Medical Issues for Performers

• Repetitive Stress Injury
• Over-use Syndrome (tendonitis, carpal tunnel syndrome etc.)
• Some thoughts on tendonitis
• On Carpal Tunnel Syndrome

Synonyms [for over-use syndrome] more likely to be found in the medical abstracts include cumulative stress disorder, repetitive motion disorder, repetitive stress injury. These all include a wide range of more specific things like various tendon disorders of particular tendons, or entrapment of nerves, or joint problems: de Quervain's is a thumb tendon, carpal tunnel is the tendons and median nerve that controls roughly the thumb and first two fingers, tennis elbow, trigger finger, bursitis, etc. Quite often, if you have any one of these, you'll have several others as well.

There is no simple easy definition, since the symptoms and affected bits of the body vary greatly from person to person, and task to task. Some of the worst things you can do to yourself include not only lots of finger motion, but grasping and squeezing, leaning on a desk edge with your wrists, palms, or elbows, holding a phone with your shoulder, carrying a shoulder bag, bad posture. The initial symptoms often involve the tendons. If it's ignored, scar tissue starts to form around the tendon sheath, causing even more friction and inflamation. If the tendonitis is in the wrong place, such as in the carpal tunnel, a nerve can get squeezed. As it gets squished, it loses its blood supply, and cells start to die, eventually causing permanent disability.

None of this necessarily has anything specific to do with musicians, but many wusicians have a lot of the predisposing factors - lots of finger motion with the hand in awkward positions, stress while doing it, tendency to practice or play for long periods without a break, tendency towards poor upper body posture. And other things you do add to the load: computer use (mice and other pointing devices are often worse than typing), hand tools (especially screwdrivers), gardening, washing dishes by hand, rowing, holding a book.

Some keys to avoiding it: 1) listen to your mom - don't slouch; 2) take frequent breaks; 3) be aware of other activities that put you at risk - e.g., if you spend a lot longer than normal typing one day, spend less time practising that day and do some sight singing instead; 4) use an exercise/muscle stretching routine so that one set of muscles doesn't become inflexible and cramp up, which can compress tendon channels. (This is the problem with slouching - it leads to tendonitis in the shoulder and/or neck, which can then trap one or more nerves.)

A few early symptoms to watch out for: 1) a deep down tickly feeling in the base of your thumbs, especially when you wake up or push a shopping cart over a rough surface (vibration sensitivity in general); 2) numbness or pins and needles in the hands or arm especially at night; 3) twinges in the hand, wrist or arm when you do things such as reach for something or push open a door; 4) reduced touch sensitivity and/or pain in your finger tips; 5) even just noticing too much that your hands or arms exist - thinking about things that you used to take for granted and not notice.

If you notice any symptoms, run, don't walk to a doctor who knows what's going on. If a doctor doesn't ask a lot of questions about shoulders and elbows and neck, and seems stuck on a simple `carpal tunnel, therefore wrist splints at night, ibuprofen, then cortisone injections, then surgery' track, find someone else. De Quervain's tendonitis is much more common than carpal tunnel syndrome - if a doctor doesn't check for it straight off, he doesn't know enough. They should also test for diabetes and thyroid function, which are predisposing factors, and arthritis, which can have some similar symptoms. Insist on going to physical/occupational therapy as soon as possible. Don't allow a non-specialist to give you cortisone injections, and only then if physical therapy has failed, or if nerve conduction tests show impairment. Surgery is absolutely the last resort - it has a high long-term risk of complications.

Early treatment is essential. The longer you ignore it, the more it will affect the rest of your life. Some of the conditions can become permanently painful and disabling. Even early on, it can take months to recover, and you can never go back to business as usual (soft tissue injuries never heal completely; there will probably be at least some reduction of endurance, and in any case, you need to change whatever caused it in the first place). Ten per cent of the population at large is expected to get RSI, more like 25% and more if you are in a high risk group. Women are more at risk than men, and middle age people more so than young people, but young men shouldn't be complacent about it... Prevention is possible, but these days, with so many things demanding hand use, training in or at least awareness of good technique and ergonomics is a good idea. It doesn't come naturally.

There is finally an excellent book out, Repetitive Stress Injury by Pascarelli (may be slightly misspelled). It's aimed at computer users, but his computer users are a side line at a clinic for performing artists in Chicago(?). If I had had this book last fall, I could be playing Dufay trios this summer, instead of just starting physical therapy.

There have been several articles in the newsgroup from people asking about dealing with pain during or after playing their instruments. Here's a brief description of some types of over-use syndrome and a few suggestions on what to do if you have pain.

If you have pain while playing your instrument (or after playing), it might be related to what doctors now call `over-use syndrome.' This is caused by strain on muscles, ligaments and tendons causing swelling, which induces pain. One common type of `over-use syndrome' is tendonitis, caused by a swelling of the blood-vessel sheath surrounding tendons. For performers, this often occurs in your fingers, your hand, or your arm, or your shoulder. Tendonitis is common among musicians, typists, professional phone bank workers and assembly-line workers; the common denominator is work (or play) involving very repetitive motion in the fingers, hands or arms.

Another, more specific, injury is carpal-tunnel syndrome (CTS). The carpal tunnel is a wrist `tunnel' formed on three sides by bone and the 4th side by a strong ligament (the Transverse Carpal Ligament, to be technical). There are nine tendons and the median nerve which travel through this tunnel. Each tendon is surrounded by a lubricating lining, called the synovium. CTS is caused by the compression of these tendons in the carpal tunnel, either by swelling of the synovium, injury to the bone or ligament, or by fluid retention. CTS should be treated by a doctor. There are several types of treatment for CTS, including surgery, but surgery is the last resort and should never be done on a musician without a second or third opinion.

If you think you have tendonitis, there are several things you can do on your own to try to relieve it:

1. If possible, stop practising for a day or two. Also try to avoid doing a lot of typing or other repetitive hand activity. If the pain persists after a couple of days, see a doctor.
2. Before practising, warm up your hands, wrists, arms with warm water or a heating pad on a low setting. Keep the affected area from getting cold while playing (say, from sitting under an air-conditioning duct).
3. While practising, stop frequently, put the instrument down (unless, obviously, you're a keyboard player) and relax. A slow warm-up session with several short rest
4. You can use an anti-inflammatory medication (such as Ibuprofen, also sold under such names as Nuprin, Advil, and others). A doctor can prescribe stronger medication. You may want to take Ibuprofen after eating to reduce stomach upset. Aspirin is slightly less effective than Ibuprofen, but works. Tylenol (acetaminophen) is not an anti-inflammatory drug.
5. Right after playing, apply a cold pack or ice to the affected area. An ice cube massage right after playing can do wonders for tendonitis in the hand or fingers or arms. I have a large cold pack I keep in the freezer which I used to use for my shoulder. You can apply lots of cold for short periods of time, but don't go overboard and get frostbite.
6. Sometimes a hand brace can help by immobilising the hand, wrist, arm while not playing the instrument.
7. If you type a lot, say while writing messages for rec.music.classical.performing, use a wrist rest for your keyboard. They even make mouse wrist rests if you do a lot of mousing at the computer. Avoid computer games that call for a lot of typing or clicking.
8. Again, though, if the pain continues, seek a doctor's care. Cortisone shots, prescription anti-inflammatory drugs, physical therapy and even surgery can be required. There are special medical clinics for performing musicians.
9. Tell your teacher. Perhaps there is a way to change your technique to relieve stress on a particular muscle or tendon. A doctor who is familiar with instrumental technique can analyse what is causing the problem and suggest solutions. Some doctors specialise in keyboard instruments, wind instruments, string instruments, etc.
10. Try to stay in good general physical condition. Normal exercise can do a lot to prevent over-use. Many musicians, in school or later, often neglect their general physical (and mental) well-being. This information, based on personal research and experience, is not professional medical advice. If you want professional advice, seek a good physician.

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    Some thoughts on tendonitis

    The following advice comes from Cassie Conley <cc37@cornell.edu> who has had tendonitis (or a similar problem) for seven years. These simple remedies were suggested by her physical therapist.
    • Lift small (1-2 pound) weights and stretch your arms and hands to warm up before playing. Move the weights slowly the whole range of motion of your arms (back and forth at shoulder level, then over your head) with only a few repetitions of each motion. The chinese `harmony balls' which have recently become popular in the US are also good to excercise with, in moderation. Also stretch your arms with palms together, fingers pointing up, then down. I'm sure that there are many other stretches.
    • Use alternating warm and cold water baths any time you feel pain or tension in your injury (e.g., after practising). Repeat this 3-5 times: 1 minute in an ice-water bath or rubbing the area with ice, then 3 minutes in a warm (not any hotter than comfortable) water bath, moving/massaging the muscles gently.
    • Something which worked for me but may not work for everyone is to take Gamma Linoleic Acid supplements (Borage oil is best, but also black currant oil or evening primrose oil). GLA is a fatty acid which is incorporated into cell membranes; it helps reduce swelling and lubricate tendons. Take 1 pill/day for the first several weeks, then cut back to 2-3 pills/week, and it takes about a month to see any improvement. This stuff is rather expensive and may be hard to find outside of a health food store or herbal shop, but, as I said, it really seemed to work.
    A combination of these things and taking lots of breaks to rest has me back playing (violin) after having my arm in a brace for 2 years. Now if only I can persuade myself to practise... I hope this helps!

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    On Carpal Tunnel Syndrome

    Lawrence E. Mallette <mallette@bcm.tmc.edu> is a physician and musician and gives the following advice on CTS.

    [first line missing] travel through this tunnel. These are the tendons that flex the fingers (toward the palm). The transverse carpal ligament is very strong and has little pliability, so the tunnel can not expand much. Each tendon is surrounded by a lubricating sheath, called the synovium. CTS develops when there is increased pressure in the tunnel that compresses the tendons and nerve. The increased pressure can arise from swelling due to inflammation of the synovial tendon linings caused by an inflammatory disease or simply by overuse, from injury to the bone or ligament, or from fluid buildup in the tissues due to systemic illness (low thyroid or excess growth hormone, for example). Once the synovium becomes inflamed and the pressure increases, the process becomes self perpetuating, as the increased pressure will allow formerly normal and non-injurious levels of use to incite continued inflammation. Pain developing in the wrist is an indication of swelling or inflammation there. The only proper response is a period of several days of enforced rest to allow the swelling and any inflammation to subside completely, followed by a gradual return to a somewhat lower level (or at least a different pattern) of activity, with more frequent intervals of rest. Otherwise, continued insults and the resulting prolonged inflammation may produce scarring that further reduces the room within the tunnel, and the CTS may develop. Proper hand/wrist positioning during activity, avoidance of pressure on the wrists during finger motion, and gentle application of exercises that help stretch the ligament may all help prevent CTS. Pain in the wrist that does not subside with rest or that returns rapidly with resumption of activity after a few days of rest may indicate an evolving CTS, and medical advice should be sought. CTS should be treated by a doctor.

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