MUSCULOSKELETAL PROBLEMS IN MUSICIANS By Miriam C. Daum, P.T., M.P.H. The biographical notes of Robert Schumann (1839), pianist and composer, describe a musculoskeletal disorder related to his musical activity. "Some fingers (no doubt because of too much writing and playing in earlier years) have become quite weak, so that I can hardly use them". Renowned pianists Gary Graffman and Leon Fleisher, as well as Max Weinberg, well-known drummer in Bruce Springsteen's E Street Band, provide more contemporary examples of musculoskeletal hazards in music. All three suffered physical motor control disabilities that seriously affected their playing. Although accurate statistics about music related injuries and disabilities are scarce, one survey of 250 musicians revealed that approximately half had some musculoskeletal symptoms. Another survey of 900 musicians indicated that almost 50 percent of the respondents were playing with some job related pain or discomfort. The signs and symptoms encountered in neuromuscular and musculoskeletal ailments of musicians are similar to those of the athlete, or indeed to those of any physically active individual. Pain, stiffness, tingling, numbness, weakness, aching and loss of control are among the most commonly reported complaints. They indicate anything in the wide spectrum from a minor, short-term, irritation that resolves without further attention to a more serious disorder that requires accurate diagnosis and appropriate treatment. This data sheet will cover musculoskeletal/neuromuscular disorders as they relate to the musician, causes and effects of those injuries, a discussion of preventive measures, and an overview of currently available diagnostic and treatment procedures. Hearing loss and general occupational problems are covered in separate data sheets. TYPES OF MUSCULOSKELETAL DISORDERS The Musculoskeletal System The human musculoskeletal and neuromuscular systems are composed of bone, joint, and soft tissue components that are designed to interact harmoniously for optimal function. Muscles are composed of elastic, fibrous tissue, connected to bone by tendons at either end. As muscles contract, they provide both movement and/or stability for body segments. Tendons, by contrast are non-elastic and may tear if overstretched. Ligaments are also non-elastic fibrous bands, which provide stability to joints by connecting bone to bone, and may also tear under excess stress. A joint is the area of union between two or more bones and is lined by a synovial membrane which produces a lubricant called synovial fluid. This allows for smooth movement. Bursae, saclike cavities also containing synovial fluid are strategically located in areas where friction may develop, usually surrounding joints, (eg in the shoulder or knee regions). Cartilage covers the ends of bones for smooth joint movement. Intervertebral discs in the spine and menisci in the knee are specialized types of fibrous cartilage to provide extra cushioning in these areas. Fascia consists of sheets of fibrous tissue located between layers of muscles and can be a source of pain or tightness. Nerves are cordlike structures that transmit electrical impulses to and from the body parts they control. Impulses coming from muscles and other local areas relay sensory messages to the brain such as touch, temperature, pain and pressure. Impulses going to muscles provide the stimulus for movement. Types of Injury A neuromusculoskeletal problem can be acute, meaning of rapid onset, with sharply defined symptoms, and a relatively short course; or chronic, having a slow, insidious onset, symptoms usually of a less severe nature and persisting over a long duration. An acute injury, if unresolved, can go on to become a chronic disorder. Irritation or injury to the neuromusculoskeletal system will manifest itself either locally, at or near the site of damage, or distantly, in an area removed from the site of the damage (termed "referred pain"). For this reason it is often difficult to pinpoint the area of pain. Although the neuromusculoskeletal system is subject to a variety of disorders, the most common musically related problems fall in the category of overuse syndromes. When excessive stress is placed on muscles, tendons, ligaments and/or joints, the result is often inflammation. Thus the terms tendinitis, bursitis, synovitis etc. ("itis" indicating inflammation). Tissues become painful, warm and swollen. As part of the inflammatory process, there is an increase of fluid in the affected area which may exert pressure on adjacent structures. An example of this phenomenon is Carpal Tunnel Syndrome, where tendon swelling in the wrist area produces compression and irritation of the median nerve situated underneath the tendons. This may result in pain, tingling, numbness and/or weakness in the affected wrist and hand. It is important to note that the absence of inflammatory signs such as swelling or warmth does not necessarily mean there is no injury. A typical finding in overuse syndromes is pain and localized tenderness over a tendon and/or muscle. This will increase by stretching or contracting the muscle against resistance. This may or may not be accompanied by the other symptoms of inflammation. There is a wide range of other less commonly encountered neuromusculoskeletal disorders, which include microfractures, osteoarthritis, myofascial pain syndrome, fibrositis, nerve entrapment syndromes (carpal and radial tunnel syndromes, thoracic outlet syndrome, cervical radiculopathy) and occupational palsies. An accurate medical assessment is essential in differentiating between these various diagnoses. The pathological changes associated with injury may include microscopic tears in muscle, tendon or other connective tissue, edema (swelling) and hemorrhage (bleeding) in the tissues. Scarring with adhesions may occur as part of the repair process. CAUSES OF MUSCULOSKELETAL PROBLEMS It is often extremely difficult to accurately and directly pinpoint cause and effect in music related problems since a number of factors contribute to the extent and severity of a neuromusculoskeletal problem. Performance Factors Causes of most neuromusculoskeletal problems associated with music making fall into the general categories of position, movement and the instrument in relation to the musician. 1. Position: Holding or manipulating a musical instrument often requires body segments and the spine to assume and maintain a fixed position for prolonged periods of time. A violinist has often spent so many years with head rotated and bent over the instrument's chinpiece that even when not actually playing, her/his neck is still somewhat deviated from the neutral (straight) position. In the situation where almost continuous playing is required (e.g. solo or nature of the musical piece), the body segments directly involved in playing must be maintained in a limited position range for the duration. These circumstances require muscles to maintain a static "holding contraction" without allowing sufficient time for the muscle to relax. This decreases bloodflow through the muscle and results in the accumulation of muscle waste products (lactic acid). Joints are required to remain in "non-anatomical" positions for prolonged periods, often resulting in ligamentous strain. Reports of numbness in the left index finger of a flautist demonstrate a possible effect of the position of particular body parts on the instrument. In this case, the flute's key was a source of excessive pressure against a superficial nerve in the finger. 2. Movement: Superimposed on the static position or posture of body parts are the intricate movements of instrumental playing. They require muscular strength, endurance and fine coordination. A muscle and its tendon that is expected to perform excessively may protest in the form of pain, weakness, tingling or loss of control, hence the term "overuse syndrome". In addition to the quantitative factors of overuse syndrome are the qualitative aspects of musculoskeletal abuse. A pianist with small hands may be subject to difficulty playing the large stretches of Liszt and Rachmaninov. Conversely, another musician may find long fingers cramped by the passagework of Mozart. The angular and rotational movements involved in playing trills, arpeggios and octaves have been associated with tendon inflammation. Muscles, tendons and ligaments need preparation to perform optimally. Returning to playing after a period of decreased or no activity (e.g. vacation, illness, layoff) requires a gradual, graduated increase in playing time and intensity. Going into a performance or practice "cold" is a good example of neuromusculoskeletal abuse. If an acute or chronic injury has occurred, forced playing through the injury (even if pain or discomfort is minimal or absent), is another form of abuse. A relatively minor problem can often be resolved with adequate rest and treatment. Too early a return to activity may transform a small problem into a large one, whereby an already injured joint, muscle, tendon or ligament, is now sustaining even more damage. 3. Instrument in Relation to Performer: Musical instruments are usually chosen for their musical potential rather than for the physical comfort of the musician. A small, slender harpist will be likely to make some "nonphysiological" postural adjustments in order to reach and control all the instrument strings. The weight of a clarinet is borne on the musician's right thumb and wrist, resulting in excessive force in that small area which may result in joint or soft tissue irritation. There have been several reports of neuromusculoskeletal problems after use of an unfamiliar instrument. This may occur with a new instrument (of the same type the musician is accustomed to) or a different type of instrument (e.g. switching from oboe to English horn). An unresponsive piano requiring excessive forcefulness in depressing the keys, will produce an abnormal stress on the musician's finger muscles. Risk Factors The following are a variety of risk factors which can contribute to the likelihood of developing neuromusculoskeletal problems in musicians. Nature of Activity Three major factors contribute to the total amount of neuromusculoskeletal stress resulting from a specific activity. These are duration - how long a period of time is the activity sustained (seconds, minutes, hours, frequency - how often (once daily, twice weekly etc.), and intensity - how great are the neuromusculoskeletal demands of the activity, at any given time. For example, a rapid musical tempo requiring numerous, quick muscle contractions in a short period of time or compositions with difficult fingering or bowing require intense use of muscles, tendons, joints and ligaments, even with brief duration and low frequency. The Human Body 1. Individual Anatomy and Physiology: Since no two individuals are anatomically and physiologically identical, exposure to the same risk factors and neuromusculoskeletal stresses may result in a large variability of results. Joint flexibility provides a well-known example of this situation. Some people appear "double-jointed", displaying a large range of motion, whereas others have relatively "tight" joints or limited flexibility. In the case of famous violinist, Paganini, anatomical idiosyncrosies proved an advantage. His tremendous ligamentous laxity ("loose ligaments") allowed him instrumental playing feats that would otherwise have proven impossible. 2. General Physical Condition: An individual's strength, endurance, posture and general physical fitness provides the background for the activity his/her body can tolerate. Needless to say, a "well-tuned" cardiovascular, cardiopulmonary and neuromusculoskeletal system will not only function more smoothly and efficiently, but will prove much more resilient to any stresses it encounters. 3. History of Injury or Illness: Current or prior medical conditions may influence music related physical capabilities. For example, diabetes-related neuropathy (a degeneration of nerve conduction, usually in the hands and feet) could interfere with manual dexterity and strength. The joint swelling associated with rheumatoid arthritis can significantly limit joint mobility. A mild scoliosis (curvature of the spine) may prove problematic during prolonged sitting even though it would otherwise have been asymptomatic. Some mild or moderate medical conditions may be aggravated by the added stress (both physical and psychological) of musical performance. Prior injuries of sufficient severity could present limitations to current neuromusculoskeletal demands. For example, bone fractures and extensive muscle/tendon/ligamentous tears, although healed, may never again function to full capacity. Injured tissue is replaced by inelastic scar tissue, which is less flexible or resilient than the original normal tissue. This may predispose an individual to sustaining a new injury in the same or adjacent areas. The body's normal reaction to injury and subsequent lack of function in one area is to attempt compensating for it in another area. This then places added strain upon the compensating group of muscles, tendons, ligaments and joints, rendering that segment more vulnerable to injury. 4. Insufficient Recovery: If an injury has occurred, forced playing is likely to exacerbate the problem. This is true even when pain or discomfort is minimal or absent. Without adequate rest and treatment, a relatively minor problem may become a big one, as an already injured joint, muscle, tendon or ligament is now sustaining even more injury. Environmental Conditions 1. Medications: The vast array of medications available, either by presciption or over-the-counter, can present potential hazards to the musician as well. Tranquilizers, some muscle relaxants and pain killers may (as in the case of recreational drugs and alcohol) decrease fine muscular control and coordination as well as obscure warning signs and symptoms of injury. Consultation with a knowledgeable physician is therefore advisable to determine the appropriate medication and dosage for the musician's specific needs. 2. Lifestyle: Recreational drugs and alcohol decrease fine control and coordination. In addition, their capacity to distort reality can obscure symptoms of physical injury such as pain, tingling, and incoordination, thus allowing a potentially injurious activity to continue on to cause further damage. Among the many well-known effects of smoking are changes in lung tissue which make breathing less efficient and more difficult, and can interfere with the high energy demands often encountered during performance. In addition smoking produces vasoconstriction (narrowing of the blood vessels), which decreases circulation in body segments that require increased bloodflow during physical activity. 3. Heat/Cold: Extremes of hot and cold ambient temperatures result in respectively dilating (widening) and constricting blood vessels in the limbs. Dilated blood vessels allow an increased bloodflow to the area with the sensation of "swelling" or fullness in the hands and feet. Conversely, blood vessel constriction decreases bloodflow to the area with a subsequent sensation of stiffness, numbness and lack of fine muscular control. Although these effects are usually subtle, they could prove significant to the musician who requires a superior level of rapid, controlled fine movements. 4. Psychological Stress: The psychological stresses associated with auditions, performance anxiety, peer pressure, demands of teachers, coaches, and conductors can all contribute to excessive muscle tension either temporarily or chronically. Muscles now have even less opportunity to rest, adding to the total amount of activity or "dose". In addition, one has less control over a tense muscle, thus increasing the chance of injury. 5. Other Physical Activities: Symptoms often result from the cumulative effects of numerous minor injuries and stresses. Individual practice, rehearsal and performance all contribute to the sum total of physical activity. Where demonstration is required during teaching, another portion is added. Activities of daily living may contribute heavily to neuromusculoskeletal demands. Leisure activities and hobbies (tennis, woodworking, skiing, prolonged automobile driving/riding etc.) contribute to the overall debt. PREVENTING MUSCULOSKELETAL PROBLEMS Many solutions to the musicians occupational problems arise from a careful analysis of the difficulties themselves. The key to prevention is to gain a better insight into and understanding of the human body. There are countless anecdotes of musicians with significant physical symptoms who manage to "tune out" their pain during a performance. Although this dramatically demonstrates how the euphoria derived from music and music making can obliterate even marked discomfort, the underlying cause of the pain remains and must be addressed. 1. Conditioning: Appropriate maintenance of the body, as with a highly technical machine, will increase years of useful service. A general conditioning program is recommended including stretching, strengthening and endurance training. Body parts directly involved in playing should be specifically trained and exercised for their respective tasks (e.g. rapid fingering movements, prolonged positional holding, stretched positions, etc.). All other body parts will benefit from generalized stretching and strengthening, especially in areas where this is particularly necessary. A general endurance program could include regular swimming, bicycling etc, with the aim of training the entire body (respiratory, neuromusculoskeletal and cardiovascular systems) to work efficiently and economically (concerning energy expenditure). 2. Preparation for Playing: "Warm-ups" prior to activity, actually produces an increase in muscle temperature as well as stretching muscle fibers and loosening up joints preparatory to actual performance (similar to what athletes do prior to sports activities). Following "peak" activity i.e.maximal output, during practice or performance, a period of "cool-down" i.e. a brief series of low intensity exercises is advisable. After a period of relative inactivity, such as vacation, illness or layoff, return to activity should be on a gradual, progressive basis with increasing increments of intensity, duration and frequency. For example, after one or two weeks of no or minimal playing, begin with less demanding pieces, practicing only one or two hours once a day initially. Then progress to more difficult pieces, two to four hours, twice daily etc. Breaks should be interspersed frequently between playing intervals, even if this prolongs the toal practice duration. It is better to have five fifteen minute breaks in a total of three hours playing time then only one or two breaks and a two hour playing time. Certainly, each activity prescription must be tailored to the individual and his/her situation. General Guidelines To combat the problems of some performance factors several conditions may be subject to modification: 1. Posture - correct position and alignment of the head, trunk, arms and legs - is often the basis for minimizing or eliminating neuromusculoskeletal pain and discomfort. Evaluation and instruction by a physical therapist, kinesiologist or movement analyst may provide a valuable factor in prevention of injury. 2. Optimal positioning of the musician in relation to the conductor should be determined to allow alternate viewing of the conductor's baton and the musical score without postural changes or discomfort. 3. Chairs should be chosen to provide optimal postural support, considering factors such as seat height and adequate backrest. 4. Music stands should be positioned for optimal visibility without the necessity for unnatural postural accomodations. .sp 5. Several instrument supports (slings, braces) are currently being designed and tested for their ergonomic benefits, for example, neck or shoulder straps for guitar or percussion instruments. If proven advantageous, they may aid in decreasing the neuromusculoskeletal strain resulting from holding/supporting an instrument over a prolonged period. 6. Instrument modification itself may provide a solution. One flautist has reported significant alleviation of finger symptoms after having built up the flute keys. Other examples are the addition of or changes in chinrests or shoulder rests for violin/viola and alteration of the thumb rest on wind instruments. 7. Appropriate choice of music and instrument for each individual has been noted in a previous section. Anatomical and physiological differences may determine suitability of a particular type of music and/or instrument already in the early years of a child's musical training, thus preventing the onset of later difficulties. Nevertheless, even an advanced musician, with many years of playing experience may still benefit from a re-evaluation of difficulties with consideration to a choice of music or perhaps even (in extreme cases), a change in instrument. 8. The importance of carefully scheduling practice and performance "exposures" has already been mentioned above. Wherever possible, playing periods should be interspersed with "relative relaxation" allowing body parts to rest and recover from the physical demands made on them prior to the next period of activity. 9. A careful evaluation of technique may prove the clue to neuromusculoskeletal discomfort. Often, appropriate modifications may not only eliminate/decrease symptoms, but also improve actual playing. TREATMENT OF NEUROMUSCULOSKELETAL PROBLEMS Diagnosis The key to successful treatment of a neuromuscular or musculoskeletal problem is the correct diagnosis and identification of causative factors. Unfortunately, this is also one of the most difficult aspects in medical care of the musician. Identical symptoms can be caused by a variety of disorders of varying severity. Pathological changes may occur in several areas simultaneously, sometimes resulting from different causes. Signs and symptoms of injury often begin slowly, in a subtle manner and are difficult to localize. Injuries may be a result of performance factors, non-performance or any combination thereof. One must therefore first determine if the symptom(s) are being caused by an underlying medical problem or a mechanical situation such as incorrect posture, technique, instrument, etc. The most important component of a medical evaluation is a detailed, accurate history of an individual's symptoms including when and how they began, their nature and character, what makes them better or worse and the type of activity(s) they are associated with. A complete diagnostic workup would involve a careful physical examination, possibly including assessment of range of motion, strength, sensation, coordination and posture. Electromyography (EMG) and Nerve Conduction Velocities (NCV), both forms of electrical tests, are often helpful in determining a nerve or muscle problem. X-rays, revealing bone, cartilage and joint condition are sometimes performed. Where necessary, more sophisticated procedures such as CAT scans (Computerized Axial Tomography) or MRI's (Magnetic Resonance Imaging) are required to provide a more detailed view of internal structures. Finally, observation and evaluation of the musician's posture and movement while playing his/her instrument could provide important clues to the actual problem. Needless to say, precise questioning of an individual about risk factors and past medical history is crucial in arriving at a conclusive diagnosis. Types of Treatments 1. Acute treatment: Acute injuries in general, are best treated immediately (after determining that there are no fractures, dislocations or other condition that requires more aggressive medical management), with RICE: Rest, Ice, Compression, and Elevation. Rest means a decrease in activity, ranging from complete rest of the injured segment to temporarily curtailing or reducing any musical practice or performance. When necessary, total immobilization may be required to assure adequate resting of the affected part. Use of splints (made of rigid plastics, metal, canvas or various combinations) are often recommended. Ace bandage wrapping or taping for immobilization may prove helpful. Occassionally, splinting, bracing or bandaging can be utilized for long-term protection of an injured or vulnerable segment. Ice, in the form of cold packs commercially available or crushed ice wrapped in a moist towel is often helpful in reducing swelling and relieving pain. Compression with ace bandaging, taping and/or splinting provides counterpressure against the swelling process. Elevation of the injured part allows gravity to assist in reducing edema (swelling). After the initial swelling and pain have subsided, gradual, progressive movement can begin. This involves exercises aimed at restoring flexibility, strength and coordination. 2. Physical and Occupational Therapy: In the post-acute or chronic phase, Rehabilitation Medicine has a large and diverse spectrum of treatments available for soft tissue injuries. Some theraputic options include ultrasound, iontophoresis (driving medication through the skin by a small electrical current), electrical stimulation, traction, whirlpool, manual therapy and medical massage. An important component in the musician's rehabilitation is an appropriately designed exercise program tailored to the individual's condition and needs. Biofeedback and relaxation techniques provide a valuable learning tool for the individual to identify and control muscle tension. 3. Medications: Commonly prescribed medications either taken orally or by injection include anti-inflammatories, muscle relaxants and analgesics (pain killers). Caution must be observed in cases where medication would mask important symptoms. Some drugs act on the central nervous system and increase an individual's response time (i.e. "slow reflexes") thus allowing the possibility of injury. Medications often have side-effects, precautions, and contra-indications. Therefore, medications should be taken only under the direction of a physician. 4. Surgery: Surgery is sometimes necessary for conditions such as carpal tunnel syndrome or thoracic outlet syndrome as well as some bone fractures and soft tissue injuries. Due to the varying medical opinions concerning the recommendation for surgery in a particular situation, it is usually advisable to consult with more than one physician prior to making a final decision for or against a surgical procedure. 5. Other Treatments: A number of less conventional treatment options are available including acupuncture, chiropractic manipulations, and vitamin therapy. Although some of these treatments have been reported to prove beneficial in a number of cases, we do not as yet have sufficient information about their efficacy and mode of action to draw any concrete conclusions about their general applicability. Often, there is not only one ironclad treatment of choice for a particular problem. One should therefore inquire about alternate management options that may be attempted without endangering or compromising one's medical condition. REFERENCES Caldron P et al: "A Survey of Musculoskeletal Injuries in High Level Musicians." Clin Res 32: 820A (1984). Fry HJ: "Overuse Syndrome of the Upper Limb in Musicians." Med J of Aust 144(4) 182-3 185 (Feb 17, 1986) Fry HJ: "Overuse Syndrome in Musicians - 100 Years Ago. A Historical Review." Med J Aust 145(11-12) 620-5 (Dec 1-15, 1986) Fry HJ: "Occupational Maladies of Musicians: Their Cause and Prevention." Internat J Music Educ 2 63-66 (1984) Henson RA, Urich, H: "Schumann's Hand Injury." Br Med J 1 900-903 (1978) Hochberg FH et al: "Hand Difficulties Among Musicians." JAMA 249, 1869-1872 (1983) Lederman RJ and Calabrese, LH: "Overuse Syndromes in Instrumentalists." Medical Problems of Performing Artists (Mar 1986) SOURCES OF ADDITIONAL HELP For information about noise induced hearing loss and the general occupational hazards faced by musicians, the Center for Safety in the Arts has prepared two data sheets: Daum, M: "Hearing Loss in Musicians" 4pp Daum, M: "Occupational Hazards in Music" 4pp Written and telephone inquiries about health hazards for the musician will be answered by the Information Center of the Center for Safety in the Arts. The Information Center has a variety of written materials available on this subject. Permission to reprint this data sheet may be requested in writing from the Center. Enclose a self-addressed, stamped envelope for our publications list. Write: Center for Safety in the Arts, 5 Beekman Street, New York, N.Y. 10038. Telephone: 212/227- 6220. This data sheet has been made possible through funding from the New York State Department of Labor, Occupational Safety and Health Training and Education Program. The Center for Safety in the Arts is also partially supported with public funds from the National Endowment for the Arts, the New York State Council on the Arts and the New York City Department of Cultural Affairs. (c) Copyright Center for Safety in the Arts 1988