Abstract
Elite musicians may practise at and play their instrument for some 8 h a day, year in, year out. By athletic standards, this would be anticipated to place strain on those parts of the musculoskeletal system used, in the case of musicians mainly in the arms. Moreover, whilst instruments come in standard pre-determined size; musicians are of varying shape and size. It follows that even with adequate training in technique and sometimes the use of ergonomic aids attached to the instrument, exceptional strain can be placed on instrumentalists who are not suited to their instrument anatomically, compared to those that are. Overuse injury is accepted in sport [1] and ‘the over-training syndrome’ [2] has been intermittently fashionable. It would stretch credibility if musicians were not to be susceptible to such problems.
Keywords
- Carpal Tunnel Syndrome
- Overuse Injury
- Reflex Sympathetic Dystrophy
- Thoracic Outlet Syndrome
- Focal Dystonia
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.
Introduction
Elite musicians may practise at and play their instrument for some 8 h a day, year in, year out. By athletic standards, this would be anticipated to place strain on those parts of the musculoskeletal system used, in the case of musicians mainly in the arms. Moreover, whilst instruments come in standard pre-determined size; musicians are of varying shape and size. It follows that even with adequate training in technique and sometimes the use of ergonomic aids attached to the instrument, exceptional strain can be placed on instrumentalists who are not suited to their instrument anatomically, compared to those that are. Overuse injury is accepted in sport [1] and ‘the over-training syndrome’ [2] has been intermittently fashionable. It would stretch credibility if musicians were not to be susceptible to such problems.
Most musicians are extremely dedicated. Their profession is their art such that they have every incentive to remain fit and playing, not least because the profession tends to be over-subscribed. Musicians therefore provide an excellent model for the study of ailments of the arms, once conventional clinical diagnoses have been excluded, since there is often little prospect of successful litigation compared to certain other occupations supported by stronger trade unions. Moreover, musicians are acutely sensitive to the precise onset and localisation of symptoms that have not previously occurred [3], making the profession an excellent model for the study of conditions contentiously termed ‘repetitive strain injury’ (RSI). Music played prior to or at the onset of symptoms can be analysed in terms of the number of notes required, often allowing surprisingly precise correlation between quite short and specific passages of music and the onset of symptoms. Since choreography is usually also recorded, similar arguments apply to dancers, especially when the choreography is not especially suited to a particular dancer or, more frequently, when the cast for which the piece was designed leaves to be replaced by new dancers of different physique.
This article discusses the current rather unsatisfactory definition of RSI, reviews previous experience of this condition, notably the epidemic that occurred in Australia [4], and highlights particular instrumental pitfalls that may predispose to overuse with certain instruments. It argues, at least on the evidence from musicians, that the syndrome exists but that it is probably not a single entity with a multifactorial aetiology. Accepted medical conditions that may mimic RSI, which probably account for a proportion of all cases, are reviewed with conjecture on the possible overlap with some types of dystonia, a condition covered in a separate article and for which accepted medical guidelines exist.
Work-Related Upper Limb Disorder
For many work-related upper limb disorder (WRULD) has replaced RSI, a term highly suggestive of causation and repetitive strain disorder (RSD), which tended to be confused with the abbreviation for reflex sympathetic dystrophy although it will later be argued that there may be occasional overlap between these two conditions.
The term WRULD tends to be used in the face of persistent symptoms once more conventional medical conditions of the forearm such as tenosynovitis, carpal tunnel syndrome and epicondylitis at the elbow as well as causes of referred pain such as cervical spondylosis have been excluded. It is therfore essentially a diagnosis of exclusion. To suggest it is a function of the industrial age is incorrect. Before the industrial revolution it was endemic in agricultural workers, such as fish workers who, prior to the advent of refrigeration, had to work fast and intermittently as each catch was filleted before it decayed [5]. Clerk’s palsy, described 275 years ago, may have been the white collar equivalent even though epidemics of ‘writer’s cramp’ in the British Civil Service around the 1830s were attributed to the introduction of the steel nib [5].
Various aetiologies have been suggested. Amongst these is controlled evidence for certain histological abnormalities in affected patients [6], though others sought to explain the condition in terms of problems with pain amplification [7]. In the case of the Australian epidemic [8], the cumulative growth of symptoms coincided with the introduction of a work compensation system that allowed lump sum payments for work-related disease [9]. Even amongst musicians the unusual frequency of symptoms has been recorded intermittently by many authors over the last 100 years since Poore’s first description in 1887 [10, 11].
Various attempts have been made at defining diagnostic criteria [12, 13, Hussain K, 2003, Diagnostic criteria for work related upper limb disorder, personal communication] but none have found universal acceptance.
Problems Specific to Musicians
These are often only highlighted through a meticulous history of playing and performance, sometimes beyond the scope of the doctor lacking experience in this area who may not be familiar with the common instruments and their many variations.
Overuse injury has been defined as ‘the damage that occurs when a tissue is stressed beyond its anatomic or physiologic limits, either acutely or chronically’ [14]. Some allow this to overlap with tenosynovitis [15], others with damage in the muscle, ligaments and joint capsule [16]. Pathological studies and biopsy studies obviously create ethical difficulties in practising musicians though these have been performed on keyboard operators [17]. The majority of injuries are precipitated by playing [18], particularly an increase in the time and intensity of playing [19].
The piano writing of composer/pianists, always keen to outshine competitors, reflects the unique features of their respective hands. Brahms, Liszt and Rachmaninov all had large hands, Rachmaninov’s middle fingers capable of significant lateral movement. By contrast, the piano works of Bach, Mozart and Schumann require a more compact hand. It is the clinical experience of this author that quite short passages of exceptional difficulty can tip the balance into overuse when the player is close to this threshold. If the particular passage is re-fingered, re-structured or even re-composed, the problem is sometimes alleviated.
There are also certain pitfalls among instruments. The commonest is when a violin player transfers to the viola or vice versa. The difference in size and weight of these two instruments creates additional strains to which the performer is unaccustomed. A similar relationship exists between the oboe and cor anglais, the latter instrument being slightly larger and heavier, though mainly with the same fingering. The wide variation between the size and shape of the many members of the saxophone family and the strain that transfer from one of these instruments to another can cause is not always appreciated by the clinician. Although the clarinet and alto saxophone have similar size and fingering, the angle at which the instrument is held is quite different (the saxophone requiring a slight rotation of the spine) and can predispose to overuse, especially if there is a slight natural corkscrew twist of the spine in the opposite direction to that in which the instrument is held.. Spinal scoliosis or rotational twists also causes a problem with the cello since the spine is slightly rotated with the pelvis additionally fixed against the instrument. Although the double bass is a larger more cumbersome instrument, the player has more freedom of spinal movement so this is less likely to occur.
Whilst there is some dispute about the prevalence of thoracic outlet syndrome in musicians, especially amongst violin and viola players [19, 20], the evidence for ulnar nerve entrapment at the elbow whilst playing the violin is much stronger [21] and is normally supported by abnormal nerve conduction studies and EMG. The pressure is thereby localised to the aponeurosis of flexor carpi ulnaris or its underlying fascia.
The complete assessment of musicians requires the musician to be observed playing their instrument. Sometimes the idiosyncrasies of positioning and holding, given the wide diversity of size and shape amongst individuals, clearly demonstrate the compression of soft tissue against a hard surface of the instrument for long periods of time, presenting a risk that is immediately apparent to the physician.
In the experience of this author, the classical guitar and flute are instruments presenting particular problems and account for many referrals to music clinics, once correction is made for the frequency with which these instruments are played. With the classical guitar, significant lateral stretch of the fingers is required in just one hand. Although the flute appears light and easy to play, the position in which it is held is most unergonomic compared to other woodwind instruments, often requiring contortions of the arms and shoulders to accommodate it.
Similar arguments apply to embouchure in brass players and the larynx as an articulation in singers but both are beyond the scope of this review.
Diagnoses that May, in Part, Mimic WRULD
It remains a possibility that if several discreet medical diagnoses are present in the same arm, as can often occur with the complex use of the arm required by musicians, symptoms of each may overlap causing diagnostic confusion. Normally this can be unravelled by a detailed history and careful examination but if a nerve root compression, often at the neck, compounds with a peripheral nerve entrapment, giving an unusual distribution of nerve compression symptoms, this may in part account for the paraesthesiae that are so often a feature of WRULD in musicians.
It is also possible that discreet accepted medical diagnoses, present in mild form, sometimes sub-clinical in respect of clinical examination, may also summate to give symptoms attributable to a WRULD. Eight such possibilities are listed in Table 8.1.
Overuse, as experienced by athletes, is an accepted part of sports medicine [22]. Accepted extrinsic factors felt to contribute include excessive load on the body (both the type and speed of movement and the number of repetitions), training errors (too fast a progression and too high an intensity) and poor equipment. All of this equates with musical training, the instrument representing the equipment.
That micro trauma may be present is partly conjectural but strongly believed by some [17], though this argument is hard to take further in the absence of pathological biopsy material from controlled studies, which is largely unethical in professional musicians.
Excessive training, to the point of fatigue and even exhaustion, may invoke physiological results such as lactic acidosis. Lactate accumulates in muscle during exercise [23] and muscle strength, fibre type and enzyme activity all contribute to the severity of this in a given individual [24, 25]. It remains probable that this sort of inter-subject variation occurs in musicians as well as in athletes.
Inherited abnormalities of muscle metabolism such as McArdle’s syndrome may also exist in sub-clinical forms, perhaps with partial penetration, which may aggravate the susceptibility to overuse syndrome caused through lactic acidosis.
Peripheral nerve entrapment in violinists is already described above [21]. It has also been described in flautists where the contorted position of the elbow probably predisposes to pressure entrapment [26], certain myelinated conducting fibres probably more susceptible than others [27]. Nerve compression can also occur around the shoulders in musicians [28] where the contour of the cervical and thoracic spines may also contribute.
Compartment syndrome might also be the cause of some symptoms. Here a physical overuse of muscle, restricted within its collagenous fascial sheath produces an increase in pressure which is symptomatic and in severe cases can lead to muscle necrosis. Usually associated with the legs (‘shin splints’ in dancers), it seems inconceivable that musicians should not be susceptible to this in the arms. Investigation is by the measure of pressure in the muscle compartment and treatment is by surgical release [29]. By implication, both physiological and anatomical features predispose. Examples occur in the arm after surgical trauma [30–32] and it seems feasible that compression of the arm against the firm surface of an instrument might precipitate this as well.
Although unlikely in musicians, it remains a strong possibility that certain psychological factors contribute, especially when symptoms of overuse become established. Thus, overuse syndromes are sometimes felt to be less frequent in the self-employed though this may be artefactual if the self-employed simply adapt a higher threshold for pain in order to continue, working through the symptoms they experience from a genuinely induced pathology.
The precise localisation of symptoms in some musicians is probably attributable entirely to ergonomic factors associated with their specific instrument or, perhaps, the amount of repetitive trauma placed upon a single digit by a particular composition or even a short passage within that composition. Nevertheless, the potential putative overlap with focal dystonia [33] is clear and such dystonias, usually presenting initially in the form of cramps, have been recognised to afflict musicians for some 150 years [34]. Symptoms are often extremely task specific and highly localised in relation to that task. Electromyography often reveals certain abnormalities [35, 36] and the affliction of several elite pianists is undoubted [37].
Aggravating Factors
There is a strong suspicion that certain factors aggravate. One is scoliosis of the spine, particularly with a stringed instruments where a quite different function is required from each of the two arms. Symptoms of this sort are invariably unilateral contrary to a true overuse injury in a keyboard or woodwind player where the symptoms are normally equal and bilateral. In general, this also applies to brass instruments with the exception of the trombone.
There is also a strong clinical impression that joint hypermobility predisposes to overuse syndromes. This would seem logical. Simplistically, extra effort is required to stabilise the hypermobile joint in a position of function before additional effort is applied to move it. In the non-hypermobile joint, the strength of the collagen through the joint capsule and the ligaments, stabilises the joint at rest prior to movement.
Overuse in Dance
It seems probably that most of the above arguments also apply to dancers though here in respect of all parts of the musculoskeletal system, especially the legs and trunk. The muscles and joints concerned are likely to be larger than those in the arm, and invariably will be weight bearing but exactly the same principles apply.
This is partly born out by the acceptance of overuse syndromes or over training syndromes in sport and athletics, for which detailed accounts are available elsewhere.
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Bird, H.A. (2016). Overuse Syndromes. In: Performing Arts Medicine in Clinical Practice. Springer, Cham. https://doi.org/10.1007/978-3-319-12427-8_8
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