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 Quervain’s 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 Quervain’s 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 (golfer’s 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