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STATE OF THE ART. VARIOUS ASPECTS OF HAND AND UPPER LIMB PATHOLOGY IN
MUSICIANS
by Yves Allieu Professor at the Medical Faculty of MONTPELLIER (France).
Head of the Orthopaedic and Hand Surgery Unit
Troubles of the hand and upper limb appear frequently in musicians,
particularly professional ones. Over 60 percent of string instrumentalists
suffer from such ailments. A professional musician should be considered as a
high competition sportsman. Intensive training of six to ten hours daily is
necessary to any instrumental practice. These demands prove excessive on the
organic (the hand is not made for such a purpose) as well as the
neuro-psychological levels. Disturbances occurring on musicians should not
be put down to particularly sensitive human beings, showing "vague"
psychological reactions, or even hysteria. The organic and neurological
overwork demanded from musicians' hands is largely sufficient to supply
objective reasons for such troubles.
Let us distinguish the "Peripheral Hand" from the "Central Hand":
An artificial, though actually didactic discrimination
1. The Peripheral Hand or "tool-hand" (Levame) is a motor-organ of great
perfection, provided moreover with a very fine discriminative sensibility; a
true sensory organ (the violonist can place his fingers on string positions
defined to the tenth of a millimeter). Although, analytically speaking,
functional possibilities (i.e. muscles, joints and tendons) are more or less
similar for everybody, they can be used in a completely different manner
(i.e. a violonist's hand or that of a manual worker are built the same way,
but they are totally different in their respective functioning). The actual
differences in the hand are not so much anatomical characteristics but
rather functional possibilities depending themselves from the "central hand"
which uses this "peripheral tool-hand" more or less efficiently. The great
adaptational faculties of the "tool-hand" enable the general practice of any
musical instrument, even with a not so advantageous morphotype.
It is wrong, when learning to play an instrument, not to take those
morphological differences into account and systematically to resort to a
method demanding movements which are not adapted to anatomical conditions.
Such a mistake may provoke functional troubles later on and should be
avoided through closer contacts between music teachers and hand specialists.
A similar collaboration with makers of various music instruments seems just
as necessary. Hands being different, shouldn't instruments be adapted to
them?
Even if the hand can do almost everything thanks to its many adaptive
faculties, it is nonetheless certain that some hands are anatomically better
adapted than others to playing an instrument.
Although small hands can enable great pianistic achievements, as in the case
of MARIA PIRES, young musicians whose rather small hands are spotted early
on might do better to be directed towards an instrument more suited to their
own build, thus avoiding later complications due to overwork of an
ill-adapted hand.
Equally, too stiff or too loose joints, (or other minor characteristics such
as the relative length of the 4th and 5th fingers for violonists) should be
given more consideration in music conservatories before orienting pupils
towards one particular instrument.
2. The "Central Hand", is in fact an extension of the brain, the hand
governing the "tool-hand" which it uses to greater or lesser degrees,
depending on individuals. Its conscious cortical projection is very
important, but it is also located at the level of the unconscious
sub-cortical brain (the unconscious brain participating at 80% whereas the
cortex participates at 20%); the latter giving an instrumentalist the
automatic reflexes of his virtuosity. The "Central Hand" governs through
infinitely complicated circuits the "Peripheral Hand". These circuits
integrate the conscience as well as various sensory centres (hearing,
vision, balance, body posture) and memory centres. Thus, the musician's hand
also submitted to his or her moods and sensitivity reflects in fact their
whole being.
The "Central Hand" improves continuously through proper training. This
cerebral plasticity conditions the gift, and above all willpower and
movement repetition. The command, at first conscious in researching and
producing the adequate movements, then becomes virtually automatic. At any
age, training creates, selects and strengthens sub-cortical circuits,
several billions of which are normally never used. Hence the importance of
training, particularly in the child whose cerebral plasticity is at its
highest (between 4 and 6 yrs). Such training must be continuous.
Two types of troubles can be identified in musicians' hand and upper limb
ailments: organic and unorganic pathology.
I, ORGANIC PATHOLOGY ("peripheral" hand and upper limb troubles)
A, Tendinites and tenosynovites
These are organic troubles due to overwork, the Anglo-Saxon "overuse
syndrome". They are due to micro-traumas caused by over intensive, too fast
and too often repeated effort. This pathology is similar to that of
sportsmen's tendinites. Thus, pianists and violonists can suffer from finger
extensor or flexor tendinites. Violonists are often plagued with
epicondalgia (pain in the elbow's lateral side induced by overwork of the
wrist's extensor tendons, which insert on the epicondyle) in the bowing arm.
Shoulder tendinites also occur, particularly in violonists and string
instrumentalists; they mainly affect the supraspinatus muscle which
maintains the shoulder in abduction position. Such troubles may occur
through faulty instrumental technique and can be cured simply through
correction of the actual playing movements. A medical treatment with
anti-inflammatory drugs, coupled with rest could prove necessary. Activity
must, however, be resumed progressively, for example through an appropriate
program, specific to each instrument.
B.Troubles of the fingers' tendinous independence
a) Extensor tendons' subluxation at the basis of the 4th and 5th fingers, on
the metacarpo-phalangeal level.
This ailment provokes a sudden involuntary start impulse, the fingers feel
blocked when the subluxation is mobile, or unable to part when it is fixed.
An anatomical malformation of the fasciculi binding extensor tendons at this
level, or more rarely a trauma can account for it, requiring resection of
the latter and re-setting in the right position of extensor tendons on the
dorsum of the hand. This is often unnecessary, as re-education of the actual
playing gestures and postures is a cure in itself and surgery, as a rule,
not needed.
b) Flexors' congenital anastomoses
There can be an anastomosis between the flexor pollicis longus which flexes
that finger and the forefinger's flexor profundus which flexes the latter's
last phalanx and creates an inter-dependent flexion of both fingers, which
might cause a tendinous irritation with a tenosynovitis of the flexors.
Resection of this congenital anastomosis in the palm of the hand is the best
treatment in case of hindrance, particularly when a violonist's left hand is
concerned.
C. Nervous Compression Syndromes
Such ailments induce sensory troubles with paresthesiae (prickling) in the
fingers. Median nerve compression at the level of the carpal canal can occur
with pianists, violonists or wind instrument players; whereas violonists
might be affected by compression of the elbow's ulnar nerve, of the brachial
plexus and of the blood vessels at the base of the neck.
They are due to several factors: - a wrong posture: exagerated flexion of
the wrist (inducing a carpal canal syndrome through median nerve
compression), or of the elbow (inducing a compression of the ulnar nerve) or
retroposition of the shoulders and rotation of the neck (inducing a
vasculo-nervous compression syndrome of the brachial plexus at the level of
the thoracic outlet). - Muscular hypertrophies: Instrumental practice
demands important muscular efforts. Muscular hypertrophy due to intensive
training may induce nervous compressions. - Tenosynovites (among which the
one affecting flexor tendons in piano intensive practicing may compress the
median nerve at the level of the carpal canal).
These nerve compressions alleviate in general when the patient can rest, if
he corrects his playing posture and after treatment with anti-inflammatory
non-steroidal medications. In certain cases, however, surgery must be
considered, particularly to handle the carpal canal syndrome. This entails
simple surgical handling, but should be resorted to only in case of failure
of medical treatment. The thoraco-brachial outlet syndrome heals well after
appropriate re-education, as the ulnar nerve syndrome at the elbow reacts
positively after correction of movement and posture defects. Whenever
necessary in more difficult cases, a period of rest with immobilization
orthesis of the elbow in extended position may be required.
There are other more seldom seen nervous compression syndromes, such as that
of the anterior inter-osseous nerve of the median nerve branch, or of the
radial nerve at elbow level due to prono-supination micro-movements, which
materializes mainly as epicondylitis. Healing is achieved through medical
treatment associated with a rest orthesis in slight supination position with
elbow flexion.
D. Joint Pathology Hyper joint laxity, considered as a classical advantage
ever since Paganini, might be prejudicial. This is the case mainly for wind
instrumentalists whose finger play can be hindred when a highly precise
pressure should be exerted. The most often encountered problem is that of
trapezo-carpal pain at the base of the thumb, which might be the first sign
of an arthritis - revealed or induced by instrumental playing. Pianists and
violonists can suffer from it. For pianists the thumb plays a particularly
important part: its spreading ability is conditioned by the first web
enlargement, and that of the metacarpo-phalangeal and trapezo-metacarpal
joints. The violonist might be affected by such an ailment because of not
holding the instrument correctly, the thumb thus being in a wrong position.
Ortheses might then complete the medical treatment so as to correct above
all wrong posture and playing movements.
II. Unorganic Pathology ("Central Hand" troubles or functional dystonies)
Clinical examination proves negative in such cases, as do complementary
investigations (radiographies, electromyographies, etc.). At least, they are
currently negative, in the present state of our knowledge. Maybe one day,
even command and neuronal circuit troubles will be located through
instruments of the cerebral scintigraphy type.
Diagnosis of unorganic trouble or functional dystony must be a "diagnosis by
elimination".
It must not be the outcome of an insufficient examination of the hand,
having overlooked slight organic troubles (tendinous anastomoses hindering
finger independence; morphological differences causing inadaptation to
instrumental technique and to the instrument itself; neglected minor trauma
sequelae...) We think that the development of the knowledge of this specific
pathology - relating to musicians' hands - will reduce the ailment category
of so-called "functional dystony" which is sometimes just a pathology
re-grouping created by our lack of knowledge of minute organic problems in
musicians, either at the level of execution or of hand command. Present
traditional medicine often abandons the musician as having "psychic
troubles". Although even now, one can find in the course of a thorough
clinical examination tiny causes of neuro-muscular balance dysfunctioning,
upsetting the precise and so delicate balance of virtuosi. These troubles
are mostly either of an organic or neuro-psychological nature. More often,
musicians actually exhibit psychological troubles. They are mostly not the
first at the origin of the ailments, but secondary, i.e. caused by the
impossibility of reaching the level of performance the artist would like to
achieve (anxiety of the musician not to be able to keep his place in an
orchestra, anxiety of a pupil before an examination...) Musicians are
sensitive beings, perfectionists submitted to an ever lasting challenge in
order to maintain their place in their profession. The slightest
psychological trauma (in personal or family life, or a change of teacher)
can break a fragile balance. An examination of the whole being and
personality of the patient might show posture troubles on which one can act.
Such troubles are evidenced through wrong attitudes, muscular imbalances
which perturb the whole energetic chain of movements ending with those of
the hand. These imbalances influence the weakest element of this "central
hand - peripheral hand" combination which very often corresponds to the
complex motions of the fourth and fifth fingers. In harp playing, where the
fifth finger is not used, functional dystonies are seldom seen. Only a vast
experience in the examination of musicians and a pragmatic knowledge of
problems encountered enable us nowadays to delineate and correct such
troubles. We think, however, that research wiII develop so as to help us
further, in better defining and isolating these balance defects.
Those unorganic pathologies are regrouped under the term of "Functional
Dystonies".
Thoroughly studied by Raoul Tubiana and Philippe Chamagne, they are often
wrongly attributed to "professional cramps", whereas in those cases, there
is no painful "muscular cramp". Under certain particular conditions (some
difficult parts in a piece of music) fingers - mainly the fourth and fifth -
escape the musician's control, lose their velocity, execute abnormal
movements, all without any pain. Those dystonies are due to troubles in the
neuro-muscular command of the "peripheral hand" by the "central hand". They
can occur through a minor organic trouble of the peripheral land, when the
latter is ill-adapted to a demand it is trying to meet.
A thorough overall clinical examination usually reveals faulty attitudes and
muscular imbalances. Those imbalances are mainly located at shoulder level
as well as in the whole of the rachis. Thus, the over-raising of one
shoulder, shoulders jutting out or a faulty posture of the rachis or the
pelvis are often observed; at upper limb level, they might show through a
collapse of the transversal metacarpo-phalangeal arch in the fourth and
fifth radii area, or a pronation of the forearm. Treatment is based on
re-education and has been well codified by P. Chamagne. It does not concern
the hand and forearm muscles only, but also the whole of the body balance.
The musician must become conscious of his faulty attitudes which are at the
origin of the imbalance and the troubles which have occurred. A muscular
balance rebuild is necessary, which should be followed by a complete new
training in instrumental practice, using the body in the appropriate way,
and adapting attitudes accordingly.
The therapist must help the musician to find the best position conditioned
by his own morphology and the necessities of the instrument. Sometimes, the
latter will have to be adapted (violin or cello support, for instance).
Ortheses can be useful to correct a faulty attitude (to keep the thumb in
the right position, to stabilize the proximal inter-phalangeals of the
fourth and fifth fingers). Psychological responsibilization is, however, a
must.
When treatment is carried out correctly, it is possible to cure more than
half of these functional dystonies. Although one should stress that such
therapy should be started early, as a functional dystony which has settled
in is much longer and more difficult to treat, the failure percentage being
proportional to the ailment's age and development.
III. Hand Traumas in Musicians
Any hand trauma in a musician must be taken very seriously. The saying
"there are no small wounds in the hand" applies particularly well in this
case. Emergency and specialized units are then of paramount importance.
Retaining finger pulp sensibility is very important. Any wound of the hand -
even slight in appearance - demands an emergency exploration to make sure
that no nerve injury occurred. If it did, the repair of the hand's small
nerves under microscope in emergency specialized surgical units is a must.
Any trouble of the pulp sensibility can considerably impede instrumental
playing. Remember that a violonist positions his fingers with a precision of
a tenth of a millimeter.
Hand immobilization to treat fractures, luxations and sprains must be short,
limited and followed with an early physiotherapy to avoid any stiffening. A
perfect break reduction and a stable contention might yet necessitate a
surgical operation with miniaturized elements (screws, plates), to enable
immediate re-education of the broken finger. The hand surgeon will have to
be aware of the demands of musical training: the mobility of a distal
inter-phalangeal digital joint is relatively secondary for a pianist,
compared to the requirements of a violonist, for instance: the latter having
an absolute need for such movements, the surgeon will have to resort to
every possible skill and means to restore them.
In case of distal amputation on a musician, the imperative will be to
preserve as much as possible the length of the finger. We would like to
stress that distal digital re-implantations effected in specialized surgical
units are presently 90% successful, thanks to microsurgery.
IV. Socio-professional aspects of the hand and upper limb pathology in
musicians
The professional musician. overtrained, must sometimes stop his career
during a period of time or even for ever. This can entail the ensuing tragic
development of hand troubles which would have remained unimportant in a
normal human being. This socio-professional problem, presently neglected,
must be considered, taking into account the specific pathology inherent to
the profession.
Hand and upper limb pathology in a musician is a medical super-specialty. It
necessitates specialized pluri-disciplinary consultations with hand
surgeons, specialized therapists, psychologists and music teachers. The
latter play a particularly important role in this connection, as only a
dialogue between medical entities and professional musicians will enable any
progress to be made. This specialty is currently developing fast and should
gain a great importance in the years to come. As a conclusion, one should
insist on the major part prophylaxy should play in music schools and
conservatories.
(European Medical Bibliography, vol. 4, n? 1, 1994)
Close <http://www.medecine-des-arts.com/eng/themes/>
-----Message d'origine-----
De : pianotech-bounces@ptg.org [mailto:pianotech-bounces@ptg.org]De la part
de Tompiano@aol.com
Envoye : mardi 16 decembre 2003 11:14
A : pianotech@ptg.org
Objet : Re: Carpal Tunnel problems
Randy,
Has it been firmly diagnosed as carpal tunnel or could it be the results of
"trigger" points, which often lumped into one category?
Trigger points can have the same symptoms as Carpal Tunnel and can be quite
crippling. Both of these ailments can be treated successfully without
surgery but will require much attention on your part. I have been pain free
for one year due to deep self message, supplemental vitamins (glycossomine,
calcium, and bromoline), concentrated efforts of counter movements.
If I find myself getting forgetting to take the vitamins and the message for
a period of a week, I can feel a hint of my hand problems reoccurring.
Our hands take a beating during the tuning process. Times that my so many
instruments a day/week/year/ 20 years- it takes a toll and it's no wonder
these problems exist.
Tom Servinsky, RPT
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