musicians and musculoskeletal injuries

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

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Injuries related to music performance

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Page 1: Musicians and Musculoskeletal Injuries

MusiciansMusicians andandMusculoskeletal injuriesMusculoskeletal injuries

Cynthia C. CarsleyCynthia C. CarsleyB. Sc. B. Sc. PhysiotherapyPhysiotherapy

M. Sc.(A) M. Sc.(A) OccupationalOccupational HealthHealth

Page 2: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSI

�� OverviewOverview ofof healthhealth issuesissues�� Musculoskeletal injuriesMusculoskeletal injuries

�� AnatomyAnatomy�� SpecificSpecific disordersdisorders�� RiskRisk factorsfactors�� PreventionPrevention�� TreatmentTreatment

Page 3: Musicians and Musculoskeletal Injuries

OverviewOverview ofof healthhealth issuesissues�� MusiciansMusicians’’ websiteswebsites

�� Part 1: Introduction and Background.Part 1: Introduction and Background. Preventing Preventing Musculoskeletal Injury (MSI) For Musicians And Dancers:Musculoskeletal Injury (MSI) For Musicians And Dancers:A Resource GuideA Resource Guide

http://www.shape.bc.ca/resources/pdf/part1.pdfhttp://www.shape.bc.ca/resources/pdf/part1.pdf�� Part 2: Musicians.Part 2: Musicians. Preventing Musculoskeletal Injury (MSI) Preventing Musculoskeletal Injury (MSI)

For Musicians And Dancers: A Resource Guide For Musicians And Dancers: A Resource Guide http://www.shape.bc.ca/resources/pdf/part2.pdfhttp://www.shape.bc.ca/resources/pdf/part2.pdf

�� Musicians and injuries. Engineering Electronics Shop Musicians and injuries. Engineering Electronics Shop http://http://eeshop.unl.edu/music.htmleeshop.unl.edu/music.html

�� DaumDaum, M.C. Musculoskeletal problems in musicians. , M.C. Musculoskeletal problems in musicians. Center for Safety in the Arts Center for Safety in the Arts

http://http://www.sierranevada.edu/life/safety/musicsaf.htmwww.sierranevada.edu/life/safety/musicsaf.htm

Page 4: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSI

�� OverviewOverview ofof healthhealth issuesissues�� EarEar, , nosenose & & throatthroat�� HearingHearing lossloss�� Skin Skin disordersdisorders�� Dental Dental problemsproblems�� PsychologicalPsychological aspectsaspects

Page 5: Musicians and Musculoskeletal Injuries

OverviewOverview ofof healthhealth issuesissues

�� EarEar, , nosenose andand throatthroat�� Quick Quick diagnosisdiagnosis�� Quick interventionQuick intervention

Page 6: Musicians and Musculoskeletal Injuries

OverviewOverview ofof healthhealth issuesissues�� HearingHearing lossloss* *

�� 30% rock (pop) 30% rock (pop) musiciansmusicians�� 50% 50% classicalclassical musiciansmusicians�� SolutionsSolutions

�� EnvironmentalEnvironmental techniques techniques �� EarplugsEarplugs, monitors etc., monitors etc.

�� TinnitusTinnitus�� Pitch perception Pitch perception

problemsproblems

* * ChasinChasin, M. , M. MusiciansMusicians & & thethe PreventionPrevention ofof HearingHearing LossLoss. . HearingHearing ReviewReview 1999. 1999. SeeSee www. www. musiciansclinics.commusiciansclinics.com

Page 7: Musicians and Musculoskeletal Injuries

OverviewOverview ofof healthhealth issuesissues

�� Skin Skin problemsproblems**�� VaryVary widelywidely�� Point Point ofof contactcontact�� BruisesBruises, , callusescalluses, , cutscuts, ,

abrasions, abrasions, ulcersulcers, , eczemaeczema((bowbow resinresin))

�� 62% 62% violinistsviolinists & & violistsviolistsunderunder chinchin ((leftleft))

�� 32% string 32% string playersplayers�� 27% 27% windwind & & brassbrass

* Ostwald, P.F. et * Ostwald, P.F. et alal, , PerformingPerforming arts arts medicinemedicine. West J . West J MedMed 1994.1994.

Page 8: Musicians and Musculoskeletal Injuries

OverviewOverview ofof healthhealth issuesissues

�� Dental Dental problemsproblems**

�� PeriodontalPeriodontal diseasedisease�� MalocclusionMalocclusion�� LooseLoose teethteeth

Brasses & Brasses & woodwindswoodwinds

*Ostwald, P.F. et *Ostwald, P.F. et alal, , PerformingPerforming arts arts medicinemedicine. . West J West J MedMed 1994.1994.

Page 9: Musicians and Musculoskeletal Injuries

OverviewOverview ofof healthhealth issuesissues

�� PsychologicalPsychological**�� Social pressureSocial pressure�� FatigueFatigue�� IncreasedIncreased adrenalineadrenaline�� AnxietyAnxiety�� FinancialFinancial instabilityinstability

* Ostwald, P.F. et * Ostwald, P.F. et alal, , PerformingPerforming arts arts medicinemedicine. West J . West J MedMed 1994.1994.

Page 10: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSI

""SomeSome fingersfingers, , nono doubtdoubtbecause because ofof too much too much writingwriting andand playingplaying in in earlyearly yearsyears, have , have becomebecomequitequite weakweak, , soso I I cancanhardlyhardly use use themthem..""

Robert Schumann (1810 -1856)

Schumann (1839)

Page 11: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSI

Musculoskeletal injuriesMusculoskeletal injuries�� Muscle, Muscle, bonebone, tendon, joints, ligaments, nerves, , tendon, joints, ligaments, nerves,

bloodblood vesselsvessels andand relatedrelated soft tissuessoft tissues�� CatchCatch--allall termsterms (RSI, (RSI, CTDsCTDs, , WRMSDsWRMSDs))�� 50% 50% ofof allall musiciansmusicians**�� Can Can limitlimit, , interruptinterrupt or or endend a a careercareer

* * Part 2: Musicians.Part 2: Musicians. Preventing Musculoskeletal Injury (MSI) For Musicians And DancePreventing Musculoskeletal Injury (MSI) For Musicians And Dancers: A Resource Guiders: A Resource Guide

Page 12: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSI

�� OverviewOverview ofof healthhealth issuesissues�� Musculoskeletal injuriesMusculoskeletal injuries

�� AnatomyAnatomy�� SpecificSpecific disordersdisorders�� RiskRisk factorsfactors�� PreventionPrevention�� TreatmentTreatment

Page 13: Musicians and Musculoskeletal Injuries

AnatomyAnatomy

�� MuscleMuscle�� ConnectedConnected to to bonesbones by by

tendons (tendons (atat eithereither endend))�� ElasticElastic�� ProvidesProvides movementmovement andand

stabilitystability

�� FasciaFascia�� SheetsSheets ofof fibrousfibrous tissue tissue

betweenbetween layerslayers ofof musclesmuscles�� Source Source ofof pain pain andand

tightnesstightness

Page 14: Musicians and Musculoskeletal Injuries

AnatomyAnatomy

�� TendonTendon�� RopeRope--likelike structure structure mademade

ofof strongstrong smoothsmooth fibersfibers�� NonNon--elasticelastic�� TearsTears if if overstretchedoverstretched�� DuringDuring movementmovement, ,

slidesslides in in lubricatedlubricatedtendon tendon sheathsheath

Page 15: Musicians and Musculoskeletal Injuries

AnatomyAnatomy

�� JointJoint�� Area Area ofof union union betweenbetween 2 2

or more or more bonesbones�� LinedLined withwith synovial synovial

membranemembrane�� Membrane Membrane producesproduces

lubricantlubricant calledcalled synovial synovial fluidfluid

�� Synovial Synovial fluidfluid allowsallowssmoothsmooth movementmovement

Page 16: Musicians and Musculoskeletal Injuries

AnatomyAnatomy

�� BursaeBursae�� SacSac--likelike cavitiescavities filledfilled withwith

synovial synovial fluidfluid�� FoundFound aroundaround jointsjoints�� Friction Friction maymay developdevelop

Page 17: Musicians and Musculoskeletal Injuries

AnatomyAnatomy

�� CartilageCartilage�� CoversCovers endsends ofof bonesbones for for

smoothsmooth joint joint movementmovement

Page 18: Musicians and Musculoskeletal Injuries

AnatomyAnatomy

�� NervesNerves�� CordlikeCordlike structures structures

transmit transmit electricalelectricalimpulses to impulses to andand fromfrombody parts body parts theythey controlcontrol

Page 19: Musicians and Musculoskeletal Injuries

AnatomyAnatomy

�� PeripheralPeripheral nervesnerves�� TravelTravel fromfrom cranialcranial nerves in nerves in brainbrain or spinal or spinal

cordcord to to outerouter regionsregions ofof bodybody

�� MotorMotor nervesnerves�� SendSend signalssignals to musclesto muscles

�� SensorySensory nervesnerves�� Transmit pain, Transmit pain, temperaturetemperature, position, , position, andand

pressure in skin, muscles & joints to pressure in skin, muscles & joints to thethe brainbrain

Page 20: Musicians and Musculoskeletal Injuries

AnatomyAnatomy

�� IntervertebralIntervertebral disc disc and menisciand menisci�� FibrousFibrous cartilagecartilage�� Provide extra cushioningProvide extra cushioning

Page 21: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSI

�� OverviewOverview ofof healthhealth issuesissues�� Musculoskeletal injuriesMusculoskeletal injuries

�� AnatomyAnatomy�� SpecificSpecific disordersdisorders�� RiskRisk factorsfactors�� PreventionPrevention�� TreatmentTreatment

Page 22: Musicians and Musculoskeletal Injuries

Musculoskeletal Musculoskeletal disordersdisorders

�� SignsSigns andand symptomssymptoms�� SwellingSwelling�� RednessRedness�� DifficultyDifficulty movingmoving jointjoint�� LossLoss ofof motormotor controlcontrol�� NumbnessNumbness�� TinglingTingling�� PainPain

Page 23: Musicians and Musculoskeletal Injuries

Musculoskeletal Musculoskeletal disordersdisorders

�� PainPain�� Unique for each individualUnique for each individual�� High threshold in performersHigh threshold in performers�� Performers normalize painPerformers normalize pain�� No pain, no performanceNo pain, no performance�� Fear label Fear label ‘‘musician with injurymusician with injury’’�� Lack of resources to subsidize and prevent early Lack of resources to subsidize and prevent early

treatment treatment

Page 24: Musicians and Musculoskeletal Injuries

Musculoskeletal Musculoskeletal disordersdisorders

�� PainPain�� DefensiveDefensive mechanismmechanism intendedintended to to protectprotect�� May May notnot appearappear duringduring activityactivity responsibleresponsible�� May May occuroccur duringduring sleepsleep�� May May appearappear suddenlysuddenly or or graduallygradually overover monthsmonths�� PayPay attention to attention to whenwhen? ? howhow long?long?

influence on influence on abilityability to to performperform ADLsADLs? ?

Page 25: Musicians and Musculoskeletal Injuries

Progression of MSI signs & symptoms in performersProgression of MSI signs & symptoms in performers(SHAPE(SHAPE--Preventing MSI for Musicians and DancersPreventing MSI for Musicians and Dancers--A Resource Guide, 2002)A Resource Guide, 2002)

Pain occursPain occurs after after class, practice, rehearsal or performance, class, practice, rehearsal or performance, but the musician but the musician performs normallyperforms normally

Pain occursPain occurs during during class, practice, rehearsal or performance, class, practice, rehearsal or performance, but the musician is but the musician is not restrictednot restricted in performingin performing

Pain occurs Pain occurs during during class, practice, rehearsal or performance, class, practice, rehearsal or performance, and begins to and begins to affect affect some aspects of some aspects of daily life. daily life. Musician Musician alters technique, alters technique, ↓↓ duration.duration.

Pain occurs Pain occurs as soon as the musician participatesas soon as the musician participates in class, practice, rehearsal, in class, practice, rehearsal, or performance , and is or performance , and is too severe to continuetoo severe to continue. Many aspects of daily life are affected.. Many aspects of daily life are affected.

Pain is continuous during all activities of daily life, and the Pain is continuous during all activities of daily life, and the musician is unable musician is unable to participate in class, practice, rehearsal,to participate in class, practice, rehearsal, or performance.or performance.

Level ILevel I

Level IILevel II

Level IIILevel III

Level IVLevel IV

Level VLevel V

Page 26: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisorders

�� Tendon & muscle Tendon & muscle disordersdisorders�� TendinitisTendinitis : inflammation due to irritation : inflammation due to irritation ofof thethe

tendon tendon andand or or sheathsheath fromfrom excessexcess tension tension andandfriction friction fromfrom repeatedrepeated movementsmovements..

�� Due to Due to awkwardawkward postures postures thatthat stretch stretch andand bendbendtendons tendons aroundaround jointsjoints

�� Excessive tension & impact Excessive tension & impact →→ tearstears →→ scarscar tissue tissue →→ thickenedthickened, , bumpybumpy & & irregularirregular tendon & tendon & sheathsheath

Page 27: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisorders

�� Focal Focal dystoniadystonia�� MalfunctionMalfunction ofof muscle muscle atat a a specificspecific location location resultingresulting in:in:

�� CrampingCramping�� InvoluntaryInvoluntary flexingflexing or or straighteningstraightening ofof thethe jointjoint�� SenseSense ofof fatiguefatigue�� LossLoss ofof coordinationcoordination�� May or May or maymay notnot bebe painfulpainful�� ReferredReferred pain pain withwith crampingcramping & & spasmspasm�� InterferesInterferes withwith abilityability to to playplay

Page 28: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisorders

�� Focal Focal dystoniadystonia typicallytypically affects :affects :�� Hands & Hands & fingersfingers ofof string string andand keyboardkeyboard playersplayers�� DrummersDrummers’’ feetfeet�� VocalistsVocalists’’ vocal vocal cordscords�� Embouchure Embouchure ofof brassbrass playersplayers((SternbachSternbach 1994)1994)

Page 29: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersHand, Hand, wristwrist & & forarmforarm

�� KeyboardKeyboard & & guitarguitar playersplayers�� StrainingStraining smallsmall hand muscleshand muscles�� LateralLateral fingerfinger movementmovement & & fingerfinger spreadspread�� Stress on Stress on fingerfinger flexorsflexors atat large large MCPsMCPs ((knucklesknuckles))�� LoudLoud repeatedrepeated octaves or octaves or chordschords((ChongChong et et alal 1989)1989)

Page 30: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersHand, Hand, wristwrist & & forarmforarm

�� String String playersplayers�� LeftLeft wristwrist flexorsflexors

(pressure on strings)(pressure on strings)�� ExtensorsExtensors ofof rightright wristwrist

whilewhile bowingbowing�� Small Small rapidrapid bowbow

movementsmovements�� SustainedSustained rapidrapid tremelotremelo

causes causes ↑↑ demandsdemands on on flexorsflexors & & extensorsextensors

Page 31: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersHand, Hand, wristwrist & & forarmforarm

�� Certain Certain windwindinstruments:instruments:�� oboeoboe�� frenchfrench hornhorn�� fluteflute

requirerequire sustainedsustained extension extension to to holdhold instrument instrument whilewhileallowingallowing fingersfingers to to curlcurl intointoposition for position for fingeringfingering..

Page 32: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersHand, Hand, wristwrist & & forarmforarm

�� De QuervainDe Quervain’’s s tenosynovitistenosynovitis�� Pain in tendons Pain in tendons atat base base ofof thumbthumb & & thumbthumb sideside ofof

ofof forarmforarm�� PainfulPainful to to movemove thumbthumb awayaway fromfrom handhand�� PainfulPainful firmfirm grip or grip or twistingtwisting motionmotion

Page 33: Musicians and Musculoskeletal Injuries

De QuervainDe Quervain’’s s tendinitistendinitis

•• OboeOboe playersplayers•• ClarinetClarinet, , fluteflute playersplayers use use

thumbthumb extensorsextensors to to support instrumentsupport instrument

•• Drummers Drummers extremeextremeflexion & flexion & laterallateral motion motion ofof wristwrist withwith rapidrapiddecelerationdeceleration atat impactimpact

•• KeyboardKeyboard & & thumbthumbunderunder ascensionascension

((ChongChong et et alal 1989; 1989; ZazaZaza 19981998))

Page 34: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersElbowElbow

�� LateralLateral epicondylitis epicondylitis (tennis (tennis elbowelbow))�� EpicondyleEpicondyle atat elbowelbow isis

anchoranchor point for point for severalseveralmusclesmuscles

�� Pain Pain atat elbowelbow, , forarmforarm or or wristwrist

Page 35: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersElbowElbow

�� MedialMedial epicondylitisepicondylitis((golfergolfer’’ss elbowelbow))�� MusiciansMusicians’’ complexcomplex posturespostures

�� forarmforarm rotationrotation

�� bendingbending wristwrist withwith independantindependantfingerfinger movementmovement

�� keyboardkeyboard, percussion, , percussion, clarinetclarinet, , harpharp, , oboeoboe, trombone, trombone

Page 36: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersShoulderShoulder

�� RotatorRotator cuffcuff tendinitistendinitis�� Tendons Tendons ofof severalseveral muscles muscles thatthat stabilizestabilize armarm atat thethe shouldershoulder�� Due to Due to raisedraised shouldershoulder outwardoutward or or forwardforward

�� ViolinViolin, viola,, viola,cellocello�� String String bassbass�� BassoonBassoon((ChongChong et et alal 1989, 1989, ZazaZaza 1998)1998)

�� Pain: Pain: �� usuallyusually atat top or front top or front ofof shouldershoulder�� atat outerouter part part ofof armarm�� atat nightnight

Page 37: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersBack & neckBack & neck

�� LowLow backback pain (LBP)pain (LBP)�� ProlongedProlonged sittingsitting & & restrictedrestricted

posture posture (Fry 1986; (Fry 1986; ChongChong 1989)1989)

�� FlattensFlattens curvecurve in in spinespine

�� ↑↑ intravertebralintravertebral discdisc (IVD) (IVD) pressure pressure →→ bulgingbulging →→herniationherniation

�� ↑↑ tension on tension on posteriorposteriorligaments & ligaments & smallsmall muscles muscles →→

�� local local swellingswelling�� muscle muscle spasmspasm�� nerve compression nerve compression

Page 38: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersUpperUpper backback & neck& neck

�� OftenOften due to:due to:�� Postures Postures requiredrequired to support instrumentto support instrument�� StrengthStrength requiredrequired to support or to support or playplay largerlarger

instruments (double instruments (double bassbass, , bassoonbassoon))�� StaticStatic headhead position position →→ face & neck pain face & neck pain

(viola & (viola & violinviolin))�� TurningTurning headhead to to oneone sideside ((fluteflute & & harpharp))�� TiltingTilting headhead downwarddownward (sax & (sax & keyboardkeyboard))�� MethodsMethods ofof transportingtransporting & & carryingcarrying

Page 39: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersHead & faceHead & face

�� OrbicularisOrbicularis orisoris�� StrainingStraining ofof muscles muscles thatthat control control mouthmouth & & lipslips

((vocalistsvocalists & & hornhorn playersplayers))�� TemporomandibularTemporomandibular joint (TMJ)joint (TMJ)

�� windwind instruments & instruments & instrumentsinstruments thatthat requirerequire carefulcareful andandsustainedsustained jawjaw positioningpositioning(viola, (viola, violinviolin, sax, , sax, clarinetclarinet, , frenchfrench hornhorn))

�� Face & neck pain & Face & neck pain & headachesheadaches�� OftenOften relatedrelated to to psychologicalpsychological stress stress andand teethteeth alignmentalignment�� Excessive muscle tension (Excessive muscle tension (teethteeth clenchingclenching) ) �� DegradationDegradation ofof thethe jointjoint

Page 40: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersNerve compressionNerve compression

�� CarpalCarpal tunnel syndrometunnel syndrome�� NumbnessNumbness, , tinglingtingling & or pain in & or pain in

thumbthumb, index, , index, middlemiddle fingerfinger�� Due to compression Due to compression ofof nerves, nerves, bloodblood

vesselsvessels, tendons, tendons�� Due to Due to activitiesactivities requiringrequiring repetitiverepetitive

sustainedsustained wristwrist flexion flexion withwith alotalot ofoffingerfinger movementmovement

�� LeftLeft hand hand ofof violinistsviolinists, , violistsviolists, , guitarguitarplayersplayers (12 or 13th position (12 or 13th position tootoo long)long)((SternbachSternbach 1991)1991)

Page 41: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersNerve compressionNerve compression

�� Cubital tunnel syndromeCubital tunnel syndrome�� Compression Compression ofof nerve nerve atat ulnarulnar sideside

ofof elbowelbow�� NumbnessNumbness, , tinglingtingling pain or pain or lossloss ofof

coordination in 4th & 5th coordination in 4th & 5th fingersfingers..�� Pain Pain atat elbowelbow�� Due to postures Due to postures requiringrequiring flexion flexion atat

elbowelbow & & wristwrist withwith rotation rotation ofof palm palm upwardupward

�� LeftLeft hand hand ofof violinistsviolinists, , violistsviolists, , guitarguitar playersplayers ((ChongChong 1989)1989)

Page 42: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersThoracicThoracic outletoutlet syndromesyndrome

�� SymptomsSymptoms similarsimilar to CTS, to CTS, CuTSCuTS�� Compression Compression ofof group group ofof nerves nerves

((andand or or bloodblood vesselsvessels))travelling travelling towardtoward thethe armarm betweenbetweenthethe 1rst 1rst ribrib andand collarbonecollarbone

�� ShouldersShoulders thatthat are are roundedrounded, , forwardforward & & elevatedelevated

�� SustainedSustained use use ofof pectoral musclespectoral muscles�� BreathBreath holding & holding & irregularirregular

breathingbreathing patternspatterns

Page 43: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersThoracicThoracic outletoutlet syndromesyndrome

�� ViolinistsViolinists, , violistsviolists on on leftleft sideside ((securingsecuring instrument instrument betweenbetween chinchin andand shouldershoulder) )

�� GuitarGuitar playersplayers on on leftleft�� FluteFlute playersplayers bothboth sidessides ((flexingflexing shouldersshoulders forwardforward, ,

reachingreaching leftleft armarm acrossacross body, body, controllingcontrolling breathingbreathing))�� KeyboardKeyboard ((roundedrounded shouldersshoulders, , armsarms forwardforward, , headhead

forwardforward, , irregularirregular breathingbreathing patterns)patterns)

Page 44: Musicians and Musculoskeletal Injuries

MSI MSI specificspecific disordersdisordersNerve compressionNerve compression

�� SciaticaSciatica�� Pain in legs Pain in legs andand buttockbuttock�� Can Can occuroccur atat anyany levellevel�� SittingSitting, , bendingbending slightlyslightly

forwardforward, , rotatedrotated to to oneonesideside

�� SittingSitting surface surface tootoo highhigh, , square on square on edgeedge ofof front front ofofseatseat →→ compression compression backbackofof legleg

Page 45: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSI

�� OverviewOverview ofof healthhealth issuesissues�� Musculoskeletal injuriesMusculoskeletal injuries

�� AnatomyAnatomy�� SpecificSpecific diagnosesdiagnoses�� RiskRisk factorsfactors�� PreventionPrevention�� TreatmentTreatment

Page 46: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIRiskRisk factorsfactors

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

Diseases or health conditions Diseases or health conditions (pregnancy, diabetes, (pregnancy, diabetes,

osteoporosis)osteoporosis)

LightingLighting

Psychological stressPsychological stressVibrationVibrationSurfaces (floors)Surfaces (floors)

Addictive substancesAddictive substances(tobacco, alcohol, narcotics)(tobacco, alcohol, narcotics)

Contact stressContact stress(sharp edges)(sharp edges)

Layout or configuration of Layout or configuration of equipmentequipment

PosturePostureLongLong--duration activities duration activities (inadequate rest)(inadequate rest)

EquipmentEquipment

NutritionNutritionRepetitionRepetitionLayout of spaceLayout of space

Physical fitnessPhysical fitness(strength, flexibility, (strength, flexibility,

endurance)endurance)

Forceful exertionForceful exertionConfined spaceConfined space

Age & genderAge & genderAwkward posturesAwkward posturesTemperatureTemperature

Personal characteristicsPersonal characteristicsPhysical demandsPhysical demandsEnvironmental aspectsEnvironmental aspects

Page 47: Musicians and Musculoskeletal Injuries

ArtisticArtisticDirectorDirectorComposerComposerConductorConductor

MusicianMusician

TechnicalTechnicalSoundSound engineerengineerStage managerStage managerTechnicalTechnical directordirectorPiano tunerPiano tuner

Venue designVenue designEquipmentEquipment designerdesignerInteriorInterior designerdesignerArchitectArchitectPurchaserPurchaser

AdministrativeAdministrativeUnionUnionFundingFunding agencyagencyRegulatoryRegulatory bodybodyCompanyCompany managermanager

EarlyEarly developmentdevelopmentSchoolSchool boardboardMusic Music instructorinstructorParentParent

Influences on risk of injury in musicians(SHAPE(SHAPE--Preventing MSI for Musicians and DancersPreventing MSI for Musicians and Dancers--A Resource Guide, 2002)A Resource Guide, 2002)

Page 48: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIRiskRisk factorsfactors for for musiciansmusicians

�� A change in technique or instrumentA change in technique or instrument�� Intense preparation for performanceIntense preparation for performance�� Overly strenuous repetition of demanding musical phrases*Overly strenuous repetition of demanding musical phrases*�� Sudden increase in duration or intensity**Sudden increase in duration or intensity**�� Preparation of a new or difficult piecePreparation of a new or difficult piece�� Prolonged performance without adequate rest*Prolonged performance without adequate rest*�� Lack of warm up*Lack of warm up*�� CombinationCombination

�� Challenging scheduleChallenging schedule�� Poor dietPoor diet�� Pressure to perfectPressure to perfect�� Performance anxietyPerformance anxiety

•• **ZazaZaza and Farewell 1997; and Farewell 1997; PaullPaull and Harrison 1997; and Harrison 1997; KellaKella 19971997•• ** ** ZazaZaza and Farewell 1997; and Farewell 1997; KellaKella 1997; Norris 1993; 1997; Norris 1993; ChongChong et al 1989et al 1989

Page 49: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSI

�� OverviewOverview ofof healthhealth issuesissues�� Musculoskeletal injuriesMusculoskeletal injuries

�� AnatomyAnatomy�� SpecificSpecific diagnosesdiagnoses�� RiskRisk factorsfactors�� PreventionPrevention�� TreatmentTreatment

Page 50: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIPreventionPrevention

�� LevelLevel 11--Controlling Controlling riskrisk factorsfactors�� DevelopingDeveloping & & adheringadhering to warm up routineto warm up routine�� RestRest breaks breaks thatthat leaveleave youyou feeling feeling refreshedrefreshed�� Longer Longer restrest breaks breaks requirerequire anotheranother warm upwarm up�� GradualGradual increasesincreases to to thethe durationduration andand intensityintensity ofof practicepractice

ZazaZaza 19941994

�� LevelLevel 22--Recognizing Recognizing signssigns & & symptomssymptoms andandrespondingresponding appropriatelyappropriately

Page 51: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIPreventionPrevention--Controlling risk factorsControlling risk factors

�� Musician has most control during practice sessionsMusician has most control during practice sessions�� Focus on practice habits but also implement prevention during reFocus on practice habits but also implement prevention during rehearsals hearsals

& performances when possible& performances when possible�� Maintain personal health, fitness and nutritionMaintain personal health, fitness and nutrition�� Carry and set up equipment safelyCarry and set up equipment safely�� Maintain body awarenessMaintain body awareness�� Know your limits Know your limits

(balance physical & psychological demands) (balance physical & psychological demands) �� Adjust practice schedulesAdjust practice schedules

�� Vary difficulty of musicVary difficulty of music�� Good playing techniqueGood playing technique�� Select appropriate instruments and furnitureSelect appropriate instruments and furniture

Page 52: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIMaintainMaintain personalpersonal healthhealth, fitness , fitness andand nutritionnutrition

�� AllAll aspects aspects ofof dailydaily livingliving�� NutritionNutrition�� HydrationHydration�� PhysicalPhysical activityactivity�� SleepSleep qualityquality�� Stress managementStress management�� Smoking, Smoking, alcoholalcohol, , coffeecoffee, , drugsdrugs decreasedecrease bloodblood flowflow, ,

interfereinterfere withwith normal nerve normal nerve functionfunction, , alteralter judgementjudgement, , decisiondecision makingmaking

Page 53: Musicians and Musculoskeletal Injuries

Musicians and MSIMusicians and MSISelect appropriate practice locationSelect appropriate practice location

�� Cold Cold �� ↓↓ bloodblood flowflow to to fingersfingers�� ↓↓ lubricationlubrication tendons & jointstendons & joints�� ↓↓ nerve conduction nerve conduction velocityvelocity

�� PoorPoor lightinglighting�� Compromises Compromises abilityability to to readread musicmusic�� Compromises Compromises playingplaying postureposture�� EyeEye strainstrain

Page 54: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSISelect Select properlyproperly heatedheated & & wellwell lit lit environmentenvironment

�� Use portable Use portable tasktask lampslamps, , batterybattery poweredpowered clip clip lightslights�� RegularRegular eyeeye exam & corrective exam & corrective eyeeye wearwear�� AdequateAdequate clothingclothing�� WarmWarm hands hands

�� FingerlessFingerless glovesgloves, , wholewhole body exercice body exercice

Page 55: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIDevelopDevelop goodgood practice habitspractice habits

�� Warm upWarm up�� ↑↑ bloodblood flowflow�� WarmsWarms muscles muscles andand jointsjoints

�� 2 components: Joint rotation & 2 components: Joint rotation & aerobicaerobic warm upwarm up�� GentleGentle smoothsmooth motions x motions x severalseveral minutesminutes�� An An aerobicaerobic warm up for 5 minutes : warm up for 5 minutes : rapidrapid walkwalk, slow , slow jogjog, , skippingskipping�� Slow long notes Slow long notes beginningbeginning practice, practice, rehearsalrehearsal, performance, performance�� GradualGradual increaseincrease to to durationduration & & intensityintensity ofof practicepractice

�� Stretching Stretching controversialcontroversial�� SeekSeek medicalmedical adviceadvice on on properproper techniquestechniques

Page 56: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSITaking rest breaksTaking rest breaks

�� Mitigates stress (physical & psychological)Mitigates stress (physical & psychological)�� Allows physical recovery of tissuesAllows physical recovery of tissues�� May enhance learningMay enhance learning�� Avoid muscle fatigueAvoid muscle fatigue�� Schedule rest breaks into practice sessionSchedule rest breaks into practice session

�� 5 min rest for 25 minutes playing5 min rest for 25 minutes playing�� 10 min rest for 50 min playing10 min rest for 50 min playing�� 1010--15 min rest for 30 min playing15 min rest for 30 min playingZazaZaza 1994; 1994; KellaKella 1997; Norris 19931997; Norris 1993

�� Spread practice time throughout the day Spread practice time throughout the day KellaKella 19971997

Page 57: Musicians and Musculoskeletal Injuries

Musicians and MSIMusicians and MSIAvoid repetitionAvoid repetition

�� Variety of music & exercisesVariety of music & exercises�� Build in time for simpler piecesBuild in time for simpler pieces�� Use imaging and visualizationUse imaging and visualization

�� Note by noteNote by note�� Movement by movementMovement by movement�� Assists cognitive aspects of learningAssists cognitive aspects of learning�� Enhances speed of motor learningEnhances speed of motor learning�� Reduces physical practice time & physical risk of injuryReduces physical practice time & physical risk of injury

Page 58: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSISelect Select appropriateappropriate instrumentsinstruments

�� WellWell maintainedmaintained andand wellwell designeddesigned**�� AvoidAvoid leakyleaky valves or padsvalves or pads�� AvoidAvoid bridges bridges thatthat are are tootoo highhigh�� AvoidAvoid excessexcess deaddead spacespace atat top top ofof piano piano keyskeys* Norris 1993* Norris 1993

�� Instrument Instrument thatthat fitsfits thethe musicianmusician

Page 59: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSISelectingSelecting andand adjustingadjusting furniturefurniture

�� Chairs & Chairs & stoolsstools adjustedadjustedsoso feetfeet flat on flat on floorfloor

�� Chair Chair tootoo short short andand notnotadjustableadjustable??�� AddAdd a a cushioncushion�� StackStack chairschairs�� WoodenWooden blocks blocks underunder

chair chair feetfeet ((carefulcareful))PaullPaull andand Harrison 1997Harrison 1997

�� Chair Chair tootoo talltall??�� FootrestFootrest ((phonebookphonebook))

Page 60: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSISittingSitting posture posture

�� DependsDepends on instrumenton instrument�� MaintainMaintain lowlow backback curvecurve

�� LumbarLumbar pillowpillow�� WedgeWedge cushioncushion�� Lift Lift backback legs legs ofof chairchair

�� Foot Foot widthwidth�� WideWide basebase

�� FeetFeet in front in front ofof kneesknees�� VaryVary positionposition

Page 61: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSISelectingSelecting andand adjustingadjusting furniturefurniture

�� AdjustAdjust musicmusic standsstands�� SheetSheet musicmusic atat eyeeye

levellevel or or belowbelow�� LowerLower eyeseyes ratherrather thanthan

headhead�� DirectlyDirectly in frontin front

Page 62: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIPreventionPrevention--variousvarious gadgetsgadgets

Page 63: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIPreventionPrevention--HarnessesHarnesses

�� tubas, drums & tubas, drums & saxophonessaxophones

Page 64: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIGuitarGuitar strapsstraps, , beltsbelts & supports& supports

Page 65: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIPreventionPrevention--StandsStands

Page 66: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIPreventionPrevention

VariousVarious gadgetsgadgets�� HighHigh chinchin restsrests((violinsviolins, violas), violas)

Page 67: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSICarry Carry andand set set upup equipmentequipment safelysafely

�� Plan liftPlan lift�� AvoidAvoid twistingtwisting & & rapidrapid liftinglifting�� How How heavyheavy isis loadload??�� Stable baseStable base�� Face itemFace item�� SolidSolid gripgrip�� ClearClear route AND TAKE YOUR TIME!route AND TAKE YOUR TIME!

Page 68: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIUsingUsing appropriateappropriate containerscontainers

�� Not Not tootoo heavyheavy�� WellWell constructedconstructed, , paddedpadded handleshandles & & wheelswheels�� 2 trips 2 trips betterbetter thatthat 11�� EnoughEnough peoplepeople carryingcarrying? ? GetGet helphelp�� DollyDolly�� AvoidAvoid lifting if lifting if injuredinjured�� GiveGive yourselfyourself enoughenough timetime

Page 69: Musicians and Musculoskeletal Injuries

Musicians and MSIMusicians and MSIPractising body awarenessPractising body awareness

Movement disciplinesMovement disciplines�� Alexander techniqueAlexander technique�� FeldenkraisFeldenkrais MethodMethod�� PilatesPilates�� YogaYoga�� Tai ChiTai Chi

GOAL is a better sense of posture, movement, GOAL is a better sense of posture, movement, status of bodystatus of body

Page 70: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIPractising body awarenessPractising body awareness

A A betterbetter sensesense ofof posture, posture, movementmovement, , statusstatus ofofbody body →→

�� ↑↑ AbilityAbility to to choosechoose appropriateappropriate playingplaying postureposture�� ↑↑ fluidityfluidity ofof movementmovement�� ↑↑ understandingunderstanding ofof differencedifference betweenbetween normal normal

fatigue fatigue relatedrelated discomfortdiscomfort versus pain due to versus pain due to injuryinjury

Page 71: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSI: MSI: TreatmentTreatment

�� LevelLevel 1: 1: recognizingrecognizing signssigns & & symptomssymptoms andandadministeringadministering selfself--helphelp techniquestechniques

�� LevelLevel 2: 2: recognizingrecognizing whenwhen signssigns & & symptomssymptoms are are persisitentpersisitent & & unusualunusual thenthenseekingseeking professionalprofessional medicalmedical helphelp

Page 72: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSI: MSI: TreatmentTreatment

�� Warning Warning signssigns & & symptomssymptoms�� DiscomfortDiscomfort, pain, , pain, tinglingtingling, , numbnessnumbness whilewhile

playingplaying�� WeaknessWeakness in hands or in hands or difficultydifficulty withwith fine control fine control

ofof fingersfingers�� StiffnessStiffness�� Postural changes (Postural changes (elevatedelevated andand or or roundedrounded

shouldersshoulders))�� Local Local swellingswelling or or roundnessroundness�� DO NOT PLAY THROUGH PAINDO NOT PLAY THROUGH PAIN

Page 73: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSI: MSI: TreatmentTreatmentRICE RICE treatmenttreatment protocolprotocol

�� RESTREST�� ICEICE

�� ↓↓ BloodBlood flowflow & sensation& sensation�� 1515--20 minutes20 minutes�� Not Not directlydirectly on skin (on skin (frozenfrozen peaspeas in in dampdamp toweltowel))�� No No creamscreams, , balmsbalms, , rubsrubs�� Do Do notnot use to use to numbnumb pain to pain to keepkeep performingperforming

�� COMPRESSION (COMPRESSION (askask healthhealth professionalprofessional))�� ELEVATION (ELEVATION (aboveabove levellevel ofof heartheart))

Page 74: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIWhenWhen to to seekseek medicalmedical assistanceassistance

�� SymptomsSymptoms occuroccur eacheach timetime youyou playplay�� SymptomsSymptoms continue to continue to worsenworsen�� SymptomsSymptoms unusualunusual for for youyou�� SymptomsSymptoms persistpersist afterafter practisingpractising�� SymptomsSymptoms occuroccur atat otherother timestimes i.e. i.e. duringduring sleepsleep�� SeekSeek healthhealth care care professionalprofessional experiencedexperienced in in

treatingtreating musiciansmusicians

Page 75: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIMultidisciplinaryMultidisciplinary approachapproach

�� MusicianMusician�� HealthHealth care providerscare providers�� TeachersTeachers�� EquipmentEquipment providersproviders�� Instrument providers Instrument providers �� FurnitureFurniture providersproviders

Page 76: Musicians and Musculoskeletal Injuries

MusiciansMusicians andand MSIMSIRemindersReminders

�� IdentifyIdentify aspects aspects ofof set set upup, practice habits, , practice habits, playingplayingposture posture atat faultfault

�� IncreaseIncrease restrest, , decreasedecrease continouscontinous playingplaying ((untiluntil youyou playplaywithoutwithout symptomssymptoms))

�� GradualGradual smoothsmooth warm upwarm up�� BeBe awareaware ofof passages passages contributingcontributing to to signssigns & & symptomssymptoms

thenthen reducereduce intensityintensity & & levellevel ofof repsreps�� PerformPerform long slow notes, long slow notes, simplersimpler passages passages followingfollowing

complexcomplex passsagespasssages�� AlternateAlternate physicalphysical practice practice withwith mental practicemental practice

Page 77: Musicians and Musculoskeletal Injuries

Question Question periodperiod