Transcript Medicine and the Performing Arts Powerpoint

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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Performance Anxiety
Expectations of perfection
Competition
Self identity and esteem as musician
Financial – it’s a JOB !!
Travel stress, Sleep disturbance
ENVIRONMENTAL FACTORS
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Inadequate, cramped performance space
Poor chairs and seating
Location in relation to stand, conductor
Lighting
Temperature
Acoustics
Special effects
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
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
COMMON PROBLEMS
• OVERUSE AND MISUSE SYNDROMES
– Tendonitis, epicondylitis, bursitis, arthritis
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HYPERMOBILITY
FOCAL DYSTONIA
NERVE COMPRESSION SYNDROMES
TRAUMATIC INJURIES
DISEASE RELATED CONDITIONS
COMMON PROBLEMS
• HEARING LOSS-TEMPORARY OR
PERMANENT
• HYPERACUSIS AND TINNITUS
• DERMATOLOGIC PROBLEMS
• TMJ AND DENTAL PROBLEMS
• BACK AND NECK PAIN
OVERUSE
• 6,400 LEFT
HAND FINGER
MOVEMENTS
for STRING PLAYERS in
LAST MOVEMENT of
MAHLER SYMPHONY
No. 5
• 740 BOWING
STROKES for
CELLO in 2
MINUTES of
HANDEL’S MESSIAH
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
OVERUSE & MISUSE
• Result from stress
that exceeds the
anatomic or
physiologic limits of a
tissue
• Tendonitis, bursitis,
epicondylitis, myositis
• Ganglion cysts
• Tendon nodules
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
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)
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
MEDIAN NERVE ENTRAPMENT
• CARPAL TUNNEL
– Numbness & tingling
in thumb & index
– Aching hand
– Weak grip- drop things
CUBITAL TUNNEL SYNDROME
• Compressed &
stretched Ulnar N
around elbow
• Numbness & Tingling
in ring, small fingers
• Ache in ulnar forearm
• Weak small hand
muscles
THORACIC OUTLET SYNDROME
• Compression of
nerves as they pass
thru front of neck &
shoulder
• Numbness & tingling
some/all fingers
• Tight rounded
shoulders
THORACIC OUTLET SYNDROME
• Elevated first rib
common in
hypermobile patients
• Simple self
mobilization
stretching exercises
are very effective
• Surgery very rarely
needed
INSTRUMENT SPECIFIC ISSUES
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
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
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
ACUTE INJURY MANAGEMENT
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Rest---Stop playing
ICE
Compression/stabilization and support
Elevation
See MD and Therapist if not better in 4-5
days
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
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
REHABILITATION
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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
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
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!)
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
CUSTOM SPLINTS
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
AVOID
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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
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
RETURN TO PLAYING GUIDE (Dr Richard Norris)
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
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
PREVENTION
• Keep instrument in
good repair
• Do stress reducing
activity /exercise-Tai
Chi or Qi Gong
• Take a day off per
week
GOOD PRACTICE HABITS
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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 !
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
Music is lifelong
• I always tell patients:
“Remember,
YOU are the
instrument….”
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