax, clarinet, french horn)
• Face neck pain headaches
• Often related to psychological stress and teeth
  alignment
• Excessive muscle tension (teeth clenching)
• Degradation of the joint

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MSI specific disordersNerve compression

• Carpal tunnel syndrome
• Numbness, tingling or pain in thumb, index,
  middle finger
• Due to compression of nerves, blood vessels,
  tendons
• Due to activities requiring repetitive sustained
  wrist flexion with alot of finger movement
• Left hand of violinists, violists, guitar players
  (12 or 13th position too long)
• (Sternbach 1991)

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MSI specific disordersNerve compression

• Cubital tunnel syndrome
• Compression of nerve at ulnar side of elbow
• Numbness, tingling pain or loss of coordination
  in 4th 5th fingers.
• Pain at elbow
• Due to postures requiring flexion at elbow
  wrist with rotation of palm upward
• Left hand of violinists, violists, guitar players
  (Chong 1989)

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MSI specific disordersThoracic outlet syndrome

• Symptoms similar to CTS, CuTS
• Compression of group of nerves (and or blood
  vessels)
• travelling toward the arm between the 1rst
  rib and collarbone
• Shoulders that are rounded, forward elevated
• Sustained use of pectoral muscles
• Breath holding irregular breathing patterns

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MSI specific disorders Thoracic outlet syndrome

• Violinists, violists on left side (securing
  instrument between chin and shoulder)
• Guitar players on left
• Flute players both sides (flexing shoulders
  forward, reaching left arm across body,
  controlling breathing)
• Keyboard (rounded shoulders, arms forward, head
  forward, irregular breathing patterns)

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MSI specific disordersNerve compression

• Sciatica
• Pain in legs and buttock
• Can occur at any level
• Sitting, bending slightly forward, rotated to one
  side
• Sitting surface too high, square on edge of front
  of seat ? compression back of leg

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Musicians and MSI

• Overview of health issues
• Musculoskeletal injuries
• Anatomy
• Specific diagnoses
• Risk factors
• Prevention
• Treatment

46
Musicians and MSIRisk factors(SHAPE-Preventing
MSI for Musicians and Dancers-A Resource Guide,
2002)
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Influences on risk of injury in
musicians (SHAPE-Preventing MSI for Musicians and
Dancers-A Resource Guide, 2002)
Artistic Director Composer Conductor
Administrative Union Funding agency Regulatory
body Company manager
Technical Sound engineer Stage manager Technical
director Piano tuner
Musician
Early development School board Music
instructor Parent
Venue design Equipment designer Interior
designer Architect Purchaser
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Musicians and MSIRisk factors for musicians

• A change in technique or instrument
• Intense preparation for performance
• Overly strenuous repetition of demanding musical
  phrases
• Sudden increase in duration or intensity
• Preparation of a new or difficult piece
• Prolonged performance without adequate rest
• Lack of warm up
• Combination
• Challenging schedule
• Poor diet
• Pressure to perfect
• Performance anxiety
• Zaza and Farewell 1997 Paull and Harrison 1997
  Kella 1997
• Zaza and Farewell 1997 Kella 1997 Norris
  1993 Chong et al 1989

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Musicians and MSI

• Overview of health issues
• Musculoskeletal injuries
• Anatomy
• Specific diagnoses
• Risk factors
• Prevention
• Treatment

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Musicians and MSIPrevention

• Level 1-Controlling risk factors
• Developing adhering to warm up routine
• Rest breaks that leave you feeling refreshed
• Longer rest breaks require another warm up
• Gradual increases to the duration and intensity
  of practice
• Zaza 1994
• Level 2-Recognizing signs symptoms and
  responding appropriately

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Musicians and MSIPrevention-Controlling risk
factors

• Musician has most control during practice
  sessions
• Focus on practice habits but also implement
  prevention during rehearsals performances when
  possible
• Maintain personal health, fitness and nutrition
• Carry and set up equipment safely
• Maintain body awareness
• Know your limits
• (balance physical psychological demands)
• Adjust practice schedules
• Vary difficulty of music
• Good playing technique
• Select appropriate instruments and furniture

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Musicians and MSIMaintain personal health,
fitness and nutrition

• All aspects of daily living
• Nutrition
• Hydration
• Physical activity
• Sleep quality
• Stress management
• Smoking, alcohol, coffee, drugs decrease blood
  flow, interfere with normal nerve function, alter
  judgement, decision making

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Musicians and MSI Select appropriate practice
location

• Cold
• ? blood flow to fingers
• ? lubrication tendons joints
• ? nerve conduction velocity
• Poor lighting
• Compromises ability to read music
• Compromises playing posture
• Eye strain

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Musicians and MSI Select properly heated well
lit environment

• Use portable task lamps, battery powered clip
  lights
• Regular eye exam corrective eye wear
• Adequate clothing
• Warm hands
• Fingerless gloves, whole body exercice

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Musicians and MSIDevelop good practice habits

• Warm up
• ? blood flow
• Warms muscles and joints
• 2 components Joint rotation aerobic warm up
• Gentle smooth motions x several minutes
• An aerobic warm up for 5 minutes rapid walk,
  slow jog, skipping
• Slow long notes beginning practice, rehearsal,
  performance
• Gradual increase to duration intensity of
  practice
• Stretching controversial
• Seek medical advice on proper techniques

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Musicians and MSI Taking rest breaks

• Mitigates stress (physical psychological)
• Allows physical recovery of tissues
• May enhance learning
• Avoid muscle fatigue
• Schedule rest breaks into practice session
• 5 min rest for 25 minutes playing
• 10 min rest for 50 min playing
• 10-15 min rest for 30 min playing
• Zaza 1994 Kella 1997 Norris 1993
• Spread practice time throughout the day
• Kella 1997

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Musicians and MSI Avoid repetition

• Variety of music exercises
• Build in time for simpler pieces
• Use imaging and visualization
• Note by note
• Movement by movement
• Assists cognitive aspects of learning
• Enhances speed of motor learning
• Reduces physical practice time physical risk of
  injury

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Musicians and MSI Select appropriate instruments

• Well maintained and well designed
• Avoid leaky valves or pads
• Avoid bridges that are too high
• Avoid excess dead space at top of piano keys
• Norris 1993
• Instrument that fits the musician

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Musicians and MSISelecting and adjusting
furniture

• Chairs stools adjusted so feet flat on floor
• Chair too short and not adjustable?
• Add a cushion
• Stack chairs
• Wooden blocks under chair feet (careful)
• Paull and Harrison 1997
• Chair too tall?
• Footrest (phonebook)

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Musicians and MSI Sitting posture

• Depends on instrument
• Maintain low back curve
• Lumbar pillow
• Wedge cushion
• Lift back legs of chair
• Foot width
• Wide base
• Feet in front of knees
• Vary position

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Musicians and MSI Selecting and adjusting
furniture

• Adjust music stands
• Sheet music at eye level or below
• Lower eyes rather than head
• Directly in front

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Musicians and MSIPrevention-various gadgets
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Musicians and MSIPrevention-Harnesses

• tubas, drums saxophones

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Musicians and MSI Guitar straps, belts supports
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Musicians and MSIPrevention-Stands
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Musicians and MSIPrevention

• Various gadgets
• High chin rests
• (violins, violas)

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Musicians and MSI Carry and set up equipment
safely

• Plan lift
• Avoid twisting rapid lifting
• How heavy is load?
• Stable base
• Face item
• Solid grip
• Clear route AND TAKE YOUR TIME!

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Musicians and MSI Using appropriate containers

• Not too heavy
• Well constructed, padded handles wheels
• 2 trips better that 1
• Enough people carrying? Get help
• Dolly
• Avoid lifting if injured
• Give yourself enough time

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Musicians and MSI Practising body awareness

• Movement disciplines
• Alexander technique
• Feldenkrais Method
• Pilates
• Yoga
• Tai Chi
• GOAL is a better sense of posture, movement,
  status of body

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Musicians and MSI Practising body awareness

• A better sense of posture, movement, status of
  body ?
• ? Ability to choose appropriate playing posture
• ? fluidity of movement
• ? understanding of difference between normal
  fatigue related discomfort versus pain due to
  injury

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Musicians and MSI Treatment

• Level 1 recognizing signs symptoms and
  administering self-help techniques
• Level 2 recognizing when signs symptoms are
  persisitent unusual then seeking professional
  medical help

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Musicians and MSI Treatment

• Warning signs symptoms
• Discomfort, pain, tingling, numbness while
  playing
• Weakness in hands or difficulty with fine control
  of fingers
• Stiffness
• Postural changes (elevated and or rounded
  shoulders)
• Local swelling or roundness
• DO NOT PLAY THROUGH PAIN

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Musicians and MSI TreatmentRICE treatment
protocol

• REST
• ICE
• ? Blood flow sensation
• 15-20 minutes
• Not directly on skin (frozen peas in damp towel)
• No creams, balms, rubs
• Do not use to numb pain to keep performing
• COMPRESSION (ask health professional)
• ELEVATION (above level of heart)

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Musicians and MSIWhen to seek medical assistance

• Symptoms occur each time you play
• Symptoms continue to worsen
• Symptoms unusual for you
• Symptoms persist after practising
• Symptoms occur at other times i.e. during sleep
• Seek health care professional experienced in
  treating musicians

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Musicians and MSIMultidisciplinary approach

• Musician
• Health care providers
• Teachers
• Equipment providers
• Instrument providers
• Furniture providers

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Musicians and MSIReminders

• Identify aspects of set up, practice habits,
  playing posture at fault
• Increase rest, decrease continous playing (until
  you play without symptoms)
• Gradual smooth warm up
• Be aware of passages contributing to signs
  symptoms then reduce intensity level of reps
• Perform long slow notes, simpler passages
  following complex passsages
• Alternate physical practice with mental practice

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Question period