<html xmlns:o="urn:schemas-microsoft-com:office:office" = xmlns:w="urn:schemas-microsoft-com:office:word" = xmlns="http://www.w3.org/TR/REC-html40"> <head> <meta http-equiv=Content-Type content="text/html; = charset=us-ascii"> <meta name=ProgId content=Word.Document> <meta name=Generator content="Microsoft Word 9"> <meta name=Originator content="Microsoft Word 9"> <link rel=File-List href="cid:filelist.xml@01C3C3CE.CB829D80">  <style>  </style> </head> <body lang=FR link="#4a4a00" vlink=purple = style='tab-interval:35.4pt'> <div class=Section1> <table border=0 cellspacing=0 cellpadding=0 width=450 = style='width:337.5pt; mso-cellspacing:0cm;mso-padding-alt:0cm 0cm 0cm 0cm'> <tr> <td style='padding:0cm 0cm 0cm 0cm'> STATE OF = THE ART. VARIOUS ASPECTS OF HAND AND UPPER LIMB PATHOLOGY IN MUSICIANS = <o:p></o:p> by Yves Allieu = Professor at the Medical Faculty of MONTPELLIER (France). Head of the Orthopaedic = and Hand Surgery Unit <o:p></o:p> 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. = <o:p></o:p> Let us distinguish = the "Peripheral Hand" from the "Central Hand": An artificial, though actually didactic = discrimination<o:p></o:p> 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.<o:p></o:p> 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?<o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> 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. <o:p></o:p> 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<o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> 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). <o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> 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. <o:p></o:p> II· Unorganic = Pathology ("Central Hand" troubles or functional = dystonies)<o:p></o:p> 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.<o:p></o:p> Diagnosis of = unorganic trouble or functional dystony must be a "diagnosis by = elimination".<o:p></o:p> 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. = <o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> 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).<o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> III. Hand Traumas in Musicians<o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> 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.<o:p></o:p> IV. Socio-professional aspects of the hand and upper limb pathology in musicians<o:p></o:p> 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.<o:p></o:p> 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. = <o:p></o:p> (European Medical Bibliography, vol. 4, n° 1, 1994)<o:p></o:p> <a href="http://www.medecine-des-arts.com/eng/themes/" = onclick="window.close()">Close</a></= span><o:p></o:p> </td> </tr> </table> <![if = !supportEmptyParas]> <![endif]><o:p></o:p> <![if = !supportEmptyParas]> <![endif]><o:p></o:p> -----Message d'origine----- De : pianotech-bounces@ptg.org [mailto:pianotech-bounces@ptg.org]De la part de Tompiano@aol.com Envoyé : = mardi 16 décembre 2003 11:14 À : = pianotech@ptg.org Objet : Re: Carpal = Tunnel problems <![if = !supportEmptyParas]> <![endif]><o:p></o:p> 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<o:p></o:p><= /p> </div> </body> </html>