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Musicians and

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

Musicians and MSI





Overview of health issues


Musculoskeletal injuries
Anatomy
 Specific disorders
 Risk factors
 Prevention
 Treatment


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/resources/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.htm


Musicians and MSI




Overview of health issues


Ear, nose & throat
 Hearing loss
 Skin disorders
 Dental problems
 Psychological aspects


Overview of health issues




Ear, nose and throat


Quick diagnosis
 Quick intervention


Overview of health issues




Hearing loss*




30% rock (pop) musicians


50% classical musicians
Solutions






Environmental techniques
Earplugs, monitors etc.

Tinnitus
Pitch perception
problems

* Chasin,
Chasin, M. Musicians & the Prevention of Hearing Loss.
Loss.
Hearing Review 1999. See www. musiciansclinics.com

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,


al, Performing arts
medicine.
medicine. West J Med 1994.

Overview of health issues




Dental problems*




Periodontal disease
Malocclusion
Loose teeth

Brasses & woodwinds


*Ostwald, P.F. et al,
al, Performing arts medicine.
medicine.
West J Med 1994.

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.

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)

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:
Dancers: A Resource Guide

Musicians and MSI





Overview of health issues


Musculoskeletal injuries
Anatomy
 Specific disorders
 Risk factors
 Prevention
 Treatment


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

Anatomy


Tendon





Rope-like structure made


of strong smooth fibers
Non-elastic
Tears if overstretched
During movement,
slides in lubricated
tendon sheath

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

Anatomy


Bursae




Sac-like cavities filled with


synovial fluid
Found around joints
Friction may develop

Anatomy


Cartilage


Covers ends of bones for


smooth joint movement

Anatomy


Nerves


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

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

Anatomy


Intervertebral disc
and menisci



Fibrous cartilage
Provide extra cushioning

Musicians and MSI





Overview of health issues


Musculoskeletal injuries
Anatomy
 Specific disorders
 Risk factors
 Prevention
 Treatment


Musculoskeletal disorders


Signs and symptoms


Swelling
 Redness
 Difficulty moving joint
 Loss of motor control
 Numbness
 Tingling
 Pain


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


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?


Progression of MSI signs & symptoms in performers


(SHAPE(SHAPE-Preventing MSI for Musicians and DancersDancers-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.

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


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

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)

MSI specific disorders


Hand, 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)

MSI specific disorders


Hand, 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

MSI specific disorders


Hand, wrist & forarm


Certain wind
instruments:




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

MSI specific disorders


Hand, 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


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)

MSI specific disorders


Elbow


Lateral epicondylitis
(tennis elbow)


Epicondyle at elbow is
anchor point for several
muscles
Pain at elbow, forarm or
wrist

MSI specific disorders


Elbow


Medial epicondylitis
(golfers elbow)


Musicians complex postures


 forarm rotation
 bending wrist with independant

finger movement

 keyboard, percussion, clarinet,

harp, oboe, trombone

MSI specific disorders


Shoulder


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

MSI specific disorders


Back & 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

MSI specific disorders


Upper 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


MSI specific disorders


Head & 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


MSI specific disorders


Nerve 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)

MSI specific disorders


Nerve 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)

MSI specific disorders


Thoracic 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

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)

MSI specific disorders


Nerve 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

Musicians and MSI





Overview of health issues


Musculoskeletal injuries
Anatomy
 Specific diagnoses
 Risk factors
 Prevention
 Treatment


Musicians and MSI


Risk factors

(SHAPE(SHAPE-Preventing MSI for Musicians and DancersDancers-A Resource Guide, 2002)

Environmental aspects

Physical demands

Personal characteristics

Temperature

Awkward postures

Age & gender

Confined space

Forceful exertion

Physical fitness
(strength, flexibility,
endurance)

Layout of space

Repetition

Nutrition

Equipment

Long-duration activities
(inadequate rest)

Posture

Layout or configuration of
equipment

Contact stress
(sharp edges)

Addictive substances
(tobacco, alcohol, narcotics)

Surfaces (floors)

Vibration

Psychological stress

Lighting

Diseases or health conditions


(pregnancy, diabetes,
osteoporosis)

Influences on risk of injury in musicians


(SHAPE(SHAPE-Preventing MSI for Musicians and DancersDancers-A Resource Guide, 2002)

Administrative
Union
Funding agency
Regulatory body
Company manager
Early development
School board
Music instructor
Parent

Artistic
Director
Composer
Conductor

Musician

Technical
Sound engineer
Stage manager
Technical director
Piano tuner
Venue design
Equipment designer
Interior designer
Architect
Purchaser

Musicians and MSI


Risk 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

Musicians and MSI





Overview of health issues


Musculoskeletal injuries
Anatomy
 Specific diagnoses
 Risk factors
 Prevention
 Treatment


Musicians and MSI


Prevention


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

Zaza 1994

Level 2-Recognizing signs & symptoms and


responding appropriately

practice

Musicians and MSI


Prevention-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

Musicians and MSI


Maintain 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

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

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

Musicians and MSI


Develop good practice habits


Warm up



2 components: Joint rotation & aerobic warm up







blood flow
Warms muscles and joints
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

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

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

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

Musicians and MSI


Selecting 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)

Musicians and MSI


Sitting posture



Depends on instrument
Maintain low back curve




Foot width





Lumbar pillow
Wedge cushion
Lift back legs of chair
Wide base

Feet in front of knees


Vary position

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

Musicians and MSI


Prevention-various gadgets

Musicians and MSI


Prevention-Harnesses
 tubas,

drums &
saxophones

Musicians and MSI


Guitar straps, belts & supports

Musicians and MSI


Prevention-Stands

Musicians and MSI


Prevention
Various gadgets
 High chin rests
(violins, violas)

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!


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


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

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

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

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


Musicians and MSI: Treatment


RICE 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)

Musicians and MSI


When 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

Musicians and MSI


Multidisciplinary approach







Musician
Health care providers
Teachers
Equipment providers
Instrument providers
Furniture providers

Musicians and MSI


Reminders







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

Question period