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Musician’s Injuries

Musician’s Injuries. Jennine Speier MD Rehabilitation Medicine. SISTER KENNY REHABILITATION INSTITUTE PERFORMING ARTIST’S CLINIC. Chorus America Conference. Incidence. 75% of orchestra musicians have problems during career Keyboard & Strings most common. PSYCHOLOGICAL FACTORS.

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Musician’s Injuries

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  1. Musician’s Injuries

  2. Jennine Speier MDRehabilitation Medicine SISTER KENNY REHABILITATION INSTITUTE PERFORMING ARTIST’S CLINIC

  3. Chorus America Conference

  4. Incidence • 75% of orchestra musicians have problems during career • Keyboard & Strings most common

  5. PSYCHOLOGICAL FACTORS • Performance Anxiety • Expectations of perfection • Competition • Self identity and esteem as musician • Financial – it’s a JOB !! • Travel stress, Sleep disturbance

  6. ENVIRONMENTAL FACTORS • Inadequate, cramped performance space • Poor chairs and seating • Location in relation to stand, conductor • Lighting • Temperature • Acoustics • Special effects

  7. PHYSICAL FACTORS • Awkward postures including that defined by instrument or piece • Too much force with movement-high tension playing with high tension • Muscle imbalance • Abrupt increase in playing time

  8. PHYSICAL FACTORS • Change of playing technique, teacher, instrument • Size of instrument related to body habitus of musician • Sheer repetition and speed • Lack of warm up time • Playing too long, too much

  9. COMMON PROBLEMS • OVERUSE AND MISUSE SYNDROMES • Tendonitis, epicondylitis, bursitis, arthritis • HYPERMOBILITY • FOCAL DYSTONIA • NERVE COMPRESSION SYNDROMES • TRAUMATIC INJURIES • DISEASE RELATED CONDITIONS

  10. COMMON PROBLEMS • Hearing loss-temporary or permanent • Hyperacusis and Tinnitus • Dermatologic problems • TMJ and dental problems • Back and neck pain

  11. OVERUSE • 6,400LEFT HAND FINGER MOVEMENTS for STRING PLAYERS in LAST MOVEMENT of MAHLER SYMPHONY No. 5

  12. 740BOWING STROKES for CELLO in 2MINUTES of HANDEL’S MESSIAH

  13. MUSCLE &TENDON INJURIES • Where tendons attach muscle to bone • Lateral & medical epicondylitis • Where tendons attach to muscles • Extensor tenosynovitis • Where tendons pass through narrow tunnels • Rotator cuff, Flexors DeQuervain’s tenosynovitis • Where tendons insert into the bone

  14. OVERUSE & MISUSE • Result from stress that exceeds the anatomic or physiologic limits of a tissue • Tendonitis, bursitis, epicondylitis, myositis • Ganglion cysts • Tendon nodules

  15. HYPERMOBILITY • Can cause overuse from attempt to stabilize joint • Can strain joint if unable to stabilize joint in a neutral position • May be a localized problem or part of a syndrome

  16. FOCAL DYSTONIA • Painless incoordination of fingers or embouchure from repetition • Can also result from highly repetitive writing or computer keyboarding • Previous repetitive stress injury or nerve compression may have occurred • Abnormal “map” of hand in sensory & motor cortex of brain related to near simultaneous stimulation of the fingertips. (seen on special type of MRI used for research)

  17. NERVE ENTRAPMENT • Aggravated by awkward prolonged static postures-holding a score or instrument • Repetitive motion in awkward posture such as keyboarding on computer • May be secondary to localized swelling or inflammation of tendons and should resolve with treatment

  18. MEDIAN NERVE ENTRAPMENT • CARPAL TUNNEL • Numbness & tingling in thumb & index • Aching hand • Weak grip- drop things

  19. CUBITAL TUNNEL SYNDROME • Compressed & stretched Ulnar N around elbow • Numbness & Tingling in ring, small fingers • Ache in ulnar forearm • Weak small hand muscles

  20. THORACIC OUTLET SYNDROME • Compression of nerves as they pass thru front of neck & shoulder • Numbness & tingling some/all fingers • Tight rounded shoulders

  21. THORACIC OUTLET SYNDROME • Elevated first rib common in hypermobile patients • Simple self mobilization stretching exercises are very effective • Surgery very rarely needed

  22. INSTRUMENT SPECIFIC ISSUES

  23. PIANO • Flexor tendonitis from excessive force • DeQuervain’s tenosynovitis from compensation for tight thumb muscles with excessive thumb abduction (octaves and chords) • Ulnar tendonitis due to wrist deviation, 5th finger strain, octaves, computer mouse • Extensor pain from lifting fingers off keys, hypermobility with poor stabilization

  24. GUITAR • Neck or back pain from flexed posture • Shoulder pain on L related to combination of trunk & shoulder girdle posture • Focal dystonia, classical > rock guitar • Small hand muscle overuse • Stretch of ulnar nerve as elbow flexed

  25. VIOLIN and VIOLA • Neck, shoulder pain from clamping down on chin rest plus sustained arm elevation • Poor breathing habits • Chin rest too short, shoulder rest too high • Instrument too BIG

  26. ACUTE INJURY MANAGEMENT • Rest---Stop playing • ICE • Compression/stabilization and support • Elevation • See MD and Therapist if not better in 4-5 days

  27. HELPFUL HISTORY • Location, intensity, character, duration of pain • Onset and association with total playing time; changes in TOTAL playing time, teacher, instrument, or repertoire • How many instruments are played • Practice habits- do you take breaks? • Previous treatments & response including time away from playing • General fitness level and program • Other activities involving hand & arm use --computer, texting, biking, sports, hobbies, etc

  28. ANALYSIS at the INSTRUMENT • Observation of posture • Observation of technique, looking for signs of excessive force or tension, excessive movement, collapse of joints, awkward posture. • Biofeedback to assess and modify tension • Videotaping • Observation of instrument, size and how instrument fits body

  29. REHABILITATION • Treatment to reduce pain or inflammation • Soft tissue and/or joint mobilization • Strengthening in pain free range • Stabilization exercises esp. shoulder girdle • Flexibility exercises when appropriate • Splinting-hard & soft for resting, protection, stabilizing

  30. REHABILITATION Hand (PT or OT) as well as Speech Therapy will work on • Endurance exercise • Flexibility • Postural correction • Breathing • Body awareness-Alexander, Feldenkreis • Biofeedback • Instrument modification • Assistive devices for activities of daily living • Computer set up modification

  31. BIOFEEDBACK • Monitor electrical activity of muscles with patch electrodes • Monitor multiple muscles • You can see voltage level indicating how much force you are generating (no shocks!)

  32. INSTRUMENT MODIFICATIONS • Can get a 7/8 keyboard into existing piano • Adjust stiffness of action of piano • Slight decrease in bridge height can decrease string tension • Decrease grip force by wrapping or padding handle of bow • Custom height and shaped carved chin rests • 30 or 45 degree angled head for flute

  33. CUSTOM SPLINTS

  34. POSTURE CORRECTION • Wedge shaped firm foam cushion to optimize pelvic tilt • Ergonomic chairs • Foot rests for guitarist • Straps for bassoon and other large instruments • Core work with Pilates

  35. AVOID • Free weights • Push-ups • Downward dog position in Yoga • Basketball, sports that stress wrists • Awkward wrist postures- strive for neutral • Overuse of small muscles, use large instead

  36. AVOID • Excessive force with gripping and pinching activities-often means also modifying writing, driving habits • Exposure to vibration • Sustained rigid postures • Poor ergonomics of computer use

  37. RETURN TO PLAYING GUIDE (Dr Richard Norris)

  38. PREVENTION • DON’T play through pain • Build up gradually to full playing schedule after a break for any reason • Take breaks of 10-15 minutes every 45 minutes. • Separate practice sessions if able • Greater than 5-6 hours daily is asking for TROUBLE

  39. PREVENTION • Don’t forget to use diaphragmatic breathing instead of overusing traps • Erect, balanced relaxed posture • Don’t use more force than needed • Avoid static loading---MOVE ! • Pay attention to ALL work involving arms and hands in a whole day-driving, computer, crafts, sports

  40. PREVENTION • Keep instrument in good repair • Do stress reducing activity /exercise-Tai Chi or Qi Gong • Take a day off per week

  41. GOOD PRACTICE HABITS • Vary repertoire • Set up a plan if lots of music to learn • Memorize away from the instrument • Tape yourself to listen for problem areas • Play longer phrases • Avoid repetition > 3 times of short phrases • Be prepared-no cramming !

  42. WARM UP • In cold weather, run arms and hands under warm water • Warm up away from the instrument • Then warm up on the instrument, starting with slow easy moves, gradually building intensity • Cool down after playing with gentle stretches

  43. Music is lifelong • I always tell patients: “Remember, YOU are the instrument….”

  44. REFERENCES • The Musician’s Hand-A Clinical Guide • Ian Winspur, Christopher Wynn Parry • Journal of Performing Arts Medical Association: “Medical Problems of Performing Artists” • Journal of Hand Therapy • Playing (less) Hurt by Janet Horvath

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