Vol. 22 Issue 4
Musculoskeletal Strain Injury
Coming to a stage near you
As an occupational therapist, you may have heard the same story before a patient arrives to your clinic with a diagnosis of right carpal tunnel syndrome (CTS). Work activities cause pain and numbness, with progressive weakness in grasp and fine-motor-related activities. The patient demonstrates slouched posture and often performs repetitious tasks in wrist flexion.
What makes this scenario unusual is that you are treating a rock star.
Maybe we are not all treating rock stars, but musicians can also be plagued by MSIs (musculoskeletal strain injuries). Studies indicate that nearly half of all musicians and music students become symptomatic at some point in their careers (Chong et al, 1989; Fry, 1986a; Norris; Zaza, 1998). Whether they perform on a small stage or a large venue, musicians may incur overuse injuries by working too fast, for too long, and/or with ill-suited equipment.
What differentiates musicians from other workers with MSIs is the mechanism of injury. The musician uses highly specialized movements that may alternately require precision, speed and/or force with the goal of producing music. They also need to possess the conditioning and endurance of an athlete in both small and large muscle groups in order to perform properly. The time they spend playing music–for employment, practice and leisure–can add up to a large window of opportunity for a variety of overuse syndromes.
One of the primary risk factors toward sustaining a musculoskeletal strain injury is the physical demand that the instrument places on the musician.
Keyboard players and string players have the highest incidence of developing symptoms, due to the postures that their instruments require them to maintain. These musicians all have a common vulnerability toward developing nerve compression injuries such as CTS and TOS (thoracic outlet syndrome).
Instruments that place excessive force on the APL (abductor pollicis longus) and EPB (extensor pollicis brevis) tendons of the thumb can cause DeQuervain's tenosynovitis, as has been reported in clarinet players, flutists and keyboard players.
Focal hand dystonia is a movement disorder which causes involuntary muscle contractions, spasm, fatigue and incoordination. It may occur in situations in which the muscles are repeatedly worked beyond their physical capabilities. The lumbrical and interrossei muscles of the hand are frequently involved, as these muscles are small but have to fire rapidly and intermittently. The result may be a decrease in timing, which is unacceptable in the process of executing technically demanding pieces of music.
When the Unthinkable Happens
Acute pain or a little finger that is unable to adduct can be catastrophic to a musician's career, but diagnosis by a physician and taking immediate action can alleviate pain and improve function. Some techniques involve:
• Employing the concept of ergonomics to minimize external stresses on the body and maximize the internal force exerted by the body. This can include properly positioning the instrument and correcting the posture of the musician.
• Resting the affected areas by decreasing the amount of playing time temporarily or taking a few days off from playing, when possible.
• Avoiding the big "no no's" –slouching, unnecessary reach and repetitious gripping with the wrist in flexion and ulnar deviation. This is important not only with music-related activities, but also with hobbies and secondary occupations.
• Applying ice packs, as appropriate, to areas with acute inflammation.
The Show Must Go On
The patient's physician may also recommend occupational therapy to provide specialized intervention. Splinting can be particularly effective to provide rest to painful areas. The patient may benefit from wearing the splint for a majority of the day, removing it only for hygiene and driving, and progressing to light practice of their instrument, in acute cases. Taping or a neoprene wrap are good alternatives in providing light compression and support in the presence of more mild symptoms.
Design a gradual exercise program to improve strength and flexibility, keeping in mind the rigorous routines that serious musicians often return to. Modalities, such as, heat, cold, ultrasound, iontophoresis and electrical stimulation may reduce pain, inflammation and spasm, while increasing local circulation and tissue pliability.
Use Fry's five category grading system to assess the effectiveness of treatment on the patient's pain level (see Sidebar). Grade one is indicative of pain at only one site. Grade five indicates pain at multiple sites that persists well after the musician has stopped playing and is also caused by other ADLs. As this grading system applies specifically to pain, review the initial evaluation to analyze the difference in ROM, grip/pinch strength, coordination and sensory data on the reassessment.
In addition to the routine musculoskeletal assessment, identify other possible risk factors by asking the patient questions regarding their playing habits and routine, as well as variables of the patient's particular instrument, such as the gauge of string used on a guitar or the manner in which a large instrument is transported. Other questions that you may consider asking include: "Do you feel any other work activities or hobbies are contributing to your symptoms?", "Have you been playing on a new or unfamiliar instrument lately?" or "Have you been playing pieces that are strenuous or challenging?"
Most important is the musician's perception of his own playing ability. Demonstration or simulation of playing technique, finger positions and overall posture are useful ways to see the typical patterns of movement that the patient engages in regularly. It may take a little detective work to find out the root cause of the patient's symptoms, but removing any undue mechanical stress is the only way to set the patient on the road to recovery.
Many clinics are not set up to accommodate live musical performance, but simulation, demonstration of upper extremity posturing and subjective interview can be instrumental components of the reassessment process.
Play It Again...Safely
As with all musculoskeletal strain injuries, prevention is crucial. Patients should maintain overall health, and schedule practices and performances so as to avoid overworking vulnerable structures. Warm-ups are necessary to prepare the body for the physical demands of playing. Tai chi, the Alexander Method and Pilates are all gaining popularity in the music industry as a way to build core strength, improve posture and gain an awareness of body movements. Both the amateur and professional musician should be able to assess their abilities and perform pieces within their skill level, or take the necessary time and preparation for advancement.
Attention should also be paid to the instrument itself and the way in which the musician holds it. The musician should make sure that the instrument feels like a "good fit" to encourage proper posture. The therapist and patient can collaborate on giving instruments and their accessories the "once over" to ensure that chairs are at the right height and straps at the right length. Smaller-gauge strings can be used to decrease the amount of force to the finger flexors, while a cart can be used to transport a cello or other large instrument to lessen the strain to the abdominal and back muscles.
And as with any equipment, regular maintenance will ensure efficient function–lax strings require greater effort on the part of the musician, for example.
The sequelae of musculoskeletal strain injury can have serious impact on a musician's quality of life and livelihood. Prevention is recommended but not always achieved. Occupational therapy can provide the tools necessary to return the injured musician back to performing. That is the art and science of occupational therapy –helping people return to what they have to do and what they love to do.
References available at www.advanceweb.com/OT or upon request.
Amy Roux, OTR/L, CHT, has been working as an occupational therapist at UMass Leominster Hospital for the past 12 years. She has been a certified hand therapist since 2001.
Fry's pain scale
1. Pain at one site and only while playing
2. Pain at multiple sites
3. Pain that persists well beyond the time that the musician has been playing
4. All of these, and many ADLs begin to cause pain
5. All of these, but all daily activities that engage the affected body part cause pain
Source: Rehabilitation of the Hand, 5th Edition, 2002